Bishop, Calif., teen survives hantavirus infection with lifesaving treatment
Jordan Herbst, a 14-year-old resident of Bishop, Calif., is at home recovering from a life-threatening and rare infection with hantavirus, through the efforts of pediatric specialists at hospitals in Inyo County, Reno, Nev., and at UC Davis Children’s Hospital, including critical-care medicine physicians in the Pediatric Intensive Care Unit/Pediatric Cardiac Intensive Care Unit and the truly heroic efforts of the hospital’s Pediatric Critical Care Transport Team, which hand-ventilated the teenager for more than two hours while airlifting him from Reno to Sacramento.
Hantavirus is exceptionally rare. It is transmitted almost exclusively by contact with rodent excrement or urine. Only 55 cases have been confirmed in California, according to the U.S. Centers for Disease Control and Prevention (CDC). A notable outbreak occurred in 2012 in the Curry Village area of Yosemite National Park, where eight people became ill, three of whom died.
Jordan began to feel sick on Saturday, Aug. 10, while returning to Bishop from a vacation in Eugene, Ore. with his mother, Katharine Allen, co-president of InterpretAmerica and owner of a translation and interpreting business in Bishop called Sierra Sky Interpreting and Translation. With a population of about 4,000, Bishop sits in the northern part of Inyo County at the northern end of the Owens Valley, with the Sierra Nevada to the west and White Mountains to the east.
“The care that Jordan received at UC Davis went above and beyond all expectations. When the Pediatric Transport Team walked into Jordan’s room in Reno, we felt like the Navy Seals had come to the rescue. And then when Jordan arrived at UC Davis, it was clear that he was receiving the highest level of care possible. We knew he was dying and that his only chance was getting him to the trauma team and sophisticated technology available at UC Davis.”
— Katharine Allen, Jordan's mother
Allen recalled that her son had been feeling under the weather throughout the two-day road trip home. She thought he had a virus, possibly the flu. “On both days of the drive he was complaining of feeling achy and kind of feverish. I thought, ‘Well, he’s either getting a cold, or he’s tired from all of the driving,’” Allen said. “Still, he was pretty perky until he went to bed on Sunday night.”
Jordan became nauseous and began vomiting shortly after midnight. Allen said that she decided to spend the night in her son’s bedroom because he felt so badly. His temperature hovered at around 103 degrees. He seemed to be feeling better the next morning, though, and she thought that he had “sweat out” the fever. That evening, however, his fever returned and she spent another night with her son.
But early on the morning of Tuesday, Aug. 13, Allen said that she could see that her son was struggling for oxygen. His breathing was rapid and shallow, and his heart was racing. She had called the local clinic for advice. The nurse there was a survivor of hantavirus and suspicious of flu symptoms in the summertime. She immediately referred Jordan to the local emergency department at Northern Inyo County Hospital, a 25-bed hospital in Bishop.
Jordan had been a healthy, active and athletic teenager, whose blood oxygen saturation level on previous examinations had hovered around 100 percent. The physician suggested that Jordan might have pneumonia and immediately placed him on oxygen. Doctors there drew Jordan’s blood, took X-rays of his chest, and found that both of his lungs were filling with fluid.
Jordan’s father, David Herbst, a research scientist with the University of California’s Sierra Nevada Aquatic Research Lab, joined Jordan and his mother at the hospital emergency department.
The first airlift: Renown in Reno
The doctors told the parents that, although he was young, healthy and strong and could handle struggling to breathe for a long time, eventually that struggle would exhaust him and he would need medical support not available at Northern Inyo Hospital. Fearing that moment was imminent, they immediately made arrangements to have Jordan airlifted to Renown Regional Medical Center in Reno. Because there was room for only one person to accompany Jordan in the aircraft, his mother traveled with him. David Herbst and Jordan’s older sister, Anna, 17, made the four-hour-long drive to join them in Reno.
Jordan arrived in Reno on Tuesday afternoon. The staff there placed him on oxygen and medications, but eventually had to sedate and intubate him and place him on a ventilator. Intravenous lines were placed in his arms and into his femoral artery, signaling the therapy that was to come and that ultimately would save his life. At this point, despite their determined efforts, the physicians at Renown barely were keeping Jordan alive. His blood pressure and oxygen levels had ‘crashed.’ “We stayed up with him throughout the night as his blood pressure and blood oxygen remained at dangerously low levels,” Herbst said.
