Saturday, February 28, 2015

Children in the ETC

It must be a trying time for RK who has been here for several days now with Ebola test running from indeterminate to negative then to positive.  She was eventually transferred from the Probable Ward to the Convalescent Ward.  Today she had another positive test and she would be moved to the Confirmed Ward with Doris.  In the beginning Doris showed no symptoms but over the cause of 2 weeks she gradually manifests the natural course of Ebola infection.  RK has no symptoms now; it would be wonderful if she indeed has a minor form of Ebola.  She is pregnant and Ebola infection will put her fetus at risk.

Doris has been weakened so much that she no longer could walk without assistance.  Thankfully she is not actively bleeding and her diarrhea has stopped at least for now.  She still continues to say she is fine.  When I asked her what she would like, she requested couscous and soft drinks.   If she does eat couscous and drink, this may be signs of a turning point.  She was in respiratory distress last night but today she is able to lie with her head only slightly elevated without feeling short of breath.

In the early afternoon, 2 young brothers Ishmael and Emmanuel, ages 4 and 2 were admitted from the Observation Interim Care Center (OICC) when they spiked a temperature after staying there for 2 days.  Their father had died not long ago.  The younger one was eating until he caught sight of us in PPE.  Although he did not cry, he was obviously shrinking from us and did not like to be fussed over.  He stopped eating.  He had a fever and was a little more restless than his older brother who ate heartily.  Later on a 3-day-old baby, Abu, whose mother died of Ebola was also admitted.  Our ETC is suddenly filled with very young patients. 

Friday, February 27, 2015

Tono ai ko du Cam

The ETC in Makeni of Bombali District is full with 31 new Ebola patients; they came from a village just right outside Makeni. It seemed that one Ebola-infected person from Aberdeen, a fishing community in Freetown where some of the inhabitants are being quarantined, escaped and traveled from there by mini-van to Makeni, infecting a number of people on the way.  In Sierra Leone, the public travels in packed minivans where it is virtually impossible to avoid body contact.  Once Charles and I traveled from Gbinty to Port Loko in such a jam-packed van, a car-sick baby sitting at the back of us threw up on Charles’ back! Despite the best effort of the Ebola check-points where passengers’ temperature is taken, it only takes one symptomatic Ebola patient to spread the infection. 

This person went back to his village of 500 to seek the help of a traditional faith healer but died 24 hours later.  The family brought in the traditional healer to treat him which included touching and washing him.  Within a week the man’s extended family, father, mother, uncle, brother and the traditional faith healer ended up in the Makeni ETC.  The man’s father and the faith healer died with 2 days. Makeni had only 5 patients but on that day they registered about 50 patients with 31 confirmed cases.  Today Makeni ETC apparently has seven deaths.  The army had placed the village on a lock-down.  The flare-up came right on the heel of a report of 2 new cases in Sierra Leone. The powers that be are against transferring some patients to Lunsar ETC as we remain quiet, preferring to keep their own patients to the Bombali District.  One of our doctors is sent there to help instead.

The Cotton Tree

Tono ai ko du Cam (Today I am going to Freetown) on my day-off.  I hitched a ride to Freetown in the mid-morning.  Freetown was hot and crowded.  We drove along Lumley Beach with its inviting ocean water by Aberdeen where a section of its community by the ocean has been cordoned off by armed guards as the inhabitants there are under quarantine after a few new cases of Ebola cropped up two weeks ago.



I was in Freetown four years ago with my son Charles and recognized some of the landmarks.  Legend has it that the Cotton Tree in the center of town was the tree where the free African American slaves after landing and walking up to the tree in 1792 gave thanks.  Not too far from here they built the St. John’s Maroon Church using the beams from the slave ship as the beams for the ceiling in 1808. 
African Masks

Carvings
In front of the Big Market were hundreds of men and some women spreading their prayer rugs and saying their prayer.  This was Friday.  The market sells baskets, dolls, trinkets, hand bags, animal skins, African masks, some quite menacing looking, carvings and fabric.  The two-story market appeared dusty and dimly lit.  Some of the artifacts for sale seemed to be gathering dust.  I saw no customers except myself walking through it.  Outside were shops and traveling sale-persons selling their wares which they held in their hands, draped over their shoulders or hoisted over their heads.

