The Barbados government has established an Ebola isolation centre on an adjacent compound to the Queen Elizabeth Hospital overlooking two popular schools. This week we learned about health care workers who have become infected with Ebola after treating Ebola patients and the reason given by the … National Nurses United, the largest registered nurse union, surveys of their membership indicate that most nurses feel hospital administrations have not communicated adequately with staff about Ebola response plans – Ebola Protocol Breach Raises Questions About Where to Treat Patients
The latest development is important because if health workers like those in Jamaica threaten not to treat Ebola patients, we have a problem. The following two comments by BU family members are important to the Ebola conversation.
Two Comments by are-we-there-yet extracted from the EBOLA Virus Enters the White Man’s World #2 blog
Miller; You’ve brought up just one good point in your post above. That is “the issue of the need for people dealing with the Ebola virus to be outfitted in spacesuits as if the infection has been brought in by aliens from another world?”
Yes! It would appear to be absolutely necessary that caregivers at all phases of the development of the disease in a potential ebola stricken patient must be outfitted in adequate fool proof Personal Protective Equipment (PPE) and that they be totally trained in how to put on, take off and use that equipment. Failure to secure PPE’s of the absolutely highest standards and to use them properly appears to be an absolute death sentence.
The case histories of the persons who have contracted ebola all suggest that the disease is very infective and that absolutely strictly observed guidelines must be followed and enforced in robing, using and disrobing from those PPEs. Two of the cases of spread outside Africa so far appear to have been due to improper disrobing from the PPE’s.
If, heaven forfend, the disease gets into Barbados we will have a number of challenges re. the use of PPEs. One challenge will be getting workers to use the PPE’s in our sweltering heat. I expect that even if light weight PPE’s are used there might be a trade off between the procurement of heavy weight effective suits and lightweight (also claimed and even proven to be effective) suits that are more likely to be used sensibly by the caregivers.
Spain and the USA would not have had any such problem.
Back in Liberia, 10 of the people who assisted in getting the sick pregnant woman to the hospital there with Duncan have already died and it is likely that that is not the end of spread from that source of the virus. The video of the enclave that Duncan lived in suggests that those people in the compound wear no protective clothing whatever and that the Government workers are doing their best (also without wearing your spacesuits) to identify all contacts and move them out to quarantine areas. The conditions do not appear the best for containment of further spread.
The short history of the spread of this outbreak, its ability to infect workers in the US and Spain who are fully protected by PPE’s and its galloping spread in the infected countries in West Africa suggests to me, FWLIT, that the authorities have got it a bit wrong re. the method of spread and the infectivity of the virus. If they continue to publish the information that they are currently providing many more will die.
In the meantime, I think tightening up on the protocols for use of the PPE’s and allowing for the possibility of its spread through the air and by inactive carriers such as mammalian pets who might inadvertently transmit infective material from one human host to another, could reduce the spread potential and thereby limit the movement of the disease from where it currently has taken hold.
Note that there is no outbreak in the US or Spain. It has not reached that stage yet and we should all pray that the authorities there can contain it.
Why do you think Obama is sending so many troops into harms way. He and his advisors realises that they have no choice. I hope he is successful.
#2 comment
There are some very interesting questions raised by today’s developments in the Ebola story. viz; One or more caregivers of Ebola infected patients have contracted the Disease in the USA and Spain. There is possibly another carrier of the disease from Liberia to another part of the USA. None of the persons closest to Duncan and who were in unprotected close contact with him when he first started showing symptoms have yet shown any signs or symptoms of the disease while 2 presumably well protected professionals have come down with the disease. The Health workers around the US have been protesting that they have not been advised of the protocols which CDC says that hospitals are operating under while being blamed for not strictly adhering to those protocols. The system in the US and Europe seems rather chaotic at this time.
The questions are?
Are the US health services or indeed any country’s health services really ready for the complicated task of containing and controlling this outbreak?
Are the Health workers who might come in contact with carriers of the disease being told the full story of the epidemiology of this strain of the virus?
What does this portend for Caribbean health services in general and Barbados in particular?
Why should the virus either take longer to develop or doesn’t develop at all in unprotected black persons who were in intimate contact with Duncan at an eminently infective stage of his illness while some professional well protected caregivers and presumably white have contracted it? Is there a genetic difference? Could wearing the PPE’s be actually providing a better chance for the the virus to infect persons than if they were not worn at all? Should there be some trials done on identifying the best wear for eliminating transmission of the virus?