Then, in the early morning hours of Wednesday, Aug. 14, Jordan’s physicians came and spoke with his parents again. Jordan was pale, blue and sedated.
“They said ‘We can’t manage this. You need to get him to a better-equipped hospital,’” Herbst recalled. “His only hope was to be airlifted again to UC Davis Children’s Hospital in Sacramento, where they had a device called ECMO (extra-corporeal membrane oxygenation),” he said.
Dean Blumberg, chief of the division of pediatric infectious diseases at UC Davis Children’s Hospital, said the decision by doctors at Renown to transfer their patient was crucial to Jordan’s survival.
“One of the scariest aspects of hantavirus pulmonary syndrome is the dramatic clinical deterioration that occurs over the course of hours,” Blumberg said. “Despite maximal conventional supportive efforts, the respiratory failure relentlessly progresses. Intervening with extra-corporeal life support for a relatively short period of time is a lifesaver for these patients.”
The second airlift: UC Davis Children’s Hospital
Physicians in Reno already had contacted UC Davis Children’s Hospital, which dispatched its specially trained Pediatric Critical Care Transport Team. The team provides specialized neonatal/pediatric transports from referring facilities back to UC Davis Children’s Hospital. Although sending a specialized team may prolong the arrival to the accepting facility, recent studies have shown that improved care and better outcomes are realized with such teams.
“What’s amazing about the medical technology at UC Davis is that, you can line up all of these pieces of technology so that the net result is homeostasis. It was really impressive to see it firsthand. It wasn’t just the technology; it was the knowledgeable and truly caring people who impressed me. From the doctors who were doing the work to support him, to the nurses and respiratory technicians. They accomplished a pretty miraculous save, because they truly cared. Everybody was so stoked they saved Jordan’s life. ”
— David Herbst, Jordan's father
When they arrived at the hospital at around 9 a.m. one of the members of the transport team was Darrell Griswold, a seasoned pediatric transport nurse. Griswold informed Jordan’s parents that it was difficult to stabilize him for transport. And he had to give them more sobering news.
“He wasn’t able to maintain a blood pressure,” Griswold said. “He was pale and had really cold extremities. His oxygen saturations were in the 70s and 80s ― really low. He was one of the most critically sick patients I’ve ever transported.
“I had to tell them that he was so sick, I didn’t know whether or not he would be able to survive the transport,” Griswold said. “That was really hard.”
But the transport team was determined to save Jordan. So determined, in fact, that Griswold and another member of the team, transport nurse Ken Toles, would hand ventilate — or ‘bag’ ― Jordan throughout the trip from Renown to the fixed-wing airplane at the airport in Reno and throughout the flight to Executive Airport in Sacramento and then from the airport to UC Davis Children’s Hospital ― for a total of about two hours.
“After two hours of driving,” Jordan’s father recalled, “I heard that he had arrived alive and had been taken to the Pediatric Intensive Care Unit. Within minutes of arriving at the hospital we heard over the intercom ‘code blue on Floor 10.’ I rushed there to find his room filled with medical staff, busy in life-saving mode, that they had done CPR on Jordan for six minutes, and had just brought his heartbeat back after inserting a cannula into his heart to connect him with ECMO.
“He had been pale and blue when he left Reno. Now at least he was getting oxygen,” Herbst said.
A “miraculous save”
Herbst had witnessed his very sick son’s response to being placed on extra-corporeal life support, called ECLS, or ECMO. The technology is reserved for patients who have an at least 75 percent chance of dying should they not have access to the procedure. ECMO is used to provide pulmonary support to patients whose own lungs are so damaged that they cannot function properly. In Jordan’s case, blood from his veins was circulated through the machine, re-oxygenated and then returned to the right side of his heart, pumping blood to his lungs and the rest of his body.
At UC Davis Children’s Hospital, all patients on ECMO have a bedside nurse dedicated to the care of the patient and a second, specially trained nurse committed to the management of the ECMO machine. A physician trained in ECMO technology manages or co-manages each of the patients on ECMO and a UC Davis Medical Center perfusionist is available 24 hours a day, seven days a week to assist with the equipment and patient management.
Herbst, who is a UC Davis alumnus, said that, once Jordan no longer was struggling to breath, his immune system could do the work of fighting off the hantavirus infection.
