Remember those halcyon days before two nurses in Dallas contracted Ebola from Liberian Thomas Eric Duncan? People were alarmed but not panicked, experts assumed that certainly the average tertiary care hospital in the U.S. could handle Ebola patients, and people thought it was ridiculous to think about things like cleaning elevators after an Ebola patient had ridden in one. Schools weren't closed, planes weren't taken out of service. None of that.
In retrospect, it's clear that Dallas' Texas Health Presbyterian, the 898-bed tertiary care hospital where Duncan presented, was not equipped to handle Ebola, neither Duncan's case nor those of the two nurses who cared for him.
In retrospect, none of this should be surprising. The other two sites that treated American Ebola evacuees, Emory University Hospital and Nebraska Medical Center, were well-prepared for the patients they were expecting. They are two of the nation's four specially-equipped biocontainment units.
By contrast, Thomas Duncan just showed up to the Dallas hospital. Unexpectedly. Twice. There are reports that protocols to keep the infection from spreading kept changing, that lab specimens were sent in the pneumatic tube system, that the biohazard waste piled up to the ceiling for lack of a plan to dispose of it. And of course, there's the ultimate failure: Thomas Eric Duncan died despite heroic efforts.
When things go wrong in a hospital, it is never the fault of a single individual. Initially, the CDC blamed the first nurse for her own infection, for "a protocol breach." This is ridiculous. In medicine, as in airline safety, there are so many safety nets that in order for something to go wrong, each of the safety nets must have a hole in it, and each of these holes must line up in order for something to fall through. We call it "the Swiss cheese model" of system failure.
If a protocol to protect health care workers from a contagious disease with a high fatality rate is so easy to breach, then the protocol is flawed. Period. If the protocols in Dallas kept changing, that's also not surprising. Ebola is something completely new to us. We don't know what we are doing yet. Why should we? It's OK to admit that. In fact, we must admit that. Compared to Nigeria and Senegal and some places in West Africa, our Ebola transmission rate to health care workers is terrible.
We need to get this right. But in order to get this right, we need to ask the right questions. For now, it's clear that all U.S. Ebola patients need to be treated at one of the four biocontainment facilities as soon as they are diagnosed, but according to ABC news, together there are only 11 of these beds in the whole United States.
So we need a contingency plan in the event that the breaches in Dallas lead to more than nine cases at once, and in the event that more than 11 evacuees land back home. No staff at Emory or Nebraska got Ebola. Why not? What did staff at Emory and Nebraska do differently? How much did their staff rehearse donning and doffing protective gear prior to the patients' arrival, for example? Can their exact protocols and equipment be replicated elsewhere? How are the successful models in Africa working and how can we learn from them?
Do we have the capacity to increase the numbers of beds at our four biocontainment facilities? Or do these facilities have access to equipment and training that are simply not readily available to most other tertiary care hospitals? As our politicians weigh a travel ban, can we look at previous travel bans and if they have worked or caused harm?
One thing is certain. Finger pointing and outrage will get us know nowhere. We need to start by humbly admitting what we do not know, and then asking what is known to work. Then, maybe 21 days after the nation's last domestic case of Ebola, we can start to go back to alarm instead of panic.