A Doctor's Diary: Encountering Chaos And Kindness In An Ebola Ward
I am an infectious disease (ID) physician at Boston Medical Center, and I serve as the Director of Infection Control at National Emerging Infectious Diseases Laboratory, helping design medical response programs to potential exposures to viruses that cause viral hemorrhagic fevers. This summer I spent 12 days in Sierra Leone, serving as part of a team treating patients at Kenema Government Hospital's Ebola treatment center. The center was supported by the World Health Organization with guidance, logistics and clinicians. My colleagues and I were recruited through the Global Outbreak Alert and Response Network, a network that WHO hosts. I traveled with Dr. George Risi, a fellow ID doc, and Kate Hurley, RN, MSN, from St. Patrick's Hospital in Missoula, which provides medical backup to Rocky Mountain Laboratories.
My journey to Sierra Leone and Kenema Hospital to serve as a physician in the Ebola Treatment Unit (ETU) started more than a month before I actually traveled there. It is as much a mental journey as a physical one. What was once a textbook understanding of the virus quickly became an intimate experience of losing many around me to the disease. Before I left, traveling to West Africa to take care of these patients was an abstract humanitarian imperative for me. Now that I'm back, having seen what I have seen, I could never forgive myself if I did not make another trip.
The first day in Sierra Leone, the day of arrival, all of the flight attendants put on gloves shortly before we landed. As I walked out into the customs halls in Lungi Airport in Freetown, every wall was plastered with posters providing information about Ebola. We were asked to complete a health questionnaire and fever check — one of dozens I would receive during my time in the country. In the dark rainy night, the water taxi that carried us from Lungi airport to Freetown seemed otherworldly. Seeing my co-clinicians, who had arrived a few hours before me, at the hotel was a big step in helping me reorient to the purpose of my journey.
George, Kate and I needed to make it to Kenema in time to overlap with the outgoing team. It's a three and a half hour trip from Freetown. On the way, we saw many children on the streets. It was a weekday. We wondered why they were not in school. Our driver told us school had been canceled because of Ebola. In fact, there were no weddings, no baptisms. People had stopped gathering. In between small villages, the lush green landscape was dotted with occasional burned buildings, remnants of the civil war.
We arrived in Kenema and met the outgoing group at dinner. Their camaraderie was palpable. I could see how these relationships were critical. In this environment, you depend on the people you work with for your safety.
It was hard not to feel like the new kid.
We were somber at hearing about the continued dearth of healthcare workers and the patient load. On the first day at the treatment unit, we followed a clinician who'd been there for a while, learning about the available resources and the patients currently receiving treatment. Every thing I did that first day took a moment of reflection. OK, I am entering an ETU for the first time; I am now seeing and caring for an Ebola patient for the first time. I am carefully coming out of my personal protective equipment (PPE) for the first time in the field — a time I am statistically most likely to infect myself. But after every first time, anxiety turned into resolve, and practice made the process routine.
The following days were a blur. Hard work, the smell of chlorine, the heat. Each day started with a group breakfast, then the 10-minute drive to the hospital, a rush to get all the information, including overnight deaths, transfers, lab results. Although being inside the PPE was physically unbearable because of the heat, I felt a sense of urgency every morning to get into the unit.
At the hospital, we each collected our PPE. We counted out the six items every day, a trick to develop muscle memory: gloves, tyvek suit, hood, face shield, mask, rubber boots. It was our shield as we walked into battle. Or so it felt.
In pairs or as a team, we entered the low-risk area. Sullivan, the man at the entrance, always had a ready smile as he sprayed down our rubber boots with bleach solution. We entered the donning tent. I saw so many people in that tent and early on wondered who they were. They were porters, hygienists, food servers.
In the donning tent, we put on the equipment, checked each other out to check the suit for gaps and tears. I soon came to realize that you can spend an entire day with someone in PPE and not know what they look like. It's why we put our names on our aprons, the top layer of the PPE, so we'd know each other's identity.
And then we entered the high-risk zone. First it was the suspect wards, for patients who fit the case definition of Ebola and were waiting for a test to confirm the diagnosis. We called it the "Annex." which housed both those who will test positive and those who had symptoms similar to Ebola but may turn out to have another disease, like malaria. It was our daily challenge to separate the sick from those who are less symptomatic.
The minute we entered the high-risk zone, people were waiting on the landing of the ward entrance to ask what their test results were. Beyond the Annex were the confirmed ward and recovery wards. In the confirmed ward, the healing and the dying mingled. The hallways were filled with people at varying stages of their disease, from those on the road to recovery to those in the throes of their illness, coming to terms with the gravity of their situation. Many of these patients had already seen family members going through this and in some cases die. They were dehydrated, confused, looking at you, looking past you, too weak, bed bound, barely able to use the waste bucket next to their bed. Every day, it felt like you were putting out fires, trying to address the most urgent needs before your own resolve started to fade, your face shield fogged up, your mask was so filled with sweat you couldn't breathe.
