Wednesday, 1 October 2014

Ebola In America: One Hospital Has Already Treated Three Ebola Patients -- And Cured Two Of Them

Ebola is now in America. The CDC on Tuesday confirmed that a Texas hospital is treating the first case of Ebola ever diagnosed in the United States.

But Ebola actually arrived on U.S. soil almost two months ago. That was when Emory Healthcare leaders decided — in a much-scrutinized move — to fly in a pair of missionaries who’d gotten ill treating Ebola patients in Africa.

“We made the final decision to go forward on Tuesday, July 29,” Emory’s CEO John Fox told me. “I remember that night clear as a bell.”

I spoke with Fox about a week ago, as part of a broader interview we were doing for the Advisory Board Daily Briefing. (You can see an excerpt here.) Fox walked through Emory’s choice to accept Ebola patients, and how other hospitals could hypothetically respond if Ebola did make it to America — a scenario that’s now quite practical.

Talking to Fox reminded me of something that’s been missed in the Ebola news coverage: Several U.S. hospitals already have experience treating Ebola.

They know how to see it. They know how to treat it. And they know how to beat it.

And that wisdom can be contagious.
Ebola In America: One Hospital Has Already Treated Three Ebola Patients -- And Cured Two Of Them
Emory staff care for an American missionary who contracted Ebola in Africa. (Graphic via Los Angeles Times.)

Emory’s experience with Ebola has been incredibly high-pressure and high-profile. When missionary Kent Brantly arrived in Atlanta on August 2, a news helicopter followed his ambulance from the airport. Dozens of media trucks were parked outside of Emory’s receiving bay.

“It’s certainly the biggest media event that Emory’s ever been through,” Fox said.

Some pundits at the time suggested Emory’s decision to treat Brantly was controversial. That bringing Ebola to America would backfire. But within the hospital, staff were confident they could help and even eager for the challenge.

In a column in the Washington Post, Emory’s chief nurse Susan Grant pointed out that Emory’s special isolation unit — one of only five such units in the United States — was specifically created for treating patients with highly infectious diseases like Ebola. The unit is physically separate from other patient areas and, as a local TV station’s video shows, the unit features:
A negative-pressure air-handling system, designed to circulate the air every three minutes and prevent it from getting out;
Special gear, including oversized shells (they look like bicycle helmets) to shield health care workers from patients’ droplets; and
Uniquely designed features intended to reduce physical contact, like a light-activated, hands-free sink.

Emory’s staff also had trained years for the moment, Grant notes. That’s one reason why when Emory issued a call for volunteers — staff were allowed to say no to treating Brantly, and fellow missionary Nancy Writebol (who arrived several days later) — Emory ended up with more volunteers than the hospital needed. “At least two nurses canceled vacations to be a part of this team,” Grant writes.

Before they arrived at Emory, Brantly and Writebol had begun in Africa to receive ZMapp, an experimental serum designed from the antibodies of people who had survived Ebola, and that course of treatment continued in the United States. Emory staff also worked to replace the fluids that Brantly and Writebol were losing because of Ebola’s symptoms (which include vomiting and diarrhea), and administered a cocktail of antibiotics.

The treatment worked. Both Brantly and Writebol were released within three weeks of arriving at Emory.

A third Ebola patient, an American doctor who also contracted the disease, arrived at Emory on September 9. As of October 1, there’s been no update in his condition.
Ebola In America: One Hospital Has Already Treated Three Ebola Patients -- And Cured Two Of Them
What We’ve Learned, And What We Still Don’t Know

The evidence from Emory shows Ebola can be beaten. And according to Dr. Bruce Ribner, who runs Emory’s infectious disease unit, there’s reason to think that with the right approach, Ebola can even be beaten most of the time.

“We would anticipate that … most patients, if they have not had any substantial organ damage, will make a full recovery,” Ribner said at a press conference in late August.

Ribner said that it’s important for doctors and nurses to focus on replacing potassium, calcium and other electrolytes in Ebola patients who are rapidly losing fluids.

“One guidance we are giving back to our colleagues is that they need to pay attention to replacing these electrolytes,” he said. “Even if they’re unable to do the same tests [as Emory did], there are things they can do to try to improve outcomes.”

For example, it’s still unclear if ZMapp, or if the care at Emory — which was significantly more comprehensive than what was available in Africa — was the prime reason the two Emory patients recovered.

“If the question is, ‘Did ZMapp do this?’ The answer is that we just don’t know,” Anthony Fauci, director of the National Institute of Allergy and Infectious Disease, told Liz Szabo of USA Today.

It’s an especially timely question because the Ebola patient in Texas is now critically ill, and the CDC is exploring “experimental” treatments…but supplies of ZMapp are exhausted, and replacement drugs aren’t expected for months.

Emory’s experience also shows the logistical challenges of treating Ebola in America.

“At its peak, we were up to 40 bags a day of medical waste, which took a huge tax on our waste management system,” according to Emory’s Dr. Aneesh Mehta. But Emory’s waste management company wasn’t willing to take the infectious waste off of Emory’s hands, at first.

(The company’s decision to say no was shielded by federal law, which requires that Ebola-related waste must be handled with special packaging and by people with special training.)

As a result, Emory had to come up with a detailed workaround, which involved the university’s autoclave. “Our waste management obstacles and the logistics we had to put in place were amazing,” Patricia Olinger, director of environmental health and safety at Emory, told Reuters.

Of course, most hospitals don’t have an isolated infectious diseases unit, or staff that have specifically prepped to treat Ebola. Many facilities lack an autoclave.

But they do have experience dealing with highly contagious patients. And they’re staffed by caregivers who want to make a difference.

“Here’s the biggest thing,” Emory CEO John Fox told me. “This is our mission. This is the reason we exist.” “If we can help people—if it’s effective and if we can do it safely—we have a moral obligation to do it.”

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