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Phil LedererBOSTON, Ma. — It was Christmas Day. I was on call at the hospital and was waiting for my wife and 6-week-old son to come so we could eat lunch together. She was bringing kimbap, sweet potatoes, and avocados. But then my pager buzzed.

On the phone was a hospitalist physician.

“Is this ID? We have a new consult for you,” she said. “This man has a history of dementia. For some reason he has a urinary catheter to empty his bladder. We gave him an antibiotic, but now his urine is growing a resistant bacteria.”

I sighed. Yet another catheter associated urinary tract infection.

I walked up the stairs to his hospital room. He was bald, thin, and sitting alone in bed. The peas and fish on his tray were untouched. There were no gifts or tree in his room. I washed my hands, put on gloves and a yellow isolation gown, and introduced myself.

“How are you?”

“Ok, I guess,” he replied.

“Do you know where you are?”

“I’m not sure.”

“You are in the hospital. Do you know what day today is?”

Continue reading “Got an Infection? Good Luck Finding an ID Doctor”

flying cadeuciiAt 6:30 AM, I kissed my 14-week-old son Joe on the forehead and headed off to work at the hospital. By 3 PM I was back in bed with a hacking cough and a fever.  I had influenza.

As a doctor training in infectious diseases, I knew that the flu can be dangerous in vulnerable populations like little babies. I had visions of Joe being admitted to the pediatric intensive care unit, as I swallowed a pill of oseltamivir (brand name “Tamiflu”) and shivered under the covers.

Should I also give my little boy Tamiflu to prevent him from getting sick? The answer should be clear to an infectious disease physician-in-training, right?

I felt competing instincts. Paternal: to “do something” to prevent Joe from getting the flu. Medical: “do nothing,” as the rampant overuse of antibiotics in children has had negative consequences and the same might be true for antivirals.

As I researched the question further, I learned that the decision to give prophylactic Tamiflu is anything but simple.

Close contacts of people with the flu (including babies) can receive Tamiflu if they are at high risk for influenza complications. One Greek study of 13 newborns found that the drug was safe but did not address its effectiveness. Moreover, the number of babies who would need to receive Tamiflu to prevent one serious case of influenza is unknown.

Continue reading “Dad Has the Flu and There’s a Baby at Home”

flying cadeuciiCall it a tale of two infections. It’s the story of how hospitals have blocked transmission of a dangerous infection that patients can give doctors, while a hospital-caused infection that can kill patients continues to be widely tolerated. It involves saved lives and endangered ones ­– and also of billions of dollars spent needlessly due to unsafe care.

The infection that’s been conquered is occupational transmission to doctors and other health care workers of HIV, the virus that causes AIDS. When AIDS first burst on the scene in the early 1980s, it was “disfiguring, debilitating, stigmatizing and inevitably fatal,” in the words of Dr. Paul Volberding, a treatment pioneer. With the disease’s spread poorly understood, “the fear of contagion [was] hanging over our heads,” Volberding recalled.

However, once the mode of transmission was identified– exposure to HIV-infected blood or other bodily fluids – precautions were rapidly put into place. From 1985 through 2013, there were just 58 confirmed cases of occupationally acquired HIV infection reported to the Centers for Disease Control and Prevention (CDC), according to a Jan. 9 CDC report. Since 1999, there’s been only one confirmed case of occupational transmission, involving a lab tech infected via a needle puncture in 2008.

Reported occupational infection “has become rare,” the CDC concluded, likely due to prevention strategies and “improved technologies and training.” Continue reading “Safe Doctors, Unsafe Patients: A Tale of Two Infections”

flying cadeuciiThe recent Ebola cases and fatality have triggered a collective process of finger pointing as we struggle to understand events and hold someone accountable.

Hence, the television footage of health officials hauled off to Congress, accusatory headlines (“Alarming stumbles by the C.D.C.”) and appointment of czars. In the desire to pin the blame somewhere, notably the Centers for Disease Control and Prevention (CDC), we overlook the essential fact that in the United States public health responsibilities are fragmented among federal agencies, and decentralized throughout state and local government. The laws and regulations governing public health activities at federal, state and local levels is truly wonky terrain, but understanding these details is critical to being able to improve our response to public health emergencies. We need to know who actually has the authority to deal with specific public health functions and who should be held accountable (spoiler alert – it is not the Czar, nor the Secretary at DHHS, nor the Surgeon General, nor the Director of CDC). Often, it is a state health official, local health official or professional organization. Continue reading “Who Do We Blame Now?”

In response to several reader questions on the CDC post on safe handling of Ebola and recommended lab procedures, the CDC got back to us with this update:

In the Ebola guidance for healthcare workers and specifically for Specimen Handling for Routine Laboratory Testing  of  persons under investigation (PUI) for Ebola disease , CDC reminds all laboratory personnel to consider all blood and body fluids as potentially infectious.  The guidance further informs laboratory personnel that strict adherence to the OSHA bloodborne pathogen regulations and Standard Precautions protects laboratory workers from bloodborne pathogens, including Ebola. In this guidance, emphasis is placed on the OSHA regulation’s requirement for performance of site-specific risk assessments.  These assessments should consider the path of the sample throughout the laboratory, including all work processes and procedures, to identify potential exposure risks and to mitigate the risks by implementing engineering controls, administrative controls (including work practices), and appropriate PPE to protect laboratory personnel.  Implementation of these recommendations requires that there is designated staff that is trained, competent, and confident in performing risk assessments within their laboratories.