In the ward, the patients whose tests shows they have recovered from Ebola have to be discharged so that we can make room for the new patients who have positive tests. Suspect patients who don't have the disease have to be quickly discharged so they do not contract the infection while in the ETU. By the time you got out in the afternoon, wondering where the past few hours had gone, you were spent.
On a typical day, I'd do either three two-hour shifts in the suit, or two three-hour shifts. The other six hours of the day I'd deal with case management and collect data to help with clinical care and keep tabs on this epidemic. And recover from the stress of being in the Ebola ward.
After getting out of the PPE, I would hydrate like a marathoner. The idea that I'd put my body through that again, let alone later that afternoon, seemed unreal. But then my mind started to equilibriate with the return of the fluid and the electrolytes and I'd became strong enough to ignore the complaints of my body.
Midday, we'd regroup and have lunch and share information about this patient or that. Some days I felt good coming out after a morning in the ward, as if I had made a difference and put things in order.
Then three hours later I'd go back in and faced chaos. It's as if fate was laughing at me. New patients had arrived who had not been tested; some were deathly ill. Patients who looked good only a few hours ago had taken a turn for the worst. Some even died in the interim.
The whole process started again: helping one human at a time and providing for immediate needs, while trying to keep my mind focused through the constant, "Doctor, doctor" requests coming from all directions.
One of the largest ethical dilemmas working in this environment was striking a balance between personal safety and patient survival. At times I'd have to leave the ward because the electricity was out and it was unsafe to continue working. It didn't matter that I had a child in my hands who needed my help. Logically, healthcare worker safety is paramount because loss of workers will further stymie the response to the epidemic. But in reality, in that moment, as the provider for that patient, it will be the hardest choice you will make.
At night, after our 12-hour days, we tried to spend some time with each other, decompressing. We tried to keep the mood light, joked, shared stories from home. We wondered if any of us could truly explain to others back home what this experience is really like. I tried to talk to family but exhaustion, and fear of revealing my own anxieties about contracting the disease, made me keep the conversations short.
And then I'd do something silly, something that went against all logical understanding of this disease. I cleaned all major surfaces in my room with bleach wipes as if I was creating an invisible fortress of cleanliness, leaving the day behind me, and got into bed to fall asleep.
If there are things that I wish I could share with others about my experience, they would be:
1) Most people can survive this disease. In the patients who presented to us in time, and who stayed hydrated before and during treatment, the mortality was under 40 percent. This is despite the lack of human resources and medical and lab supplies. My favorite days were days when we discharged patients from the recovery ward. One of my co-clinicians asked the children in recovery to come up with a "recovery song," a celebration in anticipation of when their tests will turn negative and they will leave this place for home. The children would greet him every time he returned with the song. After a couple of days it was clear the adults also were partaking in this ritual. It was the most powerful thing I have ever witnessed, sometimes sitting outside the unit, hearing songs from the recovery ward. We can improve the mortality rate by just improving the number of hands helping and by giving patients the best basic supportive care. The early and continued provision of oral rehydration solution can help as well.
2) Every day I was there someone thanked me, thanked me for taking care of these patients. This encouragement was so important. I have provided care to patients in setting with limited resources, but generally as providers, we don't have to worry about our own safety. We place an artificial barrier between ourselves and the patients, as if we are somehow immune to the diseases around us. It is an important part of being able to provide care. That façade is harder in this setting, knowing how many healthcare workers have died before us and seeing so many young people present with minimal symptoms and full faculties, and then watching them become so debilitated that they cannot get out of bed to defecate. Then to see that a hundred times over breaks the most stoic of dispositions. The words of encouragement were so important in light of the loss inside the unit.
3) Inside this ward is a microcosm of humanity and almost all of it is kindness and selflessness. A sick patient one bed over might offer to translate your words if the person you are interviewing doesn't speak English. Healthier patients advocate for those who have taken a turn for the worst. Women adopted orphans and cared for them if the children's own mother had died. People gave each other encouragement from across large ward rooms. Inside the wards, you found some of the most committed nurses from the local staff. Despite losing so many of their own, having their morale decimated, nurses like French, who became the head nurse at Kenema ETU, spent hours upon hours, day after day providing compassionate care.
On one of my last days at Kenema, I found an old man in a triage tent who was extremely ill. I was giving him oral rehydration and kept asking him his name: "Sir, tell me your name so I can see if you have been tested already." He kept mumbling and when I could finally hear what he was saying repeatedly, it was, "I am nobody. I am nobody." I will never forget that moment.
This epidemic is not one of nameless, faceless individuals living far away. It is a story of family members who expressed love and grief at losing their loved ones. It's about strangers who provide kindness at the right time to others. It's about children who wandered alone through the halls of illness but then made it out and survived. It's about those who died in my hands despite all my efforts. It's about the healthcare workers who buried their own and are continuing to work. It's about entire communities that have been debilitated by this epidemic and about countries that will see an entire generation affected by it. It's about putting your fear aside and doing what you know is needed in that moment. It's about you and me and what we do next to eradicate the epidemic.
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