A single line often inverts meaning once you see what it
answers, so neighbouring messages are always shown.
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March 12, 2015 - There was a considerable misunderstanding involving a situation in Sierra Leone. Cliff Lane is trying to expand the randomized controlled trial of ZMapp versus standard of care in countries in addition to Liberia with the protocol he has already started. As it turns out the commanding general in charge of the British military hospital in Sierra Leone, Brig. Gen. Tim Hodgetts, was under the misimpression regarding the protocol was standard of care to see ZMapp + standard of care versus standard of care alone . And so he said that this trial was unethical and refused to participate in it. The reason why this is important is because an American citizen who works for Partners in Health became infected while working in Sierra Leone. We had made arrangements to air evacuate the patient to the NIH clinical Center as soon as possible. Because the patient was in the British facility, we wanted to start the randomization to one or the other arm of the protocol while the patient was still in Sierra Leone before flying back the United States. Brigadier General Hodgetts stated that he would give ZMapp as a compassionate use but would not participate in the randomized protocol. He felt it was unethical to delay the flight to the USA by giving the person a placebo if in fact the person randomized to placebo limb. We arranged a teleconference with him and I led the teleconference. I explained to the general that there was no placebo and that if the patient randomized to the standard of care alone arm we would not delay the flight and he would immediately come to the United States. If the patient randomized to the ZMapp arm we would give the personZMapp right away and then put him on a plane. When he heard that, he apologized blocking this protocol and we agreed that with the next patient who came through, he would be able to help us by participating in the protocol. However, it was too late for this patient since we had already arranged to put the patient on the plane to come back here to the United States.
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March 13, 2015 - Woke up at 1:45 AM to get to the NIH in time to greet the patient who was being flown in by chartered flight to Dulles Airport to then come to the NIH by He was working fo: Over the past 48 hours in i i has written me several e-mails indicating that he told the patient and the patient's uly that since I was taking care of the patient that he would be getting the best care in the world. The patient arrived rather sick with nausea, vomiting, liver function abnormalities, lactic acidosis, and profound weakness. His condition was deemed to be "serious". He arrived at Dulles Airport at 3:16 AM. He arrived by ground transportation at the NIH at 4:45 AM. We admitted him to the special clinical studies unit (SCSU) and he was randomized into the protocol. As it turned out he was randomized to the supportive therapy and general medical care alone. In other words, he did not get ZMapp. In some respects, this is good since if he was randomized to ZMapp, it is certain that some people would have said that we actually put him on the ZMapp deliberately because he was an American citizen. More later on this patient.
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March 14, 2015 - Today was a very important day in my personal experience with the Ebola Virus Disease. Nothing like on-hands experience. vie was in the hospital, I had the opportunity to put on personal protective equipment (PPE) and mostly observe and certainly not get involved in her direct care. Although she sick, she was not acutely ill and there was little chance of coming into contact with infected bodily fluid. However, the situation with was entirely different; he is one of the sickest people I have ever had experience with. It was a rainy day today, Saturday in Bethesda. I went over to the SCSU and put on the PPE. I went into the room with Anthony Suffredini and Rick Davey together with nurse Megan. It was an entirely different situation. I I had a rectal tube in and was putting out copious diarrhea that he was also leaking around the rectal tube. His urinary catheter was putting out good urine. He had a temperature of 39° ; his blood pressure was okay when he had diffuse maculopapular rash throughout his entire body. He was extremely weak and could barely talk. His liver enzymes were elevated and his lactate level was 2.9. His electrolytes were reasonably good. However his D-dimer was 20, which is about as high as it can get on the scale of measurement. He was thrombocytopenic and went from 140,000 platelets to 70,000 to 50,000 to 30,000. We will hold off platelet transfusions until he either bleeds and/or goes below 20,000. I assisted in all aspects of his care for an hour and 45 min. in the hot zone. This included moving and turning him in order to do an echocardiogram, examining his extremities and listening to him speak as he was coughing directly at us. I did not see any droplets coming out of his mouth as he coughed; however, I remember thinking thank goodness for the PPE. This experience brought into sharp relief for me the reason for the high case fatality of Ebola and why so many HCWs get infected. If were in West Africa, would be dead and Rick, Anthony and I would have gotten infected taking care of him if we did not have the state-of-the-art PPE. After an hour and 45 min. we doffed and waited for his parents. They came with Bible in hand to visit their son. Rick Davey, Cliff Lane, and I spent well over an hour with them explaining the situation and the seriousness of it. We then brought them into the nurse's station where they were able to speak with their son through video link. They could see him but he could not see them. Of note before we brought them into the nurse's station to see him through the video, we mentioned to that we were going to bring them into the room. He got very concerned that he wanted to get cleaned up from the diarrhea that soiled his bed and was over parts of his leg. In addition, his PIC line was bleeding around site and so that needed to be cleaned up. It took the nurses about 45 min. to an hour to get him perfectly clean so that he could feel comfortable talking to his parents even though his parents would not be able to see any of the soiled linen or pajamas from the distance that they were at the video link. It was a very moving conversation between the parents and ended up the conversation by reading a passage from the Old Testament. And then he turned to us in the room and said "what a wonderful country we live in that would put so much effort into the saving the life of one person - our son. There was not a dry eye in the room. I went home that night completely exhausted and went with Christine to Bourbon Steak bar and restaurant at the Four Seasons Hotel in Georgetown to unwind.
