When I went to nursing school, it was called isolation. When HIV became better known, ‘universal’ precautions were implemented. Every patient was treated as though they were HIV positive and they still are. Now, there’s that pesky little Ebola bug and it is causing nothing if not widespread fear and panic. It’s not blood borne and at this juncture, isolation precautions are being threatened.
Unlike HIV, Hepatitis and other blood borne diseases, nobody is able to state with complete certainty that there is no risk of exposure from casual contact with an Ebola infected patient. The odds are clearly in favor of no infection but someone wins the lottery against staggering odds every week or so. A very low risk is not the same as no risk.
We are Americans and we want absolutes; unwavering positions, assurances and guarantees. We want answers before we ask the questions and we do not sit well with not knowing.
Lacking absolutes, we conjure up every possibility in the universe. Fear sells. Anxiety is contagious. If you want to sell a newspaper, write about something frightening.
On the other hand, if you are a politician seeking reelection, preventing widespread panic and fear is the way to go. The end result is that Americans get mixed messages and trust is eroded.
Where we stand now is between the press and the politicians with two very different agendas and neither of them is completely trustworthy. It is for this reason that it’s reasonable to ask those people who have been in contact with Ebola patients to lay low for a couple of weeks until the period of incubation has expired. The risk may be very low (as per the politicians) but the consequences are dire (according to the press). It is in that measurement between risk and consequence that decisions are being made.
Kaci Hickox, a nurse, is bound and determined to convince us all that mandatory quarantine is barbaric and illegal. She knows that if she goes out in public, the fears of the community will escalate but strangely that is exactly what she wants to do. She is basing her position on science but science has not revealed all there is to know about Ebola as yet. She is forgetting that science is only half of the ingredients of a good nurse – the other half being compassion. Where is her compassion for those individuals, perhaps thousands, who will lose sleep if she breaks quarantine? Where is her compassion for her neighbors who will voluntarily isolate themselves out of fear?
I gather Kaci Hickox, who took care of Ebola patients for 4 weeks in Sierra Leone, is so utterly confident in her own isolation techniques that she believes it to be impossible that she is sick with Ebola. I have seen that kind of confidence before and it never ends well.
In comparison, Nina Pham and Amber Vinson took care of an Ebola patient in a US Intensive Care Unit – a far cry from the facilities available in West Africa. Maybe Kaci Hickox is a much better nurse than the Dallas crew or maybe she is just selfish.
Her lawyers are falling back on a supreme court opinion that says that quarantine cannot be enforced based on fear alone. One look at the number of cases in West Africa and the trend would scare the Supreme Justices, too. Just for fun, check out this graphic from the Economist.
I wish I had all the answers. This much I know…. If I had been in Sierra Leone taking care of Ebola patients and then flew home to the US, I would be tired. Jet lag is a killer all by itself. If someone offered to bring me food and told me to hang out at my house for a couple of weeks, I could live with that. I could appreciate that even though the risk of spreading the virus is very low, the risk of frightening my neighbors is very high and I do have compassion for most of my neighbors.
Maybe Kaci Hickox is fearless and brave but a new mother who ran into Ms. Hickox at the mall with her infant child might very well live in frank, abject fear for weeks when she is already tired and cranky. A corner grocery store where people shop might suffer enormously if Kaci Hickox showed up there.
None of this matters to Kaci Hickox. I am not used to nurses being selfish. She is like a three year old who wants to go out and play and doesn’t quite get that none of the other children want to play with her. I understand that the fear is out of proportion to the risk but fear is as ruthless as Kaci Hickox appears to be.
A greater concern is the fact that she is forcing the hand of authorities to use a higher level of vigilance than would be necessary if she took a break from the ‘all about me’ attitude. She is taking the attention away from where it needs to be which is on the virus and it’s prevention and cure and bringing it to herself and her own desires to wander around aimlessly regardless of how uncomfortable her presence makes others feel.
If any of you are brave enough to go to Sierra Leone, have no fear. You will have our undying support. Blog readers everywhere will make you wish you were isolated even longer so you could bask in our undying admiration for you. But, please do not go if you are not prepared to lay low and err on the side of safety when you return if you err at all. We don’t want to hear about your ‘rights’ when the consequences are so great even though the risk is small.
When science tell us there is zero chance of spreading the disease, we will come and hug you but until the guarantee is in place and supported by evidence, we’ll worship from afar.
OASIS and Coding Review 
Maybe, just maybe, if she had been treated like a human being when she returned from her humanitarian mission, she’s have felt differently. Instead the state of New Jersey treated her worse than they do a dog. They put in her a tent, in paper scrubs, with no toilet, no running water and no heat. If we did that to a prisoner in Gitmo, it would be called torture.
I’d like people to think about this. We don’t make someone with influenza stay home. In the US alone, Influenza killed over 40,000 people last year. And we have a vaccine that helps. To put it even more in perspective, TB will kill more than a million people world wide this year.
Now, I don’t want to minimize that Ebola is a risk. I just want to tell people to quit feeding into the paranoia. All it does is convince people to lie. And that makes the job of the Public Health Departments and the CDC a zillion times worse.
