Fighting the World’s Worst Diseases
Feb 20, 2015 08:00AM
By Doug Meigs
When patients with Ebola flew into the heartland, the Nebraska Biocontainment Patient Care Unit activated for the first time.
Local healthcare workers are now helping hospitals nationwide to prepare for the next generation of infectious diseases.
* * * * *As the Ebola epidemic worsened in West Africa last summer, a Nebraska nurse-turned-administrator wondered if Omaha might receive any patients. Shelly Schwedhelm wasn’t scared. She was ready.
“We were watching what was happening in Africa and started to gear up,” she says, speaking from her office inside Nebraska Medicine’s labyrinthine hospital cluster in Midtown at 42nd and Dewey.
Schwedhelm, 54, oversees the Medical Center’s biocontainment unit. She leads administrative, nursing, and logistical support for the unit’s 40-person staff of nurses, physicians, respiratory therapists, and patient-care techs. Few biocontainment units exist in the United States. The Med Center unit is especially rare, housing the nation’s largest hazardous patient capacity. It consists of five rooms and 10 beds, isolated behind security-card locked doors, and a decontamination room on the seventh floor of University Tower.
Before Schwedhelm knew any Ebola patients might arrive, she made sure all safety protocols were in place. The unit’s self-contained air ventilation system and autoclave—a pressurized heat chamber used to sterilize large amounts of waste—operated without flaw. Ebola can cause uncontrollable vomiting and diarrhea; any potential pathogens would be contained and decontaminated behind sealed doors. The unit opened with federal, university, and hospital funds made available in the aftermath of the September 11 terror attacks. The 2003 outbreak of SARS (Severe Acute Respiratory Syndrome) in Asia and Canada added impetus to local, state and federal coordination. It went online in March of 2005.
“We’re centrally located,” Schwedhelm says, explaining the logic for an Omaha site in case of a national health emergency. “We’re about as close as you can get to being smack dab in the middle of the country.” March is the unit’s 10th anniversary. Schwedhelm has managed the operation for approximately eight years. She credits the establishment to Medical Director Dr. Phil Smith.
Her career with Nebraska Medicine spans 33 years. She started working in the emergency room as a nurse, but she quickly transitioned into leadership positions. She has managed the Post-Anesthesia Care Unit, operating room, and emergency room before assuming her current title, Executive Director of Emergency Preparedness. Schwedhelm first learned about Ebola during her nursing studies. At the time, Ebola was a virtual unknown, a mysterious killer that could wipe out entire villages. Even today there is no proven treatment or vaccine, though UNMC staff are working on some leads.
In 1976, the viral hemorrhagic fever known as Ebola first emerged in Zaire (now the Democratic Republic of the Congo). The virus took its name from a local river. In subsequent decades, rare and isolated outbreaks persisted in central Africa due to human contact with contaminated primates, bushmeat, or bats. West Africa’s crisis started in Guinea, spreading unnoticed in early 2014. By spring, Ebola reached Sierra Leone and Liberia. Doctors Without Borders declared the epidemic “out of control” in June with a global tally of 528 cases and 337 deaths.
The outbreak gained momentum fast. By Aug. 22, the disease struck 2,615 people with 1,427 deaths. In stark contrast, the world’s previous worst Ebola outbreak occurred in Uganda with 425 reported cases in 2001. By the year’s end, West Africa’s epidemic would surpass 20,000 cases and 7,800 deaths. The epidemic has continued into 2015. The World Health Organization reported on January 19 that 21,759 had fallen sick and 8,668 died from Ebola in Guinea, Liberia, and Sierra Leone.
African jungles where Ebola originated are a far cry from the rolling cornfields of northeast Nebraska, the land of Schwedhelm’s birth. She grew up on a dairy farm near Pender. Nursing has supplanted agriculture as her family’s occupation. Two of her sisters, her husband, and her brother-in-law work in nursing.
For the past decade, her biocontainment team trained regularly for infectious disease scenarios ranging from novel strains of influenza to coronaviruses such as SARS or MERS (Middle East Respiratory Syndrome), smallpox, or potential biological warfare by terrorists. Ebola has been on the unit’s list of disaster scenario drills from the beginning. But the hospital had not been tested with real-world activation. One near-activation roughly six years ago turned out to be a false alarm, malaria. “The unit has sat idle from the standpoint of patients, but we’ve always remained in a state of readiness,” she says.
Then in August 2014, she received the phone call that confirmed her premonitions. A representative from the State Department was coming. He arrived, toured the facility, and asked questions about logistics, transport, and protocol. Suddenly, the Nebraska Medicine joined two East Coast hospitals on a list of destinations for repatriated Americans with Ebola. “At that time it became very real to us,” Schwedhelm says. Preparations went into overdrive. “We spent the next month fine-tuning details, enhancing our staff, running through all the motions of testing all those things that we had tested for so many years.”
The State Department began a rotation: Emory University Hospital in Atlanta, collaborating with CDC headquarters. The National Institute of Health’s hospital in Bethesda, Maryland. Then came the Nebraska Medicine’s turn.
Omaha’s first patient arrived on Sept. 5. Dr. Rick Sacra had contracted Ebola in Liberia. The 51-year-old doctor was working for the Christian missionary group SIM. He flew from Africa to Omaha. “We had been in touch with our Emory colleagues, to gain insights on how they had dealt with their patient,” says Schwedhelm, “but we really didn’t know what to expect.” Text, e-mail and phone alerts buzzed biocontainment staff wherever they were. Kendall Ryalls received the notice while traveling with her fiancé. A programmed robotic voice broke the news to the registered nurse, “Biocontainment unit has activated. Please call.” She rushed back to Omaha.
