Missive #10 – January 4, 2015

This is such a pity

The MSF-Geneva EMC is located within the expansive grounds of a private school named Prince of Wales (POW) that abuts the Atlantic Ocean but has been shut down by Ebola. In fact, all schools in Sierra Leone are closed. The EMC set-up, materials and structures (e.g. Rubhalls and Triganos) are similar to Bo, but the operation itself differs in several important aspects. One difference is that whereas Bo accepts mainly transfers that have already been confirmed to have Ebola, POW receives patients in different ways. Patients can also be sent to POW in ambulances direct from the community if they call the Ebola hotline (#117) and report suspicious symptoms, or if they have been quarantined in their houses because of a high-risk exposure such as the death of a close relative. Finally, people can walk-in to the POW facility if they are worried that they might have Ebola. All patients come first through the triage area.

December 29th was my first day in triage and it was quite an eye-opener. From 7 am to 7 pm, I saw thirty-three patients in triage, most were walk-ins, and I admitted twelve patients, most came in one of the seven ambulances that arrived from the community with their sirens blaring. We can’t do an Ebola test in triage, so we evaluate the likelihood of EVD by asking about symptoms, checking the forehead for fever, without touching, with a thermometer gun and recording their contact history. This is inexact at best but we do manage to correctly diagnose Ebola in around half of triaged patients. The others are given an official MSF letter stating that they do not appear to have Ebola. Some come just for the letter because other local health facilities often will not see them without it. I recall two pregnant ladies who had been quarantined in their house without access to prenatal care because a relative had died of Ebola. They came for the letter so they could go for prenatal care. They were negative. The decision to admit can also be quite subjective. I admitted a 13-year old boy, Abdulla, and his 9-year old sister, Fatmata, (not their real names) even though the boy had no symptoms. Fatmata did have suggestive symptoms and tragically their mother had died of Ebola on Boxing Day.

Another key difference is that the patient number in POW is growing while the patient number in Bo is declining. When I left Bo, there were twelve patients; when I arrived at POW, there were forty-six. Because of this and other factors, the workload for expats at POW is much greater. When I arrived, everyone was leaving the hotel at 6:15 am and arriving back exhausted at 9 pm. Fortunately, Greg and I expanded the expat physician team by 40% so we now have a schedule that is somewhat more reasonable but still heavy. We all still work 12 hours a day but our workload is now split up among triage, night shift (7pm-7 am), the IV team, confirmed EVD patients who are stable on oral medications and the ICU.

That’s right; POW has a 30-bed Ebola ICU. Of course, the Ebola ICU here is much less high-tech than ICUs in North America and Europe. There is a middle corridor through the Rubhall with plexi-glass on the upper half that allows for better bed monitoring without donning PPE and oxygen concentrators produce O2 that can be mask-delivered to patients.

On my second day at POW, I was assigned to the IV team along with the nurse queen of IVs, Elena from Madison, Wisconsin (not her real name or residence). She’s incredible. She can stay in PPE for 90 minutes and emerge from the doffing tent with nary a drop of sweat. And, she can probably start an IV in a flea. Elena eagerly put me through my paces and I was too exhausted to eat when I got back to the Roy Hotel. I went straight to bed. Toward the end of that memorable day, another of the expat nurses asked me to draw an Ebola blood test from a cute and shy 9-year old that had recovered from EVD clinically, but needed a negative Ebola test result to be discharged. I will call her Ruth. No one else had been able to get the blood and Ruth really wanted to go home to her family. She was brave but scared. On my second attempt, I successfully got the blood sample despite her squirming and screaming. As I cleaned up the blood test materials and took them to the high-risk trash in my PPE, Ruth slowly approached me from behind. When I turned around, she shyly handed me the tourniquet that I had forgotten. I smiled and motioned that she could keep. At this, she dropped it from her little hand and quickly backed away. The test was negative and Ruth went home the next day.