Clutching our world views with a death grip

By Mary Odum

As I write, I am sitting in what might be my last airplane seat, stacked cheek to jowl with a couple with a cute but runny-nosed baby. My trip was with girlfriends on a bike tour in California, and I made the most of it, living very much in the moment. As I traveled, I wore my infection control hat, scanning the settings with new eyes for potentially dangerous situations. I was careful in public places such as airports, trolleys, and the BART, washing my hands frequently and keeping them folded in front of me. I was much more aware of impulses to touch my face. I watched a couple in the San Francisco airport who were headed to Nairobi touch their faces, many times, as they waited. Airport bathrooms were mostly hands-free, but the automatic toilets sprayed their contents powerfully in all directions when flushed. There was a new sign in the TSA line warning us to wash our hands because of Middle East Respiratory Syndrome (MERS), but no mention of Ebola (EVD). TSA used gloves to pat me down, but they were not washing their hands after contact with people. Boarding passes, drivers licenses, and credit cards were swiped and exchanged, along with bills and coins. I saw a large homeless population on the waterfront in San Francisco with no access to bathrooms or handwashing, who were using the streets as open latrines. I saw prostitutes. Hotels had carpets and mattresses that would defy cleaning in an outbreak. I saw people hugging, and shaking hands, and doing all kinds of human, caring, or even loving things that would be extinguished in a pandemic.

Today the first nurse within the US healthcare system has acquired EVD. My nursing friends are worried. Are we ready for this? How do we communicate risk, or should we settle for optimistic reassurance that our system can handle this? What are our biggest needs in preparation?

Communicating risk or comforting memes?

There have been probable cases of EVD in eight countries: Sierra Leone, Liberia, Guinea, Senegal, Nigeria, DRC, Spain, and the US. Those keeping track of the epidemic maintain the fiction of less countries and less deaths with scrupulous reporting of grossly inaccurate counts, and by partitioning the outbreak into different categories and phases. Is it time to use the P word and call it a pandemic yet?

How The Economist views the issue
How The Economist cherry-picks the issue of readiness

Most who are communicating the risks of this situation are men, who do not work in situations with isolation gowns or patients. They do not fully understand the issues or risks in the acute care setting. Typically, the spokespeople are understating the risks, in hope of avoiding panic, optimism of the best outcome, or denial. None of us have been in a serious pandemic, since the last global pandemic was almost exactly a century ago. So there are many uncertainties surrounding this epidemic. Should we be optimistic and hope for the best, or imagine the worst and try to prepare?

How healthcare professionals view the issue (via Jesse's Cafe)
A different view of U.S. readiness for pandemic (via Jesse’s Cafe)

The massaged messages from our leaders and the mainstream media (MSM) are slowly changing over the past three weeks, from “It won’t come here” to “It might come here” to “Cases are expected, but don’t panic.” Don’t panic, when we’re under-prepared for a deadly pandemic? Isn’t that what anxiety is for—mobilization away from inertia towards preparation?

quitjobA nurse in Dallas who was caring for the first EVD patient in the US, in “full isolation gear”, has contracted the disease. Frieden’s first comment on the situation was to blame the nurse. “At some point there was a breach in protocol. That breach in protocol resulted in this infection,” Frieden said.  He looked panicky as he announced it, but that is no excuse for blaming the victim. Now you’ve made me mad, Frieden, and it seems that you have made other nurses mad, too. If risk communication by the CDC takes this approach, the nurses are just going to say “I quit” like the nurses in Madrid and West Africa. The optics are poor when a series of wealthy white men unfamiliar with isolation procedures start telling the nurses what to do and where they went wrong. Nurses’ voices have been systematically muzzled over the past two decades with the privatization of healthcare, but this may be where we find our voice.

oopsnurseFirst, the CDC cannot be sure that it was a breach in protocol. This case might have been acquired from fomites. The meme that EVD is only spread thru body fluids is simply inaccurate. Or it could be any number of other gaps in the system.

When there are systemic errors, such as gaps in protection from a deadly virus, you don’t blame the nurse. You fix the system. We know there are big gaps in the system. We cannot fix the problems if we immediately seek to place blame on people and not address the systemic problems.

“The majority of medical errors do not result from individual recklessness or the actions of a particular group—this is not a “bad apple” problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them” (Institute of Medicine, 1999, To Err is Human PDF). Errors happen all the time in complex systems, and blaming the nurse is not the way to fix them. And we need to fix them, now, or else we will have to adopt a community-based caregiving model for this or another pandemic when hospitals become overwhelmed. Hospitals in the US are overly complex, with excessive treatment. Preexisting gaps in the chain of infection for this deadly disease could create avenues for spread if not closed. And we will have to make some ethical decisions about triage and fair care if this pandemic expands further.

Sally Sellers, RN illustrates just one of the systemic problems that needs to be worked through in our system. Our isolation rooms typically have a single anteroom, which may have been adequate for less lethal diseases. But Ebola is different.

“. . . when it comes to an isolation room, whether it has negative pressure or not, there is only one ante room where both the dawning of clean PPE and disrobing of contaminated PPE is performed….where there is a linen cart for dirty PPE, where there is a trash can for contaminated supplies/PPEs. What the heck are the chances that a nurse takes off her PPE correctly inside-out and disposes correctly . . . but the ante room is dirty as it is in contact with infectious material? Awaiting the well trained nurse to touch contaminated surfaces in the ante room . . . awaiting the next healthcare worker who has yet to dawn PPE to touch contaminated surfaces, etc.?” (Sellers, 10/12/14)

scratchfaceIn addition to systemic problems, there is the problem of human complacency, fatigue or lack of training for the degree of caution needed with this virus. As a nursing professor, I taught students how to safely protect themselves in situations where isolation was required. After reading about infection control and practicing isolation techniques in the lab, students would apply what they learned in actual hospital isolation rooms with patients. Invariably, garbed students would attempt to touch their faces within minutes of entering the isolation room, sometimes multiple times after being reminded. I have also seen complacent experienced nurses forget and do the same. I’ve seen huge lapses in isolation room compliance, by visitors who seem to be exempt from isolation rules, ancillary staff, physicians, and housekeepers. Even in a good hospital, there are gaps, poor handwashing compliance (less than 50%, typically), and spread of drug-resistant germs in hospitals through contamination of the setting.

