Some U.S. hospitals weigh withholding care to Ebola patients
October 24, 2014 6:46 AM   Subscribe

"The possibility of withholding care represents a departure from the 'do everything' philosophy in most American hospitals and a return to a view that held sway a century ago, when doctors were at greater risk of becoming infected by treating dying patients. 'This is another example of how this 21st century viral threat has pulled us back into the 19th century,' said medical historian Dr. Howard Markel of the University of Michigan.
posted by Jacqueline (156 comments total) 17 users marked this as a favorite
 
I thought this was an interesting ethical dilemma and would love to hear the opinions of the MetaFilter Brain Trust.
posted by Jacqueline at 6:47 AM on October 24, 2014


Their concern is that poorly trained or poorly equipped hospitals that perform invasive procedures will expose staff to bodily fluids of a patient when they are most infectious

Then the solution would be to invest money into training every hospital in this country on how to deal with infectious disease. (Full disclosure: New Yorker, my mom is a nurse and both my grandfathers were doctors.)
posted by roomthreeseventeen at 6:54 AM on October 24, 2014 [27 favorites]


From the US cases so far, it does seem like you really do have to be pretty ill before you're extremely contagious: Thomas Eric Duncan's nurses got infected, but his family members who had taken care of him with no protection and then were trapped in the apartment with his soiled bedding didn't.

So it seems like it would be reasonable to expect nearly any hospital to be able to handle ebola-stricken walk-ins (with appropriate protective gear and training provided to staff, not "uh, can't you guys just wear two masks or something and we'll blame you in the press if you catch it?") long enough to transfer them to a facility that's actually set up to take care of them.
posted by Blue Jello Elf at 7:00 AM on October 24, 2014 [3 favorites]


There is no reason Ebola should overwhelm the United States' developed, relatively well-funded healthcare system. Democratic Republic of the Congo and Uganda have successfully contained Ebola with a fraction of the resources.
posted by ChuraChura at 7:00 AM on October 24, 2014 [66 favorites]


r317 has it. Proper equipment and training for how to deal with Ebola isn't limited to being effective for one disease only.
posted by feckless fecal fear mongering at 7:01 AM on October 24, 2014 [13 favorites]


My MIL is a nurse too and she said her hospital has done nothing except establish a "task force." The nurses have received no training or other instructions. Several of the younger nurses with young children have already told their fellow nurses that they'll quit their jobs before they treat an ebola patient because of their obligation to their families outweighs their obligation to their patients.
posted by Jacqueline at 7:03 AM on October 24, 2014


Several of the younger nurses with young children have already told their fellow nurses that they'll quit their jobs before they treat an ebola patient because of their obligation to their families outweighs their obligation to their patients.

The problem is not treating these patients. It's not knowing that you are treating these patients, and therefore, not protecting yourself.
posted by roomthreeseventeen at 7:05 AM on October 24, 2014 [18 favorites]


Withholding care would be a great way to further spread the disease.

Having designated Ebola Centers (well-equipped, with well-trained staff) would be a much better approach.
posted by entropone at 7:06 AM on October 24, 2014 [15 favorites]


My wife is an ER nurse at a major urban hospital owned by the Hospital Corporation of America, the hospital chain once run by Rick Scott. ...

My wife’s ER has an ‘ebola cart’ with some lightweight protective gear and written instructions for putting on a PPE, but the instructions are a loose bundle of papers and the pictures don’t match the gear in the cart and has inaccuracies that put them at serious risk. It’s an object of gallows humor for the staff. That’s the totality of their training or preparedness so far.


TPM Reader JM on Rick Scott, hospital preparedness and the "Ebola cart"
posted by T.D. Strange at 7:06 AM on October 24, 2014 [10 favorites]


As ethics goes, withholding care would also fall under the umbrella of letting people die if they wish, or if brain dead.
posted by Brian B. at 7:07 AM on October 24, 2014


There should absolutely be training for any potential medical outbreak, but at the same time, it doesn't seem like the Western media is doing such a bang-up job of not inciting fear, hatred, and racism over Ebola. I've been avoiding a lot of social media regarding this because I just can't handle the ugliness this has brought out in people.
posted by Kitteh at 7:09 AM on October 24, 2014 [13 favorites]


Seems reasonable to me.

Even in those professions that are most noted for "putting their lives on the line" there are always practical value judgements made. If a fire is burning too hot, for example, a firefighting team will weigh the risk to their own lives against the prospect (or even the certainty) that some people remain alive within.

Likewise, in certain contexts where a person suspected of a crime is exhibiting behavior that suggests he might be reaching for a weapon and verbal warnings do not dissuade him from doing so, it is reasonable for a police officer to shoot first.

Hell, even in the military, an unambiguious act of martyrdom (such as throwing oneself atop a grenade) is met with almost equal parts admiration and bewilderment.

I don't think any job should require that of its practitioners.
posted by The Confessor at 7:09 AM on October 24, 2014 [7 favorites]


Withholding care would be a great way to further spread the disease.

If you read the article, you'll see that they're not talking about withholding ALL care, just refusing to do the procedures that put their staff at the greatest risk for coming into contact with infectious fluids -- e.g., CPR, dialysis, etc.

I don't think anyone is saying (yet) they'll turn patients away completely. But they might not do anything other than quarantine and clean until the CDC shows up to either take over or transport.
posted by Jacqueline at 7:09 AM on October 24, 2014 [2 favorites]


As ethics goes, withholding care would also fall under the umbrella of letting people die if they wish, or if brain dead.

Wow, what? I'm pretty sure that would fall under the exact opposite umbrella.
posted by roomthreeseventeen at 7:09 AM on October 24, 2014 [12 favorites]


As ethics goes, withholding care would also fall under the umbrella of letting people die if they wish, or if brain dead.

No it wouldn't, at all. In your first case that is care withheld by consent of the patient, in the second case they are already dead.

Ebola is treatable in some cases, and not enough is known yet about where that line stops.
posted by feckless fecal fear mongering at 7:09 AM on October 24, 2014 [9 favorites]


Withholding care when you don't have the procedures and equipment to handle a disease safely? I get that. If the equip is in place and the training has been given, I'm not seeing the out for people that want to not care for these patients.
posted by Slackermagee at 7:09 AM on October 24, 2014 [1 favorite]


As ethics goes, withholding care would also fall under the umbrella of letting people die if they wish, or if brain dead.

Those seem like very different things to me.

With witholding care, somebody's like "I'm sick please help" and people whose job it is to help say, "no."

With DNR, somebody's like, "this is enough. I'm just going to die" and people whose job it is to help people say, "Okay."

Pretty different, no?
posted by entropone at 7:10 AM on October 24, 2014 [5 favorites]


The flu season has come to the US early this year; it will likely kill many more thousands of people than the Ebola virus will.

That said, it does put doctors and nurses at risk to have them work directly with patients infected with Ebola, and doctors and nurses that are incapacitated or killed from getting infected cannot help other patients. The resulting multiplier effect can put more strain on healthcare system and be problematic for all manner of sick people.

Minimizing worker risk is rational and serves the greater good. Isolation of the infected is one way to minimize risk, as is providing adequate training and support to healthcare workers. Isolation should certainly be considered as one prong of a multitiered defense strategy.
posted by a lungful of dragon at 7:11 AM on October 24, 2014 [6 favorites]


Is this an exercise or a suggestion? As far as I know, pandemics planning always includes this scenario (or at least quarantine with limited support which is effectively the same.)
posted by Lesser Shrew at 7:11 AM on October 24, 2014 [1 favorite]


I'm not sure how this enters genuinely new territory from an ethical perspective, refusing to provide care to patients that puts others at risk is a standard and accepted position to take. If a hospital cannot safely provide certain procedures to a patient then it cannot provide them and must then weigh the benefits against the drawbacks of moving the patient to a facility that can provide them.

Pediatricians currently withhold care to unvaccinated children all the time to prevent the spread of epidemic disease in their waiting rooms.
posted by Blasdelb at 7:12 AM on October 24, 2014 [10 favorites]


Specifying PPE, training personnel in its use, and creating systems to usher contagious patients through a facility is a typical industrial operations task.The dirty little secret that makes US healthcare such an expensive clusterfuck is that hospitals are run by clinicians and clinicians just plain suck at industrial operations.
posted by klarck at 7:13 AM on October 24, 2014 [7 favorites]


There should be no special training or equipment, since this stuff should be standard. It applies to all infectious diseases.
posted by blue_beetle at 7:13 AM on October 24, 2014 [5 favorites]


Is there a reason why we simply can't fly patients into larger medical centers that have the resources to adequately treat them?

Like.... don't we already do this for many other (significantly less rare) conditions? To cherry-pick an example, there are surprisingly few Level 1 trauma centers in the US. As another example: A friend was recently diagnosed with HIV, and discovered that there wasn't a single specialist in his state. (Luckily, he's no idiot, and quickly realized that the doctor was giving him ridiculously bad and outdated advice, and found a real specialist in a neighboring state)

If small hospitals aren't trained to contain infectious diseases, that's a huge problem (and any hospital that turns a patient away for this reason deserves the onslaught of lawsuits that they are certain to get). However, it strikes me as eminently reasonable for the procedure to be "Isolate the patient and call a helicopter" if the hospital has limited resources.
posted by schmod at 7:14 AM on October 24, 2014 [13 favorites]


In your first case that is care withheld...

