After four health care workers with Ebola were flown from West Africa to the United States for care last month, the first case in the U.S. has been diagnosed in a Liberian man visiting Dallas. While it's extremely unlikely this case will lead to a widespread outbreak, it causes concern amid reports the patient may have had direct or indirect contact with some 100 people before he was placed in isolation.
Fortunately, all indications are that Ebola is not especially contagious, but this case is a sirens-wailing warning to the public and our medical community. In spite of millions of dollars allocated and legions of physicians, epidemiologists and nurses working to prevent contagion, no containment strategy to prevent an epidemic will work unless doctors adhere to the basics of good medical practice. That includes asking patients questions and listening, carefully, to their answers.
The Dallas patient first presented to Texas Health Presbyterian Hospital late Sept. 25 with symptoms of fever and abdominal pain. He was sent home from the emergency room despite federal warnings that people with a travel history to West Africa should be evaluated for Ebola. The doctors who treated him failed to ask and did not know that the patient had recently traveled from Liberia, one of the countries most severely affected by Ebola. It was not until the patient returned to the emergency room Sept. 28 that the diagnosis came together. This time lapse increased his number of contacts and the chances for transmission of the virus.
How did a hospital fail to recognize a potential case of Ebola despite notifications from the U.S. Centers for Disease Control and Prevention and widespread awareness of the disease? Joseph McCormick of the University of Texas School of Public Health, an investigator during the first Ebola outbreak in Africa in 1976, told the website MedPage Today: "It was inevitable to have someone arrive who was exposed, but not yet ill. The question is why a travel history was not taken when he was first seen days before he was admitted to the hospital."
The patient had told a triage nurse when he first came to the hospital that he had recently returned from Liberia, a fact supported by the woman who accompanied him to the hospital. Officials at Texas Presbyterian blame the setup of their electronic medical records system for not conveying this information to the treating physicians. While this points out a flaw in the current generation of computerized medical records — it's unlikely a doctor reading a paper ER chart could have missed such an important fact — blaming electronic snafus for thwarting the chance to control this Ebola exposure misses the point.
Yes, this episode illustrates the potentially devastating consequences of over-reliance on technology. But that doesn't acknowledge the physician responsibility. Especially in a potentially serious situation, doctors aren't absolved from asking their own questions, an essential part of any diagnosis. "Taking a history," as it's called, is one of the first things aspiring doctors learn in medical school, not a task to be delegated entirely. A few simple questions by the ER doctors and a response mentioning "Liberia," at minimum, should have prompted a call to the hospital infectious disease consultant. That would then have set in motion a more aggressive diagnostic and isolation response. "We're too busy" or "We don't have enough resources" are not excuses for ignoring good medical practice, especially with a risk of domestic Ebola.
Domestic Ebola. Pause on that phrase.
The simple failure of one or more doctors to ask the right question is the type of mistake that is easy to prevent but could happen again. Chicago is one of the world's busiest centers of international travel, so an unsuspected carrier of Ebola presenting to one of our ERs is certainly a possibility. We also have some of the world's best hospitals, infectious disease experts and protocols to minimize the chance of pandemics gaining footholds.
But for all of that to be effective, our physicians and other first responders — yes, that term applies here — have to learn from the Dallas mistake. Doctors that we trust assure us that the lesson is as elemental as "First, do no harm." Talk with every patient. Question every patient. Listen to every patient.