disgustingIntensive care nurses are particularly vulnerable in caring for EVD patients, as we deal in extreme procedures that aerosolize body fluids. One issue here is the recurring ethical question of extreme care of some patients in intensive care, when other patients who lack healthcare do not receive any. It also raises the ethical question of varying levels of protection for caregivers. At this point, most hospitals do not have BLS-4 type hazmat suits, and hospital administrators consider “full Isolation gear” to be paper disposable isolation gowns that are one-size-fits-all, and often too short, leaving much of the body exposed or which tear in use (see header). Masks are either simple surgical masks, or N-95 respirator masks that do not screen out all aerosols, and nurses must wear their own scrubs and shoes home and wash them at home, potentially exposing their families. At the very least, these inadequate costumes need to be upgraded to theater gowns or some other more impervious garb. Another gap is chronically understaffed nursing care, which also creates lapses in infection control, as nurses have to pick which policies and standards are most important. There are both holes and inequities in the healthcare system that add to systemic gaps in infection control. Unfortunately, the gaps are large enough to drive a truck through.

PPE considered essential by MSF leaves no skin showing, in contrast to standard full isolation PPE in use in US hospitals
PPE considered essential by MSF experts leave no skin showing, in contrast to standard “full isolation” PPE in use in US hospitals

Another comforting meme or spin is that EVD may become endemic and become the next AIDS. How did we rush past epidemic to endemic in the minds of journalists, when pandemic is what we are headed for? AIDS is now often considered a chronic illness, and antiretrovirals have been effective at holding off immunodeficiency. In comparison, Hepatitis B is about 20 times more transmissible than AIDS, and Ebola, due to its virulence and multiple modes of transmission, is probably much more transmittable than hepatitis. Yet journalists and spin doctors choose AIDS as a comparison disease. Ebola is much easier to catch than AIDS, as it is transmitted in all body fluids, and the disease causes very messy viral shedding in its victims. Transmissibility is a critical issue that needs more research.

Why did they stop the simulation at 78 days?
The assumption used for Ebola CFR is probably too low. Click on the Washington Post link to see the simulation run.

Another comforting meme is that we must keep global air transportation moving so that we can “fight it over there so it doesn’t come here.” We are mobilizing a lukewarm linear response to an exponentially growing pandemic. Branswell’s analogy to burning embers in a fire is an apt one. West Africa is a conflagration, with burning embers scattering everywhere as the fire grows. But it will eventually come here, slowly perhaps, if we do shut down air travel, but inexorably, especially as it reaches other crowded countries that are not isolated, either by geography or by modern travel. If you could halt air travel to slow the transmission of EVD to the US, would you? In descent we will have to slow or stop using air travel—this would be a good trial of what it would be like. Or this is how air travel might go away?

What now?

iwearbodyfluidsSpanish nurses are defecting from the fight in Madrid, citing poor pay and inadequate PPE. I have been there, working in isolation rooms that weren’t set up properly, or with disposable isolation gowns that were too short or gloves that were too thin or too small and tore easily, with a patient load that didn’t allow time for adequate or safe care. If I was close to retirement age and I was a nurse, and my hospital administrator earned 20 times or even 100 times what I earned, and he was telling me that hospitals were prepared, and I knew they weren’t, and I was powerless to change the situation, I would be ready to walk.

need-to-be-autoclavedNurses are on the front line of this disease, unlike hospital administrators or even physicians in most cases. Unless one works in the rare Magnet hospital, where high level, autonomous nursing care is prevalent, and nurses have a voice in managing the system, hospitals these days are run by MBAs in suits, who know more about profitability than healthcare. What would stop me from quitting, and saving my ammo to care for my family, if I knew that a deadly pandemic was coming, and my hospital would not listen? Those journalists who promote headlines blaming the spread of EVD on nurses need to reconsider the slant they are promoting. And the MBAs running hospitals had better give nurses a seat at the table to manage these issues, now, before this pandemic heats up and we go into crisis mode. Focus groups with nurses to tighten up the gaps would be a good place to start.

Healthcare workers and the general public need to be educated. We will need to teach community members how to protect themselves for the long term, and perhaps also how to care for family members safely. We need to teach people about quarantine, why it is important, and how to prepare for the possibility. We need to teach people about the chain of infection and the basics of infection control.

Doctor Schnabel [Dr. Beak], a plague doctor in seventeenth-century Rome
PPE trends over time–Doctor Schnabel [Dr. Beak], a plague doctor in seventeenth-century Rome
There are many research needs. We need much better science on how this disease is transmitted—there is still much we do not know. We need to research the best non-disposable PPE gear, and the best ways to decontaminate. Another need is an optimal formula for oral rehydration therapy (ORT). At Emory, the team found that patients had significant hypocalcemia, hypokalemia, and hyponatremia, requiring specific intravenous fluid replacement dependent on lab values. A low-transformity ORT specific to EVD for home care (with and without sugar) is needed. We need community care kits with bleach, buckets, PPE, and other items for caring for EVD patients in the home. And we need to figure out how much waste incineration is necessary for Ebola patients in both home and hospital settings. The apartment clean-up in Dallas was very dangerous because of inexperienced workers (15 people), and it created 140 drums of waste, and a $100,000 bill. Who will pay that bill, is it sustainable as the plague spreads, and would it just be simpler and safer to burn houses down if thorough decontamination is really necessary? We also need self-organizing networking capabilities where people can report exposure, contacts, home care needs, and deaths on a community organization basis.