As stated.
posted by Brian B. at 7:15 AM on October 24, 2014


What exactly is the rationale for withholding care for Ebola patients? What transmission vectors are unique to Ebola?
posted by schmod at 7:15 AM on October 24, 2014 [4 favorites]


Well yeah I didn't want to give the impression I think that every hospital everywhere should be prepared for Ebola specifically--that's inefficient and just silly. But every hospital everywhere should be prepared for dealing with highly infectious diseases, with proper equipment and staff training. At the very least this means protective gear, an isolation area, and a hotline to the CDC for a helicopter.

The dirty little secret that makes US healthcare such an expensive clusterfuck is

...insurance companies and the profit motive. Not whether doctors are running the place.

In your first case that is care withheld...

As stated.


Oh come on. Care withheld with the consent of the patient. Don't cherrypick what I said.
posted by feckless fecal fear mongering at 7:16 AM on October 24, 2014 [4 favorites]


However, it strikes me as eminently reasonable for the procedure to be "Isolate the patient and call a helicopter" if the hospital has limited resources.

That's essentially what HAS been done so far here. However, the helicopters do need to be specially equipped themselves.
posted by roomthreeseventeen at 7:16 AM on October 24, 2014 [3 favorites]


well, we already withhold care to millions of Americans without or with inadequate insurance; it seems like a no brainer. I mean, just think what an Ebola patient could do to the hospital group's quarterly earnings statement. And, you know, since the hospital isn't going to treat Ebola patients to the best of their abilities because it's too risky, if I were infected I would just stay home.

It takes an MBA and years of killing people with spreadsheets to be able to stand up and pretend this is some serious ethical question.
posted by ennui.bz at 7:17 AM on October 24, 2014 [30 favorites]


schmod, I think it's not so much that the vectors are unique, but that Ebola is more virulent within those vectors, and if you do catch it, you have a much higher risk of death than you would have if you caught the flu (your chances of dying from the flu are very slim if you are otherwise healthy, and I think those comparisons are specious).
posted by desjardins at 7:19 AM on October 24, 2014 [6 favorites]


What exactly is the rationale for withholding care for Ebola patients? What transmission vectors are unique to Ebola?

My understanding is the high mortality rate is the concern more than the transmission vectors. That changes the expected value calculation considerably.
posted by Jacqueline at 7:19 AM on October 24, 2014


"There should be no special training or equipment, since this stuff should be standard. It applies to all infectious diseases."
This is the procedure for "doffing," or removing, the level of Personal Protective Equipment required for handling Ebola patients. With its high mortality, capacity for permanent damage to survivors, and our inability to adequately treat it, the hazard to health care workers from Ebola is of a fundamentally different magnitude than just a cold or the flu. If you find yourself fascinated by this sort of thing, here is an hour long training presentation for health care workers.
posted by Blasdelb at 7:19 AM on October 24, 2014 [26 favorites]


Invisible Green Time-Lapse Peloton, is there any evidence of any healthcare worker not self-monitoring?
posted by roomthreeseventeen at 7:20 AM on October 24, 2014 [1 favorite]


It takes an MBA and years of killing people with spreadsheets to be able to stand up and pretend this is some serious ethical question.

People might consider reading the article before commenting this time. The proposal is not absolute denial of care for ebola patients, it's withholding care that a hospital might not be trained or equipped to give without substantial risk.

There's a lot of ignorance and surprising weirdness in this thread. No, highly infectious disease protocol isn't the standard procedures.
posted by Sangermaine at 7:20 AM on October 24, 2014 [10 favorites]


I dunno, IGTLP, I seem to recall something about medical professionals (pre-Ebola fearmongering) being blase about protection in many case because they're doctors/nurses/etc so they know what they're doing. Poor risk assessment based on overconfidence, basically.

(That medical staff have been woefully under-trained for dealing with this is also an enormous factor here specifically; I'm talking about general cases.)
posted by feckless fecal fear mongering at 7:20 AM on October 24, 2014 [5 favorites]


Care withheld with the consent of the patient. Don't cherrypick what I said.

It's still an ethical issue for medical treatment. A cancer patient may be temporarily depressed, for example. Being brain dead is obviously a huge ethical issue, since ethicists are called in routinely to assess it.
posted by Brian B. at 7:22 AM on October 24, 2014 [1 favorite]


"The idea that a doctor would stick to his post to the last during an epidemic, that's not part of the Hippocratic Oath," Markel said. "If you feel your life is at risk you don't have to stay and provide care."

This seems like a serious attitude problem. You're not supposed to operate on how you "feel," you're supposed to make informed decisions. Hospitals need to provide training so their staff understands the issues, or else they are in danger of have massive staff defections because people don't feel safe.
posted by CheeseDigestsAll at 7:22 AM on October 24, 2014 [5 favorites]


Yes, the nurse who got on a plane even when she had a fever, and the doctor who rode the subway.

The nurse was told by the CDC via her physician to get on the plane, and the doctor was experiencing NO symptoms on the days he rode the subway.
posted by roomthreeseventeen at 7:24 AM on October 24, 2014 [28 favorites]


It's still an ethical issue for medical treatment. A cancer patient may be temporarily depressed, for example.

In which case informed consent is investigated. Do you really not understand the difference between "I do not want this procedure" (everyone has the right to refuse treatment if competent) and "we will not give you this procedure," seriously?
posted by feckless fecal fear mongering at 7:26 AM on October 24, 2014 [6 favorites]


I can see why they're having trouble. I spent two years doing my best to look out for a friend who had a disabling stroke, and whose family basically disowned him, leaving him a ward of the state. He couldn't talk, he had severe aphasia, and one half of his body was paralyzed. He wasn't a close friend, just a guy from my social group, so I didn't have any power to do anything except make a stink when things were egregiously bad. But I felt that no one should be so completely alone in that situation so I did my best, tracked him down as they shuffled him through awful nursing homes and back and forth to the hospital, played phone tag with the court appointed guardian, bought him socks and underwear to replace the stuff that got lost every time they moved him, etc.

Anyways, during this time, he had several infections that were serious enough that they put him in isolation wards and set up elaborate gown/mask/glove rituals to enter his room. Because of HIPAA they wouldn't tell me what he had, when this happened, but nurses would watch to be sure I put on the isolation outfits before I went in.

But do you know what the process was, to get OUT of those suits? You can't come out of the room wearing them. Instead you take them off while you are in the room with him, and climb over the corner of his bed in that too-small room, to get to the biohazard bin you chuck them in, and to wash your hands in the sink. After that, you climb back over the corner of his bed, and walk out the door

I am not a medical professional of any sort. Just a reasonable clued layperson. And I have to say this looked more like ritual biohazard theater, than it looked like useful precaution. I always took great care not to touch anything until I had washed again in a sink down the hall. I never got sick, but I don't think that the gowns and gloves were anything but waste, not like that.

The nurses were all scared to death of him when this was going on, and they took absolutely shitty care of him. I was so relieved when he came out of the biohazard room.

Jeez, this is the 21st century and it's supposed to be a developed country. Just because he's indigent doesn't mean he's not contagious enough to do these things right. No wonder he caught hospital infections, if that was any sample of how they manage contagion. What do they teach in nursing school?
posted by elizilla at 7:26 AM on October 24, 2014 [41 favorites]


a lungful of dragon: The flu season has come to the US early this year; it will likely kill many more thousands of people than the Ebola virus will.

If the media could push the buttons on fear, ignorance, and latent racism to get more ratings on the flu, Ebola would be forgotten by next week.
posted by dr_dank at 7:27 AM on October 24, 2014 [11 favorites]


Proper equipment and training for how to deal with Ebola isn't limited to being effective for one disease only.

The big picture here is that if virulent diseases are a national threat then a well-funded, well-coordinated national health care system is front-line national defense, and should be funded as such.
posted by mhoye at 7:28 AM on October 24, 2014 [14 favorites]


In which case informed consent is investigated.

So it is an ethical issue, no special pleading required on your part then.
posted by Brian B. at 7:31 AM on October 24, 2014


If the media could push the buttons on fear, ignorance, and latent racism to get more ratings on the flu, Ebola would be forgotten by next week.

Agreed. But we still need a plan to deal with Ebola infections and their containment, both for patients and workers who help them. The disastrous efforts in Texas showcased how ill-prepared we are for hazards of this sort.
posted by a lungful of dragon at 7:31 AM on October 24, 2014 [1 favorite]


Best healthcare system in the world!
posted by Bovine Love at 7:31 AM on October 24, 2014


People might consider reading the article before commenting this time. The proposal is not absolute denial of care for ebola patients, it's withholding care that a hospital might not be trained or equipped to give without substantial risk.

No. The whole "debate" is about diverting attention from the fact that our for-profit health care system is almost completely incapable of acting in the public interest. The idea that your doctor won't do everything to save you if you have a deadly illness has exactly the same public consequences as if they weren't treating you at all. Especially if you already know from hard experience that those doctors have no particular interest in your heatlh. Remember that the first Ebola case (poor black man) was turned away from the wealthy private for-profit hospital, even though he had early symptoms and knew he had been in an Ebola zone. Why do you think that was?

