A medical record from an Ebola case made for grim reading, but Ian Crozier could not put it down. Within days of the first symptom, a headache, the patient was fighting for his life. He became delirious, his heartbeat grew ragged, his blood teemed with the virus, and his lungs, liver and kidneys began to fail.
“It’s a horrible-looking chart,” Crozier said.
It was his own. Crozier, 44, contracted the disease in Sierra Leone while treating Ebola patients in the government hospital in Kenema. He was evacuated to Emory University Hospital in Atlanta on Sept. 9, the third US citizen with Ebola to be airlifted there from west Africa. He had a long, agonizing illness, with 40 days in the hospital and dark stretches when his doctors and his family feared he might suffer brain damage or die. His identity was kept secret at his request, to protect his family’s privacy.
Illustration: Mountain People
Now, for the first time, he is speaking out. His reason is to thank Emory for the extraordinary care he received and to draw attention to the continuing epidemic, he said. He and his family granted their first interviews to the New York Times and gave permission to interview his physicians.
His account offers glimpses of the hardships and dangers that have confronted doctors and nurses who volunteered to fight an epidemic that has claimed the lives of more than 330 healthcare workers — most of them African — and of the desperate need that has drawn them to the frontline.
Crozier told of three brothers, aged four, five and 11, who fought for their lives on his ward in Kenema. Not long after, he lay near death in an isolation room at Emory, with his mother reading him poetry through an intercom.
Crozier, soft-spoken and genial, is now on the mend in Phoenix, Arizona, where his parents and sister live. Yet the disease has taken its toll. Standing 1.9m tall and weighing 100kg before he got Ebola, he has lost 14kg, much of it muscle. He tires easily, but has begun a grueling physical therapy program to rebuild wasted muscles.
“Ian was by far the sickest patient with Ebola virus that we’ve cared for at Emory,” infectious disease specialist Jay Varkey said.
Doctors say his recovery has taught them that aggressive treatments, even life-support measures like ventilators and dialysis machines, can save some Ebola patients.
Bruce Ribner, who leads the Emory team, said that until recently the general practice was not to bother intubating Ebola patients, or put them on dialysis, because if they got that sick they were going to die.
“One of the things Ian taught us was, guess what, you can get sick enough to need those interventions and you can still walk out of the hospital,” Ribner said. “I think it has sent a message to our colleagues around the world.”
CRACKS OF JOY
Crozier was born in Bulawayo, Rhodesia (now Zimbabwe), but his family moved to the US when he was 10, and he became a US citizen. He went to medical school at Vanderbilt University on a scholarship, specializing in infectious diseases.
He was always drawn back to Africa. He was living in Uganda, treating patients with HIV and training doctors at the Infectious Diseases Institute in Kampala, when Ebola broke out in west Africa. He wanted to help.
“Anyone who was on the ground in Africa and not in west Africa, you would think, maybe we’re missing the bus, missing something remarkable,” he said. “And my skills meet the need.”
Crozier signed on with the WHO — expenses only, no pay — and by August he was in Kenema. He planned to stay three or four weeks.
It was even more wrenching than he had imagined — the sights, the sounds, the smells, the steady stream of deaths. There were often 60 to 80 patients, sometimes more, suspected and confirmed cases, from all over the nation. They arrived day and night.
Blood, stool and vomit were ever-present though cleaners mopped with chlorine several times a day. Choruses of delirious patients with bloodshot, eerily vacant eyes would shout “Doctor! Doctor!” over and over. Some were too sick to clean or feed themselves, and there were never enough staff members to tend to them. A patient might lie in one bed and a corpse in the next, waiting to be disinfected, bagged and taken away.
“Those isolation wards are horrible places,” Crozier said.
However, there were moments of grace. Mothers whose babies had died would feed children who were orphaned or alone.
“Childless parents took care of parentless children,” he said.
The protective gear required to enter the ward — hood, masks, rubber boots, goggles, double gloves, Tyvek suit — was stifling. No one could wear it for more than an hour without becoming dangerously overheated. Crozier would go into the ward two or three times a day for as long he could stand it. When he came out to cool off, he would pour the sweat out of his boots.
One night, the three young brothers were brought in. All were infected. Their mother had died, and their father was absent.
“I didn’t think they would survive,” Crozier said.
The oldest, Victor, 11, was also the sickest. Crozier, the oldest of four children in his family, saw a bit of himself in Victor. The boy had taken on the role of father, and even when he was lying on a mattress on the floor, soiled by vomit and diarrhea, the younger ones, Shaku and Ibrahim, would not leave him.
“They were this little band of brothers,” Crozier said.
Sometimes he wished he could rip off his protective gear and hold them.
The last thing he would do at night was make sure they and the other children were fed.
Returning to the ward each morning, he kept expecting to find that one or more of the brothers had died, but they kept surprising him.
“They just sort of pushed each other through it,” Crozier said.
They recovered enough to race around the ward with other children — including two boys named Success and Courage — playing, laughing and making a nuisance of themselves, Crozier said.
“In such a dark place, they were little cracks of joy,” he said.