Ryalls changed from street clothes into special scrubs. She donned personal protective equipment with the help of a colleague: booties tied up to her knee, an isolation gown wrapped around her body from neck to knee, blue hood draped over head and neck, clear face shield, white respiratory mask, three layers of gloves, etc. Then she took her temperature. Ready to go.
Sacra was non-communicative, very ill, severely dehydrated, depleted of electrolytes. Gradually, he improved with a cocktail of experimental drugs and a blood transfusion from a fellow doctor who had recovered from Ebola. “You are with the patient one-on-one for hours and weeks at a time,” Ryalls says. “You are with them so much. You don’t have that with any other nursing job.”
When Sacra regained enough strength, he used a stationary exercise bike (to minimize muscle atrophy) in confinement. He and Ryalls are both avid cyclists. The nurse would sit in the room, wearing full-body biohazard suit, encouraging Sacra’s effort on the bike or just chatting. Ryalls’ dark brown eyes were the only distinguishable features behind her mask and visor. Three weeks later, Ebola cleared from Sacra’s blood. He was released. Ryalls could finally shake Sacra’s hand without layers of gloves. He instantly recognized Ryalls “from my eyes,” she recalls with a laugh.
“I’m now an official lifetime Huskers fan! Go Big Red!” he announced at a celebratory press conference. Sacra also reaffirmed dedication to his medical mission, planning a return to Liberia where he contracted the disease. Recovered Ebola patients are thought to have immunity.
Spirits soared in Omaha. The same day Sacra was discharged, disaster struck Texas. A sick Liberian national named Thomas Eric Duncan reported to a Dallas hospital. Duncan had Ebola. He infected two nurses before dying on October 8. It was the first case of Ebola diagnosed on U.S. soil.
“We felt like we were going really good, and then that happened. There were a lot of questions from the outside, ‘Could that happen here in Omaha?’” says Schwedhelm. She felt “an almost overwhelming responsibility to make sure that every precaution was taken.” She questioned herself, “was every conceivable safety feature in place?” And her answer was always the same. “Yes. The staff was confident, and I was confident,” Schwedhelm says.
After the Dallas story broke in national media, the staff started to feel pressure from the community. One biocontainment nurse’s daughter was disinvited from a birthday party. Another was excluded from a family Thanksgiving dinner. In contrast, others received letters applauding the hospital’s efforts and unconditional support from informed family members. Ryalls told a friend about her job in the hot zone. Before a scheduled meet-up, the friend left her one-year-old baby at home to be extra safe. Ryalls didn’t take it personally. “She was just being cautious. There are pretty scary numbers about the disease in the media.” But at the same time, Ryalls felt assured that strict protocol and safety gear would prevent possible contact with fluid. The virus can only spread via body fluid to mucus membrane contact.
“I think the entire country has stepped up because of all this. Unfortunately for Dallas, they were first in having someone randomly come in, but because of them, I think the country is better prepared at all entry points,” Schwedhelm says.
The next patient, Ashoka Mukpo, arrived in Omaha on October 6. He had contracted Ebola in Liberia. The 33-year-old cameraman for NBC tested Ebola-free 16 days later, adding another victory to the Med Center’s effort. The third patient, Dr. Martin Salia was gravely ill upon arrival. A false negative test in Sierra Leone had delayed his evacuation and treatment. He came off the airplane at Omaha Eppley on a ventilated isolation stretcher.
Up until Salia’s arrival, respiratory therapist Jean Bellinghausen had been helping the biocontainment team with donning and doffing protective gear. Salia’s urgent medical condition necessitated a breathing tube, and Bellinghausen transitioned into the hot zone. The 44-year-old Salia died two days later on November 17. “Deeply saddened would be an understatement,” Bellinghausen says, recalling the mood of the biocontainment unit. “We all felt like it was a great privilege to care for him. In that small window of time he shared his life with us.”
Biocontainment unit staff gathered to hold a memorial to honor the life of the U.S. immigrant who chose to serve his native Sierra Leone during a time of need. He was the chief medical officer and only surgeon at United Methodist Kissy Hospital in Freetown. His wife and two children live in Maryland.
After a lull, activation status resumed in the biocontainment unit. An anonymous medical worker in Sierra Leone had high-risk exposure to Ebola while caring for patients. The patient flew to Omaha for monitoring and requested privacy. No signs of Ebola showed after 21 days in isolation. The patient departed Omaha on January 22.
“Situations are getting better in West Africa all the time: better supplies, better support services, and better control of the environment,” says Schwedhelm. “We have a lot of military support there, but there is still a raging epidemic that we need to control.” While she suspects more Ebola patients could arrive in Omaha, the center is also leading U.S. hospitals to prepare for potential infectious disease outbreaks on American soil. Schwedhelm’s team has hosted four training courses in collaboration with the CDC in late 2014 and early 2015. Medical professionals and administrators traveled to Omaha from nearly 40 health systems nationwide. She says the CDC hopes to establish between 35 and 50 hazardous disease centers across the United States.
“We really weren’t ready, as a country, and that’s frightening,” she says. “If you have a novel virus, then we need more than three places that could care for patients and do it safely.”
Time magazine recognized “The Ebola Fighters” as the 2014 Person of the Year. Likewise, the Omaha World-Herald recognized Nebraska Medicine’s Ebola team as “Midlanders of the Year,” an honor reserved in past years for such luminaries as Husker legend Tom Osborne and then-U.S. Sen. Chuck Hagel.
Schwedhelm and her nurses—though humbled and honored by the distinction—are quick to deflect praise. “Those real heroes and ‘People of the Year’ are on the front lines fighting every day with limited supplies, working in dire circumstances,” she says.
Ebola continues to spread in West Africa. People continue to die. Doctors continue to risk their lives to squash the outbreak. Schwedhelm and Nebraska Medicine will continue doing everything they can to aid the effort until the goal is accomplished.