I would go through this morning routine and then putter for a few minutes, checking my e-mail if I had a Wi-Fi signal. The SUV would pick us up just before seven; during the ten-minute ride to the ETU, we filled the time either with small talk about spiders or Wi-Fi or some such, or with big talk about what was happening in the unit and how this or that patient had fared overnight. We arrived and wandered about for a few minutes, looking at the board to see whether any developments had taken place.
The morning staff meeting took place in the medical tent just before eight. Upwards of twenty people working in all aspects of the ETU operations were crammed in for the proceedings: the medical staff, the operations team, the financial people, communications, information technology, and so on. We sat around the room on cheap white plastic lawn chairs with matching round white plastic tables meant for a summer patio but were cumbersome in the small space, leading to people sitting at odd angles. I would fill a mug with boiling water, spoon two heaps of instant Nescafé and grab a sugar cube. The sugar was frequently covered by small brown ants who found our little coffee bar an unexpected but delightful source of sustenance, so I’d have to brush them aside and plop two cubes into my coffee. I’d wash it down with dry biscuits, and that became my morning eye-opener. It seemed the height of decadence, and I looked forward to it every day.
The meeting covered an impressive range of items and made me realize how little I understood about the behind-the-scenes details that made hospitals run. There was an imposing amount of operational aspects to consider, even though this was about as rudimentary a hospital as one could imagine. The medical summary during the morning meeting sometimes seemed the most trivial: We would announce the total number of patients in each ward, how many had been admitted over the past twenty-four hours, how many tests were positive and negative, whether there had been any deaths, and who was awaiting discharge if their blood test was negative. Invariably I forgot to log this information when it was my turn to present, and I never failed to be surprised when I was supposed to be announcing the tallies. Someone would need to feed the data to me, to the slight irritation of my medical colleagues. To summarize the clinical situation took all of about thirty seconds, even though the meeting usually lasted a half hour.
During the meetings we would deliberate over the other questions that were central to the ETU getting through a day: Did we have enough petrol to run the generators to keep the place lit at night? Was there enough housing at Cuttington University for the various expats who were now coming and going with greater frequency? How should we coordinate with the driving staff, who had to operate on a fairly tight schedule, when we needed to courier the blood to the Navy lab for Ebola testing, which could be anywhere from ten in the morning until noon? How should we handle the all-important goggles, whose tight seal against our skin protected us from the virus but whose structure became less pliant by the repeated washings in high-concentration chlorine bleach? We reviewed supply problems, prepared for any visitors, and considered all the other aspects of the running of the facility. While this meeting was taking place, the national staff had their morning devotional, and a loud, beautiful song would waft through the compound. Those tasked with presenting during the meetings had to review their business items while talking over the singing.
Following the meeting, we headed to the changing rooms to prepare for rounds. Inside the locker room sat two large, industrial garbage cans filled with the laundered, folded scrubs that we wore underneath our PPE. I was taller and larger than almost all of the Liberians and most of the expats, so there was a premium on extra-large scrubs. Each morning I had to dig through the garbage cans to find a shirt and pants that fit, ultimately turning the nice stack of folded apparel into a heaping mess. Eventually I got so frustrated by this cockamamie process that I snuck the properly sized scrubs into a tucked-away corner in the medical staff office, hoarding them for later use.
Once the scrubs were on I had to search for the appropriately sized boots, which after soaking in chlorine were left to dry on sticks impaled in the ground in well-organized rows adjacent to the structure. They were arrayed in a completely random manner, so you had to walk through the lattice of boots to find a matching pair. Again, since I was tall, only one available size would suffice—forty-four. Finding these rare items became a scavenger hunt that in retrospect seems comical but at the time was sheer crazy-making. Aha! I would think as I walked down the rows of drying boots, spotting that second boot bearing the magic number 44, only to discover on closer inspection that it was a forty-four left, a version of which I already held in my hand, and still had to continue the hunt.
Gowning and gloving could take upwards of an hour. We tried to phase the staff into the Hot Zone in some kind of order. The WASH staff started the process as they moved through to spray down surfaces that may have become covered with virus, as well as collect the trash, sending it to the incinerator at the far boundary of the ETU. Next, the nursing assistants, so they could distribute food and drink to the patients. This was followed by the nursing staff, who would collect vitals, start IV fluids, and distribute medications. Eventually the M.D. and physician assistant came in. The final group to enter was the psychosocial support team. Since our gowning and gloving station was so cramped, the process of moving those headed in to round on the patients, perhaps ten or more in all, moved at a snail’s pace. The food was prepared in the kitchens of Cuttington, and sometimes it would arrive late, which would disrupt the order and lead to prolonged discussions about how best to phase each group in.
