When Thomas Eric Duncan first came into the hospital, he arrived with an elevated temperature, but was sent home.
On his return visit to the hospital, he was brought in by ambulance under the suspicion from him and family members that he may have Ebola.
Mr. Duncan was left for several hours, not in isolation, in an area where other patients were present.
No one knew what the protocols were or were able to verify what kind of personal protective equipment should be worn and there was no training.
Subsequently a nurse supervisor arrived and demanded that he be moved to an isolation unit– yet faced resistance from other hospital authorities.
Lab specimens from Mr. Duncan were sent through the hospital tube system without being specially sealed and hand delivered. The result is that the entire tube system by which all lab specimens are sent was potentially contaminated.
There was no advance preparedness on what to do with the patient, there was no protocol, there was no system. The nurses were asked to call the Infectious Disease Department. The Infectious Disease Department did not have clear policies to provide either.
Initial nurses who interacted with Mr. Duncan nurses wore a non-impermeable gown front and back, three pairs of gloves, with no taping around wrists, surgical masks, with the option of N-95s, and face shields. Some supervisors said that even the N-95 masks were not necessary.
The suits they were given still exposed their necks, the part closest to their face and mouth. They had suits with booties and hoods, three pairs of gloves, no tape.
For their necks, nurses had to use medical tape, that is not impermeable and has permeable seams, to wrap around their necks in order to protect themselves, and had to put on the tape and take it off on their own.