AAFP member Kent Brantly, M.D., sat down with AAFP News shortly before his Oct. 24 speech to a packed ballroom during the 2014 AAFP Assembly to discuss family medicine, his experience contracting Ebola and what he thinks needs to happen to control the outbreak that continues to rage in West Africa.
During his speech at the AAFP Assembly on Oct. 24, AAFP member Kent Brantly, M.D., explains that he "moved to Liberia not simply to save lives but also to replace hopelessness with hope."
Q. What originally drew you to family medicine?
A. I knew from the very beginning that my goal was to be a medical missionary and to work in the developing world. I wanted to be able to see any person who needed help regardless of their demographics or disease process. Through exposure to various specialties in medical school rotations, it became very clear to me that family medicine was the best fit for me. The interpersonal relationships, the physician-patient connection and also the breadth of the medical specialty were draws for me. I felt like God was calling me to serve in places that not everyone is willing or able to go. I wanted a tangible skill that I could take with me to give people real help. I saw medicine as a way to serve people and fulfill that calling that I felt in my life.
Q. How would you describe the relationship between family medicine and serving international communities?
A. There are a couple ways that family medicine connects to international service. One is the physician-patient relationship -- the importance of continuity of care in family medicine. If you are going to go serve internationally, if it is going to be sustainable, it has to be out of that interest, concern and compassion for people or you are going to burn out pretty quickly. Some medical specialties are focused on disease processes. Family medicine has that more holistic view of the patient and the family, and that connects with doing international work. The other way I think traditional full-spectrum family medicine is connected to international service is it is what is needed in these underdeveloped places in the world where people are living in poverty with no access to care in countries that have broken or no medical infrastructure. You need a physician who has that breadth of skill and knowledge and can take care of the pregnant woman, as well as the child, the person with tuberculosis and everything else.
Q. The AAFP, along with other family medicine organizations, just launched an initiative to promote the value of primary care and encourage more medical students to choose family medicine. What would you say to a student who was thinking about choosing a career in family medicine?
A. There is the easy answer: This is what real doctors do. Since working in Liberia as a medical missionary, I have fallen in love with family medicine. The chief resident from my program (AAFP member Gregory Bratton, M.D., of Aledo, Texas) when I was a second-year resident (at John Peter Smith Hospital in Fort Worth, Texas) had the honor to be involved in a panel of young leaders from different specialties in the medical field for the New England Journal of Medicine. They went around the room introducing themselves and telling what they did. When it got to be Bratton's turn, he said, "We do it all." Later, another attendee asked him, "What do you mean 'You do it all?'" He responded, "We do pediatrics, internal medicine, obstetrics, run an ICU … " The attendee said, "I thought that was just in the movies … You're a real doctor!"
Brantly receives a standing ovation before and after his speech, during which he described his symptoms during Ebola infection: "I felt like I was on fire. I had the worst headache of my life, difficulty breathing and my fever was approaching 105° F."
So I think if medical students could hear this and see it in person, they'd see that family doctors get to do everything. It's more interesting and it requires a broad and deep fund of knowledge. It's not for the faint of heart. It is a serious medical specialty. It is important to point out, too, that family medicine requires some level of uncertainty. Some people need certainty. In family medicine, you have to have some level of comfort in being able to say, "You know what? I don't know exactly what the problem is in this case, but I know how to treat the patient, and that's what matters."
Q. Can you describe the first time you treated a patient with Ebola infection?
A. There were only two isolation units in all of Monrovia, Liberia -- one at the government hospital and one at our facility, ELWA (Eternal Love Winning Africa) Hospital. June 11, we got a phone call from the Ministry of Health and they said, "We have two patients in a slum in Monrovia who are positive for Ebola." Following a long lull in positive Ebola cases, Liberia had been declared Ebola-free, and the isolation unit at the government hospital had been taken down and all of the equipment put into storage. So we were the only functional isolation unit in the greater Monrovia area of more than 1 million people. We became the first isolation unit to care for Ebola patients in Monrovia. Our shifts in the isolation unit, which were 12 hours, were split day and night, but they ended up being 16- or 18-hour days, usually. It wasn’t like when the next person got there, you could just leave. There was always more to do -- things to tend to in the hospital or patients who needed to be evaluated.
Take Ebola Seriously, Says Disease Survivor
As he wrapped up his speech at the 2014 AAFP Assembly on Oct. 24, Kent Brantly, M.D., urged the family physicians in attendance to speak out against irrational fear about Ebola in the general U.S. population. He suggested educating patients about the reality of this disease, demonstrating calm in the storm, and using physicians' influence in other spheres in society to dispel the myths and help people return to business as usual. "As one responsible reporter put it," Brantly said, "'Unless you have been contacted by a doctor from the CDC to tell you that you may have been in contact with someone who has Ebola, then you have zero risk.'"