The biggest question, however, is whether we should quarantine by limiting air travel? This is a deadly but slow disease, slower than the flu, because it is not airborne and the incubation is longer–unless you throw in global travel. Arguing not to close borders assumes we can stop this—in my opinion, we are already past that. Shutting down commercial flights to slow things down is the first step. But it would have to be shut down entirely, or else the impact would just be to slow the spread. On the bright side, many of the adaptations that we will have to make in this epidemic, such as less travel, more relocalization, and less global trade are things that we need to do anyway in descent–here is our impetus.

Hope for the best but imagine the worst

Americans are hoping for the best, but it is important to be prepared for the worst. Sandman and Lanard suggest that “telling the truth about the situation, admitting what we don’t know, acknowledging problems, asking more of people and speculating on what-ifs and worst-case scenarios” help us to improve the system.

Models suggest that there may be 1.4 million cases by January. What happens after January? What would happen if half of our society died of Ebola? It gives a whole new meaning to the idea of being left behind. Would our karma here in the U.S. consist of trying to keep the electricity and economy limping along in a society with not enough people, to run too many white elephants, such as shuttered nuclear power plants with over-stacked spent fuel pools?

 

The  Ebola series is linked here, also in the pull-down Topics list at upper left.
  • Sally Sellers RN

    Spot on Mary!

  • José Madeira Garcia

    I just took an international flight last week, and I’ve been telling folks it will probably be my last one. I’m figuring air travel will be absurdly dangerous by Christmas, and private airlines will all be broke by early next year. If commercial air travel does start up again in a few years – and if I happen to be one of the survivors – it will probably be too expensive and beyond my reach. It was interesting to see that your post started with a similar story.
    Thank you for the excellent detail. Frankly, at this point, the safest hospital would be one that is run as a nurses cooperative, with secretaries and other administrators hired on as needed. Frieden, the MBAs and their ilk really need to be swept aside.

    • Hospitals worked better when the abbesses were in charge, Jose. Even when we do everything right, there is still stuff floating around and getting on one’s hands. The VRE in this study is probably a better comparison germ than AIDS or hepatitis because of the transmission routes. That’s why Frieden’s comment is so egregious.

      “Discussion. We found that, after having contact with a patient who was colonized or infected with VRE, 17 health care workers (39%) acquired the patient’s VRE strain(s) on their gloves. Five health care workers had a patient’s strain on their hands after glove removal, whereas 12 did not. Gloves reduced the risk of acquisition of VRE on the health care workers’ hands by 71% (12 of 17 subjects), but the protection afforded by the gloves was incomplete. For 1 subject, precontact hand and glove samples did not yield VRE on culture, but VRE was recovered from the subject’s hands after glove removal. This may be due to contamination of the hands that occurred during or after glove removal, or it may be due to failure to recover VRE from the gloves as a result of the presence of a low inoculum.

      Olsen et al. [8] showed that gloves prevented contamination of the hands during procedures in which exterior surfaces of the glove were contaminated with gram-negative rods or enterococci after patient care. Our study expands on their investigation by (1) determining whether the health care workers’ hands were contaminated prior to patient contact and (2) performing cultures of samples obtained from patients and using a molecular typing method (PFGE) to assess the association between strains on hands, gloves, and patients.

      Hand washing is recommended after glove removal because of the potential for contamination of the hands to occur during glove removal or via glove leaks. Noskin et al. [9] showed that artificially inoculated VRE can last for at least 60 min on hands and that hand washing for 30 s will eliminate colonization. Our study supports the use of hand washing even if gloves are worn, although we were not able to determine the independent or added protection afforded by hand washing or the reason for the incomplete protection afforded by gloves.

      In our study, the incidence of acquisition of VRE on gloves (39%) approximated the prevalence of colonization of VRE on hands (32%), which suggests that such colonization may be a transient phenomenon. The frequency of colonization of health care workers, even after transient contact with the intact skin of VRE-infected or -colonized patients, may result in frequent horizontal transmission of VRE. This helps maintain a high endemic level of patient colonization. A previous study showed that 33% of patients in general medicine wards and 47% of patients admitted to Rush-Presbyterian-St. Luke’s Medical Center from chronic care facilities were colonized with VRE [10]. The high number of VRE strains identified by PFGE suggests an extensive reservoir. Although CDC-HICPAC guidelines are followed for patients with clinical VRE infection, surveillance for VRE colonization is not done routinely; therefore, the majority of patients who would test positive for VRE are not likely to be identified. Our data support the potential benefit of universal gloving of health care workers who are participating in patient care activities at institutions with a high prevalence of VRE colonization.

      The role of environmental contamination is suggested by the acquisition of a patient’s VRE strain by 3 subjects who did not have patient contact and also by the acquisition of 6 nonsubject, nonpatient VRE strains during the course of routine patient care activities. The role of environmental factors in the transmission of VRE has been reported [11], but its significance requires further study.

      Our data identify patients for whom—and settings in which—increased risk of VRE transmission is likely. The presence of diarrhea in a patient with VRE, the number of sites colonized with VRE on each patient, the mean VRE colony counts on a patient’s skin, and the duration of contact between a health care worker and a patient were associated with an increased risk of acquisition of VRE on a health care worker’s gloves. These findings suggest that contamination is most likely to occur under circumstances of increased bacterial inoculum size or prolonged exposure to contaminated surfaces.”

      http://cid.oxfordjournals.org/content/32/5/826.long

      And here is confirmation today of everything I said in this post. Or emoted, as the case may be.

      http://www.reuters.com/article/2014/10/13/us-health-ebola-usa-nurse-idUSKCN0I206820141013

  • aubreyenoch

    The following passage is from a AP
    article on the website http://www.oregonlive.com/today/index.ssf/2014/10/thomas_eric_duncans_final_days.html

    By this account, the nurses were
    caring for the patient with serious ebola symptoms in “gowns and scrubs”.

    “By evening, Duncan was suffering
    from explosive diarrhea, abdominal pain, nausea and projectile vomiting.
    Efforts to bring down his fever failed.

    Three more doctors were put on the
    case. Duncan received intravenous fluids to counter the dehydration, but there
    was still no firm diagnosis.