This has nothing to do with heavy philosophical problems and everything to do with a PR nightmare for the for-profit health care system in the US.
posted by ennui.bz at 7:32 AM on October 24, 2014 [64 favorites]


So it is an ethical issue, no special pleading required on your part then.

What special pleading? At the end of the day, people have the right to refuse treatment. Again I ask you: do you not understand how refusing treatment for yourself is a different animal entirely from having someone withhold treatment from you?
posted by feckless fecal fear mongering at 7:34 AM on October 24, 2014 [1 favorite]


Next up: should soldiers just run away in the face of the enemy because they might get killed? Opinions differ on this serious topic. Let's debate.
posted by ennui.bz at 7:34 AM on October 24, 2014 [10 favorites]


This is not a complicated ethical dilemma. Fly them to Emory (or Nebraska or the NIH) before they get so sick that dialysis or intubation is necessary. I live 2 miles from Emory, and I have zero problem with that plan.
posted by hydropsyche at 7:36 AM on October 24, 2014 [1 favorite]


For healthcare workers who are actually working with Ebola patients, talking about how many more people the flu will kill is totally irrelevant. The flu does not kill 50% of completely healthy people. Just because the flu is more deadly in total than Ebola doesn't mean I'd choose an Ebola patient over a flu patient to cough on me.

Shouldn't specialists be deployed when these cases crop up, rather than expecting regular nurses to expose themselves to such an incredible level of risk?
posted by showbiz_liz at 7:36 AM on October 24, 2014 [8 favorites]


"Yes, the nurse who got on a plane even when she had a fever, and the doctor who rode the subway."
There is a truly disgusting amount of bullshit being spread by people who have a responsibility to us to accurately disseminate public health information but have instead realized there is a marginally profitable advantage in doing their damnedest to scare us. You have been lied to and had your trust taken advantage of for fractions of a penny.

Both that nurse and the doctor who rode the subway were indeed self-monitoring. The nurse took that flight with all the information her doctor should have needed to advise her against it and his decision not to was a fuck up. Everything worked the way it should have with the doctor who rode the subway, self-monitored and got himself appropriate care the moment there was reason for concern. Just because there is a money to be made in making you panic doesn't mean you should let these shit heads abuse their position between you and accurate public health information.
posted by Blasdelb at 7:36 AM on October 24, 2014 [53 favorites]


So it is an ethical issue, no special pleading required on your part then.

What special pleading? At the end of the day, people have the right to refuse treatment. Again I ask you: do you not understand how refusing treatment for yourself is a different animal entirely from having someone withhold treatment from you?

I'm pretty sure that, no, he doesn't understand the difference.
posted by The Michael The at 7:36 AM on October 24, 2014 [1 favorite]




This is not a complicated ethical dilemma. Fly them to Emory (or Nebraska or the NIH) before they get so sick that dialysis or intubation is necessary. I live 2 miles from Emory, and I have zero problem with that plan.

That's great while there are less that nine patients. There are literally nine Ebola "beds" in the country right now. Bellevue's isolation of Dr. Spencer is the first time after Dallas that we will be attempting to treat someone in a room not specifically made to do so.
posted by roomthreeseventeen at 7:38 AM on October 24, 2014 [4 favorites]


The solution to this, as to most other things, is robots.
posted by Behemoth at 7:38 AM on October 24, 2014 [2 favorites]


Nevermind, sorry, mods, misunderstood the comment.
posted by roomthreeseventeen at 7:39 AM on October 24, 2014 [1 favorite]


"Shouldn't specialists be deployed when these cases crop up, rather than expecting regular nurses to epose themselves to such an incredible level of risk?"
They are, and they arrive within hours. Really what we're talking about is more related to those intervening hours and the infrastructure necessary to support that specialist enhanced care.
posted by Blasdelb at 7:39 AM on October 24, 2014 [4 favorites]


There are literally nine Ebola "beds" in the country right now. Bellevue's isolation of Dr. Spencer is the first time after Dallas that we will be attempting to treat someone in a room not specifically made to do so.

I believe he's in a room designed for highly infectious TB cases, which hopefully is just as good...
posted by showbiz_liz at 7:41 AM on October 24, 2014 [1 favorite]


This is not a complicated ethical dilemma. Fly them to Emory (or Nebraska or the NIH) before they get so sick that dialysis or intubation is necessary.

The logistics for this have worked for the handful of cases encountered so far. This approach would not scale if the number of infections multiplies, however.

Designating central isolation and control points around the country would be useful, but would involve effectively nationalizing the healthcare system, and that's not happening any time soon, short of a national emergency.
posted by a lungful of dragon at 7:42 AM on October 24, 2014 [2 favorites]


A Texas nurse on the treatment Thomas Eric Duncan received, and the way the hospital handled the patient
A symptomatic patient, Thomas Eric Duncan, showed up at Texas Health Presbyterian Hospital (Presby) in late September. He had a fever and abdominal cramps, and told the intake nurse that he'd come from Liberia, but was sent home with antibiotics. He was later readmitted with bloody diarrhea and projectile vomiting and put in isolation.

At first, Presby officials said that he had lied on his intake form; that he'd said he hadn't been in Liberia. That turned out not to be true.

Then, Presby officials said that the intake nurse had not communicated Mr. Duncan's travel history to anybody else on the health care team. That story stood for a couple of days until some bright person pointed out that travel history is right there in the electronic medical record for anybody to see, and obviously warn't nobody checkin' nohow.

Then they said that he'd been isolated immediately. That story stood until today, when a nurse at the Presby ER said no, he'd actually (during his second admission) been sitting in a common area for as long as seven hours.

Then he died. But not until after getting dialysis and being intubated, both of which the WHO says won't do shit to prolong life and *will* do a lot to spread aerosolized virus or increase the risk of bodily fluid exposure.

And, as it turns out, the nurses at Presby who cared for him spent two days in standard isolation gear (flimsy plastic gown to the knee, goggles and mask if you're lucky, gloves, booties if you can scrounge some up) and also had other patient assignments during the time that they cared for him.

Of course, the CDC said the minute the first nurse came down with the virus, that there must've been a breach in isolation protocol on her part.

But then it turned out that holy crap, the hospital had waited until final results of viral testing from the CDC had come back to get their workers into proper gear and limit their patient-care assignments. The preliminary positives apparently weren't enough, combined with the poor man's travel history, to alarm the administration. So it wasn't so much a breach of protocol on the RNs part as it was sending a nurse into a forest fire with a bladder full of piss and no backup.
ok, now let's debate about medical ethics.
posted by ennui.bz at 7:43 AM on October 24, 2014 [95 favorites]


Designating central isolation and control points around the country would be useful, but would involve effectively nationalizing the healthcare system, and that's not happening any time soon, short of a national emergency.

God, I can hear the wingnut talking points now. "Obama deliberately infects US citizens with Ebola in order to sneak his socialist healthcare agenda into law!"
posted by showbiz_liz at 7:43 AM on October 24, 2014 [1 favorite]




If you read the article, you'll see that they're not talking about withholding ALL care, just refusing to do the procedures that put their staff at the greatest risk for coming into contact with infectious fluids -- e.g., CPR, dialysis, etc.

I don't think anyone is saying (yet) they'll turn patients away completely. But they might not do anything other than quarantine and clean until the CDC shows up to either take over or transport.


I can see this being the first step in that conversation, though.

And while I'd like to believe in the goodness of the human soul, I highly doubt that the chief concern for the hospitals is staff safety but rather the risk of losing business.
posted by dances with hamsters at 7:49 AM on October 24, 2014 [2 favorites]


Again I ask you: do you not understand how refusing treatment for yourself is a different animal entirely from having someone withhold treatment from you?

I'm discussing their similarities, related to withholding treatment. As in the phrase, "When is it ethical to withhold treatment from a patient?" You refused to acknowledge any such similarities. From an ethical point of view, your blanket brain dead analysis was more central to your mistake (because they aren't legally dead yet and someone might get charged with murder if they withhold treatment).
posted by Brian B. at 7:49 AM on October 24, 2014 [1 favorite]


Reading the article is not enough. The article tells us that ethicists are reaching different conclusions but tells us little about their arguments.

Here's Joseph Fins (physician and ethicist) arguing at length that ebola patients should not receive CPR. (source: Bioethics Forum)
posted by justsomebodythatyouusedtoknow at 7:50 AM on October 24, 2014 [4 favorites]


God, I can hear the wingnut talking points now. "Obama deliberately infects US citizens with Ebola in order to sneak his socialist healthcare agenda into law!"

A sideways possibility might be to open military hospitals to civilians, and have outbreaks managed by the National Guard and state militias (might even give them something useful to do). I don't know the legal implications of that, though.

Most likely, if the infection rates are slow enough, the long-term solutions to most of this will involve developing public-private collaborations that funnel taxpayer money into private hands, in exchange for a kind of kabuki dance of safety.

In addition to training healthcare workers, there's also the messiness around dealing with biomedical waste and associated laws and licensing. Convincing shipping and disposal companies to rework their procedures and infrastructure to handle uniquely hazardous waste takes time and money.

