I was recently injecting anesthetic into a boil for incision and drainage. The abscess swelled and returned an arcing spray of lidocaine laden with blood and pus, soaking the thigh of my cotton scrub pants. A cheap plastic gown would have protected me — I usually wear one. But I couldn’t find one and had other tasks waiting. My mind went to Ebola and exposed nurse necks.
What if this were my hospital’s first Ebola patient, who also happened to have an abscess in need of treatment?
We who catch the spray of sick patients, and those tasked with the cleanup of human torrents and projectiles, are making calculations — with very limited data:
What’s the probability I will treat an Ebola patient? Extraordinarily small, unless I’m in West Africa or one of a few American hospitals.
What’s the probability that some nurse or doctor somewhere in the U.S., who did not volunteer for special duty, will be expected to treat an Ebola patient? Very likely. Just ask your hospital’s infection control people what the plan is for management of the unexpected Ebola patient, as I asked last week. The answer involves personal protective equipment, an isolation room, and a bunch of scared hospital staff with zero prior experience treating Ebola.
The people treating a hospital’s Ebola patients should be a volunteer team, in my opinion. An article, anticipating human behavior during a hypothetical outbreak of a virulent flu strain, highlights the important question: Will health care workers show up for the job?
Will staff show up to treat your hospital’s first Ebola patient?
Ebola differs substantially from the most feared workplace infections of yesterday: hepatitis, HIV, tuberculosis (TB). None of these threatens you with a fifty-fifty chance of death within the month, and perhaps to your whole bloodline the following month. That’s hugely different from contracting generally curable infections or treatable, slowly fatal diseases. Chronic diseases may be miserable, but by definition you get to live with them a while.
We all know our precise risk of contracting hepatitis or TB in our daily routines as health care workers. Just kidding. I stick a needle (or a scalpel, or a bone fragment) into the pulp of my fingertip every other year and have just a rough idea of my risk of contracting something. I do know it’s small. I dread these diseases, but accept the 1 in 10-to-the-x chance of getting one (where exponent x is between 2 and 4. Or is it 5? Or am I thinking of the risk of a blood transfusion?).
But what’s my chance of catching Ebola while draining an abscess? I have no idea. I’ve yet to see the patient-to-nurse transmissions in Texas explained beyond protocol breach or ineffective protection. Neck exposure seems an unusual suspect, and opinions (plus ambiguous terminology) abound on how a virus might travel shot-gun in a loogie or hang aloft in sneeze mist.
The transmission uncertainties and high mortality rate prompt serious self-reflection in a health care worker.
But our sacred duty is to treat patients! Yes, and I am also a single dad of a young girl. There was a time when I was available for health care hazard duty, and that day may come again. But the ethical tenets of health care — beneficence, non-maleficence, patient autonomy, and justice — need to be examined in the Ebola-at-your-local-hospital case. Is societal justice served if I die (or, say, a single mother of three or a pregnant nurse dies) treating Ebola in an 80-year-old man with a short life expectancy? It’s an ethical question the health care masses haven’t previously faced. Maybe a new tenet — provider autonomy — becomes part of the calculus when we risk orphaning our children in the near term.
A self-selected or recruited hospital Ebola team would allow staff to face the hard question in advance of the surprise case. Plus, such duties foster camaraderie and command respect, just as in other professions where self-sacrifice is a possibility (e.g., firemen, soldiers). Logistically, too, it’s easier to train and equip a small team to a higher standard.
To be clear, I think the chance of a massive outbreak in the U.S. is small. To best minimize that chance, though, we need engaged, well-trained responders. We need staff who will show up prepared for hazard duty, having already done the math.
Chris Porter is a general surgeon and founder, OnSurg.