The Old Wharf Steps or the so called “Portuguese Steps” had been washed away and destroyed about two years ago.  We walked down a very narrow set of broken stone stairs flanked by stone walls and dilapidated sheds with partially clad children playing on them.  The driver carried my backpack telling me that there were many “bad people” here and I had to be careful with my belongings.  At the end of the winding stairs we walked through someone’s kitchen and then to our left was a dark passageway and right when the steps abruptly ended was the Atlantic Ocean.  Sea breezes blew and the sheds were surprisingly cool in the heat of the afternoon.

The Slum


We passed through the slums with tinned sheds which stretch from the road to the ocean.  At another area of the slum, massive garbage dumps were smoldering with smoke and canals were choking with garbage where pigs rummaged for food.  It was a blessing that Ebola did not sweep through this crowded place.  Since the last time I was here, the streets are less congested and there are fewer vendors spreading their wares onto the roads.  The roads in Freetown are free of potholes, smooth and flawless.

At dinner, we learned that Yaema died in the afternoon.  Doris is still holding her own. 

Thursday, February 26, 2015

A Quiet but Sad Day in Lunsar ETC

It was quiet during our morning shift, no new admissions which would be good if it persists.  But in the next district of Bombali where Makeni is, the ETC has a surge of new Ebola cases.

All the patients in the Probable and Suspected Wards are quite stable, it is possible that all of them are going to be tested negative for Ebola.  The only two patients we have in the Confirmed Ward are rather ill with ten-year-old Yaema going downhill fairly rapidly.  Her family is under quarantine and no one could come out to visit her which does not help her to recover.  Yesterday she was able to resist being touched and examined but today she hardly protested except she screamed when her dressing on her foot was changed.  She no longer calls for her Ya.  Blood continues to ooze from her gums as she lies on her side, with a chux placed near her mouth to catch the drips.  She stops drinking altogether but Ebola continues to make her guts runny.

Doris in the same room with Yaema continues to struggle bravely; she still has the strength to walk on her own power.  Looking at her she does seem to grow weaker, eating only small amounts and getting exhausted very quickly.  She dozes off as I speak to her and always insisting that she is fine.  They each have their own caretaker, a luxury compared to Bong ETU.

Marie's second Ebola test is negative, that is very good news indeed.  She and her cute baby went into the shower to get washed with 0.05% and the rinsed with water. Her baby screamed as she was being doused but to me that is the scream of joy; no Ebola!

Beans and Grains in the Market

Wednesday, February 25, 2015

Ya

Gabriel finally left the ETC 14 days after he entered it.  He left in the morning so I missed his departure.  Three more patients left the ETC with no Ebola infection.  The last time we had confirmed Ebola patients was two days ago: Mohamed and Yaema.  Yesterday when we rounded on them, they were both quite ill.  Mohamed started to cough up blood as we were leaving his bedside.  Other than the blood in the sputum, he seemed strangely calm and peaceful.  By report, he ate his dinner.  However during the night he became short of breath with chin thrust forward and head hyperextended.  In the early morning just before dawn he was dead.

Ten-year-old Yaema was brought to the outside of the ETC and she lay on her side on her mattress.  She had started to bleed from her mouth yesterday and that continued unabated.  On the side of her left foot she had an injury that was also bleeding, blood seeped through her dressing.  Her eyes were puffy and she closed them tightly, refusing to open them.  She did not want to eat or drink ORS but would accept some plain water.  Four days ago she was brought to the ETC by an ambulance.  Separated from her mother and everything else familiar to her, she cried,”Ya!” or “Mommy” in Temne whenever she was touched.  The caretaker tried to clean her mouth but she shrank from their touch.  When I tried to examine her, she said with her eyes tightly shut,”Gbe pe me!” (Leave me alone), seemingly echoing the reality that her mother had indeed left her alone.  

The only other Ebola patient in the ETC was Doris who continued to tell me bravely that she was alright.  Her mother died of Ebola on arrival at the ETC less than three weeks ago and because of that her family was put in quarantine.  Three members of her family, Fatmata K, Martha, and Kadiatu died in the same ward with her in the ETC over the span of three days.  So much tragedy in such a short time still had not dampened her positive attitude which moved me.  Indeed her eyes were bright and lively unlike those of her aunt, Kadiatu whose eyes lost the light of hope long before she died.  I prayed that she would pull through this horrendous time.  She had a high fever.  The caretaker had stripped her down to her diaper and was sponging her.  Her nose no longer bled but her diarrhea persisted and she complained of abdominal pain which she told me was only diminished slightly by paracetamol.  I wrote for her to get tramadol, a stronger pain medicine.

