Inferno
Page 15
*
On rounds one day I had made my way over to the confirmed ward. I always made mental tallies as I moved about the wards, dividing the patients into three broad categories: the recovered, the tenuous, and those on the precipice of the abyss. I was nearly finished, with only two patients left to see. One of these patients was a woman named Yatta, and her status was somewhere between tenuous and the precipice. On this particular morning, she had not looked well at all, and I thought that she might not live to see the next day. She leaned over the side of her bed while I was talking to her and vomited into her plastic bucket, and the casual, automated quality of the maneuver suggested to me that she had been doing this so much over the past day or two that it had become part of her routine, as if everyone should just stop themselves in the middle of a conversation in order to heave up gastric contents.
I suddenly heard an electronic chime in the room. After a few moments I realized it was coming from under Yatta’s pillow. She turned from her bucket, nonchalantly reached under the pillow, and an insistent cell phone emerged in her right hand. We halted our already halting conversation while she answered the call. It was her brother, and she proceeded to say something that I’ve heard so many times in my day job that I wondered whether I really was on a remote jungle hilltop in rural Africa or whether I was on the seventh floor of a hospital in central Massachusetts: “The doctor is here. I’ll call you back in a few minutes.”
The cell phones made clear that this was a twenty-first-century outbreak, for at least half of the patients had come with them and regularly kept in touch with their families, and in this respect they were no different from typical patients in the West. The absence of other accoutrements of comfort—toilets, televisions, actual walls—only underscored the weirdness of the advanced technology. Some aspects of the operation would have seemed unremarkable to the forebears of these patients, like the rough-hewn timbers that formed the skeletons of the structures. But the cell phones allowing for distant communication out and the radios providing distant communication in would have blown their minds.
Needless to say, the patients weren’t the only ones plugged into this ethereal hive of communication. The expat staff all brought their laptops, which allowed us to pretend that we were just in another office space down the corridor from our colleagues, each screen a two-way window on the world. Given our interests, we spent a large portion of time following the Ebola coverage, comparing and contrasting the perspectives of print media versus television coverage, the Europeans versus the Americans, and so on.
One of the strangest (though simultaneously, most banal) ways in which we remained connected to the rest of the world was through a website that allowed us to post little updates on our lives and share them with various “friends” of our choosing. It may be true that the revolution will not be televised, but I am certain that the end of the world will be Facebooked until there is no one left standing. We had all become objects of intense curiosity to our friends, and our posts were followed and shared and liked. Some of us in the ETU had “friended” one another during the proceedings, and we could follow each other in virtual reality even as we lived the real reality separated from one another by a few feet.
The Internet access relied upon mobile Wi-Fi hot spots purchased by IMC. They were moderately temperamental devices about the size of a cigarette pack. We could count on perhaps an hour or two of access, although the connectivity was intermittent. Our e-mail messages could get cut off, leading to the occasional profane remark from someone who just lost fifteen minutes of carefully worded work. We eventually got good at saving our e-mails before sending them, something I almost never do in the States. Elvis Ogweno, one of the Kenyan expat nurses, used an old agricultural metaphor in wondering whether the hot spots were working. “Do the cows have milk?” was his oft-repeated question. Within a few weeks, the logistics team set up a satellite, and the hot spots became less important, for we had a creamery.
The laptops themselves were powered by an ersatz electrical system nearly as mercurial as the wireless access. Plugging into the outlets directly seemed a highly risky proposition, in part because the wiring wasn’t perfectly grounded, in part because the workspace where we accessed the plugs was better described as a sturdy tent than a true building, and we were still in the rainy season, where rainwater easily penetrated the periphery of the structure. Any metal piece on the laptop served as a conductor and therefore one’s own personal miniature electrocution system. MacBooks, we soon discovered from the various cries of “Youch!” and “Fuck!” emanating from the Apple-owning expat staff, had a lot more metal than PC laptops.
Touching the outlets could prove to be even more dangerous than working in the high-risk area. To avoid directly plugging in (and to accommodate the multiple users) we used power strips purchased at an electronics supplier in Monrovia. The strips, however, were of inferior quality made by a Chinese manufacturer. They were designed to accommodate various types of electrical outlets used in that part of the world, for Liberia, which uses 120-volt electricity, is different from its neighbors, all of which utilize 230-volt systems with a different style of outlet. These power strips as a consequence didn’t accept the American plugs very well, leaving them as loose as a five-year-old’s primary tooth ready to depart from the jaw, and the plug would receive the power only if it stayed in the outlet just so. Even the slightest movement could cause the plug to lose the connection, and the laptop’s battery would start to drain again. By the end of the second week, I found this process to be excruciating, and I decided to risk either me or my computer’s motherboard being fried and just went ahead and plugged it in directly to the outlet. As I am typing these words on the very same laptop, I seem to have made a good gamble.
