Video Courtesy of Emory University Hospital
The phone call that woke Dr. Bruce Ribner ’66 in the middle of the night last August was one he had been expecting for more than a decade.
On the other end of the line, a State Department official informed him that Kent Brantly, an American doctor desperately ill with the Ebola virus, was being airlifted from Liberia and would arrive in the morning at Emory University Medical Center in Atlanta, where Ribner directs the Serious Communicable Disease Unit. Two days later, an American nurse, Nancy Writebol, also was airlifted from Liberia with a confirmed case of Ebola.
After two weeks of treatment, Writebol was discharged, fully recovered, and Brantly soon followed. At a joyous press conference, Brantly and Ribner took turns before the cameras, Ribner playfully sporting a necktie studded with images of the Ebola virus. “Today is a miraculous day,” said Brantly, who, like Writebol, was working with the humanitarian group Samaritan’s Purse. “You treated me with expertise and yet with such tenderness and compassion.” When he finished speaking, he hugged Ribner and each member of the Ebola team — a statement to anyone watching.
Ribner has received three Ebola calls since then: two more health-care workers returning from Africa and a nurse, Amber Vinson, who became infected while treating an Ebola patient who died at a Dallas hospital. As of mid-January, all five patients who had been transported to Emory’s facility had recovered. Others have been treated (with one death) at similar biocontainment units in Maryland and Nebraska, at Bellevue Hospital in New York City, and in Europe. Although new cases of Ebola continue to be reported in West Africa, where more than 9,000 people have died, physicians have shown that the disease can be cured if treated early and aggressively.
Brantly and Writebol were the first Ebola patients treated in an American hospital, but Ribner, an epidemiologist and leading infectious-disease specialist, says he hesitated for only an instant before agreeing to accept them. His team’s work prompted Time magazine to include him among the Ebola responders collectively named as the magazine’s 2014 Person of the Year.
The only casualty in Ribner’s unit at Emory seems to have been his mail. The doctor routinely put in 16-hour days last summer and fall, treating sick patients, responding to press inquiries, revising treatment protocols, educating colleagues around the world, and trying to reassure the public — with mixed success — that there was no cause for panic. By early December, unopened magazines and correspondence were piled nearly two feet high in his cramped office, and a burgeoning collection of empty water bottles sat unrecycled on a nearby filing cabinet. Still, he made time to sit back and describe the long preparation for an outbreak he had known would come one day.
The disease did not even have a name until 1976, when a case was diagnosed near the Ebola (“black”) River in what is now the Democratic Republic of Congo. There have been nearly two dozen Ebola outbreaks since then, most in Central Africa. The current one is the largest, and the first since 1994 to originate in West Africa, where it has spread across six countries and infected more than 20,000 people. Epidemiologists believe this outbreak originated in Guinea when a 2-year-old boy was bitten by an infected bat.
Ebola is a viral hemorrhagic fever. Symptoms, which appear from two to 21 days after exposure, begin with fever, aches, and abdominal pain. They can be mistaken for malaria or the flu, but worsen rapidly. In a full-blown case, a patient may disgorge 10 quarts of fluid a day, causing severe dehydration and straining the bowels and vascular system to the breaking point. Then the patient begins to bleed from every orifice, including the eyes, ears, and nose. Death, from shock and organ failure, typically arrives about eight agonizing days after the onset of symptoms.
Fortunately, Ebola is not easy to contract, a point that Ribner and other epidemiologists emphasized repeatedly last summer and fall. It is spread only by direct contact with the bodily fluids of an infected person, much like hepatitis or HIV. In that sense, it is much less contagious than airborne viruses such as the flu, which infect and kill many more people each year.
Ribner did not specifically have Ebola in mind when he formed Emory’s biocontainment unit shortly after he joined the hospital in late 2000, but intended that it be equipped to treat any infectious disease, from SARS to plague or smallpox. Atlanta is home to the federal Centers for Disease Control and Prevention (CDC) as well as the world’s busiest airport, and Ribner was alarmed that there was no facility in the area equipped to quarantine and care for someone arriving with a highly infectious disease.