In the mid-afternoon, the burial team came to the morgue to take Kadiatu and Mohamed on their final journey to the Lunsar Cemetery.  

Tuesday, February 24, 2015

Ebola and Cerebral Malaria

In the mid-afternoon, the 13-year-old girl Ramata finally died.  We donned and went into the Suspected Ward to confirm her death.  She was lying on the mattress placed on the floor in rigor mortis and foaming in the mouth.  It was very difficult to straighten her arms. Her Ebola test was negative but we did not receive the result for malaria, we were still convinced that she died of cerebral malaria. She died alone in the ETC.  The WASH Team would come in to spray her body and take her to the morgue.

In the Confirmed Ward, Kadiatu, Fatmata K’s mother was gasping for breath, her breathing was agonal, head thrown back, mouth open and crusted with old blood.  Her eyes partially open, they had long lost their lustre, there was no glint of life in them.  Ebola had played havoc with her body, she stopped producing urine; her kidneys had shut down.  She died later in our shift.  Now the only member of this family remained in the ward is Doris who is in the next room.  This afternoon she had also taken a turn for the worse.  Normally she enjoys lying on her mattress outside the ward as it is an inferno inside.  Patients who sit or lie outside are those who are strong enough to do so.  This afternoon, we found her lying on her bed, stripped naked except for her diaper.  Her caretaker was sponging her to lower her temperature.  She was awake but she had traces of blood in her nostrils.

Mohamed was also coughing up blood and 10-year-old Yaema was starting to have bloody diarrhea; all signs for more severe Ebola infection.  All the patients in the Confirmed Ward were sick except for Gabriel who was still waiting for his second Ebola test.

Mayeni, the woman who came to the gate a few days ago sick with fever was all better and had no Ebola infection.  Everything that she brought into the ETC with her including her brown bag would be burnt except for some of her things that could withstand thirty minutes of soaking in 0.5 percent bleach. Wearing a pink t-shirt with a Chinese character that meant happiness, she was all smiles and headed for the shower to get ready for home.  

Marie's first Ebola test was negative and her baby Suzah was a picture of health, babbling merrily next to her.  We promised to get some baby formula for her. 

We are all eagerly waiting for Gabriel to have a second negative test for Ebola to lift our spirits here in the ETC.  It may just happen tomorrow.

Monday, February 23, 2015

The Bumpy Road to Zero Cases of Ebola

At the Medical Tent, the temperature begins to get unbearably hot at noon and the blazing heat builds up steadily and by 2 pm at sign-out, invariably everyone starts to sweat and thirst sets in.

Eleven patients were signed out to us; the twelfth patient was Martha who reportedly just passed away before sign-out.  She had to be pronounced by a physician before the burial team could be called in.  Martha was the grandmother to Fatmata K, the four-year-old girl who passed away the day before; she became delirious and confused yesterday.   Now Kadiatu, Fatmata K’s mother and Doris’s aunt is critically ill.  She is still conscious, complains of painful swallowing and continues to have profuse diarrhea, with her eye balls rolling upwards reviewing the white of her eyes.  My Temne-speaking nurse says Kadiatu is trying to die.  Doris, however seems to fight hard with every ounce of her energy while her aunt is becoming weaker by the hour despite her bulky built.  Even with frequent diarrhea and abdominal pain, whenever I ask the slender and delicate Deborah how she is doing, she flutters her thick black eyelashes and always says she is doing well.  I do hope it will be so for her.

It was the busiest day since I came to Lunsar ETC. 

There were three admissions.  Ramata, a 13-year-old girl was brought in by an ambulance, comatose and with no information.  Clad in a sarong-like wrapper, Ramata's chest was uncovered revealing her breast buds; her hair all braided in corn rows tapering at the nape of her neck.  She groaned feebly when an IV line was put in but I could not elicit much response with sternal pressure or painful stimuli.  Her neck was stiff.  She was jaundiced, and had an enormous spleen.  She was started on IV Artesunate for cerebral malaria and ceftriaxone for bacterial meningitis.  However she is in extremis and may not make it through the night.

25-year-old Marie came in with her 1-year-old baby girl Suzah.  They were placed in the Suspected Ward even though only the mother fulfilled the criteria for admission.  The baby, without a caretaker, was admitted with her.  The happiest outcome is to have both Marie and her baby to be tested negative for Ebola.

Our third patient was 7-year-old Gibriel who has Ebola exposure and a history of fever but clinically stable.

