Dispatch from Liberia: Ebola 101

As I watch the woman seizing in front of me though, I do not feel helplessness, but shame. In many ways, learning how to care for patients with Ebola means unlearning some of my most basic clinical instincts.
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After just nine days, my training with Doctors Without Borders in the management of Ebola is now complete. Tomorrow, I will travel to Bong County, in central Liberia, to help International Medical Corps set up its very first Ebola Treatment Center (ETC) and train the first 50 staff that will be needed to run it.

The details involved in managing an ETC are numerous, and my head is swimming with the various figures for chlorine concentration, criteria for admission and discharge, the intricacies of PCR testing and the complexities of contact tracing. I have committed to muscle memory the dozen steps involved in putting on personal protective equipment (PPE) and the two-dozen steps involved in taking it off. However, what stands out now most in my mind is not the numbers and checklists, but the memories of patients I have met. Some of these memories give me hope, while others will haunt me for some time to come.

* * *

On my first of training in the ETC, entering one of the large tent wards, I am surprised to see a young woman sitting on the ground in front of the tent, staring blankly at the ground. She is not wearing the full PPE required for staff entry into the high-risk zone of the ETC, but unlike all the other patients, she is wearing a mask and gloves. I wonder if she is a cleaner violating the safety protocols, and expect one of the other staff members to chastise her, but nobody does.

Just a few minutes later, inside the ward, her actual role becomes clear when we come across a young child lying motionless on his mattress.

"This must be her child," one of the nurses says softly, staring down at the small lifeless body.

"Whose child?" I ask.

"The woman outside with the mask and gloves. She was negative for Ebola and her child was positive, but she insisted on staying with him in the ETC. Her son must have just died this morning..."

* * *

On my third day of training, I come across an older man, also lying motionless on his mattress. At first I think he might be dead, but as I lay my double-gloved hand gently on his shoulder, he turns his head to look up at me. His eyes are sunken and his lips parched, his skin flattening only slowly when pinched. He is severely dehydrated from the profuse diarrhea common with Ebola. Usually a drip of intravenous fluids would be started, but the ETC lacks sufficient staff to safely place intravenous catheters for patients.

So instead I turn the patient slowly onto his back, grab the full bottle of oral rehydration solution lying by his side, and pour a tiny capful into the man's slightly open mouth. Surprisingly, he swallows it. I pour another capful, and then another, and he keeps swallowing.

Only a few hundred more capfuls to rehydrate him, but I know that in the stifling heat I am not going to last much longer in my full PPE. I find one of the other patients on the ward who is recovering from Ebola, and show her how to rehydrate the man, one capful at a time. "I have to go now, but you can be his nurse," I explain. "You're immune now, you can't catch Ebola again from him." She seems skeptical of the whole idea, but is kind enough to at least assuage my conscience by continuing to pour capfuls of fluid into the man's mouth until I leave the ward.

* * *

On my fifth day, I am working in triage, where we do not wear full PPE. Instead we interview the patients from across a double-fence barrier about four-and-a-half feet wide. If they have enough of the symptoms of Ebola, we call for someone in full PPE to come in and escort the patient to a bed in the suspect ward of the ETC, where they will await laboratory testing to determine whether they have the disease.

While I am turned away, a woman is dropped off on the patient side of triage tent -- I'm not sure by whom. Blood drips from her mouth onto the white plastic floor of the tent. She is clearly delirious, responding only incoherently to our questions.

Suddenly, her entire body tenses up, and her arms and legs begin to shake rhythmically. I have seen about a thousand seizures in my career, in alcoholics going through withdrawal and young children with malaria, in pregnant women with eclampsia and adolescents with epilepsy. This is the first time though that I simply stand by and watch the seizure happen instead of rushing over to help.

Without PPE, approaching the patient to give medications or even to turn her onto her side to prevent aspiration of the blood in her mouth is too dangerous. I have felt helplessness before as a doctor, working in settings where I lacked the equipment and drugs that I knew were needed to save my patients. As I watch the woman seizing in front of me though, I do not feel helplessness, but shame. In many ways, learning how to care for patients with Ebola means unlearning some of my most basic clinical instincts.

* * *

On my last day of training, I spend the morning following the burial team, learning the procedures involved in safely disposing of dead bodies. As a physician, caring for the dead falls outside of my scope of practice. In an ETC though, management of the dead is almost as important as management of the living, and part of my job will soon be to make sure all of these processes are carried out correctly.

The first patient of the morning is a woman in her mid-twenties, clearly pregnant. She has been dead a few hours, and is already beginning to stiffen. The burial team sprays her with chlorine then gently lifts her into the white bag they lay by her side. Next they spray all of the belongings scattered around her mattress and place them carefully in the body bag with her -- a change of clothing, a towel, a water bottle, a package of biscuits, and, inexplicably, a full bottle of ketchup. Finally, they lift the body bag onto a stretcher, and carry it off to the truck that will transport it to the county incinerator. In my full PPE, in the heat, I am already beginning to sweat just watching the men work. And there are still several more to go on their list.

* * *

Later that day, after undressing from my PPE, I stand outside drinking a bottle of water and watch a scene unfold from across the double fence surrounding the high-risk area. A nurse in full PPE walks into the high-risk area carrying a piece of paper. On it is the list of recovering patients whose lab tests show they have now cleared the virus from their blood.

The nurse approaches the first patient on her list, a young, heavyset woman with tightly braided hair and a pink shirt. I am too far away to hear the words exchanged, but I see the young woman begin to jump up and down as she hears the news, braids bouncing in all directions, and then run a few small victory laps around the courtyard of the high-risk area. She has just found out that she is cured of Ebola, and after a chlorine shower and a new set of clothing, will soon be going home.

Tears begin to spill down my face, mixing with sweat. Nothing else had made me cry this week, but for some reason this joyous scene does. The nurse moves on to the next patient to give them the good news -- she also has several more on her list.

Adam Levine is an Assistant Professor of Emergency Medicine and Director of the Global Emergency Medicine Fellowship at Brown University. He currently serves as the Clinical Advisor for Emergency and Trauma Care for Partners In Health/Inshuti Mu Buzima and as a member of the Emergency Response Team for International Medical Corps. His research focuses on improving the delivery of acute care in low-income countries and during humanitarian emergencies. The views expressed in this blog are his alone and do not necessarily represent the views of any of the organizations mentioned above.