Day 26

11.02.2015

Sneaky little virus, this Ebola.  Just when I was starting to get a bit cocky about my clinical acumen in Ebola Virus Disease, an atypical case reminds me that this virus deserves respect.

We actually hadn’t had a case of Ebola in the holding unit in over a week.  I was beginning to wonder if I shouldn’t ask to go home early – my daughter had just taken her first independent steps, and I was missing my husband terribly. 

Walking about the city, I could sense that people were beginning to relax – markets and restaurants were busier, friends could be seen casually touching in the street, boys were back playing soccer on the beach.  One local man informed me proudly that his neighborhood had not had a positive case in 41 days.  Another person at a local restaurant told me confidently that he predicted Sierra Leone would be Ebola-free in another four weeks. 

I was starting to relax, too, and in the worst possible place – the Ebola holding unit.  On Sunday afternoon, we had only 4 patients, none of whom had Ebola in my mind.  I rounded on the patients, refilling bottles of oral rehydration fluids, distributing food, providing analgesics for pain. 

I spent many minutes at the bed of one young female patient.  One day before, she had actually passed through the screening process at the hospital gate; her presenting symptoms had been cough and vaginal discharge.  Her symptoms didn’t fit the standard case definition of Ebola Virus Disease and she denied all risky contacts (contact with anyone sick, travel to an area of high transmission, funeral attendance, contact with sick bats or primates). She was directed to the general waiting area to be evaluated for admission to the regular hospital wards. But as she waited, she developed a slight fever to 38.0 and so was re-directed to the Ebola triage tent.

When I saw her, the day after admission, she was still febrile and was also weak and confused.  A brief exam revealed bedsheets and clothes soaked in urine and mucopurulent discharge.  She didn’t have the classic Ebola symptoms of hiccups, epigastric or right upper quadrant pain, conjunctivitis, vomiting, diarrhea or bleeding.  Instead, her primary complaint was left flank pain. Highest on my differential was pelvic inflammatory disease, tubo-ovarian abscess, or urosepsis with perinephric abscess.  I asked about her family; three children, the youngest only 7 months.  We stripped the bedsheets and bathed her with mild chlorinated water, and encouraged her to drink more fluids.  She had been receiving ceftriaxone as part of the standard treatment package.  Limited in my antimicrobial options, I added metronidazole for additional anaerobic coverage.

The next day, her blood test came back positive for Ebola.  I was shocked.

I wonder now if she could have been actively miscarrying.  Pregnant women infected with Ebola very often do.

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I hadn’t had any breaches of my personal protective equipment (PPE) and had dutifully completed all tedious steps of the thorough decontamination process upon leaving the unit.  But on reflection of my actions in the unit, I knew that I had been mentally lax.  I had not limited my time and contact at that patient’s bed to the minimum necessary. 

There is a tension between personal safety and clinical compassion in the unit.  By nature and by habit, I frequently touch patients to convey comfort and sympathy.  A pat on the shoulder, a quick squeeze of the hand can be enormously effective in developing a therapeutic doctor-patient relationship.  But casual contact is forbidden in an Ebola epidemic.  ‘Nor Touch Am’ is splashed in huge letters on billboards across the country.  ‘ABC = Avoid Body Contact’ is the new mantra.  Even in the unit when wearing full PPE, minimum physical contact with patients is the rule.

I make a firm resolution to redouble my mental guard, both inside and outside the unit.

The next day, two additional patients test positive for Ebola at our holding unit.  Since then, we've diagnosed one to four new cases of Ebola in the unit every day this week. This epidemic is not over.   

I stifle my homesickness and renew my commitment to stay in Freetown for the full 6 weeks as originally planned. 

Day 17

03.02.2015

When Ebola cases first showed up in Sierra Leone, it was late May 2014.  Initially, cases presented only in a small part of the country, near an eastern township called Kenema.  By early July, Connaught Hospital had its first case – a businessman who had had been visiting family in Kenema.  Since his return to Freetown, he had been sleeping in close quarters with several other people, despite mounting fever and gastrointestinal symptoms.  One of his housemates brought him to Connaught Hospital for evaluation.

