Some more pictures

Hi, everyone. While I await an okay of the four posts I've sent to Boston, I thought I'd just put up some more non-work-related, non-approval-requiring pictures.

Yesterday I took a little bike ride. You may have been wondering what the "Port" in "Port Loko" refers to, and here it is. We are definitely not on the sea, but apparently you can go by boat down this river all the way to Freetown. It was lovely to discover this, as, in fact, from what I can see, this is really the heart of the town. The scene by the river, with people bathing, washing clothes, tending boats, was "timeless" and peaceful and very pretty.

Just above the river, though, was this active covered market, as well as by far the largest and most prosperous-looking buildings I've seen in town. (Most of the buildings on our route to the ETU are one-story stuccoed concrete, with porches and corrugated metal roofs.)

There's also this mosque, which adheres to the plan that seems to be traditional around here - four minarets with layer-cake balconies, one at each corner. When I went by on the way to the river, the gate was open and someone was inside (this still seems to me (?) to be uncommon; public gatherings have been discouraged for a long time in the name of public health, and my sense is that this means that public buildings are much less used). I wanted to go in and look around, but on my way back up the gate was closed.

I also noticed this large church in town - Sierra Leone is majority Muslim, though there is a large Christian population, too. I had thought this area was more strongly Muslim, but maybe not. Gate closed, no one around, here, too.

Back in what had seemed, before I saw the port, to be the center of town, here is a building that always catches my eye. It is one of the only two-story buildings in town, and looks, clearly, like it must have been "important" at some time. I like it's faded grandeur, wondering what it looked like and what went on there in its heyday. Now it has the insignia of the APC (All People's Congress), one of the two main political parties, painted on it. This party is traditionally strongest in the north, where we are; it also has the distinction of having taken power peacefully from the SLPP (the other main party) after the 2007 elections. Everyone thinks of this as an extremely hopeful sign, after the long civil war.

Finally, another shot of the camp in the morning. Morning and evening are so nice here - actually comfortable, after the truly fierce heat of the day. Driving back from an evening shift (ends at midnight), I love the cool, heavy summer air, the few people you see still out, slowly doing one thing or another. Reminds me of driving back at night after a show one summer in Maine....

More to come as soon as it is approved.

Short and sweet

February 24, 2015 - It's official - both of the very sick men who, along with the mother and daughter I mentioned previously, were among the first patients I treated, have recovered from Ebola and gone home. Sometimes there are happy endings.

Learning, as a doctor...

February 22, 2015 - Two nights ago, a patient in our care died. He was a man probably in his early to mid-40s (people here often look much older than they are, making estimation difficult; life expectancy at birth was 48 years in Sierra Leone as of 2010). He was very sick, with what appeared to be respiratory problem, his breath rattling in his chest – we actually weren’t sure he was going to test positive for Ebola at all (though he eventually did). During most of the time I cared for him, he was not very responsive, and when it came time to transport him from the suspect to the confirmed area, we had to carry him on a stretcher. No one knows exactly how he died – when the evening shift went in, they found him.

I want, first, just to pause and honor his death. This is very much the reality of this epidemic, or at least of the “contained” phase of it – people dying suddenly, without us knowing the specific reason, in a strange and unpleasant place, surrounded by people they don’t know and who know almost nothing about them, in the absence of friends and loved ones. Even if we get “better” at treatment/cure, a sizable proportion of our patients – 20, 30, even 40% - are likely to die like this. It happens all the time.

But I also want (respectfully, I hope) to use his death as a jumping off point for talking about the inner life of a doctor – the things we deal with. What we do is sometimes difficult, and very, very strange. We take our whole imperfect human machinery, including our emotions, into situations where what we do may influence life and death, but the machinery remains imperfect. We don’t always win, and we don’t always do everything right. And then we have to live with it.

You certainly know by now how important we think giving people enough fluid is. You may also remember that I have said that there are risks in doing this, the most obvious one being that you can “flood” a patient’s lungs, making it difficult for them to breathe. The gentleman who died (sorry, I can’t use his name, and giving him someone else’s name doesn’t seem right, right now) already had a lung problem, yet we gave him a great deal of fluid, in an effort to avoid all the problems that dehydration brings. So it is possible that, in trying to avoid one mortal danger, we killed him with another.

So these are some of the thoughts that go through my head when I reflect on this:

- I think it is very important to state up frot that this is not about me, not about us. Meaning – the man was alive, the man had a life, the man died. That’s the important story. Whether we did or did not contribute to his death – if asking that question helps us learn and do better next time, fine. But whether I, personally, feel proud of my work, or on the other hand, feel guilty is entirely the wrong question. This is his story. It is not my opera.

- Having said that – and since I know nothing of his story beyond what I’ve already told you, so I can’t go any farther there – what do I see, what do I think, what can I learn from this; what light does it throw on doctoring?

- First of all – we don’t know what happened. (We very often don’t, here). He may have had a stroke, he may have had a seizure; he may, in fact, have died from dehydration. Yesterday, a similar patient in similar circumstances (minus the presenting respiratory problem) also died. A few hours before, however, we managed to run a blood chemistry study on him – and the clear conclusion was that he was “hemoconcentrated,” i.e. dehydrated, i.e. he needed more fluid. Maybe in this man’s case, maybe in my patient’s case, they both needed more fluid AND were having trouble breathing (see my previous post for how both problems can occur at once – in the States, we would just put them on a ventilator so we could breathe for them while we treated their fluid status). Or maybe the dehydration was the main problem. Or maybe the breathing was; or maybe something else was. We have no idea. We are trying to walk down the center of a path, all while having almost no tools or inputs to tell us where we are.  

