A single line often inverts meaning once you see what it
answers, so neighbouring messages are always shown.
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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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2015-03-21 00:00
Anthony S. Fauci
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.
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March 22, 2015 (Sunday)- Spent all of the day at NIH and hours in the SCSU in with patient and doing AM and PM rounds. Danny Jaswal was the ICU attending and Tuan was the ID person. Avi Nath did neuro exam and actually wwent into the room after getting trained in PPE
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March 23, 2015 - . I have some good news. His renal function continues to improve with a creatinine today of 3.6. He is in the polyuric phase of ATN with a urine output after stopping Lasix over the past 24 hours of >100 cc/hr. His LFTs have normalized. His cardiopulmonary function is good. On neuro exam today, his boardlike stiff neck can now bend by 45 degrees and his sustained clonus is now down to 5 beats. We had our ophthalmologist (Rachel Bishop) examine him today with a neat gadget hooked onto a cell phone, which together with a hand lens gave us a good look at his retina. Good news is that he has no papilledema and no evidence of clinically significant uveitis. Tomorrow morning we will attempt to stop his ketamine and fentanyl and gradually taper off his propofol. If he wakes up without being combative and is stable for a period of time, we will consider pulling his endotracheal tube. His CT is 37 and so he is almost cleared of virus from his blood. Fingers crossed. magazine as one of the world's 50 it for voting "100 of the world's most Paul Farmer called my cell phone as I was getting ready to do today and I gave him a summary of progress. Having "political issues" with the Norwegians getting upset that Cliff and I want to extend our RCT vaccine trial to Guinea since they are doing the ring vaccination there. See my comments above.
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March 24, 2015 - Same political issues regarding the potential NIH RCT in Guinea. Kai Kupferschmidt from Nature wanting to do a story about "rivalry among scientists. Like the Peter Duesberg situation decades ago, they are "equating" us with Marie-Paul Kieny of WHO. I cannot say to Kai, but Marie-Paul is an idiot. Had long 3-way conversation over the phone: Kai who just flew in from berlin for the Filovirus Meeting in DC tomorrow is connected from his hotel here in DC; Cliff from his home and me from my home (10:00 PM). We try to explain to Kai that we are not trying to interfere with the "Ring" trial; we just want to get the correct answer for the good of all of West Africa. He keeps pushing that they started off with Guinea and now that Liberia has few/no infections, we want to go to Guinea and "ruin" their study. Nonsense. You can do 2 studies simultaneously in as large a country as Guinea. Besides, ring vaccination is not a study; it is vaccine distribution of an unproven vaccine.
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March 25, 2015 - Good news at SCSU: We extubated uneventfully! Went in to see him and he is emotionally very grateful for what our team did for him. Paul Farmer came up from Haiti to visit as well as the other PIH personnel (contacts to who are "nested" in the Maryland area for observation in case they develop sxs. Organ system function markedly improving. Creatinine 1.4!! Still some muscle weakness. Will leave urinary catheter in tonight and keep him NPO since his voice is very weak and his trachea is irritated. CT is 39+; however, his CT of his trachea aspirate is 26. Could there be sequestration of virus in tracheal secretions or is this just accumulation of dead virus Kai (above) is still agitating with questions to Cliff about our upsetting the Norwegian study. Met with Morgan Fairchild in my office today at 3:30 PM to discuss what NIAID could do for Chronic Fatigue Syndrome, now re-named Severe Exertion Intolerance Disease (SEID). Will give talk tomorrow at the Filovirus Meeting in DC and so will miss Harold Varmus's last IC Director meeting. Said goodbye to him and Connie today. I will miss him greatly.