At that time, the only laboratory in the country to run Ebola PCR testing was in Kenema, a 5 hour drive from Freetown on a bumpy road.  King’s Sierra Leone Partnership staff obtained a patient’s blood sample, packaged it securely, and arranged for a courier to deliver the sample to the Kenema lab by taxi.  Two days later, the Kenema lab had still not received the sample.  The courier was tracked down, and ultimately confessed that to save some money he had opted against taking a taxi and instead had taken a boda-boda (popular form of public transportation usually in the form of a crowded mini-bus) – and had lost the blood sample somehow on the way. 

Another blood sample was drawn and sent to Kenema by another courier.  At the time, it took on average over 5 days to get results back on an Ebola PCR blood test.  The patient had died by the time the positive result was reported.  One of his housemates had also fallen ill.

Early in the epidemic, several esteemed Sierra Leonese doctors, including Dr. Kahn, head of the Lassa Fever clinic and national expert on viral hemorrhagic fever, had died.  Fearing for their lives, doctors across Sierra Leone went on strike.   

King's staff scrambled to rapidly expand their capacity to accommodate the flood of Ebola cases. The two bed isolation unit at Connaught Hospital expanded to a 16 bed unit, sometimes with as many as 20 patients.  Patient mortality was over 60%.  It still took many days to get lab results back, and when a result was positive (the vast majority), almost invariably there were no beds available in the few operational Ebola Treatment Units.  As a result, the positive cases were not isolated from the suspect cases in the holding unit, increasing risk of transmission within the unit.   

With no open beds in the Connaught Hospital holding unit, patients with Ebola were often left outside the hospital gate in the triage tent, sometimes waiting for days.  Patients often opted to return to their homes rather than wait in the tent's oppressive heat with other sick and dying patients.  King’s volunteers informally referred to the triage tent as the Tent of Horror.

It would have been easy to get mired down in the weeds of patient care given the huge and pressing needs at the small isolation unit in Connaught Hospital.  But the real issue was the public health disaster occurring at the regional level. Only two ambulances were functioning in the entire country.  Traditional funeral practices with high risk of Ebola transmission were still being performed. Ebola cases were not being isolated quickly.   People with known Ebola exposures were not being quarantined. Dead bodies were not being buried safely or quickly.

Meanwhile, almost all routine healthcare operations in the country had shut down.  Prenatal care was not available, childhood vaccines were not being administered, hospitals and clinics were shuttered, and patients with HIV and TB did not have access to treatment.  Mortality from treatable diseases sharply increased. 

The need for region-wide coordination was obvious.  The concept of an Ebola Command Center, with centralized information and coordination, was born.  King’s S/L Partnership volunteers were the brains and brawn of the center's creation. One of these early champions, Amar, recently took me through the Center and described some of the struggles and challenges of that critical time.

The first step was to understand the magnitude of the problem – making the numbers of the epidemic known - numbers of patients (suspected, probable, confirmed), numbers of case contacts, numbers of ambulances, number of beds at Ebola holding units and treatment centers, numbers of burial teams.  The idea was to put up white boards in the Command Center, initially a dank cramped and windowless office, with these numbers in real-time.

Almost immediately, the idea was met with local resistance.  There is incredible power in numbers; public health interventions and outcomes hinge on good data. But real, hard numbers can be frightening; there is a false security in ignorance.

It was a hard-fought battle, but at the Command Center, these numbers were finally made public – and they were shocking.  So many cases.  So few beds. 

Gradually, incrementally, the two or three volunteers who had founded the Command Center garnered support.  Over the next few weeks to months, the Royal Sierra Leone Armed Forces and the British military joined the efforts.  The Centers for Disease Control and World Health Organization came on board.  NGOs rallied.  The Command Center moved from the cramped office to a large conference room with vaulted ceilings, with integrated computer system and official signage designating the three pillars of Case Management, Safe Burials, and Surveillance.  A call center was created and social media churned out billboards and posters encouraging people to dial 117 with any suspect cases.  It may have been a bit premature – the call center was completely overwhelmed for weeks, but it was a start.  Slowly, Ebola Treatment Units were built and beds opened up.  Finally in November, the epi curve (number of new Ebola cases) started decreasing.  By mid-January, when I arrived in country, the numbers of new cases were falling precipitously.

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Having arrived late on the scene of this Ebola epidemic, I keenly feel the guilt of someone who came too late to be of much help.  Yes, the Ebola holding unit at the hospital is still usually full of patients, but few now have Ebola. 

This is a time of transition – scaling down disaster relief, and turning attention to the chronic, systematic needs of a country whose healthcare infrastructure has been shattered.

