Fieldset
Individuals in an Epidemic

The emergency response teams working at the Ebola project in Kailahun are very busy. Resources are limited, and the need is great. I soon became involved in assisting the medical team with their daily tasks.

Medicine in an Ebola outbreak is not rocket science. Management is kept as low-tech as possible to avoid unnecessary procedures that could expose health workers to risk of infection, for example inserting intravenous lines using a needle. As there is no current curative treatment for Ebola the focus is on “supportive treatment” only (see last post).

I would like to introduce you to a few of the isolated patients, to see what I saw and to understand some of the challenges. Whilst the cases are real, all names and identifying details are changed for the maintenance of patient confidentiality and dignity.

Once the cumbersome personal protective equipment (PPE) is applied, I have a colleague check me to make sure I have not left any small patch unprotected. Satisfied, I enter the isolation unit with the nurse, who is to be my “buddy” whilst inside. We first enter the “Suspect” case area, here are mostly patients admitted in the last 24 hours, waiting for blood test results which will determine if they move through the one way system to “Confirmed” or get discharged if not infected

Most of the patients in "Suspect" look well, there is just one man who is lying on his bed inside the hot and humid tent. I saw him on admission the day before, when he walked to the unit himself to declare his concerning symptoms. He has begun to have  bouts of watery diarrhoea and his appetite has almost gone completely. He’s still alert and able to hold a coherent conversation. We talk a bit about basic care when suffering diarrhoea, a quick assessment shows he is not clinically dehydrated so I encourage him on oral intake and make a note “not for IV”.

Some patients arrive to the unit in small convoys, whole families or chunks of a single village where there has been the tell-tale stories of mysterious deaths and traditional funerals. In the tent next door are the "Probable" cases, still waiting for test confirmation but with a solid contact and symptom history. The day before six members of one family came from a village known to have an uncontrolled outbreak, they all tested positive and moved along the conveyer to the "Confirmed" area, filling the beds of recently deceased or discharged patients.

The patients in the "Probable" tent look to be in significantly worse condition than those from "Suspect". Most are lying in fetal position, one hand resting on their stomachs (a common symptom of Ebola is stomach ache), they look weak and apathetic.

There is one small boy quietly curled up on his bed. He arrived late in yesterday’s shift, reportedly he is nine years old, he is visibly malnourished and could easily pass for much younger. He was brought by the same ambulance as his mother. The roads around Kailahun are in appalling condition, the rainy season does not help either. I can only imagine being thrown around in the back of the ambulance as it navigates each muddy bump and pot-hole, when already feeling sick and frightened on ones way to a strange unit.

When the ambulance doors were opened the mother was found to have already died during transit, her child lying next to her. To be a rural Sierra Leonian, nine years old, sick and away from home, recently bereaved and alone. Now faced with strangers in fully covering bright yellow suits. Terrifying.

He was lying in a pool of watery diarrhoea, and though awake, not able to show any sign of recognition or eye contact. He was literally frozen with fear. We take the small blood test (a swab as his veins were too challenging), and make a note for him to be cleaned and fed.

We pass through the red plastic gates that separate "Suspect"/”Probable” from “Confirmed”. Walk through a chlorine foot-bath and move on to see the patients of concern. It is not possible to see all patients during the ward round. It is too hot in the PPE and there are too many. So, before entering we, the medics, sat together and discussed who we needed to see and who we could observe from outside the high risk area. I have a piece of paper with their names and pen to make my notes. Once I’m done I will go to the inner perimeter fence and shout my findings across to another medic who writes it all down on another piece of paper. Whatever I have taken inside can not come back out.

There are many patients milling about outside, some are listening to a radio others are chatting in small circles. A community has developed inside the isolation unit, brought together by their similar predicament.

I begin to call for the first patient on my list, lying in one of the tents I find a very unwell looking woman. I check her wrist band and find she is not on my list, but she is definitely of concern. Her breathing is rapid and shallow, and her eyes open but glazed over looking far away beyond me. There is no sense of recognition or interaction. Her arms are tensely flexed and rigid, hands in fists like she is ready to begin a boxing match. She is incontinent of all waste products. It is clear that she is in the end stages, I make a note, wash my gloves in chlorine and move on. We discuss her deterioration in the medical meeting and decide to try and place an IV line, when the next team go inside they find she has passed away.

I eventually find the first patient on my list, Fatmata, she is a middle-aged woman who had been doing reasonably well but is now having diarrhoea. She is lying on the floor outside, strong enough to get out of the hot tents but looks weak and listless. I kneel down next to her to feel the pulse, check temperature and count her breathing. “Fatmata, how de’body?” I ask in my poor attempt at Creole. She looks to me, responding to her name is reassuring. She tells me and the nurse she has no complaints, no more diarrhoea and is managing to eat. The description she gives is a million miles away from how she looks.

