The stories keep changing about who really screwed up at the Texas Health Presbyterian Hospital where the first US Ebola victim showed up and eventually died. You can read this article where they touch on the flaws in the hospital EMR that I blogged about earlier. The use of quick texting or using macros or using quick texts (whatever you want to call it) are just short cuts so that doctors don’t have to type or think. We are literally taught this as we learn to use our EMR systems. Osler would have been so proud. Add to this that nurses don’t talk to doctors anymore and you have a recipe for disaster. Nowadays, nurses flag things in the computer. That should work, right? Well, my last EMR made every abnormal lab a red color. Sounds great but almost EVERY lab was red because everyone had high cholesterol, a RDW that is off, a calcium that is 10.4, etc. The consequence is that the doctor doesn’t get excited about the flag or red color and ignores it. It’s human nature. The same thing occurs when you put alarms in ICUs for every abnormality. The nurses get “alert fatigue” because most of those beeps are false. Who is to say what happened in Texas? No one was thinking about Ebola then. Why a guy with a high fever from Africa was missed is ridiculous upon hindsight. That being said, accusations of racism, as brought up by the deceased’s nephew, is utterly ludicrous. That is all we need right now during this mess. I believe the fallout in this could be huge. There will be lawsuits. Administrators will point fingers at doctors and be astonished that physicians fluff the charts. Some doctors will be let go or quit. It is going to get crazy but it really doesn’t matter. The bigger issues, now that we have another person infected at this hospital (a healthcare worker), are these:
- Why does this spread so easy?
- The CDC made it seem that Ebola is like Hep B and spread through bodily fluids. Really? I had never heard of Hep B spreading this quickly?
- This guy who died was not spurting bodily fluids everywhere. How then did a healthcare worker get sick?
- Will we have another Mary Mallon on our hands? You know her, right? She was also called Typhoid Mary.