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 The U.S. Centers for Disease Control and Prevention says the
infection of the two Dallas nurses likely occurred in the first few
days of patient Thomas Duncan's admission to Texas Health
Presbyterian Hospital in late September, and is investigating
whether they correctly used personal protective gear such as gloves
and gowns recommended by the agency.
Workers at the hospital also performed invasive procedures on Duncan
such as inserting a breathing tube and filtering his blood through a
dialysis machine, procedures that are unprecedented in the care of
an Ebola patient in the last throes of the disease. But those same
procedures make it more likely that a healthcare worker will come
into contact with bodily fluids at their most infectious.
"The thing we don't know is, was it truly a breakdown in personal
protective equipment or was it because we were instrumenting the
patient by intubation or dialysis?" said Dr Peter Hotez, a tropical
disease expert at Baylor College of Medicine in Houston.
In West Africa, where the worst Ebola outbreak on record has killed
more than 4,000 people, the use of advanced lifesaving measures is
rarely an option. But in the United States, they are routine.
"We tend to go to the mat" in an effort to save patients, Hotez
said. "Should we rethink whether we should be doing these
life-saving measures? That is a question that medicine needs to
address."
In most places in Africa, Ebola patients are only able to get
supportive care, said CDC spokeswoman Abbigail Tumpey.
"Now that we're treating patients with Ebola in the U.S., we are
using modern Western medicine that has not ever been used in field
studies in Africa," she said. Treatment approaches such as dialysis
and intubation "certainly have not been happening."
Tumpey said the CDC is now looking at the risks associated with
these procedures.
"Because we don't have experience with treating patients with Ebola
in U.S. hospitals where we have all of this technology and
resources, it's possible that some of these procedures may put
healthcare workers more at risk."
Dr. Jesse Goodman of Georgetown University Medical Center said that
despite the fact Ebola has been around for decades, it is "entirely
new to Western healthcare," and it is important to not be overly
reliant on what has worked in prior outbreaks, especially when the
healthcare systems are so dissimilar.
GREATER BENEFIT OR HARM?
To many, the questions Ebola is raising are reminiscent of the early
days of caring for patients infected with the human immunodeficiency
virus, or HIV, the virus that causes AIDS. Many of the safety
protocols developed for blood-borne pathogens were developed through
caring for AIDS patients.
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But Ebola is different in some very important ways. It rapidly turns
off the body's innate ability to fight viruses, multiplying
unchecked as the disease progresses until patients' bodies are
filled with billions of virus particles.
"Towards the last days of infection, that patient is basically a bag
of virus," Hotez said.
When a patient with Ebola is reaching the stage in the disease where
there is need for intubation or dialysis, the risk becomes greater
to the healthcare worker than the benefit to the patient because
they are "crashing" and near death.
"If it's that late a stage in the disease, the chances are that even
if those are performed, the patient is already going to die," said
Sean Kaufman, president of Behavioral-Based Improvement Solutions in
Atlanta, who helps train hospital staff on safety measures.
Dr. Marc Napp, deputy chief medical officer and senior vice
president for medical affairs at Mount Sinai Health System in New
York, said that as a general rule "any patient that comes in, no
matter what the condition, if they require certain medical therapy
based upon clinical judgment and they want that therapy, we are
obligated to provide it."
Napp said in the case of Ebola, there has not been any discussion
about withholding life-saving treatments such as intubation for fear
of harming staff members. But he said healthcare workers take risks
all of the time.
"I'm a general surgeon. I've stuck myself with a needle. I've cut my
finger on a broken bone from a person with hepatitis. We're exposed
to this regularly," he said. "What's different here is there is the
panic factor. It's a highly lethal infection.”
(Reporting by Julie Steenhuysen; Editing by Michele Gershberg and
Ken Wills)
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