Monday, October 27, 2014

Uncertain Health in an Insecure World - 3

“Relieved, unrelieved or dead”

Statistician Florence Nightingale (1820-1910) so summarized the possible outcomes of the 19th century healing arts. Blunt – yes – but very clear and hard to dispute.

A real-life story of medical clarity in the face of fear bordering on panic puts this into 21st century perspective.

In early October, 2014, a Nigerian businessman arrived from Lagos at London Heathrow Terminal 5. Like all but 77 of 36,000 West African air travelers over the prior two months, an infrared thermometer ‘gun’ indicated that he was not feverish when he boarded the flight. Traveler 36,001 used the on-board toilet twice during the six hour flight, washing his hands both times. He slept most of the flight, and had to be roused by flight attendants to prepare for landing.

After he'd run to make his Air Canada connection, flight attendants noted the man’s sweat-drenched clothing. Midway through the nine hour trans-Atlantic flight, the man developed shaking chills. He used the on-board toilet twice for new diarrhea, without disinfecting. After landing and clearing Canadian customs & immigration, he struggled aboard an airport hotel shuttle. When stepping off the bus, he collapsed. EMT’s transported him to a university medical center where Emergency Department personnel had been alerted to “take appropriate precautions” when dealing with feverish African travelers. Wearing masks and gowns, they rolled an unresponsive patient onto a gurney and into an isolation bay.

With a 103 degree temperature and West African point of origin, the infectious disease (ID) consultants were called ‘stat’ to evaluate the patient. If they judged traveler 36,001 to be “possible Ebola”, only highly trained personnel would be allowed to contact patient 1. Blood was drawn for Ebola testing at the national lab hundreds of miles away; test results would take 36-48 hours. The senior ID consultant took a detailed medical history, and determined that the man was not a health worker, and that he had no sick or recently deceased family members. Inspecting his passport, they concluded that he had not visited the Ebola “hot zone” countries of Guinea, Liberia and Sierra Leone in the previous month.

After weighing these medical facts against the odds, the consultants determined that the man was not at high-risk for Ebola. Routine isolation was initiated along with testing for more common, potentially lethal African fevers: Lassa, tuberculosis, dysentery, malaria and HIV/AIDS. A simple blood smear revealed the diagnosis: >20% of his red blood cells were infected with malarial parasites (>5% is considered “severe”). The patient was aggressively treated with anti-malaria drugs and intravenous fluids. The next day, his fever was relieved and his condition was greatly improved.

If the consultants had become caught up in the public paranoia and media blame game regarding the spread of Ebola from West Africa to the developed world, traveler 36,001 would have been dead within 24 hours of becoming patient 1.

Statistics count. Statistics can be scary

Between December 2013 and August 2014, WHO and the U.S. Centers for Disease Control & Prevention (CDC) reported 552 malaria deaths and 4 Ebola deaths. Since then, >5,000 Ebola deaths have occurred. 

Nurse Florence Nightingale treated patients, not statistics.

And despite being well aware of the statistics, our consultants made a clear-headed unemotional choice to not label the patient out of fear of unlikely consequences, but to look first for a common condition that could be readily relieved.

Only a few surviving family members remember the name of the two-year old Ebola “patient zero” - Emile - who died in Mileandou, Guinea on December 26, 2013. Emile’s sister, mother and grandmother also died within a month.

Every CNN viewer knows the name of the only dead U.S. Ebola patient – Thomas Eric Duncan. Not unlike mass murderers, CNN included his middle name. 

The growing list of Ebola-infected health workers who were relieved after intensive treatment at medical centers in New York, Atlanta, and Omaha have each had their 20 seconds of unwanted fame.

No one can possibly know the names of the over 2.5 million unrelieved Africans suffering with a fever on any given day.

But failing to treat patients due to complex public health risk mitigation protocols can delay patients’ relief, and under some circumstances, actually cause preventable deaths.

From where I’m standing in The Square, that seems pretty un-Hippocratic.

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