Adamssay in the Probable Ward lost his pregnant wife to Ebola three weeks ago.  He looks strong now but has been throwing up everything he eats or drinks.  I made a mental note to let psycho social know about his recent loss.

Gabriel in the Confirmed Ward finally has his first negative Ebola test; a second negative test will buy him an exit from the ETC.

By the end of my shift, we had 14 patients, 5 confirmed and the rest in the Probable and Suspected Wards, most of whom I hope would turn out to be negative for Ebola.

The volunteers who have been here longest have observed that the town of Lunsar appears more bustling of late compared to when they first arrived.  They wonder if the town people are less vigilant about Ebola and ignore the warning regarding close contacts and gatherings.  In the ETC in Makeni, further north from us, there has been a recent surge in their admission rate as well.  All these certainly do not bode well towards the goal of zero cases of Ebola in Sierra Leone.

At the end of my day, I received an e-mail from Wellesley College sending me a link to the College Homepage Story

Sunday, February 22, 2015

Going to Church

My days are blending together.  I cannot tell a week day from a weekend.

This morning one of the drivers asked me whether I was going to church.  Then I realized it was a Sunday.  A volunteer warned me to be careful as a number of our recent Ebola cases have come from Lunsar.  The only church I remember seeing is St. Peter Claver Parish in the center of Lunsar.  As none of the drivers knew the time for the Sunday service, we just drove there.  As it turned out, the first service was nearing its end.  The second one began at 9:30.  I learned that seventy five percent of the people here are Muslims.

St. Peter Claver Parish

The pews started to be filled with parishioners while a nun seemed to herd the men to the right side of the church and the women to the left, though this was not strictly followed.  She shushed the people when they were talking as there was confession taking place in one of the booths. There must be about 600 people in there.  Along the sides were tall stained glass windows depicting scenes from Christ’s life.  A cooling breeze gently blew through open windows and the aisles.  Before the service began, the nun exhorted the congregants to reflect on their lives but with such harsh scolding tone ringing constantly in our ears; it was difficult if not impossible to seek a quiet moment to do just that. She was the same person who wanted all to be quiet for the confession.

During the service two monitors walked along the aisles signaling people to sit apart from one another.  I chose a pew seat by the aisle but for some strange reason, the woman sitting next to me crept closer to me after each standing and sitting.  In the end I was just sitting on part of the bench with one leg settling in the aisle, almost falling off my seat.  There was no exchange of peace and only a third of the congregation took communion. I was told that other churches require washing one’s hands before entering and having one’s temperature taken.

The service continued for at least two and a half hours but I had to leave for the ETC.  Outside in the yard, a number of men and women with canes were sitting under the searing sun, waiting patiently for the service to be over and hoping to receive some alms.

At the ETC we learned that 4-year-old Fatmata K died last night having a tough time breathing.  When she was alive she seemed to be always grimacing in pain or profoundly afraid; crying without tears or uttering a noise.  In death she was reported to look peaceful, finally released from her lonely and agonizing time in the ETC where she was unable to communicate to anyone.  In the end she was never showered with assurance of love form her own mother and grandmother.  When they turned her away at their bedside, she must have felt the full impact of rejection.  I wonder how her cousin Doris, her mother and grandmother are coping with her death.   

Kadiatu K left for home, she had a miscarriage and the good news is she does not have Ebola.

By the afternoon only one of the ten admissions came, two others may still show.  I was not assigned to the ETC today so a group of us traveled west to Port Loko to attend a weekly round table conference organized by WHO for various NGOs: Goal of Ireland, PIH (Partners in Health) and IMC to gather and share cases and experiences.   This has started a few weekends ago.  We would have to take turn to host or attend the conference. 

Saturday, February 21, 2015

“Unclean, unclean, make way for the leper!”

Yesterday Sullieu left the ETC Ebola-free, I missed the celebration.  Two others, Abdul and Adamssay left the Suspected Ward having not had an Ebola infection.  Sullieu has no caretaker as his relative Gabriel is still in the ETC, so he would be held at a safe place for the moment.

This morning we have five patients, four of whom are from the same family; Martha, Kadiatu, Doria and Fatmata K.  The only other patient in the Suspected Ward is Kadie who suffered a miscarriage and her first Ebola test is negative.  She, however, did not know that she was pregnant.

