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Questions Rise on Preparations at Hospitals to Deal With Ebola
Federal health officials have offered repeated assurances that most American hospitals can safely treat Ebola, but Emory University Hospital in Atlanta, which had years of preparation for just such a crisis, found out how hard that is while it cared for three Ebola patients.
As doctors and nurses there worked to keep desperately ill patients alive in August, the county threatened to disconnect Emory from sewer lines if Ebola wastes went down the drain. The company that hauled medical trash to the incinerator refused to take anything used on an Ebola patient unless it was sterilized first. Couriers would not drive the patients' blood samples a few blocks away for testing at the Centers for Disease Control and Prevention. And pizza places would not deliver to staff members in any part of the hospital.
"It doesn't matter how much you plan," Dr. Bruce Ribner, an infectious disease specialist who directed the patients' care, said in an interview. "You're going to be wrong half the time."
Emory solved its problems, but the challenges it faced could overwhelm a hospital with fewer resources. At Texas Health Presbyterian Hospital in Dallas, mistakes in treating a patient from Liberia -- a delay in diagnosing the disease, and its spread to a health worker who had apparently taken all precautions -- have raised questions about the general level of preparedness in hospitals around the country. Medical experts have begun to suggest that it might be better to transfer patients to designated centers with special expertise in treating Ebola.
Federal health officials are also beginning to consider that idea, though they emphasize that every hospital has to be able to diagnose the disease.
During a news conference this month, Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, said: "Essentially, any hospital in the country can safely take care of Ebola. You need a private room with a private bathroom, and rigorous, meticulous training and materials to make sure that care is done safely so caregivers aren't at risk."
But on Sunday, after it was confirmed that a nurse in Dallas had been infected with Ebola, Dr. Frieden said his agency would consider whether patients should be transferred to specialty centers.
"We're looking at different options for what will be the safest way to care for patients," he said in an interview on Monday. But he declined to explain what those options were.
There are four biocontainment units around the country that have been equipped to isolate patients with dangerous infectious diseases: at Emory; the National Institutes of Health in Bethesda, Md.; Nebraska Medical Center in Omaha; and St. Patrick Hospital in Missoula, Mont. But other large hospitals around the country could also handle Ebola patients, Dr. Ribner said.
"I think the larger regional hospitals are where the care of these patients is going to have to be focused," Dr. Ribner said, adding that there is a long tradition in medicine of transferring critically ill patients from smaller hospitals to larger ones better equipped to care for them.
One reason for referring Ebola patients is that they are so ill.
"Usually, an individual is not sick for three to five days after the onset of symptoms, which will fool you," Dr. Ribner said. "You say, 'Oh, you're not going to be that sick.' Then, around Day 5 to 7, they really crash. Their blood pressure goes down, they become stuporous to unresponsive, and they start to have renal and liver failure. This correlates with the enormous viral load, which is just attacking every organ in the body."
Ebola patients lose enormous amounts of fluid from diarrhea and vomiting, as much as five to 10 quarts a day during the worst phase of the illness, which lasts about a week. Doctors struggle to rehydrate them, replace lost electrolytes and treat bleeding problems. Some patients need dialysis and ventilators.
A concern for health workers is that as patients grow sicker, the levels of virus in their blood rise and they become more and more contagious. The researchers at Emory tested patients and found high levels of the virus in their body fluids and even on their skin.
At the peak of illness, an Ebola patient can have 10 billion viral particles in one-fifth of a teaspoon of blood. That compares with 50,000 to 100,000 particles in an untreated H.I.V. patient, and five million to 20 million in someone with untreated hepatitis C.
"That helped us to understand why, if this is only spread by body fluids, why it is more contagious than hepatitis A, B and C, and H.I.V.," Dr. Ribner said. "It's just that there's so much more virus in the fluids they put out."
The high risk of infection means that health workers need extensive training on using protective gear and on removing contaminated garments without infecting themselves. Emory follows a rigid procedure that requires everyone "donning and doffing" gear to be watched to ensure that no mistakes are made.
"You can't just assume that if one of these patients shows up you can sort of wing it," Dr. Ribner said. "You have to pay attention to your training and planning before the first patient shows up."
Stephen S. Morse, a professor of epidemiology at Columbia University's Mailman School of Public Health, said, "I don't think every hospital has the facilities or the wherewithal, or for that matter the desire, to care for Ebola patients."
Dr. Morse said it would make sense to transfer patients to the hospitals with specialized isolation units, or to designate certain regional hospitals as Ebola centers. But, he added, "you obviously have to have a safe way of transporting them to a center."
Dr. William Schaffner, an expert on infectious disease at Vanderbilt University, said that a referral system for Ebola cases was worth discussing. He added that the subject came up repeatedly in conversations among doctors at a national meeting of infectious disease specialists last week.
An additional advantage of such a system, he said, is that specialized hospitals and academic medical centers have more experience than local ones in obtaining and using experimental treatments that might benefit Ebola patients.
Dr. Ribner said he expected to see more Ebola cases as the United States sent military personnel to West Africa.
"We are putting 3,000 to 4,000 Department of Defense personnel out in the field," he said. "In addition, we are putting 1,000 to 2,000 beds out there for patients, and that means many hundreds of additional health care workers there. I think it would be silly to think that some of them are not going to get infected, and if they get infected they are most likely coming back to the U.S., and some of them are going to work their way to Emory University Hospital."
[Source: By Denise Grady, The New York Times, 13Oct14]
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