Ebola 11

This could be the last message from Sierra Leone, though I might put a postscript in once I have uploaded all of my camera pictures back at home.

I’m catching the bus back to Freetown, for the most dangerous part of the whole trip: the nighttime boat trip across the sound to get to the airport. They offer you life jackets that have no means of fastening across the chest; it will be in darkness; and there is not a single navigation light in sight!

This morning I went to the ETC one last time to say goodbye to all he friendly Sierra Leonians, being greeted by many, “Dr Charles! With a big smile and the obligatory , “How are you?” It’s rude not to ask this in return. I also thanked the Cuban brigade. They have come right out of their shells now and are taking on more and more reposnsibility. Claire, a GP who has been working in he role of Quality Assurance, told me that the atmosphere was totally different in that the nurses’ station is now buzzing with national, Cuban and other international staff all working together. Three weeks ago the Cubans were hiding away in another area. So we might have helped this happen by drawing them into discussion. In the past two days when I have been leading the handovers, ( please note the correct spelling for the first time, no hangovers are really conducted at he ETC), members of the national team and Cuban team have spontaneously come forward with ideas for improvement. These are needed: this morning we started preparing a patient for discharge who was not yet ebola positive . Although she is well and will have a very low viral load now, it would have been very serious to put someone potentially still infectious into the discharge tent, shake their hands symbolically as a mark of confidence in their safety, and them send them back to their community. Their are a small number of names in supply, lots people with the name Fatima, Fatmata, Agnes, Obai, Mohammed, with surnames Foday, Kamara, Komora, Sesay. So it is common to have two patients with the same or similar names in one 10 bedded ward. We have to check the numbers obsessively.

Later I had another chat, or small lecture, on leadership, from the irrepressible and impressive Mr Tamba, the supervisor of the CHO’s. He is worshipped by them, and said his secret is to get into the ward and do he same work rather than just direct from a safe distance. I know this to be the case as he likes taking me into the red zone and giving me a dozen jobs to do, and I feel helplessly drawn into just obeying. However he calls me his brother, and when we had a dispute over one female patient who was wanting both of us as a husband, he said I could have her.

After more discussions about problems facing the unit, I headed for the discharge tent and watched a brother and sister go through the process. She looked about 14 but told me she was 20; he could have been 25 or 35. Both were clearly very poor, were thin even before Ebola, and both illiterate, as instead of signing a form they had their thumbs painted in biro and pasted a fingerprint. I did not see them leave, but left them smiling and clutching their certificates and $750,000 sierra Leonian dollars (£ 90). I wonder how the next few days and weeks are going to be for them. There is still a lot of cruelty toward survivors as people fear them.

It’s hard to leave now, but I’ve just had a swim and my head is thinking of Juliet, the children, family, home, the puppy and cheese.

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Ebola 11

Just some images. Happy christmas everybody. Am now looking forward to getting home now!

Mahawa was discharged yesterday and i missed it! Another patient was interviewed for ITV and said all sorts of nice things about us.

My Christmas afternoon was made special by having a number of the Community Health Officers join us. They are a special bunch, the real heroes of this epidemic, in it for the long term, and unrecognised. It is hard to get a scholarship to medical school unless you have the right connections, so these workers do my job with just three years training.

The other good news is that the epidemiologists are noticing the numbers of new cases in this area of the country reaching a plateau, hopefully a sign that the fire is burning out.

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Ebola 10

Three or four days into my interim role as medical director (!) role, now thankfully a joint one with my colleague Mark, and I have combined clinical work with : staffing issues and conflicts about working practices and shifts, critical incidents and responses, campaigning to get DFID a to fund the continuing provision of laboratory services on site, issues about the practice of removing PPE, the supply of clean dry scrubs and wellies, the provision and delivery of food to patients, supply of sheets and other ward requirements, a WHO infection prevention and control re-inspection on safe working practices (which went very well), getting enough radios into the red zone so we can communicate with the nurses’ station, and more.