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March 15, 2015. Came into work again today which is Sunday. The day has turned into a very bright sunny day with a brisk wind. Again, I went to the SCSU and Rick Davey and I went in together to take care of . Some lab parameters are better and some are worse. The most worrisome of all is his respiratory situation. We have corrected what we believe is over hydration by cutting down on his fluids and giving him a diuretic. However his temperature is still 39 and he is still breathing at 35 to 40 breaths per minute. Of particular concern is the fact that on 2 L/min of nasal oxygen, his oxygen saturation is still only about 88%. Also, on call is Bob Danner from the ICU. Bob increased the nasal oxygen to 4 L/min and we had a discussion about the possibility that we might need to intubate the patient since he will likely soon get soon very tired from breathing at 35 to 40 breaths per minute. Cliff Lane was on a phone conversation with the people from Emory and Nebraska and they mentioned that even when they thought that they had very good control of intake and output of fluids, around day 8 to 10 of illness, patients often had unexplained accelerated respiratory difficulty requiring prolonged intubation. I hope that it does not come to that with however, it is entirely conceivable that it will. I will go over to the SCSU again tonight for a conference with all of the team to make these decisions. Drama tonight in the SCSU. Some change in status. All metabolic numbers, BP and cardiovascular, kidneys etc. were fine and even improving. However, he continued to be tachypneic at 35-38 resp/min. During the day, his OxSats were in the low nineties and he responded first to increasing nasal O2 from 2 to 4L/min. However, as we got into the evening, his OxSats dropped into the high 80s. His resp. rate was 3840. We considered elective intubation at that point, but watched him for another hour to see if he would stabilize. Instead, his OXSats dropped to 78-80 despite increasing the nasal O2. His resp. rate went to 40+. At that point we did an elective intubation performed by Bob Danner of the Clinical Center ICU. It was uneventful and now he is paralyzed with deep sedation and on the respirator. His OxSat is now 99-100% and the machine is set at 15; he is breathing on his own at 20/min. We spoke to our colleagues at Emory and Nebraska who had taken care of Ebola patients in an intensive care setting. They said that this was exactly what they had seen, i.e. a patient seems to be doing well with good numbers and then goes into an ARDS picture. They intubated them and after a variable period of time, the patients (2 in number) recovered. Hopefully, that is what we will see with He went through the night without incident.
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2015-03-16 00:00
Anthony S. Fauci
March 16, 2015 - Spent 2 hours in the SCSU "Hot Zone" with Bob Danner (ICU specialist) and Kwan (ID Fellow). went into renal shutdown likely due to Acute Tubular Necrosis (ATN). We spent the time trying to balance the pushing of fluids with giving Lasix diuretic. Now at 24 hours after intubation, his pulmonary situation is fine. He is on 35% with 5 PEP and his Sats are 95-100%. His BP and cardiovascular function are fine. Labs are all about the same and a little better except for one disturbing trend. His creatinine has gone from 0.8 to 1.0 to 1.3 to 1.6 to 1.9 just 1 hour ago. From 6:00 to 7:00 PM he put out no urine after having put out about 40 cc the prior hour. We pushed fluids and he has only put out about 25 cc/hour over the past 3 hours. Diarrhea is still profuse. We are going to continue to push fluids to see if he opens up. Looks like ATN, which is puzzling since he has always had good perfusion with good BPs. The people at Emory tell us that this is exactly what they saw with their sickest patient, i.e. patient's numbers look good, then unexpected ARDS, the latter corrected by intubation/respirator, then unexplained ATN requiring dialysis, followed by prolonged and slow recovery. Strange disease this Ebola. We will continue to push fluids during the night and then (depending on his creatinine), consider the option of dialysis. Hopefully, we will not have to go there.
