Global Health Diaries is featuring a series of special reports from Majid Sadigh, M.D., UVM Associate Professor of Medicine and Director of Global Health Programs, and Director of the Global Health Center at Danbury Hospital/Western Connecticut Health Network. An infectious disease expert, he spent six weeks in Liberia to help treat patients with Ebola along with Margaret Tandoh, M.D., UVM Assistant Professor of Surgery.
Table of Contents
December 17: “Medical Rounds in ETU”
December 9: “Ebola in Liberia: Clinical Observations”
December 2: “A Garden of Flowers at the Season of Ebola”
November 13: “The Landscape of Medicine”
November 11: “A Girl Waters Flowers”
View a photo gallery of images from Dr. Sadigh.
- From AmeriCares, a video series called “I’m Fighting Ebola:”
Medical Rounds in ETU
Seven or more HCWs, including two workers whose sole responsibility is spraying 0.5% chlorine to maintain body “fluid” control, enter the Hot Zone together, operating as a single unit and often exiting as a group. Each team has a delegated leader who allocates clinical responsibilities. The leader also monitors the health and well-being of each member during rounds and while working within the Ebola Treatment Unit (ETU), often deciding when a rapid exit and doffing is necessary. Failure to appropriately assess or anticipate the status of staff can have potentially severe consequence, such as a fall in an Ebola contaminated environment.
Recently, one member of our team felt dizzy after spending less than an hour in PPE. On cue, we exited the ETU as a unit, and quickly directed her to Doff first. Often personnel are the worst judge of their own vulnerability, and need an expedited ETU exit before an emergency exit is required. Body temperature with PPE easily reaches 1000 F, which coupled with humidity of 100%, leads to heat exhaustion and poor judgment. HCWs working at night have to contend with insects flying around and within the PPE, as well as swarming behind goggles.
As health care workers (HCWs), we spend less than two hours in Personal Protective Equipment (PPE), which equates to 100 minutes seeing patients and the last 20 minutes doffing (structured removal of PPE). The tasks of physicians mirror that of other HCWs in the ETU. Collectively, we place urinary catheters or change diapers of terminally sick patients. We draw blood and handle blood samples, urging patients to eat their “FuFu.” For all our training, the list of practical skills is modest: administration of fluids and medications, observation based assessments in the absence of blood pressure cuffs, estimation of fluid input and output, respiratory status, state of dehydration, mental status. The larger task that we quietly perform is paying mind that our patients die with comfort and dignity from an otherwise devastating disease. Contrary to expectation, the wards are not malodorous and full of human congestion. Instead both units for confirmed and suspected cases are clean and odorless with the exception of the penetrating smell of chlorine. Chlorine collects in small pools along the irregularities of the concrete floor.
The Hot Zone contains the EVD infected patients. It demands an unexpected emotional toll, far more than the physical or physiologic. We must brace ourselves for its unedited cuts from happy to heartbreaking without compromise to self-control or analytic observation. Occasionally, I fall, broken and paralyzed. I hurry to remind myself why I have come to Liberia, and this is what drives me back on my feet before I am trampled.
While keeping these limitations in mind, bedside rounds must be both fast and efficient. Goggles often become foggy, obscuring vision, and PPE allows for limited dexterity in actions such as placement of intravenous lines in Ebola patients. Such fumbling opposes the unalterable rule—that any needle puncture incident is one too many. The injection of Ebola infected blood is one of the most frightening infectious disease emergencies.
After performing duties in the ETU patient care area, systemic Doffing must be undertaken. This procedure requires the removal of layers of protective outerwear and eye protection with all actions aimed at avoiding self-contamination. This requires strict adherence to the direction of a Doffing manager in a deliberate, slow and steady manner. This step, if nothing else, is the one in which medical providers must be most proficient. No matter the heat, discomfort, and anxiety, speed is dangerous.
After Doffing, the medical group has a joint debriefing session in a conference room located in the Low Risk Zone. Documentation of the patients’ clinical information is essential, but correct and complete information is difficult to collect. With only chlorine-soaked sheets of paper, and without access to medical records outside the hot zone, how can one recall those precious clinical details when it all becomes one vast, swarm of bodies, some wandering, some playing, others already lost, memories distorted within the hot and wet PPE.