    Because Duncan had recently traveled
    from Liberia, Dr. Gebre Kidan Tseggay noted, “Ebola virus disease should
    be high on the list” of differential diagnoses.

    Shortly before noon on Monday, Sept.
    29, Duncan asked the nurse to put him in a diaper, “because he feels too
    tired to keep getting up to the bedside commode.” His fever spiked again
    to 103, and Duncan was wracked with chills.

    “Pt said he just doesn’t feel
    good and doesn’t want to stay in the hospital and expressed concern that the
    doctor had not been here to tell him what was going on,” a nurse wrote.

    Blood tests showing damage to the
    liver and kidneys, and fluctuating blood sugar levels kept doctors scrambling.
    Tests ruled out influenza, hepatitis, parasites and C-diff, the germ notorious
    for spreading diarrhea in hospitals and nursing homes.

    “Feels miserable. Says he is
    suffering,” Dr. Oghenetega Abraham Badidi wrote in the chart. “The
    patient seems to be deteriorating.”

    Finally, at 2 p.m. on Sept. 30, doctors received the
    confirmation that all had been dreading: “Patient has tested positive for
    Ebola …” The staff attending to Duncan traded their gowns and scrubs for
    hazmat suits and attendants would scrub the room with bleach.”

    The information coming out of this situation reminds me of Tom
    Clancy’s 1998 novel RAINBOW SIX. The novel had a subplot of a biotech group
    that planned to reduce the worlds population by starting a scary epidemic and
    then providing the vaccine for the scary epidemic. The real killer agent was in
    the vaccine. It’s only a matter of time until we’ll see them bring out the
    MaxVax. To the billionaires it’s just time to cull the herd.

    • I find it hard to believe that a Liberian national with loud EVD symptoms wasn’t already on isolation, but there you have it. Can you imagine the Oh S**t moment when the positive lab test came back? All nurses have been there–sketchy, incomplete histories with poor communication between shifts, and so on. The “after I’ve been in my patient’s room a million times” meme is played out on a daily basis in our healthcare system, but never until now with such a deadly exposure.

      • aubreyenoch

        “But there you have it …..”

        We think of humans as one species. If we consider functionality, then we might divide humans into two
        homo sapiens subvarients. I call them “Homo sapiens empirico” and “Homo sapiens politico”.

        Empirico, the earlier form, survived primarily through their skill in observing their environment and
        making the successful response to those observations. It was a disadvantage to
        use wishful thinking. To recognize whether a track in the dirt was predator or
        prey could only benefit if the “hope” is left out of the equation.
        The truth was what was right before their eyes.

        As the population grew and villages became towns and towns became cities and monarchies became established
        another skill developed. In these population dense situations it became advantageous to observe the
        other humans. It became vital to be able to recognize the pecking order in the
        group. The truth became what ever the king said it was. Over time we might
        imagine that there was a selection against any empirical observation that might
        inhibits ones ability to project support of the ruling elite.

        These two subvarient lines are mixed in our present population with the Politico
        strain being expressed strongly in our policy makers and administrators. These
        people are incapable of empirical observation. They are incapable of seeing
        what is right before their eyes. They don’t see the weather. They don’t see the
        forest and they don’t see the trees. They don’t differentiate between science
        and science styled marketing. They make their living by supporting the owners
        no matter what the owners present as truth.

        It should be a good time to invest in Clorox.
        CLX is up 13% since Aug. 5.

        • “there was a selection against any empirical observation that might inhibits ones ability to project support of the ruling elite” Just watching logic get bent by those arguing for interventions that sustain economic growth while we throw public health out the window, thus guaranteeing a pandemic puts me firmly in the Empirico variant. Just shaking my head. I think I helped the CLX stock–there are some extra bottles in my kitchen. We’re going to need a lot more bleach . . . .

        • zoomzum

          Spot on. I would like to share this comment alone, and would be glad to credit you if I knew how.

      • aubreyenoch

        One recent “oh sh*t” moment
        was in the morning of Oct.1.
        I work in north Dallas three days a week and on the Wed morning after
        Mr. Duncan’s Ebola diagnosis, Ebola was the main story on KERA, the local NPR
        affiliate. Sometime between 6:00 and 7:00am, Sam Baker, the local morning
        anchor, was getting an update from a reporter that was covering the story. The
        reporter said that some fifty people had been identified as possibly being in
        contact with Mr. Duncan and were being monitored at that time. The reporter
        went on to say that one of those on the list was a homeless man and that the
        authorities had lost contact with this person but that they thought they had
        located him. Haven’t heard any more about the homeless man. This
        whole Ebola episode highlights the fraud of our profit based medical system. As
        if we needed more proof.
        Imagine the ‘Oh Sh*t” moment for the Dallas hospital big wigs when they
        realized that to say there was something wrong with their computer admittance
        program might lead to someone looking into the program. And that could lead to
        finding out that when they enter that the patient doesn’t have insurance, the
        program sends them on a series of actions that are intended to get the
        uninsured person out of the hospital as soon as possible without incurring any
        liability for the hospital for lack of treatment. There was no need to note
        that the patient had recently been in Liberia because there was no focus on any
        action other than getting the person out of there. No money to be made on this guy. So they went “oh sh*t” and changed that story real fast, and hired a PR firm.

        The story on 240 minutes of hand washing seems perfectly reasonable on a finite planet that is capable of infinite growth. It makes perfect sense to me. Us Earthlings are so special.

    • Sally Sellers RN

      “Patient has tested positive for
      Ebola …” The staff attending to Duncan traded their gowns and scrubs for
      hazmat suits and attendants would scrub the room with bleach.”….. OMG! And the CDC didn’t see the nurse infection coming?!? I can’t even imagine the terror those nurses/docs/HCW are experiencing especially after being first hand witnesses to the ravages of the disease. God help us….as long as the talking heads keep playing their musical instruments I guess no one will notice the ship sinking.

