Saturday, October 18, 2014

Lessons From The Dallas Ebola Outbreak

The Dallas Ebola Outbreak has not yet run its course. Others may be infected, or it may be over – for now. The key to defeating the spread of Ebola in America is Planning. General Eisenhower is famously quoted as saying before the D Day Invasion: “Planning is Everything; the Plan is nothing.” He recognized that even the best-prepared plan will not withstand the fog of war. CDC has proven that with the failure of its Ebola Protocols. It possessed a false sense of confidence. The keys to emergency planning are: 1) The plan 2) Training 3) Testing the plan with exercises 4) Heeding the lessons learned from the exercises Plans should be site or incident specific without boilerplate. The plans should be communicated to those who will need to implement them. The keys to fighting Ebola are 1) Diagnosis 2) Treatment and Containment 3) Disposal of potentially contaminated materials. CDC, Dr. Frieden, and the Texas Health Presbyterian Hospital in Dallas failed these tests. The first mistake was failing to understand that no human activity is risk free. Humans, even the best trained experts and professionals, make mistakes. Dr. Frieden and the CDC assumed that by circulating a protocol to hospitals the medical providers would immediately and properly implement it. The heretofore highly respected Dallas hospital proved that is not the case. Nurses from around the country attest that many hospitals fail to meet the preparedness standards. Many do not even possess the proper protective attire. Presbyterian Hospital acknowledged it received the protocols, but did not train the staff. Training and exercises serve two purposes. First, they identify weaknesses in the plan (protocol). Second, training with repeated exercises allows the staff to quickly react, almost by instinct, when the patient arrives. They do not have to “wing it,” unlike the Presbyterian nurses. Responding to Ebola is unlike any other contagious disease, even SARS or MERS. A learning curve exists. Dr. Frieden, Director of the CDC, arrogantly assumed that the protocols would be expertly followed in the field. The agency did not follow up over the past decade to ensure training, testing, and exercises were implemented. A major problem with the CDC protocol is the basic assumptions that go into the initial diagnosis of Ebola. The incubation period is not 21 days, but can range from 2-21 days and by one report extend to 42 days. Second, individuals, as with most diseases, may experience different symptoms. A fever of 100.4 may not be the initial symptom. Fatigue may be. Nor may the disease progress uniformly for all victims. The temperature marker can be defeated by aspirin, Tylenol or Advil. Questions at airports can be thwarted by lies. Isolation of the patient is possible, but containment to the initial victim is difficult, as shown by the two nurses contracting the disease in the hospital. Monitoring the hundreds, thousands, or tens of thousands of possible contacts in the jet age will be imperfect. We have problems with the use of the word “monitoring” by the CDC. It apparently included self-monitoring on the honor system. Self-monitoring failed with at least two contacts, one developing Ebola, on airplanes and cruise ships. It may be, as with contagion in the past, especially smallpox, that a strict quarantine regime may be necessary to stop the spread of Ebola. Thomas Eric Duncan’s family stayed in the contaminated apartment for days after he was admitted into the hospital because the authorities could not obtain the proper disposal methods, materials, contractor, or permits. The CDC guidelines and the local standards varied. These contingencies must be prepared in advance. Someone must be in overall command of the incident, an “incident command leader.” President Obama has appointed Ron Klain to be in overall control of the Ebola fight. Time will tell if he is the proper person. There must also be one person, a credible source, to be the media contact. Dr. Tom Frieden was not up to the task. It’s best to be upfront with the situation. If not, social media and the internet will quickly destroy the credibility of the spokesperson. The current Ebola outbreak proves another adage: Failing to plan is planning to failure. Texas Health Presbyterian Hospital failed to plan. CDC failed to properly plan. The result is a public health crisis and perhaps tragedy.

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