Among reams of coverage on the ebola outbreak, Politico just published a characteristic story with the headline, “In the world of ebola, no room for error.” The only problem is that is as soon as you introduce a human element to any system, there will be error.
That’s the reality that healthcare leaders across the United States are grappling with now in a simultaneous effort both to tighten the healthcare system’s ability to safely identify ebola patients and not say anything that would lead to widespread panic.
The CDC, political leaders, and even hospital administrators are in a tough but familiar rock and a hard place: warn people too much and you could blow the crisis far out of proportion; but if you don’t do enough to prepare you risk letting that one patient with ebola slip through the cracks, as happened in Dallas.
There is a lot to be learned from the appearance of ebola in the United States: about the shortcomings of EMRs, the importance of communication in the ER, and the public resources available to combat infectious disease. But perhaps the essential lesson is this: while we can always do better, no system is infallible, and that includes the US healthcare system.
Imagine for a moment that you’re a physician in an emergency room at the time just before the first ever ebola patient in the US was diagnosed. Maybe you’re eight hours through a twelve-hour shift, your third overnight shift in a row. You’ve seen at least 25 patients this shift, and more than a dozen of them had fevers of some sort. You know all about the ebola outbreak in Africa, but there has never been one in the US so it is not the first thing that you think of when you see a patient with a fever. In this situation, it’s not hard to see how the healthcare providers at Texas Health Presbyterian Hospital missed the diagnosis the first time around.
In the real case, the patient told the nurse they’d just returned from travelling in Africa – but that information never got communicated to the physician who took over from there, leading many to blame the EMR, the electronic medical record software in use at the hospital. But the reality is that communication can often break down in between triage and the back room, and for a variety of reasons, some related to software, some not. Do I always read every note in the EMR about every patient that comes through the door? Do I record into the EMR absolutely every detail about a patient myself? The answer in both cases is probably not.
This is not to make excuses for anyone. It’s just to say that systems that involve humans will inevitably have breakdowns. There are a lot of people right now armchair quarterbacking what happened in Dallas, but in medicine it can be both beneficial and misleading to second-guess decision-making with the advantage of hindsight.
There’s no doubt that the ebola outbreak should give US hospitals and healthcare providers an opportunity to review their protocols for just this sort of highly lethal infectious disease. Providers on the front lines should be well-educated to identify potential ebola cases, and hospitals should have a specific protocol for immediately isolating and treating such patients.
Right now healthcare providers are getting advice and direction from all sides: from their hospital administration, from the CDC, from the news media, from their supervisors. The good news is that the American healthcare system has been here before (it’s not the exact same scenario, but swine flu, SARS, and the Anthrax scare come to mind), and we are certainly capable of dealing with the problem. Ebola is scary for patients because of how lethal it is. It’s scary for those who are trying to contain the disease because patients can be infected for weeks without symptoms showing, and then one day they can find themselves on a plane, contagious with a fever.
But now that we know what to look for (and what to look for is not complicated), there’s little excuse for not being able to contain ebola in the US. And yet we can’t set up a system in which there will never be a mistake. Particularly when a healthcare worker becomes infected, we study what happened and then find ways to improve the protocol. Perhaps we add a buddy system, or a new disinfectant. We advance medicine by learning from the past, not laying blame or stoking fears. It would be good to remember during this time of borderline hysteria to stick to the facts, train your people well, and communicate. Mistakes will be made, but we can handle it.