At the time, there was only one biocontainment unit in the United States, a two-bed facility run by the Army at Fort Detrick, Md., known as “the Slammer.” The mordant joke among epidemiologists was that the best they could do for anyone confined to the Slammer was lock the door and hope they got well. Working with the CDC, Ribner secured funding to create an up-to-date communicable disease unit at Emory, the first civilian biocontainment facility in the country.
The 622-square-foot unit is in a far corner of the hospital to restrict access and ensure privacy. It typically has three beds, but as many as 11 patients can be squeezed in. Except for negative-airflow equipment, which is not needed for Ebola patients but runs constantly anyway in accordance with hospital policy, the rooms are outfitted like any intensive-care unit. In an adjacent room, a small lab space covered by a protective hood enables technicians to prepare specimens or blood samples without having to carry them to unsecure parts of the hospital.
Before last August, there had been only two patients admitted — neither for Ebola — and both proved to be false alarms. The fact that the unit was almost never occupied led to suggestions that its budget be cut, which Ribner likens to dropping your fire insurance coverage because you haven’t had a reason to use it. To keep everyone prepared, though, doctors and nurses drill up to three times a year, frequently going off-site to respond to mock calls of sick patients arriving at Hartsfield-Jackson Atlanta International Airport. “I have to admit to you, a lot of people sort of saw this like Noah’s Ark,” he told Time magazine.
Ribner decided to become an infectious-disease specialist as a fourth-year medical student, after a rotation in epidemiology at Tufts University taught by Louis Weinstein, a pioneer in the field. Upon earning his medical degree at Harvard and completing a residency and fellowship at New York’s Mount Sinai Hospital, he embarked on a career as a medical researcher before realizing that “I really didn’t want to spend my whole life in a lab.”
He went back to school and earned a master’s degree in public health at the University of Michigan, then took up a new subspecialty called hospital epidemiology — the study of how diseases spread within medical facilities and how to prevent it. Today, Ribner juggles several jobs at Emory: clinician, epidemiologist, associate director for occupational-injury management, and professor at Emory’s medical school. Even when it is quiet, though, the biocontainment unit takes up about a third of his time.
Although he has come in contact with some of the world’s most virulent diseases during the course of his career, Ribner, who is soft-spoken with a sly sense of humor (the public’s overreaction to Ebola is a favorite target), says he has no concerns about contracting any of them himself. Neither does his wife, a registered nurse, who has gotten used to her husband’s sometimes-risky job. “She’s a very levelheaded woman,” he says.
Seven physicians and 19 nurses, working in rotation, staff the biocontainment unit. Besides technical skill, Ribner says, he looks for an ability to handle stress, the stamina to put in very long hours, and a willingness to work as part of a team. Ebola is a particularly labor-intensive disease to treat; while most ICUs are staffed at a ratio of two patients for every nurse, with Ebola it’s the reverse — two nurses for each sick patient, who is never left unattended. Ribner is clearly proud of the unit and his staff’s strong sense of mission. As soon as they learned last summer that the first Ebola patients had been admitted, two of the nurses on Ribner’s team canceled vacations and hurried back to Atlanta to help. Susan Grant, the chief nurse at Emory, says she was dismayed to read reports that some questioned the wisdom of bringing Ebola patients back to American soil. “If they can’t come here,” she asks, “where can they go?”
Part of the team’s mission included making the patients, frightened and sick with a frequently fatal disease, feel like people rather than specimens. Brantly recalls that Ribner was determined not to let the bulky protective gear inhibit his or his staff’s interactions with their patients, insisting that they call each other by their first names. “It stood out to me that even though he was the boss of the whole operation, he made a point to come in and talk to me and discuss my treatment,” Brantly says in an email.
Over the past decade, Ribner and his colleagues have developed elaborate protocols for every aspect of patient care. Everyone coming in contact with a patient wears a full Tyvek suit and booties, a hood with a face shield, a personal respirator, and two pairs of gloves. Shoes worn under the booties remain in a locker and never leave the unit. Sinks are light-activated, so the taps do not have to be touched, but hand sanitizer is also used constantly, even on gloves. The most minor spills trigger a long cleanup procedure, with detailed instructions on how to dispose of the waste and how to change any clothing that might have been contaminated. Little of this is particularly high-tech, just very meticulous — and effective both in keeping the doctors and nurses safe and ensuring that the virus does not spread.
