HL20: Bruce Ribner, MD—Treating Ebola

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Bruce Ribner, MD.

This profile was published in the December, 2014 issue of HealthLeaders magazine.

"We learned how intensive the medical management was both from a physician and a nursing perspective."

Bruce Ribner, MD, an infectious disease specialist at Emory University Hospital in Atlanta, has more than a decade of experience treating or preparing for contagious diseases such as SARS, Marburg virus, and Ebola.

For the most part, he says, the clinical team at the hospital was well prepared for the arrival from West Africa last summer of the first two Ebola patients to be treated on U.S. soil. But even with three days' notice to prepare, and help from advisors at the Centers for Disease Control and Prevention just down the street, there were surprises.

"It sounds funny, but one of the biggest eye-openers we had was waste disposal," Ribner recalls. "We had always planned that anything coming out of a room of a patient infected with the Ebola virus or any viral hemorrhagic fevers was going to be autoclaved before we gave it to our contractor who disposed of our regulated medical waste. We rapidly discovered that the autoclave we had in the unit was grossly inadequate. It was an old laboratory autoclave that looked fine to us, but over the first 24 to 48 hours we started getting more and more garbage cans of infectious waste lining up in the hallway."

Hospital officials wheeled in a larger autoclave, but with that problem solved, another quickly emerged.

"There are a few disconnects between official CDC guidance and realities of life," Ribner says. "For example, CDC says that regulated medical waste is everything that comes out of an area where there are infectious pathogens. Our contractor said, 'We will not take any infectious waste unless you can guarantee there is no Ebola virus in it.' So, again, we couldn't just take the waste and give it to them. We had to make sure it all got autoclaved. We had to track every box of infectious waste because that was required by our contractor."

Once the first two Ebola patients, Kent Brantly, MD, and Nancy Whitebol, were brought into the specially designed Serious Communicable Disease Unit, Ribner and his team quickly learned that the two missionaries would require a tremendous amount of oversight in the several days before their conditions improved.

"We had a nurse in each patient's room continuously for at least the first week and a half. They required an enormous amount of nursing care," Ribner says. "They have diarrhea like patients with cholera have diarrhea. They are putting out four to six liters of stool a day, almost continuously—that plus all of the other blood pressure support and interventions and so on."

Within the first day, the normal 12-hour ICU shifts were reduced to eight hours. "Even with the eight-hour shifts, the nurses needed a one-hour break in the middle of the shift to survive for eight hours. We had to have one of our physicians in the unit because there were always questions coming up about management. We have now decided that whichever physician is on that day, that is absolutely the only thing they are going to be able to do that day. We learned how intensive the medical management was both from a physician and a nursing perspective."

Accessing the isolation unit also proved difficult. "The official guideline from CDC is contact precautions, which means no blood or body fluids from the patient comes into contact with the healthcare provider," Ribner says. "Now, officially, you are supposed to wear a fluid-impervious gown, gloves, shoes, and leg coverings. When you get finished saying all of that, we just found it was much more efficient to use the body suits. The media accused us of overdramatizing everything. It was a practical way for us to meet the requirements, especially when you have patients putting out four to six liters of stool per day and you are trying to prevent stuff on your shoes and legs."

The clinicians weren't prepared for what Ribner called "the tsunami of media." "We thought, 'Meh! We might get a little bit of PR when we bring these two patients back, but it would be like when we brought the guy back with Marburg virus infection about seven years ago.' We couldn't have been more wrong," he says. "There must have had 50 media tents on our campus for the first week that these patients were in the hospital. We called it Ebola village."

While the public interest was warranted, Ribner says the undertone of fear that crept into some of the coverage was not.

"I read a survey that said that 40% of Americans felt there was a good chance we would have an Ebola outbreak in the United States, and the authors of this survey attributed this to the way the media has handled the event," he notes. "I saw that in my emails. I can't tell you how many hundreds of hate emails I got. Things like 'You're going to feel so guilty when people are dropping in the streets of Atlanta from Ebola virus.' 'You've brought the next plague to the United States.' We actually had all of our packages and mail screened in an outside security facility. My understanding is that there were several bomb threats made on campus during that first week. There was a lot of angry citizenry responding to this event." By the time a third Ebola patient was brought to Emory in early September, though, much of the media hoopla had subsided.

Ribner says he has grave concerns about the spread of Ebola across Africa, but virtually no worries about the virus gaining a toehold here. "The potential for spread in the U.S. is close to zero, if not zero," he says. "All you have to do is look at those two MERS patients who came at the beginning of the summer. How many secondary cases do we have? Zero. We are more attuned to hygiene."

With Emory's ready access to some of the most advanced medical resources on the planet, Ribner says he also has a profound respect for the physicians, nurses, and other caregivers in Africa, who are often exposed to great risk of acquiring the virus while "flying blind" with few medical resources available.

"On the other hand, it is not that labor intensive for them because there isn't much they can do," he says. "That is not being derogatory. It's kind of like 80 years ago doctors did house calls because there wasn't much they did for you anyway. I wonder how we would do if we took all of our ICU patients and treated them at home. I don't think we would do a whole lot better than our colleagues in Africa."