Lots of problems to deal with, with tough solutions and constrained resources. I don't envy Obama's team the mess they are dealing with.
posted by a lungful of dragon at 7:52 AM on October 24, 2014 [1 favorite]


From reading the article it seems that the main questions are about dialysis, and whether it's medically necessary and worth the risk to workers. Quoted in the article is the claim that not all hospitals are equipped to properly perform the procedure (a big change from the CDC's twitter-boasting two months ago). Heck, it seems to be an open question whether most hospitals can properly isolate a patient until they get them to one of the 20 "anointed" hospitals.

The headline reads like "Ebola Death Panels Are Coming" but I think the fact that we're admitting that most of our hospitals are horrible and establishing a standard of care is a step in the right direction.
posted by RobotVoodooPower at 7:53 AM on October 24, 2014 [2 favorites]


That story stood for a couple of days until some bright person pointed out that travel history is right there in the electronic medical record for anybody to see, and obviously warn't nobody checkin' nohow.
From NPR a week ago:
When index patient Thomas Eric Duncan first entered the hospital on Sept. 28, he informed a nurse of his travels from Africa, and that information was entered into Presbyterian's electronic records system. When he was seen by a physician, the doctor asked his own question about where Duncan lived, and Duncan gave his local address.
So, who actually reads the electronic medical records?
posted by ChurchHatesTucker at 7:53 AM on October 24, 2014 [6 favorites]


I'm discussing their similarities, related to withholding treatment. As in the phrase, "When is it ethical to withhold treatment from a patient?" You refused to acknowledge any such similarities. From an ethical point of view, your blanket brain dead analysis was more central to your mistake.

"when the patient asks to do so" is extremely different, ethically, from "we are deciding without the patient's consent."

I'd also add that withholding treatment when brain dead and on life support generally also requires consent--of next of kin or whoever holds power of attorney.

That you think these are similar ethical situations--that is, with consent vs without consent--is disturbing. Let me be more simple:

"I do not want this apple" (even though I am starving)

is different from

"You cannot have this apple" (even though you are starving)

Functionally and ethically, they are totally different situations. Sure, if you squint from a distance and it's hazy out they might look similar, but they are far more different than they are similar.
posted by feckless fecal fear mongering at 7:55 AM on October 24, 2014 [5 favorites]


BTW the Dallas nurse is getting discharged from NIH today. She got a blood transfusion from a survivor of the virus.
posted by RobotVoodooPower at 7:57 AM on October 24, 2014 [8 favorites]


Why New York's Ebola Case Will Hurt Infected Patients Everywhere
Sebastian Vidal, a field coordinator for MSF, told NPR he was “flabbergasted” at the lack of international response. “We see that Western countries are preparing themselves in case they have one or two cases,” said Vidal. “This is not acceptable. You just cannot let a whole continent become infected and people die by hundreds.
A much-needed bluntness, IMO. It seems a bit odd to be discussing the medical ethics of not performing some procedures in a potential future epidemic when we are already inadequately responding to a current epidemic. Like we've just given up on Guinea, Liberia, and Sierra Leone.
posted by muddgirl at 7:57 AM on October 24, 2014 [22 favorites]


Not to potentially derail, but I'd be interested (for historical context) to hear how the reaction in the medical community compares with the early days of the AIDS epidemic (or other diseases) when people didn't know very much. Were there a lot of similar debates? Is everything old new again?
posted by C'est la D.C. at 8:00 AM on October 24, 2014 [3 favorites]


C'est la D.C, I don't even know if it was being debated ethically at all. Doctors and nurses were flat out mistreating people with HIV and AIDS.
posted by roomthreeseventeen at 8:01 AM on October 24, 2014


No. The whole "debate" is about diverting attention from the fact that our for-profit health care system is almost completely incapable of acting in the public interest.

Actually, the debate arises in countries with single-payer health care systems as well. If medical staff are at high risk of infecting themselves, they could spread the infection to other patients, which is most certainly not in the public interest.

Hence denial of CPR. Rushing in on a code without putting on protective gear would pose an unacceptable risk to staff, but taking minutes to put on gear before administering CPR would be futile. Etc....
posted by justsomebodythatyouusedtoknow at 8:02 AM on October 24, 2014 [5 favorites]


It seems a bit odd to be discussing the medical ethics of not performing some procedures in a potential future epidemic when we are already inadequately responding to a current epidemic.

Not giving a shit about people dying in Africa is just business as usual, unfortunately. If we really cared about reducing African mortality we would be working on clean water, sanitation, food security, parasite eradication, and distribution of basic vaccinations. Those would save many more lives than an ebola epidemic will kill and at a fraction of the cost.
posted by Jacqueline at 8:04 AM on October 24, 2014 [12 favorites]


From reading the article it seems that the main questions are about dialysis, and whether it's medically necessary and worth the risk to workers.

My local dialysis clinic treated a patient with AIDS. Her machine was cordoned off and the nurses who attended her wore additional protective gear and kept the curtain closed when using the needle. They were very careful, they had protocols, and the nurses were extremely professional.

This probably would have been unheard of when AIDS was emerging. But they found a way to do it safely.
posted by mochapickle at 8:08 AM on October 24, 2014 [3 favorites]


Yes, you're right, which is why I am finding the scaremongering in the US particularly abhorrent. No one cares about a nation of people across the water, but as soon as it threatens America, OH NOES PANIC.

I mean, I know we're not as good a country in terms of consideration as I'd like us to be, but it really brings it into stark relief.
posted by Kitteh at 8:10 AM on October 24, 2014 [1 favorite]


If we really cared about reducing African mortality we would be working on clean water, sanitation, food security, parasite eradication, and distribution of basic vaccinations. Those would save many more lives than an ebola epidemic will kill and at a fraction of the cost.

Those things go hand-in-hand with preventing epidemics, too. You'd think we'd have a selfish reason to work towards these goals, at the very least.
posted by muddgirl at 8:10 AM on October 24, 2014 [6 favorites]


I hate that we're discussing this as a solution to just how badly the Dallas situation was handled. We have no idea if the later treatments were to blame, or if it was the lack of training, protective gear, etc... The nurse in this article claims dialysis won't help, but numerous other places cite that it will. But we really shouldn't be making decisions on the worst handling of a case. After all, that is why we're having this discussion.
posted by [insert clever name here] at 8:14 AM on October 24, 2014 [1 favorite]


"This is pretty tin-foil-hat/Kennedy assassination by aliens stuff."
Watch this Fox News coverage, and check out the various news organizations that covered their bullshit artist's stunt. Its not just Fox News asking the shit stirring 'question' of whether we can trust the CDC, but CNN, basically all of the right wing media, and an embarrassing number of staid liberal institutions. There is a reason why a unilateral travel ban on the affected countries in West Africa, no matter how obscenely stupid and counter-productive that would be, is so popular in the American public right now that even Democrats are abandoning the President.

Our media has almost categorically abandoned their responsibility to educate and inform in favor of simply doing anything it can to attract eyeballs and we're now left with the problems this causes. Public Health, especially as it related to epidemic disease, absolutely must be deeply fucking sacred from this kind of bullshit and the partisan hackery that has dominated everything about or response that faces the public. Instead of commitment to the well being of the body politic, with the notable exceptions of Obama who doesn't have the luxury of abandoning his responsibility and a variety of Democrats, what we've gotten from our politicians has been a desperate scramble to either demonstrate hollow "leadership" or tear down the efforts of their colleagues to then point at the damage.

We need to expect more, this isn't the behavior of a society that lasts. It almost certainly won't be Ebola, but there are terrors lurking in the basic biology of ourselves and our planet worth a hell of a lot more respect than this pathetic squabbling indicates. Our unprecedentedly massive population of medically vulnerable people packed in close proximity, our unprecedentedly connected world, and both climate change as well as unprecedentedly huge populations disrupting diverse ecosystems filled with blood curdlingly terrifying bugs infecting mammals, most of which we haven't even described, means that there will be much worse monsters coming bump in the night that we will need to fight.

That means giving a shit about the security and well being of Africans, putting our various forms of bullshit aside when Public Heath needs arise, and funding scientific research.
posted by Blasdelb at 8:16 AM on October 24, 2014 [50 favorites]


Here's an entire page of ethicists arguing about ebola related ethical issues (Johns Hopkins Bioethics Center)

Nancy Kass (quoted in the OP's original article) has multiple articles there, including what appears to be an hour long panel discussion of the treatment that ebola patients ought to receive.

There's a huge amount to chew on at that link. RTFArguments, I would suggest. At least, I'm backing out of this thread until I've had time to read up.
posted by justsomebodythatyouusedtoknow at 8:17 AM on October 24, 2014 [7 favorites]


For a little international perspective, read The Economist: Much worse to come about efforts to create treatment centers in West Africa
“something in between a tent and a concrete structure”. But it has all the necessary features: quarantine rooms, decontamination areas and large toilet spaces (patients suffering from vomiting and diarrhoea may pass out). It is close enough to villages for people to reach, not so close for them to protest at its presence.

