The Long Road Back

From the Winter 2015 edition of Vanderbilt Medicine Magazine

Photo by Nick Cote
Photo by Nick Cote

In early September 2014, Ian Crozier, M.D.,’97, supervised the jet evacuation of a critically ill patient from Kenema, the epicenter of the raging Ebola epidemic in Sierra Leone.

An exhausted Crozier told the medical team that he hoped he didn’t have to see them again. One week later, he did. This time he was the patient.

For 42 days last fall, Crozier, deployed by the World Health Organization (WHO), was known to the outside world simply as Patient No. 3. He was the third patient flown from West Africa to Emory University Hospital’s special isolation unit in Atlanta, set up in collaboration with the Centers for Disease Control and Prevention for patients with Ebola and other serious infections. Kent Brantley, M.D., the first patient, stayed for 19 days; American missionary Nancy Writebol, the second, was there for 14.

Brantley and Writebol were identified by the media at the time of their treatment and received a significant amount of media attention. When Crozier anonymously arrived in Atlanta on Tuesday, Sept. 9, both had been discharged and were continuing their recoveries at home.

Crozier, 44, became ill on Saturday, Sept. 6, when he developed a fever and headache during his morning rounds in Kenema. He aborted his rounds, alerted his team and isolated himself in his hotel room, where he was given a blood-drawing kit and drew his own sample. And then he sat down to wait for the results. “I had seen so many patients die in the past few weeks; of course my head and heart were aware of what might happen (to me),” he said recently in several conversations with Vanderbilt Medicine.

When he was given the positive Ebola diagnosis, he remembers briefly feeling afraid, but also an “odd” relief that he could actually get some sleep. Crozier began to talk with the WHO, preparing for his evacuation to Atlanta, and then to his brother, Mark, and his parents, telling them what was in store. “I told them I would be fine, and that I wanted them to be able to go through this privately,” Crozier said. “I remember this (waiting to be evacuated) being a very lonely time. I suspect that being both doctor and patient through this experience will be a watershed moment in my life. I’m still learning about how to be both, particularly as the story continues to unfold.”

Crozier, dressed in personal protective equipment, with Ebola-positive Sierra Leonean children. Schools remain closed in Sierra Leone and Liberia, two countries hit hard by the Ebola outbreak. Photo by WHO/K. Hurley.
Crozier, dressed in personal protective equipment, with Ebola-positive Sierra Leonean children. Schools remain closed in Sierra Leone and Liberia, two countries hit hard by the Ebola outbreak. Photo by WHO/K. Hurley.

Crozier, like many other health care workers infected during the epidemic, does not know how he contracted the virus. He had no obvious high-risk exposures, outside of normal patient care in the isolation unit, and does not recall any breaches of protocol while donning or doffing personal protective equipment (PPE). “Of course, almost every moment of my day was in some way engaged with suspected or confirmed patients, so the real possibility of exposure was always there; so was the constant and careful vigilance required to prevent transmission. But we trusted our PPE and had to keep in tension the need to prevent infection and the need to provide care.”

Outside the unit, there was a “no touch” policy, he said. “In fact, it was rare to ever actually touch another human being outside of PPE.”

Crozier said he remembers nothing about the first three weeks of his stay at Emory after walking “a few awkward supported steps” into the isolation unit. Soon after he arrived his diarrhea worsened (as much as 2 gallons a day), and his condition deteriorated. As the viral load (the amount of virus) in his blood reached extremely high levels, he became delirious, and his organs started to fail. On the sixth day in the hospital he was placed on a ventilator when he began to have difficulty breathing.

His knowledge about the course of his own disease comes from his medical team and his family and from “sobering” reviews of his own chart. Crozier said he “cannot find words” to express how much of a role his family and friends played in his recovery. His mother, Pat, spent nights at the hospital and through a curtained window with a phone line, read to him, including a poem written by his uncle, poet and novelist John Eppel, “that I will weep about for the rest of my life,” Crozier said.

“Ian was the sickest patient we had at Emory,” said Colleen Kraft, M.D., one of his doctors. “He had multi-organ failure, requiring mechanical ventilation and continuous dialysis for his kidneys. He had a viral hepatitis and we presume that he had encephalitis.”

Kraft said that medical literature has shown that patients with a higher viral load have a poorer prognosis, and Crozier’s was the highest among the patients cared for at Emory.

“When Ian was at his sickest, and even in the early phases of his recovery, we were not sure that his neurological status would return to baseline, and we were not sure that his kidneys would recover either,” Kraft said. “It has been very rewarding to see him make what we feel is an extraordinary recovery.”

Crozier said he didn’t allow himself to think about his mortality. “Even after I woke up at Emory many weeks later, I wasn’t fully aware of how closely I had looked death in the eye. Given my own clinical experience, if you had told me during my first week at Emory that I would soon develop encephalopathy, respiratory failure, kidney failure, cardiac arrhythmias, etc., I would have expected my survival chances to be almost zero.