Was there a distinct difference in the care in the US of Duncan as compared with that of the others who had contracted the virus and been treated using experimental medicines. If there is a difference could that explain to some reasonable extent why Duncan died and the others have survived?
Should Barbados and the Caribbean seek to have some of its IT professionals in collaboration with our health professionals, work out and develop a total epidemiological package for Ebola that would allow us to manage Ebola better when it gets here?
Comment by Sargeant extracted from the EBOLA Virus Enters the White Man’s World #2 blog
@David
What is happening with these health workers contracting Ebola? A worker who nursed Duncan affected
+++++++++++
They are overlooking basic precautions, wearing the Hazmat suit is not enough, you have to be careful when removing it also, the exterior has to be disinfected prior to removal less any of the virus is present on it. Like going to a public washroom and washing your hands but opening the door with your bare hands which is a no-no. One should always try to avoid public washrooms but if you must go grab a paper towel to hold onto that door handle on your way out.
173 responses to “ebola, EBOLA”
[…] ebola, EBOLA […]
David
The anouncement of this refusal by these Jamaican nurses to care for the potential Ebola patients, signals a very serious issue in my estimation. Because if these Jamaican nurses choose not to care for these potential Ebola patients, then government ought and must move vehemently to revoke their nurses licenses immediately. Now, if you have potential health crisis facing your country and those who are trained and paid quite well to take care of the sick and dying, decides to turn their backs on the helpless in their time of need. Then their ought not be addressed as nurses because their refusal to care for the Ebola patients, out of their self-interest and self-preservation, undermines their right to be addressed by this title in estimation.
The medical fraternity is refusing not because they are heartless but because they judge the faculty/preparedness to be deficient and places their lifes in harms way.
http://www.jamaicaobserver.com/news/Jamaica-not-prepared-to-handle-Ebola—health-official_17730531
I watch a documentary once where people wearing the so called space suits has to shower while wearing the full suit in a 4% Lysol solution before they move from one level of a CDC facility to the next. The only explanation for the nurse developing the disease while being fully clad is that her bare skin came into contact with the outside of the suit.
I went through all of that to point out that those schools are not in any danger unless persons there come into direct contact with an infected person or some contaminated material.
but who can blamed them.as of now it seems as if the CDC and the WHO does not know exactly the strain of virus they are dealing with ,, it is like a blind man walking down a dark street trying to find his way.,
http://www.vox.com/2014/10/1/6878695/ebola-virus-outbreak-symptoms
Here’s how you can (and can’t) get Ebola
Caswell Franklyn
The suits, gloves, and mask are all part of what is called Universal Precautions. In addition to proper hand-washing techniques which constitutes the core of a healthcare worker front line against contamination and infectious diseases.( how often must I emphasized this point) In any event, what I have indicated above is part and parcel of the bigger program called “Infection Control” which every healthcare worker in the America has to take annually.
AC
The proper adherence to Universal Precautions ought to protect the doctors, nurses and healthcare -workers, on the front line of Ebola. We also have to bear in mind that alot more doctors and nurses were on the front line of Ebola, in Nigeria and Liberia before the very two Americans got infected. Not excluding the local nurses and doctors from the African continent which beg the question: what are their doing differently that the first two Americans to be infected haven’t done?
David;
I didn’t realise that you had lifted my post in the other thread to produce another discussion. Grateful if you would lift my last post from that blog to here. But having read, the above link from vox.com in your 8:12 post here. I must say that the writer there, in spite of being right in most of his article has got the last part wrong; The writer says;
As you’ll probably have noted, Ebola isn’t very easy to transmit. The scenarios under which it spreads are very specific. And Ebola doesn’t spread quickly, either. A mathematical epidemiologist who studies Ebola wrote in the Washington Post, “The good news is that Ebola has a lower reproductive rate than measles in the pre-vaccination days or the Spanish flu.” He found that each Ebola case produces between 1.3 and 1.8 secondary cases. That means an Ebola victim usually only infects about one other person. Compare that with measles, which creates 17 secondary cases. If you do the math, that means a single case in the US could lead to one or two others, but since we have robust public health measures here, it probably won’t go further than that. Compare that to West Africa, which is now dealing with upwards of 6,000 cases in a completely broken health system. That’s where experts say the worry about Ebola should be placed.
