JANUARY 22, 2015--When Dr. Daniel Lucey met 4-year-old “Joseph” in a hospital Monrovia, Liberia, this past October, the little boy was sick, really sick.
He had arrived at the hospital run by the international organization Médecins Sans Frontières (MSF) with his 10-year-old sister. The organization is known in the United States as Doctors Without Borders.
The children, whose parents were dead, lay almost motionless on adjacent mattresses on the floor of one of the tents.
Decades of Work
Lucey, an infectious diseases physician and adjunct professor with Georgetown University Medical Center (GUMC), is no stranger to deadly viruses.
Since 2003, Lucey has regularly worked with colleagues outside the U.S., physicians and public health officials, traveling somewhere, anywhere, to help with outbreaks of emerging infectious diseases.
He has provided treatment or consulted at the epicenter of many of the world’s infectious emerging diseases, including HIV/AIDS in San Francisco in the early 1980s, H5N1 avian flu in Egypt and Indonesia, SARS in Hong Kong and Toronto and Middle Eastern Respiratory Syndrome Coronavirus (MERS) in the Middle East and Northern Africa.
Before his time in Liberia, he treated Ebola patients this past August in a non-MSF hospital in Sierra Leone, where the conditions were so bad he didn’t even have all the right protective gear.
It had been difficult to see anyone suffering, but it was especially hard to see children struggling at the intersection of life and death.
The Life Force
In Liberia, “Joseph” (names of Ebola patients have been changed for confidentiality) and his sister had each other, but not for long. The young girl died within a few days of arriving at the hospital.
“If I had had to guess, I would have said he was going to die before she died,” says Lucey. “He looked just terrible. His lips were cracked. His tongue was beefy red. He couldn’t drink anything. I thought, ‘So how is he going to live? He is not going to live. How can he live? He is so weak. He cannot sit up. Even when you sit him up he won’t stay up unless you hold him.’ ”
Intravenous fluids were not available. Even in Liberia, the conditions were stark. At the edge of every mattress were three buckets – one for stool, one for urine and one for vomit.
He says patients lost fluid from the vomiting and diarrhea that Ebola causes, but also from the heat. Sweating out salts can contribute to death if the levels are too low.
Lucey expected Joseph to die the day after his sister did. And then the day after, and then the day after that.
“He didn’t die, but he didn’t move much on his own because he was so weak,” the doctor explains. “He was just there. We tried to get him to drink but he could not keep anything down. The body can’t survive that way for very long. And yet he had already survived much longer than I thought he could.”
One day Lucey went into the tent and noticed a small, rectangular box of juice with a clear short straw attached and a plastic cover. He wasn’t exactly sure where it came from – had a nurse or aide left it there?
“I took off the straw, but the plastic wasn’t coming off easily, and you are always afraid you are going to tear your glove,” Lucey explains. “If you tear your glove, you are out, as in out of the tents and maybe out of the country if you are deemed to have a significant exposure to the virus and thus of no more help to your Ebola patients.”
He finally got the straw out and poked a hole in the juice box.
Joseph lay there with his eyes closed, large blisters on his lips. Lucey placed the straw in his mouth. Nothing. But just as he was about to give up on the boy, he slowly started pulling in the liquid.
“It was so hard for him, just drinking the juice,” the doctor says. “Really hard. His eyes didn’t really even open. I have to tell you it felt like I was witnessing the life force itself. I thought, ‘This boy wants to live!’ So we sat him up and gave him more juice, and more juice and he opens his eyes.”
No Atheists in Ebola Hospitals
Lucey says it was a miracle.
“You know they say there are no atheists in the foxhole,” he says. “I would say there are no atheists in an Ebola hospital.”
He told the staff of nurses and aides to give the little boy juice and then the Oral Rehydration Solution (ORS).
Another wonderful thing happened – an 18-year-old man, “John,” who wasn’t related to the boy and was himself recovering from Ebola “basically adopted” Joseph, took care of him while he recovered and eventually returned the boy to his village.
These are the victories that Lucey lives for.
“I feel privileged to be able to treat these patients,” he says when asked why he does what he does. “I enjoy the intellectual and the emotional sides of it. By emotional, I mean being able to interact with both the patients and colleagues, medical and public health colleagues.”
Without the good team of doctors, physician assistants, nurses and nurses’ aides in Liberia, he says, he would have been lost.
“It takes one minute to realize that you are not going to have any impact solely by yourself,” Lucey explains.
He did everything he could to avoid getting sent back to the States. He even shaved at night so that that if he nicked himself, any tiny cuts would heal by morning.
Even the smallest cut could mean potential exposure and he would not be allowed to provide care to the patients. Depending on the exposure, he would have to go home, and he notes that MSF is extremely strict about safety precautions.