Kadiatu, Fatmata K’s mother, has been weak and sick with diarrhea while her grandmother Martha has a fever and fortunately has not had much “wet symptoms”; she reports feeling stronger today.  Kadiatu who has a disabled right leg contrives to use the bucket by half sitting on her bed; in the process she spills her diarrheal stool on the cement floor.   Both she and Martha, however, did not want to have Fatmata K visit with them this morning when she was brought to their bedside.  Kadiatu, Fatmata K’s mother just shook her head and waved her away.  She received no hugs or any words of endearment.  When the caretaker turned to her grandmother, she too shook her head and did not reach out to poor Fatmata K.  Fatmata K was carried away by her caretaker with tearless sad crying eyes and a mouth open with a voiceless, silent cry.  I could perfectly understand the predicament of her mother and grandmother; they are too ill to want company.  She would be a handful for either of them at this time.  However even a tender embrace and some loving words would have gone a long way.

Fatmata K has not been a picture of health, still refusing to eat but has been able to be coaxed to drink a little ORS.  Her breathing is a little rapid with mild upper abdominal retractions and when she is upset she also shows nasal flaring, all signs of her having some difficulty breathing.   

Two more patients were admitted, both of them are related to the four patients in the Confirmed Ward: 29-year-old Mohamed and 10-year-old Yaema.  Yaema is admitted to the Probable Ward because he vomited in the ambulance.  These patients were triaged while the medical team was still rounding in the ETC.

Around noon, Mayeni, a 38-year-old woman walked up to one of the gates having been sick for three days despite being seen three days ago at the Lunsar Community Clinic.  According to her she has no Ebola contact or contact with a dead person but has a myriad of symptoms which buy her an admission into the Suspected Ward.  I walked the long gravel path to question her with Fatu, my Temne translator.  We found a diminutive woman squatting by the iron gate with her wrapper covering her head shading her body from the fierce sun.  When we asked her for a contact number, she reached out from under her a small brown bag and fumbled in it and handed a piece of folded paper with a number written on it.  

Later a nurse in partial PPE walked with her on the long gravel path outside of the ETC to the ward, followed by a sprayer who sprayed the path taken by her with chlorine.  Seeing this parade of three strangely clad people taking this long laborious walk under the hot sun reminded me of the leper who walked into the city seeking healing from Jesus, all the while he was obligated to cry out to the crowd, ”Unclean, unclean, make way for the leper.”

Shortly after, a woman brought in a sick 6-month old baby by the same gate but sadly the baby died before admission.

As we were handing over, there was news of possibly another 10 more patients to be brought in from the Marampa Chiefdom, relatives of the four confirmed patients in the ETC.  If this were really true our dribs and drabs admission would now become a downpour.

Friday, February 20, 2015

Bureh Beach and an Accident

This morning, the sheep wondered near the restaurant.  She butted my fist with her forehead as her form of greeting.  Kalomere is Temne for sheep which seems to be a more beautiful name than Shikira.  From this day on, she shall be called Kalomere.  Yesterday was the Year of the Lamb/sheep/goat/ram of the Chinese New Year but for Kalomere every day is the same.

A day off for me. 

A Police Check Point

Five of us went to Bureh Beach.  It was about a 2-hour drive.  We passed through very busy markets and the driver said the markets were closed at the heights of the Ebola outbreak.  The traffic slowed at Ebola check points while passengers got off minivans to get their temperature checked.  Our van was waved on without us having to get off.  On the wind screen was placed a certificate marking our vehicle as an Ebola response conveyance.  Like Malawi, the stretch of land to the beach is largely deforested for firewood or charcoal; only remnants of trees grow in the land.  Like the people here the trees are very resilient, despite all that slashing shoots grew everywhere, including shoots from the burnt stumps of palm trees. 

Bureh Beach

The driver drove through a village to get to the beach which seemed to stretch far into the distance.  Tall slender coconut trees lined part of the beach especially near the rocky section.  To one side was a river flowing towards the ocean.  Unfortunately in the river, on parts of the beach and ocean particularly those near habitation are scattered a variety of trash which found its way into the water.  I dug my feet into the soft sand and we plunged into the warm water, catching some waves.

Spending a lazy day on the beach was the perfect way for us all to relax. For lunch, I had coconut rice and mackerel.

On our way home through Lunsar a mini passenger van was on its side in a deep ditch.  I saw a person in PPE while someone else saw a body being put on a stretcher to be carried to an ambulance.  The days of Ebola make all these precautions necessary.  The road though smooth is still a dangerous place to be, casualties through road accidents are still one of the most common causes of death in Africa.  We learned later that two passengers were killed in the accident.

