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OneThousandOne represents the amount of time, verbally, that it takes to count to one second. In this one second of time, a great thing happened at The Nebraska Medical Center. In fact, several great things probably happened. A patient was cured, a researcher found the missing link, a nurse treated an injury, a doctor comforted a family or maybe a child just smiled.
MOMENTS IN MEDICINE at THE NEBRASKA MEDICAL CENTER
Fall | Winter 2006

An Isolated Incident

what if... although it’s been said to be unlikely, what if, a large-scale Avian flu epidemic struck this country, what would be its impact? The consequences could be severe.

Ten minutes after the shrill tones from his pager jolt him awake, the first member of the team arrives at The Nebraska Medical Center. Monitored by video cameras as he steps briskly down the quiet hall, he touches his electronic ID card against the card reader to gain access to his destination. He passes between one set of doors, and after they close behind him, through a second set of doors, a measure designed to prevent the backflow of potentially contaminated air.

Rubbing the last traces of sleep from his eyes, he enters a changing room where he undresses and hangs his street clothes in one portion of a divided locker. He dresses in sterilized medical “scrubs,” all the while silently pondering the horrific possibilities. Avian Influenza? Ebola? Smallpox? Plague? No matter. Whatever the medical challenge he is about to face, the immediate goal is the same. Isolation.

One by one he is joined by other members of the volunteer, on-call medical team. They enter the main portion of the high-tech, high-security medical unit, a facility with reinforced firewalls and tornado-proof glass, where the floors, ceilings and walls are seamless to reduce the risk of infectious germs or bacteria hiding in the cracks. As anxiety and excitement quicken the pace of their breathing, the air they take in is being cleansed by the unit’s negative airflow system, a series of devices that introduce fresh air 15 times per hour while carrying outgoing air through a filter and treating it with ultraviolet radiation, eliminating all contaminants before safely dispersing it outside.

The team hurries to another changing room called an “ante” room where they slip into one-piece protective suits and don breathing masks. Looking more like astronauts than doctors and nurses, they proceed to the first of five double-bed hospital rooms, each room capable of functioning as a “mini intensive care unit,” able to cope fully and independently with nearly any medical situation that could arise. They enter the room and make certain the door latches shut behind them. If the door were kept open more than a minute, an alarm would signal a potential break in the room’s airflow barrier.

Awaiting further instructions, they receive a call on the room’s two-way video phone from Philip Smith, MD, medical director of the Nebraska Biocontainment Unit at The Nebraska Medical Center and chief of Infectious Diseases at the University of Nebraska Medical Center (UNMC). There is no need to check supplies, start up equipment or fully prepare the unit. This was a drill. They are congratulated for their prompt response and are released to go home.

The team members smile and shake hands, knowing the next time their pagers go off, it could signal a fearful biological emergency unlike any the United States has ever faced. In a war against a microscopic enemy, they are part of the first line of defense, the 10-bed Nebraska Biocontainment Unit, the largest of its kind in the U.S. and the nation’s only civilian facility.

“Our unit can handle any of these threats,” notes Dr. Smith. “Just our basic level of isolation, is far above anything you’d find in any other hospital in the area.”

Like the members of his team, Dr. Smith, a physician specializing in infectious diseases for nearly 30 years, volunteered to direct the unit.

“This is the ultimate challenge for an infectious disease doctor,” he says. “All of my various experiences in clinical infectious diseases, public health and epidemiology were called upon to develop this unit. This is definitely the most exciting thing I do.”

Completed in March 2005, the Nebraska Biocontainment Unit is designed to adapt to almost any type of biological threat, says Dr. Smith. “If there was an outbreak in Nebraska today and we were able to isolate the source,” he says, “we could stop an epidemic in its tracks.”

In addition to the unit at The Nebraska Medical Center, two two-bed units exist at the U.S. Army Medical Research Institute of Infectious Diseases at Fort Detrick, Md., and in Atlanta, as support for the federal Centers for Disease Control and Prevention (CDC). Those units, however, are not available to the public.

Chemical and biological agents have been divided into several categories by the CDC, based on lethality and the likelihood of their use in a biological attack. Those considered to be the greatest threat include anthrax, plague, smallpox, hemorrhagic fevers, tularemia and botulism. Others associated with moderate morbidity and low mortality include SARS, monkey pox, avian flu, and food-borne or water-borne agents such as salmonella, dysentery, E-coli and cholera.

“Our unit can handle any of these threats,” says Dr. Smith. “Just our basic level of isolation is far above anything you’d find in any other hospital in the area.”

Development of the unit was motivated in part by the terrorist attacks of Sept. 11, 2001 and the ensuing incidents involving anthrax. As the threat of biological terrorism rose, the federal government began to fund efforts in local communities to bolster disaster preparedness among healthcare facilities and other frontline public health emergency agencies. The Nebraska Department of Health examined the community’s preparedness and the need for a medical facility where individuals could be treated after a biological or chemical outbreak.

The Nebraska Medical Center proved a logical choice for hosting the unit. The campus is home to the state’s only Nebraska Public Health Lab (NPHL) designated by the CDC as a high-level testing facility for chemical and biological threats. Also, at the time there was space available within the University Tower hospital building, space with its own air-handling system – a critical requirement for a biocontainment facility. The Nebraska Medical Center agreed to support the project, which became a collaborative effort with the Nebraska Department of Health and UNMC.

“I was looking for a new challenge at the time,” says Lenaghan. ““Becoming involved in developing the country’s first public biocontainment unit was an opportunity I couldn’t pass up.”

