Dr. Joseph Howard Meier was well into his overnight ER shift when he first saw the patient.
The man complained of a headache and abdominal pain. Meier looked him over, checked his vital signs and ordered tests. After a few hours, Meier diagnosed him with sinusitis, prescribed antibiotics and sent him home.
That night at Texas Health Presbyterian Hospital Dallas would become part of U.S. medical history.
The patient, Thomas Eric Duncan, returned two days later in an ambulance. He was far sicker than before, and a blood test soon revealed his true condition as Ebola. Meier, it turned out, had been the first physician to encounter a patient with the deadly virus in an American emergency room.
And he’d missed it.
In Meier’s first public remarks since then, he described the experience as “a little bit like getting struck by lightning, but mild in comparison to what Mr. Duncan’s family has gone through in losing a loved one to Ebola.”
Presbyterian Hospital’s handling of Duncan’s initial visit has come under national scrutiny. The world learned Duncan had just arrived from Ebola-stricken Liberia, something Meier says he didn’t know at the time. Hospital administrators apologized to Congress for the misdiagnosis after offering shifting explanations. They pointed to a nurse’s actions, then to flawed electronic records, then said the records had no flaw.
Absent from hospital statements, government hearings, and wall-to-wall news coverage was almost anything about the person most central to Duncan’s initial care — the doctor.
Meier, 53, graduated from a leading medical school and started at Texas Health more than a decade ago. The Texas Medical Board shows no disciplinary action for him.
Though Meier declined to comment when first approached in October, he agreed last week through a prominent lawyer to answer written questions from The Dallas Morning News. Meier acknowledged the missed diagnosis, but he said his care was appropriate given what he knew then.
“As medical professionals we aspire to perfection in the diagnosis and treatment of all our patients and have regrets when an incorrect diagnosis occurs,” wrote Meier, who continues to work at Texas Health hospitals.
“It’s very easy to make a diagnosis of any condition after the patient’s medical evaluation confirms the final diagnosis,” he wrote. “Unfortunately, such 20/20 hindsight is not available to medical professionals caring for patients in real time.”
Many experts have said Duncan’s recent arrival from Africa, which a nurse made note of that first night, should have caught his doctor’s attention. One of those experts was Dr. Anthony Fauci, the head of the infectious disease unit at the National Institutes of Health.
“We learned that in medical school as part of your physical diagnosis course: One of the important things you ask somebody is a travel history — ‘Have you traveled out of the country lately?’ or, ‘Where have you been lately?’” Fauci said at the National Press Club last month. “I mean, it’s just the natural part of asking them if they smoke or if they are on any medications.”
Some experts, though, have also sympathized with the difficult task of making the nation’s first Ebola diagnosis. Ebola’s early symptoms can appear flu-like.
“It’s not even a needle in a haystack; it’s a needle in a hayfield,” said Dr. Ryan Stanton, a representative of the American College of Emergency Physicians and a practicing physician in Lexington, Ky.
When new ailments are first spreading, it can be tough for doctors to pick them out until a pattern emerges, Stanton said.
“With Ebola, we don’t have that luxury. We can’t miss one,” he said. “That’s the challenge of the practice of medicine: being able to identify something you may only see once in your career.”
Drawn to ER medicine
From childhood, Meier was drawn to emergency medicine. Details of his career emerge from various records, along with the responses he provided.
“When I was growing up I had a neighbor who was an ER doc,” Meier said in a deposition during a 2003 lawsuit. “So I used to hang out in the ER, and that’s kind of — I knew I wanted to do that.”
He didn’t enroll in medical school straight out of college. He spent about eight years in Los Angeles as a writer — “Scripts, poems, short stories, things like that,” he said in the deposition. He also did some teaching.
“I spent much of my time working in the alternative schools with kids that had been expelled from high school for gang activities, drugs, etc.,” he told The News.
He’d always intended to go to medical school, he said. “It was just a matter of timing.”
In his early 30s, he took some pre-med courses at California State University in Los Angeles, he said in the deposition. Then he was accepted to the Mayo Medical School, the educational arm of the renowned Mayo Clinic in Rochester, Minn. The program accepts only a few dozen students each year out of thousands of applicants.
