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Ebola Richness of Embarrassments: Were Lessons Learned?

The handling of the first U.S. Ebola case has been one embarrassment after another for the U.S. health care system.

Thomas Eric Duncan was about as infectious as an Ebola patient can get when he showed up in an ambulance, vomiting and with diarrhea, at Texas Health Presbyterian Hospital in Dallas last month. Even though he had told at least one nurse he had been to Liberia, he wasn’t tested for Ebola right away.

Two of the nurses who treated him have become infected themselves.

And even though she shouldn’t have, one of the nurses took a commercial flight to Cleveland and back – boarding even though she had a low-grade fever. Now the plane she took is being disinfected and 132 people must be tracked down and watched.

The handling of the first U.S. Ebola case has been one embarrassment after another for the U.S. health care system. Even as Centers for Disease Control and Prevention director Dr. Thomas Frieden has reassured the U.S. public that any hospital should be able to handle an Ebola patient, the Dallas case has contradicted him at every turn.

It may seem like matters are out of control. While CDC has predicted from the beginning that someone might show up from West Africa with Ebola, and has been issuing guidelines to hospitals, basic human error pops up time and again. CDC isn’t immune to this: it’s revised its guidelines several times and admits mistakenly having advised an infected nurse that she could fly on a commercial jet.

Duncan first felt ill Sept. 24. He should have immediately sought care, having just arrived from Liberia and having handled a woman who later died from Ebola. He didn’t — it’s not clear why not and stories from various relatives are not clear on why not.

“She did call us and we did not tell her she could not fly."

When he finally sought care at Texas Presbyterian on the night of Sept. 25, he was already very ill, vomiting and suffering from diarrhea. He should have been isolated immediately and treated as if he had Ebola whether he tested positive or not. It is still not clear whether this happened, but the National Nurses Union, which does not represent nurses at the hospital, says its members have spoken to nurses who said Duncan was not isolated and that they were not given sufficient protective gear at first.

Once Duncan was diagnosed — three days later — nervous nurses did what they could to protect themselves, anyway, layering up in protective gear and sometimes putting on three pairs of gloves. Now, it seems, they may have in fact put themselves more at risk by doing this.

“Our investigations increasingly suggest that the first several days, before the patient was diagnosed, appeared to be, the highest risk period,” Frieden told a news conference.

“These two health care workers both worked on those days and both had extensive contact with the patient when the patient had extensive production of bodily fluids. because of vomiting and diarrhea.”

Both Nina Pham and Amber Vinson were helping Duncan, and would have been close to him as he suffered the terrible effects of the virus and struggled to breathe.

Nurses who have asked to remain anonymous have said they were not sure what to do to protect themselves. Frieden says the records support this.

“When we reviewed the records for the first several days of the patients stay before he was diagnosed, we see a lot of variability in the use of personal protective equipment and when our team arrived the same day the patient was diagnosed, we noted for example that some health care workers were putting on three or four layers of protective equipment in the belief that this would be more protective,” Frieden said.

“We certainly understand the fear and the anxiety that’s normal and it's understandable, these are good, dedicated people who worried about themselves and their families and they were trying to protect themselves better. But in fact, by putting on more layers of gloves and other protective clothing, it becomes much harder to put them on, it becomes much harder to put them off, and the risk of contamination during the process of taking these gloves off, it gets much higher.”

Now CDC has sent a team of experts to the hospital, including a site manager who will ensure that staff caring for Pham do everything by the book. And they’ll send a “go team” to any hospital that may get an Ebola patient in the future.

As they should have, staff who treated Duncan were keeping an eye on their temperatures. Vinson traveled to Ohio to plan for her wedding, and even called CDC before she came home on a commercial flight to report her temperature was 99.5. “She did call us and we did not tell her she could not fly,” a CDC spokeswoman told NBC News. The threshold that’s considered a fever with Ebola is 100.4.

Such flubs are to be expected, says Tommy Thompson, a former Wisconsin governor who headed the U.S. Health and Human Services Department from 2001 to 2005. “I see mistakes being made, but there are always going to be mistakes made,” Thompson told NBC News.

“Any time you have an outbreak, you are going to have mistakes made,” added Thompson, who oversaw a disastrous response to the 2001 anthrax attacks in which five people were killed and 17 made sick.

Thompson turned the anthrax debacle into a $14.8 billion program to rebuild the nation's public health infrastructure. The question, says Thompson and other experts, is whether the federal government, state governments and hospitals learn quickly enough from the current mistakes.

“I see mistakes being made, but there are always going to be mistakes made."

Frieden says they have. “Ebola is hard to fight but we know how to fight it and we know how to beat it,” he said. “The situation changes every day, we're always going to be open with what we know, and share more rather than less. We're going to put an extra margin of safety to protect Americans.”

He’s admitted to errors. "We could've sent a more robust hospital infection control team and been more hands-on with the hospital from day one about exactly how this should be managed," he said Tuesday. "I wish we had put a team like this on the ground the day the patient — the first patient — was diagnosed. That might have prevented this infection.”

Pham and Vinson were both diagnosed and isolated quickly, and doctors say early treatment can help Ebola patients survive better. Pham’s in good condition. Vinson was sent to Emory University hospital, which successfully treated Dr. Kent Brantly and Nancy Writebol, and which is treating a World Health Organization doctor infected in Sierra Leone who’s asked to remain anonymous.

The hospital has also apologized.

"We did not correctly diagnose his symptoms as those of Ebola. We are deeply sorry," Dr. Daniel Varga chief clinical officer for Texas Health Resources, said in testimony prepared for a hearing Thursday.

"Also, in our effort to communicate to the public quickly and transparently, we inadvertently provided some information that was inaccurate and had to be corrected. No doubt that was unsettling to a community that was already concerned and confused, and we have learned from that experience as well."

Now CDC has added 75 people to the list of those being watched — 75 who treated or contacted Duncan while he was ill. President Barack Obama canceled a fundraising trip and held a high-profile meeting with cabinet officials Wednesday.

On Thursday, Frieden and other top health officials will testify before Congress about the nation's Ebola response.

Obama, whose last health-related mess, the fumbled rollout of the Obamacare websites, happened precisely a year ago, said his cabinet was reviewing what happened in Dallas "and how we're going to make sure that something like this is not repeated and that we are monitoring, supervising, overseeing in a much more aggressive way exactly what has taken place in Dallas initially and making sure that the lessons learned are then transmitted to hospitals and clinics all across the country."