On Sept 30 I wrote a blog post about how CDC’s Director Frieden was wrong to claim that any US hospital could manage an Ebola patient. Circumstances sadly proved me right in the case of Dallas, Texas. Has that changed now that we have had more time to prepare?
After the death of Thomas Eric Duncan, every Ebola patient in the US was treated in one of 4 specialized US bio-containment ICU-level facilities, and survived. Then Dr. Spencer developed Ebola, and he was placed in NYC’s Bellevue Hospital, in an Ebola-designated isolation ward. As best we know, he has done well. Does this mean US hospitals have gotten up to speed on Ebola?
No. Most people are not aware that both Mr. Duncan and Dr. Spencer were treated in ICUs where they were the only patient. Everyone else was moved out. Bellevue had to transfer patients to another hospital to free up the many staff needed to care for him. Nurse Pham had 25 health care providers working on her alone, at NIH. The WSJ noted that building an appropriate isolation room, comparable to a hospital within a hospital, cost Bellevue $3-4 million dollars per patient room.
Last night, the Associated Press did an in-depth story about the Ebola preparedness of US hospitals. It echoed my concerns. Specifically:
- 75% of ER and Infectious Disease docs felt their facilities were not prepared for Ebola
- the average number of protective suits with powered air-purifying respirators (PAPRs) per hospital is ten
- Despite hundreds of millions of dollars spent on Ebola research, there are no countermeasures
- As of last week, there “were no [federal] emergency stockpiles of the waterproof gowns, surgical hoods, full face shields, boot covers or other gear that the CDC recommends for treating Ebola patients.”
- “Among isolation care doctors and nurses, 14 percent said they’d call in sick, and one in four critical care and emergency staff said the same. Among the isolation care staff, 17 percent said they wouldn’t work near Ebola patients; half of critical care and emergency staff said the same.
- Adalja, a member of the Public Health Committee of the Infectious Disease Society of America, called the survey findings troubling and contended they show that many medical staffers “are not confident in the infection control procedures at their hospital.'”
Both the AP story, and the head of Johns’ Hopkins Emergency Services, note the need for more bio-containment units, where patients can be safely treated without exposing healthcare workers or other patients to Ebola. But bio-containment units will be insufficient if the US has hundreds or thousands of Ebola patient, as the number of patients will exceed the entire country’s ability to safely and effectively provide them the very complex care that is needed to pull them through. Right now there are 19 bio-containment beds for the entire US.
Ebola causes a clinical illness characterized by cytokine storm, capillary leak syndrome, disseminated intravascular coagulation, and multiorgan failure. This is why some patients have needed dialysis and ventilation. Dr. Bruce Ribner, who cared for several Ebola patients at Emory, notes:
“The general dogma in our industry in July was that if patients got so ill that they required dialysis or ventilator support there was no purpose in doing those interventions because they would invariably die,” Ribner said.“I think we have changed the algorithm for how aggressive we can be in caring for patients with Ebola virus.”
Even with the best of care at US hospitals, patients with these syndromes have an approximately 50% survival rate. It is unlikely that the US healthcare system will be able to duplicate the current 89% survival rate, once the number of Ebola patients needing care increases. And the dogma could revert to one of not performing such aggressive measures, which place healthcare workers at the most risk, once case numbers rise.