Thursday, February 19, 2015

“Moon atonaton atonaton”

Many of our recent patients are from the village of Kontabana in the Chiefdom of Marampa of the District of Port Loko.  In the Suspected Ward Abubakar was tested negative for Ebola yesterday, he will have to wait for a second negative Ebola test before he can be released.  Adamssay who came with him had an indeterminate test.  From reports, recently there have been a whole lot of indeterminate results and these have been viewed as laboratory errors.  They are both doing well.

In the Probable Ward, Kadiatu has a high fever and Martha is having diarrhea.  They look weak with Kadiatu looking more deflated and exhausted than the older Martha.  The doctor who speaks Krio and I were accompanied by a nurse who speaks Temne.  Being nauseated, Martha could not take big gulps of ORS, so we asked her to “Moon atonaton atonaton” (drink slowly, slowly or take small sips).  This became the morning mantra for the rest of the patients which the doctor repeated in a sing-song manner inducing delighted smiles from some patients especially Gabriel in the Confirmed Ward.

In the Confirmed Ward, Gabriel and Sullieu came into the ETU together eight days ago, however yesterday Gabriel’s repeat Ebola test was still positive while Sullieu’s turned negative.  Their tests will be repeated.  Gabriel argued with the staff that if Sullieu is discharged he should be discharged at the same time because he is the only caretaker left for him.

The Medical Tent is boiling hot from noon onwards; a respite is to be had in the corridor closer to the entrance of the ETU where there is always a welcoming refreshing breeze blowing.

The ambulance brought in Kadie from the same village of Kontabana.  She has no Ebola exposure but has fever and vaginal bleeding which she says is her menses.  However she has a positive pregnancy test.  The afternoon staff will need to query her further and examine her to determine her gestational period.

There are now nine patients in the ETC, 3 in the Suspected Ward, 2 in the Probable and 4 in the Confirmed Ward.  My mask moved its way upwards to my left eye as I rounded, making it extremely uncomfortable to see and examine the patients.  Somehow we finished seeing all our patients.  


The Changing Tent

Wednesday, February 18, 2015

Tope ander-a? (How are you?)

This morning three doctors and a nurse did our medical rounds on all the patients from outside the fence as almost all of them were able to sit outside.  The advantages are the patients could relate to us without our PPE and the 4-year-old Fatmata K is less afraid of us; our time spent in PPE in the ETC is curtailed.  The nurse and the doctors are all from Sierra Leone and they all speak Temne except for one who speaks Krio.  In the Suspected Ward, we have the youngster Abubakar who looks well overnight as his fever is gone but he still has muscle pain and occasional hiccoughs.  I could hear words in Temne that sounded like “hiccups and weak”.  Adamssay, the older woman continues to have pain and begins to have some diarrhea but otherwise quite well.

Over to the Confirmed Ward, the sickest person is Fatmata K, still refusing to eat but could be coaxed to drinking some water.  She refuses to drink the ORS so we continue her IV fluids.  Her cousin, Doris, has started to be febrile and now has muscle pain.  Sullieu and Gabriel are being tested for Ebola to see if they have cleared the virus, they are getting better every day.  Slowly they are regaining their strength and there is the beginning of a sparkle in their eyes.  Gabriel ate his raw cassava root yesterday but evidently did not get poisoned by it; he seems to be immune to the cyanide.

After our outside the fence rounds, the nurse and I donned to see the little girl.  We paid Adamssay a brief visit in the Suspected Ward, she looked well.  Fatmata K was lying on a mattress outside the Confirmed Ward.  She has been receiving IV fluid as she is still not drinking enough.

While I was rounding, the ambulance brought in Marhta, Doris and Fatmata K’s grandmother and Kadiatu, Fatmata K’s mother and Doris’s aunt to the ETC.  They are both from the quarantined area and live in the same household where Doris’s mother contracted Ebola and died.  Martha is 64, tremulous but she does not have a fever while Kadiatu has a high fever and reportedly has diarrhea.  She has a long dress that hides her legs.  Getting up from a sitting position posed an enormous problem for her.  She first had to lean her body weight onto a table and pushed herself up and even then her legs seemed to give way from under her.  The aides handed her cane and she almost fell taking a few steps on her own.  In the end she was transferred to the Probable Ward on a stretcher.  We could not clarify what kind of disability she has.

Transmission continues in the quarantined area, perhaps symptomatic persons should be pulled out to the ETC early for Ebola testing, minimizing further exposure to the rest of the quarantined villagers.

