Saturday, October 4, 2014

Do The Math

Exactly as predicted, now that the horse is some distance down the road, the government officials paid to prepare for emergencies, after being caught in their usual pants-around-their-ankles condition, are busily trying to find a lock for the barn door, and assuring all and sundry that "We've got this."

And also as I noted going back weeks and even years, no, they don't.

But still we get the unicorn-farted happygas from the Dutiful Minions:

At the White House Friday, federal officials sought to reassure the public that the nation’s health-care system was well-equipped to treat the virus and stop it from spreading.
“It’s very important to remind the American people that the United States has the most capable infrastructure and the best doctors in the world, bar none,” said Lisa Monaco, assistant to the president for homeland security and counterterrorism. “The United States is prepared to deal with this crisis.”
Okay, yes we do have the best infrastructure and the best doctors in the world, bar none.
But unless we know how high that bar is, that's like saying you have the world's largest unicorn. It sounds like a lot, but it's not as impressive if you find out it'll fit in your shirt pocket, is it?

So let's look at that infrastructure.
There are, in fact, a total of four medical isolation units in the entire United States, as we noted yesterday, that are capable of handling infected Ebola patients near endlessly.
Where are they, and what can they handle?
Emory University's Serious Communicable Disease Unit is in Atlanta, GA. That's where Brantly and Writebol were treated. It has three beds.
St. Patrick Hospital's ICU Isolation Unit is in Missoula MT. It has three beds.
The National Institute of Health's Special Clinical Studies Unit is in Bethesda MD. It has seven beds.
And the biggest, the Nebraska Medical Center's Biocontainment Unit is in Omaha NE. It has ten beds.
3+3+7+10=23 beds, coast to coast.

So, for the entire country, all 316,100,000+ of us, we're fully prepared to treat 23 Ebola patients at the same time. (For reference, that's how many Ebola patients Liberia had last April. It hasn't gone well.)

But the 316M-person question is, what happens when we have 24?

More happygas, anyone?

"But any major medical center could really take care of an Ebola patient," said William Schaffner, an expert on infectious diseases at Vanderbilt University's School of Medicine. 

Most ICUs have isolation rooms that are used for patients suspected to have tuberculosis, SARS, Middle East respiratory syndrome or another infectious disease. Schaffner said that not much would be different for an Ebola patient, though more stringent precautions might be taken to ensure that health care workers are following all protocols.

Why yes, gosh darn it, of course they can!
Just look at how well that worked at Texas Health Presbyterian, a top-tier 968-bed acute primary hospital in Dallas, and a regional healthcare keystone in that city.
They misdiagnosed their first patient.
Their computerized EMR doesn't dump the nurse's triage notes onto the doctor's page, so critical screening information was missed.
They exposed their hospital lab to specimens that weren't safe to handle, because they didn't know Thomas Duncan needed a BL4 response and specimen handling.
They exposed doctors, nurses, staff members, patients, and visitors to Ebola unknowningly.
They sent him back into the community to expose family, friends, EMS workers, and random strangers as well.
Which led to inappropriate hazmat cleaning at his home;
the potential exposure of four public schools to the disease, which has necessitated closing them for cleaning while parents keep their children home, some withdrawing them completely;
and on and on, with 18/100/50 (depending on which number is currently operant) people under self-imposed quarantine and monitoring.

And that was a good look at how it's going to go everywhere else, the first time "shit's getting real". It's called the Normalcy Bias. "We've never had an Ebola patient walk in the door, so we never will, and we won't assume otherwise." Because ABCNNBCBS haven't been hawking any news to the contrary for months, right?

There are other problems: as noted yesterday, once you start traipsing highly infectious patients, frequently vomiting and squirting Ebola-laced body fluids everywhere, the hospital is unavailable for any other use.
That's not even news, it's CDC standard policy!

But don't believe me, go to their Ebola Info Sheet:

Questions and Answers  

on Ebola


How do I protect myself against Ebola?

