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NFT: Second TexasHealthcare Ebola Patient Traveled

BigBlueDownTheShore : 10/15/2014 12:05 pm
on a plane the day before she was diagnosed positive for it.

This shit is getting really scary very quickly.
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That's what they say  
buford : 10/16/2014 11:12 am : link
the hospital says his fever wasn't that high and they were following CDC guidelines. Obviously that was wrong, but it's not the hospitals fault and it didn't have anything to do with insurance.
Bill L  
SwirlingEddie : 10/16/2014 11:34 am : link
Please post back if you get any further info on transmission/contagion relative to symptoms. I'm very curious about the current threshhold of fever (100.4 apparently lowered now from 103!) as the point of risk to take treatment or quarantine actions.

Thanks!
And where is this coming from?  
Cam in MO : 10/16/2014 11:38 am : link
Quote:
To blame it on the hospital or no insurance or racism or whatever they come with next is absurd.


The only mention of any of that in what the nephew wrote is the insurance thing I quoted above- in which he just accuses them of fucking up and says we don't know why or how exactly.


RE: Bill L  
Bill L : 10/16/2014 1:15 pm : link
In comment 11923052 SwirlingEddie said:
Quote:
Please post back if you get any further info on transmission/contagion relative to symptoms. I'm very curious about the current threshhold of fever (100.4 apparently lowered now from 103!) as the point of risk to take treatment or quarantine actions.

Thanks!


I can't find info on that and the people that i've asked don't have a good answer.

However, there is a very good article in today's NEJM that talks about the epidemic and discusses mortality rates etc. It actually addresses the rates question that montana and I mentioned yesterday. Their estimate is 71% mortality. One interesting finding was that there is an average of 5 days between when a person becomes symptomatic and when they're admitted to the hospital. That's pretty scary IMO. Of course, it's in Africa and not the US but they also found that the number was the same for regular people and health care workers. Since health care workers should be the more informed and culturally modern, that might (or might not) say something about how people would act here.
RE: And where is this coming from?  
Bill L : 10/16/2014 1:16 pm : link
In comment 11923059 Cam in MO said:
Quote:


Quote:


To blame it on the hospital or no insurance or racism or whatever they come with next is absurd.



The only mention of any of that in what the nephew wrote is the insurance thing I quoted above- in which he just accuses them of fucking up and says we don't know why or how exactly.



There have been a few reports of Jesse Jackson and John Wiley Price (a crazy Dallas councilman) claiming that Duncan died in large part due to neglect or non-use of experimental therapeutics completely due to his race.
Bill  
ron in new mexico : 10/16/2014 1:34 pm : link
I think the reason for the confusion on the fever is the CDC itself(no surprise there).
Reading through their literature today they list for medical health care professionals a fever of 101.5 symptomatic of ebola. However in the section on airline travel, in the general section(I did not peruse all potential documentation related to this) they state fever only. They then go about describing symptoms of a fever.

So it appears in general terms for airline travel any fever is a reason for a airline to deny the ability of a person to fly(accompanied with flu like symptoms and travel history). However in ER treatment Ebola is not suspected unless the symptoms are accompanied by a fever of 101.5.

A note on fever, some peoples normally have differing temperatures. It is rare but quite possible for someone to have a normal of 99.6 or 97.6. 98.6 is normal for about 6 billion of us but then we may have still millions that have normals which differ.Statistically it is very rare but it happens and environmental circumstances may in fact very greatly affect body temp. When cold we may drop a degree or 2 when hot up a degree or 2 as in when exercising .
Did insurance status have anything to do with the first patients medical ER treatment……. I would say absolutely not. Most admitting in hospitals ER's have separate personal doing the paperwork and they rarely if ever communicate with the medical staff. The nurses and docs don't have a clue if who they are treating is insured or not. Later on when admitted it is then that insurance comes into play.

There is some dispute on the temperature of the first patient in the ER. I have heard 103. If that is true he was released back to the community considering his history of travel inappropriately.
If that is true the hospital screwed up big time. As they did with their infection protocols when treating the patients allowing 2 nurses to get ebola.
I suspect it is true, this hospital is worse than the CDC, they seemingly really suck. the CDC as displayed by their contradictory statements on temperature which confuses and causes concern unnecessarily, just plain suck.

No offense to the docs and nurses working at the hospital nor the scientists and such at the CDC, this is most certainly a administrative issue.

