May-June 2015 | Health

How Bethesda’s NIH Prepared for Its First Ebola Patient, Nina Pham

The behind-the-scenes story

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“To some degree, we had to be agile, and to be able to make real-time decisions and judgments,” Cohen says. “At some point, we could only gird ourselves for what was coming.”

AROUND 11 P.M. ON OCT. 16, the team of NIH workers that would be welcoming Pham gathered in the common area of the SCSU to wait. The television was tuned to CNN. “We could see which exit the ambulance was passing on 270, so we could tell when it was time to go downstairs and get in our suits,” Palmore says. “It was surreal. The CNN helicopter feed is usually not part of our work flow.”

Cohen watched the same footage from the office of the director of the Clinical Center. “I’m a communications professional, and I have a tremendous regard for the media,” Cohen says. “But personally, I was just praying that the patient’s comfort was not being hindered by the frenzy of it all.”

When the ambulance reached Rockville, the team walked downstairs to meet its patient. A quiet, eerie scene unfolded as the ambulance approached the Clinical Center’s west ambulance entrance around midnight. Though satellite trucks were stationed nearby at the NIH Metro stop’s Kiss and Ride lot, the campus itself was nearly silent.

Lee recalls seeing Dr. Richard Davey, a deputy clinical director at the National Institute of Allergy and Infectious Disease Division of Clinical Research; Dr. John Gallin, director of the NIH Clinical Center; and Fauci watching and waiting from 50 feet away, in white coats but without PPE.

Lee watched as two doctors, two nurses and two EMTs, all in full protective gear, wheeled a stretcher that appeared to be covered by a huge plastic bag. Inside, there was a small figure wearing a mask.

“That scene is seared in my brain,” Lee says. “There was a feeling of knowing we’ve done all we can do to prepare.” Palmore and several nurses from the SCSU greeted Pham warmly and walked alongside the stretcher. “The thing I remember the most is that everyone was cheerful and upbeat,” Palmore says. “It was long past all of our bedtimes, but we were all just excited that we had this patient, and excited that we were going to be able to take care of her.”


Pham, surrounded by family members and NIH staff, is all smiles during an Oct. 24 press conference announcing that she was free of the Ebola virus. Photo by Bill Branson

The work of containing the virus began immediately. Phillips had staffed every door and elevator along Pham’s path with operations and maintenance personnel, and in some cases, NIH police officers. She had nearly a dozen mechanics standing by in the event of an elevator malfunction.

Once Pham and the team started moving, Phillips made a radio call to freeze all other staff members along the route in place. “I kept asking myself, along the route, what can break? What can stop them from moving along?” Phillips says.

In less than 10 minutes, Pham was in her room in the SCSU.

Few front-line SCSU employees went home that night. Palmore helped the NIH firefighters who had driven Pham’s ambulance take off their PPE, helped disinfect the stretcher, and watched the first shift of nurses start providing care.

When things settled down at around 4 a.m., Palmore tried unsuccessfully to sleep in her office. She decided to stay up and keep working.

Meanwhile, Cohen checked into a room at the Hyatt in downtown Bethesda to catch a couple hours of sleep on his own dime before a 6:30 a.m. all-hands meeting that he and his staff were helping to organize. Cohen says the last email of the night came in at 2:30 a.m., and the first of the morning arrived at 4 a.m.

“I remember very vividly pulling up to the Hyatt and seeing a long line of TV trucks that had just been at the hospital waiting to check into the hotel,” Cohen says. Though he and the reporters didn’t talk shop in the hotel lobby, he says seeing them underscored the work ahead for the communications staff. He knew that there would be dozens of satellite trucks lined up in front of the Clinical Center in the morning, poised to provide live updates at regular intervals throughout the day.

Before falling asleep, Cohen texted his team members to ask if they could come in early for the 6:30 a.m. meeting. “I thought, ‘I wouldn’t blame anyone if they wanted to pretend not to see my text,’ ” Cohen says. “Instead, the replies I got were, ‘Why don’t I come even earlier? Maybe I can be helpful.’ ”

At first glance, the room in which Pham was treated is unremarkable: a hospital bed, cabinets for equipment, and monitors for patient vitals. It’s the mostly unseen details—the elaborate airflow system that prevents air from escaping the patient’s room, the epoxy paint that’s especially easy to disinfect—that set it apart.

Ann Marie Matlock, the Clinical Center’s nursing department service chief for  medical surgical specialties, had overhauled the nursing schedule to account for the intensive care an Ebola patient would need. Two nurses in full PPE had to be in the room with the patient at all times. One nurse provided care, while the other watched for breaches in protocol. Phillips and her staff added windows to each door to allow nurses who weren’t in full PPE to observe from outside, ready to fetch gear or handle other requests from the nurses in the room. A closed-circuit video camera enabled staff at the nursing station to observe the patient, too.

“The number of hours someone can be in gear is two,” Matlock says. “We had to set up the nurse staffing plan accordingly.” Each eight- to 12-hour shift, therefore, required four nurses. Matlock says she scheduled a rotation of 20 to 25 nurses per week, with 80 to 100 more trained to step in if a second patient arrived.  

All the nurses who work in the SCSU have experience in intensive care or infectious disease. When the SCSU is not treating a patient, the nurses work in other parts of the Clinical Center. According to NIH staff, not a single SCSU nurse shied away from caring for Pham.

Nurses began their shifts by donning protective gear in the hallway of the SCSU under the direction of a person called a WatSan, which is short for “water and sanitation.” The WatSan narrates each step of putting on and taking off protective gear, which includes a helmet-like head covering that provides ventilation for the caretaker, who is wearing a cumbersome face mask and hood.

“You literally have a person standing in front of you when you put your garb on and take it off, and you do not move until the WatSan tells you to move,” Lee says. “The WatSan tells you to put on your right bootie, then your left bootie, and so on.”

When the nurses’ shifts were over and they were ready to leave Pham’s room, they took off the outer layer of their protective gear, including shoe covers, their second pair of gloves and their impermeable gowns—all under direct observation of another nurse. Then they walked into an anteroom—a sort of middle ground to prevent contamination—to remove the rest of their gear under the watchful eyes of a WatSan before entering the hallway.

Though health care privacy laws prevent NIH employees from disclosing information about Pham’s care, Ebola patients generally are treated for symptoms. They receive intravenous fluids to hydrate and balance electrolytes, their oxygen status and blood pressure are monitored carefully, and they are treated for other infections should they occur.

This February, Pham told The Dallas Morning News that she also received four experimental treatments: plasma from Ebola survivor Dr. Kent Brantly; TKM-Ebola, which blocks the virus’ genes from making copies; brincidofovir, which stops the virus from making copies of itself by blocking enzymes used in replication; and ZMapp, three antibodies that neutralize Ebola. It is not clear whether she received these treatments at the NIH or in Texas.

While Pham was being cared for, Phillips, like Lee, tried to imagine every possible worst-case scenario in order to prepare for it. “Our bad day would be water—if a fire sprinkler goes off, or if a pipe above the SCSU bursts,” Phillips says.