In the weeks leading up to their diagnosis, more than 80 people who had possibly come in contact with Duncan were monitored for symptoms after it was revealed the hospital turned him away with a 103 degree fever. The hospital, it seems, also knew Duncan had recently traveled to West Africa.
And those are just a few of the myriad mistakes the hospital and the Centers for Disease Control and Prevention made in the days following Ebola’s arrival in the U.S.
In the wake of multiple diagnoses, health officials from both institutions are admitting there were oversights that may have put others at danger. On Thursday, the Texas hospital where Duncan died released a statement, saying they were “deeply sorry” for their mistakes. The CDC, which has come under fire for their handling of the situation, also admitted to mistakes and vowed to work closely with the nation’s hospitals to promote a safe environment for all.
But what were those mistakes, exactly? And did they lead to the infection of two American healthcare workers? Possibly. Take a look below:
Improper Protective Gear
It was a full two days after Duncan was admitted that healthcare workers started to wear biohazard suits. Others wore gowns that left their necks uncovered. And others weren’t even aware that there was protocol in place for Ebola cases. The result was an “evolving set of protocols” that nurses implemented to protect themselves. But did these off-the-cuff protocols actually work?
CDC Director Dr. Thomas R. Frieden admitted this week that these were just some of the hospital’s lapses. But nurses who actually took extra care by putting on layers of protective gear may have caused more harm than good.
From the New York Times: Some, he said, donned three or four layers of protective equipment and closed openings with tape in the belief that it would afford greater safety.
“In fact, by putting on more layers of gloves or other protective clothing, it becomes much harder to put them on, it becomes much harder to take them off, and the risk of contamination during the process of taking these gloves off is much higher,” he said.
The hospital also released a statement admitting that some of the biohazard gear was too big a fit for nurses.
“We have since received smaller sizes, but it is possible that nurses used tape to cinch the suits for a better fit,” the statement said.
Duncan’s Waste Was Disposed Of Improperly
The hospital admitted that protocol wasn’t in place to dispose of Duncan’s waste properly. In a statement, the hospital said a tube system was not used to transport his lab specimens.
“His specimens were triple-bagged, placed in a container, and placed into a closed transport container and hand-carried to the lab utilizing the buddy system,” the statement said.
Nurses also allege that hazardous waste was allowed to pile up to the ceiling.
Nurses Weren’t Trained, CDC Didn’t Respond Quickly
In the wake of the Ebola scare, nurses have come forward, some anonymously through National Nurses United, to reveal that Ebola training was limited, if it was offered at all.
From CNN: “We never talked about Ebola. We never had a discussion,” Briana Aguirre said. She said she was not involved in treating Duncan, who received care at the hospital in late September and died there on October 8. Training for Texas Health Presbyterian’s nursing staff amounted to “just information,” she said. “We were never told what to look for.” “All I know for sure is that he (Duncan) was put into an area where there are around seven other patients,” she said. “We took around three hours to make first contact with CDC to let them know what we had of our suspicion. There were no special precautions other than basic contact precautions. No special gear.”
A statement from National Nurses United also stated that they had to “interact with Mr. Duncan with whatever protective equipment was available.” Nurses also say those caring for Duncan were also caring for other patients in the hospital. In the face of evolving protocols, nurses were allowed to follow whichever guidelines they chose.
The CDC, scrutinized for their handling, also did not respond to the first Ebola case quickly enough.
From CBS: The agency now admits a mistake. Its rapid-response team should have been mobilized to Dallas right away to help train the staff caring for Duncan, something the agency said it will do from now on.
The CDC wants to better prepare U.S. clinicians to treat Ebola patients while also protecting themselves.
“What we are doing is giving people the practice here so they can have the appropriate confidence,” Ebola training course interim director Patricia Griffin said.
Duncan Was Sent Home
In what could be considered the first mistake of the Texas hospital where all three U.S. Ebola patients were treated or are employed, hospital staff sent Duncan home when he arrived in the emergency room complaining of a fever. He returned two days later, much sicker. Duncan died on Oct. 8 after treatment in the hospital, which could have exposed healthcare workers to the deadly disease.
From CNN: Dr. Daniel Varga said Texas Health Presbyterian Dallas mishandled the case of Thomas Eric Duncan. Duncan was initially sent home from the facility despite having a fever and telling a worker he was from Liberia.
“Unfortunately, in our initial treatment of Mr. Duncan, despite our best intentions and a highly skilled medical team, we made mistakes,” Varga, the chief clinical officer for Texas Health Services, said in written testimony to the House Energy and Commerce Committee.
“We did not correctly diagnose his symptoms as those of Ebola. We are deeply sorry.”
In addition, representatives of National Nurses United, citing anonymous health care workers at the hospital, reports that a nurse supervisor who had demanded that Duncan be moved to an isolation unit faced resistance from other hospital authorities.
Amber Vinson Was Given Clearance To Fly
Even after caring for Duncan and calling the CDC to report a slightly elevated fever, a CDC official gave Amber Vinson, the second nurse to be diagnosed with Ebola in the U.S., clearance to take a passenger plane from Cleveland to Dallas.
The CDC is now recognizing that as a mistake. Dr. Frieden said Vinson should have never been allowed to fly because she had been exposed to the virus while caring for Duncan. Health officials are now scrambling to locate the more than 100 passengers aboard the commercial jet to inform them of Vinson’s status.
From CBS: Frontier has taken the aircraft out of service. The plane was flown Wednesday without passengers from Cleveland to Denver, where the airline said it will undergo a fourth cleaning, including replacement of seat covers, carpeting and air filters.
Schools in both Texas and Ohio have canceled classes following the news of Vinson’s diagnosis.
How do you think the CDC and Texas Health Presbyterian Hospital should have handled these Ebola cases? Sound off below…
PHOTO CREDIT: Getty