Get out of the kitchen?

March 5, 2015 – 99 degrees today. I went in in the afternoon and after about 45 minutes began to feel anxious – a kind of panicky feeling, like I won’t be able to handle…something. I and a colleague were working on a particular project: Cleaning up and ordering all the medical supplies in all the rooms. You can perhaps imagine how they become a complete mess: People going in can’t check what is already in a given room (after all, you can’t go into the room unless you’re in full PPE). So we bring things we think we might need – IV tubing, “flush” syringes, IV fluid, needles, oral rehydration solution. When we get into the room, we put what we’ve brought down on a bed, but usually – since we are always being better-safe-than-sorry – we don’t use it all. Most of the time, we’re working pretty hard in there, so we don’t take the time to consolidate whatever we’re not using with whatever is already in the room. So, over the course of many shifts, little piles of miscellaneous, mixed equipment collect all over unused beds. It’s a complete mess – and beyond making things hard to find, it’s just depressing – makes it feel like things are out of control, which you’re already close enough to feeling during those busy, limited sessions in the unit anyway.

We had gotten all the “suspect” rooms organized in the morning, but my colleague was handling a torn plastic pill package that cut through both her gloves, so we had to leave before we’d done much with “confirmed.” So, in the afternoon, we started there – only to realize the rooms were such a mess that each was going to take maybe 30 minutes to organize.

Anyway, I breathed through the anxious feeling – a little difficult since the only masks we have available are the ones affectionately referred to as the “waterboarding” masks. They are soft paper/fabric, and as you sweat they gradually get saturated and collapse, till you’re trying to breath through what amounts to a wet towel millimeters from your face. Periodically the anxiety would rise, periodically I would breathe it down – I really, really wanted to get the rooms cleaned! Over the next half hour, I noticed my heart rate rising, my breathing rate rising, my head beginning to pound, my concentration beginning to unravel, and always the anxiety…. In the last room, I got the medication box organized and most of the supplies consolidated, and then my colleague (who is probably 25 years younger, but was also hurting) and I kind of shoved it all into a more-or-less rational pattern and got out.

Definitely the worst PPE session to date. I took my temperature (100.3 on a thermometer which usually clocks me around 97.9), downed a couple of liters of water and ORS, and, interestingly, gobbled down some cold French fries – maybe craving the salt? Now, two and a half hours later, I feel more or less okay – sleepy – tired – but okay.

Meanwhile – remember that time I told you that no one had died in the confirmed ward for a week? Well, I’m pretty sure that, over this past week, no one there has survived. I remember a fellow student in medical school who lamented – “Whether I study or don’t study, I still get the same grade on every test!” It’s beginning to feel that way here – we do what we do, fine-tuning it, “improving” it week to week, but whatever we do, half the patients die. It’s the same dispiriting picture as when I first got here….

I actually think we are delivering GOOD care. That is, given the limits of what we can do here (and of what we know – it’s incredible how much about the basics of just what happens to your body when you have Ebola no one knows), I think we are doing what we can. We’re giving each patient personal attention; we are treating every problem of theirs we find that we can treat; we are giving them medications to suppress other infections that might add insupportably to the strain on their bodies. There is nothing obvious we could be doing that we’re not. And yet we’re still nowhere near the survival rates achieved in the West. Maybe you just simply need more and more sensitive monitors, a wider range of life-support techniques, and more continuous (i.e., not just 15 or 20 minutes six times a day) care to dependably survive.

A break

March 4, 2015 – The silence ends! I don’t really know why I haven’t written lately; perhaps because I had 4 evening or night shifts in a row, which upsets one’s sleep schedule and makes one less productive. Perhaps because I just worked 7 days in a row (which, I hadn’t really realized till now, is pretty uncommon in our usual work lives, isn’t it?) and am just tired. Perhaps because – despite some dramas and concerns re: treatment that I won’t go into here – the work has become more routine – not in the sense of boring (it is VERY engaging), but in the sense of familiar and thus less in need of being described, from my point of view. In any case, I have felt less like coming home and sitting down at the computer to dash off my thoughts.