The brothers survived, but others like them did not.
STRUGGLE TO SURVIVE
Many local nurses had contracted Ebola and died in Kenema. Aid workers from other nations also became infected and Crozier arranged medical evacuation flights for several of them. He never dreamed he would become a passenger on that plane.
On the morning of Saturday, Sept. 6, during rounds on the ward, he developed a fever and a headache. He isolated himself in his hotel, hoping he had malaria. A colleague brought equipment so Crozier could draw his own blood for an Ebola test.
She called him the next morning, crying: His Ebola test was positive.
He had no idea how he had become infected.
The plane picked him up on Monday. The WHO paid for the flight and his medical care. Neither the WHO nor Emory would provide an estimate of the cost, but a spokesman for Emory acknowledged that treating Ebola patients was very expensive.
Crozier took pictures of himself during the flight as his face swelled and he broke out in a rash. It might have been a way to disconnect from fear, he said.
“I had seen seven, eight, nine, 10 people a day die from what I had,” he said, adding: “If I had stayed in Kenema, I would have been dead in a week.”
He has no memory of the three weeks after he arrived at Emory. The isolation unit there was built 12 years ago at the request of the US Centers for Disease Control and Prevention (CDC), which is less than 2km away.
Varkey said there were warning signs early on that Crozier might become severely ill. The viral load in his blood was extremely high, more than 100 times that of the other patients Emory had treated. In addition, he was becoming delirious, a sign of encephalitis. Doctors do not know why some patients become so much sicker than others. Crozier’s age might have worked against him: People over 40 tend to have worse outcomes than younger ones.
His family and girlfriend were filled with dread as they watched him decline. They could not enter his room, but could see him through a window and talk to him over an intercom. His temperature was 40oC. His hands shook violently. He spent more and more time sleeping, and sank into delirium, his mind still in Kenema.
The family had been warned that Ebola often causes such intense diarrhea that patients can lose 3.6 liters to 4.5 liters of fluid a day, and Crozier was heading toward that stage. He would be pumped full of fluids and salts to prevent dehydration, which kills many Ebola patients. The family thought that once he got through that phase, he would start to improve.
Instead he got worse. By Friday he was struggling to breathe, his chest heaving. The sight tore at his relatives. On Sunday morning, he was placed on a ventilator.
“It seemed to signify final stages,” his sister Anne said.
A nurse who had also been infected in Kenema, Will Pooley — whose evacuation Crozier had supervised — flew to Emory from England and donated several units of plasma. Survivors have antibodies that can help fight off the virus, and a number of patients have been given such transfusions.
Crozier’s virus levels began dropping, but his kidneys failed, and he was connected to a dialysis machine. He had swelled up with 9.1 liters of excess fluid, and all that his relatives could see through the window were tubes, machines and a bloated face they barely recognized. He had begun having abnormal heart rhythms. Doctors warned that he might not survive.
He was on the ventilator for 12 days and on dialysis for 24 days. Members of his family read him e-mails from friends, played his favorite music and told him over and over that he would be all right. They gave his nurses dozens of family photos to tape to his walls.
His mother, Pat, spent most nights at the hospital. She spoke to her son, hummed hymns and every day read him a poem that her brother in Zimbabwe, the poet and novelist John Eppel, had written for him.
The poem recalled Crozier as a bald, big-headed boy who waged war with syringa berries, “the stick-breaker, the toddler I carried on my shoulders up and down the dirt tracks.”
Pat Crozier had been a nurse-midwife, and her training made her painfully aware of signs that her son was deteriorating.
“The really tough part was the thought that he was going to die and that I was not going to be able to touch him before he left the earth,” she said. “So he was either going to go in a body bag to the CDC for research, or he was going to be incinerated rapidly.”
BACK FROM THE BRINK
He began to recover physically. However, there were ominous signs that he might have suffered brain damage: His eyes wandered in different directions and he took a long time to wake up when his sedation was withdrawn.
“I thought we would be discharging him to a nursing home as a cognitively impaired person,” said Colleen Kraft, one of his doctors.
She said his difficult course had left her in a “dark psychological place” that, for a while, had made her feel hesitant about treating more Ebola patients, for fear that they might be as sick as Crozier.
When he finally did open his eyes at the end of September, a few days after his 44th birthday, he looked around the room in a way that reminded his sister, Anne, of a newborn baby. She spoke softly through the intercom, as if he were a child. Her voice, reassuring him that he was all right, is the first thing he remembers.
At first, he had trouble making conversation. However, he grilled doctors about his lab results, so the family knew his mind was intact.
There are scar-like lesions on his retinas, and it is not clear whether they are getting better or worse. Though people around him do not notice it, he said his mind was not working as fast as it should, and he sometimes has trouble thinking of the word he wants to say.
“It’s a fear,” he said. “Am I going to be myself again, completely?”
Crozier hopes to return to west Africa by February or March to help treat more Ebola patients. Survivors are thought to be immune to the strain that infected them, so he figures he has built-in protection.
“There’s still a great deal left to be done,” he said.
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