After graduating in 1998, Meier began his resident doctor-in-training work at another leading medical institution, the UC Davis School of Medicine in Sacramento, Calif. When he finished in 2001, Meier moved to McKinney and became licensed to practice in Texas.
“I had a friend in medical school that was from this area,” Meier said.
He began working for the contractor that operates Presbyterian’s emergency department, Texas Medicine Resources LLP.
Court records show one malpractice lawsuit filed against him — a previous complaint over a missed diagnosis. In that case, a woman said Meier and other caregivers missed an infection she had developed following a 2001 tooth extraction at a Texas A&M University Baylor College of Dentistry clinic.
The woman said she sought aid three times to no avail — at the college, at Baylor University Medical Center’s ER and then at Presbyterian’s ER, where Meier treated her for jaw pain. The infection wasn’t diagnosed until she returned to Presbyterian four days later, according to court records. By then, she needed surgery and was hospitalized nine days.
The lawsuit was filed in 2003 and named her dentists and other physicians involved in her care. Meier and the others denied the allegations in court records.
Meier later explained in the deposition that he’d been unable to examine her mouth because she couldn’t open it. He said he phoned an oral surgery specialist for advice before releasing her. A plaintiff’s medical expert said Meier should’ve considered infection as a possibility and asked the specialist to examine the woman.
The case was eventually settled and dismissed in 2005. Terms weren’t clear from the court file, and The News found no indication of any admission of liability. In his response last week, Meier said he was dismissed from the case and wasn’t part of the settlement.
A few years into his medical career, Meier also took jobs as an expert witness on behalf of doctors defending against malpractice cases. He said he no longer testifies in such cases.
Away from Presbyterian, Meier and his wife started a small company called Maxx Graphics LLC, which marketed an application for working with photos on the Internet.
“Initially, we designed software to edit digital images and then parlayed into oil painting reproductions and portraits,” Meier said. “Overall, the company did not do well financially, but I do have a beautiful portrait of my daughter as a result of the venture. So it was worthwhile.”
Meier served as the company’s president from 2002 until 2009, when he dissolved it.
One doctor who has worked with Meier described him as a “very thorough and very reliable emergency-room physician.” The two have been colleagues for several years, the doctor told The News.
“I’ve never experienced any problems with him,” said the doctor, who commented only on the condition that his name not be published because he is not an authorized spokesman for Presbyterian or Texas Medicine Resources LLP.
‘Came from Africa’
Duncan arrived in the U.S. from Liberia on Sept. 20. He was visiting friends and family on a U.S. visa granted in August.
Five days later, he walked into Presbyterian’s ER.
The Centers for Disease Control and Prevention had cautioned that someone like Duncan could be coming.
By the end of July, more than 800 people had died of Ebola in the West African nations of Guinea, Liberia and Sierra Leone. And it was spreading. The disease by then had killed a patient in Nigeria and struck two U.S. health care workers in Liberia.
On July 28, Presbyterian’s parent company, Texas Health Resources, received a CDC advisory about the outbreak, hospital officials later acknowledged to Congress.
“These recent cases, together with the continued increase in the number of Ebola cases in West Africa, underscore the potential for travel-associated spread of the disease,” the CDC warned.
The CDC said “the possibility of infected persons entering the U.S. remains low.” Still, it urged doctors to “be alert for signs and symptoms.” Patients with fever and muscle pain, headache, vomiting and diarrhea who had traveled to Ebola-stricken countries within 21 days needed to be isolated and tested, the CDC said.
A Texas Health official would later tell Congress the hospital chain posted signs in its emergency departments and distributed subsequent CDC alerts about Ebola to frontline caregivers, including ER doctors.
“I do remember receiving the CDC email at the beginning of August,” Meier said. But he said he “was not aware of any specific training for Ebola” at the hospital.
In response to this, Texas Health spokesman Wendell Watson emailed The News that: “Training regarding Ebola had been available and provided at Texas Health Dallas, however, it was not mandatory prior to September 25.”