> Avoid hospitals where Ebola patients are being treated.
Hey, that's not fair, when we said "If you travel to areas affected by the Ebola outbreak, we didn't mean American areas! Stop quoting us exactly!"

Because things are different here, because Magic Beans, right?
Ebola behaves differently on American soil, in American hospitals, for American patients, than it does in Africa? Really??

So, you can either have an Ebola hospital, or a regular one. Personally I work at a hospital with +/- 10 negative airflow rooms, in the entire building. So that's how many Ebola patients we could care for, max. But 6 of those rooms are in the ER. Let me be more specific: 6 of those rooms are in the ER that sees 300-500 patients a day 24/7/365, 110,000+ patients a year, and of whom 99-and-change% of them go home alive. So we can care for them, or we can take in 6 Ebola patients, of whom 0-3 will likely survive. While all those other patients go somewhere else. Or nowhere else. And we can multiply that times every city that gets an Ebola patient, if we try to use existing facilities. Sorry, if my choice is the entire community, or a handful of individuals of whom 50-90% will certainly die anyways, "Best wishes with your Ebola, we have a bus waiting outside to take you to the treatment center in BFE."
Not even close to a tough call. And it's a choice we'll have to start making if ever the patients coming in overtop our ability to deal with them. And if you're in a one-hospital locale, that'll be the choice on Day One. I can't imagine the community that'll rather see everybody with a heart attack(stroke/asthma attack/diabetic emergency/car get the idea) die, just to save a few of the Ebola patients. Call me when the head of the CDC, or the local hospital CMO talks about that on the news, and they're ready for it.

But certainly, our medical people are up to the task.

"We have been training for this," Ribner said of preparations for the two American Ebola patients. These doctors know how to handle Ebola and will use an abundance of caution when working with an infected person.
Medical workers across the country have also been told to watch out for Ebola symptoms and question patients who have recently traveled to West Africa. They are trained to recognize Ebola cases and can quarantine them early, keeping others from coming into contact with an infected person's bodily fluids while the disease runs its course.
Let's be fair: CNN pulled that quote from Dr. Ribner, of Emory, totally and completely out of context when they tried to make him say all healthcare workers everywhere in the US are prepared, rather than just his team at their special unit. What he said was true; what CNN did, in trying to lie it into a general quote about the entire American healthcare system, is exactly the sort of bullshit editing and outright falsehood we're all up against every time we read a story on something without digging into it like a terrier with a rat. We shouldn't have to, and the press shouldn't lie, but they do, 24/7/365, and on this subject, frequently out of both sides of their mouth at the same time.

Back to the greater question, how are healthcare workers going to do with this, if they're forced to try to cobble a response to it out of facilities not designed for it, with staffs untrained for it, and without adequate equipment? (If any of you are reading this from Liberia or Guinea, stop me if you've heard this one...).

They're going to fall flat on their ass, and it's going to kill people. Duh.
Says who?
They have these protocols and policies in place , but they don’t actually make it down to the level where the nurse is providing that care,” said Deborah Burger, a registered nurse in California and co-president of National Nurses United, the largest nurses union in the country.
She cited a study that the union recently completed of nearly 700 registered nurses around the country, in which the vast majority said their hospital had not communicated any policy with them regarding the potential admission of Ebola patients. To the extent there had been training, the nurses said, it was largely conducted by computer and didn’t offer the chance to pose practical questions about how to provide such care. A third of the respondents said their facility lacked adequate supplies of protective gear.
So somewhere, they have a CYA binder for when the Joint Commission breezes in, to prove they have a policy, which apparently everyone will gather around to read when someone's at the front desk shitting their guts out.
Then they'll travel out to the back parking lot, break into the ISO shipping container where all those expensive supplies are locked up, and based on 15 minutes of mandatory pencil-whipped computer "training" they'll become instant experts equal to the folks at those four dedicated facilities, who drill on the same thing regularly, frequently, and intensely, and actually train other facilities and workers in foreign countries.

Sh'yeah, right. When monkeys fly outta my butt.