- Second – the strange and hard thing is, this is how doctors learn. You really would prefer not to learn on real people. But most of the time, you do. That’s just how it is. Let’s say you are trying to learn how to play tennis. First of all, no one would think it the least bit odd that, when you first started out, you were not nearly as good a player as after you’d been playing for a while. That’s what learning is, right? And, also, you might be able to work on some techniques and skills in a simulator (do these exist, for tennis?), with a machine throwing balls at you, for example. But, eventually, if you wanted to actually play tennis, you’d have to do it with another person, and that would be different. The thing is, though, that when you’re a not-as-good-as-you’re-going-to-be player, what’s the worst that can happen? Your opponent might get bored and decide not to play with you any more, but he/she will go on with his/her life just fine. And certainly the ball and the racket won’t care one way or the other. When you’re a doctor, however, the ball and the racket DO care. Meaning – when you start out, as in anything else, you aren’t as good as you are later, and when you’ve been doing it for 10 years, you aren’t as good as you are when you’ve been doing it for 20 – but, all that while, you are treating real people, who matter to themselves and others, and who care about the outcome of what you are doing. There is simply no other way to do it, and no other way to learn. You can do all you want in a simulator (and my sense is that training programs ARE doing more with simulators, which I think is great). But in the end, if you are going to be a doctor at all, you have to treat people. And that will be different. And you will be worse at it at the beginning than you will be later on.

- I am CERTAIN that there are things I could have paid more attention to that might have given me a better idea if the man was, in fact, getting fluid overloaded – I have learned something from treating this man. I’m not certain that it would have changed what we did, or, if it did, that it would have made any difference. The person primarily taking care of the patient was a colleague of mine with more experience, and he elected to do the same thing I did. Who knows?

I think this is the hardest part of being a doctor, for me. Realizing that I could have taken a different treatment course that might have had a better result. Knowing that I’ll think of it next time, but I didn’t think of it this time. Learning on the job. How should I “integrate” this? The more I treat it as: Well, you know, I was trying, we all make mistakes, it might not have made any difference – the more I do that, the more I feel I become callous – treat what is an earth-shaking event in the lives of a group of particular people as though it is nothing much. On the other hand, to treat every instance of this sort of thing (happily, it doesn’t happen THAT often!) as though I, personally, had killed or maimed someone – well, for one thing it seems like it runs the risk of making it about me, not the person (see above) – but also, frankly, I just can’t do it. I can’t continue, if I’m thinking like that. So, I don’t know – I try to register it and go on. Hope it won’t happen again, knowing it probably will. Hope I’ll remember the lesson. Which does, I have to say, seem more like option 1 than option 2 (I think their work DOES make most doctors callous).

Anyone else have a better idea? Or any thoughts about this in general?

More pictures

The camp at dusk and at dawn, when we wake up to get ready for our day.

Two insects that do a very good job of looking like live and dead leaves (katydid (?), swallowtail moth - love all the little "eyes" on the moth).

The landscape is dotted with these wonderful, huge "cotton trees" (or kapok trees). They (and maybe some other trees, too) have these magnificent "buttress roots" - fold after fold.

Late afternoon, River No. 2 Beach


A few of us spent the last couple of days (off days) on the Banana Islands, so named by the Portuguese many centuries ago because their shape resembled a banana. There are two towns out there, maybe 800 people total. Otherwise - thick forest. The people mostly fish, which seems to be a relatively good way of making a living in Sierra Leone. Fishing towns (including Dublin, the town on the Banana Islands that we were staying next to) have more than their share of concrete-block and/or multi-story buildings, and maybe a generator or a satellite dish from time to time. (They are, needless to say, still very poor!) The islands figured quite a bit in both the history of slavery and the history of anti-slavery in this area, so there are several historic bits and pieces out there - cannon, old lamp-posts, overgrown forts, churches. We stayed at a very basic guesthouse with delicious food (king mackerel that even I, a fish-hater, liked). A nice break.

The tidy church which replaced the collapsed 19th century building in 2011. Reminds me irrelevantly, of the church in The African Queen.

View from the guesthouse patio.

Looking back to "the Peninsula" (where Freetown is located) from the island.

Only time I've seen a sail used here, so far - looks more or less like the bedcovers they sell in the markets, strung up on a couple of poles above an ordinary fishing boat. It was beautiful, and put me in mind of a tiny Viking ship. They seemed to be making good time!

Systemic inflammation for non-doctors - or, yet another reason why our patients need fluid

I’ve spoken at length (ad nauseam?) about fluid, the importance of keeping patients hydrated, and the ways the disease process of Ebola works against that by making you vomit and poop and sweat out a lot of liquid. But there is (at least) one other reason why our patients need a lot of water, which is probably less intuitive. It has to do with inflammation.

Think what happens when you stick your toe with a big thorn. The toe gets red and warm; it swells up a little. What is happening, at a microscopic level, is that your body is swinging into action to fight any possible infection and to repair any possible damage. These things happen: Blood vessels open up in the toe to ensure that lots of blood arrives at the injury (since blood carries many of the factors and cells that are going to get the job done). More than this, though, the walls of the capillaries actually become more permeable, so plasma (the liquid in blood) and the factors it contains can actually leak out into the tissue, bringing the immune infantry into even closer contact with the insult. So the toe swells up (more blood; more fluid leaking into the tissue) and gets warm (ditto).