On Sept. 25, the night Duncan first came to Presbyterian, Meier was working a routine overnight shift.
He said the shift started at 10 p.m. and ended at 5 a.m. “It was busy for a Thursday night, but not unusually so,” Meier said.
Details of ER trip
Duncan waited about an hour before seeing a triage nurse at 11:36 p.m.
He was accompanied by a companion. Medical records identified her as Louise Troh, who was his fiancée. She is a Dallas resident whom Duncan had met years earlier in Liberia before she fled that nation’s civil war. Troh, through a representative, declined to comment for this story.
Details of what happened next in the ER were provided by hospital officials to the U.S. House Energy and Commerce Committee’s oversight and investigations panel. They are also in Duncan’s medical records, which his family shared with The News.
The medical records name caregivers such as Meier. The congressional testimony identifies them only generally, referring, for example, to “the physician.”
The triage nurse recorded Duncan’s temperature of 100.1 degrees, which hospital officials later characterized as a “low-grade fever.” He complained of abdominal pain, nausea, headache and dizziness. He also gave his pain level as an 8 on a 10-point scale.
Meier briefly checked in on Duncan at 12:27 a.m. Sept. 26, the records show. The doctor accessed the triage nurse’s report, but didn’t begin an examination.
At 12:33 a.m., ER nurse Bigi Sunny continued Duncan’s assessment. She asked Duncan or his companion about his recent travel and learned he’d come from Africa, hospital officials told the congressional oversight panel.
Sunny had been on long plane flights, too, and they chatted about it, the nurse later recalled to hospital officials. But she “attached no further significance” to it, hospital officials told Congress.
It’s not clear whether Duncan, his companion and the nurse referred in their conversation only to “Africa,” or more specifically to Liberia. In a presentation, hospital officials say they now train nurses to “be specific about countries the patient has recently traveled to or from.”
Although Texas Health officials answered some questions posed by The News, they declined to say more about Duncan's initial ER visit or respond to many other detailed questions posed in writing by The News.
In Duncan’s electronic health record, where it prompted for travel information, Sunny recorded: “Yes, came from Africa on 9/20/14.” The hospital told Congress, “this information was not verbally communicated to the physician, as prompted” by the hospital’s electronic records system.
Sunny did not respond to interview requests. Meier told The News that “our nurses are very good, and they provide excellent care.” He said it would be “unfair to speculate after the fact” why she didn’t tell him about the travel.
“Nurses typically bring doctors important or medically significant information verbally,” Meier wrote. But, he added, “It’s rare that travel history is medically significant.”
The ER physician returned at 12:52 a.m. and began his evaluation of Duncan, hospital officials told Congress. He also gathered “personal history and health” information from Duncan and his companion, hospital officials said.
The section of the medical records designated for Meier’s notes say in one place that Duncan was “negative for fever and chills.” Meier told The News that the notation — in seeming contradiction to Duncan’s arrival temperature of 100.1 degrees — was based on information that came “directly from what the patient tells us.”
“Gastrointestinal: Positive for abdominal pain. Negative for nausea, vomiting and diarrhea,” the notes go on. “Neurological: Positive for headaches (sharp). Negative for dizziness, seizures, weakness and light-headedness.”
Hospital officials later told Congress that the ER physician’s exam was “remarkable only for nasal congestion and a runny nose along with mild abdominal tenderness.”
Meier’s notes in the medical records say Duncan “denies any sick contacts.” Duncan reportedly helped a pregnant woman with Ebola days before he traveled from Liberia. But it’s not clear whether Duncan was aware she had Ebola. According to some accounts, he thought her malady was pregnancy-related. Duncan’s nephew said that in a phone call before his uncle’s death, Duncan denied helping the womanat all.
Under the “social history” portion of the medical records, Meier’s notes say Duncan was a “local resident.” There was no indication that the physician asked about travel.
In his response to The News, Meier said he is uncertain whether he asked Duncan about travel.
“I have a general recollection of Mr. Duncan, but I don’t recall the specifics of our discussions,” Meier wrote. “However, I routinely pair the recent travel question with the sick contact question so it is likely that I did so in this instance.”
