On Thursday, I had an experience-based hunch about the Dallas Ebola case:
Who missed Ebola? I assume nurse entered travel history into electronic record & doctor didn't grasp significance. Will any reporter ask?
— Steve M. (@nomoremister) October 2, 2014Easy to blame nurse (see, e.g.: http://t.co/doLd65s5kT). But docs often act as if info is less important than their instincts
@nomoremister
— Steve M. (@nomoremister) October 2, 2014Also, docs are taught "When U hear hoofbeats, think horses, not zebras." Leads them to dismiss possibility of rare conditions. @nomoremister
— Steve M. (@nomoremister) October 2, 2014Then we learned -- or thought we learned -- that the intake software didn't present Thomas Duncan's travel history to the doctors. Now we find out that wasn't true:
Dallas Hospital Alters Account, Raising Questions on Ebola CaseLet me venture a guess as to what happened, based on recent (and not-so-recent) experiences with the health care system.
... the hospital that is treating the patient and that mistakenly sent him home when he first came to its emergency room acknowledged that both the nurses and the doctors in that initial visit had access to the fact that he had arrived from Liberia.
For reasons that remain unclear, nurses and doctors failed to act on that information, and released the patient under the erroneous belief that he had a low-grade fever from a viral infection....
It's true that a lot of medical professionals are still getting used to electronic record-keeping. They probably haven't developed an instinct for where to look on the screens for the most important information.
On the other hand, long before electronic record-keeping in medicine, I noticed that doctors barely read any patient information before seeing someone. Quite a few times over the years I've been asked to get a test of some kind -- usually a blood test -- and then, when I showed up for a follow-up visit, often weeks after the test results were sent to the office, I watched the doctor skim the results in a few seconds just after entering the examination room to see me.
Doctors don't familiarize themselves with written information before seeing patients. To me it seems that they diagnose on observation, experience, and instinct far more than on data.
Plus, they've been told since med school to diagnose following the dictum "If you hear hoofbeats, think horses, not zebras." This advice is supposed to tell them: Consider common conditions first, before considering rare ones. In practice, I believe most doctors interpret it as: Don't trouble your head with rare or unusual diagnoses.
I may be misinterpreting how doctors work, but I've had a couple of long periods in my life when low-level but nagging conditions were repeatedly misdiagnosed, and this is what I've seen: not much attention paid to data, and not much willingness to consider less obvious diagnoses.
I think that's what happened in Dallas -- the doctors didn't read, and Ebola was assumed to be a zebra. That mustn't happen again.
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(More responses to this story at Memeorandum.)
9 comments:
Great minds think alike:
http://www.newyorker.com/news/daily-comment/ebola-epidemic-stoppable
Or, most of the interaction with the patient was with much lower paid patient access/receptionist, then a CNA gathering data, with the nurse and/or the doctor coming in for a few moments each.
Hospitals around here are cutting pay and increasing responsibility and workload for now part-time "on call" patient access staff who now need CNA accreditation. Patient access used to pay $15-17 an hour, and CNAs got about $20, but now the positions are combined and being paid $12 an hour.
Your (very) plausible theory RE: who f'kd up illustrates why tort reform is so dangerous.
Mr. Aimai and I onceworked on a computer based simulation to train ER doctors on how to spot anthrax. This turns out to be basically impossible unless there is an Anthrax scare on that is in the forefront of everyone's mind-and even then you would probably get hundreds of false positive diagnoses rather than catch the real one.
ERs are not a great place to catch a serious disease that is a) unusual and b) unfolding. All these illnesses present looking just like a more or less severe version of something totally normal. Unless it has progressed so far that the patient is incapacitated and needs to be hospitalized the patient is going to be sent away from the ER. There is ENORMOUS pressure on ERs and hospitals not to admit people "just for observation" or on a hunch.
Patient zero is almost always going to be missed. That's just the reality of the situation.
For reasons that remain unclear, nurses and doctors failed to act on that information, and released the patient
Doctors released the patient. As far as I know, nurses don't have that authority.
Exactly.
My sister-in-law had no medical insurance when she started having severe pain in her abdominal area. In order to save money, I took her to a private clinic that would cost less than an ER visit would in case is wasn't appendicitis.
The doctor at the clinic said that she displayed all the classical signs of appendicitis.
When I took her to the ER, the doctor asked if she had had a BM that morning. Told that she did, the doctor stated she probably didn't have appendicitis, because it's not usual that one can have a BM without bursting the inflamed appendix.
Fortunately for my S-I-L, they ran a quick MRI on her and found, that yes, she did have appendicitis, and, looking back at her history, she probably had a chronic, ongoing low-grade infection until it flared up, which, of course, would allow for a BM that wouldn't bust her appendix like a squeezed grape.
This wasn't even zebra tracks, it's just the fact that in some cases, infections won't act like they do in the majority of the population or the textbooks about them.
Can't we just blame Obama?
I think Fraud Guy is onto something. The "cost trimming" in hospitals and medical practices, powered by insurance companies and Medicare, are lowering reimbursements to healthcare institutions and doctors, forcing professionals and their staff to see more people, in less time, for fewer bucks.
What did you expect to get for that – healthcare improvements?
All insurers, including Medicare, have to shell out more. Otherwise, you'll find not only Ebola-sized mistakes, but also more docs fleeing patients who are covered by insurance in favor of richer patients who can afford healthcare without insurance. It's already not only starting to happen, but accelerating in some areas. And that, too, will create more privilege for the rich and lousy healthcare for the rest of us.
Yours crankily,
The New York Crank
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