Training day 4

Last night, many of us in the team ended up sitting around the living room swapping stories. The team is gelling very nicely, and I’m struck by how much it feels like – being in a play! You come together with strangers whom you will have to work with for a set period. You feel your way a bit into who they are. You find ways to laugh together. You start to trust each other, and to sense who you can rely on for this, who you might have to support a bit for that. And all for this goal that is bigger than any of you individually. (It might sound strange to compare producing a play to ending an Ebola epidemic, but when you are doing them they can both feel very important.) I guess it’s just the nature of collective undertaking. But it was nice, and both a bit surprising and a bit concerning (because in a way it made me feel young and more fragile again) to find myself coming back around the circle.

Today (2/5/15) we wore the PPE (by the way – I said that meant “personal protective gear,” which might have confused everyone – it is, of course, Personal Protective Equipment!) while treating “patients” in teams inside a mock Ebola Treatment Unit (ETU). I was elected team captain because (to my mild alarm), it turned out I was the only MD on our team. But, once inside, it went very well. I don’t know what it is about medical trainers, in general (this happened all the time in medical school), that they like to put you in situations they have not explained very well and then yell at you when you don’t figure them out the way they want in the time they want - ! There was a bit of that – but, in general, the PPE was bearable, and, when it comes down to it, the treatment of Ebola patients is (as I’ve said) not particularly complicated. I feel like I’m pretty good at supervising clinical people – telling them clearly what I’d like them to do; summarizing information collected and stating simply what we need to do in response – so that’s what we did in there, and the trainers seemed happy. Basically, it’s evaluate the patient’s “fluid status” – how much water they have filling their blood vessels – and, if it’s low (as is very likely in this case), figure out why. It could be due to the patient losing water (vomiting, diarrhea, sweating), to the patient losing blood (the “hemorrhagic” part of Ebola Hemorrhagic Fever – actually, a relatively rare occurrence, though a serious one if it happens), or to the patient having a massive systemic infection (“septic shock”). Once you think you know which one it is, you treat it – although, ha, ha, in this case, all the treatments are all the same, since we can’t give the patient blood, and we give all patients antibiotics whether we know they have an infection or not since it is very likely that they have or could develop one. That only leaves IV fluid, and, whatever the reason the volume status is low, we give a lot of this. Add an antimalarial (many, many people will come in with malaria, whether or not they also have Ebola), some Tylenol for their fever, a multivitamin, and other drugs (anti-nausea medications, stuff for seizures, sedatives…) as needed. Clean the patient up, replace his/her linens, make him/her feel as comfortable (and hopeful!) as possible – then check again in a little while. And hope that, as you do this again and again over several days, their body, in the meantime, will cure them.

By the time we got out, there were little lakes of water in both of my sleeves, my face shield looked like the inside of a kitchen window on a snowy night, but with the help of my colleagues, I got everything on and off, more or less in order.

Interesting to note: While doing “triage” exercises (deciding whether or not a person who comes to the ETU should or should not be admitted as a potential case), if it wasn’t crystal clear what the right answer was, the Sierra Leone colleagues were more likely to say “yes, admit them” than the foreigners were. They’ve been doing this for a while and it’s their country – my guess is that a) they’ve seen how the disease can surprise you, and b) they’re more acutely aware of the havoc than can be wrought by an infected person NOT being isolated. The downside is that you risk giving the virus to someone who in fact does not have Ebola to begin with, if you bring questionable cases in. Which error would you choose?

To Port Loko, and a real, active ETU, tomorrow.