How does an American nurse contract Ebola? With directions like these.

Timm Schamberge
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Here’s what’s scary about the Dallas health-care worker infected with Ebola: she knew she was treating an Ebola patient.

That’s not supposed to happen. We’ve been told that Ebola can be stopped using modern medical protocols. An American health-care worker who is part of a team that knows it’s treating an Ebola patient is supposed to be able to protect herself. So what happened?

READ MORE: 18 things you should know about Ebola

The simple answer is that the Ebola treatment protocols are complicated. It helps to look at this Centers for Disease Control and Prevention checklist. These are the instructions the federal agency gives caregivers for how to take off the protective gear that workers wear when treating patients with deadly diseases, like Ebola.

It is 21 items long. There are full sections on the gloves, and the gowns, and the face mask —each with multiple steps. Imagine trying to keep all this in mind while also trying to treat a patient:

ppe removal


There are “ifs” and “thens” and asterisks to better define terms. There’s a big caveat at the bottom about what to do if the checklist fails and hands get contaminated, but nothing about other body parts.



Then, there’s a whole other page outlining an alternative way to remove the gear, with no clear preference expressed for when which method ought to be used.



CDC director Tom Frieden has stressed how important it is for health care workers to follow government protocols like these. During a press conference on Sunday, he also acknowledged that it can be difficult.

“The care of Ebola can be done safely but it’s hard to do it safely,” Frieden said in his Sunday press conference. “Even an innocent slip-up can result in contamination.”

Forty-nine slides, but still not enough detail

This summer, the CDC produced a PowerPoint detailing how to put on and take off Personal Protective Equipment, or PPE. It has 49 slides.



“Change gloves as needed,” captions to this slide, meant to be read by a CDC official using the PowerPoint in a training, instruct. “If gloves become torn or heavily soiled and additional patient care tasks must be performed, then change the gloves before starting the next task.”

What counts as “as needed” or “heavily soiled”? Health care workers have to decide. A separate slide makes this point more blatantly, while discussing the use of personal respirators.



“YOU are responsible for fit checking your respirator before use to make sure it has a proper seal,” the caption to that slide reads. The CDC does not officially recommend respirators for Ebola, since it is not airborne, but Frieden said that the hospitals treating Ebola patients have been using them anyway.

These presentations are summaries of a longer, more official set of guidance, the 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

This 225-page document (145 pages without footnotes) is arguably the United States’ most comprehensive guide to wearing protective health care equipment. One section, on page 52, talks about the challenges of finding the right mask:

Since procedure/isolation masks are not regulated by the FDA, there may be more variability in quality and performance than with  surgical masks. Masks come in various shapes (e.g., molded and non-molded), sizes, filtration efficiency, and method of attachment (e.g., ties, elastic, ear loops). Healthcare facilities may find that different types of masks are needed to meet individual healthcare personnel needs.

How does a hospital choose the right mask after reading that paragraph?

Protocols can be followed. But it takes work.

Three hospitals have treated Ebola patients without a health care worker becoming infected. Those three facilities — Emory University, University of Nebraska and the National Institute of Health — all have specialized biocontamination units. These are the places where workers who contracted Ebola in Africa were sent specifically because these hospitals have spent years running drills and preparing for patients with contagious and deadly diseases. They are facilities we built for these exact situations.

Most hospital workers don’t have that kind of background. Digesting lengthy guidelines and implementing them during high-adrenaline and high-stakes situations is incredibly difficult. Here’s how the New Republic’s Jonathan Cohn describes the challenge:

Hospital officials say that she was observing safety protocols, like wearing recommended protective gear. CDC Director Tom Frieden said that some kind of breach in those protocols must have occurred. The two statements might sound contradictory, but they may not be. The safety procedures are complicated and, particularly if you’re tired, it’s easy to make a mistake.

“Look, even in a regular, garden variety operating room, there’s a charge nurse watching to make sure no one has broken sterile technique, like scratching their nose or wiping their brow or touching something, and that is damned hard to do,” says Howard Markel, a professor at the University of Michigan Medical School and author of When Germs Travel. “Now multiply this scrutiny a million fold because it’s Ebola and you get an idea how tough it is to maintain the protocol.”

The CDC has recognized the importance of not just having protocols, but making them easy to use. “One of the things that’s important is that we have practical solutions,” Frieden said in a Monday press conference. “We’re looking at the ways to do this most safely and easily.”

Protocols can be incredibly powerful and important documents in healthcare. Atul Gawande has written extensively about the importance of checklists, and how a simple set of guidelines can go a long way. In one experiment he writes about, intensive care units who followed checklists decreased infections rates by one third in just three months.

“It’s true of cardiac care, stroke treatment, H.I.V. treatment, and surgery of all kinds,” Gawande writes. “It’s also true of diagnosis, whether one is trying to identify cancer or infection or a heart attack. All have steps that are worth putting on a checklist and testing in routine care.”

It is undeniably good that the CDC has a checklist for how to put on the protective gear needed to treat Ebola patients. It’s less good, however, that the protocol is difficult to follow and leaves space for human decisionmaking — and thus space for dangerous human error.

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