Meier’s notes in the medical records say he had reviewed the nursing notes. Hospital officials told Congress that the ER physician several times accessed portions of the electronic records where the nurse had recorded Duncan’s arrival from Africa. It wasn’t clear, though, “which information the physician read,” hospital officials told Congress.
Meier told The News he hadn’t seen the Africa notation in Duncan’s records. The physician said the hospital’s electronic medical records system contained a lot of information, which, like patients, “must also be triaged.”
The “travel information was not easily visible in my standard workflow,” he said. “This has now been modified very effectively.”
The News asked Meier whether knowing Duncan’s travel history would have changed his evaluation.
“If he told me he came from Liberia, this would have prompted me to contact the CDC and begin an evaluation for Ebola,” Meier said, “but the likelihood would have still been low since Mr. Duncan denied any sick contacts.”
Over the next few hours, Meier ordered tests, along with an IV for saline. He prescribed extra-strength Tylenol, which the nurse gave Duncan at 1:24 a.m. Meier reviewed Duncan’s vital signs. CT scans of Duncan’s head were “unremarkable,” the medical records say, showing no sign of sinusitis.
Doctors typically order CT scans to rule out more serious possibilities, such as a hemorrhage or meningitis. In his responses to The News, Meier said he ordered the CT scan because of Duncan’s headache.
Meier did not say whether the CT scan’s lack of an indication of sinusitis factored into his diagnosis. “Sinusitis is mostly a clinical diagnosis,” he said.
At 3:02 a.m., Duncan’s temperature was 103 degrees, his medical records say. Sixteen minutes later, however, Meier entered a note saying: “Patient is feeling better and comfortable with going home.” Meier told The News he hadn’t seen the higher temperature in Duncan’s chart.
Duncan was discharged at 3:37 a.m. with the diagnosis of sinusitis. His last recorded fever, at 3:32 a.m., was 101.2 degrees. Meier prescribed Duncan the antibiotic Zithromax, 250-milligram tablets, to be taken twice the first day and once daily for four more days.
“Patient understands to call the referral physician, their PCP [primary care physician] or return to the ER if their symptoms worsen,” say Meier’s notes in the medical records. “I have stressed the importance of follow up with YOUR DOCTOR.”
The medical records note, under the heading “Physician(s),” that there was “No primary provider on file.”
The News asked Meier whether Duncan’s 103-degree fever would have been valuable to know.
“Given what little information I had, a 103 temperature would most likely not have helped with the diagnosis of Ebola,” he said. “Although, if it did not quickly improve, he could have possibly been admitted to the hospital.”
‘We made mistakes’
Two days later, on the morning of Sept. 28, Duncan’s fever was at 103 degrees. He had been suffering from vomiting and diarrhea. His fiancée’s daughter dialed 911.
“I’m calling for ambulance please,” she told the dispatcher, with an accent he had difficulty understanding.
At the hospital, Duncan told an ER nurse that “he just moved here from Liberia,” his medical records show. The doctor who saw Duncan this time, Dr. Otto Javier Marquez-Kerguelen, listed Ebola among the possible diagnoses. He did not respond to a request for comment.
About 48 hours later, tests confirmed Duncan had it.
Hospital officials said they had planned for a potential case.
“We have been meeting literally for weeks in anticipation of such an event,” hospital epidemiologist Dr. Edward Goodman said in a news conference on Sept. 30 — five days after Duncan first arrived at the hospital. Officials would later say in a letter to the community that “our training and education programs had not been fully deployed before the virus struck.”
Questions about how Presbyterian handled Duncan’s initial visit quickly dogged the hospital.
Officials said in an Oct. 1 news release that Duncan had a “low-grade fever” and stomach pain, conditions that “did not warrant admission.” They also acknowledged in a news conference that same day that a nurse knew Duncan had been in Africa and “regretfully that information was not fully communicated” to the entire medical team.