Drying Aprons and Scrubs in the Hot Sun

Tuesday, February 17, 2015

Pick Your Poison

This morning someone brought in a black baby goat into the compound of Bai-Suba, he was grazing not far from Shakira which stayed in the shade.  For some reason she did not befriend him but did stay close by.

Fatmata K died shortly past midnight, we could not help her.  It was a small consolation that she had a caretaker with her.  This morning, Joseph, the patient with possible incarcerated hernia was thankfully transferred to a hospital in Freetown where there is an Italian surgeon. Lucee who was tested negative for Ebola is still ill so she was transferred to Port Loko Hospital and last but not least, the long-awaited discharge of the Ebola-free Augusta with her new hair-do.  I was not there to witness it but by all accounts it was a joyous occasion for all.

When I arrived for my afternoon shift, 2 patients were brought in through triage.  There were two patients in the Confirmed Ward and 4 in the Suspected Ward with the new admissions.  Before we went into the ETC, we circled on the outside to see the patients who were hanging outside of the wards in the backyard.  The two patients who were admitted yesterday were tested positive, Doris and Fatmata K, the mute four-year-old.  Doris remained asymptomatic so her result surprised us. There would be contact tracing in that quarantined area.  Transmission in the communities continues.  Fatmata K was still weak, drank but refused to eat.  She continued to be terrified of us.  Doris has been worried about Fatmata K, now she will be moving with her to the Confirmed Ward.

WHO reported total weekly case incidence increased for the second consecutive week, with 144 new confirmed cases reported in the week to 8 February in the three countries. Transmission remains widespread in Sierra Leone, with 76 new confirmed cases.  The resurgence in cases in the western district of Port Loko continued for a second week. It means that there are still continued pockets of transmission in these countries.  

The two patients that were brought in had Ebola exposure, they are from Ktonbana.  Abubakar is a 17-year-old man, febrile, with body ache and Adamssay is a 48-year-old woman with similar symptoms.  For the moment they are stable.

There are now only 2 patients in the Confirmed Ward, Sullieu and Gabriel, both spending their time outside, getting better.  Sullieu asked for an orange and an ice cream while Gabriel, a raw cassava root which contains cyanogenic glycosides and these convert to the poisonous hydrogen cyanide after chewing. The kitchen staff did not blink when we conveyed his request.  I ate quite a bit of uncooked cassava roots when I was young thankfully with no ill-effects.  We assumed Gabriel knew what he was doing.


The sun had set as we were leaving the ETC.  Twilight descended.  We seem to have between 6 to 8 patients a day with admissions coming in dribs and drabs.  The road to zero cases of Ebola plainly will not be a smooth one.

Monday, February 16, 2015

ABC (Avoid Body Contact) in the Lunsar Market, Hugging while Wearing PPE

Last night storm clouds gathered threatening rain, but this is the dry season here.  However sometimes during the night, I heard loud rain drops.  Opening my door, humid and sultry air greeted me, I saw Shakira running back and forth, not knowing where a safe place was.  Lightning lit up the dark clouds in the sky.  I called to her “Baaaaaah.”  She instinctively answered and her cry sounded desperate and scared.  I was told that she was brought in here to Bai-Suba with a bunch of goats but when two goats died, the rest of the goats were taken away leaving her alone, friendless.

Lunsar
A Sign in Freetown

This morning I went to the market in Lunsar with another doctor who will be on duty with me this afternoon.  Market closes on Sunday afternoon so this morning it was very crowded.  The streets as in most of the streets in Africa, have no sidewalks forcing us to walk on the road, motorcycles and cars honking constantly.  The loudspeaker blared ear-splitting music.  We carefully considered whether we should plunge into the crowds with this dictum of avoiding body contact (ABC) in the Ebola outbreak.  The other doctor is almost finishing up her time here so she led the way.  We tried to wriggle around avoiding skin contact but contact is almost inevitable.  The market has fresh produce, fresh fish and dried ones, bread, spices, palm oil, Kola nuts, as always no shortage of Chinese made goods, basins, buckets, slippers, radios...  Young girls carry basins with fresh mints, potato leaves, onions to sell while the boys follow us around, one of them asking for money.  St. Peter Claver stood guard at the end of one of the streets.  It was closed so we could not take a peek.

The Market

Kola Nuts

Mountain of Red Peppers

Lunsar has not had new cases of Ebola for a few weeks now.  Most of the new cases come from other parts of Port Loko.

