American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, September 5, 2014

Why are we dialing it up to 11?

We recently posted an excellent summary of what’s happening in U.S. hospitals as they scurry to plan for the public health issue du jour of Ebola. He astutely points out that there seems to be a disconnect between what we know about Ebola transmission and what we’re doing (or planning to do) with regard to safely caring for patients infected or suspected to be infected. I thought it would be interesting to examine what’s driving the disconnect. As I see it, a number of factors are at play here:

Mixed messages

As noted by Dan, at a press conference prior to the transport of 2 Americans with Ebola infection to Emory University Hospital, Dr. Bruce Ribner stated: “Emory University Hospital has been asked to accept two patients who are currently in Africa infected with Ebola virus infection. Our facility was chosen for this because we are 1 of only 4 institutions in the United States capable of handling patients of this nature.” Not stated, but nonetheless presumed by the infection prevention community is that the agency doing the asking was CDC, given CDC’s physical proximity and given that quite a number of CDC physician-epidemiologists hold faculty appointments at Emory’s schools of medicine and public health. However, just a few days later, CDC’s primary message was that any hospital in the U.S. should be able to safely care for Ebola patients.

It’s also difficult to reconcile the CDC recommendation for contact and droplet precautions—highly familiar to all health care workers—with the images of health care workers on the ground in the outbreak epicenters and in Atlanta dressed in Tyvek spacesuits. And who hasn’t seen the video footage of the infected American doctor emerging from the ambulance in Atlanta also dressed in the same manner? However, it’s important to keep in mind that the exposure risk for healthcare workers in the outbreak setting, caring for multiple very ill, infected patients with scarce resources, is far different than the controlled setting of the average American ICU.

Fear and managing risk

Our greatest fears often revolve around areas where we lack experience, and very few health care workers in the U.S. have ever cared for a patient with viral hemorrhagic fever. Importantly, not only does Ebola fever not have any proven effective therapies, there is also no post-exposure prophylaxis. A simple lapse in infection control protocol cannot be undone with a pill or injection. One way we attempt to manage fear is to overprotect: if 1 barrier works, 2 must be better. In general, redundancies mitigate risk, but this isn’t absolute. As Dan pointed out in his post, we may inadvertently increase risk by complicating infection control protocols with gear that healthcare workers may find distracting, uncomfortable, and lack training to use. The litigious nature of American society also impacts our decisions regarding infection prevention strategies. And many health care workers, while willing to accept much greater health risks in their personal lives, demand zero occupational risk.

Non-epidemiologic decision making

In many hospitals today, health care epidemiology staff have become advisors to hospital administrators who ultimately make decisions regarding the logistics of infection prevention. And their decisions may not be purely based on science. They often have aversion to approaches that would appear to be out of the mainstream of what other hospitals are doing, even if that’s suboptimal. In addition, infection prevention seems to be increasingly used as a public relations tool. If you don’t believe that, do a simple Google search and you will find scores of press releases published in local newspapers from hospitals who have purchased germ-zapping robots.

By the way, I believe that one of the best uses for a hydrogen peroxide vapor robot would be terminal disinfection of the Ebola patient room. Perhaps those hospitals who have invested in this technology should be the first to receive Ebola patients.

Paramilitarization of public health

In the run-up to the Iraq War, the Bush administration sought to engage the public health and medical communities in the war on terror. Much effort was devoted to preparations for bioterrorism. Who can forget the smallpox vaccine debacle? Preparedness was all the rage, and the Joint Commission couldn’t resist jumping on that bandwagon.

Admittedly, some of the impacts of this were positive. For example, hospitals became more tightly linked to public health agencies and those agencies became much more engaged and proactive. But a new group of professionals emerged who are employed to make us prepared, and perhaps a little scared. A physician colleague who works in the IT world tells me that the constant fear mongering by IT security specialists is in part a job security tactic. So the folks who work in preparedness stand ready to help, perhaps in a more aggressive way than necessary this time.

Ok, anyone still surprised we’ve cranked it up to 11? I’m with Dan in hoping that we’ll be able to dial it down to 8 this week.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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