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New Yorkers Learn Hard Ebola Lessons From Dallas

Monday, 27 October 2014 12:21 PM

Dallas breathed a collective sigh of relief after Nina Pham, a nurse infected with Ebola, was discharged and declared free of the virus. Now it’s New York City’s turn to flip out.
Craig Spencer, New York’s first patient to test positive for the deadly Ebola virus, had the run of the city before he checked into Bellevue Hospital Center three days ago with a 100.3 degree fever. Spencer traveled from his Harlem apartment on three subway lines, first for a walk on the High Line park for a cup of Blue Bottle coffee and then, the following day, to Williamsburg, Brooklyn for an evening of bowling before returning home via an Uber taxi.
Spencer’s outings present a nightmare scenario for medical experts. They’re now retracing his steps, even as Mayor Bill de Blasio and Governor Andrew Cuomo seek to calm the city’s 8 million residents.
To understand what New York health experts and public officials are contending with and what their days ahead may be like, experts are scrutinizing Dallas’ Ebola learning curve.
“We are as ready as one could be for this circumstance. What happened in Dallas was exactly the opposite,” said Cuomo at a press conference on Thursday.
The Dallas story begins with Thomas Eric Duncan’s first arrival in the emergency room of Texas Health Presbyterian Hospital Dallas, at 10:37 p.m. on Sept. 25.
What, exactly, Duncan told the nurse is still disputed. Sometime between 12:33 a.m. and 12:44 a.m. on Sept. 26, the nurse noted on the electronic records system that Duncan “came from Africa 9/20/14.” Duncan’s sister and nephew have said Duncan told the nurse he was from Liberia.
Wendell Watson, a hospital spokesman, declined to comment when asked what Duncan had told the nurse.
Unseen Notes
Whatever Duncan said, it appears that the doctor who next met him did not see the nurses’ notes. Sometime around 1 a.m., the doctor gathered Duncan’s personal data, which shows “Mr. Duncan and his companion advised that he was a ‘local resident,’ and that he had not been in contact with sick people,” according to a timeline that the hospital provided to Congress.
By 3 a.m., Duncan was still in the hospital, hooked up to an intravenous saline drip and given Extra Strength Tylenol. His temperature was 103 degrees Fahrenheit, a high fever. Half an hour later, when it lowered to 101.2 degrees, he was discharged with a diagnosis of sinusitis and abdominal pain.
Five days later, on the day the CDC announced Duncan had tested positive for Ebola, CDC Director Tom Frieden told the public that there was nothing to worry about and that the nation’s hospitals were well equipped to deal with the deadly virus. “Virtually any hospital in the country can do isolation for Ebola,” he said at a press conference in Atlanta.
Up to Speed
At about this stage, Judge Clay Jenkins, Dallas county’s top executive who was about to become a central public figure in the Dallas response, was just getting up to speed. When Duncan returned to the hospital a second time in an ambulance on Sept. 28, the hospital suspected Ebola and notified the CDC and the state immediately, he said.
The next day, the hospital had a positive diagnosis, according to a statement issued Oct. 2. The state and the CDC said they ran tests on Sept. 30.
But Jenkins said that he wasn’t made aware of what was happening in his own county during those first two critical days. He first found out about Duncan on Sept. 30, he said.
“I didn’t know at the time that I would be at the center of the response effort,” Jenkins said.
Behind the scenes, the CDC’s contact tracing team, a special unit created to track everyone with whom Duncan had come into contact, was scrambling. After interviewing Duncan, they fired off calls to more than a hundred people to whom the disease could have potentially spread.
‘Stigma Attached’
“You try to do it gently,” said David Daigle, the communications officer for the team, in an interview last week. Daigle was dispatched to Dallas and has now been sent to New York. ‘There’s such a stigma attached to Ebola. You expect to see it in West Africa but not in Dallas County.’’
The conversation starts like this: “I’m so-and-so, with Dallas County, working on the investigation with the CDC, we’re contacting to follow up because you had a possible contact or exposure to a patient with Ebola.”
The callers are often greeted by silence.
“There are some people who might have gotten a little emotional,” Daigle recalled, so the contact tracers have to be more than just good investigators and interviewers, they also have to do on-the-spot counseling. “I understand you’re scared, but we may have to work with you and trace you daily,” they’ll say, said Daigle.
