Ebola, From the Tarmac to the Isolation Unit

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Texas nurse Amber Vinson, left, steps from an ambulance at Emory University Hospital in Atlanta on October 15, 2014. Jerry Jordan/Reuters

Updated. On August 1, Emory University Hospital in Atlanta prepared to receive the first person to be treated for Ebola in the U.S. when Dr. Kent Brantly was diagnosed with the virus after treating patients in Liberia. For Dr. Alexander Isakov, it was a moment 12 years in the making.

In 2002, when the hospital created a unit to help the Centers for Disease Control and Prevention (CDC) with serious communicable diseases, staff realized it would need to have a transportation plan in place to get patients to the unit safely.

Isakov, a member of Emory University’s emergency medical faculty and a physician qualified in emergency medicine and emergency medical services, was asked to develop the transport team, the Grady EMS Biosafety Transport Program, and train faculty at the emergency medical services (EMS) component of Atlanta’s Grady Health System. Together with his team, he has put emergency physicians and the transport team through drills and exercises to perfect the transportation of patients with infectious diseases.

“When you’re transporting person with Ebola virus disease or a person with suspected Ebola virus disease, it’s important that the health care workers aren’t exposed,” Isakov told Newsweek by phone on Wednesday. “You don’t want to allow for a secondary transmission by not having a process in place.”

Since August, the Emory University Hospital Serious Communicable Disease Unit has received and treated four patients, all of whom survived and have been released from the hospital virus free.

Before he addressed a gathering of the American College of Emergency Physicians in Chicago on Tuesday, Isakov spoke to Newsweek about what it takes to transport an Ebola patient from the tarmac to the isolation unit.

Q: How long have you and your team been preparing for Ebola?

We were actually preparing for any serious communicable disease, those that are recognized like SARS or a viral hemorrhagic fever like Ebola or Marburg, or a novel influenza virus that would have the potential to make humans sick.

[We have been preparing] since the inception of the unit, around 12 years or so. I think it was only as the public health emergency in West Africa got much bigger [that] we started to realize there may actually be a need to repatriate someone to the United States. That all happened rather quickly, that there was a need to have someone come to Emory University Hospital.

The education that’s required for people in the EMS and in the hospital, to understand the nature of the Ebola virus disease specifically, and the training that’s required so that they can manage a patient that’s seriously ill, and provide for their own protection by the use of [personal protective equipment (PPE)] and procedures to allow them to remove that PPE without contaminating themselves, it’s all an important part of it. All that preparation, as well as logistics with lab sampling and waste management in the hospital setting.

Q: Was Emory at the top of the list of U.S. hospitals for repatriated patients when Brantly was due to come back?

There was an evaluation process. At the time there were four total health facilities that had some special isolation unit: Emory, Nebraska Medical Unit, [St. Patrick Hospital] in Missoula, Montana, and the [National Institutes of Health in Bethesda, Maryland]. Through some assessment, the request came to Emory University Hospital to take Dr. Brantly and they accepted it.

What’s the process when a patient arrives at the airport and you transport them into the isolation unit?

Bringing us all the way to the point where you’re prepared and you get a phone call, the amount of lead time you would get would vary. Typically what would happen is there’s either a patient coming in from overseas or a patient coming in from the U.S. A request has already been made to the serious communicable disease unit [as to] whether they would accept a patient. Once the patient is accepted, there’s a series of events that would cascade that includes the activation of the biosafety transport team at Grady EMS, so we coordinate with whatever agencies are involved in bringing the patient to [Emory].

Whatever airport the patient arrives, we’re prepared to go and meet them and do the patient transfer right on the tarmac. The idea always with patient transfer is to limit exposure of that person to others that aren’t protected. In anticipation of that patient transport, a few hours in advance the paramedics, the supervisor and the physicians will gather some place where they prepare the unit to best move that patient without risking gross contamination of the ambulance, so that it can be properly disinfected. They also put on the appropriate PPE so they don’t get exposed to blood or infectious fluids.

The [ambulance] is already prepared, the driver compartment isolated from the passenger compartment, [there are] barrier drapes, impervious drapes put up so if the patient has vomit or diarrhea it doesn’t hit the equipment.

Q: Is this just a regular ambulance?

It’s a regular ambulance. We needed to provide education and training for our medics to prepare this ambulance, but it didn’t need to be something so unique, special and expensive that it couldn’t be replicated in other communities. Other communities don’t have to wait for a special ambulance to come, they can apply these principles of barrier and infection control on any ambulance in the U.S.

Q: So it’s like PPE training for an ambulance?

Pretty much. The whole idea about biosafety and even the clinical transport of patients with a serious communicable disease, it’s not just the PPE. It’s about administrative policies and procedures, education and training. How can we limit the truck’s environmental services to infectious bodily fluids or blood so we can more effectively decontaminate and disinfect it when we’re done? That’s in great part what the preparation of the ambulance is for, it’s more efficient and effective decontamination.

Q: What happens when you get to the airport?

