Jane Pool, director of Infection Prevention and Control at Landstuhl Regional Medical Center, hands Lt. Col. Nicholas Conger, then the hospital's top infectious disease doctor, a face mask during the 2009 treatment of Sgt. Robert Gordon. It was the military's only known case of Crimean-Congo Hemorrhagic Fever, a contagious and lethal infection similar to the Ebola virus. (Photo courtesy U.S. Air Force)
Sgt. Robert Gordon struggled to breathe as he was wheeled into the intensive care unit at Landstuhl Regional Medical Center.
Evacuated from Kandahar province in Afghanistan, the 22-year-old soldier was extremely ill. His eyes, hands and feet were swollen, and blood seeped from an intravenous site, as well as from his nose and throat. Barely conscious, he was feverish and covered with petechiae — purple spots of blood visible under the skin.
It was Sept. 11, 2009, and although they didn’t know it yet, the LRMC nurses and doctors had just received the military’s first and only known patient with the highly infectious, often deadly viral disease Crimean-Congo hemorrhagic fever. Transmitted to people by ticks, CCHF is a “Biosafety Level 4” disease, in a category shared with Ebola and other of the world’s most dangerous pathogens.
It can have the same devastating effects on the body as Ebola, and is transmitted from human to human the same way — through contact with body fluids — putting health care providers at serious risk.
Gordon’s illness was an emergency, not only for him, but also for the medical team that would try to save his life. Despite the team’s best efforts — dialysis, numerous transfusions, repeated bronchoscopies and use of an antiviral drug — Gordon died on his fifth day in the hospital.
As up to 3,000 U.S. troops deploy to Liberia during the next 18 months to help contain the West African Ebola viral disease epidemic, the military has stressed that the infection risk for troops who won’t be dealing with patients is low. Still, returning troops are to be quarantined for three weeks, a precaution that appears to be largely supported by servicemembers and their families.
If any of those returning to Germany show symptoms such as a fever that could possibly be caused by Ebola, they’ll be taken to Landstuhl.
The little-known 2009 CCHF case illustrates the expert capabilities military medicine can bring to bear in treating patients with contagious, lethal viral diseases. It also demonstrates just how difficult it is.
“We’ve always studied this process in the event of bioterrorism, but when you’re faced with actually figuring out how to do this and make sure everyone is safe, it’s very harrowing,” Jane Pool, LRMC’s director of infection prevention and control, told Prevention Strategist magazine some weeks later.
“You have to regulate the medical waste, trash, linens; everything coming out of the room was contaminated by blood or body fluids,” Pool told the magazine. Military officials declined to make her available for an interview with Stars and Stripes.
Health workers infected “It did keep me up at night, praying there wouldn’t be any secondary cases,” said Lt. Col. Nicholas Conger, the Air Force’s infectious disease consultant, who was the doctor who led Gordon’s treatment team.
But even at Landstuhl, one of the military’s top hospitals, two women who treated Gordon — an intensive care unit nurse and a respiratory therapist — became infected with CCHF. Both had provided much of Gordon’s care and had been splashed with blood during procedures. They had been involved in several resuscitations of Gordon and in numerous emergency bronchoscopies, which can generate infectious aerosols.
There was a lot of blood. In addition to bleeding from Gordon’s eyes, nose and mouth, a pulmonologist suctioned two liters of blood from Gordon’s lungs during one procedure. His blood soaked his sheets, his mother, Diane, recalled in an interview. The hospital staff organized and participated in massive blood drives for Gordon’s repeated transfusions.
The two women were the first LRMC staffers to treat Gordon as he arrived at the hospital. They had manually ventilated Gordon — giving him oxygen with a handheld device — and they had not worn masks or eye protection, Conger said.
Any exposure could have been the infection point, but Conger said he believed it was probably the initial contact.
“The people I worry about most are the first responders, where you don’t know what’s coming or you miss the diagnosis,” Conger said.
The respiratory therapist’s face shield had dislodged right after she’d been sprayed with blood during one procedure, Conger said. The ICU nurse got blood on her wrist during a resuscitation, when her gown sleeve slipped from the glove.
Neither one was aware of the breaches; colleagues reported seeing them.
“This is something you read in the literature,” Conger said. “People working with these dangerous agents and have a breach — they don’t recognize it or they’re in denial.”
Neither of the women became very ill. That was probably because they — along with 14 others who had cared for Gordon — received the drug Ribavirin, the only known treatment for several viral hemorrhagic fevers, although not Ebola, as a prophylaxis, Conger said.
The respiratory therapist had become the most ill.
“I believe the Ribavirin saved her life,” Conger said.
Anxiety, exhaustion It’s unclear how Gordon, with the 5th Stryker Brigade Combat Team, 2nd Infantry Division, became infected with CCHF. When he went to the base clinic on Sept. 8, he’d reported tick bites and exposure to undercooked goat meat and blood and was initially diagnosed with gastroenteritis.
CCHF is endemic in the Balkans, Turkey, India, Africa and Afghanistan. But no U.S. servicemember had ever been known to be infected with it.
“It was on our radar, but we’d been there so many years and had never seen a case,” Conger said. “I’m very proud of the way we handled it. They thought of it as a possibility so soon, and they got a diagnosis so quickly.”
LRMC staff isolated Gordon quickly in an airborne-infection isolation room with an anteroom, which had restricted visitation. Although experts say hemorrhagic viruses are not transmissible through the air, such rooms offer extra protection. Sign-in sheets tracked who entered the room, and those who did were required to wear fluid-resistant gowns, gloves, respirators, eye protection or face shields and shoe coverings.
Gordon’s diagnosis likewise was rapid. Staffers at the Bernhard Nocht Institute in Hamburg worked deep into the night to get blood test results to Landstuhl the next morning. By contrast, U.S. military officials in Italy have said getting test results from a lab in Rome for any suspected Ebola patients could take about three days.
Even once the diagnosis was confirmed, perfect compliance with rigorous, cumbersome protective measures proved physically and psychologically difficult.
“Your heart rate does go up. There’s anxiety,” Conger said. “I became much more deliberate. It is exhausting, and that was with one patient.”
Contact-tracing was begun as soon as Gordon’s diagnosis was confirmed at Landstuhl. More than 100 people underwent blood tests, including soldiers in Gordon’s unit, none of whom was infected.
A number of health care workers were concerned they might have been exposed to the virus. A medic who had treated Gordon on the medevac flight worried because he’d gotten blood on his ungloved hand during an emergency intravenous catheterization. A doctor at the U.S. combat support hospital in Kandahar who had performed an emergency intubation and had not worn a respirator also was worried. Blood tests showed that only the nurse and the respiratory therapist had been infected.
Conger and Pool recently teamed up to write an article about the case for the journal Emerging Infectious Diseases.
In the journal interview published at the time, Pool reflected on the experience of caring for Gordon, the most serious infection prevention case she’d ever had.
“I’m tired,” she said. “The whole thing was very emotional, because we did so many things to try to help this young man survive.
“And the whole time, you’re thinking: ‘What if 10 more come?’ ”
Jane Pool, director of Infection Prevention and Control at Landstuhl Regional Medical Center, hands Lt. Col. Nicholas Conger, then the hospital's top infectious disease doctor, a face mask during the 2009 treatment of Sgt. Robert Gordon. It was the military's only known case of Crimean-Congo Hemorrhagic Fever, a contagious and lethal infection similar to the Ebola virus. (Photo courtesy U.S. Air Force)
A Landstuhl nurse helps Dr. Erik Osborne get into his personal protective equipment that would be used if the medical center needed to treat someone infected with Ebola. (Photo courtesy U.S. Air Force)