The most important area is working with the national staff, particularly the CHOs, to empower them in providing the continuity of care over time. We are asking them to hand over to each other, with the international Drs and nurses contributing. This way we can draw back in the Cuban clinicians who came here first but were partly pushed away when UK staff arrived. We are doing the handovers as a group bilingually, and I think the working relationships are improving. I enjoy working with the the Cuban staff, and they have a great sense of humour, flirting with the national nurses mercilessly.

Survival figures are improving. Since the ETC started providing IV fluids more aggressively, supported by laboratory services , we have seen a big improvement in survival especially in those coming in with diarrhoea, vomiting and resulting dehydration. Half of the patients have what is defined as an acute kidney injury, something taken very seriously for any patient in the UK. So with early fluid resuscitation we may avoid the worst of the illness developing.

Mahawa is better! Her ebola test was negative yesterday and she is now asking for and eating rice and stew, and whatever else we give her. I think many people will want to attend her discharge ceremony and I want a front seat.

Only 5 days to go for our group. More are coming today and will hopefully be up to speed by the time we go; this is why we need the national staff to take the main role.

So I came here expecting to be a nurse, quickly combined roles as nurse and doctor, and now have a management role. It reminds me of the old Tommy Cooper joke:
“So I was in my car, and I was driving along, and my boss rang up, and he said ‘You’ve been promoted.’ And I swerved. And then he rang up a second time and said “You’ve been promoted again.’ And I swerved again. He rang up a third time and said ‘You’re managing director.’ And I went into a tree. And a policeman came up and said ‘What happened to you?’ And I said ‘I careered off the road.’

Photos from the site: the staff canteen and the staff shelter.

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Ebola9

Wednesday evening

I’m sitting in front of the sea, the waves thumping the beach rather than lapping. It’s a far cry from the ETC. I’m still doing my routine shifts but spending more time accompanying Tom at management meetings about the place. This is a different project, it seems, for NGOs used to humanitarian disaster and setting up field hospitals for trauma. It was suggested we describe it as a hospital in order to get a better idea of what the management requirements are.

The senior managers change over on a regular basis, as do the clinicians, making it hard to set a clear strategy, in addition to which the context of the illness changes. The place was set up to see suspected as well as confirmed cases, that is ones where the very accurate blood test is positive. However it has been successful over the past few weeks in expanding its capacity to treat confirmed cases but not accept suspects. In the meantime others have established “Holding centres” where suspected cases are kept until a positive test is obtained, or a decision is made to move them to a treatment centre. There is a constant business of adapting the site to the changing requirements, and frank discussions take place on a daily basis. These people show huge commitment and passion, which can spill over at times. So having escaped the constant preoccupation and angst that comes with being a GP commissioner for purely clinical work, I have been dragged into the same discussions in which each person has their own idea of what is best, and a compromise has to be reached.

We received between 6 and 9 cases yesterday and today, a pretty chaotic process in which ambulances arrive and we don’t quite know what to expect. On each day one patient was not on the list we had received, and tragically one man died on the trolley whilst we were deciding where to admit him; we did not even know who he was.

They vary from people only a few days into the illness without much vomiting or diarrhoea, to dreadfully ill people with severe dehydration and resulting kidney failure, unbelievable diarrhoea, vomiting, and confusion. Those working with the illness describe three types of presentation which seems accurate: those with mild illness consisting of fever , aches, and sore throat ; those with intermediate illness with D and V, liver and kidney involvement; and those with the most severe type, with the diarrhoea and vomiting complicated by confusion and sometimes bleeding. The third group rarely survive, and it is the second group that we try hard to keep alive until the immune response overcomes the infection and the viral load, that is the quantity of viral particles in the body ( probably billions).

