The Blog

How Could an ER Miss Ebola? Let Me Explain.


How did the emergency department staff of a Texas hospital see, and discharge, a patient infected with Ebola? Despite the fact that blame spreads through hospitals faster than hemorrhagic fever viruses, I'm not interested in pinning down a single person, or a single thing, which may have allowed that to happen. I am very interested, however, in offering a few insights into what combination of factors might make it easy to send home a West African man with a fever, without establishing the fact that he had a dangerous, contagious disease which finally caused his death.

First of all, America's emergency departments are straining to keep up with the volume of patients that come through their doors. In 2010, the number of visits in the US was 129.8 million, according to the CDC. This numbers rises every year, despite the belief that the Affordable Care Act would direct people to primary care doctors and away from the ER.


Furthermore, many people with insurance (including Medicaid and Medicare) can't find doctors, and large numbers who had insurance before subsequently lost it in the reshuffling of health benefits that has been going on since the ACA was passed. The emergency department is often all they have.

Second, it's getting much, much harder to focus on that pesky but ubiquitous feature of the modern hospital, the patient. There is data to enter (which keeps nurses and physicians more focused on screens than adolescent boys playing on their Xbox). The electronic medical records systems are unfortunately complex and rarely intuitive. They require so much information that often, relevant points like 'fever and came from West Africa,' can be lost in the midst of endless time stamps, and required fields like 'feels safe at home,' 'denies suicidal thoughts' and 'bed rails up, call light at bedside.'


Third, the rules for admission are ever more complex, based on what Medicare, Medicaid and private insurers are willing to cover. Patients we admitted without question ten years ago are now sent home and told to 'come back if you get worse.' In fact, it's so hard to admit people that I now send home patients I would never have discharged, simply to avoid the misery of explaining the problem to already over-taxed hospitalists who are themselves constrained hand and foot by impossible rules. In this milieu, an otherwise healthy man with a fever is barely a blip.

I know this because earlier this year I was working in a teaching hospital and called the infectious disease specialist on call. My patient had just returned from a mission trip to the Caribbean and had a high white blood cell count, a fever, chills and rash. I was curious if I should have any particular exotic concerns. The specialist's annoyed answer was this: 'Sounds like he has a virus. He needs to see his family doctor this week.'


I agree. We need a plan. But the system, as it stands, functions every day on the very razor's edge of disaster. We need to address that fact if we're going to have any hope of dealing with Ebola, or other potential calamities, in the future.