  • The case doubling time for Ebola appears to be close to its incubation time, about 21 days. With today’s case load, we have about 27 doublings to reach over 7,000,000,000. That’s about eighteen months.

    What would you do if you had eighteen months (or less) to live?

    • will, mdjd

      I figured the same, Jan. One case becomes 1,000 in 6 months, 1 million in a year: that’s about right so far, as they say the current West Africa epidemic comes from a single case last December. International barriers will require the epidemic to double from single or a few cases in each country or area, presuming that there will be attempts to limit cross-border travel. My son is planning to go to India for a year next month. If he’s back in a year, one presumes there will only be a million cases in India, give or take, and he should make it back – if he can still access return transportation, which seems increasingly unlikely. But we’ve already had our first case in the U.S., and no assurance that we won’t be at a million in a year, although we definitely won’t have a billion cases 6 months after that. Will it be any safer here than anywhere else? Compare: “You have cancer. There’s a chance that treatment will cause a remission, even a cure, but otherwise you won’t live more than a year and a half.” Is that a good analogy? Let’s see if we hear it on the ‘MSM’.

      • If you are going to get Ebola in this country, get it early and avoid the rush, while we still have luxury of extra ICU beds, adequate staffing, and deluxe air taxis to Emory. Whack-a-mole will work briefly, until it doesn’t. Later on, don’t expect such perks.

  • Holger Hieronimi

    Wow – once again – thanks for this series of posts – Reading your comments on hand washing and “touch the face”-habits (that I have myself) I ask you something more practical: are there some “barefeet hygiene” guides available – I think I should better do an online crash course.

  • Sally Sellers RN

    Game over. Second HCW infected in Dallas hospital…..now all the nurses are speaking up. + blood sent through tube system to lab! Tape around nurse’s necks? No protection of scrubs below knees or shoes. Duncan’s nurses taking care of other patients. No training. No equipment…..still even now that they have 2 + patients in-house. Hospital execs are circling their wagons and CDC Dr Friedan no where to be found….packing for Cayman Islands? All I know is that I woke up to the second secondary hospital induced Ebola infection this morning and 4 separate invites to county and surrounding counties holding pandemic preparedness table top exercises STAT! Ok….Hail Mary Pass!

    • Sally Sellers RN

      My heart is sinking further and further…..it would be funny if it weren’t so tragic. The King Has NO Clothes! And the wheels are coming off the system. Stock market down 450pts….and that’s today’s good news. Jezzeee….I was hoping we could make it to the farm planned for next summer….I guess I should’ve prepared plan B.
      The talking heads are what is so disturbing ….. they keep just adding another ooops! to their list and the hospital has muzzled the troops and loyalists as Mary states…..but the troops know just how F***’d they are that they are hollering now. When faith is lost in the system the system will seize. Ahhhhh.

      • greendoc

        I am a family practice naturopath in California. I have been getting calls from concerned patients and family members (brother a first responder in Omaha and sister in law an ICU nurse in Kentucky) who want to know if complimentary alternative medicine has anything to offer. I see alot of stuff out there in the internet about stimulating the immune system. Unfortunately the medical literature does not really support that idea, as EVD is so lethal due to overactive immune response known as cytokine storm. If any HCW has interest in a compilation of evidence based strategies that may help inhibit cytokine storm you can download a PDF here: http://www.ebolastorm.com. I do have charge a nominal fee to offset all the costs associated with accessing research and setting up the website. Of course, it is all theory as to how it could help with Ebola, as no one has researched this specifically. But there as been alot of interest and research in controlling cytokine storm as it relates to ARDS, sepsis, influenza.

        Meanwhile, I am not looking forward to flu season…for obvious reasons. I also vote for Mary being head of the CDC. And yet another reason always electing lawyers or rich white men to hold office is not a great idea. We need scientists, teachers, farmers, HCW in key positions.

        • Very good point about trying to limit cytokine storm, Greendoc. It would help if we had better data from West Africa. At one point they said that mortality was predominantly women, but then they said no, it was evenly split. I imagine the women caregivers get it from their patients, and then give it to the men–equal opportunity virus, because of the virulence. I don’t think we know if this is impacting the young or old more, which might tell us how much of a factor cytokine storm is–the 1918 Influenza impacted young adults–deaths were mostly due to ARDS and secondary bacterial pneumonia, but it sounds as though MODS was involved there too. Yes, one of the best ways to prepare is to take care of ourselves, and make sure we are not Vitamin D deficient, for example.

          • greendoc

            It is interesting that in the 1918 pandemic, aspirin may have played a role in morbidity and mortality.
            http://m.cid.oxfordjournals.org/content/49/9/1405.full
            http://www.nytimes.com/2009/10/13/health/13aspirin.html
            And yes, it is so frustrating we are not getting pathophysiological feedback yet about this current outbreak. The link to “lessons learned” from Emory University had more information about dealing with the Media than any patient support protocols.

            Previous outbreaks have been well studied.

            PLoS Negl Trop Dis. 2010 Oct 5;4(10). pii: e837. doi:
            10.1371/journal.pntd.0000837.
            Human fatal zaire ebola virus infection is associated with an aberrant innate immunity and with massive lymphocyte apoptosis. Wauquier, N, Becquart P, Padilla C, Baize S, Leroy, EM.