They do advise health care peoples to call the CDC with questions on diagnosis of ebola but do not make any statements on their advise or protocols being mandatory or binding. To my read that establishes them as a resource but not a director of treatment in a professional health care context(rightly so I would say).
No insurance is definately a culprit  
WideRight : 10/16/2014 1:38 pm : link
Those who call it absurd don't know anything about how ERs triage.
God Forbid someone with arthritis gets Ebola  
Bill L : 10/16/2014 1:43 pm : link
and is taking tylenol everyday.
A comment about insurance in ER's  
ron in new mexico : 10/16/2014 1:51 pm : link
years and years ago the federal government found in necessary to establish a right to care for patients. Basically they enacted legislation that forced hospitals to care for all patients in a emergency context.

Subsequent to that hospitals found the necessity for care but no funds to pay for this care. A situation whereby they would lose cash on a daily basis and soon go out of business.
Varying solutions some based solely on the federal medicaid model some based upon state initiatives arose.
These solutions allowed hospitals to be paid back by state or local governments for no retrievable health care costs subsequent to the federal mandate for care.

The solutions by state vary greatly, in how the hospitals are paid. But ER visits are compensated for in all states by some manner by public funding of some sort. NM uses part of a land tax delegated to this

When admitted this no longer applies and degree of care is greatly affected by insurance coverage or lack of. In the ER I would say never.
A note on the CDC  
ron in new mexico : 10/16/2014 2:00 pm : link
some may be familiar with them and some not so much.

This is not like FEMA, boots on the ground, hands on people, who have done the job and are drawn from the real world.
Largely to my experience they are academics drawn from that type of environment. Great teachers, scientists epidemiologists, perhaps but these peoples are not ones you would choose to handle emergency situations.

This is not how their organization is set up nor functions as a emergency response unit.
These are peoples who you go to on advise on how to textbook, handle things. The real world as Bill mentions with his exception on tylenol and arthritics, is not textbook.

So they guide but can not manage.To expect them to do so causes problems, some of which we are seeing.
The local health care communities must handle this crisis by developing responses guided by CDC instruction, but not depending upon them to each and every extent.
If our most recent experiences in the ER is an indicator  
Bill L : 10/16/2014 2:03 pm : link
sometimes not having insurance benefits you. Often times the mode of transport is by ambulance and people arriving in ambulances get bumped to the head of the line, no matter the underlying reason for coming to the ER in the first place.
That is true as well  
ron in new mexico : 10/16/2014 2:15 pm : link
but most ambulance/rescue crews will advise their patients if they need to go to the hospital by ambulance or not. One can absolutely refuse to go on their own to go by taxi or some other means and go by ambulance, but that is rare. Most places no longer provide bill free transport, regardless if the transport is by public entity or not.

Typically they are told up front, this ride costs money and you can save a bill by not going by ambulance(if they don't need to). Ambulances in most places are set up as separate entities from hospitals in a legal sense and bill separately.

But absolutely right, ambulance patients receive first treatment. It is assumed their conditions are worse then walkers in.
RE: And where is this coming from?  
buford : 10/16/2014 2:15 pm : link
In comment 11923059 Cam in MO said:
Quote:


Quote:


To blame it on the hospital or no insurance or racism or whatever they come with next is absurd.



The only mention of any of that in what the nephew wrote is the insurance thing I quoted above- in which he just accuses them of fucking up and says we don't know why or how exactly.



Cam, this is in the article

'But he was a man of color with no health insurance and no means to pay for treatment, so within hours, he was released with some antibiotics and Tylenol.'.

So which is it? They fucked up or they are racist and didn't want to treat him because he had no insurance?
So ron...  
WideRight : 10/16/2014 2:25 pm : link
Your patient just shows up from Africa with a fever a no insurance. Its low grade he's otherwise well. Suspecting a tropical disease and admitting him will cost the hospital big $$$, and lead to reviews about necessary or unnecessary admissions by ER attendings (especially if you're wrong).
What do think is a likely outcome?

If your same patient had insurance and admitting him and testing would be profitable to the hospital (wether your hunch was right or wrong) what do you think would happen?
No one is going to make money off of an Ebola  
buford : 10/16/2014 2:37 pm : link
patient. It costs millions to treat them. The accusations are absurd.
WR  
ron in new mexico : 10/16/2014 2:43 pm : link
In theory what you say could happen.

In practice the ER staff is never critiqued on admissions unless there is a overt problem, like lots of peoples being admitted erroneously or potentially lots of people being not admitted.

The hospitals(some of them) have stats on how many patients percentage should result in admissions. Fall above or below that and they may study the issue to determine why. But that is a crew or shift study not a individual.

So docs have little fear of seeing their admissions being considered inappropriate by the rational of fee retrieval. A floor or speciality doc has no more pull nor weight in hospital administration than a ER doc. In fact the opposite is usually true as the ER docs position is very much harder to fill. And it is the docs who determine who is admitted and who is not. The nurses advise.
The billing is kept separate from the ER docs knowledge.

