Dead Texas Ebola Patient’s Family Questions Hospital Care

Hours after Dallas Ebola victim Thomas Eric Duncan died, his family called for an investigation into his care as top infectious disease doctors said he may have survived if his treatment had begun earlier.

The family cited his initial release from a hospital emergency room, which put him on the streets of Dallas for two days until he returned in an ambulance. They also questioned why Duncan didn’t get an experimental drug for the disease earlier, citing its use by other Ebola patients treated in the U.S.

“We begged and pleaded several times,” for doctors to do more, Josephus Weeks, Duncan’s nephew, said in a text-message interview. “They said it’s too late in his treatment. They didn’t try any other options but saline, oxygen and water.”

Duncan died yesterday, ending a case that helped bring into sharp focus the nation’s risk from the disease. The incident showed that Ebola could quietly make its way into the country, and that hospital protocols designed to control it may not always work. At the same time, it rang an alarm for medical and federal officials to tighten the safety net.

Doctors say if Duncan’s hospital treatment had started sooner he might have survived. Instead, he didn’t get treatment for days after his symptoms first appeared, and he wasn’t given brincidofovir, an experimental drug produced by Chimerix Inc., until 10 days after he fell ill. At that point, his kidneys no longer worked and he needed a ventilator to help him breathe.

Other patients who were treated in the U.S. and survived “were all diagnosed very, very quickly,” allowing them to get supportive care to keep their organs functioning while their bodies fought off the virus, said William Schaffner, an infectious disease specialist at Vanderbilt University Medical Center in Nashville.

“If you start all those things earlier, you are much more likely to have the body respond appropriately,” Schaffner said by telephone. “The longer the illness goes, the more difficult it is to restore the patient to good function.”

Jana Shaw, an infectious disease physician at Upstate Golisano Children’s Hospital in Syracuse, New York, said the experimental drug treatment may have been started too late to possibly make a difference.

“If you start treatment when the virus is integrated they may not help at all,” she said by telephone. “It’s very likely his body was already overwhelmed by this virus and this drug had very little chances of working.”

Duncan’s death at age 42 came less than three weeks after he arrived in the U.S. from Liberia to marry his girlfriend Louise Troh, who is now being quarantined and monitored for symptoms. He was diagnosed with the disease on Sept. 30 after contracting it in West Africa, where Ebola has infected more than 8,000 people, killing about half.

The calls for an inquiry come at the heels of a series of confusing incidents. Duncan was sent home with antibiotics by physicians at Texas Health Presbyterian Hospital Dallas after visiting the emergency room on Sept. 25.

At first, officials said a flaw in its electronic records system meant Duncan’s physician didn’t see a nurse’s note that he had recently been in Africa. Later, the hospital said electronic records weren’t at fault and the information was available to everyone, making it unclear why Duncan wasn’t suspected of having Ebola on his first visit.

Now the family is wondering why doctors waited so long to administer experimental medicines, and why Duncan wasn’t given blood serum from surviving patients, treatments that other Ebola patients in the U.S. have received.

Dallas lawyer Michael Sawicki, a plaintiff’s attorney who takes medical malpractice cases, said a lawsuit against the hospital or doctor in the Duncan case is likely to fail because Texas law makes specific exemptions for emergency care.

Quoting a 2003 Texas legal rule, he said a person who in good faith administers emergency care is not liable for civil damages for an act performed during the emergency unless the act is willfully or wantonly negligent. “That means you have to intend for the harm to occur,” Sawicki said.

There has been no case in Texas where a plaintiff has proven a case under that rule, according to Sawicki. “The law is written so in emergency care you’re not responsible for anything,” he said.

The Texas Department of State Health Services said it is considering an investigation of the hospital where Duncan died, though its current priority is continuing to track people who had exposure to him while he was sick with Ebola.

“It’s under consideration, but our top focus right now is the contact investigation and monitoring,” said Christine Mann, a spokeswoman for the agency.

Troh, Duncan’s girlfriend, said she is dealing with his death with “sorrow and anger” that Duncan’s son, Kasiah, a 19- year-old college student who lives in San Angelo, Texas, wasn’t able to see his father before he died. Kasiah Duncan visited his father at the hospital Oct. 7, but wasn’t able to go into his room, Wilshire Baptist pastor George Mason said yesterday at a church news briefing.

“I trust a thorough examination will take place regarding all aspects of his care,” Troh said in a statement released by the church.

The hospital has declined to clarify why it waited before given Duncan treatment beyond standard-of-care for Ebola, which includes staving off infection, maintaining electrolyte balance and blood pressure in patients.

Physicians have emphasized that Durham, North Carolina- based Chimerix’s brincidofovir, and other Ebola medications are experimental and unproven. Among patients who have gotten other experimental drugs and recovered, it is unclear what role the medicines played as some people’s immune systems can fight off the disease on their own.

“We have no idea whether any of them work. That is a great question mark,” Vanderbilt’s Schaffner said.

Of dozens of drugs that have been shown promise in the lab against Ebola, only ZMapp from Mapp Biopharmaceutical Inc. and TKM-Ebola from Tekmira Pharmaceuticals Corp. have been shown to completely protect monkeys infected with the virus, said Thomas Geisbert, a virologist at the University of Texas Medical Branch at Galveston.

Chicago-based civil rights activist the Reverend Jesse Jackson traveled to Dallas on Oct. 7 to pray with Duncan’s family and urge better care for Ebola patients.

“He just wants the same treatment and consideration” given to patients in Georgia and Nebraska, Jackson said, referring to the two humanitarian workers who were brought from Liberia to be treated in Atlanta, and the NBC cameraman in Liberia brought to Omaha for treatment.

Duncan spent 11 days in the hospital, including yesterday. The likely costs for such a stay may have risen to as much as $500,000 for Duncan’s treatment to cover kidney dialysis, isolation and drugs, among other things, said Dan Mendelson, chief executive officer of Avalere Health, a Washington consulting firm.

Texas health officials will cremate Duncan’s body, according to a statement released yesterday by the state health department. The process will kill any virus in the body so the remains can be returned to the family, the department said.

Duncan’s failure to respond to a last-ditch treatment effort and his direct contact with 10 people now being monitored for Ebola symptoms, have sharpened fears of the spread of the disease in the U.S. Some have called for greater screening measures of people traveling from the affected region in Africa.

Travelers from Guinea, Liberia and Sierra Leone – the countries at the center of the outbreak – will have their temperatures taken and be asked about possible exposure to Ebola as part of new entry measures into the U.S. at five major airports, the U.S. Centers for Disease Control said yesterday in a statement.

Tom Frieden, the CDC director, said in a call with reporters that Ebola now has a face in the U.S. and Duncan’s death should serve as a reminder of the patients that health workers are trying to save in West Africa.

“We remember what a deadly enemy Ebola is,” Frieden told reporters yesterday. “And how important it is that we take every step possible to both protect Americans and stop it at its source.”

(With assistance from Alex Wayne in Washington, Michael Sasso in Dallas and Caroline Chen in New York.)