The problem with massive systemic infections like Ebola (or like sepsis – a disseminated, blood-stream borne infection) is that processes that work well for a toe don’t always work well for your whole body. If you get a SYSTEMIC inflammatory reaction, you have blood vessels opening up everywhere, and blood vessel walls becoming more permeable everywhere. Which has consequences: Your blood pressure drops (if all the “hoses” get bigger, but the amount of blood doesn’t, the pressure goes down), which means that your organs become less and less well perfused. In other words, they get to a point where they are at risk of not getting enough blood (and the oxygen it contains, and the cleansing of waste products it provides) to keep on functioning. And this effect is even greater because, with all that “capillary leak,” the volume of blood/fluid actually inside your blood vessels doesn’t remain constant – in fact, it goes down. So – bigger hoses, less blood --> organs at risk of not getting what they need.

As you can see, then – it isn’t just that Ebola patients vomit and poop and sweat out a lot of fluid. It is that – plus the fact that they lose fluid inside their bodies, as well. Liquid that ordinarily would be inside their blood vessels has leaked out into their lungs, their abdomen, their tissue in general. (Hence the puffy appearance of many ICU patients – a person can actually have so much fluid in their tissues that they appear bloated, while still not having enough fluid actually inside their blood vessels.) All this while their blood vessels may be much more open than usual, so the ability of their lowered blood volume to fill the “hoses” is decreased yet further. Which opens the door to falling blood pressure and organ failure – kidneys, intestines, liver that aren’t getting what they need to survive, and thus begin to die.

In the States, we wouldn’t just put fluid back into the blood vessels, as we do here. We’d do that – but we’d also use “pressors,” drugs that actually tighten the blood vessels so that not so much fluid is needed to fill them. And sometimes we might use “inotropes,” too – drugs that make your heart beat more forcefully, which also increases blood pressure.

Here we just have fluid – lots and lots of fluid, by IV or by mouth, if the person can swallow it. Trying to replace the fluid they’ve lost through vomiting and diarrhea and sweating, but also the fluid they’ve leaked out into their tissue; and trying to, if anything, increase the amount of fluid circulating in their blood vessels from what it was before they were sick, since these vessels are likely to be opened up by the disease process and thus in need of greater fluid volumes to remain full.

You can see why I talk about it all the time!

Much activity - and a death

February 20, 2015 - An active day. We discharged something like 10 “suspect” cases (see the post about how the ETU runs, if this doesn’t make sense to you) who came back with negative PCR tests. Unfortunately, we also moved 5 or 6 people into "confirmed" whose tests were positive. And, overnight – a child died. Gravely ill children are just so fragile (at least, to this non-pediatrician they seem so) – they have little bodies and thus high surface-area-to-volume ratios, which means they probably lose more fluid by sweating (proportionally speaking) than adults (and as I’ve said so many times, fluid is key). And they simply contain less fluid than an adult, so really bad diarrhea can dangerously drain them faster than it does us. And – I don’t know – they just seem fragile – they have a reputation for “going south” incredibly rapidly when things go seriously wrong, in the States as well. Anecdotally, I’ve been told that the mortality rate for young children in the ETU is very high, significantly higher than for adults.

However, since making some modifications to our treatment regimen, our “record” is six survivors, just one death (the child). We remain hopeful. And (more of the good news I hinted at a couple of posts ago), one of the VERY sick men that we’ve been taking care of for a week or so, whom we’ve seen at a really low point, pouring out diarrhea and/or vomit, seemingly psychologically disoriented – he’s been looking better and better, and today his repeat PCR came back negative!!! There were cheers in the office when this was announced, I can tell you. (He’s still very weak – I don’t know how soon he’ll actually be able to go home. But, in theory, he is now no longer at risk of Ebola.)

In the afternoon, there were only two people in suspect (as recently as two days ago, there were maybe 16), so almost all of us went to work in confirmed. And though there are some very sick people, the treatment situation looks generally good – we have a good IV (and usually two) in everyone, and have gotten 4 or 5 liters into most of the sick folks, with evening and night shifts still to come. I felt like we “hit our marks.” In fact, I feel like I’m figuring out, more and more, how to do this. (A lot of it, frankly, is organization and time management – feeling our way into how to get the really important stuff done every time we go in, in the limited time available.)

I’m also realizing one of the things I contribute. Oddly enough (because I am VERY disorganized, as a person), it is thoroughness. I think, in fact, that BECAUSE I’m disorganized, I’ve developed the habit of going over things again and again, which adds up in the end to being thorough - ! I think that, more than some (not all) of the clinicians, I notice when, for example, our system of administering malaria medications (which need to be given twice a day for 3 days) is allowing people to fall through the cracks and risk missing doses – or when we court danger by not sufficiently emphasizing when a patient has gotten a recent dose of Tylenol (if you overdose this, as you probably know, you can cause serious liver damage, which would be a hideous thing to do to a patient who has come in expecting we’ll take care of him/her). And I do this little obsessive thing quite naturally – I don’t have to “whip myself into shape” to make this particular contribution. Everyone here, no doubt, has something like this that they bring. So often, I equate “work,” or “doing something worth doing” with grinding, bitter effort. Which I’m sure it is sometimes (ask a teenager practicing the piano!). But when it’s more “in the zone,” more “flow” – it’s nice.

Some good news

February 19, 2015 - Okay – so a part of the good news I hinted at in a recent post: The mother and daughter in the confirmed ward both recovered! I am so very, very happy about this. And, in fact, over the past 6 or 7 days, no one has died in the confirmed ward at all (one person came in and died within a few hours, before we could determine what she was sick with; another died, but not of Ebola). And four people have recovered.

This guarantees ABSOLUTELY NOTHING about the future. It could be a complete coincidence. But it sure does help our spirits. And – who knows – maybe we ARE getting some things right.

