Midlanders of the Year:
The Nebraska Ebola Team

22 nurses, 10 lab workers, 6 respiratory therapists, 5 care techs and dozens of physicians

Sunday, December 28, 2014


‘The whole world was watching’

A wave of anxiety hit Dr. Daniel Johnson as he walked toward the Ebola patient’s room.

Johnson needed to place a tube in the patient’s neck to allow caregivers to draw blood and administer medicine, nutrition and fluids.

As procedures go, Johnson said, this one has a higher risk than most for the physician because of the potential for exposure to the patient’s blood. With the often-deadly Ebola virus, less than a teaspoon of blood can contain enough viral particles to infect millions of people.

By that day in early September, 240 health care workers in West Africa had contracted Ebola. More than half of those had died. The patient Johnson was going to see, Dr. Rick Sacra, had himself been infected while performing cesarean sections in a Liberian hospital.

Johnson stopped. He thought about his wife and their two children, ages 3 and 2.

Then, choking up, he recalled: “I thought about what our military personnel are asked to do on a daily basis. They are put into much more frightening situations than what I was walking into. So I took a deep breath, I reminded myself that I was extremely well trained for the procedure that I was about to go do. ... I said two prayers, took another deep breath and I walked in.

“Once I actually made eye contact with the patient and saw that this is a human being who needed my help, I was fine.”

Johnson, a critical care physician and anesthesiologist, is a member of the team of 22 nurses, 10 lab workers, six respiratory therapists, five care techs and several dozen physicians who treated three Ebola patients in the Nebraska Medical Center’s biocontainment unit.

The team, along with hundreds of other people from the midtown hospital and its academic partner, the University of Nebraska Medical Center, contributed to the effort. Others not on the campus, including public health officials and public safety crews, also pitched in.

For the dedication and effort shown by the people who risked their own health to restore the health of others, The World-Herald honors the Ebola fighters as the 2014 Midlanders of the Year.

CONTENTS

  • 'Looking at us for guidance'
  • Staff anxiety
  • 'No longer a drill'
  • Experimental drugs
  • Treating patients
  • One goal
  • Meet the team
  • Ebola timeline
  • Past winners


  • SHARE THIS STORY



    Main photo, above

    Erica Elder, a nurse on the team that has cared for Nebraska Medical Center's Ebola patients, is photographed in the personal protective equipment worn in the biocontainment unit. An image of the Ebola virus is projected behind. Photo by Kent Sievers / The World-Herald


    Dr. Martin Salia, who contracted the Ebola virus while treating patients in Freetown, Sierra Leone, arrives at Eppley Airfield on Nov. 15. (Photo by Brendan Sullivan / The World-Herald)


    Hospitals and public were ‘looking at us for guidance’

    The eyes of the nation were on the Nebraska Medical Center during the treatment of the three Ebola patients, in September, October and November.

    A service that tracks references to the hospital in the print and broadcast media tallied a potential audience of nearly 895 million from Sept. 4 through Nov. 25.

    The scrutiny of what was happening with the Ebola patients and their care was “withering – the media interest and the public interest,” said Dr. Phil Smith, the biocontainment unit’s medical director.

    Hospital spokesman Taylor Wilson said he received hundreds of calls and emails per day from news media outlets around the country while the patients were here.

    “We obviously treat a lot of sick patients in the hospital,” said Dr. Angela Hewlett, associate medical director of the unit. “But I’ve never had somebody with pneumonia in the hospital where there were reporters camped out outside. It’s just different.”

    Peter Iwen, director of the Nebraska Public Health Laboratory, said people were “looking at us for guidance as to how this is being done. ... And I don’t want to be the scientist that does bad science.”

    Dr. Jim Sullivan, a critical care physician and anesthesiologist, said “the biggest stress I had was the fact that I knew the whole world was watching. And I didn’t want to be the guy who screwed up.

    “I’m comfortable taking care of crazy-sick people, because that’s what we do. I don’t have several million people wondering what’s going on every day.”

    Angela Hewlett, MD, Associate Medical Director Nebraska Biocontainment Unit


    Reaction to patients’ arrivals in Omaha included pride, disbelief and hostility

    The first two patients brought to Omaha, Sacra and freelance journalist Ashoka Mukpo, recovered. The third, Dr. Martin Salia, died about 36 hours after he arrived extremely ill on an air ambulance from Sierra Leone.

    The three patients were among the 19,000 people, mostly in West Africa, who have been infected with the Ebola virus during the current outbreak, which is the largest in the history of the disease. Of that total, more than 7,300 have died. (Health care worker deaths have risen to 365.)

    After they became ill, the three were flown thousands of miles to Nebraska and a 4,000-square-foot, five-room unit in the hospital’s University Tower that once held pediatric transplant patients but now is specially equipped to contain the spread of disease.

    The reactions of area residents to the Ebola patients’ arrivals have ranged from pride to disbelief to hostility.

    An information line set up by the Douglas County Health Department fielded 131 calls over 2 1/2 months, with questions ranging from “When will the patient be released?” to “Will smoking marijuana prevent me from getting Ebola?”

    In a letter to The World-Herald’s Public Pulse page in early September, an Omahan wrote, “We should be honored and proud that the Med Center was selected to care for this patient.”

    In October, another Pulse contributor offered, “We don’t fly terrorists with bombs on their backs into this country. So why on Earth are we flying carriers of the Ebola virus here?”

    The public didn’t know much about Ebola, but people knew it could kill you, and they feared an outbreak close to home.

    Ebola is a highly infectious disease, meaning that it takes only a few viral particles to infect someone.

    Ebola is spread through direct contact with the blood or body fluids of a person who is sick with the infection. You get it if it enters your body through broken skin or mucous membranes in, for example, the eyes, nose or mouth.

    Each caregiver in the unit dons a face shield, a mask, three pairs of gloves and other protective gear before entering the patient room. Their used gear is cleaned by high-pressure steam before it’s hauled away and incinerated.

    Many on the care team had trained and planned for years before the first Ebola patient entered the unit. Others got less time to prepare but leaned on their medical backgrounds and their colleagues.

    An ambulance transports Dr. Rick Sacra from Offutt Air Force Base to the medical center before dawn on Sept. 5. Medical missionary Sacra, who contracted Ebola while performing cesarean sections in Liberia, was Omaha’s first Ebola patient. (Photo by Ryan Soderlin / The World-Herald)


    Worries led some to lose weight

    Because the slightest error in removing soiled protective gear could expose the wearer to the Ebola virus, the biocontainment team sets aside the traditional hierarchy of a hospital setting.

    Respiratory therapist Frank Freihaut once spotted Smith grabbing the front of his mask after Smith had left the patient room. Protocol, Freihaut said, dictates that you grab the back of the mask to remove it, because the back, which faces away from the patient, is less likely to have virus on it than the front is.

    “I said ‘Stop, stop, stop, stop. Change gloves,’ ” Freihaut recalled. “He said ‘Oh, thanks for catching that.’ That’s what we do.

    “We try to keep an eye on each other. You don’t feel like somebody’s telling you you did something wrong, it’s ‘Hey, thanks for having my back.’ ”

    Donning the personal protective equipment that people must wear in the patient room is a passive process for the physician, Johnson said. “The nurses who do it day in and day out do it to you. Because they do it perfectly. To suggest that you’re going to come there intermittently and you’re going to do it well is foolish.”

    The risky nature of the work weighed on the team’s leaders.

    Hewlett lost almost 10 pounds during Sacra’s first week. Smith lost 15 pounds over the three weeks of Sacra’s treatment.

    “I wake up (during the night) and I just think about the people,” Smith said. “It’s like being a parent with 50 children. All one of them has to do is make one mistake. So it drains, that part of it. You worry more about the group you’re responsible for than yourself.”

    Shelly Schwedhelm, the unit’s emergency preparedness and infection prevention director, said she trusted the team – made up of “clinical expert, kind of rock-star folks” – and the unit’s often-refined procedures and protocols.

    Still, she said, “It’s a daunting responsibility to know that your team is in a position where every certain thing needs to come together perfectly and work exactly as designed.”

    Frank Freihaut: “We try to keep an eye on each other. You don’t feel like somebody’s telling you you did something wrong ...”