Right now, I am on the tail end of a blessed two days off (the first was the day after a midnight-to-8am shift, though, so it doesn’t REALLY count!), during which I came down to Freetown to spend some time with one of my favorite cohort-mates, who was assigned to a different facility and whom I thus haven’t seen in almost four weeks. Such a nice visit; so nice just to get a change of scene; wonderful how refreshed I feel! I think it is two things:

First – the work is, I believe, more stressful than I actually realize when I’m doing it. I’ve touched on all the reasons why this is so at one time or another in this blog – the ever-worrying knowledge that our care is not all it could be, due to resource and time constraints; the consciousness of the imperfections of being a clinician; the concern to “hit our marks” (give enough fluid to those who need it; give scheduled medications to everyone on our list while also treating any fevers or other symptoms we happen to come across; clean any patient up who is lying in their own diarrhea; etc.) every time we go in; the tension between fluid, on the one hand, and difficulty breathing, on the other (the disease seems to get to a place with most very sick people where their lungs are “wet” but their blood vessels are “dry,” as I explained in an earlier post, leaving us uncertain what to do). Etc. Also – and I tend to discount this, but I think it is real and ever-present – the background worry about actually catching the disease. I do NOT think about this, let alone obsess about it, very often, but I think it is always there. Did everyone read Craig Spencer’s article in the New England Journal (or the description of it in the Times)? Here it is:

http://www.nejm.org/doi/full/10.1056/NEJMp1501355

Reading it is a reminder that having the disease is no picnic, even if you do get better (and that is by no means guaranteed, despite the success with expat patients up till now). Also – I don’t know if you’ve heard about this or not – there is a lot of evidence suggesting that, even when you have recovered, there is the possibility of a “post-Ebola” syndrome – inflamed eyes, weakness, tiredness, aches, confusion – that may affect some or many people, for literally no-one-knows how long. You don’t want to go there, if you can possibly avoid it! So, when you look at that sleeve smeared with diarrhea after you’ve moved an incapacitated patient to a clean mattress, or that glove running with blood after you’ve bandaged the site of a former IV that the patient, thrashing around, has pulled out, you do kind of wonder – am I sure that none of this is penetrating the protection? I have no reason to think it is – but you do ask the question.

Second – and this I hadn’t really registered till I came to Freetown – it is, in fact, stressful living in my temporary, provisional digs. There is the long hike to the toilets; the (very good but) institutional food eaten on their schedule, not yours; the always vaguely icky, humid shower tent. Most importantly, I NEVER sleep well at the camp, probably because, for some reason I do not understand, the Danish insist that all public lighting – in the corridors of the tents and outside – stay on ALL THE TIME! Also, the cots are maybe 2.5 feet wide, the mattresses are thin, and I have arthritis in both hips, making finding a comfortable position difficult at the best of times. In any case, I wake up again and again all night long, and almost never feel rested. This despite my two recent improvements: Playing the arthritis card to get a SECOND thin mattress from the camp staff (the same sweet, vaguely humorless young Dane who checked us in told me that they didn’t have many of the mattresses, but, “in your case, it is a medical reason. We need to have you fresh to care for your patients!”). And – TMI coming up – peeing in a bottle instead of hiking out of the tent every time I have to urinate in the middle of the night (something which inevitably left me completely awake by the time I got back to bed). Mornings I can be seen sporting my backpack to the toilet block in order to furtively pour the night’s production down the can.

So – stressed at work, stressed at “home.” I am NOT complaining (more reporting), and I feel, all the time, so glad to have the chance to do this really important work. But, you know – I have been counting the days till my departure since I first got here, and I’m counting them still. Six more shifts. I will happily come back again in a few months, if the need continues (wouldn’t it be nice if it didn’t?). But I’m happy that this stint will be over in a week.

