The Clare Spark Blog

James Pagano, MD

This is a guest blog by James Pagano, M.D., and author of two novels

Dr. Tom Frieden, head of the CDC, appeared in a taped interview last evening on Megyn Kelly’s program. His intention was to answer some of the questions regarding his handling of the Ebola problem, to explain why the things he is or isn’t doing are correct, and to reassure the audience that all would be well.  He failed miserably.

The CDC and Dr. Frieden are likening Ebola to hepatitis or HIV. Like Ebola, both are diseases caused by viruses, and both require contact with infected body fluids for transmission from one individual to another.  Neither, though, is anywhere near as infectious.  In the case of HIV, a healthcare worker who experiences a needle stick injury from a needle contaminated with an HIV patient’s blood has about a 0.3% chance of being infected.  By comparison, it appears Ebola can be transmitted by coming into contact with minute amounts of fluid, such as that which could be on the exterior surface of a protective gown.

Pagano’s first novel

A disease that infectious, with a mortality rate of over 70% in Africa and at least 50% if contracted and treated here should be taken seriously. Everything that can be done to prevent its spread in this country should be done.  Unfortunately that is not how it is being handled.

The only effective way to stop an outbreak of a lethal illness for which there is no specific treatment is by isolating those who already have the disease and preventing its spread to other areas of the globe. This requires travel restrictions and quarantine.  While we are still able to identify West Africa as the danger zone such restrictions would be relatively easy to impose.  Anyone wanting to come to this country from West Africa and anyone who has been in that area would need to wait 21 days before being allowed to come.  It would require checking passports and keeping people with stamps from countries in which the disease is epidemic off planes until they are cleared.

Dr. Frieden disagrees. He believes that such restrictions would somehow make the outbreak harder to fight in Africa and put us in greater risk here.  He cites difficulty getting healthcare workers and others joining the fight into and out of the area as one of his major concerns.  This is absurd.  His logic is so convoluted it causes one to question everything else he has to say.  It is possible he’s parroting the party line.  If so, he should admit it, say what he really believes, and offer to step down if it displeases his boss.  The stakes here are far too high for political correctness, or politics at all.

He then goes on to say much is known about Ebola, how it is transmitted, how it can be stopped. Given his rationale for not limiting travel one wonders.  It is true that Ebola requires contact with infected body fluid to pass from one person to the next.  In that way it is similar to HIV and hepatitis.  How much body fluid is required is unknown.  During the height of the AIDS epidemic I ran an emergency department in a hospital with an HIV ward.  The disease at that time was a death sentence for those who contracted it.  Still, it was our understanding that it could not be transmitted by casual contact.  The only time we put on gloves, gown and mask was if we were drawing blood or performing some invasive procedure.  Very few healthcare workers were infected by patients, and those who were had exposures to large amounts of infected material or had been accidentally stuck with a hollow needle previously in the vein of the patient.

By contrast healthcare workers treating Ebola patients are dying by the hundreds despite wearing haz-mat suits.  This is a different disease.  There are even studies in animals that suggest certain types of Ebola can be transmitted through the lungs.  People from endemic areas should stay put until they’ve been quarantined for the full length of the incubation period, 21 days.

Another of the CDC’s proclamations is that any hospital with an isolation room can safely handle an Ebola patient. This is also nonsense.  Meticulous care must be taken with barrier protection to maximize safety.  It is nearly impossible to remove the booties, gowns, mask, goggles and gloves without at some point touching the exposed surfaces with either your bare hands or your clothing.  It requires a lot of practice.  Community hospitals that may see one potential case will not have sufficient experience to treat the patient safely.  And this doesn’t address the risk to other hospital personnel, such as phlebotomists, lab techs, and housekeeping.

Saying the CDC will offer training to thousands of doctors and nurses is not only absurd, but pointless. To receive the best care, these patients should be treated in designated centers by dedicated teams of physicians, nurses, and ancillary staff.  The role of community hospitals should be that of recognition, isolation, notification of health officials, and transfer to a designated center.  This can be done by the ER staff.  Instead of trying to train everyone in every hospital, training the ER staff is something that is actually feasible.

Emergency departments across the country are experiencing increased patient volumes due in large part to the ACA. The one at which I am the medical director is busier by more than 20% year over year.  We are on the verge of the winter flu season which typically brings an addition flood of patients to the ER.  This is a bad time to add Ebola to the mix.  Travel restrictions to minimize the chance of an infected person entering the country would go far to protect both the healthcare workforce and other citizens from this disease.  Coordinated care at specialized centers will give those infected the best chance of survival while at the same time minimizing the spread of Ebola.

It makes no sense to assume everything will be all right until we’ve done everything possible to ensure the best results. So far the CDC, and its leader, have not convinced me they have done so.

[Update 10-17-14, from private communication to Clare Spark: “Whether we have a large outbreak in this country or a small one, the disruption of the healthcare delivery system will be devastating. For the past two weeks we have been running drills on how to safely don and remove the various pieces of barrier protection we’ve been advised to wear when dealing with a potential Ebola patient. These drills have been almost slapstick. The gowns, etc., are inadequate and it is practically impossible to remove everything after the patient encounter without contaminating yourself. I am certain hospitals across the country are experiencing the same difficulties. The early Obama claim that ‘any hospital with isolation capability can care for an Ebola patient effectively and safely’ belies a complete failure to understand what we are facing. Interesting that the most recent cases have been transferred to designated treatment centers.

We are about to enter flu season. Thousands of people with fever, vomiting, diarrhea, and headache will be presenting to ER’s. These are the same symptoms someone in the early stages of Ebola will exhibit. If we have 20-30 confirmed cases around the country and no travel restrictions ER personnel will be forced to approach every patient with these symptoms as a possible Ebola patient. A crowded ER, and ER waiting room, are not ideal places for a number of these patients to be boarded. The amount of time the ER staff will need to care for them will increase exponentially because of the isolation and gowning precautions. The system will experience huge delays, patients will be placed in danger, and the ER staff will be overwhelmed.” [End Pagano update.] Dr. Pagano also points out that nine physicians have died in Africa treating Ebola. No time to be sanguine about Democrat management of this crisis.

Frieden as educator