Mistakes were made that led to Thomas Eric Duncan, the first Ebola case diagnosed in the U.S., being initially misdiagnosed, acknowledged the Dallas emergency department physician who initially treated him. The care provided to Duncan was “appropriate,” however, based on the information he knew at the time, the doctor said.
Dr. Joseph Meier, Texas Health Presbyterian Hospital Dallas emergency physician, said in a report published Sunday in the Dallas Morning News that he did not recall whether he asked Duncan, a Liberian national, about his recent travel history during his visit on the night of Sept. 25. Meier might not have asked because of Duncan's reply when asked if he had recently come in contact with anyone who had been sick, Meier said.
“I have a general recollection of Mr. Duncan, but I don't recall the specifics of our discussions,” Dr. Meier stated in a written response to inquiries by the newspaper. “However, I routinely pair the recent travel question with the sick contact question, so it is likely that I did so in this instance. According to the medical records, Mr. Duncan at least said 'no' to the sick contact part.”
Meier said he was unaware Duncan had registered a temperature of 103 degrees a little more than a half an hour before he was allowed to leave the hospital. Two days later, Duncan arrived back at the emergency department after his condition had worsened. He was tested and diagnosed to have the Ebola virus.
“I was unaware of a 103 degree temperature,” Meier wrote. “It appears in the chart, but I did not see it.”
Meier did not see the part of the electronic health record that noted Duncan had traveled from Africa, he said, adding that had he known Duncan traveled from Liberia, he would have contacted the Centers for Disease Control and Prevention and started an Ebola evaluation.
Texas Health has come under scrutiny for the way it handled Duncan's first visit and the series of public relations missteps that followed in its effort to explain what caused the initial misdiagnosis.
Hospitals officials first said Duncan's travel history had not been communicated to the entire medical team dealing with his case.
During a news conference on Oct. 1, Dr. Mark Lester, vice president of the hospital's parent company, Texas Health Resources, said that a nurse had asked Duncan whether he had traveled to Africa, but that miscommunication led to personnel lowering his risk status.
“Regretfully, that information was not fully communicated throughout the full team,” Lester said at the time. “As a result, the full import of that information wasn't factored in to the clinical decisionmaking.”
By Oct. 3, the organization backed off that initial explanation, releasing a statement that said the problem was caused by a “flaw” in portions of the EHR system that allows for the sharing of information between nurses and doctors.
“Protocols were followed by both the physician and the nurses. However, we have identified a flaw in the way the physician and nursing portions of our electronic health records (EHR) interacted in this specific case. In our electronic health records, there are separate physician and nursing workflows,” the statement read. “The documentation of the travel history was located in the nursing workflow portion of the EHR, and was designed to provide a high reliability nursing process to allow for the administration of influenza vaccine under a physician-delegated standing order.
One day later, the system revised its explanation yet again, putting out a short statement that said the EHR system was not to blame. “As a standard part of the nursing process, the patient's travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician's workflow,” the statement read. “There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.
Duncan died Oct. 8. Two nurses who were treating Duncan when he was eventually diagnosed with Ebola also became infected, but both have recovered.
When asked how he was dealing with the experience of treating the first U.S. Ebola case, Meier said it was “a little bit like getting struck by lightning, but mild in comparison to what Mr. Duncan's family has gone through in losing a loved one to Ebola.”
Follow Steven Ross Johnson on Twitter: @MHsjohnson