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Why Don't We Know Yet Exactly What Happened When Our Ebola Patient Zero Appeared?

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The commenters are already whetting their knives on Stephen Young's piece here a bit earlier reporting that Dallas County Commissioner John Wiley Price has raised the issue of racism in the treatment of Ebola Patient Zero, Thomas Eric Duncan, at Texas Health Presbyterian Hospital. But maybe we could all acknowledge one tiny element of legitimacy in what the commissioner is talking about: The question of why Duncan was sent home initially instead of isolated is still the most stubborn mystery in the saga of "Ebola Comes to Dallas."

See also: "John Wiley Price "Knows What Happened" at Presbyterian in Ebola Case"

Even the typically meticulous New York Times still stumbles on it. In an editorial today titled, "Stopping Ebola in America," the paper says, "It is incredible that doctors in a Dallas hospital reportedly made no effort to ascertain the patient's travel patterns."

But four days ago the same newspaper reported the opposite about the hospital's first encounter with Duncan, newly arrived from Liberia. In a news story headlined, "Dallas Hospital Alters Account, Raising Questions on Ebola Case," the Times told readers the hospital had "acknowledged that both the nurses and the doctors in that initial visit had access to the fact that he had arrived from Liberia."

The New York Times is not the Lone Ranger here. Almost two weeks after Presbyterian sent Duncan home with undiagnosed Ebola, that one key transaction is the single piece of the entire puzzle most stubbornly missing from the overall picture. If the nurses knew and the doctors knew that Duncan was a recently arrived immigrant from a hot zone in Africa, why was he sent home?

But did they really know? Or was his travel history merely information buried at the bottom of a computer file no one had time to read?

Or was it something else? Most of the treatment of the question so far seems to assume a bungle, a mistake. But why would we leap to that conclusion? The Dallas Morning News reported on October 2 that two Texas Health hospitals in the Dallas/Fort Worth area, Presbyterian and Harris Methodist, are among three in the area with far worse records than most their size for sending patients home from the emergency room who later must be readmitted. That rubric -- ER readmissions -- is one way the federal health system measures the efficacy of hospital emergency services. Both Texas health hospitals have been penalized for their high rates of readmissions.

If Duncan's dismissal from the emergency room on his first visit was a bungle, then it's reasonable to assume that everybody knows about the bungle by now and a similar goof is unlikely to happen again at any decent hospital in America. But if the handling of Duncan grew out of something more systemic, especially a business or management style or policy, then it may be less reasonable to assume the next hospital will be immune from the same issue.

Especially as other details come clear and early mistakes in the Texas Ebola story are sorted out, it's all the more remarkable that the Texas Health Presbyterian emergency room story remains cloudy. Three days ago a former Boston hospital CEO, Paul Levy, called on Texas Health to open up: "A failure by a hospital to be open about what went wrong in a major medical case such as this," Levy said, "does a major disservice to everyone else in the health care industry."

Unfortunately, the hospital company started the ball rolling with a very detailed, almost ornate explanation of what happened that turned out after a few days to be untrue. On October 1 Texas Health issued a statement saying, "The documentation of the travel history was located in the nursing workflow portion of the EHR (electronic health record), and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order. As designed, the travel history would not automatically appear in the physician's standard workflow."

Three days later, as the Times and The Dallas Morning News reported, the company conceded that "there was no flaw" in its electronic health records system. The company said "the patient's travel history was documented and available to the full care team in the electronic health record, including within the physician's workflow."

The initial statement sounds like the product of some analysis. So how did they get it wrong? The statement was surely written by a public relations person, not a physician, but why was it so emphatically wrong and in such rich detail?

Does that mean a group of doctors or some doctor knew Duncan was newly arrived from Liberia, thought about it and decided to send him home with the wrong prescription anyway? That's a far leap and ignores other possibilities that seem more likely somehow. The fact that information is in a chart does not mean everybody on the case looks at it or even sees it. In the mad crush that an urban urban ER can become on any day at any hour, lots of information may fall through the cracks.

I have a personal dog in this hunt. When they were at the ends of their lives, Presbyterian was the home hospital to my own parents, who have been gone 12 years. It's probably all changed around since then, but I used to know that emergency room like the back of my hand.

If anybody is reading this from far away and wonders what kind of medical care people get at Presbyterian, I would have to testify, based on my own experience, that the care there is top-drawer. Or can be. As far as I could see back then, the hospital was staffed by some of the very best doctors, nurses, tech and cafeteria workers in this area, maybe in the country, maybe in the world.

I was shocked to read about its history of ER readmissions because that information is so starkly in contrast with my own experience, where every admission, again and again from the nursing home, was taken seriously. My parents never went home until the hospital had done everything possible for them.

To put it bluntly, 12 years ago Presbyterian was where you went yourself or sent your loved one if you had good insurance. If you had no insurance, if things were dicey or you just wanted to dodge a co-pay, there were other hospitals in Dallas where you were more likely to go.

But the world around Presbyterian has changed dramatically since my parents were in and out. The entire vast immigrant neighborhood in the Five Points area just blocks east of the hospital is a new phenomenon since then, created by policies of the relief agencies and by settlement patterns.

How has that affected the hospital? How many of the immigrants have insurance? What does it cost Presbyterian to care for the ones who do not? What will it cost Presbyterian to care for Eric Duncan? Who eats that cost? You and I can vow he should be cared for no matter what, but somewhere at some desk somebody has to put that money down in the books. Where in the books? Whose books?

Ownership, management, responsibility, liability: these questions are more complicated than anybody could have imagined even 12 years ago. Right now Christus St. Vincent Regional Medical Center in Santa Fe, New Mexico, owned by a Texas company, is effectively suing its own emergency room to settle a question of liability.

The ER there is run under contract by a doctor's group. The hospital company anticipates an expensive lawsuit from a case that went bad involving the wife of the former New Mexico attorney general. While insisting that everything was done properly in its emergency room, the hospital company nevertheless is suing its own ER doctors to make sure, if an expensive verdict does come out of it, that the doctors will be on the hook for it and not the hospital company.

I don't offer that information with a value judgment, merely as evidence that hospital medicine, especially emergency medicine, is an extremely high stakes business enterprise. It's one in which medical practitioners and hospital administrators may find themselves in seriously adversarial roles. (I have a question in to Texas Health Presbyterian about who runs its ER Haven't heard back yet.)

All of that may turn out to be totally irrelevant this case. If the truth of the matter is that some doc was exhausted from keeping people alive all night and goofed on a single piece of data, then I really don't believe that person should be publicly pilloried or excoriated for it. The rest of us laymen are damned lucky anybody can even get through a medical education anymore and that people are willing and capable enough to do it. Emergency means emergency. It means risk. It's not a hat shop.

But if the Eric Duncan mistake flowed from something more systemic, then we absolutely need to know what it was and how it happened so that we can look for the same problems everywhere else. If it was a non-medical problem, I can almost guarantee you it will turn out to be an issue not be unique to this hospital.

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