    Erin and Dr. Jim Sullivan at home, flanked by their nine children, from left: Peter (red shirt), 10; Maggie, 9; Kathleen, 15; Seamus (on Erin’s lap), 2; Brigid (flowered dress), 5; Joseph, 8; Thomas, 13; Anne, 16; and John, 18. The Sullivans are expecting their 10th child in May. (Photo by Matt Miller / The World-Herald)


    A nurse's daughter disinvited to birthday party

    The opposition by some area residents to treating an Ebola patient in Omaha was shared by some of the treatment team’s family members.

    In early September, Sullivan called his wife, Erin, from a medical conference in Arizona to tell her an Ebola patient was coming to the Nebraska Medical Center. Sullivan would be helping to treat him.

    “I was not happy,” Erin Sullivan said. “My initial reaction was being very scared. I had read a book called ‘The Hot Zone’ 20 years ago, and the Ebola virus has always stuck with me, always petrified me. So, yeah, I was upset. I was just, like, at first, ‘Jim, you can’t do this. You can’t do it.’ ”

    The Sullivans have nine children, ages 18 to 2, and another one due in May. Erin home-schools them.

    “My fear was the kids, mostly,” she said. “What’s going to happen to them or us if Jim gets sick?”

    LuAnn Larson’s mother didn’t find out that Larson, a researcher and nurse, was treating Ebola patients until after the third Ebola patient was on the air ambulance to Omaha.

    Larson told her mother, who was coming to Omaha from Norfolk to see a performance by the Radio City Music Hall Rockettes, that she couldn’t accompany her to the show because she had to work that night. “That was a mistake,” Larson said. Her mother knows she normally doesn’t work nights. “That other Ebola patient is coming in to the med center,” her mother said. “They’re all getting research drugs. Are you ...?”

    “Well, you put two and two together right,” Larson answered. A flurry of questions and concerns followed. “I finally just said ‘I’m not afraid, so you shouldn’t be afraid.’ ”

    To varying degrees, Smith said, family members “express the fear that they have. Is something going to happen to a spouse? A parent? It’s normal.”

    Hewlett said she sat down with her daughters, ages 9 and 6, and told them, “ ‘There’s a sick person coming and he really needs our help and I’m going to be at the hospital a lot taking care of him.’ That’s what Mommy does for a living, and they understood that.”

    Vicki Herrera, who works in the public health lab and processed the patients’ blood samples, said her family and friends know what she does for a living and how protected she is. “There’s definitely lots of anxiety, and part of that just comes from people not understanding,” she said. “That’s kind of with anything – if you don’t understand it, you fear it.”

    She explained to her kids, ages 11, 8 and 5, about the virus and that she would be working long hours for a while. “The 5-year-old was the one that missed me if I wasn’t right at home in time to pick her up from day care, but they were fine.” Her husband, Jon, a teacher and assistant football coach at Wahoo High School, ended up with “double duty some days. He had football and he had all the parenting and all the house.”

    People weren’t always supportive. The young daughter of one of the biocontainment nurses was disinvited to a birthday party, said Kate Boulter, the unit’s lead nurse, and another nurse was told by her family not to come to their Thanksgiving meal.

    A friend of Boulter’s told her that she wanted to go to lunch sometime, but not until after Boulter had cleared the 21-day incubation period for the virus. Boulter also was asked to speak at an event, but only if she could do so via Skype.

    “There were people who have been disinvited to dinner parties or visitation of friends and relatives ... that has happened to almost everybody,” Smith said. “I would venture to say that every member of the team, their family has paid the price. They worry about them or maybe they’ve gotten a comment or two. Not much happens. But a little bit happens to people and it makes their lives therefore difficult.”

    And then there were those who were enthusiastic backers of their parents’ work. Smith said his three adult sons encouraged him: “They’d say ‘This is your biggest professional challenge you’ve ever had. You’ve got to go for it.’ ”

    Dr. Diana Florescu, an infectious disease physician and researcher, said her 17-year-old daughter, who wants to be a physician, “was so thrilled with all this. She wanted to come to the unit and help. ‘I can come! I know how to gown, dress up! I can do something.’ I said ‘No, you can’t.’ ”

    Florescu’s husband, Dr. Marius Florescu, a nephrologist, also wanted to contribute. He would ask his wife about the patients’ kidney function to see if he was needed. He ended up working with the last patient, who was in kidney failure when he arrived.

    “How many people had the chance to do dialysis with an Ebola patient?” Diana Florescu said. “If we don’t study and we don’t learn here, we cannot apply it to other patients here or in Africa.”

    The Sullivans decided not to tell their kids about Dad’s Ebola duty. “The three older ones figured it out pretty quick,” Jim Sullivan said. “The rest of the squirrels didn’t figure it out at all for the first (patient). Then when we were getting the second patient, then everybody knew about Ebola.

    “Thomas, who’s 13, he figured it out and he ratted me out to the little ones, and they were not happy,” Sullivan said. Sullivan found the couple’s 10-year-old son, Peter – “our cerebral one; he thinks about everything” – crying in a corner at home. “I’m, like, ‘What’s wrong?’ ‘You’re gonna get it, you’re gonna die.’ I’m, like, ‘We’re wired tight, everything’s fine.’ ”

    Erin Sullivan had met Hewlett through a YMCA soccer team their daughters played on together. She said it occurred to her that Hewlett also would be taking care of the patient, “and she has two kids. Her kids aren’t any less precious than mine are.”

    And then she thought about the other members of the treatment team. She asked herself, “Who am I to think that my husband shouldn’t put himself at risk when so many other people are, too? I can’t do that. That’s not right. He’s good at what he does. He can’t back out and say ‘I have kids.’ So do a lot of other people.”

    Jim Sullivan reads to Seamus. Wife Erin was concerned about the possibility of Ebola exposure, and several of the children were upset.


    A space originally intended to be one of five patient rooms on the “dirty” side of the biocontainment unit now serves as a point-of-care lab, left, to help doctors monitor a patient’s vital signs.


    ‘This is no longer a drill,’ staff told

    When the $1 million biocontainment unit opened in 2005, funded by federal, state and hospital money, team leaders worried about a bioterrorism attack – possibly a release of smallpox in an airport. As time went on, the team, which drilled at least quarterly, focused on naturally occurring outbreaks such as SARS, Avian influenza and Ebola.

    “Each year,” Smith said, “we would take a different pathogen and practice the different gowns and masks and whatever was appropriate for that (infectious) agent.”

    On Aug. 1, a day before the first U.S. Ebola patient arrived at Atlanta’s Emory University Hospital, representatives from the U.S. State Department inspected what’s formally called the Nebraska Biocontainment Patient Care Unit to make sure the staff could handle an Ebola patient.

    “After that, we sort of knew,” Smith said. “So we sat down with our leadership, and said to everybody around the table, ‘Are you ready? Is your area ready?’ They said they were ready to go. We talked to our staff: ‘This is no longer a drill. This is not a drill.’ ”

    The years of training and research allowed the Nebraska group to avoid problems that arose elsewhere with Ebola patients. But the plan wasn’t perfect.

    “We had holes,” said Iwen, director of the public health lab, which analyzes the patients’ blood samples. “You don’t know what it’s like until you actually do it. I suspect that (if) another patient shows up, things are going to change as well.”

    Smith said: “You can never really simulate what it’s like to have a real, live patient in your bed.”

    At CDC behest, team trains 100 hospital leaders from across the U.S. on proper Ebola treatment

    The med center’s plan proved workable and comprehensive enough to help shape the Ebola treatment guidelines of the U.S. Centers for Disease Control and Prevention. The hospital and UNMC prepared two free Ebola education courses, one for clinicians and one for the public, and put them online.

    After a fast-tracked review, the American Journal of Clinical Pathology published a paper Iwen and his colleagues submitted about the safe testing of Ebola samples. It normally takes months to go through the peer review process, but the Nebraska team had requests for the list of tests from labs across the country. The information was available electronically in about 10 days.

    The U.S. Departments of Defense and Health and Human Services sought unit leaders’ help with caregiver training and clinical and basic research. Team members have advised hundreds of health officials from around the country and the world about what to do if a patient with Ebola shows up in their emergency room.