“As a result, the full import of that information wasn’t factored into the clinical decision making,” Dr. Mark Lester, a clinical leader for Texas Health Resources, said in the Oct. 1 news conference, standing alongside Gov. Rick Perry. “The clinicians did not factor it in. So it was not part of their decision making.”
The next day, hospital officials offered a new account. In a written statement, they said a nurse put Duncan’s travel history in his electronic records, but suggested a design “flaw” in the system kept the information from getting to the physician.
And then a day after that, the hospital changed its explanation again. “The patient’s travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow,” hospital officials said in another written statement.
Duncan died the morning of Oct. 8.
Within two weeks, hospital officials hired a global public relations firm and began offering apologies.
On Oct. 16, Dr. Daniel Varga, the top clinical officer for Texas Health, spoke to the congressional panel. He testified that “we did not correctly diagnose” Duncan.
“Unfortunately, in our initial treatment of Mr. Duncan, despite our best intentions and a highly skilled medical team, we made mistakes,” Varga told Congress. He added later in his testimony, “Where we fell short initially was in our ability to detect and diagnose EVD [Ebola virus disease], as evidenced by Mr. Duncan’s first visit.”
Varga also said Texas Health was making numerous changes to its emergency room procedures.
Nurses, a hospital presentation later spelled out, would “be specific about countries” where patients had traveled. The hospital chain would increase “visibility and documentation” of travel and possible Ebola exposures in its electronic health records system. And to “avoid relying solely” on the electronic system, there would be a “new emphasis on face-to-face dialogue to bolster team communications between nurse, doctor, and patient,” the presentation said.
Three days later, Texas Health chief executive Barclay Berdan echoed Varga’s testimony in a “letter to our community” published in The News and Fort Worth Star-Telegram.
“On that visit to the emergency department, we did not correctly diagnose his symptoms as those of Ebola,” he wrote. “For this, we are deeply sorry.”
Berdan went on: “In short, despite our best intentions and skilled medical teams, we did not live up to the high standards that are the heart of our hospital’s history, mission and commitment.”
The News asked Meier for his reaction to Varga’s and Berdan’s remarks.
“The ER functions as a unit with many moving parts,” he said. “The hospital has a right to acknowledge that mistakes were made. I certainly didn’t take that personally.
“As a medical team,” he said, “we certainly would have liked to have made the diagnosis that night.”
Last month, Presbyterian’s parent company and the contractor that employs Meier settled a malpractice case brought by Duncan’s family. The suit, which did not name Meier, said that Duncan’s caregivers “failed to use ordinary care in providing treatment,” causing his death. Texas Medicine Resources officials denied the allegations in court records and referred all questions to Texas Health. Details of the settlement are being kept confidential.
Meier said people should understand this: “That the enemies are Ebola and infectious diseases in general — not the caregivers who are on the front line of diagnosis and treatment of patients.”
In the aftermath of Duncan’s case, experts in public health and infectious disease have said that a patient’s recent travel is a key part of diagnosing an infectious illness, especially since air travel has made transmission easier.
If someone came from, say, Puerto Rico, a doctor may need to rule out dengue fever. It’s that kind of probing that ERs used when SARS emerged in China and spread through globe-trotting patients more than a decade ago.
The hospital’s shifting explanations for why Duncan’s travel history wasn’t considered have focused on communication between nurse and doctor. But that fails to address a point made by many experts: A doctor should gather that critical information independent of nurses and other staffers who may already have recorded it.
Patients’ stories “change a little, or they withhold information,” said Deena Brecher, president of the Emergency Nurses Association. “We all need to be asking the questions.”
Stanton, the representative of the ER physicians’ group, agreed.
“It’s our responsibility to review that information,” he said. “One, to ensure we know the information and, two, to ensure that it’s accurate.”
But other experts say many ER doctors, at least before the Ebola scare, didn’t automatically collect a travel history from every patient who came in.
“The reality of it is that in the emergency department, and even on the hospital wards, you tailor your questions to what you think the potential diagnoses may be,” said Dr. Rawle “Tony” Seupaul, chairman of the Department of Emergency Medicine at the University of Arkansas for Medical Sciences.