... The minimum basis for community care is to have two structures, which might be tents or shacks, set aside for suspected and confirmed cases. The carers would not be health workers, but trained community members with proper protective gear.
In Sierra Leone, where people are actually getting the disease and dying, the focus is on having two separate rooms just to try to separate patients who are confirmed to have Ebola vs. people who merely suspect have it. And the standard of care is palliative, a way to give someone a tiny hope they won't also get infected when they try to bring water to the patient sweating and bleeding out two+ gallons of virus-infected liquid a day. A primary ethical question is how hard you try to keep family away from the dying and dead so that the infection doesn't spread to them, assuming it hasn't already.
posted by Nelson at 8:23 AM on October 24, 2014 [1 favorite]


A much-needed bluntness, IMO. It seems a bit odd to be discussing the medical ethics of not performing some procedures in a potential future epidemic when we are already inadequately responding to a current epidemic. Like we've just given up on Guinea, Liberia, and Sierra Leone.

Those of you with access to the BBC iPlayer should take a look at last night's Newsnight which followed the incredibly brave ambulance crews and doctors in Liberia, dealing with about 50 ebola cases a day with barely any resources. It's not just ebola patients who are dying either, as the collapse in the healthcare system has led to people with many other conditions not being able to access treatment.
posted by sobarel at 8:23 AM on October 24, 2014 [6 favorites]


If we really cared about reducing African mortality we would be working on clean water, sanitation, food security, parasite eradication, and distribution of basic vaccinations. Those would save many more lives than an ebola epidemic will kill and at a fraction of the cost.

The West is working on those issues, albeit in an uncoordinated, ad hoc sort of way. The difference is those are chronic, more familiar problems, and they take more time to kill people. Ebola can kill you in days and doesn't exist anywhere else, but it could spread. It's a different sort of threat, more "I'm currently being threatened with a loaded gun" than "I'm poor and can't afford to buy food regularly."
posted by Small Dollar at 8:25 AM on October 24, 2014


there are surprisingly few Level 1 trauma centers in the US

And there are 4 in the DFW area, 3 in Dallas Alone. Unfortunately, Presby is not one of them.
posted by LizBoBiz at 8:29 AM on October 24, 2014


I have a question: If a nurse dies of Ebola caught while at work, could her family sue the hospital? What about a patient?
posted by marienbad at 8:32 AM on October 24, 2014


It's a different sort of threat, more "I'm currently being threatened with a loaded gun" than "I'm poor and can't afford to buy food regularly."

Read the description of the treatment given to the guy who died of Ebola in Dallas again. What it shows is that going to the doctor, for many many americans, is essentially equivalent with calling Comcast for technical support.

It's because the threat is different that the desperate inadequacy of the health care we receive shows.
posted by ennui.bz at 8:38 AM on October 24, 2014 [19 favorites]




I have a question: If a nurse dies of Ebola caught while at work, could her family sue the hospital? What about a patient?

Sure, anybody can sue for anything. Whether the family would win would depend on the exact facts of the case.
posted by Justinian at 8:45 AM on October 24, 2014 [1 favorite]


You know, Ebola is just two mutations away from becoming E.coli. (three, if you include the period)

(Note this is my satirical response to the constant Ebola news.)
posted by dances_with_sneetches at 8:47 AM on October 24, 2014 [1 favorite]


roomthreeseventeen: The problem is not treating these patients. It's not knowing that you are treating these patients, and therefore, not protecting yourself.
Since medical workers who knew they were treating ebola patients have developed ebola, your statement is obviously false.

Both situations are a problem.
posted by IAmBroom at 8:49 AM on October 24, 2014


Since medical workers who knew they were treating ebola patients have developed ebola, your statement is obviously false.

Not really, though. The first time, they sent Mr. Duncan home, because they had no idea what they were dealing with. The staff at that hospital was directly responsible for Mr. Duncan getting worse. I'm not blaming the nurses for getting Ebola, but the hospital should have done a better job protecting their entire staff, and their patients.
posted by roomthreeseventeen at 8:51 AM on October 24, 2014 [4 favorites]


One of the Dallas nurses was discharged today and the other is reportedly recovering. Good news. It sounds like the fatality rate for ebola is overstated if you receive excellent care. The only fatality here so far is Duncan and he was apparently already in very bad shape when he was admitted. Kicking him to the curb on his initial visit likely killed him and I hope we get some answers as to exactly how that happened. The hospital has been slow walking information in the likely correct belief that we'll forget about it when the next shiny thing appears.
posted by Justinian at 8:52 AM on October 24, 2014 [9 favorites]


Brian B.: As ethics goes, withholding care would also fall under the umbrella of letting people die if they wish, or if brain dead.
Not helping the needy hardly falls anywhere near the ethics of allowing self-determination of the needy. I can't imagine how you can believe these are anything alike.
posted by IAmBroom at 8:52 AM on October 24, 2014 [1 favorite]


The Ebola panic is a useful reminder that human beings are unbelievably, shockingly, tragically incapable of sensibly ranking risks.
posted by yoink at 8:59 AM on October 24, 2014 [6 favorites]


Nina Pham says that from the moment she fell ill she put her trust in god and her medical team. Between the two I'm pretty sure I know which is responsible for her recovery.
posted by Justinian at 8:59 AM on October 24, 2014 [10 favorites]


donating blood for further treatments should be mandated

I don't think one can reasonably "mandate" that people must donate blood. It would certainly be sensible to mandate that people are asked if they would be willing to make such donations.
posted by yoink at 9:00 AM on October 24, 2014 [3 favorites]


well, it's a distraction from the implications of climate change, i guess.
posted by angrycat at 9:01 AM on October 24, 2014 [1 favorite]


Journalist Maryn McKenna tracks instances of hysteria - which she calls Ebolanoia - on her Further Adventures of Germ Girl blog. A teacher in Maine was actually placed on leave because she had simply traveled to Dallas. The ignorance is boggling.

Nigeria and Senegal have kicked Ebola's ass. Even with institutional problems, we ought to have the public health infrastructure to do the same. The real problem is in impoverished African countries like Liberia.

While the ethicists debate, the most courageous doctors, nurses, ambulance workers, and other health care personnel are stepping up on the front lines and doing what needs to be done. My admiration and appreciation for this courage and compassion has no bounds - I keep donating to Doctors Without Borders.

The infrastructure failings I worry most about are our hysterical media competing for viewers and unethical politicians who use fear-mongering and lies to get elected and to destroy people's confidence in the concept of a functioning government. I'm expecting the Obama FEMA camp myth to resurface any minute in relation to quarantines.

This is story with pictures and profiles of survivors is great. Ebola: Survivors at the frontline of the response
posted by madamjujujive at 9:07 AM on October 24, 2014 [12 favorites]


If a nurse dies of Ebola caught while at work, could her family sue the hospital?

If she/he caught it while at work, it would likely fall under workers' compensation. Workers comp is the exclusive remedy for work-related injuries and illnesses, meaning that you can't sue. (Well, you can try but there are big hurdles to pass.)
posted by madamjujujive at 9:11 AM on October 24, 2014


So, who actually reads the electronic medical records?

Judging by how many times I have to re-give the same information in the same visit, nobody. Or the whole damn system goes down and they have to make paper notes.

I too am hopeful this serves as a wakeup call about the fact that care in the "greatest system" is often not that great, sometimes criminally negligent.

A friend of mine died from vomiting aspiration at a local ER last month. He was having stomach issues, but otherwise healthy and in his early 50s. The hospital he died at is the same one that I took my husband to for food poisoning about 12 years ago. They hooked him up to an IV with fluids and anti-nausea meds, but forgot to turn it on. I had to do so, because no one would come and help us. I also had to clean up his diarrhea on my own, same reason. So when my friend died, there, you can just say, I had my own opinions about what really happened.
posted by emjaybee at 9:22 AM on October 24, 2014 [10 favorites]


emjaybee, those are horrifying events. I am very sorry about the recent loss of your friend.
posted by madamjujujive at 9:33 AM on October 24, 2014 [4 favorites]


It's worth noting, by the way, the insidiousness of the media panic around Ebola. The linked article in the FPP is a good example, because it's "serious journalism" and not obviously in the Fox News wailing-sirens-flashing-lights-Ebola-carrying-terrorist-Guatemalan-Isis-children mode. But it's still absurdly overblown. The headline is just utterly, utterly misleading; hospitals aren't, at all, weighing withholding care to Ebola patients. They are engaging in a debate about appropriate standards of care and considering what are acceptable and unacceptable risks to care providers. That is an entirely standard risk analysis process which applies to all kinds of infectious diseases. It's a risk analysis that we're so familiar with in parallel cases (such as first-responders in the wake of a disaster) that we take it for granted. Can you imagine a newspaper article about "firefighters weighing not bothering to rescue fire victims" because firefighters have ongoing discussions about when it is and is not safe and practicable to enter a burning building to effect rescues?
posted by yoink at 9:46 AM on October 24, 2014 [12 favorites]


I have a question: If a nurse dies of Ebola caught while at work, could her family sue the hospital? What about a patient?
Sure, anybody can sue for anything. Whether the family would win would depend on the exact facts of the case.


If the hospital is in Texas they're probably bulletproof and the family is outta luck, due to "tort reform". The bar is set pretty high.
posted by aramaic at 9:52 AM on October 24, 2014


If we really cared about reducing African mortality

Don't kid yourself, we—meaning Western governments broadly—don't.

