Emory at Grady Hospital: Tracking down TB

Susan Ray
Sooner or later, every single case of diagnosed or suspected tuberculosis at Grady is referred to hospital epidemiologist Susan Ray.

 

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Many doctors in the U.S. have never seen a case of tuberculosis.

Doctors at Grady Hospital diagnose a case per week, more than the total diagnosed in some states in a year. It’s not that Atlanta has more TB than other large cities, says Susan Ray, chief of Emory’s infectious disease service at Grady. It’s that Grady doctors know when to screen for TB—and how to recognize it when it isn’t obvious.

That expertise saved Carlos Flores. When Flores’ headache and cough wouldn’t go away, leaving him progressively weaker and thinner, his girlfriend persuaded him to go to Grady.

The first shock was being told he was HIV-positive. An HIV diagnosis both raises the risk of TB and changes how it behaves. His previous doctor thought Flores had a bad cold, perhaps because the simple TB skin test misses a third of active cases and Flores had no coverage for other tests. At Grady, X-rays showed enlarged lymph nodes in his chest, but sputum smear test results were negative. It took bronchoscopy, with use of a molecular probe, to confirm TB.

The second shock for Flores was learning not only that he had TB but the extent of its invasion. Hidden away, his TB had traveled stealthily through his lymphatic system, affecting nodes in the spinal cord and brain. As treatment began, his immune system fought back with inflammation and swelling, leaving him temporarily unable to walk.

Steroid therapy slowly resolved the swelling. If Flores had not had TB, he would have been sent to a nursing home to recover. Instead he spent six weeks in the Grady ICU. Today, months later, his HIV is under control, thanks to care from other Emory infectious disease specialists at Grady’s Ponce de Leon Center, and he is no longer contagious for TB. He is back home and back to work in a local restaurant.

While the cost of uncompensated care in such cases is always high, finding and wiping out this patient’s TB was worth every penny, says Ray, both to him and to others at risk for spread of the disease.

       
   

Sooner or later, every single case of diagnosed or suspected tuberculosis at Grady is referred to Susan Ray. As hospital epidemiologist, the Emory medical professor helps Grady maintain its nationally recognized ability to prevent the spread of TB and other infectious diseases. As state TB consultant, Ray also makes sure new TB patients are referred to their local health department and, for patients who are HIV positive, linked to good HIV care.

Emory faculty and residents provide 85% of the care at the publicly funded Grady Hospital, where patients receive extraordinary care, often in Emory-led programs not widely available elsewhere in the region, including poison control, high-risk pregnancy, burns, HIV/AIDS, stroke, cancer, diabetes, and sickle cell disease.

Emory faculty provided $25.4 million in uncompensated care at Grady in fiscal year 2014-2015.  All payments for Emory services for patients who do have some coverage go to the Emory Medical Care Foundation, which uses this revenue—$45.4 million last year—to support Emory’s mission at Grady.

 

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