The current Duncan case has proven that math to be eminently wrong. I watched a video this morning where a journalist in Liberia interviewed persons in the compound where Duncan was living. 10 of the people that either lived in close contact with or went to the assistance of the pregnant lady that Duncan assisted when she collapsed, have died from subsequent infections of ebola. In addition, there is already one confirmed case of transmission from Duncan with possibly more to come. His figures therefore appear to be quite wrong at least as far as conditions in the US are concerned. He may be right for West Africa but it does not appear that his figures are correct for the current outbreak.
@are-there-yet
The assumption is that all others around an Ebola infected person are aware. Unfortunately this is only possible in a controlled environment.
Occupational Safety and Health Administration (OSHA), has a set of guidelines for the treatment boodborne pathogens that is specifically related to the healthcare industry.
Now we have already established that Ebola is not an airborne disease: meaning that it does not travels through the atmosphere.
Ebola is caused by bodily fluids contacted much like HIV, AIDS, MRSA, Hepatitis C etc right?
Okay, I have worked with patients who have had Methicillin Resistant Straphyoccocus (MRSA), it is bacteria that is very contagious and it lives in hospitals, nursing-homes and in your nose as well as on your skin. MRSA resistant to treatment! It is a bacteria which simply eats away at your skin to you cease to exist no more.
Furthermore, I have worked with people who have had HIV, AIDS as well as Hepatitis C, and like Ebola, they’re all caused by bodily fluid exposure/ bodily liquids. But I was wise enough to apply the principles of Universal Precautions, every and any time I came into contact with these patients and has never gotten infected.
David;
The problem is that Duncan’s hospital room was a controlled environment and yet it appears that the virus was able to move from there presumably because of lax adherence to perhaps non existent protocols. The story is not yet completed re. the possible infection of some of the people close to Duncan when he was sick in his room and outside it at the infective stage of the virus so there is a good possibility that the secondary cases from the Duncan infection will be significantly more than the one or two which the mathematical epidemiologist determined to be the norm for whatever strains of the pathogen that he worked with.
The article is a good one as it more aptly details the conditions under which the virus is likely to spread and the ones in which it cannot than is seen in the current advice given by CDC but there are some conditions that still need to be clarified more fully, IMHO. eg. The time during which the virus can exist in body fluids outside the host suggests that it is possible that passive transmission can occur by a pet walking in infective vomit or urine and rubbing himself on an innocent owner. In a caribbean situation where many people are coming down with Chikungunya and dengue and where symptoms could be quite similar to Ebola’s, an ebola case may well be confused initially with a dengue case and can wreak havoc before it is properly and correctly identified. How are our protocols dealing with this situation which is not relevant to the US or Europe?
I noticed above that Caswell Franklin considers that the schools near to Enmore would only be at risk if ….. persons there come into direct contact with an infected person or some contaminated material. . I think that the adverse reaction of the Health workers in Jamaica and the US and Europe to the current situation re. those countries’ preparedness to adequately deal with transient Ebola, suggests that even though these persons might be of the same opinion as Caswell, that they don’t trust the current protocols to protect them from direct contact with an infected person or contaminated materials. Of course the schools are physically separated from the Quarantine facility but at this stage where one cannot be 100 percent sure of all the epidemiological modalities of this strain of Ebola, I think it is better to err on the side of caution than to concretize a decision that could put children from all over the Island at more risk than they have to be placed under.
Three Russian Ebola vaccines ready within six months: Moscow – Latest News
I just thought about something very fundamental with respect to Ebola and the nature of it transmission. In my mind when I compare Ebola to HIV, AIDS, MRSA and Hapitis C etc, something very important stands out with respect to Ebola. Now, with Ebola, I have realized that the Doctors, Nurses and Healthcare Workers are exposed to more bodily liquids, which increasings the likelihood of exposture because of the volume of diarrhea, and vomit contend their come into contact with in order to treat the infected patient.
