Being a nurse is a risky job. Needle-stick injuries, violence, back injuries, and infectious disease are all potential threats. But until recently, nursing was not usually viewed, like police work, or commercial fishing, as a life-endangering career choice. Those who risk their lives for their work go into it knowing the risks, and receive intensive training and protective gear.
Not so the nurses at Texas Health Presbyterian Hospital Dallas and other hospitals across the country.
I remember reading The Hot Zone by Richard Preston. An account of the outbreak of Ebola in Africa during the 1990s, Preston describes how CDC personnel tracked the virus through remote villages, trying to find its source and halt the spread of infection. They worked in spacesuit-like protective gear, breathing through respirators a la Darth Vader, liberally spraying bleach solution wherever they went. These microbiologists, epidemiologists, and doctors — with years of specialized training — understood the lethality of the Ebola virus and its rapid transmission and high mortality rate. Their lives were on the line; and when they returned to the CDC, they would handle specimens in a special biosafety level 4 containment lab.
An online slide show created by the CDC describes the grading of biosafety levels (BSL), and places Ebola at level 4 (most dangerous). “There are a small number of BSL-4 labs in the United States and around the world,” it explains.
“The microbes in a BSL-4 lab are dangerous and exotic, posing a high risk of aerosol-transmitted infections. Infections caused by these microbes are frequently fatal and without treatment or vaccines. Two examples of microbes worked with in a BSL-4 laboratory include Ebola and Marburg viruses.”
The lesson goes on to describe the equipment necessary for handling such deadly microbes, including a “full bodied, air supplied, positive pressure suit” and a “dedicated supply and exhaust air (source, as well as) vacuum lines and decontamination systems.” Personnel are required to shower after removal of protective equipment and change clothes. An observer must be present at all times to watch for a breach in protocol.
It should also be noted that these requirements are for highly skilled personnel who only deal with blood samples under microscopes. Nurses, like those caring for Thomas Duncan, deal with urine, feces, sputum, vomitus, blood, and aerosolized droplets created during procedures like dialysis and intubation (which Mr. Duncan had), as well as daily tasks like emptying urine bags, cleaning the mouths of intubated patients, drawing lab samples, etc.
When the first two Ebola patients, Dr. Kent Brantley and Nancy Writebol, were brought back to the U.S., I thought it was very risky. However, Emory University /Grady Hospital (affiliated with the CDC) proved that their BSL-4 protocols worked — no health care personnel were infected. A sigh of relief! Perhaps this virus was not as infectious as first described? Indeed, the CDC kept reassuring us of its “low probability of transmission.”
Why then did the Dallas nurses contract Ebola? Unlike Texas Health Presbyterian Hospital, Emory (and Nebraska, Maryland and Montana — the only four high-level biocontainment facilities in the U.S.) had prepared for years for an event like this. These four hospitals have the dedicated staff, equipment, and training to care for these highly infectious patients. The nurses at the Dallas hospital were given personal protective equipment (PPE) that would meet the vague safety requirements suggested by the CDC’s reassurances.
A Google search for “CDC recommendations for Ebola,” finds this on the CDC website, from October 6: “Standard, contact, and droplet precautions are recommended for management of hospitalized patients with known or suspected Ebola virus disease.”
In an October 13 Associated Press/NBC 5 online report, a Parkland Hospital training video is featured. (Note: Parkland is not affiliated with Texas Health Presbyterian). A nurse is shown putting on knee high foot covers, an impermeable gown, a thick mask covering her mouth and nose, goggles, and a hair bonnet. Then she puts on two pairs of gloves. (Note that this goes beyond the safety guidelines above recommended by the CDC.)
However, her cheeks, ears, forehead, sides of her face, and neck are all uncovered. And this is following full protocol. When the Dallas nurse, Nina Pham, said that she didn’t break protocol to become infected, she didn’t have to! Any procedure involving blood or sputum (like intubation or the placement of venous and arterial lines as in dialysis), would send showers of aerosolized and infectious particles through the air and onto her unprotected skin. At the end of the video, the nurse demonstrates “proper removal” of the protective wear. Again, these unprotected skin surfaces are overlooked: never addressed, never cleaned. She never showers, she never changes clothes.
I am not sure what protocol the Dallas nurses were following. But what is abundantly clear is that the nation’s top infectious disease experts do not even have a consistent recommendation: Is it BSL-4 protection (like CDC training slideshow) or is it “standard, contact, and droplet precautions,” found on a CDC frequently asked questions resource?
Even a cursory glance at the Parkland video in comparison to the CDC’s earlier description of BSL-4 protections would lead a seasoned nurse to wonder who is making these decisions. It is often the case that a disconnect exists between administrators and officials who issue directives and the bedside staff who must carry them out. I imagine that the microbiologists who had to wear protection from Ebola had a say in its design and level of protection.
A nurse friend at a regional hospital recounted an Ebola false alarm that left her convinced the hospital was not prepared for these patients. Although the hospital provides safety suits more in line with BSL-4 gear, no one present that day knew how to use them. (Those who have been specially trained attended one day of training.) Apparently there were no on-call staff, and in the scramble to receive the patient (it turned out to later to be a drill) the message the protesting nurses received from upper management was “well, someone will have to take the patient.”
Nurses sometimes forget they have the right to refuse any patient assignment that they feel is unsafe. A 2009 position paper from the American Nurses Association (ANA) states: “Registered nurses … have the professional right to accept, reject or object … to any patient assignment that puts patients or themselves at serious risk for harm. Registered nurses have the professional obligation to raise concerns regarding any patient assignment that puts patients or themselves at risk for harm.”
Hospital administrators and the CDC should be on notice now that nurses all over the country are concerned. Perhaps it is time to invite those who issue edicts for bedside patient care to join us in carrying them out. Indeed, when their lives are on the line, they may take this risk more seriously. Until then, who is looking out for the nurses?
Kelley Reep is a nurse and can be reached on Twitter @reepRN.
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