Ebola kills people.
I owe the Rev. Jesse Jackson a congratulatory card and a graduation gift. He has apparently gone all the way through medical school since last time we spoke. Maybe I’ll get him a nice Littmann cardiology II stethoscope. How else to explain his sudden expertise in international infectious diseases? The relatives of Thomas Eric Duncan, the Liberian who died of Ebola in a Dallas hospital, have, with the assistance of “Dr.” Jackson, decided that the treatment he received was substandard and that it was because he, the patient, was African.
Yeah. Because that’s what we do. We healthcare providers just decide to give substandard care. Of course we do.
Dr. Jackson is, naturally, aware of what Ebola is. It is a virus, which means antibiotics don’t work against it. The US, and the world, have no effective treatment for Ebola. Here is what Ebola (EVD) looks like on presentation, according to the CDC: http://www.cdc.gov/vhf/ebola/hcp/clinician-information-us-healthcare-settings.html
Patients with EVD generally have abrupt onset of fever and symptoms typically 8 to 12 days after exposure (incubation period for current outbreak has a mean of approximately 9 to 11 days). Initial signs and symptoms are nonspecific and may include fever, chills, myalgias, and malaise. Due to these nonspecific symptoms, particularly early in the course, EVD can often be confused with other more common infectious diseases such as malaria, typhoid fever, meningococcemia, and other bacterial infections (e.g., pneumonia). The most common signs and symptoms reported from West Africa during the current outbreak from symptom-onset to the time the case was detected include: fever (87%), fatigue (76%), vomiting (68%), diarrhea (66%), and loss of appetite (65%).
OK let’s stop there. The ER in Dallas has been roundly castigated for sending Mr. Duncan home with a fever of 103. Given the viral news coverage for Ebola, and the fact that Mr. Duncan was from Africa, the ER should have included Ebola in it’s differential. But remember Ebola is really very rare, with an incidence in the US of 3/330,000,000 so far. My last bout of the flu looked just like it.
Patients can progress from the initial non-specific symptoms after about 5 days to develop gastrointestinal symptoms such as severe watery diarrhea, nausea, vomiting and abdominal pain. Other symptoms such as chest pain, shortness of breath, headache or confusion, may also develop. Patients often have conjunctival injection. Hiccups have been reported. Seizures may occur, and cerebral edema has been reported. Bleeding is not universally present but can manifest later in the course as petechiae, ecchymosis/bruising, or oozing from venipuncture sites and mucosal hemorrhage. Frank hemorrhage is less common; in the current outbreak unexplained bleeding has been reported from only 18% of patients, most often blood in the stool (about 6%). Patients may develop a diffuse erythematous maculopapular rash by day 5 to 7 (usually involving the neck, trunk, and arms) that can desquamate.
Translation: From looking like the flu, Ebola progresses to diarrhea, vomiting, abdominal pain, chest pain, trouble breathing, confusion, headache, bleeding from gums or rectum, seizures, and rash that results in skin peeling off.
Patients with fatal disease usually develop more severe clinical signs early during infection and die typically between days 6 and 16 of complications including multi-organ failure and septic shock (mean of 7.5 days from symptom-onset to death during the current outbreak in West Africa).
Dr. Jackson, as an infectious disease expert, has a healthy fear of multi-organ-system failure (MOSF in ICU lingo). What generally happens in severe cases is that patients get so dehydrated from diarrhea, vomiting, and bleeding, that the amount of blood in their veins can no longer provide a blood pressure that sends adequate oxygenation to the vital organs, which start to shut down and die. In West Africa the fatality rate is 71%. Almost three-quarters of people who get Ebola and aren’t treated adequately die. Why aren’t the African patients treated adequately? Because the resources required to save the life of one patient with MOSF include the following:
ICU-level nursing, multiple blood transfusion of red blood cells and clotting factors, one or more intravenous medications to support blood pressure, large-bore intravenous access, preferably into the subclavian vein or internal jugular, warehouses full of protective gear for caregivers, ventilators for lung failure, dialysis for renal failure, intravenous nutrition, gallons of IV fluids, sodium, potassium, arterial blood pressure monitoring, and state-of-the-art monitors.
In the US doctors are five per square foot. In Africa they are five per 1000 square miles. Approximately.
Did Mr. Duncan get all the treatment US medicine could throw at him? I don’t know, but I bet he did, at significant risk to the nurses and doctors who waded through his feces, blood, and vomit to care for him. Because it turns out that when someone is dying we forget the color of his skin, how much they can pay, or what perceived value to the world they have. Maybe the Rev. Jesse L. Jackson and Mr. Duncan’s family should stop assigning blame and start thanking the Dallas staff members for doing their best against a nasty disease. Mr. Duncan died because Ebola kills people.