    Earlier this month, at the request of the CDC, Omaha team members hosted 100 leaders from big-name U.S. hospitals for two-day courses on treating Ebola patients. More such seminars are scheduled at the med center and at Emory University Hospital, where most of the Ebola patients have been treated in the United States. (Patients also have been successfully treated at the National Institutes of Health in Maryland and Bellevue Hospital in New York.)

    The number of calls and emails fielded by the biocontainment unit team leaders picked up significantly in October after the Ebola diagnosis and, later, death of a Liberian man in Dallas who initially was sent home. Two nurses at the hospital who treated Thomas Eric Duncan later tested positive for the Ebola virus. Both nurses recovered.

    “A lot of the U.S. communities shifted and saw ‘OK, we have active transmission of Ebola in the U.S., so this is getting real,’ ” said John Lowe, a decontamination expert and researcher who serves on the eight-member biocontainment unit leadership team. “They started really quickly developing and enacting policy” and wanted guidance.

    Nebraska biocontainment patient care unit

    Located on the seventh floo or the Nebraska Medical Center's University Tower, the 4,100-square-foot facility was commissioned by the U.S. Centers for Disease Control and Prevention and opened in 2005. The "dirty side" on the map is where patients are treated and gear is considered contaminated. The "clean side" is where the uncontaminated gear and staff are.



    Dr. Phil Smith: “You can never really simulate what it’s like to have a real, live patient in your bed,” the unit’s medical director said.


    In this photo – taken by Sacra’s wife, Debbie – Sacra models a Husker T-shirt that was given to him by Dr. Angela Hewlett so he could cheer on the home team in its Sept. 20 game against Miami. The doctor proved a good-luck charm as the Huskers won, 41-31.


    Experimental drugs got speedy OK

    Setting up a biocontainment unit and learning to use the necessary personal protective equipment is one thing. Treating an Ebola patient is another.

    No drugs have been approved to treat Ebola. The standard of care is to replace the fluids and electrolytes Ebola patients lose with all the vomiting and diarrhea they experience. The hope is that this will give the body’s own immune system time to develop antibodies against the virus.

    The first two American Ebola patients at Emory, Dr. Kent Brantly and Nancy Writebol, were treated with an experimental drug, ZMapp. Only a small amount had been manufactured, and there was none left for Sacra.

    Before and during the treatment of Sacra, doctors in Omaha consulted with doctors at Emory. Hewlett also talked with the doctor in Africa who had treated Sacra before he was flown to Nebraska.

    Biocontainment unit leaders enlisted Dr. Chris Kratochvil, UNMC’s associate vice chancellor for clinical research, to help research and obtain experimental drugs for all three of the Nebraska Ebola patients. In emergency cases, the U.S. Food and Drug Administration can allow doctors to use drugs that haven’t gone through the normal approval process, which usually takes years.

    For Sacra, Kratochvil worked with the drug maker Tekmira to secure the drug TKM-Ebola. It had been tested on healthy volunteers, Kratochvil said, but not Ebola patients. After the FDA’s OK, the company provided the drug and, after he signed an agreement not to release information, shared its research with Kratochvil.

    Sacra’s doctors also got emergency FDA approval to give Sacra what’s called convalescent serum, or plasma from an Ebola survivor. The thinking is that antibodies in the survivor’s blood will help boost the Ebola patient’s immune response.

    “Even though it’s been used in a lot of different viral diseases,” Kratochvil said, “there’s not a lot of robust data, or a lot of robust experimentation, to show it works. It may be just the fact that it has proteins in it, it may be the fact that it’s helping to give them fluid.”

    Brantly, a friend of Sacra’s, donated plasma for him. Brantly later also donated to Mukpo and Dallas nurses Nina Pham and Amber Vinson.

    UNMC’s institutional review board held emergency meetings to sign off on the plasma and the drugs the patients received. The board reviewed the risks, benefits and other treatment options, and made sure the consent forms adequately laid out what might happen to the patients.

    Doctors were planning to put a central catheter in Sacra’s arm, but he was so dehydrated when he arrived that his veins would collapse. So Johnson inserted the line in his neck, Sullivan said.

    Sacra’s condition left him delirious for his first few days in the unit, he said. “He was on drugs for delirium that can affect your heart, he was on anti-nausea drugs that can affect your heart,” Sullivan said.

    Sacra remembers being “in and out. I certainly had periods where I was kind of out of it or confused.”

    Sacra’s low potassium level, Sullivan said, was especially concerning. Potassium, he said, plays an important role in the functioning of the heart and lungs.

    “Potassium relaxes things,” he said. “So it allows the heart to relax. ... If you have too much potassium, it will just stop the heart. ... If you don’t have enough potassium, (the heart) gets really irritable and it can go into bad arrhythmias and things like that. It affects breathing, because if you can’t relax the diaphragm, you can’t breathe.”

    Ebola patients’ potassium levels are “crazy low,” Sullivan said, “just because everything passes out of them” from vomiting and diarrhea.

    He never had seen a case like Sacra’s. “Never seen anything like this at all, that he could be so screwed up and still alive. His electrolytes were so messed up it took days to get him back. Usually it takes a day.”

    The lack of information about the best way to treat Ebola patients was an interesting challenge, but also scary, Sullivan said.

    “You give me some sick old patient with a dead gallbladder who’s septic as hell, yeah, I can fix that. I know exactly what I’m doing,” he said. “I have no idea exactly what I’m doing (with Ebola). I know what I want to do. How am I going to replace this guy’s potassium safely? I have no idea.

    “So we’re going to try a little. OK, that didn’t do anything. We’re going to try more. That didn’t do anything. ... You know, it was the guesswork that I didn’t like. That bothered me.”

    Even though they watched Sacra and Mukpo recover, doctors say they still don’t know what works on Ebola patients – the intensive supportive care, the experimental drugs, the convalescent plasma or some combination of those.

    But Sullivan thinks the drugs and plasma helped. “I think it did something,” he said. Sacra’s “viral load started coming down. Fluids don’t knock your viral load down.”

    Critical care, in general, is supporting the body while the body heals itself, he said. “I think we supported it, but I think those drugs and I think the plasma fixed it.”

    A well-protected nurse Bridget Boeckman plays chess against Dr. Rick Sacra in the biocontainment unit as the Ebola patient continued to improve.

    People stayed late, returned to work to get lab work done

    Iwen, the lab director, said critical care physicians are used to ordering lab work on patients at any time of the day or night. But because of the hazardous nature of Ebola-infected body fluids, samples couldn’t be sent to the hospital’s core lab and had to go to the biosafety level 3 public health lab. Iwen said his staff of six couldn’t run a lab 24/7.

    “Within days,” he said, “we sat down and said ‘Oh, we gotta figure this stuff out, folks.’ ”

    Before their first patient arrived, Smith and Hewlett, who are infectious disease physicians, had met with Iwen and his staff to discuss what lab tests would need to be run. After Sacra came, Iwen said, all soon realized that the critical care physicians had to be more involved in the day-to-day care.

    “Critical medicine had never talked to us before,” he said. “Then all of a sudden they wanted (lab tests) we didn’t even talk about.”

    The group came up with a list of tests that could be performed safely and drew up a testing schedule that wouldn’t require the lab to be staffed around the clock.

    “People were staying late, and they were coming back” to run tests, Sullivan said. “Kudos to the lab guys.”

    But the long turnaround time for obtaining lab results continued to be a problem, delaying adjustments in Sacra’s fluid and electrolyte levels.

    Before the rubber-topped test tubes could be taken to the public health lab, which is about a half-block from the hospital, they were wiped down twice with bleach wipes and put into small plastic bags that were heat-sealed. The bags then were run through a dunk tank filled with a chemical solution.

    Then the bags were put inside a hard-sided container that was placed inside another hard-sided container. Two technicians or a technician and a security guard transported the samples to the lab, where someone would run the tests.

    “We were doing the best we could,” Iwen said, “but we could only do it so fast to get stuff back and forth. We said ‘We’re gonna have to get the lab up here in the unit.’ ”

    Two of the five rooms in the unit already had been converted into “dirty” and “clean” storage – “dirty” for used equipment and gear that had not yet been sterilized, “clean” for equipment, such as a ventilator, that might be needed in a hurry.