*
The communications system wasn’t the only aspect of the operation where the mix of nineteenth-, twentieth-, and twenty-first-century technologies all had to comfortably coexist. As doctors and nurses, we ran what seemed like a hospital: There were rounds, there were tests, there were medications. Yet because we worked with this particular virus, whose clinical behavior was only dimly understood and whose lethality imposed severe restrictions on just how we could behave as clinicians, we were sometimes—well, often—left to incomplete trails of evidence by which we based our treatment decisions.
Our possession of the space-age technology of the Ebola PCR test was hampered by the circumstances the virus imposed, which frequently turned the care of patients into a maddening exercise in medieval medicine. Why, in fact, were people dying at such appalling rates? It is the kind of question that drives every physician who thinks about disease, and unlike what most of us did in our regular jobs—which was simply treat disease that we more or less understood—we were asking this question aloud on a daily basis like physicians living in the pre-microscope era had asked about cholera. And we felt a sense of urgency in trying to arrive at some kind of an answer, even if only a crude one, so that we could put a dent in the mortality and save a few lives in the process. But how to glean information and make reasonable scientific observations in a clinical environment devoid of even stethoscopes? Everything was a guess.
One of the topics that came to dominate the discussion for weeks was the problem of potassium. We had all been surprised to see just how much fluid the patients were losing, and we all understood that electrolyte levels must be going haywire. The fluctuations in these electrolyte levels might hold the key to at least part of the high-grade mortality of the disease. Manage the electrolytes well, and maybe you can help people to ride out the storm.
Managing potassium is one of the most critical activities of doctors and nurses the world round. Sodium, calcium, magnesium, and chloride all can tolerate wider swings before causing real trouble, but potassium levels must remain within a narrower window, mainly because of its effect on the electrical conduction of the heart muscle. Go too low, or especially too high, and the heart can experience a total electrical shutdown.
The tricky part about profound diarrhea is that such fluid losses also lead to kidney failure, and the kidneys regulate potassium levels. So one other interpretation of why patients were dying was not because their potassium was falling too low but instead because it was going too high when the kidneys shut down. In that case, trying to provide patients with more potassium, whatever the route, might be doing exactly the wrong thing.
The simple way to resolve this dispute, in a manner that could have been performed in even a backwater regional hospital in the United States of the 1950s, is to check a patient’s serum potassium level along with their kidney function. There are machines now that can perform these laboratory tests without the need for specialized technicians or even a central power source. But we had no such capabilities. Running such tests introduced complexities into lab protocols that would require careful consideration far too slow for the pace of the outbreak, for working with the blood of such patients constituted genuine risk for whoever was handling the samples, and such advanced technology might not work in the African humidity, or might require special outlets not available in rural Liberia, and on and on the logistics problems went.
So instead, the doctors and nurses kicked the problem around in the manner of a Talmudic discussion. Well, the reasoning went, it’s probably hypokalemia (low potassium), so we should provide potassium supplementation.… But since they might be dying of hyperkalemia, we’ll just be giving them bananas, which aren’t really going to bump their potassium much anyway. When we finally did come to something approaching a consensus on the bananas, I realized I had succumbed to the kind of medicine I swore I would never perform. I was practicing homeopathy.
*
The high-risk area, especially the confirmed ward with its mounting dead, was capable of being a depressing place. But mainly the staff focused on the positives. Once patients survived the worst of the virus, they still had to remain in the isolation of the Hot Zone while their viral loads drifted back down to undetectable and therefore would no longer pose a risk of transmission. This could last for weeks. Surviving a near-death experience, followed by lounging around with very little to do, is probably the all-time award winner for anticlimax, but most bore the tedium well. Genesis, one of the first survivors I knew, had a viral load that kept tailing off, and our predictions that he would be able to leave after the next blood test was taken proved to be wrong a few times. When the test would come back, still positive, I’d look for some glum humor in the situation. “Genesis is still waiting for his Exodus,” I said the first time we were caught by surprise, which helped lighten the mood a little. When the next test came back positive a few days later, I noted, “Well, Genesis has decided to take a pass on Exodus and has just gone straight to Leviticus.” This time the remark was met with wan smiles.
Yet when his moment finally did arrive, there was jubilation. Every discharge was a celebration, with dancing and singing and smiles in abundance. A picture of Genesis hearing the news of his negative test was featured in The New York Times. His arms are raised into the sky, both his fists clutched together, a triumphant smile across his face. Every patient who received such news reacted similarly. It was not a happy moment only for them or even for the staff; the other patients, some of whom were still about to face the worst of what Ebola had to offer, could at least see this and take heart. Whatever the rumors were circulating out in the community that the ETU was just a place to die, here there was evidence to the contrary that couldn’t be missed.