CNN Health
She saved her mother, father and sister from Ebola using a simple household item. Now her method is being taught to others in West Africa. Meet Fatu: http://cnn.it/1uLMltQ
Now, let’s forget of about Duncan and focus more on the containment of Ebola with the idea of applying the principles of Universal Precautions, alone with medication theraphy. I am thinking in terms of direct contact with the patients who have Ebola and a more effective way of avoiding the large volume of bodily liquids, while administering effective care at the same time.
this article should be of interest to all the new health experts who belive that this virus is as simple as treating the flu,, now go wash your hands, yeah..
http://www.bbc.com/news/health-29060239
David;
I posted the below submission to the other thread earlier. I am reproducing it here as I think it is quite relevant to your 9:58 pm post about the effective makeshift gear that Fatu improvised. That case and the seeming success of the NIgerians in containing their transient outbreak are success stories that we can be proud of . It also flags a seeming similarity in the resistance of Duncan’s relatives and Fatu’s family to the disease which contrasts clearly with the infection of others after getting probably lesser titres of the pathogen.
THE EARLIER POST
There are some very interesting questions raised by today’s developments in the Ebola story. viz; One or more caregivers of Ebola infected patients have contracted the Disease in the USA and Spain. There is possibly another carrier of the disease from Liberia to another part of the USA. None of the persons closest to Duncan and who were in unprotected close contact with him when he first started showing symptoms have yet shown any signs or symptoms of the disease while 2 presumably well protected professionals have come down with the disease. The Health workers around the US have been protesting that they have not been advised of the protocols which CDC says that hospitals are operating under while being blamed for not strictly adhering to those protocols. The system in the US and Europe seems rather chaotic at this time.
The questions are?
Are the US health services or indeed any country’s health services really ready for the complicated task of containing and controlling this outbreak?
Are the Health workers who might come in contact with carriers of the disease being told the full story of the epidemiology of this strain of the virus?
What does this portend for Caribbean health services in general and Barbados in particular?
Why should the virus either take longer to develop or doesn’t develop at all in unprotected black persons who were in intimate contact with Duncan at an eminently infective stage of his illness while some professional well protected caregivers and presumably white have contracted it? Is there a genetic difference? Could wearing the PPE’s be actually providing a better chance for the the virus to infect persons than if they were not worn at all? Should there be some trials done on identifying the best wear for eliminating transmission of the virus?
Was there a distinct difference in the care in the US of Duncan as compared with that of the others who had contracted the virus and been treated using experimental medicines. If there is a difference could that explain to some reasonable extent why Duncan died and the others have survived?
Should Barbados and the Caribbean seek to have some of its IT professionals in collaboration with our health professionals, work out and develop a total epidemiological package for Ebola that would allow us to manage Ebola better when it gets here?
@Are-we-there-yet
Already updated your ealier post to the blog.
The trash bag story although unscientific is useful because if Ebola were to come to our shores, God forbid, the health system will become overwhelmed. It is already overwhelmed.
Hypothetically speaking, if this strain of the Ebola Virus decides to metamorphosize and becomes resistant to chemical theraphy. Then the focus ought to be on the containment of the disease with a wide eye on Universal-Precautions, and with a stronge focused effort on decrease the number of infected persons.
Was there a distinct difference in the care in the US of Duncan as compared with that of the others who had contracted the virus and been treated using experimental medicines
+++++++++
Of course there was a difference, on his first visit he was discharged even though his temperature was 103 and even the hospital acknowledged that this was an anomaly. Who knows if the delay in treatment proved fatal? One also wonders if the fact that he was visiting from another country and probably without medical insurance also played a part in the decision to send him home.
Lastly he was given a different experimental drug, at this stage they should have gone with what appears to have worked in the past.
Of course we hope it doesn’t come to this Hollywood scenario
[…] David The Barbados government has established an Ebola isolation centre on an adjacent compound to the […]
Sergeant, most hospitals in America require that you have some kind of medical insurance, but I have never heard of any case where the hospital refuse to treat a patient because he or she hadn’t any health coverage. Normally those without medical insurance are billed directly at their home our place residence.
@Dompey
They didn’t refuse to treat him, they treated him but he wasn’t assigned to a bed and that’s where the majority of the charges are generated. No Insurance? “Bill directly to home”? Send my bill to Monrovia, Liberia, Yeah right
Sergeant
First of all, Duncan did not tell the truth to hospital authorities, so quite frankly the hospital wasn’t operated under assumption the Duncan’s high temperature was associated with Ebola. And why would a hospital assigned Duncan to a bed with a high temperature, when the general practice is to give Tyrenol/acetamenophen which works quickly in some patients? Now, are you aware of the fact that a patient can refuse treatment? And based on my five years of experience working in a hospital emergency room (ER): I could assure that Duncan was in the ER for sometime and his tempt was being monitored, but if Mr.Duncan decides that he wanted to go, I am sure that the attending doctor would have written Mr. Duncan a prescription of Tyenol and released him.
