We receive our patients in several ways: sometimes they walk or ride in cars to us individually, but seldom. We are in a rural setting, the roads are bad and it is a distance from town. More often our patients arrive stuffed into ambulances from “isolation centers” and sometimes from hospitals, frequently located many hours distant from us. They may be relatively okay, delirious with fever, obtunded by weakness, and sometimes they die along the way.
Two days ago an ambulance arrived at 7pm, which is dark here near the equator. Ambulances in Sierra Leone are usually 4x4 Land Cruisers or Land-Cruiser-like vehicles in various stages of disrepair. They have bench seats onto which as many as 10 or 12 people may be squashed.
In this case, there were only three inside. They had been riding for about eight hours. There was an about eight-year-old girl (few people know their birthdates or actual ages), an about-30-year-old woman, and an adult male corpse.
The child had difficulty speaking as she struggled out of the vehicle into our triage area, frightened eyes searching the corners of the dirt floor, slumped and disheveled. She could tell us little, but gradually looked up and responded as best she could to our questions as we gently tried to interview her. Her father had been worried about her, feared she had Ebola, and sent her in the ambulance in the morning with two living strangers.
Along the way, the gentleman died. The two remaining passengers had no choice but to ride the entire day on rough roads through the sweltering heat with the uncontained and almost certainly contaminated corpse. It’s hard to imagine the terror of such an experience for an 8-year-old, nor for that matter for the young adult woman also in the ambulance.
We were angry to think they had sent an apparently well child in circumstances that could and in this case absolutely did expose her to potential infection. We were wrong to be angry. The child is positive for Ebola, with infection that preceded her ambulance ride, as is the young woman. We were not wrong to be outraged by the terrible experience she endured, but it is part of the dilemma of the circumstances and not the fault of the ambulance driver.
We know there is no reservoir of virus more contagious than a fresh corpse. You may have read that dead bodies and burial rituals have become a major source of disease transmission. Bodies are handled by MSF staff only in full spacesuit personal protective equipment - available almost exclusively in our Ebola Treatment Center (ETC) - are bagged in impermeable plastic bags, and buried deep by the Red Cross, who take the bodies from our morgue.
Despite the unconscionable image of a corpse rolling around in the back of an ambulance against two living and horrified beings, there was no alternative. Here at the ETC the body was removed by people trained to do so, dressed in full gear, and disposed of safely.
Another ambulance story:
I have told you we have been the only functioning treatment center in all of Sierra Leone. As of today, that is still the case. So our patients are coming from all over the country. For three days we have been awaiting three ambulances with 23 patients from an isolation center associated with the hospital in Makeni, a large city located in the north center of the country, perhaps 10 hours drive from us.
Evening after evening we await them. They have become a gloomy joke among us - they are our phantom ambulances, they are lost in a dark hole, they are stuck in the mud or lost in a vortex or evaporated into thin air. Day after day we hear our FC (MSF talk for Field Coordinator), on-site boss of all of us in the field, struggling to maintain her composure as she speaks with the authorities responsible for ambulance transport in Sierra Leone trying to find out what is happening to these patients and their dodgy vehicles. Turns out that at least once they made it to Kenema about two-and-a-half hours from here, where there is an MOH hospital and a separate Ebola isolation unit with some capacity and equipment but no facility for treatment or management of Ebola patients, from which, for some reason they were turned back.
We have no idea whether they stayed the night in the ambulance or were housed temporarily back in Makeni - or what? Yesterday they made it back to Kenema, one ambulance with eight patients, now one dead. The corpse was removed in Kenema and they continued on to us, arriving at about 10 pm with seven patients, another one of whom, a four-year-old girl, had died. That’s 25% mortality before they hit the door.
Rough start, but at least the remaining six have now beds, testing, ORS (oral rehydration fluids), medical oversight, and pain medicines if needed. It is little enough we can offer, but hopefully an infinite improvement on endless bumping on the bench seat of the ambulance over rain-destroyed, red gumbo roadways. Unfortunately the other two vehicles with - we think - 15 patients seem to be still circulating in the ether, yet to be located.
On this Sunday evening, third day of their epic journey, we have no word of the condition of the vehicles or the patients.
Patricia wrote this post on 21st September 2014 in Kailahun, Sierra Leone. For more information about MSF's work on the Ebola outbreak in West Africa please visit msf.org.uk/ebola