Ebola in the ER…would you make the diagnosis?

ebolaBy now, you have heard that the first US Ebola death in the US was originally seen in the ER on September 25th and sent home. Most media outlets are quick to point out this lapse in diagnosis, including the NY Times. Of course hindsight is 20/20 and while the diagnosis seems obvious now, would you have made the diagnosis at that time?

 

The Context

Consider the circumstances. Even as recently as 3 weeks ago, the possibility of someone coming into the US with Ebola seemed unlikely. Certainly if someone flew from Liberia, Guinea or Sierra Leone into the country vomiting with high fever on the plane, that situation would have been very blatant. But we’re a country that still believes in movement of travel, so if someone flies into the country without symptoms, we assume they’re healthy.

 

But when someone comes to the ER with fever and vomiting, that’s not nearly as blatant a display of Ebola infection as someone with those symptoms on a plane en route from an Ebola-plagued environment. In other words, fever and vomiting in an ER is typical. I’ve never seen someone vomiting with fever on a plane. That behavior sticks out on a plane, not in an ER.

 

The Scene in the ER

So a patient comes into your ER with fever and vomiting. Based on ER records, it seems as though he mentioned his recent travel from Africa but it’s not clear that he specifically mentioned Liberia. It’s possible the patient didn’t specify where he came from because he didn’t think it was important. Maybe he too hadn’t realized his recent travel from Liberia and recent contact with an infected patient was associated with his current illness. Clearly, now, it seems like a lapse in diagnostic detective work by the doctor not to connect the dots between recent travel from Africa and possible Ebola infection, but 3 weeks ago, believe it or not, it wasn’t on the tip of our collective tongues.

 

I’m not suggesting that this wasn’t a disappointing lapse in judgement on the doctor’s part. Certainly we all wish he/she would have made the diagnosis. But to vilify the doctor and suggest that it should have been obvious to them isn’t fair. You might think that as a doctor I’m biased, but I’m not supporting the ER doctor simply because I’m a doctor. What I am saying is that as a doctor, I’ve worked in an ER and things aren’t presented to you in clear sound bites or 5 minute segments between commercials that are black and white. It’s conflagration of paperwork, tests, other patients, mayhem, chaos, trauma, heart attacks and seemingly more serious illnesses.

 

Maybe a more seasoned doctor would have made the diagnosis. Maybe a doctor that had a special interest in infectious diseases would have picked up on it. But maybe the doctor that picked up on Ebola would have missed making the diagnosis of a heart attack in the patient down the hall. No matter how it is portrayed, making a diagnosis isn’t always as simple as the media might suggest.

 

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  1. Pingback: Ebola in the ER...would you make the diagnosis? Dr. Kaplan

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