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.