Dr. Smith led more than two years of design and construction that incorporated input from the CDC, the National Institute for Occupational Safety and Health (NIOSH), military leaders and the Nebraska Department of Health.

At the same time, Pat Lenaghan, RN, MSN, who now serves as operations manager of the biocontainment unit, was organizing local disaster preparedness. A former emergency room nurse and administrator, Lenaghan was involved in writing disaster plans for local healthcare organizations and mobilizing local agencies to develop a coordinated effort for disaster preparedness. This eventually became known as the Omaha Metropolitan Medical Response System (OMMRS).

Dr. Smith approached Lenaghan about serving in the biocontainment unit. “I was looking for a new challenge at the time,” says Lenaghan. “Becoming involved in developing the country’s first public biocontainment unit was an opportunity I couldn’t pass up. It was a good fit for me.”

Designing the unit was a challenge. “There was no blueprint to follow,” Dr. Smith says. “This had never been done before.”

He and Lenaghan worked diligently making certain the unit would meet the proper safety control standards, as well as writing policies, standards of care, infection control standards and procedures for training staff. They gathered input from state safety officials, the CDC, military leaders and NIOSH.

The result is a unit that is receiving national attention and providing several tours a week to varied groups of public and private healthcare officials, many of whom hope to duplicate it at their own facilities. Julie Gerberding, MD, director of the CDC, has toured the facility.  

A total of 35 on-call volunteer medical personnel from The Nebraska Medical Center stand ready to work in 12-hour shifts as long as they are needed. “Initially, we were concerned that we wouldn’t be able to get enough volunteers,” says Lenaghan, “but that ended up not being an issue. We had so many individuals rise to the occasion because they wanted to have this opportunity to have an impact and do something more challenging.”

To prepare for a bioterrorism emergency or infectious disease outbreak, the unit’s staff supports its intensive disaster training with quarterly drills. Other mandatory training includes basic and advanced life support, disaster life support, pediatric life support and continuous education on chemical and biological terrorism and infectious diseases.

A total of 35 on-call volunteer medical personnel from The Nebraska Medical Center stand ready to work in 12-hour shifts as long as they are needed.

“Part of our role is daily monitoring of infectious agents worldwide,” says Lenaghan. “We are becoming familiar with physical symptoms, looking for cues and studying the history of infectious diseases like the avian flu. This information is shared with our staff on a regular basis.”

If an actual emergency were to put the biocontainment unit to use, specimens would be sent to the NPHL microbiology lab for testing. To prevent contamination, the specimen would be sealed in two plastic bags and temporarily placed into a “dunk tank” filled with disinfectant.

Transportation of potentially infectious patients to the unit presents another challenge. In especially dire situations, patients would be taken to the unit inside an ISOPOD – a self-contained, portable isolation system designed for the transfer of highly-contagious patients. Somewhat like a vinyl tent, the ISOPOD permits medical personnel to perform simple healthcare tasks via a series of gloved access points. The pod’s integrity is maintained by a battery-operated, filtered air system.

To further reduce the possibility of contamination, the biocontainment unit employs an electronic medical records system that may be accessed by other departments in the hospital.

The need for the Nebraska Biocontainment Unit is becoming more evident each day. In the case of avian flu, for example, the U.S. has been working closely with other countries and the World Health Organization to strengthen the systems that could detect outbreaks before they result in a pandemic.

“The effects of a pandemic can be reduced if preparations are made,” says Lenaghan. “We are continually reviewing the latest information and data, as well as updating our procedures and protocols. Having a state-of-the-art facility like this right here in Omaha is a wonderful asset to the community.”

And perhaps, one frightening night in the future, an asset to the entire nation.

how likely is an avian flu outbreak?

Most cases have resulted from sick and dying poultry such as domesticated chicken, ducks, and turkeys, or surfaces contaminated with secretions and excretions from infected birds.

Because avian influenza (H5N1) has not yet been detected in the Western Hemisphere there is little risk of people here being sickened by it, says Philip Smith, MD.

To date, most cases of avian influenza in humans have resulted from direct or close contact with sick or dying poultry, or contact with surfaces contaminated by fluids from infected birds. About 10 cases of avian influenza being passed from one ill person to another person have been reported, Dr. Smith says.

The most likely opportunity for avian flu in the U.S. would occur if a person became infected in a foreign country and traveled here.

“One of the biggest issues with avian flu is that it has a delayed symptomatic response,” Dr. Smith says. “This means the infection could be spread before people actually display the symptoms and realize they are sick.”

If an individual in Nebraska were suspected of being infected with the avian flu, Dr. Smith and the State Department of Health would be notified. Arrangements would be made to transfer the patient to the biocontainment unit. The volunteer biocontainment staff would be alerted. Once the case was confirmed, other individuals who had come into contact with the infected person would be identified and brought to the unit, where they would be vaccinated and isolated for observation.

“Our goal would be to prevent it from spreading in the community and among healthcare workers,” says Pat Lenaghan, RN, MSN. “Containment is very important.”

A major concern with avian influenza is that the current virus could become adapted to humans, resulting in a new human influenza strain, one for which humans would lack immunity, says Dr. Smith. “Flu is notorious for mutating, and it can exchange genetic elements, making it more aggressive and contagious. This could touch off a global influenza pandemic.”

A vaccine for humans is being tested. “The problem is that this vaccine is only effective for the H5N1 strain,” Dr. Smith says, “so if the strain changed, it wouldn’t work against the new strain.” Development of a vaccine to combat a new strain, he says, “could take six months to a year.”

Next article in the Fall | Winter 2006 issue of One Thousand And One:
Field of Medicine