Ebola in Liberia: Clinical Observations
Since the beginning of this epidemic, we have dealt with more than 10,000 confirmed cases of Ebola with no sincere attempt to uncover the pathophysiology of this disease. No progress has been made in even the most basic of clinical questions. No alteration can be made in the natural history of this enigmatic disease without knowledge of its depth. An effective vaccine or treatment may ameliorate the fear of acquiring the disease, which stands as the major barrier to clinical observation and research. It is a sad fact that we are more equipped to use this virus as a weapon, a fatal biological agent, than to prevent and treat it.
Both were young men, probably 20 or 22.
Both febrile to touch (no thermometer), tachycardic (may be 120 or more).
Both with good pulse pressure and fast capillary refill with no clinical evidence of heart failure.
We cannot measure blood pressure or pulse oximetry, and are without EKG.
Appeared to be stated age, good skin turgor without tenting, no lesions, clean, in an adult diaper.
They did have mild conjunctivitis (a common finding). No jaundice or pallor.
One with Cheyne Stokes and the other with Kussmaul respirations.
Both moving air freely, no audible breath sounds, or gross indication of congested lungs.
Significant abdominal breathing, without use of accessory muscles, with PMI visible, strong, rapid, and steady.
Their abdomens were soft without organomegaly.
Bladder of one was clearly distended to the umbilicus.
Comatose, unresponsive to verbal or tactile stimulation. Neither with spontaneous movement or tremor or asterixis.
No edema. No adenopathy. No sign of hemorrhage (eye, rectum, mouth, gingiva, or urine).
No manifestation of shock.
In one patient, I considered primary lactic acidosis, similar to what is seen in HIV or in mitochondria diseases, or in similar to “base of brain” injury such as meningoencephalitis or “hyponatremia.” So many other etiologies came to mind for the second patient.
I am learning that many patients present and then die this way from Ebola Viral Disease. Though it is clear that these men will not live long, I am assured that they are not in pain.
I wish we had access to more testing, documenting, observing to discover some of the secrets of this puzzling virus.
The patient with Kusmaul respiration died overnight. The other one with bladder distension and Cheyne stokes struggling even as Cheyne stokes has given way to Kussmaul. Without receiving any fluid, he made 1750 cc of urine in less than 8 hours.
We placed a foley that showed urine of a color I have never seen before—dark, turbid, muddy without obvious blood. Based on some reports, at this stage of disease, urine contains billions of viruses in each cubic millimeter of urine, still much fewer than the trillions of virions in the same amount of blood. I was in full PPE with three layers of gloves, frequently washing my outer gloves with 0.5% chlorine solution.
The following day, the patient remains deeply comatose and febrile, not pale, not jaundiced with worsening conjunctivitis (in those who finally recover, conjunctivitis improves first) and no hemorrhagic manifestations. There is nothing else new in the physical examination except sunken eyes and poor skin turgor. Despite obvious hypovolemia, he has a bounding pulse with impressive tachycardia.
I think about Diabetes Insipidus and urosepsis, though I have no clear explanation for the bizarre color of urine. Perhaps this is because the light inside ETU is dim, my goggles are foggy and I am color-blind!
Patients presenting to the ETU can be grouped into three defined categories. The first include those who are stable and improving or ready to be discharged, requiring less than a minute of time to assess, congratulate and encourage increased Oral Rehydration Solution (ORS) and nutrition. The second group includes those who are stable but symptomatic, requiring two to three full minutes to be advised to drink ORS and to eat, to inquire after and record signs, symptoms, and medications. The final group consists of unstable patients, those who are unresponsive, somnolent, drowsy, whose care is directed towards comfort and dignity.
And then there is the unexpected group—those who appear to be well into their recovery phase, without vomiting or diarrhea, who are physically active, engaging socially with others, on a regular diet, or simply waiting to be discharged, when a sudden death event or seizure and rapidly kills them. The cause of this phenomenon is unknown, though the theory exists that an electrolyte imbalance, such as sodium or potassium, leads to cardiac arrhythmias, as seen with potassium in Crush Syndrome. This unanswered question must be addressed in order to implement novel management strategies to prevent such deaths. The lack of “routine” laboratory resources and monitoring equipment are unavailable or impractical in rural Africa.