Speaking of which, the 6 year old girl on my ward, Mahawa , seems to be turning the corner much to everyone’s surprise. Today I spooned a mixture of “plumpy nut”, a sort of peanut butter high energy goo, and full cream milk, into her in 3-4 teaspoon doses, asking the patient next to her to help out. We had to get blood from her femoral vein in the groin today, which must have been painful for her. So from getting ready to mourn her loss 2 days ago we could all be dancing at a discharge in a few days time.

Having not felt as upset as everyone seemed to think I would be by all this death and misery for the patients, it has crept up on me at times, I think more because of seeing small children afflicted. We often have conversations about staying longer or coming back, as 5 weeks of clinical work seems such a short time, a drop in the ocean of need here. However I admire hugely the physical and emotional resilience of those who have stayed in west Africa for longer, as the tide of cases is still rising and the scale of suffering has not peaked yet. I think I will have done this for as long as I can; as always this is probably affected by the knowledge it all ends in 11 days, and were it longer the feelings might be different.

Sierra Leone desperately needs doctors, as the absolute number is maybe only a two or three figure sum for 6 million people, and so far 11 have died from Ebola. They have invested in CHOs, community health officers trained to respond to people presenting with the most common illnesses here: malaria, typhoid, childhood infection and malnutrition. Many of these amazing young people want to become doctors, the barrier being cost: the fees are £2,500 per year, let alone the books and living expenses. I plan to find out more about what scholarship schemes are available, and will suggest to DFID a that this should be a focus if they have not developed a scheme already. I spoke to Mohammed, one of the CHOs, last night, asking him how he got the job. He had a call from the national CHO chief, informing him he was to be redeployed at an ETC. He describes this opportunity with great pride, but his mother threatened to lock him in the house to stop him!

So now to get the bus to the place where we eat. I’m looking after body and soul with a swim and a meditation session, but am also looking forward to the bottle of beer.

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Ebola 8

Ebola 8

Sunday morning

Just a short one today. Amadou is getting better, the 2 year old I thought would die. It’s an achievement as infants generally have a poor prognosis, so this maybe another sign of improvement overall. I talked with Oliver, the new humanitarian director here; the signs are that survival is now above 50%, which is a landmark.

The Cuban team meanwhile had a party, which a few others were invited to. The night shift was a little harder for this, however I think they needed to let off steam so it may help bring them right back into the larger team.

We had a death on the ward yesterday just before the late shift started, a man who was clearly very unwell and getting more agitated presumably due to the encephalitis that can occur. He became a danger to others and had to be sedated, but died suddenly, another feature of the illness. I think the opinion is that a combination of electrolyte disturbances and sepsis may lead to overwhelming organ failure and cardiac rhythm problems. So I had to go in and attach a label to his body, so that the hygienists could double bag him and take him to the mortuary whilst others cleaned up the bed and surrounding area.

The six year old is still holding on. I had to use a little emotional blackmail with her older sister who is now well, making it clear her sister was very ill and needed her big sister to keep making her drink and possible eat a little. We may need to insert a nasogastric feed to build her strength back up.

Coming back to the chalet at around 10.30 pm we saw in the darkness a group of men hauling on a rope attached to a huge fishing net cast out by boat about 500m into the sea. They continued hauling until the net came in with many fish, sardine sized. During the whole process there was a rhythmical chant from two of the men, and every few seconds one would make a sudden sharp heave to pull the net in another foot or two. It all reminded me of a black and white tv series the BBC used to repeat in the 1960s, about a west African fishing village, and I suspect this way of fishing and the chanting go back a long way. It was a good haul and they were pleased. The temperature is falling to maybe 18 degrees at night, drawing the fish into shallow warmer waters, whilst the national staff at the ETC complain about the cold and wear ski jackets!

Back to bed now to get a bit of rest before the night shift this evening.

Ebola 7

Friday

Things are developing well at the centre. More international health staff have arrived and are nearly ready to work in the red zone safely, and a group of 30 Sierra Leonian Ministry of health nurses are on track, so the number of staff available will be much higher . I think another 500 wellies are needed to cope with the throughput.