I think we are, in general, getting more organized about care (really, really difficult in a poorly equipped facility with staff turnover every week and a disease that no one knows the “definitive” treatment for, all while you can only work a maximum of 90 minutes – maybe two hours if you push it – at a stretch). And that we are, most of the time, continuing to get more fluid into sick people, often via two IVs. Also, we’ve started using Imodium for people with non-bloody diarrhea, and it may help. If you are losing tons of body water via diarrhea every day, you can see how slowing down the diarrhea might help you keep hydrated. (On the other hand, if the poop just stays in your body longer, but the liquid in it isn’t actually reabsorbed, it may not.)

So we go on. One thing new that I am learning is how hard the sessions in PPE during the heat of the day can be. In theory, it sounds like you could ensure it wouldn’t be too bad – hydrate really, really well before going in, come out if you feel faint or otherwise on the verge of not functioning. But, in practice – what do you feel like before you stop being able to function? How do you know you’re getting close to the edge? In all likelihood, it won’t be a linear process – it seems much more likely that one moment you’ll be working, and the next you’ll be on the floor. So you monitor your body, and when you begin to feel, in one way or another, more “bad” than you want to, you come out. (Often, there is an anxiety component to it – as you might imagine!) And you hope you notice in time – when there is stuff to do, there is quite a strong incentive to keep doing it, and when you’re working, sometimes you’re not paying close attention to how you’re feeling….

But the two or three hours immediately after one of these sessions do make you wonder what, exactly, you are doing to your body. Generally, I feel a bit light-headed, a bit confused (not centrally, but around the edges), very tired. I drink a lot, of course – sometimes I’ll polish off 1.5 liters in the first few minutes after I’m out. But drinking doesn’t return me to feeling normal. Is it mild electrolyte abnormalities? Is it, literally, my brain has heated up and is not functioning optimally? I don’t know. When the time comes to go in again, it does tend to focus the mind. But I can see myself doing things pretty inefficiently sometimes – going into a room 4 or 5 times to take care of everything, instead of 1 or 2. By the end of the day (or earlier?), I don’t think we are functioning at peak. (That said, if you make a good list of tasks before you go in, you can manage to do most or all of them, which feels good.)

Getting into the swing

February 17, 2015 – Haven’t written much in the past couple of days – now that I’m treating patients, there is a certain sameness to the rhythm that isn’t “anecdotal” enough to inspire the impulse to write. Things are going well. Or, rather, within the limits of a constantly changing staff, working in an underequipped facility, in an extremely poor country, against a deadly disease – things are going well! I remain dispirited at the fact that we aren’t succeeding in curing that large a percentage of patients. That, as I talked about in a previous post, the main benefit we are providing is isolation of cases; actually helping, in an assured, dependable way, those “cases” (i.e., people) remains a harder task. As you probably know, all (er – I’m pretty sure it is all) of the western folks who have contracted Ebola and been flown back to the US, Switzerland, etc., for care have survived. This is not a very large sample – maybe it would regress toward the mean if more people had been infected – but it certainly suggests something that I think “doctorly instinct” makes us all feel, as well – that with top-of-the-line care, the disease is very, very survivable. That we know this, but still are seeing upwards of 50% of patients dying, because, in the end, we can’t deliver/aren’t delivering top-of-the-line care (and distinguishing between those two is key), is frustrating. Upsetting.

However, I MAY have some happier news in the next couple of days. Don’t want to talk about it yet, just in case. But stay tuned.

I’ve been working evenings and nights. Different rhythm, because instead of having 5 or 6 people to look after, you have the whole unit – 15, 20, 25 people. It’s definitely more “make a plan – go in and execute – get out” than it is “holistic” care. But, in fact, I suppose it’s never that here – frequently being unable to understand even one single word between you and the patient (and sometimes close to that between you and the translator!) makes that a difficult goal to achieve. Evenings and nights, we focus on who most needs fluids, along with what medications remain to be given for the day. If we’re working well, as soon as we enter the unit, we go hang fluids on those who most need them (so there will be a maximum amount of time for them to “run,” equaling a maximum volume delivered), then start administering necessary medications, and only at that point do we turn to cleaning up a patient lying in his diarrhea, or finding something to eat for someone who (happily!) has developed an appetite, or finding a covering for someone who is chilly. In fact, we almost always get to those things, too, I’m happy to say. But sometimes you leave things till morning.

I went for a bike ride during the day yesterday. Stayed on the road. Hot, humid air; baking, unruly green land; iron-red soil. It sort of reminds me of the North Carolina of my youth, if it had been left in a "natural" state, rather than fenced and cultivated. Although dustier – dust everywhere. And, of course, little children calling after us at every turn. I think they were usually just saying “white person!” (“apato!”, if I have that right), but it was a very cheery sight/sound. I wonder if, in the Depression, when the land in North Carolina probably WAS a good deal less fenced and cultivated, a fair number of residents there lived at a comparable level of poverty? Probably so – although, even then, the richness of the country as a whole, the availability of educational resources, the relative nearness of cosmopolitan cities, may have modulated it somehow. But it’s true, the Dorothea-Lange-like pictures one sees – large families in one-room shacks – it does seem similar to the rudimentary dwellings and many children you see along the roads, here. Someone was talking last night about the illusion that “we” are different than “them,” whoever them might be. It is very easy to fall into that, here – to think this level of material poverty is somehow inconceivable, as though it pertains to people from another planet. I like it when I see the connections, hard as it is for me to do.