            Instead of watchful waiting with temperature monitoring, I would love to see some precautionary support for immune modulation in those who had contacts with Ebola patients. And there is certainly room for alternative medicine alongside vaccine trials. Paul Herscu, ND, MPH writes about it here: http://www.paulherscuepidemics.blogspot.com/2014/10/ebolavirus-2014-outbreak.html

  • Judy

    Thanks so much for this post Mary. I am new to this site, but I am so glad to read such logic and honesty about the situation. I am not in healthcare, but have also been thinking that they have to shut down the flights, to slow the spread. Bringing back known infected people for treatment seems madness, but allowing a free access to flights anywhere, is just suicidal.
    I agree that it seems too late to stop the spread now. It was when they tried to quarantine West Point, a shanty town of more than 50,000 people, after they raided a medical centre and carried away patients and contaminated bedding, that I felt it was too late. It was never going to work, as the healthy people would try to escape once they saw their neighbours dying.
    Our best shot now, is to slow the spread of Ebola, so that surrounding countries have time to prepare and there is more time to develop a vaccine. I would feel much better if you were in charge of the decisions, because you seem to be thinking along the same lines.
    I was carrying out an energy survey in a Hospital yesterday and I kept thinking about the surfaces that I touched, and hands that I shook, and how hard it is to avoid the spread of disease. I really tried hard to stop myself touching my face, but failed miserably. I even held my pen in my mouth whilst juggling paperwork – to a look of disgust from the hospital manager accompanying me. And even after that I still caught myself doing it again!!! It is all reflex, and must take enormous effort to stop doing it. So thanks for the advice and reading material in the comments. Once Ebola has reached our shores, I am not expecting to be able to avoid it, but it would be nice to be prepared for looking after my loved ones as best as I can, before, during and after.

    • Hi, Judy, welcome. Pen in mouth–been there, done that. We’re pretty lax about where we eat in the unit, too. That’ll have to change. It takes time to form habits, and there’s no time like the present. Energy surveys–good luck with that. I’m afraid that we may have to convert entire hospitals into Ebola treatment units, because of the lax infection control, one by one. Starting with Texas Presbyterian. Clean up your act or lose your profit center. Maybe that will be a motivator for the executives. Dead people don’t pay their bills :}

      • Judy

        Thanks Mary. I am in the UK, so Energy surveys are required by EU regulations for most public buildings. I like it because I often get a behind the scenes view. I did ask while I was there if any preparations were underway to deal with Ebola. They said none. I wonder when someone will decide it is serious enough to roll out additional training and increase available beds? Probably not until it is serious enough to stop flights from affected countries, which won’t be until we have multiple cases in the UK. By which time it is too late! Maybe people are sitting up and taking notice now after nurses in US have been affected.
        Profit is not a motivator here as healthcare is free for all, although the conservatives have been busy privatising all the support services like cleaners, laundry, catering and maintenance. Don’t know how that will work out once Ebola hits.

        • The UK is way in front of the US on energy assessments and equitable healthcare systems. The Barry book on the Great Influenza described the same behavior in 1918 that you are describing in the UK and we are seeing with the CDC and our president: governmental and community propaganda downplays the situation as groups try to avoid panic or economic loss, there is slow or inadequate quarantine and intervention by countries, and government propaganda does not match visible reality, causing panic and lack of commitment to public health efforts, aid, and quarantine efforts.

          http://prosperouswaydown.com/barry-great-influenza/

          Privatized support services. When I did my hand hygiene research about 10 years ago, I was shocked to find that the hospital used contract housekeeping. I had no idea, as a staff nurse. So when we tried to design a multi-modal behavioral intervention to change handwashing behaviors (as Pittet suggests is needed), we couldn’t reach housekeepers. They don’t attend inservices put on by the hospital, they are only indirectly managed by the hospital, no one really knows who they are, etc. We’re screwed.

  • AlaskaEcoEscape

    Hey Mary! Nice and scary! I’m looking at the same kinds of stuff even just going into Anchorage! 🙂 Unfortunately I read THE HOT ZONE many years ago and that’s a scary book! Here’s a doctor who’s scared. Have you seen this? http://www.cnn.com/video/data/2.0/video/us/2014/10/05/nr-intv-dr-mobley-hazmat-suit-at-airport-ebola.cnn.html

    • Hi, CK! Good to hear from you! No I had not seen it, thanks for posting the link. He is right on, the CDC is dissembling because we’re headed for a slow motion train wreck. The CDC is going to get nurses, who tend to be caring and dutiful, infected unless they start refusing unsafe assignments. Mobley is right about the chaos caused by a single patient in Dallas. One Ebola patient infected many nurses (2 and counting, there are strong rumors of more) and we haven’t heard about Duncan’s family members. They dropped off the radar. In a high-transformity high-hierarchy system such as a city or a high-tech hospital, specialization creates many hands that touch patients and their body fluids. The article below describes very aptly how a complex urban setting could perhaps create a higher R0 (number of cases patient zero spreads to). We should see in the next few days. How many–R6? More? We’ll see. Cities and hospitals–perhaps a hindrance in this case.

      “Containing the Ebola virus in a major U.S. city requires more than just a trained hospital staff and good equipment. It takes a long list of people and companies, from clean-up firms willing to haul away Ebola-infected waste to landlords ready to house potential carriers of the virus to social workers who could ease the stress of an outbreak, from many corners of a community. “Literally hundreds of people somehow touched this to make it happen,” Dallas Mayor Mike Rawlings said. “Every time you turn around, you find another expert you need. It literally is a village making this process happen.”

      http://www.usatoday.com/story/news/nation/2014/10/14/ebola-dallas-response-community/17258995/

      Mobley is right. We have too much complexity in our system to deal with this. I am very angry with the CDC, which appears to have sold nurses down the river to maintain appearances of control. I hope nurses take the initiative to protect themselves, which, if this continues in this vein, might mean walking off the job for some hospitals with hardened bureaucracies.

  • fordhammsw1

    One thing I have seen mentioned only once is the definition of “direct contact”. The term seems to be used to mean direct contact with bodily fluids, and my guess is most people think of it that way. Imagine my surprise when I read the following from the New York Times:

    Ebola spreads through direct contact with body fluids.
    If an infected person’s blood or vomit gets in another person’s eyes,
    nose or mouth, the virus may be transmitted. Although Ebola does not
    cause respiratory problems, a cough from a sick person could infect
    someone who has been sprayed with saliva. Because of that, being within
    three feet of a patient for a prolonged time without protective clothing
    is considered to be direct contact.
    Specialists at Emory University
    Medical Center in Atlanta have also found that the virus is present on a patient’s skin after symptoms develop, underlining how contagious the disease is once symptoms set in.
    http://www.nytimes.com/interactive/2014/07/31/world/africa/ebola-virus-outbreak-qa.html

    If true, this definition is one that needs to be shouted from the rooftops.