Most of Fatmata’s family have already died, in the last days her husband passed away too. An expert in Ebola recently told me “this disease kills those you love the most, the people closest to you and those that you are most likely to care for”. Wise and poignant words, true to the cruel nature of transmission in this disease.

I ask again how she is feeling, “sad”. An understandable and natural reaction. She is emotionally exhausted, and literally giving-up her own fight now to go join those she has loved and lost. I make my notes and arrange for the psychologist to see her, despite his best efforts she would not come to speak with him. On my rounds the following morning I find Fatmata lying in her bed, in the same boxing posture as the other woman. Eyes open and body fixed in rigor mortis.

As the only gynaecologist I have been given a special assignment, a 30 year old woman had painfully swollen breasts that needed attention. Mariama was admitted to the isolation ward with her four year old son. She had recently given birth and was still breastfeeding her baby when people in the village began dying from fever. Mariama’s mother was the first in the family to die, then one by one Mariama’s children died from the same illness, till the only one left living was the four year old who she was now isolated with.

Mariama was tall and skinny, her skin slightly sagging. She looked generally well, able to walk about the isolation unit freely and talking normally. Her left breast was large and heavy with milk, that had no mouth to feed. We went over the technique to empty it out, explaining that the pain would resolve with repeating the procedure. Breast milk also carries Ebola virus (as do all body fluids) so she needed to understand how to safely dispose of the infected milk.

Together we moved on to see her son, Augustine, lying on the floor looking like he had arrived from a famine zone. Flies flew around his head, eyes sunken and dull, his skin was loose with signs of severe dehydration. His gums were bleeding leaving dried scabs over his lips and tongue, his liver was large and clearly tender. During the examination he only made an occasional whimper, otherwise he remained floppy, focusing only on working hard to get air into his young lungs. Mariama confirmed that Augustine had profuse diarrhoea. He desperately needed hydrating. As a team we discussed little Augustine, where were we going with his treatment? What was a reasonable measure between assisting him and unduly distressing him? We decided to get a line in and at least try and replace the fluids.

The following day I reviewed Augustine, whilst he was still clearly a very sick child, the improvement was clear. His skin had regained turgor, and he was more aware of what was happening even fighting off my examination a little. We were cautiously optimistic. Another lengthy discussion as we debated attempts to build up his nutrition. Decisions that would normally be easy become contentious in an Ebola context, the line of what to treat and how is ethically and emotionally challenging. Together we decided his improvement was a sign to give him extra support. We agreed on placing a nasogastric tube (a tube inserted through the nose into the stomach) to feed him nutritional supplements, but also agreed that this was going to be our maximum intervention. When the other doctor entered isolation to place the nasogastric tube he found little Augustine lying still next to Mariama. Her last remaining child, now she had lost them all to this pointless epidemic.

It is hard to convey humanity in an Ebola isolation unit. There are sad stories, people suffering physically and looking into uncertain futures.

As a health worker I am used to reaching out and touching my patients. Letting them know they are not alone, that even if I can not know their fears and pain I can at least support them on their journey. In the unit contact is between double gloves, and full triple layered protective clothing. The only part of me that can be seen is my eyes, behind their misted goggles and the small slit in my head-dress. Compounded by the distance of linguistic and cultural differences, and a lack of understanding of what this shadow is that has been cast over them and their loved ones. I have never felt at once so far and so intimately close to a stranger as when I rested my hand on Mariama’s and with only my eyes and subtle movement of my head conveyed my deepest sympathies.

It was something I regretfully learnt to do several times whilst working in Kailahun.

There is a small group of children who are doing surprisingly well inside the unit. Together they have come together to create a pseudo-family, the older kids caring loyally for the younger. It is a pleasure to see these children, a true sign of hope during this dark time.

Each day a couple of patients will be discharged, an incredibly joyous moment. When a child leaves, it is often with some trepidation, returning to a world forever changed. The isolation unit had become a safe haven, and for some of these children they return as orphans. As a team everyone is focused on these positive moments, supporting the patients and assisting their reintegration back into society.

Together, the emergency team work long hours to try and find the way to guide as many patients as they can through the one way system and back out of the front door. Of course, we all know that success lies with the patients alone, but the efforts to support and maintain hope are of vital importance. The epidemic persists to slowly burn, and till there is sufficient coordination and resources to extinguish the fire these needlessly sad stories will continue to be all too common.