EXPOSED

EXPOSED

After an accidental needle stab, a doctor's Ebola watch begins

Published on November 3, 2014

A few days after he accidentally stuck himself with a needle in an Ebola ward in Sierra Leone, Lewis Rubinson’s temperature topped 103 degrees.

The fever swept in with a headache, muscle pain and nausea. And, soon after he arrived for care at the National Institutes of Health in Bethesda, it brought on the bone-shaking shivers doctors call rigors.

His fever was unlikely to be caused by Ebola, Rubinson told himself – and for much of the time in the isolation unit he had only himself to tell these things to. He didn’t have the rash he had seen pocking the torsos of Ebola patients. Nor did he have another ominous sign: blood in the whites of his eyes. Still, whenever he felt well enough to climb out of bed and go to the bathroom, he would peer in the mirror to check.

Dr. Rubinson: The exposure

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An accidental needlestick left Dr. Lewis Rubinson in fear of Ebola. (Gabe Silverman/The Washington Post)

There was no way he had Ebola, a doctor friend insisted over the phone. The timing was wrong; the temperature had come on too soon; his feverish shaking was probably his response to an experimental drug he had taken.

But Rubinson, who is director of the critical care resuscitation unit at the University of Maryland’s Shock Trauma Center, had just spent three weeks working for the World Health Organization at the Kenema Government Hospital, and he knew that a fever was usually the first signal that a person harboring the deadly virus has become infectious. Now, he thought, the moonsuited doctors and nurses looking after him seemed surprised by how sick he was. The needle had provided the virus with an ideal route to invade his body. And if that needle hadn’t infected him, Rubinson found himself wondering, could he have had an earlier exposure that he hadn’t even known about?

Because when your temperature is that high, your brain starts to play games with you. And the truth is, nobody knew for sure: Was he a doc with a feverish reaction to a new drug, or was he an Ebola patient?

 

In Kenema, 90 minutes to two hours was about all the time the clinicians could tolerate in the Ebola ward in the full heat of their protective gear. Rubinson was working quickly, squeezing clear plastic IV bottles to force fluids faster into ailing bodies, when he spotted the needle. It was in a bottle hanging above a young woman’s bed. He pulled it out, disconcerted that somebody still hadn’t learned how dangerous it was to leave a needle like that. He then walked maybe 50 paces across the ward to throw it out. The sharps container was full. As he repositioned the needle in his hand, the tip jabbed into his flesh, and he felt blood oozing under the two layers of white surgical gloves.

Sheer stupidity – and a little embarrassing to make that mistake one day before he hoped to wrap up his team’s mission in Sierra Leone’s third-most-populous city. And he couldn’t ignore a pang of anxiety.

Rubinson rinsed his gloved hands quickly under a chlorine spigot and asked his fellow doctor to take over. He left the ward to peel back his layers of protective clothing under a targeted spray of bleach solution according to the highly choreographed, 15-minute routine he had followed so many times before: outer gloves, apron, folding it soiled side inward, then hood. Spatter, spatter, spatter. Coveralls, mask, goggles. More bleach spatter. And finally his undergloves.

Once his hands were free, Rubinson could see blood covering his left thumb and some of his palm. He was sure his gloves were contaminated; and he could now tell that the needle had gone in deep. Not good.

He walked 350 yards across the hospital grounds to a makeshift office to call the WHO risk strategists in Geneva. He talked for 25 seconds, and the call dropped. Tried again. Maybe 15 seconds this time. He could pick out every third word. He circled, listening for the cellular sweet spot. It must have taken an hour and a half to explain what had happened.

Finally, a decision became clear: He should evacuate.

It was the only thing to do. It would be hard to get him out if he got sick. That was the irony: Africans who were sick couldn’t get out, but an American doctor who had pricked himself with a needle could get out after a series of half-heard phone calls.

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It was Friday, Sept. 26. The incubation period for Ebola is two to 21 days. Symptoms typically occur eight to 10 days after infection.

In Sierra Leone, WHO reported 2,021 confirmed, suspected and probable Ebola cases and 605 deaths in the current outbreak.

In Texas, the first person who would be diagnosed with Ebola in America, Thomas Eric Duncan, was staying at his fiancee’s apartment, having been discharged from the ER with antibiotics.