There will be a Level 1 Spaz-Ex, followed by a Chinese Fire Drill (my apologies to actual firefighting professionals in Beijing or Shanghai) to get into unfamiliar equipment and render care under conditions they seldom experience every day.

Some among the Grand Order of Internet Assclowns keep trying to portray this exercise as "just following standard precautions, but with a little more stuff".
Let's go to the tape::

“When we started putting them through the PPE (personal protective equipment) exercise, everyone was excited, trying to be first in line to try on the gear,” Hurley said. “But then they’d get it on and start moving around for 30 or 40 minutes and realize – this is kind of tough.”
Ebola clinic staff must wear full-body protective suits including complete face shields. Hurley said the hardest thing for her to get used to was the condensation that would fog over the mask, limiting her vision to the places where sweat had trickled down.
“You can’t touch your face,” Hurley said. “You can’t move your hands above your shoulders. You can’t sit down. And you stay in this for three or four hours at a time. It got to be all about the hydration.”
Hurley said clinicians used a buddy system to check that gear was worn properly, procedures were done carefully and no one was getting too tired to work competently.
“We got really good putting it on and taking it off,” she said of the clothing.

Hurley is the nursing supervisor at the Missoula ICU BL4 Isolation unit. She's got years in the ICU with normal isolation procedure, yet this is clearly not just another day at the office, for her, for the doctors, or anyone else.

What are we talking about?
A freaking hazmat suit. If you're a long-time medical or EMS professional, you may know the arcana of the difference between this:
and this:
For most people, especially if you see people walking towards you on the street, or in a hospital, it's of no practical matter or difference.

The bottom line is, none of those three are everyday wear in most US hospitals, anywhere, anytime. And the number of US healthcare workers who are experienced in working in them regularly is probably smaller than your high school graduating class, unless you were homeschooled.

Feel free to explore what getting ready to work involves. Compared to most hospitals currently, where starting your shift normally means only showing up and clocking in.

So, does your hospital currently have people ready to see patients who are suited up like this 24/7 right now?
I ask because there are currently over 100 instances, so far, of patients walking in the door to be evaluated as potential Ebola victims. And because the CDC sent out an Ebola Preparedness Checklist to every hospital in the country three weeks ago, well before Tom Duncan was even infected in Liberia.
It includes:
Review, implement, and frequently exercise the following
elements with first-contact personnel, clinical providers,
and ancillary staff:
Appropriate infectious disease procedures and

protocols, including PPE donning/removal,
Appropriate triage techniques and additional EVD

screening questions,

So since they know to do this, why haven't they done so?
Because when someone walks up to the first stop at the ER check-in desk, coughing blood and puking their guts out, it's too late at that point to begin the 20-minute suiting up process.
Do they have their tents set up outside to segregate possible Ebola victims from everyone else, and from each other, so the real ones don't infect the ones who are negative?
If they don't, now that it's here, and now that multiple potential cases are showing up, why don't they?

And if they aren't set up to screen such patients, segregate those patients for everyone's safety, and have appropriately prepared and equipped staff members to see, transport, and treat them, how in flaming F**k can anyone say "We can handle this."

We aren't ready for anything.




  1. Wow. That was exceedingly well written (and seemingly well researched, though I haven't vetted this info yet) and has completely freaked me out.

    Thanks. (gulp) I think.

  2. Is the CDC actually improving the, providing hazardous materials suits at more hospitals? Shouldn't we do what the English did...stop flights/passengers from Sierra Leone, Guinea and Liberia until we are more prepared, at least? Yes, it could hurt those countries' economies, but the U.S. needs to consider the health of its own citizens.

  3. TSA Agent at IAD Arrivals, "Step over here, sir. Let me take your temperature"... "Ok, you appear to be normal - no signs of Ebola yet, welcome to the U.S. of A., and do have fun at Disney World!"

    Ubiquitous airport sign: NO SMOKING, EVER, ANYWHERE!

  4. Time to open Ellis Island....for real.