Blowin’ in the wind
The time as I write this last missive from Sierra Leone is 2am on Saturday morning and I am preparing to enter the high-risk zone for one last time. I want to see all of the children again on the off chance that I can do something for one of them. Except for the damned mosquitoes, the EMC is remarkably quiet tonight after only six admissions, three discharges and one death earlier today. There are eight remaining ICU patients, including three children, but incredibly none actually have or require an intravenous line at the moment. They are all tolerating oral fluids. To my utter amazement, the young woman that I admitted in a coma two days ago is awake, alert, and being discharged tomorrow. No, my swift and decisive action did not save her life from a dramatic and rapidly advancing infection like meningitis or cerebral malaria. Her problem was certainly more common and arguably more tragic. She was beaten into unconsciousness by her ‘boyfriend’ and left to die.
I have had a bit of time to reflect on my experience with Ebola and Sierra Leone. The people here are lovely, caring, and remarkably cheerful given their difficult lot in life. The weather has been tolerable most of the time but I’m glad that my departure precedes the hot and rainy season. My expat colleagues are compassionate, committed, and hard working. Most of them are also very young. The food has been filling but not very tasty but I do love the groundnut stew. However, I am growing tired of instant Nescafe with powdered milk… yuk! And, if I never see chlorine again, it will be too soon.
I think that I have learned about Ebola. It really is not a very complex or complicated disease. But, it is impressive that a tiny filamentous virus with only 6 proteins has such a high mortality rate. The patients that I have seen have fallen into fairly well defined groups according to their signs and symptoms. For many, the gastrointestinal system seems to have been specifically targeted resulting in an illness characterized by vomiting and diarrhea. These patients get dehydrated, cannot tolerate oral medications and seem to benefit from IV fluids. For others, neurological symptoms and signs dominate the clinical picture and these patients are prone to confusion, disorientation, combativeness, and wandering around the complex or moving from bed to bed. I generally avoid IVs for these kinds of patients because they are prone to pulling them out and contaminating their surroundings with blood. Still others present with profound weakness. I once admitted a strapping 40 year old carpenter who had to be carried into triage by two of his brothers because he could hardly move a muscle after only two days of illness. I was somewhat skeptical when I first heard patients complain of profound and debilitating weakness. But, now I am convinced that it is real.
Age is clearly an important prognostic factor in most studies and in my own experience. The elderly and the very young do poorly. Pregnant women also seem to be affected more severely. The results of the Ebola blood test can be predictive since this reflects the plasma viral load. Of course, a higher viral load results in a higher mortality rate. Hiccups are a unique symptom in Ebola Virus Disease, but I have not found them predictive of the outcome. Finally, bleeding is certainly a bad sign. Ebola is a haemorrhagic fever after all. But, the bleeding problems seem to come late in the course of the disease, as a terminal manifestation rather than an aid to diagnosis.
Dr. Mike Rekart
Watching young children die is the thing I hate the most. Once they have passed away, the tragedy itself has happened and the grieving can start. I guess they call that closure. But, watching life gradually leave a lonely child is hell. They grab your arm and stare up at you with clenched teeth and pleading eyes. I know that most of them are confused and delirious, but their faces betray their terror. And, morphine is all we can offer.