Once in, rounds lasted a little more than two hours. The nurses, who started earlier, were frequently inside for up to three hours. We had heard rumors that other ETUs were running in one-hour shifts for staff safety, given the heat and possibility that someone might faint. Colin, who had taken over as medical director while Pranav was taking R & R, had once proposed that we limit shifts to this length. That experiment lasted exactly half of one day, since it was impossible to make it through even the suspect ward in that amount of time and moreover didn’t make much sense since everyone could easily tolerate the first sixty minutes in PPE. But you started to notice your body after the first hour, and you could feel the strain around ninety minutes, and things got progressively more taxing from there.
*
The distribution of medications was a key feature of morning rounds. We were giving patients an enormous number of drugs: We gave antibiotics for, well … something is the best thing that can be said, and we gave antimalarials since large numbers of patients were simultaneously infected with the parasite, and Ebola might in theory increase their susceptibility to malaria’s more deadly effects. We also gave antinausea medications, antianxiety medications, and acetaminophen to try to halt the roaring fever of Ebola and also take the edge off the muscle pains that were common.
But it was one pill that encapsulated, as it were, the problems with providing this miniature formulary: vitamin C. Somehow vitamin C ended up on the WHO’s list of standard treatments for Ebola, so the aid organizations were essentially obligated to put this on the list of required drugs for patients. It made the alternative medicine types back in the States crow with joy, for they believed it underscored that natural remedies, and not all those sludgy, toxic medical-industrial-complex products designed to enrich the salaries of pharmaceutical company executives, could solve the Ebola crisis.
I had virtually no doubt that vitamin C made no appreciable difference to the patients’ overall prognosis, and while I don’t object to giving harmless pills in most cases, vitamin C in this case wasn’t a completely harmless pill, for it was huge—a horse pill if ever there was one. Providing them that vitamin C pill put patients at risk of throwing up the other pills, a few of which, like antibiotics, might actually make a difference.
During the rounds, the job of “doctor” would often morph depending on the circumstances. It became clear to Colin and me after about a week that an ETU was for the most part a nursing prod
uction. The care of patients was driven largely by protocols drawn up by MSF and WHO, and consequently there wasn’t much “big” decision making for the patients—that is, do we give this drug to this patient or that drug to that one. Those kinds of decisions, however, are often where physicians provide their value-add to patient care, and in the daily routine of the ETU, it was the nurses who brought much more immediate value with their technical skills: the ability to obtain blood samples and throw IV lines, among other procedures. It wasn’t that I couldn’t do either of those things, but I hadn’t done them regularly since my residency, which I had completed more than a decade earlier. To relearn the art of IV line throwing would likely involve missing a vein here or there and could conceivably lead to a needle stick exposure, but working with Ebola patients left zero room for error, and so I left that work to the nurses who had the hands for it. I did draw blood on a few occasions, a skill I felt more comfortable with.
Ideally, the M.D.s could have become data-collection and data-processing machines, which was desperately needed given the potential spread of the epidemic over the next several months. Previously, Ebola had always been managed in emergency situations, usually by MSF, whose priority has never been clinical data collection but instead has been, appropriately, crisis management. Now, though, with the epidemic already much larger than all of the previous outbreaks combined and with no sign of stopping, one small upside was that the virus could be studied. I know that seems coldhearted, but to study patients with Ebola carefully now meant that we might know more about how to approach future patients in outbreaks that have not yet happened. It is how medicine progresses. If the international health community executed its response to the West African outbreak as it would in a small village in the Congo, a great opportunity would be lost to help anyone unlucky enough to be infected by Ebola five or ten years from now. The best we could do for those people was to be scientists and be meticulous about what information we could glean. That mainly consisted of recording temperatures and checking boxes that aligned with specific symptoms that were already printed out on the paper, like filling out a questionnaire that neatly systematizes and documents horror.
The act of recording such information may sound simple, but in the physical environs of the Bong ETU, the systematic gathering of data was a good deal messier. Every patient had a chart, which was basically a series of photocopied pages stapled together. (That doesn’t sound like much, but under normal circumstances you can do a lot with a couple of pages of paper per patient, provided the recorded information is carefully organized.) Each chart page itemized various parameters that could be measured on a daily basis: what meds had been administered, their temperatures, their symptoms, and so on. In theory, we could record and tabulate that information and would be sitting on a treasure trove of material that might provide clues to help unlock the mystery of why Ebola killed with such ruthlessness, and might even suggest which treatments were helping (like, perhaps, antibiotics) and which were not (like, perhaps, vitamin C).
Unfortunately, the heat and humidity of Bong County proved a worthy adversary to this project. The damp would cause the paper to soften and curl, making the process of recording information cumbersome. Then our sweat would drip onto the already moist paper, sometimes making the ink from previous entries run or causing the pen to rip the paper like a knife through butter when recording a measurement.
The page devoted to recording symptoms was so carefully thought out that if we had a well-gathered set of this data from the patients we had seen in the first three weeks, we could easily have submitted a paper to The New England Journal of Medicine that would have been taken very seriously. It listed more than twenty signs and symptoms, each known to be associated with the disease, and placed all of these items in a grid so that they could be marked as to whether they were present or absent each day they were there. You could then see when the muscle aches tended to abate and when the severe nausea began, or learn when the more unusual symptoms, like hiccups or confusion, were associated with better or worse prognoses.