Dr. Rubinson: Journey into fear

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Rubinson was quickly evacuated from Sierra Leone. (Gabe Silverman/The Washington Post)

Rubinson knew before he left for West Africa that the Kenema Government Hospital had become ground zero for health-care workers’ infections. Nearly 30 had been infected, many had died, and few people were willing to take their place in the ward. The team working there had done a phenomenal job, Rubinson thought, but the doctor he replaced, another expat, had developed the disease and been evacuated.

So when Rubinson arrived on Sept. 10 to lead a team of not quite 10 WHO clinicians in coordination with local staffers, he found a hospital famous for its research on another viral hemorrhagic fever – Lassa – straining under the burden of Ebola.

The dilemmas they faced were stupefying.

If he and his fellow doctor focused immediately on saving the 20 or 30 people who were most sick, what about the other 80 or 90, including some, he believed, who weren’t infected with Ebola but were stuck there among the sick and the dying?

The team had little information about who was in the ward among the confirmed cases, suspects and confirmed convalescing. If you asked just basic questions (“What’s your name?” “How long have you been here?” “How long have you had symptoms?”), giving each patient two minutes, you would soon exhaust a two-hour stint without having provided any care.

And how to even record the information? You couldn’t bring electronics into the dilapidated one-story building, with its unreliable electricity and no WiFi. And you couldn’t take pieces of paper out of the ward for fear they would carry the virus.

The team came up with a system: Write the data on paper; then, when you leave, just before the sprayer begins disinfecting (“Show me your hands”; “Spread your fingers”; “Turn over your hands”; “Put your arms out”), somebody meets you with a camera phone and takes a picture of the paper with all its crucial data.

So many problems to be figured out, and when you are doing that, you’re not treating patients.

Then what about the stream of sick people outside the hospital who needed help? If the team let in more patients than the ward could accommodate, the whole treatment process would break down. You had to say no to people when you knew there was nowhere else for them to go.

And when so many people are dying, how far do you put yourself into harm’s way to care for them? Were health-care workers’ lives more important? From an operational point that made sense. But it felt weird – and weirder still as his costly lapse of attention propelled him toward some of the most sophisticated health care in the world.

Following call after dropped call, an evacuation plan emerged: Rubinson would travel that afternoon with a WHO driver to Freetown, Sierre Leone’s capital, where Rubinson would stay until colleagues at the Centers for Disease Control and Prevention in Atlanta could arrange for an experimental drug to be flown out to him. He would fly back to Washington on the same plane.

The drug had never been used on a human being during an Ebola outbreak. It belonged to a small group of new therapies aimed at preventing someone who has been exposed to the virus from falling sick. None is known to work. None had passed the rigorous process of randomized clinical trials required for Food and Drug Administration approval.

Collecting data about a drug’s efficacy is notoriously difficult when a new disease emerges or an old one suddenly starts to spread. The real world is not “CSI”; scientific investigation moves at a far slower pace than infection. So new therapies are often pressed into use without anybody learning whether they actually work. Rubinson had seen that happen during the SARS epidemic in the early 2000s. And he had helped lead the U.S. government’s effort to gather useful information during the swine flu outbreak of 2009 when the FDA authorized emergency use of the experimental antiviral Peramivir for some hospitalized patients; 1,200 people were given the drug, but not in a way that provided conclusive data about its efficacy and safety.

So the decision to take an experimental drug was an easy one for Rubinson. What happened to him would be data for the clinical trial. This was his life’s work – he had a PhD in clinical investigation. The difference this time was that he’d be experiencing it from the other end of the stethoscope, from inside the test tube.

He settled up at the Kenema guesthouse, then took 30 minutes to go through the dispiriting process of air-hug goodbyes – staying three feet from colleagues who had been through so much with him for three weeks.

That evening, the WHO driver delivered him, bearded and now in jeans, to Freetown to await the plane. The hotel where he spent the night – this time, he chose the best in town – turned out to be where many senior members of the international Ebola response were staying. It had showers, air-conditioning, WiFi. He found fresh fruit. A disco. People were dancing.

Touching.

Rubinson was less than 200 miles from Kenema but already a world away. In Kenema, “no touch” was the mantra. Your pen was your pen. Your phone was your phone. You shared nothing.

 

He was symptom-free for almost the entire 12-hour flight to Frederick, in the privately owned jet under contract with the State Department and operated by three pilots and two nurses. It was equipped with an isolation unit he had no need for. But about 10 minutes before the Gulfstream GIII eased in to land in suburban Maryland, Rubinson started to feel flu-like and unsettled. That was just when doctors suspected the drug would kick in. He climbed into protective gear – with the slightly queasy awareness that it was now a means for others to safeguard themselves against him, just in case. And as soon as the plane stopped rolling, he was swept off to NIH at breakneck speeds in an ambulance.