“What’s amazing about the medical technology at UC Davis is that you can line up all of these pieces of technology so that the net result is homeostasis,” he said. “It was really impressive to see it firsthand. It wasn’t just the technology; it was the knowledgeable and truly caring people who impressed me. From the doctors who were doing the work to support him, to the nurses and respiratory technicians,” Herbst said.
“They accomplished a pretty miraculous save, because they truly cared. Everybody was so stoked they saved Jordan’s life.”
A collaborative approach to medicine
John Holcroft, assistant professor of pediatric critical-care medicine, was the attending physician when the young patient arrived in the intensive care unit. He spoke for all of the emergency and critical-care medicine physicians, and the specially trained nurses and therapists who treated Jordan at UC Davis.
"It is a privilege to work with so many caring, hard working providers at UC Davis Children's Hospital,” Holcroft said. “Upon Jordan's arrival, he had waiting for him: a cardiothoracic surgeon, a cardiologist, an echosonographer, an ECLS perfusionist, several registered nurses (including one called in from home to monitor the ECLS circuit), a respiratory therapist and administrative support. All of these people, working together, saved Jordan's life, and that was just in the first few minutes of his arrival. Within hours, many other physicians, nurses and therapists continued to provide support. I believe that this collaborative approach to medicine is what makes UC Davis Children's Hospital special."
"This is what we do here,” Holcroft continued. “We have the state-of-the-art equipment and the highly skilled people trained in its use who can treat the very sickest patients, often bringing them back from near death. I feel very glad to have been able to be a part of caring for Jordan, and am genuinely gratified that we were able to send him back home to his family and friends. It's the best part of what I do here."
Jordan would remain on ECMO for about 60 hours. He would be removed from the device on Thursday, Aug. 22. In a rapid turnaround, he would be ready to be discharged from the hospital five days later on Aug. 27. The teenager is continuing to mend at home, and is expected to make a full recovery, though he will receive physical therapy to help him regain his strength. Throughout the ordeal he lost 10 pounds, most of it muscle.
Allen said that everyone at his school, and as is typical in a sparsely populated community, everyone in the Eastern Sierra knows about his illness.
“The care that Jordan received at UC Davis went above and beyond all expectations,” said Allen, who frequently works with hospital systems to help them improve care systems for non-English speaking patients. “When the Pediatric Transport Team walked into Jordan’s room in Reno, we felt like the Navy Seals had come to the rescue. And then when Jordan arrived at UC Davis, it was clear that he was receiving the highest level of care possible. We knew he was dying and that his only chance was getting him to the trauma team and sophisticated technology available at UC Davis.
“I will be forever grateful to the many, many wonderful providers who first saved Jordan’s life, and then worked so tirelessly to limit any long-term negative outcomes from his near-death experience. They never lost sight of a future for him that included a complete recovery. Thanks to them, Jordan is home and solidly on the path back to a healthy, normal, teenage life. For us, it is a miracle.”
Jordan had one simple message for all of the doctors, nurses and others who cared for him, from Bishop, to Reno to UC Davis.
“I’m very thankful I’m alive,” he said. “Thanks for saving my life.”
About Extra-Corporeal Life Support
Extracorporeal life support (ECLS), also known as extracorporeal membrane oxygenation or ECMO, is one of the most advanced forms of life support available to patients experiencing acute failure of the cardiac and/or respiratory systems. The ECLS machine does the work of the heart and lungs, artificially oxygenating and purifying the blood and returning it to the body, allowing the patient's heart and lungs to rest and heal.
At UC Davis Children’s Hospital, ECLS is provided by a team of physicians, nurses and perfusionists trained to provide extra-corporeal life support. All patients on ECLS have a bedside nurse dedicated to the care of the patient and a second specially trained nurse committed to the management of the ECLS machine. A physician trained in ECLS technology manages or co-manages each of the patients on ECLS and a UC Davis Medical Center perfusionist is available 24/7 to assist with the equipment and management of all patients.
Last year, UC Davis Children's Hospital received the Excellence in Life Support Award from the international Extracorporeal Life Support Organization (ELSO) for its Extracorporeal Life Support Program. The program provides lifesaving support for failing organ systems in infants, children and, in some cases, adults. The award recognizes centers worldwide that demonstrate an exceptional commitment to evidence-based processes and quality measures, staff training and continuing education, patient satisfaction and ongoing clinical care. UC Davis Children's Hospital is one of only a few hospitals to receive the award since its inception in 2006.