At least, not anything like we care about preventing Ebola from spreading to the West.

I mean, people on the ground presumably care quite a bit about the lives of the people they interact with, but there's a reason that Ebola is getting a whole lot more resources than, say, malaria—which has killed more people than Ebola even just over the same time period—and it's because malaria doesn't have any risk of suddenly jumping an ocean and ravaging New York or London.

And on the governmental level it's not really a fallacious risk assessment, in the same way that individuals freaking out about Ebola is. Ebola, like smallpox and polio, actually does represent an across-the-board threat that merits a worldwide response, for purely self-interested reasons if nothing else. Individuals here in the west who are freaking out about Ebola, when they have a greater chance of slipping in the shower and drowning, are morons. (And the politicians who are fanning the flames of panic are mendacious and vile, but that's pretty much de rigueur.)
posted by Kadin2048 at 9:55 AM on October 24, 2014 [5 favorites]


yoink: The Ebola panic is a useful reminder that human beings are unbelievably, shockingly, tragically incapable of sensibly ranking risks.

I tried watching TV with these new glasses I got, but all I can see on the screen is FEAR, OBEY, & CONSUME.

Maybe LensCrafters will let me exchange them.
posted by dr_dank at 9:56 AM on October 24, 2014 [8 favorites]


Invisible Green Time-Lapse Peloton: "Perhaps donating blood for further treatments should be mandated for anyone who receives successful care?"

That noise you hear is a medical ethicist exploding.
posted by boo_radley at 9:57 AM on October 24, 2014 [5 favorites]


Individuals here in the west who are freaking out about Ebola, when they have a greater chance of slipping in the shower and drowning, are morons.

First, I don't think name calling helps at all. But more to the point, lack of scientific understanding of a dangerous and highly deadly virus does not make someone a moron.
posted by roomthreeseventeen at 9:58 AM on October 24, 2014 [2 favorites]


I'm only watching tweets of the NYC press conference, but they are apparently asking people who suspect they may be sick with Ebola symptoms to go to an emergency room and NOT to their PCP.
posted by roomthreeseventeen at 10:11 AM on October 24, 2014


If you read the article, you'll see that they're not talking about withholding ALL care, just refusing to do the procedures that put their staff at the greatest risk for coming into contact with infectious fluids -- e.g., CPR, dialysis, etc.

I still don't get it. This leaves them either sending the patient in the street to die, or dying at the hospital - in which case, you've still got a risk of spreading the infection. Just handling the body of someone that has died of ebola is often extremely dangerous, especially without proper training and equipment. It's just about self-preservation for individual doctors and nurses?
posted by ryanshepard at 10:20 AM on October 24, 2014


Judging by how many times I have to re-give the same information in the same visit, nobody.
posted by emjaybee at 11:22 AM on October 24


This can happen for sensible reasons too. I work at a hospital, and one of my duties is to administer the MM&I lectures for my department. MM&I is Morbidity, Mortality & Improvement, and it's where doctors talk about recent cases (anonymized) that were unusual or went badly or for some other reason are medically interesting. One of the overall purposes of MM&I (also called M&M at some hospitals) is to identify systemic issues that are causing problems for patients.

There's an approach to harm reduction that's called the Swiss Cheese approach, where you try to put several people between the patient and a possible mistake, so if one person misses something the next person will catch it. "Swiss cheese" because - picture lining up several slices of Swiss cheese (each slice representing a person or task or procedure). If all the holes line up, a mistake can happen - if you have a slice which doesn't match up, then there's no hole anymore (analogy: mistake is caught and prevented).

So some hospitals ask you for information over and over again to prevent mistakes. If the Dallas hospital had asked for travel history each time instead of asking for it once, putting it in the medical record and never referring to it again, maybe the patient who had traveled to Liberia wouldn't have been discharged on his first visit. I'm not saying it's the fault of the doctor who didn't ask - it's a systemic issue, you should never have only a single person ask important questions.
posted by joannemerriam at 10:21 AM on October 24, 2014 [24 favorites]


I'm only watching tweets of the NYC press conference, but they are apparently asking people who suspect they may be sick with Ebola symptoms to go to an emergency room and NOT to their PCP.

Great, and when you're wrong and it's just the flu or something else you could have treated at home, now you owe hundreds or thousands of dollars. I wish there were some temporary exemption from medical costs for serious public health risks.
posted by desjardins at 10:22 AM on October 24, 2014 [5 favorites]


The nurse was told by the CDC via her physician to get on the plane.

What do we actually know? I've read multiple reports where Vinson says she called the CDC several times and was told her low fever was within guidelines.

I've read conflicting stories of the CDC response to her claims.

Early local stories included quotes from a CDC directive asking hospital staff who had treated or been on the floor with Duncan to avoid public transportation (including cabs and planes), but I read those concerned about people who depend on the bus and haven't seen anything subsequent to Vinson's diagnosis that shows she, specifically, heard those instructions.

(Mods - if this is a derail, delete and accept apologies. Trying to determine to what extent we even have simple processes in place for Ebola care.)
posted by Lesser Shrew at 10:24 AM on October 24, 2014 [1 favorite]


New guidelines: Health Department will now monitor EVERYONE coming from the three nations in West Africa affected by Ebola. (No link yet, just from Mayor deBlasio)
posted by roomthreeseventeen at 10:25 AM on October 24, 2014 [1 favorite]


This seems like a good time to trot out Bruce Schneier's essay on the psychology of security. It explains the Ebola scare in the U.S. pretty well.
posted by charred husk at 10:25 AM on October 24, 2014 [4 favorites]


"First, I don't think name calling helps at all. But more to the point, lack of scientific understanding of a dangerous and highly deadly virus does not make someone a moron."
This

We do have a deeply serious problem with how the public is reacting to this epidemic, and the appalling state of scientific literacy does clearly contribute significantly to it, but it seems like there is something new and deeper that is much more important and only made worse by calling people morons. There is something I've seen a dramatic shift in over my short lifetime that seems to me to be the biggest reason why this epidemic is being panicked over rather than respected, where past ones were not. Its the trivialization of expertise that have become so endemic in our conversations on just about anything authentically complicated. Where it has become just so natural for people from journalists to sysadmins - both liberal and conservative - to assume that they know better than career epidemiologists when it comes to emerging epidemic disease, trained climatologists when it comes to global warming, working immunologists when it comes to vaccines, dentists when it comes to fluoride, and physicists when it comes to whatever hazard might be posed by the Large Hadron Collider.

Its obscenely easy for transparently ridiculous authors to convince people to not trust the word of the CDC, convinced as we all are of the power our own intuition and thruthiness. As the understandings of specialists get deeper and deeper, our respect for specialized knowledge seems to only get shallower. All you need to do is appeal to our ideological biases, whether its mistrust of "corporations" or "the government" or the inherent wisdom of "the free market" or "nature", and its insane the crazy things you can convince people of while demonstrating a clear lack of the foundational kinds of knowledge needed to even coherently interrogate the ideas being discussed.
posted by Blasdelb at 10:27 AM on October 24, 2014 [28 favorites]


I don't think people overreacting are morons at all, but it does feel like they don't have a reliable trusted way to properly educate themselves. It seems there is a lot of reliance on what news networks tell you about Ebola and if that's the benchmark, what chance do people trained and educated in the study of disease have against emotional rhetoric?
posted by Kitteh at 10:33 AM on October 24, 2014


My mom has been a nurse (ICU/PCU and hospice) for 45 years and works full time at nearly 80 now. I've known a lot of nurses in my life. Bravest and most selfless people, in the aggregate, on planet earth. I don't believe the vast majority of nurses would ever shirk from caring for a patient in any circumstances if they felt the proper and best available protections were in place.

Nurses ought to be celebrated like soldiers are. We should have a national holiday to honor them. If doctors disappeared tomorrow and left nurses in charge we'd be ok. Vice versa, we'd be fucked nine ways to Sunday. And any doctor who has ever worked in a hospital setting will agree with that.

So goddamit Americans stop acting like a bunch of scared sheep, and focus on supporting our troops, which in this case means nurses. They need the best training and equipment we can provide just as if they were storming a fucking beach somewhere.
posted by spitbull at 10:36 AM on October 24, 2014 [30 favorites]


Its obscenely easy for transparently ridiculous authors to convince people to not trust the word of the CDC, convinced as we all are of the power our own intuition and thruthiness.

You know what would help to undermine this? Having a federal government whose officials don't routinely and transparently lie to the public.
posted by ryanshepard at 10:39 AM on October 24, 2014 [6 favorites]


But we still need a plan to deal with Ebola infections and their containment, both for patients and workers who help them. The disastrous efforts in Texas showcased how ill-prepared we are for hazards of this sort.

To derail a bit, this is why I'm probably going to vote for Hillary in the primaries. The difference in Obama's ability to run ahead of disasters and catastrophes in his first term of office is markedly different in his second term, where he keeps a wait-and-see attitude and doesn't seem to know to lay down the groundwork in case something blows up. I have to believe this is because Clinton left the cabinet, and her absence altered the institutional culture of the Executive branch as a whole, and not for the better.

