Out of Africa
Dr. Jay Varkey, Arts ’98, recounts the 72-hour scramble to get Emory University Hospital’s serious communicable diseases unit ready.
By Joni Moths Mueller
“Be ready in 72 hours.”
The phone call from the U.S. State Department told authorities at Emory University Hospital to prepare for the arrival of the first of two U.S. Ebola patients. Dr. Kent Brantly was being rushed by air ambulance from Liberia to Atlanta for treatment on the hospital’s serious communicable diseases unit, where a medical team trained to respond to this level of health crisis assembled. Nancy Writebol would arrive three days later. Four Ebola patients in all would be treated at Emory Hospital from August to October 2014.
Dr. Jay Varkey, Arts ’98, right, an infectious diseases specialist and assistant professor of medicine, was a member of the team called into action.
“That’s what started the ball rolling,” he says of the phone call. “It was an incredible 72 hours.”
Varkey came to Marquette in 1994 enrolled in a pre-medical scholars program established in affiliation with the Medical College of Wisconsin. But for a confluence of events the fall of his fourth year of medical school, Varkey might today be working as a pediatrician or internist. When a planned trip abroad was derailed by the 9/11 attacks in New York, Washington, D.C., and Pennsylvania, he chose instead to use the time to take an elective class on infectious diseases. “I loved it,” he remembers. “It was absolutely fascinating. It’s one thing to study ‘bugs’ in the lab, but to actually see antibiotics help someone get better — I greatly enjoyed that aspect of infectious diseases.”
Varkey completed a residency and fellowship in infectious diseases at Duke University Medical Center, and, in 2009, joined Emory Hospital’s medical staff, where he began working closely with professor of medicine Dr. Bruce Ribner, who is the director of the serious communicable diseases unit.
Until then Varkey hadn’t heard about this level of isolation unit. That changed quickly. “I was aware of the drills and knew some of the staff personally, but I wasn’t actually part of it until we found ourselves in the midst of things that August,” he says.
Mad scramble to prepare
Emory Hospital’s isolation unit was built 10 years ago in collaboration with the Centers for Disease Control. It includes two ICU-style patient rooms with contained bathrooms, locker rooms where medical staff can dress in the required protective clothing and take emergency decontamination showers, and dedicated laboratory space. Everything in the unit is self-contained so no virus particles are disseminated beyond its confines. Negative air pressure keeps air flowing into patient rooms to ensure that no airborne particles escape and enter exterior hallways.
Infectious diseases specialists worldwide were aware the Ebola virus was out of control in West Africa, Varkey says. The staff at Emory Hospital had talked internally about the possibility that the unit could be asked to accept patients. That possibility became real in late July, Varkey remembers, when reports came that two ill Americans were potentially bound for the hospital in Atlanta.
The Ebola patients were carrying a communicable virus that had never before crossed U.S. borders. The hospital had 72 hours to make sure everything was ready to go. Staff members tested and re-tested all of the systems built into the biocontainment unit. Pretty quickly, Varkey says, it became apparent that the unit was not large enough to accommodate the laboratory needs of two patients. He credits the hospital’s facilities engineers for their resourceful response. Within that 72-hour window they commandeered an office next door to the unit and retrofitted it with a biosafety cabinet and functioning point-of-care lab.
Meanwhile the medical team practiced the procedures that are critical to caring for patients who have a highly communicable disease like Ebola. Absolutely paramount, Varkey explains, was ensuring the safety of health care workers. One key procedure — donning the gear worn when in contact with highly contagious patients — requires medical personnel to manage what Varkey calls “a tricky shimmy” to pull on and take off the hazmat suit, boots, gloves, hood and mask without contaminating themselves or other people. For a Wisconsin reference, he compares that to getting into and out of a snowmobile suit without touching the outside of it. “The group had been practicing this every six months for 10 years, but at this time it became really intense,” Varkey says. “There were talented doctors and nurses who weren’t able to do it, who were asked not to be direct care providers for these patients. That was tough.
