The words “State Department” flashed on the cell phone of Phil Smith, M.D. “We think you have a great unit. How would you like an Ebola patient?”
It was Sept. 2, 2014, and the international president of Doctors Without Borders was telling the United
Nations how the world was “losing the battle” to contain the Ebola outbreak.
Dr. Smith, medical director of the Nebraska Biocontainment Unit (NBU), turned to Angela Hewlett, M.D.,
associate medical director of the NBU and the only other physician trained for biocontainment: “I hope you don’t have plans for the next week.”
“Boy, was that an understatement,” she said.
They spent the next several weeks in around-the-clock care for their first patient, Richard Sacra, M.D.
From the day Dr. Smith’s vision of a biocontainment unit became a reality 10 years ago, his team had drilled for a variety of scenarios – an emerging disease like pandemic influenza, a bioterrorist attack, a public health emergency. They had even practiced for managing patients with viral hemorrhagic fevers, which include Ebola.
And that’s exactly what the unit was first used for in the fall of 2014. One at a time, over a period of three months, three patients were treated for the contagious and deadly filovirus. Since then, the actions of the NBU team have propelled UNMC and Nebraska Medicine onto the world stage. Dr. Smith, professor of infectious diseases at UNMC, and his team set standards that are being shared with providers and organizations around the world.
After the Sept. 2 call, Dr. Smith activated his chain of command. Nebraska’s unit is the only one in the U.S. that is independent of the federal government. UNMC, Nebraska Medicine and the Nebraska Department of Health and Human Services (DHHS) are partners in the unit and must agree to accept patients. Dr. Smith conferred with Joseph Acierno, M.D., chief medical officer and director of public health for DHHS, and UNMC Chancellor Jeffrey P. Gold, M.D.
On Sept. 3, Dr. Smith received the green light and immediately sought advice from the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and Emory University, where two Ebola patients already had been treated.
“I learned that aggressive supportive care is key,” he said. “Watch the labs and give plenty of fluids and nutrition.”
With a two-day notice to fully activate the unit, Shelly Schwedhelm, executive director of infection prevention and emergency preparedness at Nebraska Medicine, and Kate Boulter, lead nurse of the NBU, alerted the team. “It seemed like there were 50,000 things to do,” Schwedhelm said. “We’re a just-in-time department and all supplies need to be fresh.”
Medical supplies were stocked, equipment prepared and personal protective equipment (PPE) procedures reviewed. “No request was too much,” she said. “Whatever we needed, it got done.”
Some technology updates were added to the unit. Max Thacker, associate director, ITS Video Services, recommended that a video telephone system be installed to allow patients to video chat with family and health care professionals outside the room and around the world.
“New technology connected the patient with his family,” Schwedhelm said. “That was a major benefit.”
Although the 40-member team had drilled quarterly, there was excitement and apprehension about being around a deadly virus. Still, no one on the team backed out. In fact, many more volunteered, Schwedhelm said.
“I’m very proud of our team,” she said. “There is incredible breadth and depth of expertise to the entire team.
The work is taxing and precise. We encourage everyone to speak up if they see something not quite right.”
Meanwhile, because Ebola kills within two weeks of infection, Dr. Smith knew his window to treatment options depended on Dr. Sacra’s condition upon arrival – and the possibility of using experimental drugs and convalescent serum.
Chris Kratochvil, M.D., associate vice chancellor for research, worked with individuals from the CDC, the Food and Drug Administration, and the pharmaceutical industry to identify potential treatments and a pathway to obtain them.
“That first 24 hours we had significant conversations with many individuals from across the federal government, industry, and internal teams, all of which were more than happy to pitch in and facilitate the process,” Dr. Kratochvil said.
Very few experimental drugs were available, but the Canadian drug company Tekmira had a promising drug, TKM-Ebola, which they provided for free. The drug works by blocking viral RNA and keeps it from replicating. The drug had been tested on animals and a small number of humans, but not people with Ebola. Dr. Kratochvil worked with the UNMC Sponsored Programs Administration team that rapidly reviewed and executed the necessary documents and signed the confidentiality disclosure. He then arranged for shipping.
Members of the Institutional Review Board (IRB), Clinical Research Center and the Pharmacy and Therapeutics Committee jumped into action. Procedures that normally take weeks were completed within hours.
“We literally worked through the night,” Dr. Kratochvil said. “Everyone dropped what they were doing and got it done.”
The 20-page IRB document spelled out risks and benefits for the drug, options for treatment, consent, what would happen and any costs incurred in participating in the trial. There were no costs to the patient for receiving the research drug.
Testing the patient’s contaminated blood presented other issues. Peter Iwen, Ph.D., director of the Nebraska Public Health Laboratory (NPHL), which contains a BSL-3 containment laboratory and is located on the UNMC campus, was finishing his report on the West Nile virus in Nebraska when his phone rang: He realized that the NPHL would become the first state public health lab in the U.S. to test Ebola virus-infected specimens.