“What happened in Dallas was unfortunate, because I think that same mistake would have been made had that patient traveled to New York, or any other state in the United States,” Seupaul said.
‘A lot ... going on’
Electronic health records can make things more difficult rather than less, many experts say. The systems collect vast amounts of data not immediately relevant to clinical care, such as insurance information. And experts say the systems are too often replacing important, old-fashioned communication among caregivers.
Doctors, meanwhile, are only human and ERs can be fast-paced places, said Dr. David Klein, chief medical officer and president of Medical Emergency Professionals. The firm contracts doctors and other professionals to emergency departments in Maryland and other states.
“You’re under a lot of pressure; there are a lot of things going on,” Klein said. “If people think we’re going to get everything right 100 percent of the time, it’s just not going to happen.”
Klein said it’s important to look at the overall emergency department system — its protocols and checklists.
“If you blame the doctor, you’re saying, ‘The system is good, it’s just the person,’” Klein said. While that’s true sometimes, he said, the presumption is dangerous because then “we’re not looking at the bigger picture of what’s going to prevent it from happening again.”
In Meier’s responses, he said whether he asked about travel history depended on the patient’s complaint. Though he couldn’t speak for other ER doctors, he said, “many have told me that their approach would be similar to mine.”
Meier said he’s not aware of any policy that instructed the hospital’s ER physicians to ask about travel history. “There is now,” he said.
Watson, the hospital chain spokesman, did not confirm this policy change. “Dr. Meier may be referencing the changes we made to the EHR to make travel history more prominent,” he said in an email, referring to the electronic health records system.
Hospital officials have previously said that “in the interest of transparency,” they secured Duncan’s permission to release some details and speak about his treatment.
As medical experts criticized Presbyterian on national television, its leaders expressed a desire for “other U.S. hospitals and providers to learn from our experience.” Nurses and a physician who treated Duncan the second time gave television interviews about the effort to save him. The hospital rolled out a vigorous public relations campaign with the slogan #PresbyProud.
Meanwhile, hospital officials scarcely referred to Duncan’s initial ER physician. After declining last week to answer questions about Duncan’s initial ER visit, Texas Health sent The News a statement saying that “rehashing the same set of facts over and over does little to advance the healing process.”
Berdan, the CEO, then sent an email to his medical staff to warn them about this story.
“We have weathered challenging and unfair coverage in recent months, and this will be no different,” Berdan said. “Public sentiment about the hospital has improved dramatically in recent weeks, and the latest census numbers are strong.”
The News learned Meier’s identity in October and approached him. A reporter quickly heard from one of the nation’s most well-known libel, defamation and First Amendment attorneys, L. Lin Wood.
Wood is famous for helping those under the glare of the national media spotlight. His high-profile clients have included the parents of JonBenet Ramsey, as well as Richard Jewell, the Atlanta security guard falsely accused in the 1996 Olympic bombing.
Wood told The News Meier did not want to be interviewed and requested that Meier’s name not be published. The newspaper weighed that request against the public’s interest in knowing about one of the central figures in an important episode in U.S. medicine.
After the misdiagnosis at Presbyterian, two nurses who treated Duncan caught Ebola and a national health scare prompted great public anxiety. It also cost taxpayers. Federal officials tracked down passengers on various plane flights, several schools were shut down, and the president named an Ebola czar.
Last week, The News let Wood know it was going ahead with a story that would identify Meier. Wood asked for written questions, along with copies of the medical records upon which the story would rely.
After the newspaper agreed, Wood provided Meier’s written answers to the questions.
“It can be a challenge to diagnose disease and illness,” Meier said. The more rare the disease, he said, the harder it is.
“Since this first case, we have better protocols in place, but, even then, it can still be very difficult to diagnose something so rare,” he said. “We do the best we can to get it right based on our training and experience.”
Looking back, would he do anything differently?
“Hindsight is always 20/20 so it’s virtually impossible to answer this question,” Meier said. “Based on the information I had at the time, I believe that the care and treatment were appropriate.”
Staff writers Daniel Lathrop and Miles Moffeit contributed to this report.