Just finished reading another excellent diary here on DailyKos, which consists of the transcripts from Anderson Cooper's televised interview with Briana Aguire. We don't get CNN here in Kathmandu (maybe they do at the big hotels but I stay in a Guest House in a low-rent district of town) and I haven't watched TV since the World Cup.
As a nurse who has worked with infectious diseases and also been a hospital-level middle manager, I can't recommend it enough. The interview gives a lot of raw data, and made me do a face-palm a few times. They did what!?!?!?!?!?
I've written one previous diary about this from the nursing perspective, and in my own blog from Nepal I have described the feeling of inadvertently encountering an infectious contagious disease before you knew what it was.
Step onto the isolation ward with me, but - see that orange squiggly blob of unknown bodily fluid? don't get it on your shoes!
The subject is diarrhea
I thought about writing a bunch of comments on the transcripted blog, but then I didn't want to hijack it, so I'm writing my own. Bear with me. And yes, I know how laborious it is, to make the printed word from a TV interview. Many thanks!
I don't want to make light of the Texas Presby situation, but - any person who grew up with Star Trek can recall the episode titled "The Trouble with Tribbles." In that episode the Starship Enterprise was taken over by lovable furry critters that bred exponentially. They were charming at first, then over-ran the ship. And a sort of grim humor took over.
Texas Presby as The Starship Enterprise
I've previously said there was some kind of systems error, and this interview is a gold mine for those who look at hospital systems. What jumps out at me? They had no system for getting rid of the waste. Or what they had was a total breakdown. Reading that diary, I get the clear impression that when they filled each plastic bag with waste, or when they filled each linen bag with diarrhea-contaminated linen, nobody came to get it. It wasn't removed from the patient-care area. And like the tribbles in Star Trek, the pile of bags accumulated.
Picture this.
First, the bags in Texas filled an adjacent room, then it got so full that they couldn't open the door. Then, the staff was forced to just pile the bags along the corridor walls, according to the transcript. It got to the point where the halls were lined with trash bags. All this, according to the transcript.
Not just any trash bags - these were full of a known biohazard. Now, the Trouble with Tribbles was a hilariously comedic episode of good clean fun. But this situation in Texas should have been recognized as unacceptable after about twelve hours. at the very least, they could have rented a dumpster just for the waste until they figured out what to do with it and where to go.
It needed to go off the floor and away from the patient care area. This is a logistics problem. No staff nurse should ever have been expected to design a system for this kind of hazardous waste.
Exactly how many days did this go on? Exactly who was the manager that did not get this collected? Who did she or he call? Exactly how was it that the CEO, the one who just apologized in the New York Times, was personally unaware of this dire situation?
An old management aphorism in health care, is that you have to be truly incompetent not to see that the clean linen arrives and the dirty linen goes away. It has always been a minimal expectation. Elementary logistics, my dear Watson!
Nepal story, of course
One day at a hospital in rural Nepal where I was stationed, teaching nursing to the second-year batch of students on the medical ward, I gathered my little band of students and asked them to get out their pocket English-to Nepali translators, or their little dictionary. They did.
"Look up the word 'glamor,' " I told them.
" 'Glamour?' g-l-a-m-o-u-r? that word?"
"yes."
they gave the answers "sexy" "attractive." and we all chuckled.
"Good job," I told them. "Well, at report we learned that we have eighteen patients with diarrhea here today. so - what we are doing is - the opposite of glamour."
We maintained our of sense of humor. But I don't see how anybody at Texas Presby could have done so. On many of the nursing units where I have worked, you'll run into some 'clean freaks' who begin each shift by wiping down every flat surface with disinfectant, cleaning the pens they might use, and even the computer keyboard. These are the nurses who clean the refridgerator and they are friends with the housekeeping staff. Sometimes on a nursing crew, the others make fun of them for being compulsive - but these people who pay attention to hygiene are the ones who make it safe for all of us. In a hospital, you expect that somebody is doing that ever single day.
Processing a new self-image for nurses
On FaceBook, my nursing friends in Maine, far from Dallas, were coming to grips with this new idea that the daily work may soon require a hazmat suit. Lots of bravado about being on the front lines. Most of it, I expect, is not going to be needed. This served the purpose of processing a new role for nursing and unexpected higher visibility in a public health emergency. I hope we manage to control Ebola here, and despite the people who are taking this opportunity to dump on the entire system, I think we will. The followup here requires concerted effort to review the handling of the waste, not just what the nurses do. That's why the nurses of the USA are unanimous in saying don't blame the nurse.
Exactly how much diarrhea are we talking about here?
I don't have personal experience with the amount of diarrhea that an Ebola victim produces, but they say it is prodigious ( up to twelve liters a day I read somewhere, and in the gallows humor among nurses, if a nurse says there was a lot of diarrhea, you best be not asking too many questions......). I recommend one video from Patriot Nurse on the treatment of diarrhea. This one focuses on Cholera, not the same disease obviously but one which also produces diarrhea. On the bedside management level, I expect that they probably had a rectal tube in place, but even that simple measure may not have been enough.
When the have a cholera epidemic in a low income country (Ayiti comes to mind), they usually adopt the system in which the stretcher is lined with plastic. There is a hole strategically placed halfway down, under which a bucket is placed. (making a hole in the bedding is not something you can do with a thick American hospital mattress). That way the human waste runs down the hole, directly into the bucket. This is a simple but effective system, though perhaps not the most dignified, since the victim lays there with no diaper or sheet. You don't generate so much dirty linen, but you do have to empty all the buckets. In some of the videos from the Haitian cholera epidemic you can see just a split-second view of what I am describing and how it is set up. Usually, the actual nitty-gritty is not the focus, since the is no privacy and dignity in being publicly naked. Here is a video where you can see the system if you look closely.
In the Zimbabwe cholera epidemic, the cholera didn't get out of control until the housekeeping workers, the sanitation team, abandoned their jobs. I would not have thought we would have the analogous situation here in Texas, but if the transcript is to be believed, it sure sounds like we did. And we are fortunate that there were not more hospital-acquired infections among health care workers than there were. In Nepal, cholera is endemic, and we had a few cases, but kept it under control with the usual precautions. Lots of handwashing with peach-scented soap.
Two final thoughts:
First, the American public needs to get an accurate idea as to exactly how a hospital in a Low Income Country is administered. Maybe that will help understand why the effort needs to focus on what is happening in the affected country. You are all invited to read one of my two books on the subject. The first was The Hospital at the End of the World, published in 2009. The second is The Sacrament of the Goddess, new this year.
If you need pictures, go to the FaceBook page for The Hospital at the End of the World. For that matter, check out the blog of my current project, teaching Cardiac Life Support skills in Nepal.
The first book was non-fiction but readers thought it was too depressing, so the second was fiction in order to keep the readers engaged. I think people do need to understand that a hospital in most of the world, is not like a USA hospital. Yes, it's a bit of self-promotion here, but I don't pretend to be a commercial author and I never wrote either with the expectation of being on the NY Times best seller list.
Second, I'm still on #TeamNina. She, and the other hospital workers in USA, will be on my daily prayer list.