How an ETU works

February 14, 2015 – Happy Valentine’s Day, everyone. I have the morning off, as today I am scheduled for my first evening shift. It is HOT – getting up to 100 today – and Port Loko is not, needless to say, entertainment central. I’m planning to read and write and maybe snooze till I have to go in.

It occurs to me that I should give you a clearer description of what, exactly we’re doing. So: I am working in an Ebola Treatment Unit (ETU) called “Maforki,” which is currently the busiest one in the country. The purpose of the unit is to isolate and treat people who either are confirmed to have, or suspected of having, Ebola. 

It works like this: People come to the ETU who have symptoms of some kind and/or have an established contact with an Ebola victim – they lived in the same house; they shared a long taxi ride; they took part in the person’s funeral. Occasionally, we have “walk-ins” – people who all by themselves have decided they might have Ebola. Mostly, though, the patients come in ambulances, and mostly they are sent by contact-tracing teams. These teams are out in the community looking for, and then following the health of, anyone who might have come into contact with Ebola. They are really the front-line soldiers in the struggle – the ones getting on top of what could otherwise be an exponential rise in cases, getting any possibly sick person into isolation before he or she can affect anyone else.

Once the person arrives at the ETU, they are screened – by someone from Sierra Leone, who speaks the language, needless to say. We need to see if they “rule in,” or “meet criteria” – that is, if they have enough signs and symptoms to make us conclude they might have Ebola. Currently, the screening is “high sensitivity/low specificity” – in other words, we cast a wide net. The thinking is that it would be much worse to fail to identify an Ebola case (who could then go on to infect 20 or 30 other people) than it would be to keep someone in isolation unnecessarily who does not have the disease. But we can’t pretend this is 100% benign – it is completely possible that someone who does NOT have Ebola but whom we bring into the isolation unit will then CATCH Ebola from another patient while they are there. As you can see, we are deciding that risking one additional (and isolated) case is better than risking 20 (un-isolated) cases. But it might not feel that way to the person involved. (If they are careful, they shouldn't catch Ebola in the unit - but what about a family with young kids - are the kids really going to avoid touching their family members? Unlikely....)

The criteria for admission are, as I say, strict. If you have a known contact with an Ebola patient and a fever; a known contact and at least one of a long list of symptoms; a fever and three symptoms, without a known contact; or if you meet any of a couple of less-common criteria, you are admitted. We try to place an IV and give you some basic medications (including malaria treatment for everyone, since it is so widespread). We also take your blood for laboratory analysis. We then move you to the “suspect” ward – where people stay who do not have confirmed Ebola. 

The suspect ward is, as much as possible, divided into two parts – “dry” and “wet.” Which means what you might imagine – if you are vomiting, have diarrhea, or are bleeding, you go into “wet;” if your symptoms are limited to things like fever, weakness, and headache, you go into “dry.” This is because wet people are more contagious (the disease is spread via bodily fluids, after all), and also probably more likely to actually have Ebola. Separating wet and dry is a way of trying to avoid, as much as we can, any spread from infected to uninfected people in the suspect ward. (For the most part, people are all together in big rooms with metal beds and not much else in them – we are isolating cases from the community but, except in some special cases, we can’t completely isolate patients from each other.)

Meanwhile, the blood we drew is going to a lab, where a little miracle of modern bioengineering called a “polymerase chain reaction” (“PCR”) test takes place. The test increases the quantity of DNA in a sample to the point that different DNAs can be detected by different tracer molecules. If you have DNA from the Ebola virus in your blood, the test will find it. In that case, you are “positive” for Ebola, and moved from the suspect to the confirmed ward. If, however, you are “negative” – and, critically, if the blood was drawn at least three days after your symptoms started (three days being the generally understood time it takes for the virus to multiply enough to become detectable) – you are considered “Ebola-free” and can be discharged. (If It’s been less than three days, you have to stay in the unit a little longer so the test can be run again at the appropriate time.) Some “negative” people are still clearly sick – with TB, malaria, HIV, malnutrition – sometimes we have a pretty good sense of what it is, sometimes we don’t. These people are discharged to “Government Hospital” for further care. People who are otherwise well get to go home. But, of course, everyone who has been in the unit must be followed for 21 days after leaving, because – see above – they might have picked up Ebola while in the ETU. So the contact-tracing teams I’ve already referred to will add these patients to their list and keep tracking them.

Things are, in many ways, simpler once you go to the confirmed ward. Obviously, we try to maintain basic hygiene, as much as possible, but it is less critical to separate wet and dry, since everyone is already infected. Similarly, while we have to be obsessive about hand-washing, etc., in the suspect ward – the last thing any of us wants to do is to bring Ebola from an infected person to someone who is not infected – we can be thorough but more efficient in the confirmed unit since, again, everyone is already infected. (For now, there is no evidence that there are multiple “kinds” of Ebola virus in this epidemic – one person’s virus is the same as another’s. So even if one patient receives some virus from another it shouldn’t make any difference, since everyone is full of the same virus anyway.)

As I’ve said many times before, there isn’t a whole lot we can do specifically to “fight” Ebola. Either your body fights it off or it doesn’t. What we try to do is to give your body the best chance possible of doing this, by keeping you from getting other infections (antibiotics), by keeping you strong (food, if you can eat; vitamins; IV glucose if you can’t eat), by keeping enough water in your body (IVs, oral rehydration solution), and by keeping you comfortable (anti-nausea medications, pain relievers, Tylenol for fever, anti-anxiety drugs, sleep aids). These are the treatments you get in the confirmed ward (and in the suspect ward, too, if you are already clearly ill). There is certainly some debate about the BEST treatment – one ETU has published data indicating a survival rate of over 70%, and, needless to say, everyone is interested in adopting their protocol – but that is more or less the range of things we use.