“This is one of the reasons the critical care provided me at Emory was so important. It blazed a trail so far thought to be futile. And I would have agreed. No one can script the alternative, but I believe I would have been dead a week later had the same clinical course unfolded in Kenema.”

Crozier agreed to a New York Times interview about his experience following his first follow-up exam at Emory in November. “The focus had been on my recovery, and the ability to do that off the radar was a gift,” he said.

Crozier, standing in scrubs, and one of the Sierra Leone nurses, kneeling, pose with a group of survivors after they were discharged from the Ebola Treatment Unit. Photo by WHO/Jackson Amone.
Crozier, standing in scrubs, and one of the Sierra Leone nurses, kneeling, pose with a group of survivors after they were discharged from the Ebola Treatment Unit. Photo by WHO/Jackson Amone.

But he also wanted to thank those who had helped him – the WHO, for deploying him to Kenema in the first place, for arranging his evacuation with the State Department, and for enabling his care; his “remarkable” health care team at Emory; and he also felt it was important to share medical and scientific aspects of his care that could impact the way the sickest Ebola patients are cared for. For instance, at that point, neither mechanical ventilation nor renal replacement had been well described in Ebola patients.

Crozier said that much work is left to be done in treating and controlling Ebola. “Remember that this epidemic, and its potential to spread to other parts of the world, will not be over until six weeks after the last contact with the last case. We are far from finished.”

 

Mentored at Vanderbilt

Crozier grew up in Bulawayo, Zimbabwe, then immigrated to the United States with his family when he was 10. After stops in Kentucky and North Dakota, the Croziers ended up in a small Iowa town, and much later relocated to Phoenix. He was one of 149 students awarded the Justin Potter Medical Scholarship (available from 1964-1994) while at Vanderbilt University School of Medicine.

His four-year scholarship funding provided full tuition, and a small stipend, and enabled Crozier to pursue interests after his training without being constrained by debt. “Over the years I’ve come to recognize even more how much the Potter Scholarship enabled. It’s been such a gift,” he said.

After medical school, Crozier was an Internal Medicine resident at Vanderbilt and then chief resident. He then joined Doug Kernodle, M.D., for a research fellowship in the Division of Infectious Diseases. Crozier fondly recalls his time in Nashville. “These were Camelot years for me; I found my thinking about both the science and art of clinical medicine so wonderfully shaped by incredible mentors, whether they knew it or not. Those clinicians and teachers had such an impact on the way I think and on the way I relate to my patients as a doctor.”

 

A profoundly changed life

After Vanderbilt, Crozier partnered with Accordia Global Health Foundation, and was living in Uganda, treating patients and training Ugandan doctors in increasingly complex HIV medicine at the Infectious Diseases Institute in Kampala. In August as the Ebola epidemic rampaged through West Africa, he contacted a good friend and colleague working in Sierra Leone about helping. He signed on with the WHO Global Outbreak Alert Response Network (expenses only, no pay) and was in Kenema a week later helping treat up to 60 to 80 patients a day. He had been in Kenema only three weeks when he became infected with the virus.

His experience treating patients in Kenema and then contracting the virus himself have left a few scars, Crozier said. He initially lost 30 pounds, has lost most of his thick crop of brown hair, and still struggles with some word-finding and short-term memory. And there are long-term, yet-to-be-determined lessons as well. “In some ways, I’m starting to feel the soil under my feet again,” he said. “And while I would never choose this outcome on the front edge, of course, the chance to engage this epidemic as both doctor and patient will be something that will profoundly change my life in many ways.”

Having been in both spaces, he said he has a new appreciation for the “harsh, uncomfortable, lonely and undignified space that is any Ebola Treatment Unit” in which his patients in Kenema recovered or died. “It’s a privilege not only to provide excellent technical clinical care, but also to lend suffering patients some dignity in that setting,” he said.

“I was just in Kenema for a short while. There are many incredibly quiet heroes among the national staff and international responders who have been doing this for much longer, and with very little fanfare, and some of them can no longer tell their stories,” he said. “We should honor their stories, and in doing so, consider how we might respond to both the short- and long-term needs on the ground. The short-term devastation is obvious; we have much to learn as the long-term effects of this epidemic become painfully obvious.”

Crozier hopes to return to West Africa as soon as he can, but he isn’t sure in what capacity. It will depend on how soon he regains his health. He is still recuperating, initially fighting extreme fatigue and some cognitive and short-term memory issues, and recently battling a sight-threatening inflammation in his left eye. He had been getting stronger in Arizona with his family after being discharged from the hospital, but more recently has been undergoing extensive testing and treatment at Emory related to his eye.“I have some ongoing clinical skirmishes which will require attention for a time. Aside from that, though, I’m incredibly grateful to be alive,” he said.