Nina Pham is a nurse in Texas who recently contracted Ebola after treating a patient. She was wearing full personal protective gear and knew that she was treating a highly infectious patient with the disease. How could she have been so careless?
It turns out that while there are specific procedures for treating these patients, it isn't always so easy to follow the protocols exactly. It is very complicated. There are also many sections where the directions are ambiguous or unclear. Here is an example from the actual CDC document:
Each of the five sections actually has a more detailed longer section with step-by-step instructions. There are specific instructions for what to do if your hands are contaminated, but nothing about what happens if some contamination infects another part of the body. There are also two examples shown for removing personal protective equipment with no preference stated for one over the other.
An article in Vox quotes CDC director Tom Frieden acknowledging the difficulty in following the protocol:
"The care of Ebola can be done safely but it's hard to do it safely," Frieden said in his Sunday press conference. "Even an innocent slip-up can result in contamination."
There is a 49 slide PowerPoint which gives more detail. It is only a slice of what is available:
These presentations are summaries of a longer, more official set of guidance, the 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.
This 225-page document (145 pages without footnotes) is arguably the United States' most comprehensive guide to wearing protective health care equipment. One section, on page 52, talks about the challenges of finding the right mask:
Since procedure/isolation masks are not regulated by the FDA, there may be more variability in quality and performance than with surgical masks. Masks come in various shapes (e.g., molded and non-molded), sizes, filtration efficiency, and method of attachment (e.g., ties, elastic, ear loops). Healthcare facilities may find that different types of masks are needed to meet individual healthcare personnel needs.
How does a hospital choose the right mask after reading that paragraph?
The article closes with a few quotes from Atul Gawande, one of the leading proponents of checklists:
Protocols can be incredibly powerful and important documents in healthcare. Atul Gawande has written extensively about the importance of checklists, and how a simple set of guidelines can go a long way. In one experiment he writes about, intensive care units who followed checklists decreased infections rates by one third in just three months.
"It's true of cardiac care, stroke treatment, H.I.V. treatment, and surgery of all kinds," Gawande writes. "It's also true of diagnosis, whether one is trying to identify cancer or infection or a heart attack. All have steps that are worth putting on a checklist and testing in routine care."
It is undeniably good that the CDC has a checklist for how to put on the protective gear needed to treat Ebola patients. It's less good, however, that the protocol is difficult to follow and leaves space for human decisionmaking — and thus space for dangerous human error.
Here is the link to the full article: How does an American nurse contract Ebola? With directions like these. - Vox
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