How did the emergency department staff of a Texas hospital see, and discharge, a patient infected with Ebola? Despite the fact that blame spreads through hospitals faster than hemorrhagic fever viruses, I’m not interested in pinning down a single person, or a single thing, which may have allowed that to happen. I am very interested, however, in offering a few insights into what combination of factors might make it easy to send home a West African with a fever, without establishing the fact that he had a dangerous, contagious disease which finally caused his death.
First of all, America’s emergency departments are straining to keep up with the volume of patients that come through their doors. In 2010, the number of visits in the U.S. was 129.8 million, according to the CDC. This numbers rises every year, despite the belief that the Affordable Care Act would direct people to primary care doctors and away from the ER. The emergency departments of America bear the brunt of trauma, poisonings and drug abuse, of chronic diseases and social drama. They hold suicidal and psychotic patients for days to weeks when there is no other option available.
An Ebola victim, with general, initial symptoms of fever, chills, vomiting, diarrhea, abdominal pain and headache, is a small needle in a big hay pile of feverish, vomiting, suffering humanity. Furthermore, many people with insurance (including Medicaid and Medicare) can’t find doctors, and large numbers who had insurance before subsequently lost it in the reshuffling of health benefits that has been going on since the ACA was passed. The emergency department is often all they have. Second, it’s getting much, much harder to focus on that pesky but ubiquitous feature of the modern hospital, the patient.
There is data to enter (which keeps nurses and physicians more focused on screens than adolescent boys playing on their Xbox). The electronic medical records systems are unfortunately complex and rarely intuitive. They require so much information that often, relevant points like “fever and came from West Africa,” can be lost in the midst of endless time stamps, and required fields like “feels safe at home,” “denies suicidal thoughts” and “bed rails up, call light at bedside.” Also, there are rules to follow to avoid censure. There are metrics to measure: time to stroke treatment, time to the cardiac cath lab for heart attacks, time from lobby to room, time from triage to doctor, time to discharge and many more; all of them contributing to the Holy Grail of modern health care, the high patient satisfaction score. (Which is being increasingly tied to job security and reimbursement, despite the bad science involved in the process.)
Who has time to focus on a single, sick patient when so much depends on screens, rules and data entry? Third, the rules for admission are ever more complex, based on what Medicare, Medicaid and private insurers are willing to cover. Patients we admitted without question ten years ago are now sent home and told to “come back if you get worse.” In fact, it’s so hard to admit people that I now send home patients I would never have discharged, simply to avoid the misery of explaining the problem to already over-taxed hospitalists who are themselves constrained hand and foot by impossible rules. In this milieu, an otherwise healthy man with a fever is barely a blip. I know this because earlier this year I was working in a teaching hospital and called the infectious disease specialist on call. My patient had just returned from a mission trip to the Caribbean and had a high white blood cell count, a fever, chills and rash. I was curious if I should have any particular exotic concerns.
The specialist’s annoyed answer was this: “Sounds like he has a virus. He needs to see his family doctor this week.” Now that we have Ebola in the U.S. we are reminded that we in medicine, on the front lines, might miss something important. The medical pundits are wagging fingers and lecturing everyone about how best to manage this crisis. (Lecturing, that is, from the relative calm and safety of television studios, rather than the in the mind-numbing chaos of the ER.) I agree. We need a plan. But the system, as it stands, functions every day on the very razor’s edge of disaster. We need to address that fact if we’re going to have any hope of dealing with Ebola, or other disasters, in the future.