Tomorrow (if I can make it back to Maforki, ha, ha – there seems to be some uncertainty re: the transportation), I get to present my game-changing idea for preventing IVs from coming out so easily. I jest, but, on the other hand, if it works, it would in fact be a great relief to us all. It’s based on something I saw them do in Switzerland, and I could kick myself because I should have thought of it weeks ago. I’ll let you know how it turns out….

A really cool feature in the New York Times

In case you haven't seen it. 

http://www.nytimes.com/interactive/2014/10/31/world/africa/photos-of-workers-and-survivors-braving-ebola-at-a-clinic-in-liberia.html

The white guy looking soaked, with the fogged glasses - that's what we look like when we take off our PPE.

Tourism in a poor country

February 27, 2015 - Today’s class in first-world problems consists of one multiple choice question (BTW, this is a 100% serious question, my tone notwithstanding):

You have a morning off and you bike into town to have a look around. When you are surrounded by children asking to ride your bike and saying “apato!” (“white person”) and, not infrequently, “apato, give me money!”, you should (circle all that apply):

a) Smile, redirect them, and play. They’re just kids, after all

b) Give them money – you have a lot more of it than they do

c) Don’t give them money – no one really likes being a beggar, and it’s best not to encourage it

d) Let them have a spin on the bike – they’re just kids who want to ride a bike, for Chrissakes

e) Don’t let them ride your bike – if one does, everyone will want to, and you’ll be there for hours.

f) Don’t let them ride your bike – it’s way too big for them, and what if one of them got hurt, then you’d probably be fired and also subject to a local justice system that you know nothing about and that might land you in a heap of trouble (you’ve seen the prison right down the road from where you live, after all)

g) Don’t let them ride your bike, and wipe it down with chlorine at the next opportunity – they might have Ebola!

h) Smile and say hi and carry on – you’re here for a legitimate reason, after all, and everyone has a right to take a trip downtown

i) Next time you have a morning off, stay at the camp – all you’re doing in town is exciting envy, an ugly feeling no one likes to feel

j) Next time you have a morning off, go back into town – it’s a global world now, there’s no turning back, and contact and communication are good

k) Next time you have a morning off, do whatever you feel like doing – if you imagine the little commotion you caused in town had any significance in the overall days of the people you encountered, you're dreaming

l) Once you are back home, put some work into finding an organization that is doing good, helpful, generous, committed and integrated development work here and give them a large contribution

m) Once you are back home, never come back here again unless there is another health emergency – the history of the West in Africa is a horrific tale of brutal exploitation, and there is no reason to believe we’re doing that much better now

n) Once you are back home, think long and hard before you come again – tourism dollars generally stay with a small elite, and just lead to increased exploitation and environmental degradation for everyone else

o) Once you are back home, start to plan your next vacation trip here – the beaches are beautiful, and tourism dollars help pump up the economy for everyone

p) Once you are back home, start to plan your next vacation trip here – it’s a global world (see j) and we might as well start getting to know one another

q) Once you get back home, never go anywhere more than 50 miles from your home ever again – given the changes to the climate and the planet, no one should be flying anywhere, ever, unless there is an overwhelming need

r) Remember what you learned the first time you went to India: Just because people’s lives look different than yours doesn’t mean they enjoy them any less than you do. Aside from instances of dire poverty (to the point of malnutrition and homelessness) and/or critical health problems, there are probably just as many happy people, depressed people, angry people, positive people, peaceful people here as there are back home. Get over yourself

s) Other: _________________________________________________________

The best answer is probably a – but anyone who has been reading this blog probably realizes by now that I’m too anxious to do that very well! Given that, my answers are probably: Wholeheartedly: c, e, h, k, l, n, and r. Less certainly: i and m. And I think about f and g, but try not to go down the road of that kind of hypothetical fear, if I can avoid it (that way madness lies).

And then there is q, which seems to me unimpeachably true, but which I have not found, and do not see myself finding anytime soon, the willpower to honor (see Elizabeth Kolbert’s wonderful writing on this subject, most recently in her New York Review of Books essay on Naomi Klein’s global warming book*).