    The lab was set up in one of the other three patient rooms. The move reduced the number of patients who potentially could be treated in the unit at one time, but it also reduced the turnaround time by about an hour.

    Peter Iwen: The lab director soon realized that one patient room should be converted for lab test use, to get results more quickly.


    Shawn Gibbs and John Lowe make sure the biocontainment unit – including the ambulance used to bring a patient to it – is free of contaminants, but they have to do their work wearing heavy, cumbersome and very hot personal protection equipment.


    Even with AC, ‘Ebola land’ is hot

    Once a nurse gets into the personal protective equipment and enters the Ebola patient room, she or he usually is in the gear for three hours.

    “Two was a little too short,” said Erica Elder, a former ICU nurse who took care of Sacra and Mukpo. “Once you kind of got to four, it’s too much: ‘I’m done.’ ”

    The gear consists of a surgical gown, a surgical cap, a face shield, a mask called an N95 respirator, three pairs of gloves and boot covers over a set of surgical scrubs and Crocs shoes.

    The gear protects the wearer, but even in an air-conditioned room, Elder said, it can get hot fast. Especially, she said, “when you’re up doing things when they’re sick and throwing up and you’re cleaning up or you’re helping bathe or whatever.”

    “Oh, God, yeah, it’s really hot,” Larson said. Sacra, she said, “looked over at me one day and he goes ‘Are you hot?’ I said ‘Yeah.’ He’s, like, ‘Just think if it was 100 degrees now.’ ”

    He was referring to the health care workers in West Africa who wear such gear in outdoor treatment centers.

    And if your nose starts running while in the gear? “You let it drip down your face,” Elder said, “and you wait till you get out to take a shower.”

    Freihaut, the respiratory therapist, kept his glasses down on his nose so he still would be able to see even if the glasses fogged up. He ran the glasses through a bucket of bleach water when he left the patient room.

    Whatever was touched got the bleach treatment. Boulter, the unit’s lead nurse, said that whenever nurses did anything in the patient room – hand the patient his water cup or do a patient assessment – they would remove their outer gloves, wipe the inner gloves with a bleach wipe, then don new outer gloves.

    Unlike most of the team, Larson, who was enlisted at the last minute, had minimal training in the unit. She said she knew Ebola isn’t airborne, but the vomit spray concerned her. “I had a lot of questions that I was asking the nurse that was in there with me, because she had been one that had trained.”

    The decontamination team, Lowe and colleague Shawn Gibbs, and Smith, the unit’s director, had decided before the first patient arrived that human waste would sit in a hospital disinfectant for 10 minutes before it was flushed.

    The CDC had said untreated waste would be safe in the sewer, but the group anticipated concerns. “You can imagine what the first person who has to respond to a backing-up toilet somewhere else in the hospital thinks about it,” Lowe said.

    Lowe and Gibbs took more than a dozen calls about liquid waste the first day Sacra was on campus, and they still get calls about it. “It’s now best practice,” Lowe said. “Every biocontainment unit that’s treated an Ebola patient has adopted that pretreating.”

    Nebraska Medical Center patient care technician Derek McCroy participates in one of the many drills held in the biocontainment unit.

    Without use of housekeeping staff, unit's nurses kept everything in patient’s room mopped and disinfected

    A typical day in what Sullivan called “Ebola land” started with the shift change. Schwedhelm would come in at 6:30 a.m. and sit in on the huddle with the departing night shift and the arriving day shift. They would discuss “what worked well with the care of the patient,” Schwedhelm said, “and what we need to adjust.” All team members were emailed a report, and it also was printed out and posted on a wall.

    Boulter would arrive at midmorning and stay until 7 p.m., when the night shift came on and the day shift left.

    The unit would get cleaned every night, Elder said.

    “So everything in his room, we’d bleach. You’d get kind of sweaty doing that, because you’re wiping everything down with bleach and then mopping. ... We’d wipe down the outside of the shower and the walls and the bathroom, wiped down the bed, the controls on the bed, the leads that went to the patient.

    “Anything we touched a lot – any tabletops we touched a lot, door frames, the slide-in tables, our computer monitors and keyboards and mouse, any hand sanitizer (dispensers) – we’d wipe down.”

    The bleach smell didn’t hang around too long, she said, because of the unit’s air-handling system, which exchanges the room’s air more than 15 times per hour.

    Sacra noticed the nurses’ hard work.

    “It was not easy being a nurse in that unit because there wasn’t any other staff,” he said. “No housekeeping staff. None of the support people. They were doing all their own. They were mopping the room every day and cleaning the bathroom, dealing with all the trash. The nursing staff had to do everything.”

    A computer monitor equipped with a video camera stayed on all day and night in the room.

    The bleach has left some keys on the black keyboard spotted with white.

    Physicians who didn’t need to be in the room could communicate with the patient or the nurses via video, as could the patients’ families and friends. A nurse at the front desk could watch what was happening in the room at all times. If the patient was asleep, nurses in the room could communicate with the front desk via instant messaging.

    For Salia, who was on a ventilator, the camera would allow physicians to check ventilator readings and make suggestions to the respiratory therapist in the room.

    “Unless we were up with the patient, we kind of left (the monitor) faced toward us, the nurse who was sitting there in the room with the patient,” Elder said. “If we got up, we tried to turn the camera to where someone could see us treating the patient and they could talk to us while we’re doing things. Just (for) that extra set of eyes constantly making sure that we kept ourselves safe.”

    Before they stepped out of the room, caregivers would wipe their hands with a bleach wipe and wipe the door handle.

    Once outside, they would stand on a doffing pad and remove the protective gear in a 22-step process overseen by a “doffing partner,” who was waiting outside the room, also wearing the full protective gear.

    The doffing partner watches and helps the person remove the gear in the proper sequence. The used gear, which is dropped onto the pad, is scooped up and placed into an autoclave bag. The bag then is taken down the hall to an autoclave, which sterilizes the gear using high-pressure steam. After the disposable gear is sterilized, it’s taken out of the autoclave’s “clean” side, put into a hard-sided container and hauled away to be incinerated.

    “Any time we came out of the room and showered out,” Elder said, “we would try to take at least a 15-minute break to have a snack and hydrate.” The refrigerator in the biocontainment unit’s break room is stocked with Gatorade and water.

    Nurses usually worked in the patient room for two three-hour periods during their 12-hour shifts, Elder said. In between, nurses would “work the clean side of the autoclave, help restock in our areas. Whatever we needed.”

    Shelly Schwedhelm: At shift change, they would all discuss “what worked well ... and what we need to adjust,” she said.


    Patient No. 2, Ashoka Mukpo, gets a farewell hug from Morgan Shradar, a biocontainment unit nurse, upon his release from the facility on Oct. 22. (Photo by Nebraska Medical Center)


    Variety of skill sets, but single goal

    Team members say the group functioned with surprisingly little angst in a stress- and adrenaline-filled environment.

    Smith said leaders avoided recruiting “a hothead, a quick reactor. We want people who are team players and willing to improvise if necessary, but we also need people who are not afraid to look out for each other.”

    Researcher Kratochvil said: “I can’t think of a single time that I heard anybody even raise their voice. I think everyone was very cool. They knew what they had to do and they did it and they worked together as a team.”

    Not all the biocontainment unit nurses come from the intensive care unit, Boulter said. “We have a labor and delivery nurse, (operating room) staff. I’m a med-surg nurse. When we come to work here, we know each other’s skills and we teach and we share our knowledge with each other. ... “They all add something way different to the care of the patient.”

    Using nurses from different departments in the hospital also keeps any one department from being too hard-hit when the unit is activated.

    The nurses worked well together, and their skills were complementary, Larson said.

    “An ER nurse charts much differently than an ICU nurse: ‘How do you fill this in? Where do you find the level of consciousness on here? Where is all this stuff?’ So they taught each other. And nobody put anybody down for not knowing it.” It was “ ‘I have a skill. Let me share it with you.’ It was kind of fun to watch.”

    Elder said the nurses “all just picked up each other’s slack. If anything needed to be done, we just did it. It wasn’t ‘Well, that’s your job’ kind of thing. It was everybody’s job. We were here to do one job and make sure it’s done properly and that none of us gets sick in the process. It was very nice. Because you don’t always get that.”