Sergeant
Now, the question many here in the medical community is asking is this: “Why had it taken the hospital 6 days to administered the experimental antiviral drug Brinicidofovir to Duncan?” When those who were infected overseas had gotten Brincidofovir right away. And the hosiptal responded later by stating that, “By the time Duncan had been treated the second time around, his entire system had already been compromised by the Ebola virus.” But, I heard one doctor on CNN who stated last week that, ” It was all the more reason to administer the antivirual Brincidofovir to Duncan.” Now, the cries of racism permeates the racially divided Republic once again.
Sergeant
It was apparent that the second time around Duncan did not receive the treatment afford to the medical experts who had been infected in Liberia prior to him. So there is more than enough cause to question the medical decisions of the hospital with respect to the treatment of Mr. Duncan. Now, irrespective of Duncan lacked of medical insurance, on mere humanitarian grounds the decision should been made to administer the antiviral Brinicidofovir to Duncan because of the potential health threat he had posed to the American public, and the escalation of the disease in Liberia, as well as the cost of human life associated it.
Sergeant
I am going to bring this part of the discussion to a conclusion: I am confident that Mr, Duncan was kept in the ER and his temperature was being monitored for sometime. I do not believe that Mr.Duncan went to the hospital with a high tempt and was given a prescription and he left. And one important fact you ought to bear in mind Sergeant: it is highly unlikely that a hospital in America would admit a patient like Mr. Duncan with a mere temperature, especially if the hospital is located in a high crime area. Where most of them are generally located in the United States. But that’s neither here nor there: the fact of the matter is, Duncan left the hospital on his own volition and probably against doctor’s counsel. And all that simply means is that he was standing vertical when he walked out the hospital doors, so in essence, he appeared to be well at the time of his discharged.
Why do we debate issues unnecessarily so?
Dompey | October 12, 2014 at 10:41 PM |
Hypothetically speaking, if this strain of the Ebola Virus decides to metamorphosize and becomes resistant to chemical therapy. Then the focus ought to be on the containment of the disease with a wide eye on Universal-Precautions, and with a strong focused effort on decrease the number of infected persons.
And I can tell you, if /when it gets here, good luck finding staff for the hospital.
People will stay locked in their houses for weeks.
You actually think anyone, even those who work there, going near the hospital then, unless dire emergency?
And in terms of resistance, it is obvious that this virus has mutated and become airborne just like flu (sneeze particles etc).
Only an absolute moron would place the quarantine area near to highly populated areas including schools.
But, that may be moot, as the slightest indication of a patient there and that area will become abandoned.
Dompey;
Duncan did not lie to the LIberian authorities nor the American authorities. It is almost certain that he did not know that the pregnant girl he and others had helped was sick from Ebola. Much of your conclusions above about the treatment of Ebola are figments of your own imagination. Not facts.
It is clear from monitoring commentary coming out of the US Ebola has caught the US health care workers as if a deer in headlights. There is a lot Barbados can learn given the missteps in the US and elsewhere.
Just like firefighters in Chernobyl the Jamaican and Barbadian medical professionals should have to bite the bullet and help or suffer the consequences They have taken money for many years . Not to say they shouldn’t be given the best equipment possible, which should be bought now but fear mongering is not the way to beat this epidemic.
Isn’t it odd that the people around Duncan have not got the disease but a later contact did, is it possible they were aware of his condition( although they say they weren’t ) and avoided contact?
It is easy to see even a good hospital with decent equipment with the correct training can have accidents .
David, we not know that the hospital that treated Mr. Duncan had had some mistakes in the past. And that the two Americans who were infected with the Ebola virus first were taken to Emory Hospital Specialized Isolation Units, which obviously accounts for they survivability. As well as the hospital healthcare professionals who treated Mr Duncan, as does the majority of healthcare workers in America still need the appropriate training to care for Ebola patients.
http://www.guyanatimesgy.com/2014/10/11/nigerians-ebola-monitoring-below-par-at-cjia/
QE believes it can control ebola through diet, when asked how a nurse spokesman explained we will feed them pizza for breakfast and pizza for lunch and pizza for supper every day. Will that cure ebola she was asked? probably not ….but it is the only thing we can shove under the door.