The most important thing is that we sense a fall in mortality. This could be due to improved care, but also that the message is getting through that we need the patients to be transferred as early as possible in the illness, as we can keep in top of fluid losses better at way.

Manufacturers of PPE suits, hoods, masks, goggles and visors, non latex gloves, wellies and plastic aprons must be having a very good year, though I suspect anyone else trying to get hold of these items is cursing.

We are working hard to make systems work better, so that we can measure the amount of fluid being drunk or infused, ensure that procedures involving needles are safe to do, working harder at providing relief for pain and nausea, and to reliably keep drug regimes working well. It is so much harder to coordinate this between two areas with a one way system in operation; any backwards flow from the red zone would be disastrous.

What else do you need for an ETC? The red zone is a small strip on the edge of the site. There is a huge warehouse, a canteen, an office, a laboratory staffed by Porton down and other lab workers from the UK, a beautifully air-conditioned pharmacy, always worth a visit for 5 minutes, wash houses for the wellies, theatre scrubs and aprons, changing areas, huge firepits burning the huge quantities of plastic material. Then there is the waterworks, providing piped caustic 0.5% chlorine. How the plumbing will hold out against this piped alkaline, caustic fluid I’m not sure.

Then there are the training tents and the best place in the whole camp: the discharge tent. Survivors come here after leaving the red zone, having a shower and being given clothes, all their possessions at entry including mobile phones being incinerated. They receive counselling about what to expect as survivors. Rejection through fear is common, adding insult to the injury of having lost loved ones in the days and weeks leading up to their own illness, or worse becoming orphans. They are given a ration of food to last three months: a sack of rice, a sack of corn meal, cooking oil, a Jerry can, gloves, soap and washing materials, money and the all important certificate to prove that they are cured and therefore not infective. How this is interpreted in small village I’m not sure. Lastly they are given 90 condoms and told its best to abstain for three months as virus can be present in sperm for that long.

Four young girls were in the limelight today. Two were smiling, one was quiet and one was distressingly silent and withdrawn, clearly deeply traumatised by the experience of the past week or so. Three of them gave short speeches expressing their gratitude and then we sang a song, and there was a short dance. I could not quite enjoy it, seeing the one young girl so unwell psychologically, but overall it is a joyful occasion.

We took the handover from the night shift and then went through the patient list again, identifying the tasks we needed to get through. The team comprised myself, national nurse Agnes , Cuban nurses Luis and Niorge, with another UK Dr, James, helping out.

Our most poorly patient remained Mahawa, only six and fighting to survive. It was great to see that she was looking me in the eye, rather than into nowhere, and asked for a drink, so I sang her another song. Early days but she might just make it.

There’s work to do to make the shifts run smoothly and get all the different aspects
of care covered. This requires teamwork between the different cultures, which is complex, and it looks like I am taking on this role in part. I talked to the Save the Children director of humanitarian work who is visiting and problem solving for 3 weeks. It’s clearly been a tough year for the charity/NGO, with the Philippines typhoon, Syria, Palestine and now Ebola and more. People seem only too happy to criticise NGOs for being inefficient, just as clinicians love to blame managers for obstructing what seem obvious and necessary aspects of patient care. What I see is hard-working people problem solving continuously whilst trying to drive strategy, from an open office in a hotel lobby, bringing together many different players. It is a logistics nightmare, and as with much hospital care, one bottleneck can hold up the whole system. So if a combination of water supply problems and cleaning staff not quite doing the job means the wellie washing is not fast enough, the clinicians cannot get into the red zone.

Later on we had 9 or so new admissions, one dead on arrival. I think people are sensing an improvement in survival rates already, so hopefully the hard work will pay off and give more hope to this part of Sierra Leone at least.

