What is more, the C.D.C. arrived in Dallas only after Mr. Duncan’s test came back positive, on Sept. 30, two days after the hospital first called the agency. It is too soon to tell whether the response to Dr. Spencer’s infection will continue as smoothly as it began. And because he is a doctor who was diligently monitoring his own temperature, his case was always going to be different from that of Mr. Duncan, a welder from Monrovia visiting the United States, who showed up unannounced and told health workers that he had not been exposed.
Even so, Dr. Spencer’s case, as it unfolded across New York, with disease detectives chasing his trail from a Brooklyn bowling alley to his Harlem apartment, seemed to ring in a new era.
“We are all much smarter now,” said Dr. William Schaffner, an infectious-disease specialist at Vanderbilt University Medical Center in Nashville. “We have all learned from the Dallas episode.”
Nurses at Texas Health Presbyterian Hospital in Dallas supported their employer a week after Thomas Eric Duncan died of Ebola there.
The first time Mr. Duncan went to the emergency room at Texas Health Presbyterian feeling ill, shortly after 10:30 p.m. on Sept. 25, a nurse noted in his record: “Patient recently came from Africa.” But that did not raise any flags.
A series of tests was ordered, and at 3:18 a.m., Mr. Duncan was released.
But three days later, on Sunday, shortly after 10 a.m., he was back, this time in an ambulance. Its crew had been warned by one of Mr. Duncan’s relatives that he might have an infectious disease.
“Nurses were saying: ‘No. Could it be Ebola? No,’ ” said one hospital nurse, who spoke on the condition of anonymity because of concerns about job repercussions.
The next 72 hours would be crucial. According to the C.D.C. it was during this time that Ms. Pham and Ms. Vinson most likely became infected.
The hospital had been assuring the public that it was ready. Dr. Edward Goodman, an epidemiologist at the hospital, said on Sept. 30: “We have had a plan in place for some time now.”
But a review of hospital records and interviews with hospital workers, federal officials and relatives of Mr. Duncan evoke a picture of worry and uncertainty in which health workers, in the absence of any training and facing rules that were constantly changing, had to improvise while racing to try to save Mr. Duncan’s life. “We’d see pictures of Dr. Frieden in Africa, and we were like, ‘If this is Ebola, we shouldn’t be wearing gowns, right?’ ” one nurse said, referring to Dr. Thomas R. Frieden, the director of the C.D.C., who traveled to West Africa in August. “We were looking at these pictures and seeing what other people were wearing and saying, ‘We’re not wearing anything like that,’ ” said the nurse, who asked not to be identified because the hospital told employees not to speak with reporters.
“There was no training, no explanation, nobody around to help them,” said Dr. Pierre Rollin, an Ebola expert at the C.D.C. who arrived on Oct. 12 to help train the nurses after Mr. Duncan’s death. “They had the impression that they were running after the ideal personal protective equipment, and they didn’t have it. It was like a race.”
Mr. Duncan’s first days in the hospital’s intensive care unit, where he was moved at 4:40 p.m. on Monday, more than 30 hours into his hospital odyssey, highlighted the problem. That first night in the I.C.U., nurses wore two gowns to cover front and back, shoe covers, a surgical mask and a face shield that went to the chin, one nurse said. By the next night, after Mr. Duncan tested positive for Ebola, they added Tyvek suits with hoods and respirators. Then came plastic aprons and triple layers of bootees and gloves. The C.D.C. later said too much gear actually increases risk.
The hospital says it was consulting with Emory University Medical Center in Atlanta, which had treated Ebola patients, as well as county health officials and the C.D.C. on protective gear.
Wendell Watson, a hospital spokesman, said in an email that the hospital immediately isolated Mr. Duncan from other patients when he arrived in the emergency room, and that it emptied an entire 24-bed unit to dedicate to Mr. Duncan’s care once he was admitted, even erecting temporary walls around his hallway for better protection. Ebola training had recently started when the virus struck, Mr. Watson said.