When the plane lands at whatever airport they land, patient transfer happens on the runway or on the tarmac. We don’t go into any terminals to limit exposure. Through coordination with whatever escort we might have and in communication with Emory University’s serious communicable disease unit, we start heading in their direction. Usually it’s a half an hour drive. The patient’s assessed, but some of these patients have come from 14-[to]-16-hour transits, so it’s not entirely clear in terms of their clinical condition or what intervention they might need.

The crew is really ready to do what would be required to resuscitate the patient and revive them if needed. That’s in part why they wear the PPE that they do—the full Tyvek, the [powered air purifying respirators]—it gives them full skin coverage, full splash protection from blood, vomit or diarrhea and prepares them should a procedure be required that’s known to have the potential for generating aerosol. If that’s required, they’re already in an appropriate level of equipment.

Q: Could you explain what’s meant by an aerosol-generating procedure?

Ebola is not known to be transmitted through aerosol, unlike tuberculosis and measles, two diseases that can be [transmited by tiny micron-sized particles across long distances].   

If I do an aerosol-generating procedure [in an ambulance or hospital], like you’re so sick that I need to help you breathe so I have to put a breathing tube in your trachea, that’s on a list of procedures in the health care environment that are considered to be aerosol generating, [so as an added measure of safety, healthcare workers apply the necessary respiratory protection. But let me be clear, this is not a risk point for the public, individuals with Ebola Virus Disease are not known to transmit the virus by aerosol].

Q: What happens on the way to the hospital?

With the hospital and the special isolation unit, we’ve arranged special entry points [that] limit exposure of that patient to others patients, to bystanders, to other visitors, to unprotected staff. We sometimes walk a patient into the hospital because it’s the most direct route into the isolation unit. If you require a stretcher, we can arrange that, but it does change the entry point into the hospital. Wherever this is being done, these transports have happened at the Nebraska Medical Center and NIH, they all have their route to the isolation unit but whatever route that is, it’s designed to limit exposure to others.

Q: What happens once you get to the hospital?

For a lot of the media, the story is over when the patient arrives at the hospital and the cameras stay focused on the hospital. But for the EMS crew, it means going to a designated location where the process of decontaminating and disinfecting the ambulance, then coming out of the PPE, happens. It can be a lengthy procedure depending on how messy things have become in the course of the transport.

It’s also a risk point for health care workers because if, for example, you are taking of your PPE, which has afforded your protection all this time in a way where you have touched some of that diarrhea or vomit or sputum or something else that’s infectious, and you don’t recognize it, it’s a chance to get in contact with an infectious bodily fluids. So you have to control for that and prevent it.

The way you prevent [this] is train people to do this well, but another really important element is these processes should be supervised. Not just leaving you to your own devices, but have someone watching you do it and guiding you through the checklist, making sure you don’t skip a step or make a mistake.

Q: What was it like working with Brantly in August when the CDC guidelines were different from how they are now?

The CDC’s guidance, which we understood even before Dr. Brantley came back to the U.S., was standard contact and droplet precautions, and aerosol if there was an aerosol-producing procedure required. We knew that. The types of PPE you could choose to wear to implement that, but for us it was 10 years of exercising and training.

What we learned was, if you’re a paramedic in August in Atlanta, whatever you’re wearing, your face shield’s at risk for fogging, you’re sweating and you’re hot, as disciplined as you are you want to wipe your forehead, you have to control for all those things. The best way to control that in our work environment was head-to-toe Tyvek, which meant the hooded [powered air purifying respirator] (PAPR) and the Tyvek suit, and the PAPR is blowing air, so keeping your visual field clear. It all made sense operationally, so we never tried to say we exceeded the CDC’s guidelines.

It’s maybe semantics, but I think we implemented the CDC guidelines in a way that accounted for our patient’s condition and our work environment.

Q: The three West African countries worst hit by Ebola—Liberia, Sierra Leone and Guinea—don’t have the same resources as U.S. health care facilities, so what are some of the essential elements for transporting patients there?

Patient transportation systems in West Africa are not uniform with regard to resources or expertise (they are not uniform in the U.S., for that matter). While not uniform, essential elements are similar.

Patients need access, meaning they need to know how to summon EMS and the EMS needs to know how to find the patient, [which is] not always easy when street names and addresses may be absent. The EMS needs to know which facilities will accept its patients for evaluation. Getting the patient to‎ the right facility may be challenging given early symptoms of Ebola virus disease [like a fever] may look similar to other more prevalent diseases such as malaria [or] typhoid.

EMS providers [in West Africa] need to protect themselves from blood and infectious bodily fluids‎ to prevent contracting the illness. EMS providers need to clean and disinfect their vehicle to prevent transmission of the virus to others.

Given limited resources, these are significant challenges. For many cases, I suspect transportation by EMS is simply not available, and families and friends are left to their own devices for transport of ill loved ones, as was the case for the Liberian gentleman who died in Dallas. [When he was still in Liberia, Thomas Eric Duncan helped the Ebola-stricken daughter of his landlord to the hospital and back. She later died from the disease, as did he after he reached the U.S.]