“I think you are afraid every day,” the doctor says. “What I feel and what I believe strongly, is that if you are not afraid you should not be doing this work. But clearly it is a matter of controlling the fear and redirecting it to help make you as vigilant as you need to be so that you don’t get exposed.”
In Monrovia, Lucey had a total of 46 patients in his four assigned tents when he arrived in the beginning of October.
“I was the only physician for these patients,” he explains, “but there was a large team of courageous and dedicated Liberian nurses and several physician assistants who provided care 24 hours a day.”
There were only two other physicians who provided similar care for the other laboratory-confirmed Ebola patients in the other tents.
A Matter of Minutes
Because MSF only allows doctors to see patients for 45 minutes a day – a rule that exists for the protection of health care workers – initially he could see each patient on average for no more than one minute.
There was no air conditioning at the tent-hospital and the average temperature hovered in the high 80s.
Lucey says after putting on his full-body protective gear, known as Personal Protective Equipment (PPE), he started to sweat profusely after only a few minutes.
“Pretty soon you realize you are walking on water in your boots,” Lucey recalls. “It is your sweat in your boots. If you stay much longer then your mask gets full of your own sweat, and it is harder to breathe.”
He realized a week into his time in Liberia that having a list of survivors from the four tents he and his team were responsible for (which rose to 74 patients by the time he left in mid-November) was important for the morale of other patients, himself and the large number of Liberian health care workers.
“Every time we had survivors we added the names to the list, updated the list and printed out two copies, then posted them in our nursing team tent at eye-level at the exits,” Lucey recalls.
The Four Steps
He also created a system, and, at the suggestion of another health care worker, hired an artist to create a poster on “Four Steps to Help Our Patients Survive Ebola.” He put the poster up in each of his patient tents and in the main nursing tent, as did two of the other physicians.
Step one was helping patients sit up so they could drink ORS while administering medications to decrease their vomiting and diarrhea. In step two patients could sit up on their own but still needed help to drink and eat enough to stay alive.
Getting outside of the tent by any means comprised step three. The patients outside the tent could drink and eat but still needed some assistance.
“It is the most important step on the road to recovery,” he adds. “Get out of the tent. I say if you never get out of the tent you never get out of the tent. You die.”
In step four, the pre-survivor step, the patient can walk, talk, eat and drink.
There were three times during his 42-day stint in Liberia that the 59-year-old doctor worked all day and all night.
“I was very scared because I am getting old and I hadn’t stayed up all night for a long time,” Lucey says. “I stopped drinking coffee in August and thought I would have to start again, but I didn’t need it. I was so wide-awake.”
It is harder for Lucey to talk about his experience with Ebola patients in Freetown, Sierra Leone.
The testing unit he worked in this past August was a small part of a former emergency medicine area of a large referral hospital. The space contained no individual rooms and little light.
Patients who eventually tested negative for Ebola could spend several days in the same area as patients who eventually tested positive. This ironically meant that people without Ebola faced a risk of infection with the virus within the Ebola testing unit itself.
“Dante’s Inferno is what came to mind,” he says.
The doors were locked from the outside so patients couldn’t get out and spread the virus.
“One day we go in and we go around the corner and there is a mom sitting in her bed just rocking back and forth and saying something, but I cannot understand what,” Lucey says.“You see on the floor next to the bed is a body of a little boy and it turns out it is her 7-year-old son.”
Lucey tears up just thinking about it.
Some of the protective gear – such as the gloves – was inadequate.
In this Sierra Leone Ebola testing unit all the gloves only came up to his wrists. Was he in danger of exposure?
“I wouldn’t say easily because I didn’t get infected,” he says. “But you had to improvise, and Ebola is not the time to be improvising on safety issues. You have to improvise on other things – like how do you get patients to drink enough lifesaving fluid for it to be lifesaving. But not on safety.”
Lucey used a sharp object to put a hole in the sleeve of his protective gown and put his thumb through it so his thumb constantly pulled down on the sleeve to cover his wrist.
The bleach the health workers had to spray on their hands needed to be a specific ratio of chlorine to water to properly combat Ebola.
“If you use the wrong concentration, you’re in danger,” he explains. “And if you use a high concentration for your bare skin you get a chemical burn, and then you are on the plane and out of there.”
It was so easy to make a mistake.
In Sierra Leone, he knew a doctor who later tested negative for Ebola accidently stuck himself with a needle, potentially exposing himself to the virus and sending him back home for a post-exposure prophylaxis protocol.
A Lack of Leadership
He says the lack of adequate supplies have less to do with money than with accessibility.
“You can order the right kind of gloves, but how do the gloves get on the hands of the health care workers who are seeing the patients?” Lucey says. “You would think it would be easy but it is not. Are there planes available to fly in the equipment? What about the airport? Is the equipment allowed to pass through customs? Is there a warehouse to put the equipment or where does it go?