For me, a tiny cog in the wheel, it is hard to know where I fit in this time of transition.  I’m not seeing the loads of Ebola patients that I expected, although working in the Ebola holding unit is still intense.  The needs are now greater on the general hospital wards; patients with HIV and TB who need treatment and care.  Public health systems are beginning to grind to a start.  Other hospitals and healthcare facilities need support as they open slowly, cautiously.

I have three weeks left in Sierra Leone.  Three weeks can be a lifetime in the timescale of disaster relief, but it is only an instant in the timescale of effecting real healthcare system change. 

I am starting to wonder if I shouldn't ask to go home a few weeks earlier than planned, given that the Ebola crisis seems to be largely over.

Day 10

28.01.2015

Screams of a grieving mother break the morning calm.  Death is very visible here.  Every day, inside and outside the Ebola holding unit, patients die.  On most days a taxi will drive into the hospital with a corpse in the back seat; we carefully note “Dead on Arrival” in our large notebook of Admissions, Discharges, Deaths.  We bring the body into the holding unit morgue and obtain an oral swab to check for Ebola; a burial team comes to collect the bodies each morning. 

Grief is loud and public, and often involves a screaming female mourner physically restrained by others.  Frequently, the body of a patient that has died on the general wards is wheeled on a rickety hospital bed through the grounds to the mortuary. Onlookers rise to a stand, a silent gesture of respect, watching the corpse wheel by.

Those patients that survive to discharge from the Ebola holding unit often face enormous challenges.  Of course, Ebola is not the only illness here.  Cardiovascular disease, cancer, diabetes, and sickle cell are ever-present, as well as many other infectious diseases.  HIV, malaria, and tuberculosis are the Big Three, but many vaccine-preventable illnesses are now on the rise after almost a year of no public health interventions, including routine vaccinations.  Few hospitals are open; those that are function on a skeleton crew of young, often unsupervised, house officers. 

This week, we admitted a young woman to the Ebola holding unit for diarrhea, vomiting and malaise.  She looked chronically ill; HIV or TB seemed much more likely than Ebola.  She tested negative for Ebola, and was discharged. 

But she was still too ill and too weak to walk.  We requested a direct admission to the general wards.  “No beds,” came the expected response.  Pervasive fear of Ebola often makes it very difficult to obtain general hospital admission for patients discharged from the Ebola holding unit, even when they can pay.  And this patient, without family or financial means, could not. 

The young sick woman was left outside on a bench to pass the night. No beds the next morning either. 

Almost all medical care in Sierra Leone is ‘fee for service’.  Before a hospital admission, a registration fee must be paid.  Before the doctor sees a patient, a doctor fee must be paid.  Each tablet, each injection, each catheter, each lab requires a fee paid up front.  If there is no one accompanying the patient to advocate and pay for the patient’s needs, no treatment is provided.  More often than not, the nurses station looks more like a cashier’s desk, covered with bills and account books. 

In mid-morning, we are in the green zone ‘office’ when we hear a commotion outside.  Maintaining a safe distance, a small crowd has gathered around the young woman who is seizing on the cement floor, tonic-clonic movements, frothing spittle at the mouth.  Probably toxoplasmosis, cryptococcus, or TB meningitis.

I go back to the hospital senior staff to plead that the patient be immediately admitted for evaluation and treatment.  A bed suddenly materializes.  I write a careful referral form, recommending HIV testing, basic labs, chest Xray, sputum for TB testing, LP.  We start the complicated, protracted process of qualifying the patient for ‘destitute funds’, which requires tracking down senior staff for multiple signatures.  Two days later, the patient is receiving expensive antibiotics in the wards that she probably doesn’t need, the paperwork hasn’t been signed, and she still hasn’t had an HIV test. 

The obstacles to providing quality medical care here sometimes seem insurmountable. The needs are enormous.  The system and culture of the current healthcare system needs a fundamental change. 

The organization that I am volunteering with, King’s Sierra Leone Partnership, was created to strengthen the healthcare system in Sierra Leone through long-term partnership with local leaders and healthcare providers to develop organizational structures, resources and commitment to improving health.  

I believe that consistent efforts driven by this philosophy can achieve the seemingly impossible goal of delivering quality healthcare here.  But each day toiling toward that goal is a challenging and heartbreaking process.