Ebola 6

The first night shift from 8pm to 8am and another poorly child worrying me through the night. At handover Tom Fletcher had suggested we check the RDT or rapid diagnostic test for malaria, as this can often coexist with Ebola and confuse or worsen the picture. Once we had assigned tasks I went in with one of the Cuban doctors, to find the poor 6 year old Mahawa barely responding to verbal commands, very dehydrated and hard to assess. Our attempt to do the malaria test was thwarted by my rapidly steaming goggles meaning I could not have interpreted the result. We tried to get her 17 year old sister to help find out whether she was in pain and to encourage her to drink. Her sister, being well, came across and asked her some questions to no avail, then raising her voice, then raising her hand as if to hit her sister, at which point we stopped and asked her to get back to her own bed.

I tried another mask and entered again this time with Agnes, a young CHO, community health worker who has done a three year health degree in Freetown and who clearly knows what to do. We managed to get a finger prick sample and did the tests for both sisters, but again my goggles misted and Agnes had to finish off. Mahawa’s malaria test was positive , so the next thing I had to do was draw up the right dose of artenusal anti malarial medication, re-enter and inject into her bottom.

The Cubans have been here for a month and will be here for 6, with 21 days in country quarantine followed by 21 days quarantine at home, so they will not rejoin their families until June 2015. It’s a way of life for some; Thomas, one of the nurses told me he had been sent to Pakistan after the earthquake for 6 months, had spent 24 months in Bolivia after a landslide and 3 months in Haiti . They don’t get much of a choice and you cannot blame them for being moderately less enthusiastic than the UK NHS volunteers only deployed for 5 weeks. So they split the night shift into 2 and take their time.

Miguel, another doctor, saved the night for me by getting an IV line into Mahawa’s arm so we could start to rehydrate her properly. I’m hoping to see a much better result in a couple of days. The 2 year old Amadou had responded to this. In the morning a Cuban paediatrician came on duty. I think if we really organised ourselves we could do great work together. In the meantime I am using the Spanish Juliet and I learned from Irini, our wonderful (Greek) Spanish teacher, taught us prior to visiting Chile earlier in the year.

The big sister took her medication with some ORS this morning and promptly threw up on my right wellie! I watched carefully as the hygienist sprayed the wellie down with the ebola killer 0.5% chlorine. It apparently takes 6 microseconds to do its job, and certainly makes a good job of bleaching any clothes you are wearing, and we often have an end of shift cough from the fine spray during doffing PPE.

Back to the chalet along the paradisical white squeaking sands and blue sea. There’s a lovely breeze to keep things cool whilst I sleep as long as I can. I woke up refreshed and went for another bout of bodysurfing. It’s not all bad.

I had a rest day today (Thursday ) but went to do a morning shift as one of our team, Daxx, had been asked to help train the next NHS and national teams in PPE. So I went back to work in the same ward and saw Mahawa again. She’s a little more responsive and less dehydrated but still seriously ill. I think her malaria is probably under control but the Ebola is now progressing, as I had to change her nappy twice in the shift, and a little blood was oozing from a previous venous catheter site. I decided to start singing whilst doing procedures with her, and I think she responded a little more.

We are getting a bit more organised. Tom is leaving soon and was hoping an NHS consultant would be coming to provide the medical director role. Instead he has asked me to do this for the next couple of weeks as an interim. So having just got into the role I may be directing things. The other NHS staff seem happy with this, and it would give us a chance to negotiate again with the Cubans. I’m sure there is unused expertise in abundance there, they are lovely people and like teasing the national staff.

Am wandering back along the beach now to the place I share with Ben, a nurse. Hopefully we will see the crocodile on the way.

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Ebola 5

It’s been a week of change here, so not much writing done. I’m reflecting back on various aspects of what has happened.