“It was a mad scramble to make sure that when our patients walked through the door we could stop worrying about all the external operations stuff and just deal with caring for the patients. None of us were sleeping particularly well,” Varkey admits. “We would squeeze in sleep as we could until Saturday, Aug. 1, which is the date our first patient arrived.”
A stunning virus
Emory Hospital began receiving real-time updates from the pilot and then from the ambulance transporting Brantly. Of course, Varkey says, the medical team also watched CNN, which was televising updates to the entire world tuned into the unfolding drama. “I remember feeling an eerie sense of calm,” he says, of those minutes before the ambulance arrived with their patient, “because we really felt that we had worked extraordinarily hard to be as ready as we could be.”
Initially the hospital asked Varkey to act as the spokesperson providing media with status updates. Three days after Brantly entered the unit, Nancy Writebol arrived. At that point Varkey moved from a communication role to become a direct member of the medical team. “One of the challenges is that at that point two doctors were doing 12-hour shifts. You’re on for 12, and then you go home and try to sleep. Fatigue was setting in,” he says, “and we were concerned that if we didn’t spread out the work a little more there was a potential for making mistakes.”
Four Ebola patients in all came to Emory Hospital, and the medical team grew from two to six doctors plus Ribner, plus a legion of nurses, lab technologists, facilities services staff and other providers to accommodate them. “I wouldn’t say it was frightening but it was certainly tense,” Varkey says, of the experience. “When you walk into a room with someone who has Ebola, it’s sort of like walking out of the tunnel for the Super Bowl. It’s an intense, highly charged atmosphere, but once you’re in the room the training and science take over.”
Ebola is merciless, highly infectious and the most traumatic virus Varkey has seen. “The thing that’s just so stunning about Ebola is the disease robs the patient of dignity. It is such an aggressive virus and it does such horrible things to the body,” he says. “When you think about patients losing five to 10 liters of fluid just in vomiting and diarrhea, that made me respect the kind of challenges health care providers face in West Africa.”
The medical waste poses a potential danger if not handled correctly. For two patients under their care for 33 days, more than 3,000 pounds of medical waste were generated, including gowns and sheets. “We anticipated 300 pounds,” Varkey says. “That highlights for me that caring for someone with Ebola is really a team effort. Our senior environmental services staff was present 24/7 to make sure we were handling trash properly.”
Ebola continues to surprise
Dr. Ian Crozier was the third patient brought from Africa to Emory Hospital — and the most critically ill. He developed respiratory failure and was put on a respirator for two weeks. His kidneys failed, and he was placed on dialysis for 24 days. Despite these dire downward turns, he rallied under medical care and was discharged 40 days later.
But nine weeks after he had cleared all of the virus from his blood, Crozier and Varkey suspected a painful irritation in Crozier’s left eye might actually be the result of remaining Ebola virus squatting inside his iris. Crozier returned to Emory’s Eye Center, where they aspirated a few drops of fluid from inside his eye to “hopefully prove,” in Varkey’s words, that he was negative for Ebola.
“You can imagine my shock a few hours later when I was at my kid’s piano recital and the laboratory technologist called to tell me he tested positive for Ebola,” Varkey says.
The discovery revealed there is more work to be done to ensure the continued health of patients who survive Ebola. Thankfully the health care systems and resources available in the United States — and the ability to marshal them together quickly on behalf of patients — helped all four patients recover.
Any time the world has to deal with a new illness, Varkey says, it is understandable that the initial response is fear. “One of the key jobs we have as health care workers — and, to be honest, I would include the media in this — is to care for those who are ill and to advance knowledge.”
Though the outbreak in Africa has been contained, Varkey cautions that another health crisis will surface, and it’s important to be prepared.
“If you look at Dr. Brantly’s case, he arrived in Atlanta on day 13 of his illness,” Varkey says. “His first basic labs were done in our unit. Getting a CBC or Chem5 for electrolytes is such a basic test that I can order it with a couple clicks of a mouse and have the results delivered to my phone in 45 minutes. The infrastructure for most hospitals in Africa is so different that even those basic tests aren’t possible. That’s ridiculous.”
In a fair and just world, Varkey says, better health care infrastructure should be available everywhere: “That is something we need to work on together.”