Once ebola became a thing, Obama should have been leaning on H&HS and Homeland Security to gameplan out when (not if) it arrived unnoticed on a jetliner, and have a solid, practiced plan in place to bolster local resources, with contingencies for worst case (incompetent hospital and local response). I mean, sure, it's not actually a pandemic, but it's high profile enough where he should have known what a lackluster response would mean in a mid-term election year.

Her absence has made the administration notably worse - I can only imagine how on top of things her administration would be if she were calling all the shots and not just advising.
posted by Slap*Happy at 10:52 AM on October 24, 2014 [2 favorites]


Blasdelb, it all goes back to the by-product of the fragmented media landscape of today. Thanks to the internet, you can wall yourself off in an echo chamber and live the reality you choose. Any idea, no matter how half-baked it is, can be "confirmed" and reinforced by a ten second google search. Want to believe that Ebola is a plot by the Kenyan Usurper to usher in martial law and prison camps? You'll find it. Want to believe that the US government is hiding the "truth" of Ebola, you'll find it. Want to believe that every person who came within three miles of this doctor will start spewing liquid horror out of every oriface in the next thirty seconds? You'll find that too.

Tell the average american that they'll be killed by the food they eat and the car they drive long before some African andromeda strain knockoff and they'll look at you as if you're the idiot.
posted by dr_dank at 10:56 AM on October 24, 2014 [5 favorites]


Blasdelb: This is the procedure for "doffing," or removing, the level of Personal Protective Equipment required for handling Ebola patients.

Quick update: I work on the HEROES project that developed the video Blasdelb linked to (Thanks, Blasdelb!) . At the Nebraska Biocontainment Patient Care Unit (NBU), Level C suits were not used for either of the patients they cared for. In the past week we've been working on the Donning and Doffing videos for the Biological PPE for Ebola as used in the NBU. We just made them public about 15 minutes ago.
posted by zedbends at 11:02 AM on October 24, 2014 [25 favorites]


Thats really awesome zedbends, thanks for sharing it!
posted by Blasdelb at 11:05 AM on October 24, 2014 [3 favorites]


Right now somebody is bowling with that ball, with infectious Ebola sweat coating the finger holes.

Oh my goodness, a 7-10 split!

This calls for nachos; no time to wash hands, let's eat!

Damn, these nachos are gooey [licks every finger repeatedly]...
posted by Renoroc at 11:24 AM on October 24, 2014 [1 favorite]


The Doc was not infectious at the time, the bowling alley is engaging in sterilization theatre to meet your ebolianora needs, and you were probably going to catch something anyway with that kind of behavior.
posted by ChurchHatesTucker at 11:29 AM on October 24, 2014 [16 favorites]


"Ebola is killed with hospital-grade disinfectants (such as household bleach). Ebola on dry surfaces, such as doorknobs and countertops, can survive for several hours." Also, more to the point, THEY CLOSED DOWN THE BOWLING ALLEY.
posted by showbiz_liz at 11:30 AM on October 24, 2014 [1 favorite]


While I appreciate that we should listen to epidemiologists and experts on the virus, I think arguments that we shouldn't worry about Ebola because it hasn't killed a bunch of Americans yet are kind of stupid. It feels kind of like arguing that we don't need to close the barn door because the horses haven't escaped.

Regardless of the danger of an emerging pathogen, there's always going to be a time when it hasn't killed anyone yet over here, but that doesn't mean that we don't need to deal with it. Hell, that's often the best time to deal with it. Ebola may or may not be a severe danger to the US population, but the fact that it hasn't done a lot of damage here yet can't be used as an argument that it necessarily can't or won't.
posted by Mitrovarr at 11:48 AM on October 24, 2014 [7 favorites]


I think arguments that we shouldn't worry about Ebola because it hasn't killed a bunch of Americans yet are kind of stupid

If by "we" you mean health care professionals or people traveling to West Africa, then absolutely.

If you mean, e.g., people employing people who have traveled to Dallas, then you need a time-out from participation in public conversation.
posted by ChurchHatesTucker at 12:11 PM on October 24, 2014 [6 favorites]


That doffing video is kind of terrifying - so many opportunities for both the doffer and their partner to unintentionally be contaminated. So many layers, and so many materials that are stretchy and can "fling" any substances on them into the air.

One thing I was wondering is to what extent the very complex nature of the protective gear, and the process for putting it on and taking it off, may be contributing to transmission.
posted by rtha at 12:39 PM on October 24, 2014


ChurchHatesTucker: If by "we" you mean health care professionals or people traveling to West Africa, then absolutely.

If you mean, e.g., people employing people who have traveled to Dallas, then you need a time-out from participation in public conversation.


Well, the response from the employer of the person who traveled to Dallas was stupid. However, poor performance from the government during previous epidemics does suggest to me that people may need to drag a decent response out of the various agencies. I was not at all impressed with how the Swine Flu outbreak was handled, for instance. I think often economic considerations trump public health and safety.
posted by Mitrovarr at 12:40 PM on October 24, 2014


I'll also state that the prospect that worries me the most about Ebola isn't that it makes it to the US directly from Africa. I think the real danger is that it could make it to, say, southeast Asia, where the combination of crazy population density and poverty could make it absolutely devastating.
posted by Mitrovarr at 12:46 PM on October 24, 2014 [6 favorites]


dumb question: who doffs the doffing partner after they walk off with that bag of hazardous material? are they just... less likely to be contaminated because they didn't treat the patient or something? doffing partners all the way down?
posted by twist my arm at 1:20 PM on October 24, 2014 [2 favorites]


Watching fear and disinformation being spread to further people's agendas over this is so disheartening to me. Countries with a mere fraction of our resources, such as Nigeria and Congo, have shut Ebola down. People who lived with Thomas Duncan in a small apartment for days while he was deathly sick failed to develop the disease. So far, the only people who have caught the disease in America are people who were treating Ebola patients.

So, what have we really learned that we didn't know before? We learned that treating Ebola in the late stages of the disease can be dangerous if proper precautions are not taken and the necessary equipment is not available. We learned that hospitals in Texas are shitty places to work and don't give much consideration to patients who are poor and lack health insurance.

We already knew these things. Luckily for Texas, and Nigeria, Ebola spreads very slowly outside of contexts that are quite specific to certain countries in Africa. As a result, there is actually quite a margin for error between a fuckup and a pandemic. As a matter of fact, I would go as far as to say that it is impossible for an Ebola pandemic to occur in this country. The conditions that allow it to spread in parts of Africa simply do not exist in the United States.

Because this country has many international travel destinations, it was inevitable that a few cases of Ebola were going to show up here. Because of the fragmented and poorly regulated nature of our health care system, it was probably inevitable that a few health care workers were going to catch the disease until people learned to take it seriously enough to devote the money and time necessary to prevent health care workers working with patients in the late stages of the disease from catching it. That is more an indictment of our health care system, and the problems that led to the health care workers catching Ebola show up in other areas that don't get as much attention but are actually even more dangerous to the average person than Ebola because they are more likely to be affected by them, than something associated with the response to Ebola itself.

So, there isn't going to be a mass outbreak of Ebola because that doctor took the subway or went bowling, our health care system is not going to collapse because too many doctors and nurses get sick, and Obama didn't do a damn thing wrong because he did the one thing that any rational and responsible person should have done: He didn't panic. The danger now is that the spreading panic over Ebola will hinder relief efforts in West Africa, where conditions do exist that allow the virus to spread easily. Spreading panic threatens to hinder these relief efforts, and that means lost lives. At this point, it is unethical for people not to educate themselves about this disease before talking about it.
posted by eagles123 at 1:59 PM on October 24, 2014 [13 favorites]


Not helping the needy hardly falls anywhere near the ethics of allowing self-determination of the needy. I can't imagine how you can believe these are anything alike.

I don't. The ethics part is neutral as a subject matter, not positive or negative. It is simply an ethical problem or topic that is never black and white and requires an ethicist to advise a judge in most cases. I would finally suggest that withholding care is delineated along five or six major lines. Remuneration, danger to staff, brain dead, self-determination, religion, and of course very old age in the case of organ failure. Kindly note that remuneration is a tricky one with limited resources, especially for profit. Really though, everything medical is ethical. For example, if there is only one dose of anti-venom left in the city, who or what decides who gets it if two people in need enter the hospital?
posted by Brian B. at 4:02 PM on October 24, 2014


again, the ethical questions of "this patient is refusing a procedure" vs "should we give this patient a procedure" are vastly different.

One involves informed consent. The other does not. End of story.
posted by feckless fecal fear mongering at 4:12 PM on October 24, 2014 [1 favorite]


again,

You are debating yourself, I never specified a position on anything, and never on such flimsy terms. For all you know, I could be advocating forcing care on people in all situations.
posted by Brian B. at 4:16 PM on October 24, 2014


Why don't you just say what you mean, then? What are you advocating?
posted by Justinian at 4:23 PM on October 24, 2014 [2 favorites]


Why don't you just say what you mean, then? What are you advocating?

