How did the Dallas hospital misplace the Ebola patient’s travel history?
The blame game begins
US Ebola patient zero, Thomas Eric Duncan, recent arrival from Liberia, had to go to Texas Health Presbyterian Hospital twice to get admitted. On his first go-round, the hospital sent him home with antibiotics even though a nurse had obtained information that he’d been in Liberia, and despite the fact that his symptoms were consistent with the early signs of Ebola.
If Duncan had been admitted on that initial visit his diagnosis would still have been a big story and a distressing one, but nothing as awful as the situation we’re currently in. That being said, it’s been difficult to obtain much information about how the mistake happened.
Here’s the relevant section of the initial press conference with hospital official, Dr. Mark Lester:
(INAUDIBLE QUESTION)
LESTER: A checklist was in place for Ebola in this hospital for several weeks. And Dr. Ed Goodman (ph), to my right, had led the implementation of that. That checklist was utilized by the nurse who did ask that question. That nurse was part of a care team. And it was a complex care team taking care of him in the emergency department.
Regretfully, that information was not fully communicated throughout the full team. And as a result, the full import of that information wasn’t factored into the clinical decision-making. The overall clinical presentation was not yet typical for Ebola; so as the team assessed him, they felt clinically it was a low-grade common viral disease. That was the presentation.
(INAUDIBLE QUESTION)
LESTER: He volunteered that he had traveled from Africa in response to the nurse operating the checklist and asking that question.
(INAUDIBLE QUESTION)
LESTER: I can’t answer that question because that’s one piece of information that would be factored into the entire clinical picture. The clinicians did not factor it in. So it was not part of their decision-making.
(INAUDIBLE QUESTION)
LESTER: I — that’s a question that’s really not in my domain.
(INAUDIBLE QUESTION)
LESTER: We are carefully assessing that now. And that is being investigated. So we are investigating it. I can’t give you specific information. We will look very carefully at that.
QUESTION: Sir, would I – would I call that a misstep, would you not?
LESTER: I would call that not factoring all the information among the team that was present so that all the information wasn’t present as they made their clinical decision.
QUESTION: Was there any (ph) expressed any information that this person (INAUDIBLE).
LESTER: That information was not obtained when the patient was in the emergency room.
QUESTION: But do you know that now?
QUESTION: (INAUDIBLE QUESTION) you name is, sir?
LESTER: Oh, I’m Dr. Mark Lester…
We now have a more recent hospital statement that claims it was a software failure in the hospital’s electronic records system that was the culprit:
While the patient, Thomas Eric Duncan, told a nurse that he had been in Africa, that information wasn’t automatically included in electronic records seen by the doctor, according to a statement by Texas Health Presbyterian Hospital, where Duncan is being treated. The software is made by Epic Systems Corp., according to news releases and the hospital website.
“As designed, the travel history would not automatically appear in the physician’s standard work flow” within the electronic records system, the hospital said.
But travel history is such a basic part of an infectious disease workup that this is an extraordinary glitch, if true. And if no one was aware of a flaw so basic, our reliance on electronic records could end up being a big mistake, with software taking over from human judgment and sometimes missing the obvious.
And then we have some new information which, if true, would not seem to reflect well on the hospital. The story comes from Duncan’s nephew Joe Weeks (who also is saying that Duncan is now too weak to talk to the family on the phone) [emphasis mine]:
Weeks also had concerns that the hospital wasn’t aware that Duncan may have been infected with Ebola. Weeks said that he called the hospital to report his concerns about Duncan’s condition – and when he didn’t get the reaction he wanted, he called officials at the Centers for Disease Control and Prevention and the Department of Health, at which point Duncan was put in isolation.
“They had him in the ER, like any other patient, and I didn’t think that was the right procedure,” Weeks said.
“I don’t know how long it was going to take, but I wasn’t trying to wait to see how long it was going to take, so I pre-empted and called CDC and reported that there might be a possible Ebola case in Texas. But the hospital was not doing what it needed to do at that time,” he said.
If Weeks’ narrative is true, we can consider it fortunate that he had the presence of mind to inform the CDC. If not for his doing so, there might have been an even longer delay in Duncan’s diagnosis, and his contacts might not have been traced and isolated until more time had passed.
Of course, Weeks may be making self-serving statements that are untrue; we have no way of knowing at this point. It would be good if the CDC could weigh in on it and either deny or confirm his story.
[Neo-neocon is a writer with degrees in law and family therapy, who blogs at neo-neocon.]
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Comments
I’m a doctor. The doctor who saw the patient did not take the history of present illness himself. Blaming a glitch in the software is an attempt to switch culpability from an individual to the system
What an Obama Stunt!
I can never believe this was not done on purpose.