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March 17, 2015 - Went to morning report at 8:00 AM. Bob Danner reviewed what happened after I left the Unit last night. Creatinine now up to 2.5. Patient clearly in renal shutdown. Larry Altman gave very nice James C. Hill Memorial Lecture at the Lipsett Auditorium on the Journalistic Hx of AIDS. Decided not to go to the Wilson Center for the Tom Daschle/Bill Frist dinner since renal function continues to deteriorate and I want to go to the "sign off" meeting in the SCSU at 6:30 PM. At SCSU, Creatinine up to 3.3. . I am looking for a silver lining, but the upward trajectory of the creatinine is slightly less than it was yesterday. We may need to dialyze him, but I am hoping that his creatinine stabilizes at 3.7 to 3.9 and then starts to slowly come down without dialysis. Having said that, we will not hesitate to dialyze him. Also, he has some strange neurologic manifestations with an atypical tonic/clonic movements, but no other manifestations of brain or cord disease. There is a whole new chapter of Ebola disease manifestations to be written now that we can keep people alive who otherwise would have died days ago if there were in a Unit in West Africa without the equipment and manpower that we have. Last night there were 6 of us in the room with him. The good news is that his AST is starting to come down and the best news is that his CT value is now 29.96, which means to me that his immune system is starting to control the virus replication. If the downward trend of his virus continues and we can just keep him stable for the next 4 or 5 days, I believe and hope that we can get him through this. Meeting more ICU docs including Parker Ruhl from NHLBI. She is on call tonight and checked with her at 10:00 PM by phone. Also, am doing nightly e-mail reports to Paul Farmer who is in Peru with his daughter Catherine.
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March 19, 2015 - All non-renal numbers going in the right direction. Still in acute renal failure; however, the rise in creatinine is perhaps a bit less "steep" - creatinine 5.9 and BUN 111. We may well have to start dialysis today. Decision to be made mid-day today. His cycle (CT) is now up to 31.5 and so his immune system is certainly clearing the virus. Persistent fever prompting broad antibiotic coverage. Had a scary episode last night. As we were tapering him off heavy sedation it appeared that he was calm and doing well with the taper. However with two nurses in the room and the rest of us (physicians, nurses, WatSans, et al) taking evening report, he abruptly woke up in a delirium flailing his arms and legs despite soft restraints (he is 6'2" and very strong). He pulled out his PIC line and pulled out the tubing to his endotracheal tube. It was a nightmare for the 2 nurses in the room who had to simultaneously press down with a towel on the bleeding PIC line site, bag him through the endotracheal tube, hold him down and try to get Versed into him. We all got up and scrambled to Don but this took (even going at light speed) about 5 minutes leaving the 2 nurses in the room with 5 minutes of terror. Dan Chertow, Rick Davey and Tara Palmore went in and Bob Danner and I manned the nurses station and read the monitor to the people in the room. We decided that it would ne dangerous and non-productive to have everyone in the room. Real scare came when Neil (head nurse on that shift), who was one of the 2 nurses with Kim, doffed, he noticed when he took off his inner glove that his hand was bleeding. As you can imagine, the trauma of the prior 5 minutes and now a bloody hand brought us all, particularly Neil, over the top. Luckily, the blood was his (injured his hand against bed rail when holding down patient) and his gloves were intact. Tara Palmore checked his gloves by filling them with water and there were no leaks. We soon got everything under control and he is now the same as pre-event, only now under heavy sedation, which we would have had to do anyway if we ultimately decide to dialyze him. PIC line was replaced by VAT (Vascular access Team).
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March 20, 2015 - Patient stable this AM. First day of Spring today and we have snow in DC. What a winter - Ugh! Went in again today to go over patient with Dan Chertow. In for about 65 minutes. Making morning (8:00 AM) and evening (6:30 PM) report now every day with the Unit staff.
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March 21, 2015 - Good news. Creatinine stabilized for 3 determinations in a row at around 6 with BUN at around 115. We may get away without having to dialyze. Main problem now is meningoencephalitis. Avi Nath (NINDS- neurologist) helping out with neuron-management. He can only do so by history and video since he is not trained to enter room. We cannot fully evaluate this until we lighten up his sedation, given what happened the other night, we will do this very slowly. We have started low dose heparin now that his platelets are coming up. CT (Cycle threshold) is now 34.5! All we need to do is avoid PEs and bleeding. More later. Now the Norwegians and to some extent the Canadians (much less so) are getting upset with us since we are working with the Guineans via INSERM (Delfraissy/Levy) and the interaction between the Liberians and Guineans to expand the vaccine RCT to Guinea, where there are still cases. The Norwegians are trying to do a "Ring Vaccination" study around cases similar to what was done with smallpox. However, the smallpox situation was using a proven, highly effective vaccine. You do not "test" a vaccine in a ring "study". The Norwegians are concerned that our introduction of an RCT where they are doing a Ring study would be a problem. I can understand what their concern is; however, the elephant in the room is the fact that there study is not a study. It is a "distribution" of an unproven product. This is the same European mentality that just because this is a serious disease, then there is no room for research; just distribute what you have. This same mentality led to Guinea adopting Favipiravir as standard of care based on an open access study that claimed benefit; however, when the data was presented at the CROI meeting, it was clear that there was no indication of efficacy since the outbreak incidence was shifting during the study and historical controls were not valid. God bless Cliff for sticking to his guns about RCT and good science. In this regard, my old friend Tore Godal from Norway e-mailed me with concern about our study since he is one of the Norwegians who are pushing the Ring study. Of note, in their communications, nowhere are there any Guineans. Sounds like the old paternalism.