    Team saddened by Dr. Salia — the one who couldn’t be saved

    The fact that the first two patients recovered “just made it all the harder when Dr. Salia came in so sick,” Freihaut said.

    “I don’t think anybody said it out loud,” he said, “but we all saw it in each other’s eyes: ‘This is going to be tough, if anything.’ The way he was breathing.”

    Salia, a surgeon working in Sierra Leone, had begun to feel ill in early November, but his first blood test was negative for Ebola. Results of Ebola tests taken early in the course of the illness often come back negative, experts say, because there’s not yet enough virus in the bloodstream to register.

    Salia’s symptoms worsened. He had a high fever and diarrhea and vomited uncontrollably. He tested positive for Ebola on Nov. 10, was flown back to the United States on Nov. 14 and arrived at the hospital on the afternoon of Nov. 15.

    Doctors say he was on Day 13 of the Ebola infection.

    The false negative test “is probably what defined his outcome,” Sullivan said. “If we got him four days before, it may have been different.”

    After seeing the first set of lab results on Salia, Johnson said, “our first reaction was that we hoped there was lab error. That’s how bad the lab (results) were. ... We re-sent labs, and they all came back exactly the same.”

    Dr. Andre Kalil, an infectious disease doctor who treated Salia, said the staff’s job “was to really do 110 percent that needs to be done, simply because we don’t know when is the point of no return for Ebola disease.”

    Boulter said the staff “put our heart and souls” into Salia’s treatment. Nurses and hospital officials talked often with Salia’s wife, Isatu, who had flown in from Maryland, where the family lives.

    Johnson said full critical care services – including dialysis, mechanical ventilation, advanced vascular access, multiple drugs to try to increase the blood pressure, artificial nutrition in the IV – were initiated “as fast as any ICU could do it outside of a biocontainment unit.”

    “I feel very confident,” he said, “that we gave him every chance to survive because of our efforts.”

    Johnson called Salia a “living saint.”

    “He lived the example of the ultimate physician and ultimate Christian,” Johnson said. “He purposely sought out the poorest of the poor and the sickest of the sick and he used his talents and gifts to the best of his ability to heal them. So the loss that I felt when he died was compounded by the fact that this physician was an incredibly important part of West Africa.”

    After Salia died, the staff held a memorial service. Team members talked about the loss and how their co-workers had helped them try to help Salia. “You don’t get to do that a lot at work and thank each other for being there when it really sucked,” Freihaut said.

    Hewlett said: “It’s always hard to lose a patient, it doesn’t matter what the circumstances are. But I think that this was especially hard on our team because we really gave him our all. ... Sometimes we just can’t change the outcome.”

    Kalil said it was a privilege to treat Salia. “The thought that came to my mind is ‘This is an incredible man.’ Because what he taught us here, even at the end of his life, is invaluable. What we learned treating him and doing what we had to do is something that unquestionably will help us to treat the next patient.”

    The benefits won’t be limited to the fight against Ebola, Kalil said. “Once we learn more about Ebola, we’re going to make progress with other diseases.”

    Johnson expects to see the Ebola epidemic beaten. “I think the lessons that we learned in our hospital, at Emory, at the NIH, can be publicized and used to help fight it in Africa, and also to help the rest of the world know what to do for this disease.”

    Contact the writer: 402-444-1109, bob.glissmann@owh.com, twitter.com/bobglissmann

    Biocontainment unit pioneers

    Dr. Rick Sacra, 52

    » family physician and medical missionary with North Carolina-based Christian ministry SIM

    » contracted the Ebola virus in late August in Monrovia, Liberia, while performing cesarean sections

    » released Sept. 25 after three weeks of treatment in Nebraska; plans to return to Monrovia on Jan. 15

    » he and wife, Debbie, have three sons, the youngest a high school senior; family lives in Holden, Massachusetts


    Ashoka Mukpo, 33

    » freelance cameraman and writer who had just started working with NBC News in Liberia

    » says he probably touched a contaminated surface, possibly while cleaning a vehicle

    » was treated Oct. 6-22 in the biocontainment unit

    » returned to Providence, Rhode Island, home of his parents, Dr. Mitchell Levy and Diana Mukpo


    Dr. Martin Salia, 44

    » surgeon working in his native Sierra Leone

    » permanent U.S. resident who had been working as chief medical officer and surgeon at Kissy United Methodist Hospital in Freetown

    » Salia died Nov. 17, 36 hours after being flown to Omaha with advanced stages of the Ebola virus

    » wife, Isatu Salia, and their two sons, ages 20 and 12, live in New Carrollton, Maryland

    Meet the team

    Three Ebola patients have been entrusted into the care of a dedicated group of medical professionals in Omaha

    Top, from left to right: Peter Iwen, Frank Freihaut, John Lowe, Dr. Angela Hewlett, Dr. Phil Smith, Kate Boulter, LuAnn Larson, Dr. Daniel Johnson. They represent the team that treated three Ebola patients in the Nebraska Biocontainment Patient Care Unit. (Photo by Rebecca S. Gratz / The World-Herald)




    LuAnn Larson: The manager of the Clinical Research Center made a point of extending human contact to her most-ill patient.

    Larson: Race cross-country to treat unit’s first patient

    LuAnn Larson got the call while she was in the Baltimore airport, waiting for her flight back to Omaha.

    “Guess what?” said her boss, Dr. Chris Kratochvil. An Ebola patient had just arrived in Omaha.

    Kratochvil wanted Larson, the manager of the University of Nebraska Medical Center’s Clinical Research Center, to administer the experimental drug the patient would be given.

    The drug would be arriving that evening. The patient, Dr. Rick Sacra, already was being treated in the biocontainment unit at the Nebraska Medical Center.

    Larson, 55, had a little more than an hour to learn about the drug, TKM-Ebola, before boarding the plane.

    Kratochvil emailed her the information he had, and she started taking notes “fast and furious. Writing down all the side effects, what they knew about the drug, how we had to administer it, the data that we needed to collect.”

    Larson, a registered nurse, has been doing research for more than 20 years. She was in Baltimore to check on some data being collected for a study.

    She was so busy taking notes that she hadn’t been able to think about the potential for being exposed to the Ebola virus until she got on the plane and shut off her laptop. “Then I couldn’t do anything except think about it.”

    Larson said a prayer, but she said she had every confidence that the biocontainment unit crew would keep her safe.

    Her plane arrived in Omaha about the time the drug arrived. She headed to the hospital and met with Kratochvil before donning the protective gear and entering the patient’s room.

    The drug, which is administered via an IV using a special infusion pump, had been tested only on healthy people. Larson said she was “being very careful. I was trying to be very observant, so if we needed to stop it, we would stop it.”

    “You have to think about ‘What are you giving this patient? Is this the only thing you have to offer them? Is it worth continuing if they’re having some blood pressure problem?’ ”

    Fortunately, Dr. Phil Smith, the unit’s medical director, was in the room during the infusion to help keep watch. Sacra, she said, had minimal reactions to the drug.

    Larson finished after about three hours. She was supposed to be at her niece’s wedding, but this had come up. She made it to the reception.

    Larson ran the infusion pump for the six remaining days that the drug was administered. Outside of the unit, she worked to put the data into the proper formats and get it to the drug company, the U.S. Centers for Disease Control and Prevention and the World Health Organization.

    The second patient, Ashoka Mukpo, was given Brincidofovir, an oral medication, but the third patient, Dr. Martin Salia, got an IV drug, ZMapp. So Larson returned to the unit and the patient room.

    She said she made a point of touching Salia and talking to him. “He couldn’t respond, but he could hear you. Just making sure he had that human touch. Because, can you imagine, nobody’s touched him” since he was diagnosed in West Africa. “He had gone through a lot.”

    Biocontainment unit staff

    Following are the biocontainment unit staff members who cared for one or more of the Ebola patients. Nebraska Medical Center officials note that the entire organization, including staff from the University of Nebraska Medical Center, supported this team.

