Wednesday, October 8, 2014

Purposeful Education

Now that the Ebola patient who was being treated in the Dallas hospital has died, it's time to get moving, without hysteria, with purposeful calm, on two fronts.

First, the media, particularly the virtual and broadcast media, need to tamp down the sensational hysteria and take that same amount of airtime to educate the American public about the value of flu shots, vaccinations for their children, and any other measures they feel might keep Americans safe.  I say this because we are about to deploy troops to Africa and it is likely that some of them -- or Americans already working in Western Africa -- might fall ill and need to be treated in our communities.

Second, it's not just hospitals who need to sit up and pay attention, and rehearse their response -- although from the comments of associations of nurses, it's clear that institutional strategies have not been shared, nor have the protective measures that will be put in place for personnel.  And the training and rehearsals must also include ambulance drivers and EMTs as well as a range of other medical support personnel. 

Meanwhile, vaccine trials proceed.   Trying out vaccines on patients already infected is not the same as a full on Stage 2 double bind trial that carries its own risks. In our rush to find a way to contain the virus, and to find a vaccine that works, we'll find a range of ethical questions presenting themselves.

Let's get started.

Wednesday, October 1, 2014

Public Health and the Secret Service both need better checklists

The Liberian public health and airport security personnel in Liberia did their jobs, and checked outgoing passengers at three distinct checkpoints.  We've patted ourselves on the back in this country for the sophistication of our medical capabilities, yet as I listened to the story today of the nurse in Dallas who followed a "checklist" and got a Big Red Flag answer back from the patient, but failed to escalate it in such a way that the team could isolate and contain the patient -- in fact, they sent him away with antibiotics and he came back a second time when he felt worse -- I thought once again of Dr. Atul Gawande's book, The Checklist Manifesto

This type of error is called one of ineptitude, as opposed to one of ignorance, presumably.  We don't know if this was an Ebola-specific checklist; one prepared by the hospital itself; or one from the Center for Disease Controls.  A quick read of Gawande's book might be very helpful, especially if the checklist has more than 5-7 items on it, without what Gawande calls "pause points."  His book is full of stories of how pilots, builders of skyscrapers and surgical teams perform extremely complicated feats, and how using checklists that involve every member of the team makes a difference.  His work in this respect for the World Health Organization has made a large impact:  deaths after surgeries have been reduced significantly by the implementation of several simple procedures that are part of the checklist.

I would also recommend the book to the new acting director of the Secret Service and to the panel that is currently being constituted to review the disturbing procedural/process failures over the last several years for the organization charged with guarding the president.  It may be that those procedures or processes have become shopworn.  Certainly it must be the case that, unless on a form of high alert (the United Nations responsibility, for example) agents' situational awareness is at an all time low.  Whether this is a factor related to the move from Treasury to the Department of Homeland Security or not is difficult to estimate, but will undoubtedly be reviewed by the panel.

The tipping point I mentioned last week seems more vivid as weeks go by.  Yet there was one piece of good news this morning:  that it appears Nigeria, the most populous and also most well-off African country in terms of infrastructure and medical personnel, has contained Ebola.  We just can't move quickly enough to get more personnel, hospitals, emergency operations centers and supplies deployed in the remaining countries.