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!