This is not the Zombie Apocalypse. It’s a disease. I don’t know why you became a nurse, but I became a nurse to take care of sick people. It was probably back when many people who read your blog were still in diapers. I lambasted nurses who treated HIV patients with no dignity. I do the same to you now. You should be ashamed of yourself. She’s your peer. She was treated like she was worthless. And you don’t say a word about that, only that she should stay home like she was a leper. (We treat people with Hansen’s disease better than that now.)
Quit feeding the terrorism.
I know if you let this through that more probably will nod their head and agree with you than me. But somewhere along the line, we’ve forgotten that our jobs have risk, that our lives have risk. And while every life can be precious, living one without risk, living in a bubble, is not one I personally would ever want to take.
I always welcome opposing views respectfully presented. You came very close to crossing that line with your admonishment that I should be ashamed of myself.
I agree that she should have been treated better and I understand your position about perspective. I think she would have been the perfect person to help with redesign of the process as one who knows about the virus and as one of the first people subjected to the policies. At this juncture, I am not sure she is willing to work with anyone.
The stories differ on how she was treated and how long she stayed in the holding tent. I do not believe that anyone had the intention of holding there indefinitely. By the next day she had an iPad, high speed internet, etc. Later she was allowed to go home.
I agree that risk is inherent in the job duties of a nurse. It has never been otherwise. With the decision to take a risk comes the responsibility to mitigate the risk no matter how small it is. If you were counseling a nurse about a needlestick from a known HIV positive source, would you advise him or her to take measures to prevent the spread to sexual partners? The fact is that the risk of infection from a known contaminated source is about one fifth of one percent. Still, we don’t throw our gloves in the trash or recommend abandoning caution.
If you want to propagate fear, the absolute best way would be to be placed under an order of quarantine (right or wrong) and publicly announce that you are not going to follow it.
Having said that, the CDC recommends quarantine for persons known to be at high risk for exposure. Kaci was involved in hands on care of patients with Ebola. That puts her in a high risk category. Quarantine according to the CDC involves limited movement from the place of least restriction – usually the home. They are allowed to go out if they do not use public transportation and if they maintain a distance of 3 feet from other people. The bike ride doesn’t bother me as much as her blatant defiance of an order by the governor who, by the way is a total ass. Just so you know.
I very well remember HIV at its onset. I believe we called HTLV III initially. HIV wasn’t in the nomenclature until later. As you pointed out, there were a lot of irrational fears then, as well but the answer wasn’t to force people to test their fears – it was education. We learned a lot about HIV in those first few years and the information changed almost daily if you recall.
Historically, people with Hansen’s disease were cast out of society for the duration of their life in spite of the fact that there is much more to the transmission of the disease than exposure to the bacteria that causes it. With Ebola, we are talking about 21 days after which time, there is no risk of infection.
Finally, while I agree that Kaci was treated horribly by inexperienced people in an inexperienced system, my understanding has never been that this was personal about the nurse but measure to prevent the spread of the disease in the US. Regardless of whether or not they are warranted is debatable but for now, they are in place and the way to get them relaxed is not to be blatantly defiant.
I am not ashamed of myself and I am not feeding the terrorism. I am afraid that the polarization and the politicizing of views regarding Ebola may increase our risk and we may miss opportunities to stop this in its tracks because of the distractions. I am also somewhat amazed that nobody in the US seemed to care when the rate of cases in West Africa was doubling every few weeks and we didn’t really get excited until it came to the US.
I find myself in the unusual position of disagreeing with your blog post. Kaci, like all of us, was taught to honor and practice evidence based medicine. The evidence points to self monitoring – not quarantine – as the proper precaution in this situation. This is not a new disease, nor is the disease process or infectious process a mystery. A person without symptoms – the evidence shows – is not contagious. Monitoring herself for symptoms is the appropriate action.
To take your HIV example – proper precautions when treating a patient with HIV include gloves and handwashing for routine contact, and add gowns and face shields when blood splatter may occur. To be extra super duper safe, we could wear disposable gowns and N-95’s and caps and shoe covers for all care. But we don’t, because the evidence says they are not needed when treating people with HIV.
I’d like a three week vacation, too. But I can’t afford it. Is anyone stepping forward to pay her rent for the month? To buy her groceries? If not, this isn’t a “vacation,” this is imprisonment without just cause.
And, yes, what Cerebral Chaos said. Unless we’re prepared to quarantine every nurse who comes into contact with an influenza patient, this is clearly a fear-based decision, not an rational course of action. My job as a nurse is to educate people about real risks and benefits of all sorts of interventions and precautions, not to get caught up in media rhetoric or the decisions made by politicians, rather than healthcare professionals. I’m proud of Kaci for taking a stand in favor of evidence based medicine.
Nicole, feel free to disagree with me any time. That is why I keep blogs instead of plain websites where people simply are exposed to my views with no two way communication.