Lawson; re. your 7:24 am post where you said:-
“Isn’t it odd that the people around Duncan have not got the disease but a later contact did, is it possible they were aware of his condition( although they say they weren’t ) and avoided contact?”
Think! The objective evidence, including pictures, indicates that Duncan’s relatives were NOT wearing protective gear when they brought him to the hospital twice. Isn’t it odd that such a breach did not lead to infection of any of them so far when minor breaches of PPE protocols resulted in the spread of the virus to caregivers? They would have had to be wearing protective gear all the time while in contact with him for your suggestion to hold water and obviously they did not.
I think we have to look elsewhere to understand why they were not infected.
Lawson; I should add that they were aware of the strong possibility that he had contracted Ebola sometime between the first and second hospital visit as one of them is quoted as saying that he told Ms Troh, his fiancee, something like “Love of my Life, There is no way I would have exposed you to this if I had known I was infected”.
The fact that none of them have shown an infection by Ebola so far may be just a matter of time and genetics. If I were in charge of the Ebola containment programme in Dallas I would find some way for extending the mandatory quarantine for those 10 or so persons by at least another 21 days rather than sending them out in the community when these 21 days expire.
By the way Lawson, Ebola is the name of a river in the Democratic Republic of the Congo and simply because the first case has been reported to have been recorded there.
Are we there yet
What is PPE protocols by the way? And how do you expect those in Barbados America, Canada, United Kingdom and elsewhere to understand your abbreviation?
Dompey;
If you comb through the other blog you will find where I’ve explained the acronym PPE. It means Personal Protective Equipment. Hazmat suits are a subset of PPE’s. It is a common term used by many agencies in the field of Epidemiology. I’ve linked an article on improper use of PPE’s in that blog also. It might be easier to just google PPE protocols and Ebola to find out what PPE protocols are. There should be lots of stuff there.
Are you there yet
I work in the healthcare industry here in America and have been for many years. So how is that Universal Precautions a figment of my imagination? And have you ever heard of the term sir? And may I ask with out insulting what seems to be your very limited experience in the field: where do you live in the world?
Are we there yet
“Twist the Tiger’s tail”
We had a cat called Tiger
It loves to play, it was the most playful cat that ever lived.
Its mother died soon after it was born and we raised it on a soft nipple from an empty mercurochrome bottle.
The cat thought itself to be a human because of all the attention it got and if you made the mistake to twist its tail and wake it up, it tormented you and only you the whole day until it went back to sleep
The next day it would choose its next victim…
You understand the parable, de old man ent get me insulin yet so I ranting…heheheh
@ pieceuhderockyeahright | October 13, 2014 at 11:33 AM |
Lol!!
That piece of tale from Aesop called the “Tiger and the Donkey” should be read by Dompey as an introduction to sarcasm of the highest order.
One suggestion would be to have an Ebola Hotline Number so the Health Workers in Space Suits can visit suspected patients at home and save people risk of catching the disease when they take them to Hospital
Reach Out For Me
@David
Why do we debate issues unnecessarily so?
++++++++++++
Well Dompey was generally debating with self and we generally say there is nothing wrong with talking to yourself but he is also answering himself and we know that is a sign that maybe he is “non compos mentis”.
Dompey makes up “facts”’ as he goes along e.g. Duncan left the hospital on his own volition and it is routine for Hospitals in some areas to look the other way when people with elevated temperatures come for treatment.
Are we there yet….again do you not find it odd that the family said he is from Liberia and expected the hospital staff to know that could mean ebola, yet a lot of there family back home may be infected, it is raging in their country,and Mr Duncan was obviously sick with something. Yet they expected staff to put it all together when they by choice or complete stupidity never once said the word ebola. This sounds totally ludicrous to me.
@lawson
The CDC protocol specifically stressed country visited in Africa, it is one of main reasons why CDC would have revamped the checklist to assist in triadging?
No Lawson
jUST AS DETECTIVES SOLVE CASES BY HAVING SUSPICIONS SO DO DRS
THE CORRECT DIAGNOSIS IS MADE IN 98% OF CASES ON TAKING A PROPER HISTORY
THE GEOGRAPHICAL HISTORY IS PART OF HISTORY TAKING—- THIS WAS VERY RELEVANT IN THIS CASE
IT IS TRIAGEING NOT TRIADGING ……….PLEASE FOR GOD’S SAKE!