I’d really love to know what others think.

* 'To draw on Klein paraphrasing Al Gore, here’s my inconvenient truth: when you tell people what it would actually take to radically reduce carbon emissions, they turn away. They don’t want to give up air travel or air conditioning or HDTV or trips to the mall or the family car or the myriad other things that go along with consuming 5,000 or 8,000 or 12,000 watts. All the major environmental groups know this, which is why they maintain, contrary to the requirements of a 2,000-watt society, that climate change can be tackled with minimal disruption to “the American way of life.” And Klein, you have to assume, knows it too. The irony of her book is that she ends up exactly where the “warmists” do, telling a fable she hopes will do some good.'

http://www.nybooks.com/articles/archives/2014/dec/04/can-climate-change-cure-capitalism/?insrc=toc

Artist in residence

February 26, 2015 - Another nice and surprising moment, a la the fishermen asking me to help them move their boat: When I got back from the ETU this afternoon, I went over to pick up my clothes at the laundry tent. There was a bit of a line, and as I waited, I noticed a notebook open on the table inside. I was casually looking at what was written in it, noticing a heading there, some lines there, when it dawned on me that what I was looking at was a play. And, indeed, there they were – character names followed by text; stage directions. The tent was being manned by one of the many semi-anonymous (to me - !) staff members here at the tent camp – people you see from time to time but whom you know nothing about, and whom you can’t even speak with easily due to the language barrier. This guy, like most of the laundry tent staff, had often seemed a bit abrupt and unhelpful, so that I’ve developed a mixture of mild anxiety and mild irritation every time I have to go up there. Anyway, when I got to the window I asked him, “Are you writing a play?” And he said “Yes.” And gave me my laundry. No less abrupt, no more helpful, and I still know nothing about him – but suddenly, a whole inner life opened up for a second. Not just a surly guy whom I don’t talk to – but a surly guy I don’t talk to who is writing a play. 

It’s kind of embarrassing that this sudden bursting forth of three dimensions – or of color, like in the Wizard of Oz – should have surprised and pleased me so much (I am beginning to realize that this blog is revealing more about my character than perhaps I would have chosen to show!). But I frequently don’t pay enough attention to the individuals around me, and less and less the more the distances – social, economic, linguistic, cultural – grow. It’s good to be brought up short.

After death

February 26, 2015 - My colleague and I walked into a patient’s room today and found her dead. This has never happened to me before. She was an older woman (her paperwork said she was 35, but, even accounting for how hard life can be here, this is not possible – we thought maybe 65) who had come in a couple of days ago and almost certainly did not have Ebola. She had a swollen belly, a puffy face, and was having bloody bowel movements and perhaps bloody spitup, as well. Although bleeding CAN be a part of Ebola, it is relatively rare, and the rest of the symptoms don’t sound like it at all. Plus, her first blood test was negative (since the test happened within 3 days of her most recent symptoms, though, it is not considered definitive). One of my colleagues, a “hospitalist” (doctor who takes care of patients on the floor of a hospital), and thus someone much more experienced with trying to diagnose unknown conditions than I am, thinks she may have had cancer. In any case, she had been unwell for some time, it seemed to us. 