Day 7 through 10 is a critical period in the human fight against the Ebola Virus, similar to the Ninth Night in Pneumococcal Pneumonia, as heavy drenching sweats signals recovery (recovery by crisis), versus progressive multi organ failure and death.
The new patients from remote villages are younger, and have mild to moderate hemorrhagic manifestations. I have yet to see any patient thrashing around, or anyone with severe pain or hiccups. ORS is the dominant rehydration solution method. We give every patient 20 mEq of K orally twice a day with anti-malarial and broad-spectrum antibiotics (Ciprofloxacin and metronidazole or Cefixime) on admission.
Patients who die from Ebola in ETU do so peacefully, without pain and with dignity, in a coma.
A Garden of Flowers at the Season of Ebola
A wooden tablet in an Ebola graveyard reads “Esther”. She was only 24 when Ebola claimed her life alongside her husband and child. Three remaining children, all younger than ten, were forgiven by Ebola but expelled from home by their neighbors.
We had three more human losses overnight and two more since early morning. The more stable patients or those in the recovery phase sit outside, under the shade of tents or lying silently in their beds.
A young woman in scrubs washes a three-year-old girl in front of the compound. Her gloved hands move assuredly, dipping the sponge first into the bucket of water and then to the girl’s bare skin. The girl has been sick for a long time and finally recovered, though she is all that remains of her family. The woman herself is a mere eighteen, delivered to the Ebola Treatment Unit with her mother and older sister a few weeks earlier. Somehow she has also survived where her family has not. Without a word, she has taken her place in the hot zone, tending to the weak and young. You can tell who the recent survivors are from the motionless of their faces, as though still cast away in the throes of sickness. In the background, smoke rises from incinerators filled daily with material from the hot zone.
An older woman and man sit in white plastic chairs around a small white table, convalescing.
Another constant presence here is Cecelia, who cleans the laundry. She lives in the nearby leprosy colony with her parents, both disabled by their disease.
In the first room of the unit with confirmed cases are two beds. The first bed holds the blanketed dead body of a young woman, waiting to be carried away to the morgue. In the second bed rests a patient lying motionless except for gasping breaths, in a state of coma, completely unaware of the nearby body and the fate awaiting him.
In the next room, a young woman whose energy fills the small room, sits at the bedside of a child, and begins singing, swinging her arms in dance when she hears that her blood test for Ebola is finally negative and that she can return home. She has become one of the coveted unit survivors.
In another room, a young uninfected mother breastfeeds her infected toddler without gloves or other form of protection. Patients in the ETU cannot abide by all the detailed infectious control protocols mandated in the hot zone—when have they ever had exposure to this language of sanitation and isolation? Liberia is a country of people who touch and speak with hands, celebrate their relationships with others—how to banish a child from her mother, even under the threat of touch tinged with Ebola?
The young man whom I observed briefly in the triage area the previous afternoon is tucked tidily on a floor mattress in the corner of the room, his deep, fleeting breaths pushing his nostrils wide in a drama so distinct from his otherwise unresponsive mind.
Yesterday, a three-year-old girl was sitting outside, a smile faintly turning up the corners of her mouth. Her hair braided in tiny knots spoke of care and attention. A silver heart lay at the center of her black t-shirt.
Today she was not sitting outside. Instead she lay by her mother on a mattress on the floor. Her mother was in the act of dying, folding into herself like a baby, her back turned to her child, lost to her.
The girl sits so quietly. Her face is flushed with fever, the corners of her mouth and the tip of her nose a fiery red in the backdrop of her black shirt and the small, silver heart solitary at the center.
I want to cry loudly into my full PPE.
The mother died first, and the daughter followed that same day.
The Landscape of Medicine
Though clinical medicine, global health ventures, even life in Africa, are not new experiences for us, we find ourselves in an entirely new clinical landscape. With the backing of decades’ worth of medical knowledge crafted by scientists and health care workers internationally on the subject of Ebola, we are all of us still in training, trying to grasp the totality of our roles. For one, we are not only physicians and health care workers charged with the task of providing care to the sick, but we are public health officers who must preserve the health of the community. Protection of the community exists on multiple levels, be it the community at large or as smaller units, for example a mother and her child in the treatment centers–one who is infected and the other who is not, setting limits on a tradition of healing that has always been about the human touch, now done infrequently, and through layers of fabricated plastics and vinyls. There have been too many emotionally charged clinical scenarios to name singly.