I did a night shift some nights ago in Lakka with U, a U.K. doctor early in his training. He’s not a member of the NHS team, having organised to go to Sierra Leone during annual leave. These are the people I really admire; there was no razzamatazz for him at the airport, he’s paying his own way, no lengthy preparation by the army, he was on his own. It’s not ideal though; he is very early in his medical career and vulnerable to overreaching professionally, and UK-Med would not recruit doctors at this stage at least for this first wave. The NGOs make their own decisions and here at Kerrytown we are joined by a number of doctors at various stages, from only 2 years from qualification to very experienced, and only the odd consultant. Many of the juniors are taking an alternative path to career development, and I think this is laudible, as the experience they gain goes beyond clinical professional development, to becoming rounded as responsible people with experience of teaching and leading. I wish U well, he’s a bright man who deserves success. I will speak in the future about the insane world of NGOs. Save the Children are pretty amazing really, and have pulled something out of a very difficult situation for which they were initially criticised; the pressure from the government to get the ETCs up and running is enormous given the publicity and huge financial undertaking, however to open too quickly has been shown to lead to chaos and the death of health care workers from Ebola, which is unacceptable.

So I’m polishing this off from a posh beach hotel opened a year ago. It would have been empty had it not been for Ebola, but has become instead the nerve centre full of people on computers having strategic conversations, organising supplies, problem solving, doing HR and a myriad of other things. They have to be incredible flexible and adaptable, and create solutions at scale in days. There is a lot of patience being applied as well, and we all need to remember that nobody really knows the best way to treat this epidemic.

On the way out of the night shift at Lakka we passed a large group of young men waiting to be interviewed for hygienist jobs. The hygienists have in some ways the most dangerous job, coming into the red zone to clear up rubbish, blood, vomit and diarrhoea, and the bodies of the patients who die. The latter is a careful process of double bagging without spreading Ebola, as at the point of death they are contain the greatest load of virus particles leaking from body fluids. The extra protection they get is that they wear washing up gloves instead of thin surgical ones.

Unemployment runs at 90% here; literacy at 43%. So there were many applicants but with a low educational level, looking for what is by local standards very well paid work with a large meal in the middle of the day. The danger is there, what goes unreported are the number of national health workers getting Ebola from work, and the accusation has been levelled that the international community only responded in a big way once some rich nations’ doctors and nurses got infected. Sadly one of our hygienists died in the ETC a few days ago. He had been off with a foot injury, and we will never know how he acquired the infection, whether from working at the centre or outside.

So a group of young, uneducated men come in to do a dangerous job. Milos, the chief nurse at Lakka is very thorough at teaching them how to use PPE properly and shouts very loudly at any dangerous behaviour. However he is such a charmer they love him despite the tellings off. What I find frustrating is the continued attitude outsiders to Africa have about getting things done. “Welcome to Africa” is the response, about things taking a long time, and about workers not working the way you want consistently. So I’ve been asking if education is part of the training. Do these workers even have an understanding of the concept of cells, that their bodies are made up of these, and that viruses attack by getting inside cells, multiplying and then the progeny being released as cells break down? The answer is no, they are just told what to do. At my next deployment I am going to ask if I can do some training sessions, as a basic understanding may promote a continuing sense of carrying out the procedures in a safe way. I’ve heard from those NHS workers at other ETCs about to open, that the NHS staff have been working hard on this.

The NHS team at Lakka has moved to the ETC at Kerrytown run by Save the Children . In the hiatus 4 of us walked to Lakka beach, a beautiful seaside resort sitting behind a long golden sandy beach. You can see the potential for Sierra Leone as a tourist destination, as long as the people are given ten years without another civil war or deadly viral epidemic to deal with. I’m planning to come back for a holiday with Juliet when it’s safe, it’s such a beautiful country with peaceful, friendly people.

The following day we walked with a sierra Leonian logistician, Michael, into the heart of Freetown, walking along bustling roads past the ministerial building and ending up under the Cotton tree, a vast tree inhabited by fruit bats. It was great to get a sense of what the place is about apart from Ebola. As we walked over one bridge Michael told me its name: Peace Bridge, which marks the place where the army resisted the rebel force during the civil war. Later I saw a beggar, a double hand amputee from the rebel practice of chopping off hands during that terrible time.