More than a week after Duncan was diagnosed, nurse Pham called the hospital, warning that she had a fever and that she was coming in.
Back Home
Daigle was back home in Atlanta. The eight to 10 day window when symptoms were most likely to surface had passed for the first 48 contacts of Duncan, so the CDC said he, and a few others, could go home.
“I was home Friday night, had Saturday with the kids, then Sunday morning I woke up at 5:30 or 6 a.m. and I looked at my emails and was like, ‘Oh, no!’” he said. “So a whole bunch of us went back to the airport.
Pham’s infection set off alarms. The 26-year-old nurse had worn protective equipment the entire time she cared for Duncan, and Friedan said at a news conference there had been ‘‘a breach of protocol,’’ suggesting Pham had not properly followed guidelines for putting on and taking off gear.
Some nurses listening to Frieden’s comments were infuriated that the CDC seemed to be blaming Pham. On Oct. 14, a ‘‘handful’’ of hospital staff, some who had cared for Duncan personally, called National Nurses United, a California-based union that represents 185,000 nurses in the U.S.
‘Statement of Facts’
‘‘We met with them by conference’’ call, said union head Deborah Burger in an interview last week. She declined to say exactly how many nurses called. ‘‘They put together a statement of facts that all of the nurses agreed to, got it back to us, and they signed off on the statement. It was their voice.’’
Pham was not at fault, the nurses said. Nurses working with Duncan had inadequate equipment, such as gowns that exposed their neck, leading the staff to use medical tape to wrap their necks.
The anonymous nurses’ accusations were damning, not just for the hospital but to the CDC’s insistence that all hospitals had been trained and were ready to handle an Ebola patient.
While the hospital has disputed these charges, the CDC issued new guidelines this week, saying health workers caring for Ebola patients shouldn’t have any skin exposed, must undergo rigorous training and be supervised by a qualified monitor. The protocols are more specific than previous recommendations, including prescribing the types and numbers of gloves and boots to be used.
‘Textbook Example’
‘‘If there was a textbook for how to spread Ebola, Dallas was the prime example,” said Burger.
New York may already be benefiting from Dallas’ learning experience. While the CDC originally said any hospital could handle Ebola, it’s now encouraging states to designate go-to hospitals. Bellevue was one of the first to be named, and has had extra time to prepare.
The CDC also dispatched a “go” team of experts even before Spencer’s tests came back positive. Three people were sent Thursday, including an expert in hemorrhagic fever, and four more were dispatched Friday. In Dallas, it took 6 days from the time Duncan first walked into a Dallas emergency room with a 103-degree fever and was sent home, to when the nation’s top disease detectives interviewed him.
Contact tracing is critical in preventing the spread of Ebola. Spencer alerted Bellevue as soon as he had a fever, unlike Duncan, who had a fever and was released by the hospital, which lessens the likelihood that he’d have transmitted the virus to even close contacts, said Mary Bassett, New York City’s health commissioner, in a news conference Friday.
Reviewing Contacts
Still, the city is reviewing possible contacts in the days leading up to Spencer’s fever, as he reported fatigue, a task made more challenging by Spencer’s extensive travels within the city. New York and New Jersey will now quarantine any traveler from West Africa who had direct contact with Ebola patients.
As the next days unfold, Dallas’ rocky experience will be in New York’s mind, said Irwin Redlener, a professor of health policy at Columbia University and adviser to de Blasio.
“Horrendous mistakes were made, not only by the hospital but by the public health agencies” in Dallas, Redlener said at a press conference outside Bellevue.
“Everyone in the health-care business feels in a way, ’Thank God it wasn’t us,’ because those same kind of mistakes could’ve been made elsewhere. I don’t think that’s going to happen here.”

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Dallas breathed a collective sigh of relief after Nina Pham, a nurse infected with Ebola, was discharged and declared free of the virus. Now it's New York City's turn to flip out. Craig Spencer, New York's first patient to test positive for the deadly Ebola virus, had the...
Ebola, virus, lessons, New York Dallas
Monday, 27 October 2014 12:21 PM
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