    Unit leadership team

    » Dr. Philip Smith
    » Dr. Angela Hewlett
    » Dr. Chris Kratochvil
    » Shawn Gibbs
    » John Lowe
    » Beth Beam
    » Kate Boulter
    » Shelly Schwedhelm

    Registered nurses

    » Valerie Becker
    » Bridget Boeckman
    » Erica Elder
    » Abby Fitch
    » Betsy Flood
    » Meagan Freml
    » Roman Frigge
    » Kim Hayes
    » Lois Jensen
    » Nikki Kraus
    » LuAnn Larson
    » Drew Molacek
    » Alicia Parker
    » Jeff Peters
    » Cheryl Rand
    » Karen Roesler
    » Kendall Ryalls
    » Morgan Shradar
    » Tim Sunderman
    » Jennifer Sundermeier
    » John Swanhorst
    » Angie Vasa

    Respiratory therapists

    » Jean Bellinghausen
    » Susan Denny
    » Frank Freihaut
    » Lauren Mainelli
    » Dee Pinkney
    » Deb Ray

    Patient care technicians

    » Jay Jevne
    » Kalen Knight
    » Derek McCroy
    » Ralph Nadeau
    » Anna Nightster

    Student, College of Public Health

    » Katelyn Jelden

    Physician group

    » Dr. Diana Florescu, infectious diseases
    » Dr. Andre Kalil, infectious diseases
    » Dr. Mark Rupp, infectious diseases
    » Dr. Alison Freifeld, infectious diseases
    » Dr. Trevor VanSchooneveld, infectious diseases
    » Dr. Uriel Sandkovsky, infectious diseases
    » Dr. Rick Starlin, infectious diseases
    » Dr. Daniel Johnson, critical care medicine
    » Dr. Jim Sullivan, critical care medicine
    » Dr. Steve Lisco, critical care medicine
    » Dr. Craig Piquette, critical care medicine
    » Dr. Kristina Bailey, critical care medicine
    » Dr. Joseph Auxier, critical care medicine
    » Dr. Brian Boer, critical care medicine
    » Dr. Travis Hanson, critical care medicine
    » Dr. Julia Kaseman, critical care medicine
    » Dr. M. Salman Khan, critical care medicine
    » Dr. Ji Hyun Rhee, critical care medicine
    » Dr. Adam Wells, critical care medicine
    » Dr. Troy Plumb, nephrology
    » Dr. Marius Florescu, nephrology
    » Dr. Steven Hinrichs, pathology
    » Dr. Scott Koepsell, pathology
    » Dr. Chad Vokoun, internal medicine
    » Dr. Wes Zeger, emergency medicine

    Laboratory

    » Peter Iwen
    » Tony Sambol
    » Vicki Herrera
    » David Moran
    » Sarah Trotter
    » Amy Kerby
    » Sue Peters
    » Timothy Southern
    » Caitlin Murphy
    » Karen Stiles




    Amy Steinauer: When patients’ relatives arrived, she tried to “find out some of the family dynamics and how we can best help them.”

    Nurse concierge's main job: helps ease relatives’ anxieties

    The families of the Ebola patients had a lot on their minds when they arrived in Omaha. It was Amy Steinauer’s job to help make things a little easier for them.

    “They’re not from around here,” Steinauer said. “They need help navigating the town, the hospital, everything.”

    Steinauer, 53, a registered nurse, works at the Nebraska Medical Center as a nurse concierge, dealing with corporate clients and others who need special attention. It made sense, she said, for leaders to enlist her help with the Ebola patients’ relatives.

    Starting at age 19, she has worked at the hospital, on and off, for nearly 24 years, and knows lots of people around campus who can get things done.

    After she picked up family members at Eppley Airfield, she would “try to assess what are the needs they’re going to have, find out some of the family dynamics and how we can best help them.”

    The first thing on each list, she said, was to see their loved one. “We try to get the video thing going as quickly as possible, just so they can see, since they can’t go into the room and hold his hand.”

    The hospital’s IT department helped with video links to friends and relatives who live out of town.

    With Dr. Martin Salia, who wasn’t conscious when he arrived in the biocontainment unit, the nurses in the room were able to explain to his wife, Isatu, what she was seeing on the screen.

    Steinauer stuck around the relatives at the beginning of their stays. “As they get the system down and get comfortable with knowing where things are,” she said, “then I pretty much check in with them once a day.” Debbie Sacra, Dr. Rick Sacra’s wife, “would have a list of things for me, things she’d thought about. It got to be kind of a routine with her.”

    Steinauer took one family to church and took another person to get her hair done.

    The families wanted to express their gratitude for the work that nurses and others were doing in the unit, so they paid for pizza for the crew. Steinauer helped coordinate the deliveries.

    “They’ve all been very caring and intelligent people,” Steinauer said of the patients’ relatives. She said it was interesting “just to learn about what they’ve done, where they’ve been.”

    Although Salia worked for a Methodist organization, the family is Catholic. “Many of the people involved (in Salia’s care) were also Catholic and knew what (Isatu Salia) needed.”

    With all the news media attention the patients and their families had, Steinauer said, the patients and families flew home on charter flights she and others arranged.

    Steinauer continues to help the families after they leave, forwarding mail and helping them with billing questions or getting copies of medical records.

    “What I actually physically do doesn’t really require a nurse,” she said. “But I think being able to understand what’s going on, sitting in on the conferences and understanding the medical lingo and having experience dealing with families from a nursing standpoint, I think that’s helpful in this role.”




    Shawn Gibbs: The heavy protective jumpsuit holds in body heat, causing “a gallon” of sweat to pool inside.



    John Lowe: His experiments involve “tracking ... where pathogens would go if you had a vomiting episode or a cough.”

    Cleaning crew’s protocols become model for others

    Shawn Gibbs and John Lowe wore heavier protective gear than what the caregivers wore in the biocontainment unit.

    The two, who have Ph.Ds as researchers and medical school faculty members, prepared and then decontaminated the ambulances used to transport Ebola patients from the airport to the Nebraska Medical Center. The plastic Tyvek jumpsuits keep any virus out – but trap heat in.

    After the first transport, working in a sweltering garage in late September, they removed the plastic sheeting from the ambulance, wiped down the interior and exposed it to ultraviolet germicidal irradiation.

    The suits were sloshing afterward. “If I pulled out less than a gallon (of sweat), I would be shocked,” Gibbs said. “It pools in the bottom of your suit.”

    Gibbs, 38, and Lowe, 34, serve on the biocontainment unit’s leadership team. Both are researchers and faculty members in the University of Nebraska Medical Center’s College of Public Health.

    The two oversee the proper disposal of the huge amounts of what becomes hazardous medical waste – mostly, the used protective gear and patient linens – generated in the unit. The waste is put into an autoclave – a high-pressure steam sterilizer – and pulled out the other side to be hauled away to be incinerated.

    When the unit isn’t activated, the two conduct experiments there, “like tracking the airflow and where pathogens would go if you had a vomiting episode or a cough,” Lowe said.

    Before the threat of Ebola cases arose in the U.S. this summer, Lowe and Gibbs were focused on how to handle a potential case of the Middle East respiratory syndrome coronavirus.

    Once they learned that they likely would see an Ebola patient in Omaha, they started reviewing which personal protective equipment would be needed and how they would process waste, which totaled nearly 3,700 lbs. for the three patients.

    Years ago, members of the biocontainment team decided they always would have a “doffing partner” who would supervise the removal of potentially contaminated protective gear. “It just takes a huge burden off of them to have someone say ‘Do this,’ ‘Do this,’ ” Lowe said.

    Over the years, much of the patient-transport training Lowe and Gibbs had conducted with the Omaha Fire Department and other area agencies involved transporting patients with an airborne-transmitted illness, such as SARS.

    With Ebola, which isn’t airborne, they needed to line the ambulances with plastic because of concerns about the copious amounts of body fluids produced by Ebola patients – more than two gallons per day.

    None of the three patients had any incidents during the trips to the hospital, Gibbs and Lowe said. But the two handled the cleanup of all three ambulances as if they had, and returned them to the Fire Department in pristine condition. “We keep teasing them that they give us their dirtiest ambulance and we give back their cleanest,” Gibbs said.

    After the world learned that a man exposed to Ebola had walked into an emergency room in Dallas, Lowe and Gibbs fielded requests from around the Omaha area, the U.S., Canada and Europe to train emergency medical services workers. “We have done our best to get our methods and protocols out to people as quickly as possible,” Gibbs said.