Ernest the owner of the Kona hotel in Freetown, took us to the new hotel he is building, in a very posh car. It is being built slowly but on a very grand scale. He took us to his office, which looks like the set of a Bond film where the baddie runs his operations. He was nice though, and casually mentioned he is hoping to run for president.

As I finish this section it is Tuesday. Last Sunday we drove the hour and a half journey to Kerrytown, or to be precise, to a posh beach hotel (Tokeh) that will be home for the remaining three weeks. We went into the ETC and learned their PPE routine: something to get used to is the separate hood and goggles rather than the visor. Each NGO has done its own thing, so you have to learn a new way of donning and doffing, and clinicians talk about this obsessively, as their lives depend on it. Everyone from national hygienists to consultants are very careful.

Yesterday I passed my PPE exam and did a late shift 2pm -8pm. During 2 entrances of an hour I tried to encourage a 2 year old to drink. He was tired from Ebola but not that dehydrated and we were trying to hold off from the trauma of an IV line or an intraosseous line ( less traumatic I believe than it sounds, drilling a hole through the shin bone to place a catheter in the bone marrow , an extremely effective way of delivering fluids fast). He was just miserable and asking for his mother. What a lonely place it must be for him, and none of the other women in the ward seemed up to helping out. All he really needed was a knee to sit on and someone with a cup. My nappy changing skills at least came back to me! In the end the night shift did get a line in and I’m looking forward to seeing him during my night shift tonight.

The setup seems much closer to what we we’re expecting medically. The ETC is adjacent to the military 22 bed unit that looks after national and international health workers. Their lead consultant is an amazing man, having worked with this and other viral haemorrhagic fever outbreaks as a career, and having witnessed at first hand the terrible conditions in Kenema earlier this year. His leadership is direct, clear and patient, another example of the army at its best.

We are working at least alongside, and hopefully with, a large team of Cuban health workers. They are friendly, and will work but apparently some more than others; I don’t think they were given much choice about coming. I’m trying my rudimentary Spanish and hope we can work effectively together, but the handovers between shifts could be improved. The planning before entering the red zone makes the difference between achieving something and just getting incredibly sweaty and hot. You have to keep asking yourself if any action is dangerous, and I have to slow down and do things methodically.

This has probably gone on long enough, and is a bit dry, apologies . Hope to be more eloquent later.

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Ebola 4

This illness is bewildering us all. I’m seeing experienced doctors guessing what is going on as they try to catch up with the clinical signs and progress, and with the laboratory results that tell us the body is fighting infection ( high white blood cells ), the blood is thickening through dehydration ( haematocrits of almost 60), the kidneys are shutting down, and the liver is palpably and biochemically inflamed. Then they develop respiratory failure. They are burning up, the virus is burning them.

One young doctor reminded me how unsuccessful Ebola is as an infectious agent, which is why it has been sporadic rather than endemic, that is present in low levels all the time, like chicken pox; if you kill your host, you cannot get spread around so much.

Today I felt lost in the red zone. We have to prepare carefully so we know exactly what tasks we have to do in the short time we have before the heat and dehydration demand an exit. All I had to do was check on 5 patients, deliver medication by injection and head out.

So I put on my PPE in the changing room. People want to know everything so I will describe this bit. First you check your wellies for leaks by standing in a bucket of chlorine. Then you get an orange or yellow suit, check the seams, fabric and zip, and put it on. Next the surgical hat and apron. I try to order it this way as the next steps are the start of the claustrophobia: the surgical mask and putting up the hood. Next the visor and finally two pairs of gloves , one going under the sleeves of the suit, and one above. A national worker helps you through this, checks you over and writes you name and the time on the apron so others can identify who you are and tell you if you have been in too long.

I went in with Hannah, an ICU training doctor, armed with current experience of high end UK intensive care experience. I had plastic bag containing four syringes. The first was malaria treatment for a young woman we think does not have Ebola, but who has to stay in until we get a negative Ebola test 72 hours after symptoms started. Her malaria test was positive. She had her 1 year old baby with her. Imagine being confined to a narrow hospital bed with a baby for several days. There is no complaint from these people. I had to take out a venflon, the small tube inserted into a vein, as it had blocked up and was “tissuing”, inflaming the vein. She did not like that.

