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.