From inside the hermetically sealed bag of an isolation stretcher, he still felt well enough to be entertained by the surreal spectacle unfolding through the back window: Two police cars and a fire chase vehicle were tailing them, lights flashing, sirens screaming. He had no idea what was up front, leading the procession.

Or what this whole effort might cost. No telling how many tens of thousands of dollars.

He had just seen people, babies, die in Africa without having even a handful of cash spent on them.

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On Sunday, Sept. 28, Rubinson was admitted to NIH at 4 p.m.

In Texas, Duncan returned to the ER by ambulance, was admitted and placed in isolation. Two days later, the CDC announced he had tested positive for Ebola.

NIH’s seven-bed Special Clinical Studies Unit opened four years ago to replace the “Slammer” (so named because of the sound made by the door closing behind patients), which the U.S. Army Medical Research Institute of Infectious Diseases used to operate. Only a couple of the beds in the new unit – which was designed for research as well as for isolating patients – can accommodate the specific clinical needs of people with Ebola.

That’s where Rubinson was hit with gut-churning nausea and spiking temperatures unmitigated by medication; as part of the clinical trial he had agreed to give researchers as pure a record as possible of his body’s reaction to the experimental drug.

A plastic tube called a picc line ran from a vein in his arm to a bigger vein just above his heart, providing a daily source of blood for researchers to monitor his body function, his immune system’s response to the drug, and whether he had Ebola. Four times a day, nurses appeared in their otherworldly outfits to take his vitals, rotating through to gain experience treating the first patient on the unit with possible Ebola.

His body quaking and head hammering, Rubinson lay freezing under a pile of blankets in the isolation unit, which was kept at a steady 66 degrees.

After two days the fever fell; two more days and it was gone.

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 On Oct. 1, Rubinson was five days into the 21-day incubation period.

In Sierra Leone, WHO reported 2,304 cases and 622 deaths.

In Texas, authorities began tracing Duncan’s contacts, and four people living in the apartment where he had stayed were put into home quarantine.

The drop in Rubinson’s temperature brought a drop in anxiety: The fever was clearly caused by the drug, not the disease.

But the country’s anxiety was mounting.

On TV in his room, Rubinson watched talking heads who hadn’t been to West Africa holding forth about Ebola. During his three weeks in Kenema he had seen more patients than all responders had seen in any single previous outbreak.

One so-called authority praised the possibilities for novel therapeutics – expensive new drugs that might one day change the face of an Ebola epidemic. And all Rubinson could think of was how little financial interest there was in providing the most basic of care for Africans in the current outbreak. In Kenema, health-care workers were using antiquated IV equipment.

The TV experts reiterated that U.S. hospitals were prepared to care for patients with Ebola. How could they be? Rubinson thought. All 6,000 or so hospitals? Yes, every hospital should be able to identify a patient and keep staff safe. But he knew that the specialized knowledge and equipment, as well as the costs of extensive care, exceeded the capabilities of most U.S. hospitals. The how-to-stay-safe practices he had learned in Africa from doctors who had years of experience with Ebola would surpass anything even large, high-quality U.S. hospitals could rapidly implement. For patient care, it would make more sense to focus on regional planning than to expect every hospital to be able to do everything.

He didn’t think that people were reassured by oversimplified messages.

We need better strategies, he believed, informed by sound science and boots-on-the-ground experience. That’s the role of public health.

 

Isolation is not the same as being alone, Rubinson found as days went by.

He couldn’t see the nurses’ station, but the nurses could keep a video eye on him 24/7. He would look through a window to an anteroom, where staffers scrubbed down surfaces with bleach. The nurses would come in two at a time, dressed in even more elaborate gear than Rubinson had worn in Kenema. Two nurses for one patient in a suite of his own. In Kenema, two doctors looked after more than 100 patients.

He grew used to their disembodied voices over the intercom.

“Have you decided what you want for lunch?”

“Are you okay with the smell of bleach?” Of course – he’d been bathing in it for weeks.

He began rethinking the rules for life in isolation, preferring the nurses to use the intercom than to phone in. The phone, he had decided, was for talking with friends and colleagues outside or to join conference calls about Ebola.