I found other ways to experience and transmit joy in the midst of the death. Like most people, I take pleasure in physical contact, but IMC’s rules in the middle of the outbreak were, understandably, that nobody touch one another during the crisis. I literally never shook hands, patted anyone on the back, or gave a hug to any of my colleagues. We were even discouraged from touching our own faces for fear of possibly bringing a stray virion that we might have picked up. But with the safety of PPE, touching was perfectly safe—or at least not forbidden, since Hot Zone work couldn’t exactly be described as “safe.” So rounds provided a ritual for contact. Those who were healthy, I high-fived; those who weren’t, I stroked their arms and foreheads. Kids, in particular, provided all sorts of opportunities. If any of the children needed to be taken from the suspect to the confirmed ward, I’d volunteer to be the one to do it. I made a point of picking up and spinning around the kids who had survived on the confirmed side each time I came through. Their laughter was the antidote to Ebola’s ominous silence.
The opportunities to use touch as a way to improve the morale of the adults was no less profound. I had watched a woman named Alice get worse and worse, and then one day I came in to find her sitting in a chair in her room instead of lying on the bed. “Alice, how are you feeling today?” I asked. “You look better!”
Until that point, Alice’s face had always been an expressionless mask of illness, but suddenly she looked up with a pouty tilt of her head to the left, and her eyes bored straight into mine. “My neck hurts,” she said, and pointed to the offending area.
If you have been suffering from an Ebola infection, and you now complain, sitting upright, that your neck is hurting, you are not going to die from Ebola.
“Well, Alice, we should do something about that,” I said, and then I proceeded to come over and rub the back of her neck for about five minutes. The sweat I was dripping all over her didn’t seem to bother her in the least. This became a daily ritual during Alice’s two-week convalescence, and I thought at times of adding a line in my future CV: “Steven Hatch, staff physician, and Alice’s personal masseuse, Bong County ETU.”
At the end of the second week, Sam Siakor came up to me, asking me to step aside into a private area, which was difficult in the fishbowl environment of the small compound. The outbreak had touched a family to whom he had been close, and now he was hearing that another member, a woman named Siatta, had fallen ill as well. Because Sam’s duties were with the WASH team, he wasn’t sure how to arrange for an evaluation. Because I worked inside the unit and wasn’t part of the ambulance team, I didn’t know either, but I quickly called Elvis, who was out on one of his runs. We arranged for Siatta to be picked up, and later that day, she was sitting in the suspect ward with a fever. The following day, when the test returned, we moved her over to the confirmed ward.
Clinically, she looked no different than anyone else with Ebola. To me, however, she was entirely different from all the other patients. I knew Sam and called him a friend by that point, and Siatta was a direct extension of that friendship. Everyone else in the ETU were people that I thought of in precisely the same terms that I think of the patients I care for back in Massachusetts, but I was bound to Siatta through personal connections. Intellectually, I understood that her chances of surviving the next seven days were just south of 50 percent. Emotionally, I was never going to forgive myself if she died.
5
THE UNBEARABLE CRY
Human suffering anywhere concerns
men and women everywhere.
—Elie Wiesel, Night
In Monrovia, the ETUs still operated at full tilt. A story had reached us via the journalists that a patient there had accidentally been declared dead. She had been lying in a body bag awaiting transfer to the ETU’s makeshift morgue. The protocol for removing corpses from the wards involved repeated dousings of bleach; before the body bag was zipped up, a worker would spray the solution directly on the body to decontaminate to the fullest extent possible. When the woman was sprayed with the bleach solution, she sprang to consciousness. Our staff reacted to this news with complete horror. There were enough contingencies to contemplate, but burying someone alive was a scenario too terrifying to consider.
In our corner of Bong County, the work continued apace.
The evening was one of the periods of maximum frenetic activity. Depending on when the ambulances arrived and how many patients needed to be processed, those of us working the day shift would head back home to Cuttington somewhere between 8:00 and 9:00 p.m. Two or three SUVs would ferry the expats back to campus, while a larger bus would transport the majority of the national staff to Gbarnga. If it was raining, as it often was as the rainy season neared its end, I would wrap my computer bag in one of the sample PPE suits tucked away in various nooks of the medical staff office, as their composition proved not only able to hold deadly viruses at bay but did an excellent job of keeping a computer warm and dry in a moist and rainy jungle.
On the way out we would grab dinner in a Styrofoam container, typically some theme-and-variation on grilled chicken in a spicy West African sauce with a side of noodles with chopped ham and a biscuit. Everything was prepared with palm oil, which is to margarine what cane sugar is to saccharin, and so everything tasted very rich. Since the ETU work had put me into a major calorie deficit, I didn’t mind all that palm oil so much. Sometimes there would be a slice of watermelon, which looked delectable, although I never consumed anything that wasn’t cooked for fear of catching some gastrointestinal pathogen. When I first came to Monrovia the year before, I had managed to allow this to happen, and it wasn’t fun. But in this instance, two days with fever and diarrhea would not only prevent me from caring for my patients, it would also lead to my own workup for suspected Ebola, something I was determined to avoid at almost any cost.