DALLAS -- The temperature for the first person to die of Ebola in the United States spiked to 103 degrees (39.4 Celsius) during the hours of his initial visit to an emergency room -- a fever that was flagged with an exclamation point in the hospital's record-keeping system, his medical records show.
Despite telling a nurse that he had recently been in Africa and displaying other symptoms that could indicate Ebola -- fever, sharp headache and abdominal pain --Thomas Eric Duncan of Liberia underwent a battery of tests and was eventually sent home.
Duncan's family provided his medical records to The Associated Press -- more than 1,400 pages in all. They chronicle his time in the ER, his urgent return to the hospital two days later and his steep decline as his organs began to fail.
In a statement issued Friday, Texas Health Presbyterian Hospital said it had made procedural changes and continues to "review and evaluate" the decisions surrounding Duncan's care.
Duncan carried the deadly virus with him from his home in Liberia, though he showed no symptoms when he left for the United States. He arrived in Dallas on Sept. 20 and fell ill several days later.
When he first showed up at the hospital, he reported severe pain -- rating it an eight on a scale of 10. Doctors gave him CT scans to rule out appendicitis, stroke and numerous other serious ailments. Ultimately, he was prescribed antibiotics and told to take Tylenol, then returned to the apartment where he was staying with a Dallas woman and three other people.
"I have given patient instructions regarding their diagnosis, expectations for the next couple of days, and specific return precautions," an emergency room physician wrote. "The condition of the patient at this time is stable."
After Duncan's condition worsened, someone in the apartment made an emergency call, and paramedics took him back to the hospital on Sept. 28. That's when he was admitted and swiftly put in isolation.
Duncan died Wednesday, almost two weeks after he first sought help. He was 45, according to the records. Relatives said he was 42. The discrepancy could not be immediately resolved.
A spokeswoman for the Texas Department of State Health Services on Friday said his remains had been cremated.
Josephus Weeks, Duncan's nephew, said his uncle's care was "either incompetence or negligence."
Either way "there is a problem, and we need to find the answer to it," he said, adding that it was "conspicuous" that all the white Ebola patients in the U.S. survived "and the one black man died."
Only a fraction of the documents are related to the first visit. Most are related to Duncan's care after he was admitted to the hospital.
Dr. Amesh Adalja, an infectious-disease specialist at the University of Pittsburgh Medical Center who reviewed some of the records, said the care after Duncan's second ER visit was "impeccable." Dallas physicians immediately signalled concern about Ebola and "spared no measure to try to keep him alive."
The documents show that a nurse recorded early in Duncan's first hospital visit that he recently came to the U.S. from Africa, though he denied having been in contact with anyone sick. There was no indication in the paperwork that he was asked any follow-up questions about his travels.
The federal Centers for Disease Control and Prevention had alerted hospitals nationwide to take a travel history for patients with Ebola-like symptoms.
The hospital said it had made changes to its intake process and other practices "to better screen for all critical indicators" of Ebola.
Doctors who evaluated Duncan did not respond to messages left at their offices by the AP.
A spokeswoman for the Texas Department of State Health Services said the agency was considering investigating the hospital for compliance with state health and safety laws.
The hospital has repeatedly changed its account of what the medical team knew when it released Duncan from the emergency room early on Sept. 26.
A few days later, on Sept. 30, it initially said Duncan did not tell the staff he had been in Africa. On Oct. 1, it said Duncan's nurse had been aware of the Africa connection but did not share that information with the rest of the medical team.
The next day, the hospital blamed a flaw in its electronic health-records systems for not making Duncan's travel history directly accessible to his doctor.
A day later, on Oct. 3, the hospital issued a statement saying Duncan's travel history had been available to all hospital workers, including doctors, who treated him during his initial visit.
Duncan's travel history was listed in a nursing notice but not in the physician's note, Adalja said.
The patient's 103-degree (39.4 Celsius) fever might warrant "a little more investigation," Adalja said. A chart showed Duncan did not arrive with a fever but left with one.
After it became clear that Duncan was suffering from Ebola, another option would have been to give him a transfusion from an Ebola survivor in the hopes that antibodies in the blood could help him fight the disease.
But Duncan did not receive a transfusion because the blood types did not match, the hospital said.
Dr. Kent Brantly, the first American flown back to the U.S. for treatment of Ebola, confirmed that account, saying he spoke with a doctor caring for Duncan and was willing to donate blood. But their blood types were incompatible, he said Friday in an interview with Abilene Christian University's alumni magazine.
Also Friday, the World Health Organization announced that the Ebola death toll had surpassed 4,000 confirmed, probable or suspected Ebola deaths. All but nine were in Liberia, Sierra Leone or Guinea.
Associated Press Medical Writer Lauran Neergaard in Washington and researchers Rhonda Shafner and Barbara Sambriski in New York contributed to this report.
