Twitter, of course has a lot to say about Ebola in Texas. Lots of schadenfreude. Some Snarking about Texas expanding Medicaid after all (which would be a good idea, but to do it only because of Ebala fears....Well, I'll take it.) Anyway. Lots of Twitter derision over the mistake that the nurse knew of the patient's travel to Liberia, but it wasn't communicated to the doctors.
That last one got me thinking. So far all the news coverage is that Ebola won't be a problem in the U.S. I agree, it shouldn't be a huge problem. That doesn't mean we won't see some cases of it, but I have confidence that our hospitals and public health departments are up to this challenge. A New York hospital suspected a case last February and within 7 minutes they fully implemented their infectious disease protocol. It was a false alarm, but the system worked. Conversely, it's looks like the people caring for the patient in Dallas didn't have Ebola on their radar, which based upon all the fear mongering about Ebola; that doesn't make sense. Even so, surely, they have a similar infectious disease protocol as a hospital anywhere. Ebola may be an unlikely diagnosis in the U.S. That said, there is a neighborhood within Texas Health Presbyterian hospital service area that is full of global immigrants including a lot of people from West Africa. We have similar neighborhoods like it in South Florida. Hospitals here are aware of these neighborhoods and plan to serve the people in these neighborhoods. How did Texas Health Presbyterian mess this up?
Ebola needs to land on the agenda of hospital staff meetings over the coming weeks reminding everyone about what the protocol is for something like Hep B, tuberculosis or Ebola. You may be wondering if they have a protocol. In short, yes, all hospitals must have an infectious disease protocol and no, they aren't preparing for a possible Ebola case because hospitals are supposed to always be prepared for a serious infectious disease case. Texas Health Presbyterian hospital did use an Ebola check list and it had red flag answers. They were supposed to go to a second level of a screening protocol, but we are to believe that didn't happen? With Ebola? No one entered it into the data base? No one told the doctor? They are saying a red flag survey got disregarded? Ignored? I call bullshit. HIPAA be damned. I know how gossip flies through a hospital and there's no way the concern trolls at the hospital weren't all over a story as good as Ebola. So, what went wrong in Dallas?
The details of the Dallas case are dripping out. The patient started feeling bad on Wednesday the 24th and went to the hospital on Friday. He not only wasn't tested, but because all he had was a low grade fever he was discharged. He told his nurse he came from Liberia on his first trip to the U.S. from Monrovia, Liberia to visit family in Dallas. Because the symptoms didn't exactly match a more advanced case of Ebola, ...like DALLAS HAS EXPERIENCE WITH EBOLA AND KNOWS?, he was LET GO? He wasn't advised to isolate himself? No follow up protocol? Somehow the doctors didn't comprehend what was happening? Come on! Srsly!?! If this story is true, and Texas Health Presbyterian cared enough to put an Ebola checklist in place, but didn't care enough to regard a positive result; this hospital has a serious culture and leadership problem.
The patient came back to the hospital 48 hours later via ambulance. Possibly because the family was screaming facts at them from the time they arrived to evaluate him, or maybe it was because he was staying in the "Ellis Island" of Dallas, it appears the EMT crew had an idea they needed an isolation unit. Or, maybe they clued in because, by then, the patient was vomiting "all over the place" and were able to connect the dots between Liberia and severe flu symptoms. They get there and the hospital staff still didn't think it was Ebola. Their behavior was cavalier enough that an associate of the patient called the CDC because they thought the hospital wasn't taking this seriously. That made me suspicious, you'd have to be seriously cut off from the world to not be able to connect the dots with early flu symptoms, Monrovia and Ebola. I said as much to a co-worker. She mused out loud if his insurance situation influenced the discharge. Man! I hadn't thought of that! Should've, but didn't.
If any journalist asks if the patient has insurance, they'll get a HIPAA response of "I can't say", but the story is coming out in dribs and drabs. Right now the hospital brass seems to think it's safest for the hospital to have people think the doctors made an error based on not getting good information. In today's age of the Electronic Health Record, I doubt if the record was that anemic. No doctor will admit to not reading the record, but I bet there is more than a fever in his chief complaint. The mysterious uncommunicated positive survey? It's on a piece of paper floating around ...somewhere? No one scanned it in? Typed it in? It got mistagged? what? I see in the coming days this man's friends and fiance talking about that doctor's visit last Friday and I won't be surprised if it doesn't come out the man sought treatment because he feared he had Ebola and wanted them to test him for it and he said so to everyone treating him. No this story is looking less credible by the hour.
Was this a possible EMTALA violation? Did they think his insurance wasn't going to pay? Did he admit to not having insurance? Travel insurance? I ...we know how this game is played. He was stable on Friday, so they could make the case for discharge and claim innocence, hope he goes elsewhere if he got sicker. I can only speculate, but I simply can't believe a doctor and nurse (even in Texas) wouldn't act in an abundance of caution when presented with a patient from the Ebola Zone with a fever and his claimed subjective complaints. Good grief, they had a patient come in from Monrovia, Liberia with vague symptoms, a slight temperature and they kicked him to the curb! That is either gross incompetence or worse.
I'm not buying this as a simple, but colossal screw up. There are undertones of the same old health care system screw ups we've been talking about around here for years. I think this patient had "bad" insurance or no insurance and so the hospital documented a record that could fly for justifying his discharge and if Texas expanded their Medicaid, maybe this diary would never been written. This hospital's accreditation authority and the OIG needs to come in and investigate for both EMTALA compliance and patient dumping. The city of Dallas has an interest in this too. They are incurring a lot of unnecessary costs because Texas Health Presbyterian didn't do their job.
It turns out there may a lot of exposure in Dallas, Texas. About 80 people are being monitored. We get to wait 6-9 weeks (2 cycles of the 21 day incubation period with no new cases) to see if they got this.
7:31 AM PT: Ok, I get the skepticism. Here are some questions I hope reporters get ask and get answered.
1. What was Mr. Duncan's insurance situation?
2. Did he see the physician by himself on Friday? Did he tell the doctor himself about coming from Liberia?
3. Has Texas Health Presbyterian had compliance issues within the last 5 years?