    All the research and development of the unit’s protocols turned out to be useful. And the experience, Lowe said, brought “a sense of validation, fulfillment.”




    Erica Elder: When the nurse tried to be unobtrusive during her patient’s video chats, he teased her by talking about her.

    Erica Elder: Draped in protective gear, caregiver is a voice and eyes

    Erica Elder thought that signing up for the Nebraska Medical Center’s biocontainment unit team would look good on her résumé.

    “I didn’t know that we’d actually be activated,” she said, “but I thought it would be fun if we did.”

    The 28-year-old nurse works in the hospital’s hyperbaric department, treating people with diabetic wounds and injuries from radiation treatments. A widow, she and her 3-year-old son and 2-year-old daughter moved here from Georgia about a year ago. She was an intensive care nurse there.

    Elder received “kind of a quick, on-the-job-type training. I got to see one little drill.”

    But that training, which taught her how to don and doff the necessary protective gear, was enough. With someone always overseeing the process, she never felt unsafe or unsure about whether she had been exposed. If she had, she said, “I would have never gone home. I have two little kids.”

    Elder stayed in the patients’ rooms for three hours at a time. Dr. Rick Sacra, the biocontainment unit’s first Ebola patient, was very ill when he arrived, Elder said, but became increasingly talkative as he felt better. “He would get our names, ask about our families. He was very social. If he wasn’t talking to us, once he started to feel better, he was talking to family or friends” via a video chat.

    Elder would act as if she couldn’t hear the patients’ conversations, to give them a semblance of privacy. Once, Sacra was talking via video with his friend Dr. Kent Brantly, another Ebola survivor.

    “They were being funny just to see if I was listening. (Brantly) goes ‘She must really not be paying attention to you or she’s really good at keeping a straight face.’ And I said ‘I hear everything you’re saying.’ ”

    The nurses tried to keep Sacra occupied by finding him books to read, playing chess with him and even getting him a Nerf basketball hoop. “He was terrible at it,” Elder said of Sacra’s shooting skills.

    The second patient, freelance journalist Ashoka Mukpo, had an iPad, so he could entertain himself. Mukpo “wasn’t as social, so you kind of had to chip away. You’d kind of have to pull things out of him.”

    The nurses’ eyes were the only visible part of their faces, so it sometimes was hard for the patients to tell who was in the room. Sacra, she said, “would look at me and he’d go ‘Are you Erica or Kendall (Ryalls)?’ ” But by the time Sacra was released and met the nurses in their regular clothes, she said, “he could name us.”

    It was good to see Sacra and Mukpo both well enough to walk out of the unit, Elder said. Each told the crew he was appreciative of the care he had received. That made the work rewarding.

    “As an ICU nurse, you never get to see the patient from beginning to end,” she said. “You see the patient until they’re good enough to go out to a regular floor.”