Next was an injection of calcium to a young woman about to enter the storm when the virus is inflaming every major organ. She was uncomfortable, but we seem unable to help and have to be careful with drugs. We cannot give ibuprofen as Ebola has an effect on blood clotting which would be worse, and when the liver is inflamed paracetamol could harm. Afterwards we agreed we could not quite put our finger on what was worrying us.

Next more calcium to an 80 year old man who had passed a lot of diarrhoea into his kanga pants. A UK nurse, Pauline came in at this point and I helped whilst her expertise was only too obvious, calmly and competently cleaning him up. That is what people need as much as the intensive medicine. Again, his progress is a mystery; I can’t help thinking he will get better whilst his daughter in law might die in a bed only a few feet and a layer of canvas away.

Next to the third tent where the sickest people tend to be. I had some antibiotic for a man in his 20s, who is likely to die tonight; he was sitting again in diarrhoea, a sea of live virus on the other side of my gloves. He was very restless but had his arms tied to the bed; we have not quite worked out a better way. Without such restraint at times we would have to sedate chemically, which has caused poor breathing in people needing all the respiratory drive they can muster , even with 10 litres of oxygen a minute (very high). If they wander in a confused state they could walk back into the suspected tent and infect people with ease.

I was starting to feel anxious at this point; those who know me will find this strange, as I don’t often admit to, or show much sign of anxiety. I think it was a sense of helplessness, which will improve in time as I get a clear sense of what can be done that is helpful, and what is inevitable. A headache came on, which I thought was another visor clamp pain, from tightening it too much. So at 1hour 20 I let Hannah know and headed to the doffing area. Fortunately there was only one other worker ahead of me, but it’s not over at that point. First you have to stand in one large dish of chlorine for a minute, then another for the same. There is a clock to guide you. I’m sure it ticks more slowly than other clocks as you feel your heart pumping fast, your body trying to cool inside the suit by sweating more.
Then you step forward and wash your hands in chlorine. A worker sprays your apron whilst you stand, head bent forward so your visor closes against your chest, and you shut your eyes as the spray of 0.5% chlorine ( dilute bleach ) stings. Then you pull it off, snapping the ties and neck hoop. Then you wash your hands. Then you are sprayed again, front and back. You start to feel a little cooler as the cold spray hits the suit, and you can now carefully take off the visor, before you stand in front of a mirror and slowly pull the velcroed flap covering the front zip. You have to make sure the top does not come against your neck, then you go down to the bottom of the zip and feel your way up whilst looking in the mirror, so your hand does not touch your chin. You pull the zip down, pulling the flap to the side at your neck to keep tension. Then the tricky bit, pulling the hood back without the edge touching the back of your neck, and ease it off your shoulders and pull down, turning the sleeves inside out as you go, and pulling the legs down over the boots again turning the legs inside out. You part your legs to keep the suit fixed as you pull the rest of the sleeve out, and pull off the outer gloves with the suit, then shuffle the legs to the end of your boots. I’ll make a film!
Then you wash your hands again. Ebola is inactivated in 6 milliseconds by chlorine, so all this hand washing works, unlike lady Macbeth.
Then your mask comes off forwards, wash hands again and the cap. Wash your hands says the helper, then you can step onto another dish of chlorine and have your boots sprayed down, stepping out to have the soles sprayed, and finally taking off your inner gloves without touching the outside.
A short walk across to washing hands with soap this time, and taking the boots off, your scrubs are soaking wet, so you have to change them whilst drinking a litre of water and oral rehydration fluid. Freedom!

We came back home and had a party with loads of the mainly Italian Emergency workers . They are a lovely bunch of people, alternative and unconventional in outlook.