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.)