Saturday, November 15, 2014

Ebola Clinical Illness in Well-Described Patients: The US healthcare system can only successfully handle a little Ebola

Let me start this piece with the bottom line: I want to be clear that patients with Ebola virus disease are sicker, in general, than patients with any other medical condition, in the US or anywhere else. They are subject to many more serious complications than other patients. They require more care, more lab tests, more procedures, more medical staff than patients with any other disease. (That is, if you are serious about trying to keep them alive.) The US healthcare system will not collapse like Africa's, but it will be sorely tested by an Ebola outbreak: cracks in an already-overstretched system will become readily apparent, and future patients will not receive the million-dollar care that a carefully controlled handful of patients have gotten, so far.

UPDATE Nov 18: From NBC:
“At UNMC, it has cost around $1.16 million to treat the two patients directed to us by the federal government. Treatment costs vary based on the severity of the patient when they arrive, but the cost is well beyond the normal costs incurred for an intensive care patient,” the school’s chancellor, Dr. Jeffrey Gold, said in prepared testimony…
This was part of what I tried to indicate in my September 30 post, in which I pointed out that US community hospitals could not care for Ebola patients. They will never be able to. They lack the containment to do it safely. Only large hospitals can assign enough staff away from other duties. They have no ability to get most labs and X-rays for Ebola patients.  Finally, who will pay for such high-end care in our profit-driven system? Will your insurance cover Ebola, when insurers have great latitude to reject claims?

UPDATE Nov 18:  The Nebraska Medical School Chancellor also noted“I urge Congress to approve funding and policies supporting full reimbursement of the cost of care for these unique cases that are not recoverable from insurance policies."

I have now read detailed accounts of the clinical course of the first two US Ebola patients (Dr. Brantly and Nancy Writebol) and two African patients treated in Frankfurt and Hamburg (one a physician and one an epidemiologist).  At first, the patient in Frankfurt had eight doctors working on his case.

The two African patients, from Uganda and Senegal, respectively, were much, much sicker than Brantly and Writebol. A third African patient, treated in Leipzig, died. It is rather amazing that the other two lived. The bill for the patient treated in Hamburg came to 2 million euros. (And the cost of medical care in Germany is half that in the US.)

UPDATE Nov 16: Senator Schumer has asked the federal government for $20 million to be reimbursed for the care of Dr. Spencer. (Is that why they call it the Big Apple?)
Today Dr. Salia has arrived in Nebraska for treatment, and he is said to be extremely ill, possibly sicker than any previous patients treated in the US.  He has been sick for 9 days, but that is approximately the amount of time it took before Writebol and Brantly arrived in the US. A statement released early Sunday by Nebraska Medical Center said that doctors treating Dr. Martin Salia were "using the maximum amount of supportive care possible in an effort to save his life," while the head of the hospital's biocontainment unit described the treatments as "an hour-by-hour situation." 

Brantly and Writebol received ZMapp, and Brantly received 3 units of blood (one from a recovered patient) while still in Africa.  Salia received one dose of ZMapp in Nebraska, but died within 2 days of arriving there.

It is possible that Caucasians have a less severe illness.  It is possible that early treatments with convalescent serum or ZMapp lessened the severity of illness.  With only a handful of cases to extrapolate from, neither may be true; but these hypotheses should be explored.

Six doctors (besides Dr. Salia) from Sierra Leone contracted Ebola, and (updated) now ten have died. The Ebola case fatality rate for healthcare workers in Africa is said to be 56%-80%, and the overall case fatality rate seems to be 60%--71%--74%, depending on the group studied.

I, for one, believe that the more people treated in our bio-containment units, the better for everybody. Doctors here have much to learn about treating Ebola, and we need to speed up the learning curve. MSF and other medical providers in Africa need to learn more about the illness from the first world's ability to monitor patients closely, and this will help refine and improve the treatments available in Africa and elsewhere.

Speaking of learning curve, I was surprised that even at Emory, next door to CDC, in the bio-containment unit there was no ability to get X-rays or more than a few standard laboratory tests for Ebola patients.  (Recall that I have discussed this major problem in earlier posts.) Somehow, in Hamburg, there seems to have been more advanced care available.  So the learning curve in the US could benefit from knowledge of what Europe is able to do.

UPDATE Nov 18: Emory now seems to have figured out the X-ray problem.

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