    Timeline: The rise of Ebola

    March 23Guinean officials say tests confirm that it is the Ebola virus that has killed 59 people. Health officials and Doctors Without Borders establish treatment centers.
    March 28Health officials confirm that Ebola has spread from a remote forested corner of southern Guinea to the country’s seaside capital, Conakry.
    March 30Ebola crosses the border into Liberia, where the health minister says two patients have tested positive for the deadly virus.
    April 5A crowd angry about the outbreak attacks a center in Guinea, prompting an international aid group to temporarily evacuate.
    May 9The World Health Organization says health workers have made dramatic progress in controlling the outbreak, which is blamed in the deaths of at least 168 people in Guinea and Liberia. There are signs that the spread is slowing, but it is not over yet, a WHO official says.
    May 30Sierra Leone reports its first two Ebola deaths.
    June 12Sierra Leone announces a state of emergency in the Kailahun district, banning public gatherings and closing schools.
    June 17Ebola is in Liberia’s capital, Monrovia, with a health official saying seven people have died there.
    June 18An American doctor says this appears to be the largest Ebola outbreak since the first known outbreaks in 1976 in Sudan and Democratic Republic of Congo. The WHO attributes more than 330 deaths to Ebola in this new West African outbreak.
    June 20The outbreak is “totally out of control,” says a senior official with Doctors Without Borders.
    July 23The doctor in charge of battling Sierra Leone’s outbreak becomes ill. He later dies.
    July 25The outbreak spreads to Nigeria, the continent’s most-populous nation, after a Liberian man with Ebola takes a flight to Lagos and dies there.
    July 27One of Liberia’s most high-profile doctors dies of Ebola, a government official says.
    July 31The death toll rises to more than 700 people in West Africa, and the disease is moving faster than efforts to control it, the head of the WHO warns as presidents from the affected countries meet in Guinea’s capital.
    Aug. 2American Dr. Kent Brantly arrives in Atlanta, the first Ebola victim to be brought to the United States for treatment.
    Aug. 5American missionary Nancy Writebol arrives in Atlanta for treatment.
    Aug. 17Liberian officials fear that Ebola could spread through Monrovia’s largest slum after residents raid a quarantine center for suspected patients and take bloody sheets and mattresses.
    Aug. 19Writebol, virus-free, is quietly discharged.
    Aug. 20The WHO says the death toll is at least 1,350 people and warns that “countries are beginning to experience supply shortages, including fuel, food and basic supplies.”
    Aug. 21Brantly is released from Emory University Hospital after being cured.
    Aug. 29Senegalese officials announce that an infected university student evaded health surveillance for weeks as he slipped into Senegal.
    Sept. 5American Dr. Rick Sacra arrives in Omaha from Liberia for treatment, which includes plasma from Brantly.
    Sept. 9An unnamed American Ebola patient arrives at Emory for treatment. The patient had been working for the WHO in Sierra Leone.
    Sept. 13A fourth doctor from Sierra Leone dies.
    Sept. 16The Obama administration announces plans to assign 3,000 U.S. military personnel to the afflicted region to supply medical and logistical support to overwhelmed local health care systems and to boost the number of beds needed to isolate and treat victims of the epidemic.
    Sept. 18Sierra Leone orders its 6 million people confined to their homes for three days for a door-to-door search for infected people.
    Sept. 19Volunteers begin the search in Sierra Leone. Thomas Eric Duncan, who will be the first diagnosed with Ebola in United States, leaves Liberia for Belgium.
    Sept. 20Duncan flies from Belgium to Washington, D.C., and then on to Dallas.
    Sept. 21Sierra Leone completes its search; government later says 1 million homes were visited, 130 confirmed cases discovered and 92 bodies recovered.
    Sept. 24A Red Cross team is attacked while collecting bodies believed to be infected in southeastern Guinea; one team member is wounded. Duncan begins having symptoms in Dallas.
    Sept. 25Sierra Leone announces more restrictions; about a third of the population is under quarantine. In Dallas, Duncan seeks medical care at a hospital’s emergency room, and tells nurse he had traveled from Africa; but word isn’t passed along, and he’s released early the next morning. Sacra is released from the Nebraska Medical Center.
    Sept. 27Liberia’s chief medical officer, Bernice Dahn, places herself under quarantine for 21 days after her assistant dies.
    Sept. 28Duncan returns to hospital by ambulance and is put in isolation.
    Sept. 29The U.N. mission to combat Ebola opens its headquarters in Ghana.
    Sept. 30Duncan tests positive for Ebola.
    Oct. 1The United Nations announces the first death of a staff member in the crisis, a Liberian national.
    Oct. 2Texas health officials say they have reached out to monitor 80 to 100 people who may have had direct contact with Duncan.
    Oct. 3NBC News freelance cameraman Ashoka Mukpo tests positive for Ebola in Liberia; he will be transported to the Nebraska Medical Center for treatment.
    Oct. 8Duncan dies at Texas Health Presbyterian Hospital.
    Oct. 10Amber Vinson, a nurse who treated Duncan, takes a commerical flight from Dallas to Cleveland to prepare for her wedding.
    Oct. 12Texas hospital says nurse Nina Pham, who treated Duncan, has tested positive for Ebola.
    Oct. 13Vinson flies from Cleveland to Dallas. She has no symptoms, but her temperature was 99.5 that morning. She notified the Centers for Disease Control and Prevention before boarding, and no one told her not to fly.
    Oct. 14Vinson is taken to Texas Health Presbyterian Hospital in Dallas with a fever.
    Oct. 15Vinson is diagnosed with Ebola and flown to Emory.
    Oct. 16Pham is flown from the Texas hospital to the National Institutes of Health hospital in Maryland.
    Oct. 17Officials announce that a Dallas health worker who handled clinical specimens from Duncan is quarantined aboard a Carnival cruise ship. Dr. Craig Allen Spencer arrives back in the United States via Brussels after spending a month in Guinea treating Ebola patients. He lands at New York’s Kennedy International Airport.
    Oct. 19The unnamed American Ebola patient, later identified by the New York Times as Dr. Ian Crozier, is discharged from Emory.
    Oct. 22Mukpo, testing virus-free, is discharged from the Nebraska Medical Center after a little more than 16 days of care. Vinson is declared virus-free. Defense Secretary Chuck Hagel and other federal officials ask biocontainment unit staffers to share what they have learned.
    Oct. 23Spencer is diagnosed with Ebola and goes into isolation at Bellevue Hospital in Manhattan.
    Oct. 24Pham is declared virus-free, visits Obama in the Oval Office. Alarmed by the Spencer case, the governors of New Jersey and New York order a mandatory, 21-day quarantine of all medical workers and other arriving airline passengers who have had contact with Ebola victims in West Africa. Nurse Kaci Hickox is placed in quarantine in a New Jersey hospital after working with Doctors Without Borders in Sierra Leone.
    Oct. 27Hickox returns home to Maine after threatening legal action for mandatory quarantine, which she calls "inhumane" and "completely unacceptable."
    Oct. 29U.S. Defense Secretary Chuck Hagel announces that all U.S. troops returning from Ebola response missions in West Africa will be placed in supervised isolation for 21 days.
    Oct. 31A judge in Maine rejects arguments by the state that Hickox’s movements should be firmly restricted, but requires her to submit to daily monitoring for symptoms, to coordinate her travel with public health officials and to notify them immediately if symptoms appear.
    Nov. 3UNICEF announces that it is doubling its staff to fight Ebola in Guinea, Liberia and in Sierra Leone.
    Nov. 5The WHO elects Matshidiso Moeti, a doctor from Botswana, as director of its Africa regional office after criticisms about the mission’s response to the Ebola crisis. A Spanish nurse’s aide, Maria Teresa Romero Ramos is released from a Madrid hospital, almost a month after testing positive for Ebola. Obama asks Congress for $6.2 billion in emergency funds to confront the crisis.
    Nov. 6Dr. Martin Salia, a surgeon working in Sierra Leone, shows Ebola symptoms but initially tests negative for the virus.
    Nov. 7Dallas marks the end of its Ebola crisis when the last of the 177 people who were being monitored for symptoms are cleared.
    Nov. 11Spencer is declared virus-free and is released from the hospital.
    Nov. 15Salia arrives in Omaha for treatment. By the time he’s examined at the med center, he has no kidney function, is working extremely hard to breathe and is unresponsive.
    Nov. 17Salia dies. Nebraska officials say the false early Ebola test delayed treatment until it was too late.
    Nov. 16U.S. health officials say anyone arriving in the United States from Mali will be subject to the same screening and monitoring procedures as travelers from Liberia, Sierra Leone and Guinea. About 80 soldiers from the Iowa Army National Guard and 700 from Minnesota are notified that they may be deployed to West Africa to support the fight against Ebola.
    Nov. 21Thieves stop a taxi in Guinea and make off with blood samples believed to be infected with Ebola.
    Nov. 24Mali confirms its eighth case of Ebola.
    Nov. 28French President Francois Hollande visits Conakry, Guinea, where the outbreak began, and delivers a message of hope.
    Dec. 1The WHO says Liberia and Guinea have met a target for isolating 70 percent of people infected with Ebola and safely burying 70 percent of those who die, but Sierra Leone has not.
    Dec. 2The active monitoring period ends for the last of the 114 health workers who cared for Spencer.
    Dec. 4An American health care worker who might be infected arrives at Emory University Hospital. No information is released about the patient.
    Dec. 6Two Sierra Leonean doctors die. Two people returning to New York State from West Africa, where they were exposed to Ebola, agree to a 21-day home quarantine but show no symptoms of the virus.
    Dec. 7Tenth doctor from Sierra Leone dies of Ebola.
    Dec. 8Doctors in Sierra Leone go on strike to demand better treatment for health workers infected with Ebola.
    Dec. 11An unidentified American nurse who was exposed to Ebola while volunteering in Sierra Leone is admitted to the NIH Clinical Center. The nurse did not test positive.
    Dec. 12Authorities in Sierra Leone ban public Christmas and New Year’s celebrations in a bid to halt the spread of Ebola. The last known infected person in Mali is declared virus-free and released from the hospital.
    Dec. 14Liberia postpones senatorial elections again, while some urge calling off the vote altogether for fear that the turnout would be so low that the results would not be credible.
    Dec. 15Sacra says he is returning to Liberia in January.
    Dec. 17Surveillance teams fan out in Freetown, Sierra Leone’s capital, in a house-to-house search for sick people.
    Dec. 18One of Sierra Leone’s most senior physicians dies, the 11th doctor in the country to succumb to the disease. In Guinea, a fire destroys medicine crucial to fighting the outbreak.
    Dec. 19The unidentified American nurse who was exposed in Sierra Leone is released from the hospital; officials say she will complete 21 days of monitoring at a private home in Virginia under the direction of that state’s Department of Health. U.N. Secretary-General Ban Ki Moon opens a tour of the hardest-hit countries with stops in Liberia and Sierra Leone.
    Dec. 20Turnout is very low in Liberia’s Senate elections, which were delayed by more than two months. Special precautions were taken at polling places to separate voters, and those with high temperatures were denied admission. Moon visits Guinea. The WHO says the death toll is more than 7,000.

    Sources: The Associated Press, the Washington Post, the New York Times, World-Herald archives

    Past Midlanders of the Year

    2014 — Nebraska Ebola fighters

    2013 — Evonne and Bill Williams

    2012 — Tom Osborne

    2011 — Missouri River flood fighters

    2010 — Harvey Perlman

    2009 — Daniel Neary

    2008 — Don Smithey

    2007 — Connie Spellman

    2006 — Maj. Gen. Roger Lempke

    2005 — U.S. Sen. Chuck Hagel

    2004 — Dr. Harold Maurer

    2003 — Gary E. Moulton

    2002 — Charles W. “Chuck” Durham

    2001 — Military personnel

    2000 — Walter Scott Jr.

    1999 — Volunteers

    1998 — Ben Nelson and Terry Branstad

    1997 — Tom and Nancy Osborne

    1996 — U.S. Sen. J.J. Exon

    1995 — Lied Foundation and its trustee, Christina Hixson

    1994 — Jack Diesing Sr. and Jack Diesing Jr.

    1993 — Teachers

    1992 — Foster care families

    1991 — Lee Simmons

    1990 — Men and women in Operation Desert Shield

    1989 — Harold W. Andersen

    1988 — Bob Kerrey

    1987 — Jan Stoney

    1986 — Kay Orr and Helen Boosalis

    1985 — Jerome Warner

    1984 — Families of the Land

    1983 — Nebraska football players Irving Fryar, Turner Gill, Mike Rozier and Mark Schellen

    1982 — Martin Massengale

    1981 — Eugene T. Mahoney

    1980 — Peter Kiewit and Carl M. Reinert

    1979 — Tom Osborne

    1978 — J.J. Exon and Robert Ray

    1977 — Year of the Educator: Omaha Superintendent of Schools Owen Knutzen, classroom teacher Sammye Jackson, Creighton President Joseph Labaj and UNO Chancellor Ronald Roskens

    1976 — D.B. Varner

    1975 — Year of All the People: survivors of drought, blizzards and the Omaha tornado

    1974 — J.J. Exon

    1973 — Anne Campbell and Betty Abbott

    1972 — Eugene Leahy

    1971 — Environmentalists James Malkowski and Deanie Anderson

    1970 — Bob Devaney

    1969 — Youth of the Midlands

    1968 — Clifford Hardin

    1967 — Norbert Tiemann

    1966 — Midlands farmers

    1965 — A.V. Sorensen