Me? I remember seeing a documentary about ebola 20 years ago, and a bunch of French and Belgian specialist doctors were emotionally appealing to some African doctors that they should not, under any circumstances, transfuse blood from recovering ebola survivors to severely infected ones to help them. It would be unethical to experiment on patients, they implied, and some of them refused to help. The local doctors reluctantly did the transfusions anyway, and most of the patients lived. My takeaway is that nobody is always right.
posted by Brian B. at 5:01 PM on October 24, 2014


Apparently the nurse that they detained at Newark Airport this afternoon has developed a fever in the hospital, and is being monitored and tested.
posted by roomthreeseventeen at 5:28 PM on October 24, 2014


twist my arm: dumb question: who doffs the doffing partner after they walk off with that bag of hazardous material?

Yes, the doffing partner has to doff themselves.

At the NBU the people in the room go in for shifts of 3-4 hours. On exiting the room they can be mentally and physically tired (not to mention dehydrated) and therefore the potential exists to make mistakes in the doffing process - hence the doffing partner to guide the process and provide assistance.

The doffing partner is considered to be less likely to make mistakes removing their own personal protective equipment, as they have not had the additional load of taking care of the patient in the room.

Obviously, there does exist a potential for self contamination during the doffing process. This will vary greatly depending on the transmission method of biological agent in question.
posted by zedbends at 5:46 PM on October 24, 2014 [3 favorites]


Nurses ought to be celebrated like soldiers are. We should have a national holiday to honor them.

Here's a novel thought--just give them a decent eight hour shift!
posted by BlueHorse at 7:55 PM on October 24, 2014 [2 favorites]


I think arguments that we shouldn't worry about Ebola because it hasn't killed a bunch of Americans yet are kind of stupid

That's not anybody's argument. No one is saying "we shouldn't worry about Ebola." We're saying that the precise level of threat that Ebola presents is pretty well understood. It's not some crazy new disease that no one knows anything about. It's been studied fairly extensively for some time. We've observed numerous outbreaks--and those in places with far poorer infrastructure for dealing with disease outbreaks than the US. We know that it is extremely improbable that Ebola will become a major, widespread public health disaster in the United States. As communicable diseases go it's a fairly hard one to catch and at the point when you're most infectious you're also very evidently extremely unwell.

This is not a situation of seeing a comet hurtling towards us and saying "hur hur, that comet hasn't killed anyone yet, so I guess it's not a problem." Who should be "worried" about Ebola? By and large the people who will treat patients who are seriously ill from the disease. If you're not one of those people--i.e., if you're one of the 99.9999999999% of Americans who are not nurses or doctors who will be tasked with providing care to the small number of cases of people suffering from Ebola that will be either brought to or discovered in the USA, it should be somewhere on your list of concerns well below "hey, does that thing on my toe look funny to you?"
posted by yoink at 9:09 PM on October 24, 2014 [7 favorites]


All I know is, if I end up infected with Ebola (yeah, right), I'm heading straight for the Walton family compound. Sure I'll be shot dead within a short distance of entering, but then their people will have to deal with my bodily fluids. (Just kidding NSA!)
posted by InsertNiftyNameHere at 10:41 PM on October 24, 2014


HIV is spread by bodily fluids. Yes, theoretically, you could get bodily fluids somewhere and someone else could make contact with them fast enough to catch it. But to my knowledge, nobody has ever been established--ever--as having gotten HIV from casual contact. Ebola is not going to go differently. These people who were out in the community were out at a time where they felt basically fine; the viral load becomes dangerous at precisely the time that people in the US are already going to be in the hospital. The reason all those complicated hospital procedures are necessary is that the chance of catching it at that point escalates dramatically. Those aren't the procedures you need to be safe from someone who just started running a temperature.

Like HIV, it's something that needs to be taken seriously by the government and the medical community, but that doesn't mean it's something that we as individual citizens need to freak out about getting from our everyday lives. By the time it gets more dangerous than that, people are in hospital settings, and that's where the response should be focused, not on soothing people who've been worked into a frenzy by the television.

I got to reading a lot about this because, yes, I was nervous, because Amber Vinson is from my neighborhood and had been in my neighborhood. I went to the grocery store this afternoon and drove past the bridal shop in question. But I'm not nervous anymore. This thing was dangerous but occasionally survivable before, and the world's getting better at dealing with it on a daily basis. There have been all kinds of mistakes made, but I'm not worried about getting it from a shopping cart that was touched by a person who was in a bridal shop with a person who had been infected with Ebola but was at that stage not yet symptomatic. That way madness lies.
posted by Sequence at 11:09 PM on October 24, 2014 [3 favorites]




"...getting dialysis and being intubated, both of which the WHO says won't do shit to prolong life"

Actually those are 2 procedures Emory performed to prolong (and save) the American WHO doctor's life.

(It's an interesting read if you have the time.)
posted by aielen at 7:31 AM on October 25, 2014 [1 favorite]


I should have posted this yesterday - it's really interesting.

A one hour talk/Q&A by Dr Don Francis on the Ebola outbreak. Dr Francis was on the front line of the early Ebola outbreaks as well as the early HIV days. It's pretty fascinating to hear him talk about his experiences in Africa years ago. He says that hospitals and caretakers will always be the most exposed and the vector for transmission given the nature of disease. I am not a scientist or medical person so my language may be imprecise, but if this is a topic that interests you, this is must listen.
posted by madamjujujive at 7:46 AM on October 25, 2014 [2 favorites]


Here's a novel thought--just give them a decent eight hour shift!
posted by BlueHorse


Perhaps surprisingly 12 hour shifts are greatly preferred by most nurses I've talked with about this (which is a lot), certainly those with young families.

However I am all for paying nurses a good deal more than bond traders.
posted by spitbull at 9:01 AM on October 25, 2014 [1 favorite]




Man, they're testing against placebo. I understand the theory behind that but... wow. Desperate times I guess.
posted by Justinian at 9:59 PM on October 25, 2014


Dallas Morning News: UTA grad isolated at New Jersey hospital as part of Ebola quarantine
I am scared about how health-care workers will be treated at airports when they declare they have been fighting Ebola in West Africa. ... I wondered what I had done wrong. ... I had tried to help when much of the world has looked on and done nothing.
posted by tonycpsu at 8:56 AM on October 26, 2014 [1 favorite]




if I end up infected with Ebola (yeah, right), I'm heading straight for the Walton family compound

Look, John-Boy didn't even know he was coming down with a cold that time. Can't you just let it go?
posted by yoink at 11:25 AM on October 26, 2014 [2 favorites]


The Ebola Wars
posted by roomthreeseventeen at 10:23 AM on October 27, 2014 [1 favorite]


Apparently the nurse that they detained at Newark Airport this afternoon has developed a fever in the hospital....

That is completely not true. I encourage you to provide a source when passing along "apparent" information in an ebola thread. Here's what the nurse herself said about the idiotic, unnecessarily obnoxious way she was treated:

One after another, people asked me questions. Some introduced themselves, some didn’t. One man who must have been an immigration officer because he was wearing a weapon belt that I could see protruding from his white coveralls barked questions at me as if I was a criminal...

I was tired, hungry and confused, but I tried to remain calm. My temperature was taken using a forehead scanner and it read a temperature of 98. I was feeling physically healthy but emotionally exhausted. Three hours passed. No one seemed to be in charge. No one would tell me what was going on or what would happen to me.

I called my family to let them know that I was OK. I was hungry and thirsty and asked for something to eat and drink. I was given a granola bar and some water. I wondered what I had done wrong.

Four hours after I landed at the airport, an official approached me with a forehead scanner. My cheeks were flushed, I was upset at being held with no explanation. The scanner recorded my temperature as 101. The female officer looked smug. “You have a fever now,” she said. I explained that an oral thermometer would be more accurate and that the forehead scanner was recording an elevated temperature because I was flushed and upset.

I was left alone in the room for another three hours. At around 7 p.m., I was told that I must go to a local hospital. I asked for the name and address of the facility. I realized that information was only shared with me if I asked.

Eight police cars escorted me to the University Hospital in Newark. Sirens blared, lights flashed. Again, I wondered what I had done wrong. I had spent a month watching children die, alone. I had witnessed human tragedy unfold before my eyes. I had tried to help when much of the world has looked on and done nothing.

At the hospital, I was escorted to a tent that sat outside of the building. The infectious disease and emergency department doctors took my temperature and other vitals and looked puzzled. “Your temperature is 98.6,” they said. “You don't have a fever but we were told you had a fever.”

After my temperature was recorded as 98.6 on the oral thermometer, the doctor decided to see what the forehead scanner records. It read 101. The doctor felt my neck and looked at the temperature again. “There’s no way you have a fever,” he said. “Your face is just flushed.”


Again, the *way* Chris Christie's minions handled this is the real problem. I'm as furious as anyone at that NBC "doctor" who unilaterally decided she was ok, and also think that other doctor was an ass for going bowling before the 8-10 day period when most folks show symptoms was over, but this nurse has a valid point: she was treated like shit for no good reason.
posted by mediareport at 2:58 PM on October 27, 2014 [8 favorites]




I don't know why I bother checking the CNN website. They had two separate headlines just now:

"Maine judge orders quarantine for nurse Kaci Hickox"

and

"Maine judge rejects quarantine for nurse Kaci Hickox".

Thanks, CNN. Heck of a job.
posted by Justinian at 11:29 AM on October 31, 2014 [1 favorite]


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