Fieldset
In The Shadow of Ebola

The maternity unit at Gondama Referral Centre (GRC) in Bo only treats obstetric complications and emergencies. With that in mind I had been planning and expecting the obvious caesarean sections, difficult deliveries and postpartum complications.

The maternity unit at Gondama Referral Centre (GRC) in Bo only treats obstetric complications and emergencies. With that in mind I had been planning and expecting the obvious caesarean sections, difficult deliveries and postpartum complications. Before coming to Sierra Leone I read and re-read over the emergency procedures I thought I would be likely to need to do, discussed with my consultants different techniques and management plans and spent a lot of time going over scenarios in my head.

Obstetrics in Sierra Leone, as I’m sure is the case in many developing countries, is a far removal from the world I have trained and worked in. There is little in the way of antenatal care, nearly no-one has had an ultrasound scan, there’s no proper fetal monitoring and presentations are often complicated and late. The aim of care here is ultimately to keep mothers alive and avoid putting a scar on their uterus (caesarean section), as you don’t know where they will deliver next time.

So, I’m here, ready and excited to begin.

But there’s another dimension to working in Sierra Leone currently, viral haemorrhagic fever. Lassa Fever is endemic in this region, spread by rodents and then human-to-human contact, it has a mortality of around 30%, this is an ever present danger for those working and living in the area.

Now though, the largest recorded epidemic of Ebola is also underway, and the direction of spread has put our clinic directly on course for collision. Ebola remains a very feared disease, with good reason. The disease is contagious, difficult to initially diagnose and deadly to most of those infected. Ebola is not a disease I had ever really given much thought to, firstly because till this outbreak it had been restricted to pockets in remote areas and usually burnt itself out, and secondly because as an obstetrician I had not expected it to be too much my concern. I was wrong.

The diagnosis of Ebola is difficult and works on a suspicion, isolation, then confirmation basis. There may be symptoms of fever, bleeding, abdominal pain, miscarriage, stillbirth… basically most obstetric presentations at GRC. The screening mechanism is essentially that before any patient is seen they are questioned and if there’s cause for concern an action plan, possibly isolation plan, is put into place. Presentations of high suspicion would include a history attendance at funerals or treating other sick relatives. And if after passing the questionnaire the patient enters the ward for treatment, because of the difficulty in diagnosing Ebola and Lassa Fever, they are all universally treated whilst wearing full barrier uniform (gloves, mask, goggles, gown and waterproof apron).

The effect is strange, it’s incredibly hot and uncomfortable making for very short consultations and also it creates a distance to the patient. I can’t touch them, I don’t speak the same language and I only approach in a fully covered waterproof suit. As for staff and colleagues, there’s no shaking hands or physical contact, we now tap elbows instead, and we must wash our hands with chlorinated water between entering or leaving any home or workplace.

Till I arrived there had not been any suspected or confirmed cases of Ebola in GRC, I was reassured by that. The week before I left I was chatting with friends over a drink, they asked what I was most worried about in coming to Sierra Leone. I had two answers: Ebola and needing to perform an emergency hysterectomy. Someone, somewhere appears to have been listening…