To look at this page while sitting in an office in the States, you would think it was a model of scientific and clinical precision, and if the data was logged with accuracy, it would make a lasting contribution to the field of Ebola literature. But out in the field, the eleven-point type was nearly impossible to read in the dark interiors of the patient rooms, especially with misty goggles, and the grid separating one day from the next was sufficiently small that one could easily mark a symptom as happening the day before or the day after it actually occurred. It seemed like the classic problem of myopic bureaucrats who had no understanding of the situation on the ground. But it wasn’t, for unless someone had done Ebola work in a space suit in a dark tent before, there was no conceivable way in the crazed run-up to the preparations for running an ETU that such difficulties in data collection could have been anticipated. And the charting was just one in a thousand details the staff threw together as fast as it could to get the ETU up and running.
Even if the data could have been recorded in a more optimal manner, there was the additional problem of getting the information out of the high-risk area. It seems laughably simple: Just record the data, and then enter it into a computer! But you can’t take a computer inside the high-risk area because it can’t come out—and even if IMC had decided to purchase a laptop in Monrovia for the purpose, the high-risk areas, while having electricity for lighting, weren’t constructed with outlets, so it couldn’t be recharged.
Nor could the paper charts be physically exported for the same reason that almost no other inanimate physical object could ever emerge. Informationally, the Hot Zone was quite close to being a black hole; even if the charting data wouldn’t be known to posterity as being the highest quality, it was still important and worth sharing with the broader medical community. But the only way we could extract the data was to have someone suit up, retrieve the charts, move to the boundary of the Hot Zone, and sit and read the information to someone on the outside who would then manually record the data again before heading back to the tent where it could finally be digitized by reentering the data on a laptop. Eventually, Colin and I did just this, which led to a string of odd moments where I would find myself sitting on a lawn chair in the high-risk area with my legs crossed, comfortably chirping away patient temperatures as if I was sitting on a porch in the Midwest, idly conversing with a friend on a summer afternoon.1
The goal of exporting the temperature data was to see whether there was any correlation between the Ebola viral load and how long the fever persisted. It was relatively easy to move those numbers from the inside to the outside, for it didn’t take much time to plow through one patient’s chart to read those numbers. But the even more valuable information, the clinical symptoms, would require hours and hours of transcription, and there were far too many other tasks that commanded our attention for this kind of work to proceed in any systematic manner. I belatedly understood why the clinical data from previous outbreaks was fairly spotty. We came better prepared than those medical teams, but we still encountered tremendous obstacles that were difficult at best to anticipate. Most of that information never did escape the gravitational field of the high-risk area, and my inability to find a way for it to cross the four feet that separated the Hot Zone from the world in which information can be recorded and shared is among the regrets that I will carry to my grave.
So with that important doctor-based function being limited at best, we took to helping out in what other ways we could. Sometimes that led to more problems than it solved, as the expat nursing staff, which in October consisted of a formidable collection of some of the most talented medical professionals with whom I have ever worked, were trying to coordinate the efforts of the national staff, so the offers of help that Colin and I made were sometimes perceived in ways that we hadn’t intended. After a few weeks, we had worked out enough of a system so that I would like to think we brought some additional expertise to the vario
us chores that were the daily bread of the ETU. But the immediate tasks of patient care were overwhelmingly performed by the nursing staff. The doctors weren’t entirely superfluous to the running of the ETU, but the nurses were, without any question, completely indispensable to it.
That was rounds. We made rounds about four times each day, after which we would “run the boards.” Running the boards was a process of reviewing the names of the patients on a laminate board, and the clinical team who had just seen the patients would summarize their status. Because the patient charts could not leave the high-risk area, we were forced to remember what we had encountered because that information had to be passed along orally during these rounds. It was the only way we could effectively communicate what was happening with the patients to the rest of the medical staff. We ran the boards at the shift change at 7:00 a.m., then later in the morning, again in the midafternoon, and finally at the handoff back to the night shift around 7:00 p.m.
When I got out of PPE, soaking wet from my sweat and the chlorine spray, I wanted to go straight to run the board so that I could expunge the tenuously held data in my head lest I forget details or confuse patients. Thus: “Joseph Dwolo is a twenty-nine-year-old man here in the suspect ward, who came from Ganta with fever and chills last night, and his test is still pending. He looks pretty good right now. Hasn’t gotten nausea, but he does have conjunctivitis.” We used every trick we could to remember who was in what room. Mostly it worked, with each staff member serving as a kind of cross-check of information. Every once in a while, two people would have conflicting impressions of how a patient was faring, which led to interesting conversations—or, on occasion, depending upon how stressed out we all were, wrestling matches. Verbally, anyway.
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