Next, he asked the audience to "take Ebola seriously."
"The risk of Ebola showing up at your clinic or your hospital may be statistically small," he said, "but the consequences of being ill-prepared when Ebola does arrive are unacceptable."
Every clinic and hospital in this country needs to have an Ebola preparedness plan, Brantly advised. "They need to be screening patients on their travel history and history of contact," he said. "And every staff member needs to know what to do in the event of a possible case. Health care workers account for a disproportionate number of cases in Ebola outbreaks. These preparedness plans need to be practiced just like a trauma response or a Code Blue. They need to be reviewed and acted out during Ebola drills."
Finally, Brantly called for the audience to act by donating to the nonprofit organizations that are providing front-line aid in West Africa or to volunteer to provide support in person. "The members of this audience are uniquely positioned to help in a very tangible way that not all other people can do," he said. "I challenge you to consider if you might be able to actually go to West Africa and join in this fight. … We must love our neighbors as ourselves, or we find ourselves soon enough in their shoes."
From June 11 until I got sick July 23, we had 16 patients in our isolation unit confirmed with Ebola. Of those 16, only one survived. The survival rate began to improve around the middle of July, but the number of cases skyrocketed. By the end of the week of July 23, we had 30 patients in the isolation unit.
Q. Out of these 12-hour shifts, how much of that time was spent in the personal protective equipment (PPE) suits?
A. Typically, during a 12-hour shift, we would go into the unit two or three times. So usually, we were in the isolation units about six hours a day in PPE. The longest I ever stayed in was about four hours, and it was incredibly hot. When you take off that suit, your scrubs look like you've been standing in the shower for about an hour. Over the scrub suit, I wore a Tyvek suit, rubber boots, an N-95 respirator mask, a Tyvek hood with a collar to cover your neck, which left only your eyes exposed, goggles over your eyes, two pairs of surgical gloves -- or, if you were going to take care of a dead body or clean -- you'd wear one pair of latex gloves and the second pair would be heavy-duty rubber gloves. Then over top of all of that, you wear a heavy rubber apron to cover your front. I read somewhere that it could get up to 120 degrees inside the suit. In Liberia, the temperature is almost always in the mid-80s to mid-90s, but the humidity is almost always 95 percent.
Q. Can you describe when you think you actually contracted the Ebola virus?
A. There was never a time when I knew that I had been exposed. I am very confident that I did not get it working in the isolation unit. Our equipment and our process were incredibly safe, and it was redundant to protect us. I think I got it from a patient in the emergency room. You can't wear that full PPE all the time. It's not practical, safe or beneficial to wear in the emergency room. Also, it scares people. We had a triage process in a special area to try to prevent anyone who might be suspected for Ebola from ever entering the emergency room. But there were multiple occasions where a nurse would call us and say, "There is a patient in the emergency room who I am worried about who might have Ebola."
When I would evaluate that suspicious patient, I would wear PPE, but not the full suit. I would wear a plastic gown, gloves, mask and face shield. I would avoid touching them, as well, while evaluating them and taking their history. But I know that there were times that I could have been exposed during those types of evaluations.
I think I know when it happened. I think it was on the night of July 14. I woke up feeling bad and then spiked a fever on July 23. This fits perfectly with the timing for Ebola. On July 14, I worked all day long, and then I was on OB call and back-up call that evening for the isolation unit. I got home at 7 p.m. that evening, and at 8 p.m., I went back in to check on the team in the isolation unit to make sure they were OK before I tucked in for the night. The doctor who was on call for the hospital called me and said, "I have an OB patient who I am really concerned about. I think she might have Ebola."
We went and evaluated that patient and transferred her to the isolation unit. She was incredibly sick. Medically speaking, she had a 33-week intrauterine fetal demise, eclampsia, and she had severe malaria. Transferring her safely took a few hours. I was about to leave and that doctor came back to me again and said, "I think there is another patient in the emergency room who you need to evaluate." Honestly, that was the patient who I think I contracted the disease from.
I had already been in the emergency room spraying the places that the pregnant patient had been with chlorine solution to decontaminate everything. I had sprayed in the bathroom in the emergency room not knowing that there was a patient in the bed right next to the bathroom who had been getting up every 15 minutes having diarrhea. So I ended up coming back to evaluate that patient.
I still cannot pinpoint any exposure -- like, I stuck myself with a needle -- and I was wearing the basic PPE with the plastic apron. But I also counseled that patient's daughter in the hallway outside the emergency room, explaining that we needed to put her mother in the isolation unit to provide the best care for her. I had taken off my mask and gloves. I am kind of a touchy-feely guy and have a tendency to hold somebody's hand when I am talking with them or put my hand on their shoulder. After working all night, both of those patients died early the next morning. I then went home, took a shower, had a cup of coffee and went back to work for the next day.