Emory also has developed procedures for the private ambulance service that transports infectious-disease patients to the hospital. Not only do the EMTs receive extensive training and protective equipment, they drive an ambulance with a waterproof lining inside to prevent any patient fluids from seeping into crevices. Even so, the ambulance is disinfected, inside and out, for up to five hours each time it is used.
Today there are two other biocontainment units in the United States, one at the National Institutes of Health in Bethesda, Md., and another at the University of Nebraska Medical Center in Lincoln. Infected CDC employees returning to the United States are treated at Emory; all other patients are assigned randomly among the facilities. Although the Obama administration announced in December that 35 more hospitals would be certified to care for Ebola patients, they will not be full biocontainment units because they lack the sophisticated air-handling equipment needed to treat patients with airborne viruses.
Even with so many years of planning and training, however, there were some aspects of patient care that Ribner and his team did not anticipate during the Ebola outbreak. One was how to dispose of the large amount of highly infectious waste the patients produced. When Brantly and Writebol were being treated last summer, they generated as much as 40 bags of waste a day, and the private company that hauls Emory’s waste refused to touch it. Ribner had to send hospital workers to a local Home Depot to buy as many 32-gallon rubber tubs as they could find to hold the waste, and arranged to borrow a large autoclave, which uses pressurized steam to disinfect infectious materials, before the waste haulers would remove it.
In recent months, Ribner and the Emory team have shared what they have learned, authoring articles in medical journals and lecturing colleagues and the general public. All of their protocols are posted on the hospital’s website, including a five-and-a-half-minute video on how health-care workers should don their protective equipment and a six-minute video on how they should take it off, because Ribner believes that workers are most likely to contaminate themselves by removing their equipment improperly.
There still is no cure for Ebola; although two vaccines are being tested, they have not been proven to be effective. Physicians are “a substantial distance away from having anything we can offer,” Ribner says, referring to the lack of a cure. For the time being, there seem to be four keys to treatment. As he explained, in measured medical-speak, for an article in the New England Journal of Medicine, “intensive-care nursing, aggressive oral and intravenous rehydration, electrolyte supplementation, and transfusion of blood products appeared to be critical for a positive outcome in our patients.” Or, as he put it more plainly to CNN last summer, the secret to treating Ebola — to the extent there is one — is simply “to keep the patient alive long enough in order for the body to control this infection.”
Equally important, Ribner says, may be a shift in how we view Ebola and what types of treatments are worthwhile. Fear-mongering by public officials and the press disgusts him, and he repeatedly likens the disease to HIV, recalling a time in the mid-1980s when some hospitals refused to treat AIDS patients because doing so might scare off other patients — and because they believed it was pointless.
“If you would have asked anybody in July of this year, before we had the first patient who came back from West Africa, they would have said that if somebody [with Ebola] had respiratory failure, if someone had kidney failure, there was no point in putting them on a ventilator, there was no point in doing dialysis — because they were going to die. That’s not the case anymore,” he says. For similar reasons, he thinks it may also be worthwhile to provide other forms of treatment, including MRIs, surgery, and even obstetric care.
This Ebola outbreak, however, is far from over. Ribner lauds the doctors and nurses who have volunteered to fight it on the front lines and defends the decision to send U.S. military forces to Africa last year to assist them.
“It’s not like we can shut the borders and pretend that this outbreak can rage in West Africa and it won’t affect us,” he insists. “There are going to be people coming here with this illness, and if we want to control it, it’s not by closing the borders, it’s by helping them eradicate the outbreak by treating patients who are sick and avoiding transmission to other patients. I don’t know any other way around it.”
When that happens — and when it’s clear that the last Ebola patient has left Ribner’s care — the biocontainment unit will be quiet again until the world’s next infectious-disease outbreak. And whenever Ribner receives that phone call in the middle of the night, he will be ready.
Mark F. Bernstein ’83 is PAW’s senior writer.
Courtesy Emory University