That’s my opinion and I’m sticking to it!
I had reached this conclusion, but I appreciate you confirming what I suspected. The treating physician was presented with a black patient, presumably with a foreign accent and Ebola symptoms, and he failed to ask the obvious question that I assumed would be part of his differential diagnosis.
Even if he had been admitted it wouldn’t change the fact that he exposed hundreds of people on his journey here and then exposed his girlfriend, baby, and other children in the home to a deadly disease. There is no hell hot enough for this man.
I have read elsewhere that the Ebola Medical Tourist knew he had been closely exposed to a person with an advanced case of Ebola and was concerned enough to quit his job to travel here but that he did not share this info with the ER staff on his first visit. He bears primary blame especially for putting that family and their inner city neighborhood at risk.
I would be loathe to blame the work staff for not having successfully connected the dots, particularly without knowing the case load of the doctors, nurses and administrators of that ER. ERs are designed as trauma and triage centers. Doctors working at an ER are not primary care physicians and they cannot be expected to, nor can they afford to, become closely connected to their transient patients.
So that is why the Dallas legal authorities want to bring legal charges to him.
The Dallas DA talking about bringing charges is just blowing smoke. The Liberians are charging him with lying at their airport and the feds probably could do the same.
Of course, this all depends on the guy living… in which case he will be an inspirational role model to all infected West Africans with relatives in this country.
But I will not blame the hospital staff who were using federally mandated software to electronically transfer information.
It’s not as neat and tidy a story as that. He supposedly quit on September 4, something like ten days before he encountered the Ebola patient. Supposedly he never told his wife he’d been exposed to someone who in high likelihood had Ebola, the pregnant woman who didn’t survive six hours after he helped her into a cab. Though, I don’t want to even say we know for sure he knew she died of Ebola. That’s where he should’ve strongly suspected, though. That exposure was far too close to when he flew on that plane for him to have been symptomatic yet, which makes the talk of the 25th to the 28th being when he went from ill and released by the ignorant hospital to violently ill and transported by ambulance Sunday the 28th sound actually realistic.
These data points seem confirmed, but there’s a lot of potential for lying witnesses as always. I’d have a real fun time as a detective I’m sure.
I call BS on the nephew Weeks’ narrative.
I went to the CDC site and the only 24/7 hotline is for immunizations. I haven’t called it, and the site said it there were other options……so I haven’t verified that 100%. Very VERY doubtful. Sounds like a “gimme some limelight” type.
If, indeed, this is the case, then he (if not the whole family) KNEW this guy had Ebola. Why weren’t they telling the doctors and ER triage staff that – all the while KNOWING they were exposing everyone present to this deadly illness?!?!
Sounds like, to me, the family (at least this guy) want to try to turn this around somehow and sue the hospital, regardless of whether Patient Zero Duncan (aka Ebola Medical Tourist) lives or dies.
And, may I say……calling a government agency to get people RIGHT IN FRONT OF YOU to do something……..not believable, IMHO.
Two questions I would have asked:
Did a doctor actually see Duncan or was he seen by a PA or NP with the actual ER doctor signing off?
Why was he prescribed antibiotics if they concluded he had a low level viral infection?
I’m sure the ERs in Dallas are clogged with non-paying minorities with the sniffles just like they are in every other American city. Who can blame the staff for giving this man the care that he paid for?
I blame EMTALA.
An update on the story:
Now the Dallas hospital is saying that there was no glitch with the electronic records, and that the doctor who saw Duncan on his first visit to the ER did in fact have access to the information that he had recently arrived from Africa.
The story keeps changing, and the plot thickens.
The hospital adds that “the patient, Thomas Eric Duncan, did not disclose important information,” and that he did not say that he’d been exposed to the disease, or “around anyone who had been ill” (it’s not clear whether they specifically asked about Ebola, or about illness in general). At the time he answered the question, however, it is quite likely, as I wrote here, that he thought the ill woman with whom he’d had contact back in Liberia had been suffering from either complications of advanced pregnancy or perhaps malaria rather than Ebola (you don’t catch malaria from a person suffering from it, except by blood transfusion or needle-sharing or that sort of thing).
But shouldn’t health professionals have been aware that Duncan, or anyone else for that matter, could have been exposed to Ebola and yet not have known it? People with Ebola can be contagious with only mild symptoms. In addition, oughtn’t Duncan’s disclosed travel history and symptoms have been enough for any hospital or doctor to have red-flagged him?
The take away for me is everyone involved have and has had “knowing knowledge” to the extent each person from the Liberian to the Dallas medical staff to CDC, for not divulging the information they possessed in order to protect their self interest at the sake of someone else losing their right to protect theirs. That in of itself is criminal.