Continue reading “Update on CDC Guidelines on Ebola Specimen Handling + Lab Testing”

flying cadeuciiSome years ago I was in Australia’s Northern Territory. The intrepid explorer that I was, I was croc-spotting from the comfortable heights of a bridge over the East Alligator River. The river derives its name because it is east of something. And because it’s croc-infested.

I was reading a story about a German tourist (it’s usually a German) who was attacked by a saltwater crocodile in the vicinity (1). The story concluded to reassure that one is more likely to be killed by a vending machine than a saltwater crocodile.

I imagined what the apotheosis of a left brain thinker, the data-driven Renaissance man, might have done with that statistic. Might he have peeked in to the East Alligator River looking for a vending machine and seeing none, jumped right in?

This empirical fact is useful if you suffer from croc-phobia and live in the Upper East Side of Manhattan, and the biggest voyage you ever plan to undertake is to the Hamptons. But it’s not terribly useful, and marginally harmful, if you’re deciding whether to kayak rivers in Northern Australia.

The vending machine has reared its deadly head again. It seems that more Americans have been killed by vending machines than have died from Ebola. Well let’s head to Liberia for the winter, because there are fewer vending machines there.

Sorry, I jest. But this is not a joke. Some actually think this is a relevant statistic to put Ebola in perspective. And some are actually reassured by it!

Continue reading “The Antifragile CDC”

When Thomas Eric Duncan first came into the hospital, he arrived with an elevated temperature, but was sent home.

On his return visit to the hospital, he was brought in by ambulance under the suspicion from him and family members that he may have Ebola.

Mr. Duncan was left for several hours, not in isolation, in an area where other patients were present.

No one knew what the protocols were or were able to verify what kind of personal protective equipment should be worn and there was no training.

Subsequently a nurse supervisor arrived and demanded that he be moved to an isolation unit– yet faced resistance from other hospital authorities.

Lab specimens from Mr. Duncan were sent through the hospital tube system without being specially sealed and hand delivered. The result is that the entire tube system by which all lab specimens are sent was potentially contaminated. Continue reading “Statement from the Dallas Nurses”

Texas Health Presbyterian

A group of nurses at Texas Health Presbyterian has come forward with a very different picture of what happened when Liberian Ebola patient Thomas Duncan arrived at the hospital with Ebola-like symptoms on September 28th.  If true, the allegations are certainly unsettling.

In an unusual move, the nurses spoke anonymously to the media, conducting a blind conference call in which none of the participants were identified.

After arriving at the emergency room with a high fever and other symptoms of the disease , the nurses said the patient was kept in a public area, despite the fact that he and a relative informed staff that he had been instructed to go to the hospital after contacting the Centers for Disease Control in Atlanta to report a possible case of Ebola.

Continue reading “Angry Nurses Tell of Ebola Patient’s arrival at Texas Hospital”

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The Dallas hospital at the center of the Texas Ebola outbreak has changed its story.

Last Thursday, the hospital blamed a poorly designed electronic medical record for the failure to diagnose Duncan when he arrived at the hospital’s emergency room with symptoms consistent with Ebola, including a fever, stomach cramps and headache. According to the initial story, a badly designed electronic health record workflow made it difficult for doctors to see details of Duncan’s West African travel.  Duncan was sent home.  Very bad things happened as a result, as we all know by now.

On Friday, the hospital reversed itself without explanation.

The new statement:

Clarification: We would like to clarify a point made in the statement released earlier in the week. As a standard part of the nursing process, the patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event. [ Full text ]

In other words: The EMR didn’t do it.

When the EMR story came out Thursday, critics jumped all over it. It did sort of make sense to some people, especially people who aren’t  fans of electronic medical records. The idea that a piece of key information could get lost in the maze of screens and pop ups and clicks in a complex medical record sounded plausible.

A lot of other people weren’t buying it:

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The swiftness of the hasty retreat led some critics to speculate that Texas Health’s statement Thursday provoked the wrath of EPIC, the hospital’s EMR vendor.  Industry critics pointed out that many major EMR vendors, EPIC among them, often include strongly worded clauses in contracts that forbids customers from talking publicly about their products.

After this story was posted, EPIC contacted THCB with a response via email. Company spokesman Shawn Kieseau wrote:

We have no gag clauses in our contracts.  We had no legal input or participation in our root cause analysis discussions with Texas Health staff on this issue.  Texas Health’s correction is appropriate given the facts in this situation.

Continue reading “Hospital at Center of Ebola Outbreak Reverses Its Story”

Tom Frieden optimized

There has been a lot of fear about Ebola. The health care workers who care for Ebola patients are right to be concerned – and they should use that concern to increase their awareness and motivation to practice meticulous infection control measures.

Ebola virus is transmitted through direct contact with bodily fluids of an infected person who is sick with Ebola, or exposure to objects, such as needles, that have been contaminated with infected secretions.

Travel from Affected Region

There is a risk for Ebola to be introduced to the United States via an infected traveler from Africa. If that were to happen, widespread transmission in the United States is highly unlikely due to our systematic use of strict and standard infection control precautions in health care settings, although a cluster of cases is possible if patients are not quickly isolated. Community spread is unlikely due to differences in cultural practices, such as in West Africa where community and family members handle their dead.

CDC has advised all travelers arriving from Guinea, Liberia, Nigeria, and Sierra Leone to monitor their health for 21 days and watch for fever or other symptoms consistent with Ebola. If they develop symptoms, they should call ahead to their hospital or health care provider and report their symptoms and recent travel to the affected areas so appropriate precautions can be taken.

Continue reading “The Ebola Outbreak: The CDC Director’s Guidance for Health care workers”

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