    • Yes, you are correct. I posted the ECDC’s definition a month ago, in this article on Ebola as a gamechanger. Yes, you are right, this changes everything. It might as well be airborne. And that is why the CDC’s description of air travel as low-risk made me so mad. See the posts for links/citations.

      http://prosperouswaydown.com/ebola-game-changer/#more-7219

      “[This epidemic] also different because it is the first break-out of a truly novel disease during a time of common global air travel. The ECDC has recently defined high-risk exposure criterion for Ebola as “close face-to-face contact (e.g. within one metre) without proper personal PPE, including eye protection, with a probable or confirmed case who was coughing, vomiting, bleeding, or who had diarrhea.” That definition contradicts WHO claims that air travel is “low risk,” especially as the epidemic spreads. The difference between airborne and droplet precautions is a matter of distance, and there is no established science on what distance is safe. Some have proposed that a larger distance may be safer, of up to 9 meters, considering the lethality of the disease (more discussion in linked email). And if a HCW is working in a contaminated environment or going home to a crowded environment, hazmat suits may not do much good. There are many links in the chain of infection control, and with this disease, scrupulous attention to all details are necessary to prevent contagion. That level of control is very difficult in a complex, urban environment.

      Other public transportation such as buses, trains, and taxis where people sit within three feet of each other are also high risk as this epidemic grows. Cleaning standards in public places would change, as would food preparation and serving standards. Tourism, education, places of work–all aspects of the economy would be impacted as worried citizens created self-imposed quarantines. Behaviors in all areas of one’s life would change, and adequate PPEs would become a new form of currency. An Ebola pandemic would be a game-changer–one very small virus could tip our modern, frozen bureaucracies upside-down, mandating a new set of rules.”

  • Neal Ekengren

    Can I make YOU my CDC Director?
    You actually have reasonable analysis of the situation.
    I would actually have hope that the situation could be controlled.

    The crazy stuff I’m hearing from all the big cheeses just makes my head explode.
    It defies common sense.

    Seems to me that the only care model that works for this is home based care.
    Full quarantine on the household with signs posted outside.
    We show up at the door with ANYTHING you need for free but you don’t get out until we say so.

    • Sally Sellers RN

      Our demonstrated problem is that “we” don’t show up! Evidence….Duncan’s Louise left in Dallas apartment with family members and health dept order to remain put…..no one showed up with anything. Not food, not hygiene products, not school work for minor, nothing. It wasn’t until Anderson Cooper CNN started talking to Louise via phone and broadcasting that they had been abandoned that things started to move. Want more evidence of our community caring efforts? Try to have Meals on Wheels delivered to a shut-in/disabled/sick person….you’ll be put on a “list”. That’s why pizza delivery is so busy….delivering to households unable to secure food. Problems abound. Our support structures have been systematically subverted. Sally

      • Thanks, Neal. I think the CDC really believes that we have a superior healthcare system that can handle this. It is amazing what our world views can exclude when the facts don’t fit the structure, assumptions, or beliefs.

        I agree completely that we need to prepare for home-based care right off the bat. My guess, and it is only a guess, is that the spread of initial cases (before it goes exponential) in this country will be geographically wider and also faster than in low-resource countries, because of our mobility and far distant family only available through air travel, our urban work environments, the mandate to keep the economy humming along, the fact that it’s winter, and the high transformity that accelerates the number of contacts as things start to go wrong, because we are so specialized and complex. Hospitals max out or get contaminated very quickly, and we have to switch to home quarantine.

        Yes, I agree, Sally. We have nuclear families and limited community networks for caring and sharing. Who you gonna’ call?

        • Sally Sellers RN

          How fast the Neimen Marcus of Texas hospitals has fallen……only 1/3 of their beds are occupied…. and 50 some HWC furloughed to wait out there 21 days. They’ve hustled out Nurse Pham today….cutting their losses. They hired a world class crisis management/PR company. So one Ebola patient has brought down the mighty …..amazingly so. Yes…..stock up on chicken soup, bleach and plenty of sheets & towels….its going to be a long winter between the flu and Ebola….whether you’ve been quarantined or god forbid. In those famous words….”Good Night & Good Luck”. Sally

          • Frieden let the truth slip out by accident today, Sally, at the US House Hearings on Ebola.

            “Q. Why is she being transferred?

            [Frieden] A. Her condition has not deteriorated – we have a limited capacity of beds to do this high level of care. We have two beds at NIH.”

            http://www.flutrackers.com/forum/showthread.php?t=228923

            If Frieden admits that safe care of symptomatic EVD patients requires BSL-3 or 3.5 level protection to ensure safety of healthcare workers, then he has just excluded the gear and currently available care in about 4,996 of the 5000 or so hospitals in this country. See picture below of CDC Frieden in MSF BSL-3 or so in visit to West Africa in August. BSL-4, which is what CDC uses for lab work with Ebola in very controlled and very clean settings, is simply impossible in quantity in our healthcare system (pumped in air, 7 minute decontamination showers, true moonsuits). See the link below for full descriptions of BSL 2, 3, and 4.

            So we’d better shoot for the MSF version, which is BSL 3.5 (all skin covered, careful degowning with decontamination). Or maybe we should call it BS-Best Suit, as the best we can come up with on hand. Nurses in Dallas were wearing BSL-2, basically, until the very end of Patient Zero’s care, with paper gowns, skin exposed here and there, wearing spattered scrubs and shoes home to family. That is unsafe and unacceptable, especially in highly contaminated settings such as Ebola patients in ICU. Will the new universal precautions become BSL-2 this winter, as flu and EVD emerge together in our waiting rooms?

            http://www.cdc.gov/training/quicklearns/biosafety/

  • From Francesconi et al., 2003 Emerg Infect Dis. Nov 2003; 9(11): 1430–1437. doi: 10.3201/eid0911.030339, available in full at the link. Although this may have been a different strain from the Zaire strain (not sure from article) it is a good start (n = 83) in understanding where we are over-reacting, and where we are under-reacting. The bottom line-we’ve got to protect the caregivers to prevent spread.