Recent literature highlights the link between new cases of Ebola among health care workers to breaks in the protocol, an oversight in some step of hygiene. We work in a chain, forming the rows of a beehive that ultimately make up a honeycombing pattern of connectivity. My survival is contingent upon my colleague beside me, on his/her attention to detail and maintenance of protocol every minute we prepare to both enter and exit a treatment unit. We all rely on one another in a way that extends beyond the clinical relationships that exist in the inpatient setting in the United States. While back at home, I invest in open communication with nursing staff and trust that the overnight resident will call in the event of uncertainty, my life does not rely on them, nor is it threatened by chance oversights. Thus it is with love and a fierce devotion that we make our ties and work alongside one another, meticulous, like a mother towards her child.
Thus as I face a patient, flailing with the delirium and confusion of sickness, I cannot help but think what would happen if my protective layers are accidentally punctured, if I am thus contaminated beyond the ability of sanitizing myself–not because of what it would mean to me, but for all those others who count on me.
Even while this experience treads new ground, it also resonates of centuries’ old narratives as dark as ever took place in the history of medicine. As infected people are ostracized from their communities, placed in isolation, in the corners of buildings, out of the light, their faces don with suffering of the deformed leper and the hooded figure of the plague. The dreaded hiccup and bleeding eyes and gums that signal certain end in these Ebola patients has come to rival the black eschars, the inflamed contorting lymph nodes, the truncated limbs of bubonic plague and leprosy in their power to evoke dark, even mystical powers of evil. Suffocated by these misplaced associations, the patients are cast away as if unclean and full of sin, to suffer in the seclusion of their punishment, banished by God as by humanity, only hoping for a modicum of compassion.
It is with compassion that many of us came to this land, along with a sense of purpose to use the science and the literature to guide our treatment of patients and to halt this disease. Yet no matter how rigorous our training or how much we cling to the data, fear, health and personal issues have escaped and overcome some individuals in our group. With heavy hearts, they have packed their bags and returned to the sanctity of their homes, though they are likely still as stuck as those of us who remain, in the immediacy of what is transpiring.
Even as some leave the effort, others are joining. On Tuesday, November 11 , five of us–two doctors, two hygienists, and a nurse supervisor — leave for Cuttington University in Bong County for training in an ETU, so that we can return and train others, to ultimately open and run an ETU in Buchannan, the 3rd largest city in Liberia. We are filled with anticipation, to push forward with the pull of momentum.
A Girl Waters Flowers
In between the rain showers, I sometimes see a young girl walk out of her home across from my hotel to water a large plant growing out of a felled tree. She scoops the water gently out of a bowl into her hands, dropping the water onto the plant’s leaves with an indulgence as though she has all the time in the world. Even though this region lies at the outskirts of Monrovia, Liberia, a spot now known on the map for the Ebola epidemic, there is little to suggest the catastrophe claimed by American media. Of course the schools have closed, but that has permitted steady streams of boisterous children out of doors, the cheery sounds of play mingling with the quick rhythm of their drums as they amble up and down the otherwise largely deserted streets. There are large drums of water outside every building and inconspicuous signs issued by the public health department informing the community of do’s and don’ts. Thus Ebola has become something known to these communities, rather than something to fear. So life continues in spite of close losses and quieter streets– people have moved forward with their tasks and relationships in spite of no longer being at liberty to touch one another.
My own day is full of these small observations of the world around me. Ten days have passed since I first arrived as one of the health care workers supported by AmeriCares to staff the first American Ebola Treatment Unit (ETU) in Buchanan, Liberia. I work alongside members of the United States Armed Forces whose commitment to the lives of the Liberian people has instilled newfound respect for these young, brave Americans. Daily reports from the local media of the decrease in seroprevalence of Ebola in blood samples collected from nearby communities demonstrate how this epidemic is slowly becoming less sinister, more manageable, not just for those of us who work here but those who live here, those whose minds turn to the welfare of plants and whose bodies shake to the turn of a West African drum beat.