Docs have personal bias, and may for instance see a obvious homeless person being treated and refer him to a publicly run hospital in some places, but this is a personal bias and not a system bias.

Could that have happened to this guy…I'd say no probably not.The doc would not know by looking or talking with him if he was insured or not and has no reason to ask him. ASking him would in fact be inappropriate, by other than admitting or paperwork oriented staff. A medical professional person in a ER should never ask insurance status, it is simply not their job.So they don't do so. Other staff do so. They basically don't care.

When admitted…the whole story changes. Further treatment is absolutely determined by ability to pay and potential retrievability of monies.
In the ER no it is not that way. Never say never but 99.9% sure.
so  
GShock : 10/16/2014 4:00 pm : link
In one scenario, the aide workers who had ebola are admitted to Emory under the CDC's oversight - no problems, everyone gets better, and certainly none of the treating staff become infected.

In the other scenario, a guy with ebola walks into this hospital in Texas, but is discharged. Then he is readmitted, and not only does he die, but two of the nurses who treated him are infected, and a whole host of stories about the hospital's lack of preparedness seem to be trickling out.

It seems to me the hospital was just unprepared for this high risk/low frequency event.
Agree  
ron in new mexico : 10/16/2014 4:13 pm : link
hospitals largely have no economic interest in preparing for low frequency but high risk events.

Why redo your whole facility to provide for real isolation. Why train and certify peoples to perform in epidemic or potential epidemic situations that require isolation?
In NM with Wipp there was a economic benefit as Wipp related monies provided incentive. Remodel and establish protocols and you got fed funds, it was that simple. And Radiation directly translates to ebola and other things that require isolation.

Hospitals are largely for profit. Even if not publicly so they internally are devoted to cost containment.

This is one of the problems with a for profit insurance based health care system model in America.

The s hits the fan and there are going to be significant problems. This crisis is way way hyped and overblown ebola is just not that contagious.
What will happen when a real crisis like in 1918 deadly flu type thing occurs?
This is a wake up call, but it is to no avail.
Thank you ron  
WideRight : 10/16/2014 4:36 pm : link
One more point

As the ER eval is ongoing and pt says "I just came back from Africa" every ER doc knows to put tropical diseases at the top of their differential. Maybe not Ebola, but the thought had to have been there. Simple stuff. Once that possibility is raised, admission has to be considered. But the thought process doesn't end there. The ER has to find someone to admit him. So he will ask the patient "Do you have a primary?" At that point he will essentially know the guy is uninsured, and will consider admitting to house staff. He may think house staff is 1) overworked 2) incompetent 3) a financial burden or a combination of the above. Thinking along those lines he may back up a little and say its unlikely a disease of significance, just go home.

Sounds very plausible to me, and the lack of insurance was a contributing element.
Again WR i say never say never  
ron in new mexico : 10/16/2014 4:53 pm : link
it's possible.

But most commonly to my experience the ER doc will make the decision to admit or not, and then after that decide where to admit the patient, here, where his primary works out of, and all the rest.

Decide whether to admit depending on the patient having a primary or not….I'd say not.
Of course all docs will get a med history on making their decisions but really there presence of a primary or not is pretty insignificant medically in a case like this.
Some conditions mandate interaction with a primary such as past heart problems perhaps but the ER is basically making a pretty simple decision, where to put this guy.

Then the floor doc can interact with the primary. Could they ship this guy to another hospital where his primary works out of certainly…it happens all the time(by ambulance)
To decide not to admit….I'd say no it generally does not happen that way.

Possible I say again never say never but highly improbable.
One of the decisions hospitals make, as they largely assist with malpractice insurance, (it is generally part of the compensation package) is how many situations of litigation does any doc engage in yearly.
Quite a few litigations and they may decide not to renew, as the insurance becomes prohibitive a red flag is raised.
Again not all hospitals but many. Some areas such as pediatrics and obstetrics are known for having high rates of litigation. A ER doc not so much at all.

That way of thinking would lead straight to litigation, and the doc would potentially not have a contract renewal as result.
So the hospital and the doc would personally suffer, far more then if they denied admission Even in Texas.
So largely ER docs don't do things that way.
To be clear  
ron in new mexico : 10/16/2014 5:07 pm : link
there are idiot docs just as there are idiots nurses idiot cops idiot firefighters idiot politicians idiots of all sort and shape abound.

So what you say could happen.
But the system actually works against, not for that happening.

So I cannot rule it out.
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