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3035551/

    Risk Factors
    Because of their particular exposures, infants 30 years vs. ≤30 years: PPR = 1.38, 95% CI 0.64 to 2.97) nor sex (women vs. men: PPR = 1.54, 95% CI 0.66 to 3.60) was significantly associated with the disease (Table 2).

    Contact with body fluids showed a strong association (PPR = 5.30, 95% CI 2.14 to 13.14). Persons who had had direct physical contact with a sick person were more likely to have acquired the disease (PPR = 3.53, 95% CI 0.52 to 24.11), as were those who had touched the body of the deceased person (PPR = 1.95, 95% CI 0.91 to 4.17), although these associations were not statistically significant.

    Regarding indirect transmission, sleeping on the same mat (PPR = 2.78, 95% CI 1.15 to 6.70), participating in the ritual handwashing during the funeral ceremony (PPR = 2.25, 95% CI 1.08 to 4.72), and sharing a communal meal during the funeral ceremony (PPR = 2.84, 95% CI 1.35 to 5.98) were significantly associated with disease. Although the differences were not statistically significant, sharing meals, washing clothes, and sleeping in the same hut were associated with a higher risk of acquiring the disease.

    In general, having taken care of a sick person represented a strong risk factor, although the level of risk was lower for persons who had provided care only at the early stage of the disease (PPR = 6.00, 95% CI 1.33 to 27.10), followed by the risk for those who provided care until the index patient’s death, either at the hospital (PPR = 8.57, 95% CI 1.95 to 37.66) or at home (PPR = 13.33, 95% CI 3.20 to 55.59) (Table 3).

    The risk tended to increase with the increasing number of different types of direct contact (chi square for trend p<0.001); the risk was higher among persons who were exposed through two (PPR = 1.94, 95% CI 0.30 to 12.94) or three different types of direct contact (PPR = 4.00, 95% CI 0.64 to 25.02), compared with the risk for those who had no direct contact (Table 3).

    Factors related to direct and indirect transmission were analyzed separately in multivariate analyses (Table 4). The first model (i.e., factors related to direct transmission) showed that having had contact only with body fluids (adjusted PPR = 4.61, 95% CI 1.73 to 12.29) was strongly associated with the disease, whereas having only touched the patient during illness was not (adjusted PPR = 1.56, 95% CI 0.19 to 13.04). (The weak association found in the univariate analysis was probably confounded by contact with the patient’s body fluids.) Having touched the body of the deceased person (adjusted PPR = 1.84, 95% CI 0.95 to 3.55) showed a borderline significant association.

    The second model (i.e., factors related to indirect transmission and controlled for the potential confounding effect attributed to the number of different types of direct contact) showed that sleeping in the same hut (adjusted PPR = 2.34, 95% CI 1.13 to 4.84) and sleeping on the same mat (adjusted PPR = 2.93, 95% CI 1.16 to 7.38) were independent risk factors. However, weak associations were found for sharing meals with a sick person and participating in the communal meal during the funeral, whereas the ritual handwashing during the funeral and washing the sick person’s clothes were not risk factors.

    Discussion

    Although the number of EHF epidemics in sub-Saharan Africa has been increasing and EHF viruses have recently been classified as agents that could be used as possible biological weapons (16), epidemiologic data on the modalities of transmission are still limited (6) because of the sporadic and sudden nature of outbreaks. In the Ugandan outbreak, the hospital isolation wards have been important in managing cases. This fact was demonstrated by the finding that the patients with onset of symptoms after the institution of these wards on October 10 were the only ones who did not generate contacts, with the exception of an infant born on September 28, who had onset of symptoms on October 5 and died on October 9. Moreover, the higher death rate observed among primary and secondary case-patients (100%), in contrast with that among the most recent case-patients (70.6%), could be explained by the treatment provided in the hospital, though this treatment was mainly supportive.

    The reconstruction of the chains of transmission was straightforward for three generations of case-patients, which suggests that person-to-person transmission occurred. Nevertheless, the source of infection of the primary patients remained unknown, although transmission was occurring in the community. As described in the Figure, most of the links in the chain of transmission were deceased; for this reason, most interviews were administered to proxies. Thus, the possibility that a nonhuman natural reservoir may have been involved could not be excluded.

    Among the postprimary case-patients, the most important risk factor was direct repeated contact with a sick person’s body fluids, as occurs during the provision of care. As expected, the risk was higher when the exposure took place during the late stage of the disease at home. The risk was reduced when the patient stayed in a hospitals, probably because of the use of gloves, even before strict barrier nursing was implemented (6,7).

    By contrast, simple physical contact with a sick person appears to be neither necessary nor sufficient for contracting EHF. In fact, one person in whom the disease developed was probably infected by contact with heavily contaminated fomites (patient 7), and many persons who had had a simple physical contact with a sick person did not become infected.

    Transmission through contaminated fomites is apparently possible. In fact, the association found for having slept on the same mat or having shared meals with a sick person or with funeral participants remained after controlling for direct contact. However, having washed the clothes of a sick person and having participated in the ritual handwashing during the funeral ceremony were not significant risk factors.

    Finally, although we cannot exclude the possibility of airborne transmission, this mode probably plays a minor role, if any. In fact, the association between having slept in the same hut and acquiring the disease was weak and could have been produced by some unidentified confounding variables. Furthermore, the reported Ebola virus aerosol transmission among nonhuman primates (17,18) has been demonstrated in laboratory experiments, which may be irrelevant in the natural context.

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  • Cody Carr

    The situation increasing here we are at Ebola seems to be near to its incubation time, about 21 days. With modern situation fill, we have about 27 doublings to achieve over 7,000,000,000. That’s about 18 several weeks.

    Fourneau Bruleur de Graisse