With luck, after 5 or 10 days, you start to get better! At this point, we scale back your medications and tailor them to what you need – we can take out your IVs if you’re drinking well; stop antibiotics if you’ve received a full course; make sure you have lots to eat. And, once you are without symptoms for three days, we can re-test your blood. If at that point the PCR is negative, it means you have fought off the virus and can go home! You bathe to remove any remaining virus from your skin and go, quite literally, naked into the world – anything that came with you to the unit, clothes, money, cell phone, has to be burned. On the other side of the isolation fence, you are met by people who give you clothes, some money, some basic food, some basic household equipment, and a new phone. If you are a man, you are given condoms and told to use them for 3 months or abstain altogether, since the virus appears to live on in semen for that long. And everyone is given an official certificate establishing that they have survived Ebola, which they can show to people in their community who might still be afraid of them. It doesn’t guarantee you won’t be stigmatized, but hopefully, it helps. (These days, you are also met at the gate by other survivors, who can talk to you about what it’s like, how to go back to your community, how you may be feeling if many people in your family have died, etc. It’s a wonderful program.)

That is the flow in the unit, and what I am specifically occupying myself with every day – triage, admission, treatment, discharge. I hope that makes things a little clearer!

Back to work

February 12, 2015 - Today was a good day! There are 7 patients in the “confirmed” ward, and (knock lots of wood) 5 of them appear to be doing well. Three of the men are literally dancing around to the radio, and the mother and daughter are better. The daughter has pneumonia, so she doesn’t feel so hot – but both of them are getting up to go sit out on the porch or chat (across a 1.5 meter safety divider) with a visiting relative; both of them ate the boiled eggs I brought them; the younger one downed some coconut milk (high in potassium!). And their ebola symptoms appear to be fading. (Of course, as I’ve said several times, this is no guarantee….)

Maybe the best part of the day, though, had to do with the two sick men. We managed to get 7 and 8 liters, respectively, into them during the day shift, along with potassium and glucose. There are calculations that someone with Ebola – vomiting and having diarrhea all day long – can lose 10 or more liters of fluid a day, and the heat would, if anything, make it worse. There are risks in trying to get this much fluid back into someone, especially over a short period of time – in particular, the risk that you “flood” their lungs and make it difficult for them to breathe – but we simply can’t give them fluid 24 hours a day, and we’ve more or less concluded that for otherwise healthy people, it’s more of a risk to leave them “dry” than it is to over-hydrate them. The whole point of giving this much fluid is to keep their organs functioning, and if their organs are functioning, they can probably pee out the extra water.

By the end of the day, the five patients were doing moderately to very well, the two sick patients were very well hydrated and supplemented, everyone had gotten their relevant medications, and everyone had at least one good IV (the sick ones had two good ones each). As a list, this may not sound like much, but for us it is something like a home run. (Even more so since we as a team only made “aggressive hydration,” if possible with two IVs, an official goal as of this morning. It was good to feel we had risen to the challenge.) I felt like laughing out loud as we were driving home.

Of course there are always life’s little dramas: After my last time “in,” I discovered at the “doffing station” (where we take off the PPE; there’s a mirror there) that I had some hair showing on the outside of my suit (between my face shield and my hood). Ebola isn’t airborne, I’m a lot taller than most of my patients (especially if they are lying in bed, and no one was spitting at me or upchucking on me, so the chances of those strands of hair having virus on them are small. But I did drench my head in 0.05% chlorine when I was out of my suit! Then, an hour or so later as we were turning care over to the evening team, a horsefly began biting me. I shooed it away almost immediately, then – uncharacteristically for me but with delicious satisfaction – smashed it into a pancake the next time it landed. When it fell to the ground, I noticed that it made a little bloody spot on the floor. Now – who’s blood do you suppose that was? It had only bitten me for a split second. Was it, perhaps – an Ebola patient’s blood? And, if so, was it infectious? I’ve never, ever heard of insect-borne Ebola, but – as with HIV and mosquitos 30 years ago (remember?), it makes you wonder! I washed my smashing hand (and soaked the fly and the floor where it fell) as soon as I could.

In both of these cases – what are you going to do? What’s done is done. We’ll see in the next 21 days!

And then I got home, where, standing talking to a colleague, my left SI joint, irritated when I was carrying a patient several days ago, flared into excruciating ache. One of my colleagues, who just happens to be an acupuncturist and integrated-medicine practitioner as well as an ER doc (!), gave me a lovely needle treatment after dinner. All my native endorphins and enkephalins were activated, I was as happy as a clam, and I fell into one of the best sleeps I’ve had since I got here. But I just woke up (10 pm) and – it still hurts!

To be continued….

Day off

February 11, 2015 – Today, I went to the beach. Five of us did, in fact. My first real day off since starting training in Boston 13 days ago (although I’ve been in training for almost all the time since, so – lower stress than actually working).

I didn’t realize how nice it would be to get a day off. But I’ve been feeling a bit “under the weather” – headache; tired; GI stuff; sleeping poorly; then, last night, heartburn all night (something I almost never get). Thankfully no fever! Anyway, I was feeling that way all the way to the beach – but by mid-day, after a 40-minute swim in the lovely cool water, I felt more relaxed than I have in days, and – didn’t feel under the weather any more. I guess I needed it.