But why stay here when he was no longer sick? Isolation in a hospital is for sick people; quarantine is for people who have no symptoms but could be incubating a disease.

Highly trained ICU and infectious disease nurses who had looked after him so skillfully when he was sick were now having to accommodate the needs of a healthy person. A handwritten sign, “Do not flush the toilet,” was taped to its lid reminding him that his waste was being decontaminated with virucides.

If it weren’t for the lack of control, he decided, it wouldn’t have been so bad. His room – 12 by 18 feet – was about the size of the studio he had lived in during medical school in Chicago. It had a bed and a chair and an armoire. He had been provided an iPad in a special bleachable cover. The TV screen on the wall doubled as a computer screen, and he could type with the keyboard in his lap.

Perhaps it was survivor’s guilt, but he was impatient to be back in the game. In West Africa, the number of people who had the disease was almost doubling every three weeks; in America, worries about Ebola were heightening. The knowledge base was changing so rapidly that policy risked being driven by outdated thinking and fear, rather than by science. There he was, with a career’s worth of expertise in clinical systems and disaster response and first-hand experience of this outbreak, sitting fever-free in an isolation unit, dressed in a hospital gown.

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On Friday, Oct. 3, one week after the needle stick, Rubinson was feeling fit and healthy.

In Sierra Leone, WHO reported 2,437 cases and 623 deaths.

In Texas, Duncan was still in the hospital; by the weekend, he was listed in critical condition.

Five days after his recovery from the impact of the experimental drug, with tests showing that Rubinson didn’t have Ebola and never had had Ebola, a friend picked him up from the isolation unit at NIH. They drove 45 miles through sharp fall light from Bethesda to Rubinson’s Tudor-style Baltimore house, where he began 10 days of mandatory quarantine.

The world learned that Rubinson had left NIH from the bald prose of a news release: “Earlier today the patient who was flown back to the United States from Sierra Leone and admitted to the NIH Clinical Center on September 28 for observation, following a high-risk exposure to Ebola virus infection, was discharged to his home.”

At Rubinson’s request, there was no mention of his name.

 

On Wednesday, Oct. 8, Rubinson woke up in his own bed in Baltimore for the first time in a month.

In Sierra Leone, WHO reported 2,789 cases and 879 deaths.

In Texas, Thomas Eric Duncan died.

 

The state health department home-quarantine rules were stringent, and Rubinson was careful to comply.

Four people were allowed to visit and bring him food.

Twice a day, at 9 a.m. and 5 p.m., a doctor called and ran through the same checklist of symptoms: Did Rubinson have a temperature, headache, abdominal pain, nausea, vomiting, diarrhea, unexplained hemorrhage … ?

No, no, no and no …

No symptoms, no risk to others.

Lewis Rubinson is an ICU doctor at University of Maryland Shock Trauma who was exposed to Ebola while working for the WHO in Sierra Leone. He was quarantined at the NIH for three weeks and was recently released with a clean bill of health. (Andre Chung for The Washington Post)

Rubinson worked on response strategies, participating in conference calls and monitoring the relentless progress of the disease. He felt saddened but was unsurprised to learn that two Dallas nurses had been infected from treating Thomas Duncan, the only person to be diagnosed with Ebola in America. One patient, two health-care worker illnesses. That confirmed his concerns about U.S. preparedness and infection-control practices: If every patient in Africa infected two or more health-care workers, every health-care worker there would be dead.

He saw how the virus was gaining a hold in Africa, just as fears of it were gaining hold in the United States. That’s why, for 21 days, the doctor who never had Ebola kept the story of his exposure largely to himself. Better to wait until he could take an active role using science to help combat the disease on the ground – and in people’s heads.

 

On Friday, Oct. 17, Lewis Rubinson’s incubation period ended.

In Sierra Leone, WHO reported 3,410 cases and 1,200 deaths, after having described the disease transmission as “rampant.”

About 40 percent of those cases were reported in the previous 21 days.

In Bethesda, Nina Pham, the first person known to have contracted the virus in the United States, began her initial day of care at NIH after being transferred from Dallas late the night before. One of the two Texas nurses who became infected, Pham was the first Ebola patient to be treated in the Special Clinical Studies Unit where Rubinson had stayed.

Dr. Rubinson: 'We didn’t come back to hide what we did'

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Complicated feelings, including shame, followed Rubinson's return from treating patients in Sierra Leone, where he was exposed to Ebola. (Gabe Silverman/The Washington Post)

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