Q. And you started to get sick at this point. Can you describe your symptoms and what it was like switching roles from physician to patient?
A. I kind of felt how you feel when you wake up with a cold -- a little warm and not feeling right. I had been working in the worst Ebola outbreak in history for six or seven weeks. So I knew if I wasn't feeling well, the right thing to do was to isolate myself until I knew what was happening. I called the team leader and said I was feeling ill and was going to stay home to do administrative work that day. My wife and two children had flown back to America the weekend before because my wife's brother was getting married. I was supposed to join them nine days later. I am incredibly thankful that this happened. I don't know what I would have done if I would have woken up feeling bad with my family lying next to me in bed.
I could speak during my infection with Ebola. But my memory of much of that time in Liberia is foggy now. After that Wednesday afternoon, I didn't have the strength to get out of bed. I was incontinent of stool, having diarrhea in an adult diaper.
I'm sure there were times during that week that I felt afraid, but I don't remember it except for that Thursday night when I couldn't breathe and I thought I was about to die of respiratory failure. I remember very clearly saying to the nurse standing beside me while being treated for Ebola, "I can't breathe. I am sick. I have no reserve. I don't know how much longer I can keep this up." I was working really hard to breathe. I said, "I don't know how you are going to breathe for me when I quit breathing." (There were no ventilators available.) (Elwa Hospital) had only had one Ebola survivor up to that point and he had never been really sick. So everyone I had ever seen with symptoms like I was exhibiting had died.
Q. You were the first person to be given the experimental drug ZMapp for the treatment of Ebola. Can you explain your experience with the drug?
A. There wasn't very much of it because it was still in the early stages of development. They hadn't yet published the findings from the first monkey trials for this drug. So it had never been tested for safety on a human. It was there; it was available; I was willing to be the lab rat.
The drug arrived at the Monrovia hospital on the following Wednesday. It was frozen solid, so they had to thaw it out before using it. It was a four-hour IV infusion. That morning when they told me the drug had arrived, I felt like I had turned a corner and was feeling a little better, so I said they should give it to Nancy (Writebol, nursing assistant with Brantly who also contracted Ebola). But that night, my condition started deteriorating. By Thursday evening, I was on death's door.
The doctors came that night to evaluate me and saw that I was so sick that they thought I was going to die in a matter of hours. They said, "Kent, we want to give you the antibodies." I had a conversation with one of the doctors that I don't remember, but he has since told me that he said, "Look Kent, there are three doses. If we give you one dose, you're being evacuated tomorrow. You'll be in Atlanta to get your second and third doses. That will leave Nancy with two doses, and by the time it's time for her third dose, she will also be in Atlanta. There is no reason to not try it." So I said OK.
I had a pretty traumatic response when they started giving it to me, but over a matter of a couple hours, my symptoms improved, my condition stabilized and my strength started improving.
Q. What needs to happen in West Africa to gain control of the Ebola outbreak?
A. Everything the president and the government committed to do in mid-September is great, and that is mainly what needs to happen. But it has been more than a month, and it hasn't happened yet. Four thousand U.S. troops were committed (to support efforts in West Africa), but there are currently around 600 on the ground. The government also committed to build a 25-bed critical-care hospital in Monrovia to treat infected health care workers and 17 100-bed isolation units. They haven't built a single isolation unit yet, and that 25-bed hospital still is not functional, and it has been more than a month. Part of my plea to Congress was the immediacy of these needs. The experts are saying that the cases (of Ebola in West Africa) are doubling every two to four weeks. We haven't acted quickly enough.
Another need is for health care workers to go to West Africa and treat Ebola patients on two levels. One, as these new isolation units get set up, if you don't have staff to care for the patients there, it's just a place to go and die. Every 100-bed isolation unit requires at least 200 staff to run it 24 hours a day, seven days a week.
The Liberian medical community has stepped up in huge ways, as well, to try to fight this outbreak. Estimates said that before the Ebola outbreak, there were 50 Liberian doctors in the country of 4 million people. There are additional expatriate doctors like me there, as well. The point is that the Liberian medical community has done a lot, but there are not enough of them alone. They need people to come work alongside them to boost their numbers and strength. Experts are now saying that 19,000 doctors, nurses and paramedics will be needed in West Africa by December to help fight the outbreak.
Q. What is your plan now, moving forward?
A. My wife and I plan to use this new platform that we have been given with Samaritan's Purse (the missionary group with which Brantly works) to help people in West Africa. I moved to Liberia to quietly serve people in need. But hopefully, now I can have an impact that will help thousands of people throughout West Africa.