It is weird to say it, but it wasn’t an unpleasant experience. That is – I wish she hadn’t died, and I am sad for her and for her family. What I mean is – given the fact that she was dead – that it had happened, and we weren’t going to un-do it – moving her on the bed so that she was lying straight, and then pulling a shroud over her to cover her until the team that takes care of bodies could come – I was, in a very small but still real way, thankful to be able to do it. Maybe, back when we did this in the house and didn’t call in a “specialist,” many people felt that way? Or maybe it is just some quirk in me – I definitely have a kind of awe of death, the thing that “makes these odds all even.” But it can’t just be me – there are so many things in the culture – “Fear no more the heat of the sun.” Or – does anyone else have a connection to this one? – the bass aria toward the end of the St. Matthew Passion, “Mache dich, mein Herze, rein”? It’s a piece of music that doesn’t make “sense,” and yet it makes sense. It is after Jesus has been crucified, so the whole horrid story has happened – the people have turned on and failed to save the person who loves them the most; he has been tortured and killed. And then this extraordinarily peaceful – in fact, kind of happy – music starts playing, the text saying “I will bury Jesus myself.” The implication in the song is “I will bury Jesus inside me; he will continue to live in me” – but I’ve always thought that just something about the simple fact of burying him – of taking account of reality, of what has happened, and then dealing with it, straightforwardly, respectfully and kindly – might be part of it, too. After the crisis there is peace; let’s let our dealing with it allow that peace. Since I’m not part of her family – since I don’t have any knowledge of her, no personal emotional investment – maybe this little thing is something I CAN do, gracefully, at a time when it might be harder for someone close to her - ? 

In any case, the family wouldn’t be allowed to. Even though I don’t think she had Ebola, she, like all unexplained deaths here, will be treated AS IF she did – just in case. People who have died are EXTREMELY infectious – basically, if you think of dying from Ebola (as opposed to recovering from it) as being, in the end, overwhelmed by the virus, you get the picture – by the end, the virus is just running riot – you are full of it. So they err WAY on the side of caution, to prevent possible spread.

Which means that what (as I understand it) people over here consider respectful treatment of a body – washing it, preparing it – is not allowed. In fact, families cannot usually even see a “suspect” dead relative – they may sometimes be able to be present at the burial, but they must keep a good distance, and the body will be enclosed in a body bag as it is placed in the grave (in a special area, dug very deep – again, to avoid infection). I gather that this has been (not surprisingly) very, very hard for people to accept – my sense is that a not-insignificant portion of new infections comes from people who, either out of ignorance or because they just couldn’t bear to do otherwise, have taken part in ordinary funerals, instead of the “hygienic” ones that the disease demands.

So, anyway – without being able to act with any particular knowledge of this person, without the care that someone who loved her would offer, without being able to spend much time on it, but nevertheless respectfully and kindly (and without cant), I helped get her ready for burial. Like I say – I am glad of that.

Mid-course

February 25, 2015 - As of today, I’m at the halfway point of my work at the ETU (and 2/3 of the way through this whole posting, including training). The unit only has six patients tonight. Well, really, five – one is a baby who almost CERTAINLY has malaria (which we’re treating) and not Ebola, but whom we need a negative PCR on to be able to allow to go. He (and his mother, who has no symptoms at all) are holed up in a separate building in the “suspect” area which has not housed an Ebola case for at least 10 days, with instructions to basically stay away from everyone else! I’m very hopeful we can avoid giving them Ebola while we wait for the test – which we really, really hope will be back by tomorrow afternoon.

But, anyway – a low patient census, which allows us to do our work with a thoroughness which is very satisfying. Unfortunately, however, Sierra Leone as a whole has had between 12 and 16 new cases a day over the last 4 or 5 days. That’s higher than last week, when the average was closer to 10. And if you have deduced from the above that most of the new cases aren’t in our area, you are correct – a lot of them are near Freetown, in fact, always concerning since spread in a city is everyone’s nightmare. The higher number of cases per day may end up being a statistical blip, of course. And, even if it continues, it might represent hopeful as well as discouraging facts (i.e., it might be better case-finding by public-health teams, not a higher incidence). But you can’t really call it encouraging. Again, it brings you up against how hard actually ending the epidemic, for good, will probably be.

PS, March 1, 2015 - Here are links to a couple of articles discussing the difficulty of actually ending the epidemic here. Very, very interesting reading:

http://www.theguardian.com/world/2015/feb/27/ebola-sierra-leone-village-lockdown-31-new-cases

http://www.nytimes.com/2015/03/01/world/africa/nearly-beaten-in-sierra-leone-ebola-makes-a-comeback-by-sea.html?_r=0