Monday, October 6, 2014

Ebola in Texas: Who is to "Blame?"

One of the unfortunate consequences of our 24/7 cable news cycle as well as America's political polarization is that every negative event that takes place in society needs to have blame assigned to some person or organization. Sometimes the reactions to adverse news events seems to take the form of a political Rorschach Test, where an individual's reaction to the event demonstrates their underlying political views.

This was no more true recently than the unfortunate story of Thomas Eric Duncan, the man from Liberia who presented to a Dallas hospital with fever, chills, and joint pains. A nurse who saw the patient dutifully documented that the man had traveled from Liberia in the hospital's electronic health record (EHR). However, as is often the case, the physician did not see the nurse's note. The nurse failed to verbally communicate the travel history to the physician, and the physician who saw the patient did not ask about travel history. Thinking this was just a viral illness, the physician discharged the patient home. (An additional challenge with this story is that the facts keep changing. Later reports stated that the physician indeed knew about the patient's travel from Liberia. Either way, this does not change the basic premise of this posting.)

There were certainly things that were done wrong here by many people: The nurse did not verbally report the travel history to the physician. The physician did not read the nurse's note nor take a complete history from the patient. Those who implemented the EHR did not create a workflow that easily allowed the nurse's documentation to be seen by the physician. By the way, physicians not reading nurses' notes is a problem that long predates EHRs.

It would be unfortunate if the lessons learned from this episode are just figuring out who to blame, and then shaming them in the media. Our media, especially the cable news cycle that seems to thrive on pinpointing blame, with political ideologues of all stripes then chiming in with a shibboleth that indicates to which ideology they belong. And of course, the situation is not helped by the right-wing political echo chamber that seeks to tie everything-Obama to every possible adverse news event. It is fascinating to scroll through the readers' comments on various news sites and see how easily people make the "obvious" connections between this event and Obamacare, illegal immigration, the threat of terrorism, and so forth.

The reality is that although the US healthcare and public health systems are far from perfect, we do have the means to isolate and prevent the spread of Ebola. By the same token, we need to remember that the majority of people who walk into emergency departments with fever and joint pains do not have Ebola. In fact, we run the risk now of excessive testing and other resource use because of this one case.

A good outcome of this unfortunate episode would be our learning from it, and figuring out how to build systems of care, which include use of EHRs, that make sure front-line healthcare professionals do not miss cases like this while not interfering with the assessment of the overwhelming majority of routine cases of fever and joint pains that are from more common causes than Ebola. It might even be nice to have the means to prevent the spread of untruthful memes about cases like this, but I am not overly optimistic.

1 comment:

  1. As always, your thought provoking commentary is welcomed. However, Dr. Hersh, you did not mention the exposure to the virus that might have increased the risk of infection by the health care workers who initially saw and treated the patient. They were at increased risk in addition to all their personal contacts (at home, for example), as you know.