What to say about the beach except it’s beautiful? Sierra Leone wants to develop tourism – in 2012, they had, I think, 37,000 visitors (i.e., a tiny number), and – once the cloud of Ebola lifts; nothing will happen before then – there is a lot here people could be interested in visiting. We were at Bureh beach (named after Bai Bureh, the local hero who defied the British-imposed “hut tax” at the end of the 19^th century – a Salonean John Adams!). Apparently, River No. 2 Beach (don’t ask – I don’t know) is even nicer, but it is impossible to get to (if you value your car’s undercarriage) without going through Freetown, which would add hours to the trip.

For lunch, the guys who run the little beach restaurant offered lobster, which, once we had ordered, they went out in a boat to get – we saw them carrying the catch up to the kitchen an hour or so before they served it (see photo). The other option was barracuda. Those who know me well will know that neither of these would be my first pick, but I have to say – the barracuda must have been equally fresh, because it is maybe the least fishy fish I have ever tasted.

I had such a nice encounter with some fishermen. I was walking up the beach toward where they were loading nets onto their boat. Ordinarily, I might have kept my distance – I have a painful shyness about making other people’s lives my “experiences.” I’m not sure this is really necessary – I mean, I wouldn’t mind if people visiting New York watched me with curiosity (not that they do!). Also, why do I think that I would matter enough to strangers even to bother them? But, anyway – for some reason, today I just wanted to keep walking toward where they were working; to challenge my shyness. And, as I got within shouting distance, one of them called to me and waved me over. They were trying to get the boat off the beach and into the surf, and they needed an extra hand. So I trotted over to the stern, put my IPhone onto a gunwale (!), and leaned in. They had this singing call they started whenever enough surf was coming it that they thought they might be able to float the boat; shortly after they began the song, we would all dig in and start pushing. After three or four rounds of this, we got it into the surf, at which point they said “Okay – enough – thank you!”, echoed by a couple of smiling women who were with them on the beach. After all the questioning – am I doing something useful here, do they want me here, is this just my adventure, is this another form of colonialism somehow, etc., etc., it was nice just to be able to help some guys get their boat into the water and be thanked for it. (Okay, I need to get out of my head more, I know, I get it…!)

I feel really ready to get back into the unit tomorrow. With each passing day, I feel more like I know what I’m doing, and more and more eager to do it well. I found out today that two women – a mother and a daughter, both adults – who are in the “confirmed” ward and whom I was taking care of yesterday (my first actual day treating patients) both appear to be doing better. This is NO GUARANTEE – people sometimes seem to be doing better and then die in the night – but it is heartening nevertheless. I so want them to recover; I want to get in there and do the best I can for them.

The head of the team of Cuban doctors with whom we are working said something funny and lovely yesterday, by way of counseling us new folks to take our time, pay attention, and listen. He said, “In two weeks, you will be the experts in Ebola care – but you aren’t the experts yet!” My experience confirmed the second part – I made at least two mistakes yesterday (ordinary mistakes, but still), and I also am kind of in awe of the commitment and depth of knowledge, so much larger than my own, of my colleagues, all of whom have been doctors or nurses longer than I have. But oddly enough, I can also start to believe the first part – can imagine that, two weeks from now, I will be the one informing and guiding the new arrivals, and doing it well. Another instance of that feeling of teamwork here – of participating in something larger than ourselves? – which is so remarkably satisfying.

First day treating patients

I want to take a moment to sing the praises of Public Health. Many of you already know that the vast majority of declines in mortality, and increases in life expectancy, for humans over the past several hundred years have to do not with curative medicine – making sick people well again – but with public health and preventive medicine. It’s the sewer engineers, the water-system designers, the vaccine inventors (Nicholas Kristoff just claimed that Edward Jenner, inventer of the smallpox vaccine, saved around 500,000,000 lives all told), the nutrition programs, etc., etc., that deserve the credit much more than the doctors. For an individual person, of course, the doctor is “it” – if you have cancer, it doesn’t matter to you right now that clean air and water laws may make cancer, in general, less likely. But the clean air/water guys/gals are really more important for society as a whole.

And so it is with Ebola. The reasons the epidemic has been at least stymied are 1) isolation of sick people and 2) contact tracing. These two steps – neither of which have any necessary connection to medicine at all – mean that sick people are prevented from making others sick, and that people who might be becoming sick from a friend or relative are caught before they can pass the disease on to others. So you go from a chain reaction to a slow burn.

I think about this when I go into the unit. I think what we’re doing is incredibly important – we’re the “isolation” part of the equation. And I absolutely think that, if you are going to identify and isolate sick people, you should also try to help them, as we are. But people shouldn’t think we are all that good at “curing” Ebola. I don’t know – I’m not sure if anyone knows; someone might – what the death rate from this outbreak would be if there was no treatment at all – I’ve heard 90%. If so, our death rate – anywhere from maybe 30% at the good end to maybe 70% at the bad - is certainly better. But we are not saving everyone from death. Most of what we are doing – and the most important part of what we are doing, in terms of numbers – is preventing sick people from making others sick.

I wonder how it all looks to the sick people in the unit. I wonder if they fully believe in the medicine we are providing. I wonder if they believe that all these white people (most of us are) in weird suits sticking them with needles are actually doing their very best to make them healthy again, or if they feel more like, again, it is the white world showing off its power, flexing its muscles, making a great show at their expense, and in the end, most of them die anyway. I wonder if anyone has explained the public health part of it to them, or if they have simply grasped it for themselves. I wish we could do better by them, so that the goodwill was clearer – had more results – meant more. Maybe they do pick it up, anyway. (It’s hard to know – the various distances, of language, of culture, of socioeconomic status, of time (we have to get things done fast in there because of the heat) are so huge.)