Who controls the warehouse? Is there a vehicle that safely can transport the material from the warehouse to all of the hospitals and clinics in the cities and in the rural areas that need it? Are the roads passable in the rainy season or non-rainy season? Is there petrol for the vehicles? Do the vehicles have tires that are not flat? All of these things might sound simple, but each of these steps are what has to happen.”
From Physics to Medicine
The son of an Air Force mechanic who grew up all over the world, Lucey entered Dartmouth College as an undergraduate and majored in physics.
“I wanted to discover new elementary particles,” says Lucey, who went on to get his medical degree from Dartmouth and a master’s degree in public health from Harvard.
“I was fascinated by the Manhattan Project (the project that created the first atomic bombs during World War II). But in my sophomore year of college I realized there were a lot of kids smarter than me in physics.”
He left school for a while that winter and worked in a liquor store at night. But then he had the opportunity to study in France, discovered the Euro-rail pass and traveled all over Europe.
“Somewhere riding on these trains it hit me that medicine is a universal language,” Lucey says. “One of the other students I was with was pre-med. I had not met him before at Dartmouth but we got to talking. He said, ‘Well, you know it is late to start pre-med, but it is not too late.’”
A Global Trek
He changed his major but then wasn’t sure he wanted to face four years of medical school followed by six years of residency and fellowship training right after college. But he did know he wanted to go back overseas.
He had been accepted on the early admission plan to Dartmouth Medical School, and took a year off, visiting Turkey, Iran, India, Pakistan and Afghanistan.
He felt ready for medical school after that, but the travel bug had bitten him. Hard.
“I went to South Africa,” he recalls of the summer after his first year at Dartmouth. “I applied to about 20 places. I said I am a first-year medical student and I want to come work in your hospital. And this incredible hospital in Soweto, South Africa, during apartheid, accepted me.”
“I went there and that was my first hospital experience,” Lucey explains. “It was so inspiring for the rest of my life, the best teachers, a lot of dedicated doctors, some of whom were black, some Indian and some white. We all worked together.”
After receiving his MD at Dartmouth with honors, he did his residency in internal medicine at the University of California in San Francisco and then worked as an infectious diseases fellow at Harvard University, Brigham & Women’s Hospital, Beth Israel Hospital and Dana Farber Cancer Institute.
A History of Hard Work
Since 1981, Lucey has authored or co-authored nearly 90 medical papers and 17 book chapters.
He joined Georgetown as an adjunct professor in 2004, and now teaches in the department of microbiology and immunology and co-directs the masters program in Biohazardous Threat Agents and Emerging Infectious Diseases.
This spring, he is also teaching four courses at Georgetown’s O'Neill Institute for National and Global Health Law and its School of Foreign Service: Epidemiology for Lawyers, Virus Outbreaks in East Asia 2003-2015, Emerging Infectious Disease Outbreaks: Past-as-Prologue and Infectious Disease Outbreak Epidemiology.
Before he came to Georgetown, he served briefly as interim chief medical officer and special advisor to the director on bio-preparedness for the District of Columbia Department of Health.
From 1998-2002 he was chief of infectious diseases at Medstar-Washington Hospital Center, where Infectious Disease Fellows came for training from the National Institutes of Health (NIH) and Department of Defense hospitals. He served as an attending physician and infectious disease consultant at NIH while in the U.S. Public Health Service (USPHS).
To date, he has given over 300 presentations in the U.S. and places around the world from London to Hong Kong, Capetown to Guangzhou, Lima to Cairo.
He has also received awards from USPHS, the Medical Society of the District of Columbia, the U.S. Office of the Surgeon General and the District of Columbia Hospital Association.
And he is working on a project to help create more public awareness about emerging viruses.
“Ever since I worked in Hong Kong and Toronto during the SARS outbreak of 2003, I have hoped for a large national exhibit on global emerging infectious disease outbreaks,” Lucey says.
The Smithsonian National Museum of Natural History granted final approval for the proposal, anticipated to be a two-year undertaking, this past December.
Faith in Humanity
The soft-spoken, somewhat reserved man becomes impassioned when talking about combatting killer viruses.
Ebola isn’t going away, he says, and will probably get worse before it gets better. Plus, the emergence of new infectious diseases are “inevitable.”
With factors such as climate change, deforestation, an increasingly smaller availability of water, he says it is only a matter of time before another new killer emerges.
In the meantime, Ebola and its survivors occupy his thoughts.
In Liberia, Lucey says there were two men with Ebola who had children at the hospital. While the men eventually recovered, not all of their children survived.
“They basically adopted other patients, other children, who they didn’t even know,” Lucey says. “This was the kind of selfless act that keeps your faith in humanity.”
By Georgetown University Communications