He gathered his staff of six for a pep talk and began to schedule two-person shifts to provide round-the-clock testing.
“We work on the buddy system in the lab,” he said, noting that they check each other’s PPE, safety practices while working within the biosafety cabinet – the primary containment box – and double check lab results.
“It was a unique situation,” Dr. Iwen said. “When you’re holding a tube of the patient’s blood, you realized you had a deadly virus in your hand. All safety precautions needed to be considered to include the use of plastic disposable containers and to eliminate the need for sharp objects such as glass and needles.”
Blood samples required special handling. There were entire protocols for the lab personnel to learn about preparing and shipping samples to the CDC in Atlanta for additional testing.
“You can’t ship known Ebola virus infected blood samples through FedEx,” he said. “We had a courier in place, butI later discovered that they were driving the samples to Chicago and then flying them to Atlanta. We were fortunate to work out the details to get the samples shipped in a timely fashion.”
On Sept. 5, at 5 a.m., the plane transporting Dr. Sacra landed at Offutt Air Force Base.
Waiting for him were decontamination and transportation experts Shawn Gibbs, Ph.D., professor, and John Lowe, Ph.D., assistant professor of environmental, agricultural and occupational health, UNMC College of Public Health, and graduate student Katelyn Jelden, who, having arrived at UNMC in August, was getting a unique start to her public health education.
The trio spent a great deal of time coordinating with transportation partners so that they were ready to receive the patient. This also included time preparing Omaha Fire Department ambulances to transport Dr. Sacra to Nebraska Medicine. They did this by lining the entire interior of the vehicle with 6-mil plastic sheeting and duct tape.
The 15-mile transport to move Omaha’s first Ebola patient through rush-hour traffic required a massive effort coordinated with Omaha Police and Fire and the Nebraska State Patrol, Dr. Gibbs said. “Teamwork is important and I can’t say enough great things about these people.”
Dr. Gibbs and Jelden prepared to receive the patient at the hospital, while Dr. Lowe followed the ambulance in the chase car. The three spent the rest of the day decontaminating the vehicle.
News cameras captured the action live as the ambulance turned the corner at 42nd and Emile streets at 6:30 a.m. to take Dr. Sacra to the NBU.
Pieces were falling into place. The patient had arrived, the IRB review was complete, the Food and Drug Administration (FDA) provided approval for use of an experimental drug and TKM-Ebola would arrive later that day.
All they were missing was LuAnn Larson, nurse manager of the Clinical Research Center, an experienced research coordinator who would don PPE and administer the experimental infusion.
She was in Baltimore, about to return home for her niece’s wedding when Dr. Kratochvil reached her. As she flew back to Omaha, she read the background materials about the study drug and a 50-page protocol that had been emailed to her. She arrived at the airport 30 minutes before the drug and never made it to the wedding. “How can I not be there and be part of the team?” she told him.
Dr. Sacra’s 22-hour trek from Monrovia, Liberia, to Omaha had left him dehydrated and confused. He had been sedated and encapsulated in his own biocontainment space suit the entire time.
“He was very sick when he arrived,” Dr. Smith said.
The experimental drug was administered once a day for seven days. On Sept. 6, Dr. Sacra also received convalescent serum from Emory’s first Ebola patient, Kent Brantley, M.D., who had received convalescent serum when he was in Africa, and the experimental drug ZMapp in the U.S.
For the first week, Dr. Smith spent a great deal of time in the patient’s room; most of the health care team communicated through video chat. It was difficult to bond through all the protective gear, so the team gave Dr. Sacra color photos and bios of themselves.
“He liked seeing who was caring for him,” Dr. Hewlett said. “When he left the unit, the entire team lined up to shake his hand and he correctly identified everyone. He recognized us from our eyes – the one thing he could see.”
Treating the disease was only part of the battle. The team also had to care for Dr. Sacra’s spirit. Nurses talked and played chess with him, and also brought in books, magazines and movies. As his health improved, he made use of an exercise bike that was brought into his room.
As his appetite improved, Patricia Taye, a hospital housekeeping employee from Liberia, brought home-cooked meals to him and let him know that prayers were being sent from her home country, which also had been his home for 15 years.
And three weeks later, when he left the unit, team members celebrated his recovery.
“When we planned this unit, hemorrhagic fever was not felt to be likely,” Dr. Smith said. “I thought it would be nice to get a less dangerous disease such as monkeypox or extensively drug-resistant tuberculosis.
“But, after having gone through this, our team feels they can handle anything. There’s always something new.”
- Get more details about all facets of the biocontainment unit from UNMC Discover.
- Watch the biocontainment unit 10-year celebration video.
- Read Dr. Hewlett's personal perspective on Ebola.