Having said all that, though – it is amazing to see just how unwell people can be who have little or no health care. I’ve helped transfer two people so far who did NOT have Ebola, but who were so weak or debilitated that they either could barely respond or barely walk. Yesterday, a lady we had been told could walk with help collapsed in our arms as we were taking her to be discharged, landing (gently, I’m happy to say) on the rough gravel of the yard while we went looking for some way to carry her. I don’t know what was wrong. Sometimes there are strong hints (lots of coughing for months à TB; general debilitation and skinniness à HIV; weakness and other signs à malnutrition). But other times – I just don’t know. I’m just not used to seeing young or middle-aged people like this in the States, even if they are in the hospital.

Today was my first day actually treating patients in the “confirmed” ward, and I have to say it was a good one. We are making a big push to get fluids into people, by putting in two IVs and staggering teams so we can run fluids for a longer period of time. Also, we finally got some potassium supplements (people with diarrhea can lose a lot of potassium, which can ultimately cause your heart to stop). We managed to get many liters of fluid, with potassium and glucose, into almost all our confirmed patients, along with the standard medications we are using and even some drugs to help with symptoms (vomiting; upset stomach). It’s more or less all we know how to do; hopefully, the patients are strong enough to heal themselves.

It is interesting trying to figure out what is safe, what is dangerous. I have already had several “incidents” in the unit that give pause – an IV in a big vein gushing blood upon placement; two different patients bumping into the bottom of my face shield; a patient leaning their entire body against mine; even a torn glove (it was the outer of 3 gloves, at the very end of a “shift,” with no sign at all that the area had been contaminated with body fluids – I left the unit immediately after). And colleagues have had worse – a face shield that fell completely OFF; getting stung on the head by a bee and reflexively pulling the head covering off. Things that you wonder – MIGHT this be a pathway for the virus to get to me? I think we all just fall back on reason – the disease isn’t airborne; the virus does not live long on surfaces; gloves actually ARE a barrier to liquids…. You think it through and the likelihood of danger appears tiny (unless something worse has happened, I mean!). But at least three people at this unit have gotten sick over the past few months – a Cuban doctor, a Salonean nurse, and a Salonean “sprayer” (the people who accompany the medical staff and spray us and any suspicious substance or surface in the unit with 0.5% chlorine solution whenever anything risky has occurred (and at the end, when we leave the unit)). One of them died. So you know it can happen.

February 9

February 9, 2015

More slices of life here.

- The Sierra Leonean version of “How are you?” or “How ya doin’?” is “How de body?” (“How’s the body?”). None of that anxious first-world brooding (?). If the body’s good, what’s not to like!

- A woman picking up her pace to get across the road before our car reaches her, carrying a carefully laid out platter of beautiful fruit on her head. If it fell, the whole thing, the fruit and the arrangement of the fruit, would be ruined. Apparently, she knows that it won’t.

I was digestively indisposed last night, having to get up three times to deal with it. Not surprising, in a strange and poor country. But of course the problem is that here, any standard travelers’ GI upset could be Ebola – after all, digestive problems are some of its main symptoms. The key is fever – do you have one or not? If so, you have bought yourself at least a 3-day stay in an isolation unit (apparently very well run by the British government) near Freetown. So the “roll with it” approach I’ve developed to this sort of thing over time when I travel doesn’t really apply. Happily, I did NOT have a fever, and didn’t develop one all day. And in fact the 65 minutes I spent in PPE helping to transfer a very sick (but not with Ebola) patient to the government hospital left me feeling very happy, if tired. So – dodged a bullet this time.

The girl with the pink blanket died last night. She had been getting better; we all expected she would be discharged soon. But then, she apparently had a seizure and died soon after.

We are net 9 patients fewer today – aside from the girl, this is mostly because of discharging people who did not have Ebola.

February 8

February 8, 2015 – A slice of Sierra Leonean life: These plastic garbage cans with taps on them are EVERYWHERE. They are filled with 0.05% chlorine solution, and you are supposed to wash your hands at them before entering most businesses. If the business is serious, they also take your temperature – by pointing something that looks vaguely like a gun at your head. In fact, it is an infrared, “no-touch” thermometer – who knew?

Another day of exposure to the ETU. Beginning to get a sense of how the place runs – what’s done in the morning, what at night; how the teams communicate with each other; what we need to do when we’re in there (a lot of it is what falls under “nursing care” in the states – clean patients’ bottoms, change their sheets). The training is remarkably well done – at each stage, we go from being nervous and intimidated to feeling able and being eager to work. I’m still a bit nervous about evenings and nights (when 2 to 4 of us are responsible for all the patients – tonight, it’s 31), but otherwise I feel ready to start.

There was a young pregnant woman in one of the wards today. It wasn’t even confirmed she had Ebola, but she was certainly very sick. She didn’t respond (more than to turn her head) when we spoke to her. Midway through the day, we decided that she would get better care at the maternity hospital in Freetown, which has an Ebola unit. When the ambulance arrived, seven of us quickly got into PPE. We got her off of her mattress and onto a stretcher (made of a body bag) and carried her to a bed outside in the sun, where we washed her off, front and back, with cold water from a tap (she barely moved when we poured it on her). Then we carried her to the ambulance to take her to the city. I don’t know what will happen to her (if she does have Ebola, her baby will almost certainly die). It reminded me of the JM Coetzee novel “Disgrace,” and maybe of “The Plague” (though I’m not sure, since I haven’t read it since I was a teenager). Sometimes, all you can do is what you can do. Not affect fate. Treat a person with dignity and make her more comfortable as her fate overtakes