I like that you address evidence but honestly, there have been only about a thousand cases of Ebola spread over more than a decade prior to this outbreak. I do not think that this means that the virus has changed as some people do but rather that it is has come to the big cities. The point of entry from overseas is through a limited number of airports, all in major cities. Meanwhile, our limited experience and all that we learned in the first few years of HIV is something to keep in mind.
I had not given thought to the lost wages. I erroneously assumed that whomever forced you to stay home would cover them. Alternatively, I sincerely hope that the nurses who lost time had their paycheck come in through the hospital. I read through the quarantine laws of all the states and found that it varies and that some states are introducing new legislature that – get this – wants the quarantined person’s employer to cover their paycheck without using sick time or vacation time. This would apply to people who work anywhere – not just those with a potential exposure at a hospital. Interesting but I wonder if the government has considered how much cheaper it would be to cover lost wages than it would be to care for even one patient or hire the handlers to deal with the PR mess.
The flu is most contagious the day before symptoms appear. Thus anyone who went shopping at the mall, to church on Sunday or to a school basketball game would expose hundreds of people and quarantine would be impossible. I will say that I am appalled at the number of people who do go to work sick and that likely says something about our policies regarding sick leave.
The CDC classifies people who have come into contact with the disease with hands on work as high risk and recommends quarantine. This involves the place of least restriction and also limited movements. Lower risk people would be self-monitored.
HIV is blood borne while Ebola is carried in droplets. There is a difference. Increasing the level of protection for contact isolation will not add to your protection from HIV. The level of protection needed for Ebola has been underestimated in recent history. My bet is that varying levels are needed at different stages of the disease.
Here is what I do know. The first time that someone without a readily identifiable risk factor becomes ill with Ebola, all hell breaks loose. If multiple people become infected, it will cripple our healthcare system (such as it is) to the point of no return even though a handful of people do not an epidemic make. I do appreciate evidence but we have almost no experience with Ebola and there are still unanswered questions.
I guess I would be more willing to stand behind her if she made her stand by offering education instead of defiance and litigious threats against our political leaders.
It’s getting harder and harder to keep up, but I believe you are mistaken about the CDC recommendations. I believe (although in the current climate this could change, and if it does, I hope Kaci revisits her decision; that would be changing best practices with new evidence) that right now, the CDC is recommending monitoring, not quarantine. That’s what it says here, anyhow: http://www.cdc.gov/vhf/ebola/prevention/index.html?mobile=nocontent
The quarantine orders are coming from state officials, including Chris Christie in New Jersey, who are not doctors or nurses.
I’ve been looking for a copy of the latest recommendations by the CDC, the one that the news is reporting “breaks down” people into 4 risk categories. I can’t find anything straight from the horse’s mouth, as it were. But from the news reports, Kaci is a “some-risk”, not a “high risk”, because she wore PPE and did not have a needle stick or other direct, unprotected contact with the bodily fluids of an ebola patient:
“The “high-risk” category includes people known to have been exposed to Ebola, either by direct unprotected contact with a patient’s bodily fluids or through an accident like a needle stick or a splash to the eyes, nose or mouth.
These people would be placed in isolation at home, and barred from public transportation, workplaces or public areas. They would receive in-person daily monitoring by a health official.
Health care workers returning from West Africa would fall within the moderate “some-risk” category if they did not have direct contact with the body fluids of an Ebola patient. Also in the “some-risk” category would be someone living in a house with an Ebola patient who didn’t provide direct care to the sick person.
The CDC recommends that “some-risk” people also receive daily in-person monitoring from a local health official who could check for symptoms such as fever. Local health officials also would have the option of determining whether additional restrictions on travel or public activities are warranted on a case-by-case basis, Frieden said.
However, these restrictions would be much less stringent than the quarantines that New York and New Jersey had attempted to impose.”
http://health.usnews.com/health-news/articles/2014/10/27/cdc-clarifies-treatment-policies-for-ebola-workers
If anyone can find the actual recommendation from the CDC, rather than a report about it, I’d love a link. Lots can be miscommunicated in the press, as we all know. But it still seems to me that monitoring is what the CDC is calling for in this case, rather than quarantine.
http://www.cdc.gov/vhf/ebola/exposure/monitoring-and-movement-of-persons-with-exposure.html#table-monitoring-movement
See if that link works. It is on the CDC site in the Ebola section but not really obvious. It appears to me that the restrictions on both high risk and some risk people are pretty similar. It also says that the page was updated on 10/29/31. I seem to remember it the same as you except I thought that direct hands on care was high risk. I did not make the distinction as you did between with or without proper PPE.
As I told Chaos, I don’t have an issue with her going on a bike ride. Seems like the virus doesn’t like fresh air and sunshine and she probably needed the exercise after being cooped up all day. Meanwhile, the girl can’t go on a bike ride without the press corp following her and she is not my priority.
Meanwhile, we’ve gone quite a while without any further infections. This is good. It does not mean that we should let our guard down. As a country we are not prepared for Ebola, Pandemic Flu or any other major epidemic. Hopefully, an effective Ebola treatment will be available soon and then we can breathe a sigh of relief.
Thank you for that link!