We now seem to be getting a clearer idea of the breakdown of procedures at the Dallas hospital where one Ebola victim died and two infections of hospital staff took place. A nurses’ union – which doesn’t represent the Dallas nurses but was enlisted to speak on their behalf – released a statement today detailing a mix of sloppiness, uncertain and evolving practical and lack of proper equipment in the first days of Thomas Eric Duncan’s stay at the hospital. But the more striking news – found in medical records obtained by the AP – is that there was apparently a critical two and one half days after Duncan was admitted to the hospital with a suspected case of Ebola but before his definitive diagnosis when hospital workers continued to operate without hazardous materials protective gear.
This news has been conveyed a few different ways.
According to a summary of the AP news in the Dallas Morning News …
Duncan was suspected of having Ebola when he was admitted to a hospital isolation unit Sept. 28, and he developed projectile vomiting and explosive diarrhea later that day, according to medical records his family turned over to The Associated Press.
But workers at Texas Health Presbyterian Hospital Dallas did not abandon their gowns and scrubs for hazmat suits until tests came back positive for Ebola about 2 p.m. on Sept. 30, according to details of the records released by AP.
The AP story itself puts it slightly differently …
The CDC’s investigation suggests that health care workers were at highest risk from Sept. 28 to Sept. 30, the three days before Duncan was diagnosed. Both nurses who contracted Ebola worked on those days and had extensive contact with him when he had vomiting and diarrhea, Frieden said.
Medical records indicate that the workers wore protective equipment, including gowns, gloves and face shields during that time. The first mention in the records that they wore hazmat suits was on Sept. 30.
I’m limited in this case by my lack of precise knowledge of standard hospital procedure. The emphasis in the two descriptions is different. The DMN makes it sound like they didn’t change anything until the definitive diagnosis was established. The AP account makes it sound like they took precautions but not the full hazmat gear and evidently not the precautions they decided were necessary once they were certain they were dealing with an Ebola patient.
From my limited experience of these things gowns, glove and face shields sounds like standard protection when you’re dealing with anyone who might have an infectious disease. For that matter, my dentist uses gloves and a face shield and as far as we know I don’t have any infectious diseases. It’s just standard procedure because there might be bleeding.
On the other hand, it is not clear to me that the current CDC guidelines for handling patients with Ebola require the use of hazmat suits in all cases. (See these guidelines here.) At least they do not appear to in all cases. And many different kinds of protective gear fall under this general category. I’d appreciate any information from our clinician readers on this point because it seems very important for evaluating how the hospital addressed the situation.
Apart from what procedures this hospital used, all the press reports I have seen have a significant lack of specificity about ‘normal precautions’ vs ‘donning hazardous materials suits’ when I believe there are a lot of very significant gradations between those two extremes. This isn’t terribly surprising since they are mass readership news outlets that are going to write in laymen’s rather than scientifically precise terms. At the same time, I’m not sure the CDC’s recommended protocols were as strict as some of us might now be assuming they were or should have been. Put those two factors together and you have a significant fuzziness to the picture we’re getting that makes it impossible, based on these press reports, to answer these questions with the precision we would like. For now that’s just a caveat we should bear in mind through all of this.
Meanwhile, here’s a passage from the AP article describing the conference call by nurses at the hospital complaining about the conditions in which they’d been forced to work …
Deborah Burger of National Nurses United, who convened a conference call with reporters to relay what she said were concerns of nurses at the hospital, said they were forced to use medical tape to secure openings in their flimsy garments and worried that their necks and heads were exposed as they cared for Duncan.
The nurses allege that his lab samples were allowed to travel through the hospital’s pneumatic tubes, possibly risking contaminating of the specimen-delivery system. They also said that hazardous waste was allowed to pile up to the ceiling.
The nurses’ statement said they had to “interact with Mr. Duncan with whatever protective equipment was available,” even as he produced “a lot of contagious fluids.” Duncan’s medical records underscore that concern. They also say nurses treating Duncan were also caring for other patients in the hospital and that, in the face of constantly shifting guidelines, they were allowed to follow whichever ones they chose.
When Ebola was suspected but unconfirmed, a doctor wrote that use of disposable shoe covers should also be considered. At that point, by all protocols, shoe covers should have been mandatory to prevent anyone from tracking contagious body fluids around the hospital.
A few days later, however, entries in the hospital charts suggest that protection was improving.
There’s a lot of tendency right now to hyperventilate and claim people were idiots when we were not there as events unfolded and don’t actually know all the details of what happened. But it is difficult to understand why fifty or sixty hours would have gone by when they were operating on the presumption Duncan had Ebola without taking more aggressive protective measures. This is not a case where they didn’t realize yet that he might have Ebola. They already assumed he did and had moved him to a quarantined environment.
The nurses’ account to this very non-expert ear sounds pretty awful. And it’s consistent with the records’ account which has the protective procedures waiting until the 30th when Duncan’s diagnosis was confirmed.
We have many clinicians and epidemiologists among our readers. So I’d be interested to hear any informed takes on what we should make of this news.