The ELSO Award signifies to patients and families a commitment to exceptional patient care. It also demonstrates to the health-care community an assurance of high-quality standards, specialized equipment and supplies, defined patient protocols and advanced education of all staff members.
"The most wonderful part of this program is being able to offer to patients and their families an opportunity for recovery that otherwise would not exist," said ECLS program coordinator Laura Kenny. "It is incredibly rewarding to send a child home with their parents who would not have survived without ECLS."
Recipients of the Excellence in Life Support Award are designated as Centers of Excellence for having demonstrated extraordinary achievement in the following categories:
- Excellence in promoting the mission, activities and vision of ELSO
- Excellence in patient care by using the highest-quality measures, processes and structures based on evidence
- Excellence in training, education, collaboration and communication that supports ELSO guidelines and contributes to a healing environment
"What makes the Extracorporeal Life Support Program at UC Davis so special is the chance to work closely with such a wonderful team, to help our very sickest patients," said Robert Pretzlaff, chief of the Division of Pediatric Critical Care Medicine in the Department of Pediatrics of the UC Davis School of Medicine.
The Extracorporeal Life Support Organization is a consortium of health-care professionals and scientists dedicated to the development and evaluation of novel therapies for the support of failing organ systems. The organization promotes ongoing research into the most effective treatment methods by maintaining a registry of patients receiving extracorporeal membrane oxygenation and providing educational programs for member centers and the broader medical and lay communities. More than 115 international ECMO centers are members of ELSO, which is headquartered in Ann Arbor, Mich.
Hantavirus pulmonary syndrome: What are the risks?
Recent cases of hantavirus infection linked with a campground at Yosemite have increased interest in symptoms and risks for the disease. In this Q&A, Stuart Cohen, professor of infectious diseases and chief of infection control at UC Davis Medical Center, puts the disease in perspective.
Q: What causes hantavirus infection?
Cohen: Hantavirus infection is caused when the virus is excreted by mice or rats into the environment. The virus is then transmitted to humans when they breathe in airborne dust that includes urine or fecal matter from the infected rodents. In one case a number of years ago, for instance, a hantavirus patient was infected after shaking out a stored blanket in a cabin at a Northern California campground.
Q: What are the symptoms?
Cohen: The initial symptoms are similar to the flu, including muscle aches, headache and fever. The virus may also cause nausea or vomiting. After this initial stage, hantavirus rapidly affects the lungs, causing shortness of breath, oxygen levels in the blood to drop, and possibly fluid in the lungs and decreased heart function. It's the pulmonary effects that can make the disease fatal.
Q: Is it common?
Cohen: Hantavirus pulmonary syndrome is rare — the chance of getting the disease is 1 in 13,000,000, which is less likely than being struck by lightning. There have only been about 50 total reported cases in California since the disease was first recognized in the U.S. in 1993. However, because it is uncommon, physicians aren't necessarily on the lookout for it when patients have flu-like symptoms, especially in those who are otherwise fit and healthy. Effective treatment requires active management of pulmonary symptoms well before they become severe.
Q: Is everyone at risk?
Cohen: Anyone who has been camping, working or doing outdoor activities where mice or rats are common, especially in rural areas, and comes down with flu symptoms within six weeks should seek medical treatment. A blood test can confirm hantavirus exposure. It is important to know that the virus is not spread between humans, so friends or family members with the disease are not contagious.
Q: What are the treatments?
Cohen: There are no medications specific to hantavirus, but pulmonary interventions like intubation can help patients breathe adequately and prevent the lungs from retaining fluid until the virus runs its course. In severe cases, a technique known as extracorporeal membrane oxygenation can help maintain an adequate oxygen supply in the blood.
Q: Are there any new treatments in the works?
Cohen: It is hoped that better understanding of the genetics of hantavirus will lead to targeted antiviral medications that can halt it in its earliest stages, but the best approach to hantavirus control is prevention. All indoor areas where rodents are common should be cleaned with a 10 percent bleach solution, and then dirt and dust should be wiped up, rather than swept away, to reduce the possibility of dust becoming airborne.