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.