In the ETC here the doctors do a six-hour shift in the day, 8am-2pm, 2pm-8pm and the night is 8pm-8a; the nurses do a 12-hour shift just like what we did in Bong ETU.  Today we started our shift with 6 patients, 2 in the Suspected Ward and 4 in the Confirmed Ward.  Shortly after hand-over at two in the afternoon, the ambulance delivered 2 patients from a quarantined area in Lunsar, Doris, 16 and her cousin Fatmata K, 4.  Both were exposed to Doris’s mother who died of Ebola on arrival to the ETC 9 days ago.  Fatmata K becomes sick with a fever and diarrhea. Doris is totally without symptoms but she reported that there is another sick person who lives in the same crowded quarantined area with them.  She has a black hijab studded with silver ornamentation and dresses in a long embroidered sinuous outfit which she will have to part with.  Fatmata K is mute.  She was terrified of us standing by her bed all suited up and worse still she had to have an IV line placed in her arm so we could give her artesunate for treatment of malaria; she reached for her cousin in the next bed.

Mamusa has improved though she remains weak.  Her diaper is soaked with diarrhea.  The Sierra Leonean doctor speaks to her in Temne and makes her walk all the way to the back to sit outside. Joseph is lying on a mattress placed on the gravel.  His abdomen is so distended that he looks like he is 6 months pregnant.  He has not moved his bowels for 6 days.  Why he was admitted yesterday was a mystery.  He does not have any exposure to circumstances suspicious for Ebola.  Examining him, we determine that he may have an incarcerated hernia which could cause intestinal obstruction and thus the distension.  Both the Sierra Leonean doctor and I tried to reduce his hernia without success.  I want to expedite his transfer to Port Loko Hospital for possible surgical intervention.  The quickest way is to get his Ebola test result which turns out negative.  Unfortunately here in Lunsar ETC, a suspected patient has to get 2 negative Ebola tests before he can be discharged.  As we try to get an exception to the rule, the caretaker reports across the fence that he finally moves his bowels!

Again there is no one in the Probable Ward.

Fatmata 1 is gravely ill with agonal breathing, eye balls roll up, only the white of her eyes shows.  She has retained fluids all over her body.  The neck swelling has decreased significantly but she no longer makes any urine.  We are not sure she would last through the night.

Sullieu and Gabriel are doing well.  Sullieu remains weak but seems to have rebounded from his gastrointestinal problem.

Augusta is waiting for her second Ebola test result; her first has been negative a day ago.  In preparation for going home, she has requested to get her hair braided in corn rolls.  Sitting outside at the back of the ETC, the caretaker uses Vaseline to braid her hair.  She looks happy and content.  Tomorrow she will have been in the ETC for 15 days and the staff cannot wait to celebrate her triumphal exit.  She had been "as sick as a dog" said one of the doctors and for a tenuous moment, they feared that she would not make it.  And she is feeling strong and ready to start anew.

It is overcast all day after the rain last night.  A cool breeze blows across the halls of the ETC.  The only time we could touch one another is when we first put on our fresh PPE and so today we did a lot of hugging in the donning area.  Donning PPE today in this unusually pleasant weather gives us no trouble at all with the exception of the fogging of the goggles.  It seems like we could stay in our PPE for a long time.  
The Afternoon Medical Team

Me Doffinng

Sunday, February 15, 2015

Psychosocial Issues


The ETC in Lunsar
 As part of my training this morning, we had a psychosocial session.  The psychosocial team deals with issues among family members when some become infected with Ebola and have to be separated, loss, placement of surviving members of the family.  In Sierra Leone the Paramount Chiefs are the sole authority over the Chiefs of the Chiefdoms which comprise of villages,  each village has a Village Chief followed by a Mama Queen and a Youth Leader. The psychosocial team always has to work with the Chiefs to get acceptance of the patients back to their own villages.  The villagers tend to listen to the Chiefs.  

Recently the stigma attached to a single Ebola infected patient has now been transferred to an entire Ebola quarantined village or area.  Ebola survivors once shunned by their own village now are welcome back because they are being supported by NGOs with food, clothing, beddings, and a stipend of 500,000 Leones a month.  It is the custom of Sierra Leoneans to share what they receive so some relatives may potentially benefit from their home-coming.  They continue to have problem with loss of livelihood as few people would buy produce from Ebola survivors.

A quarantined village is guarded by soldiers or police.  Food is delivered by NGOs and pushed into the cordoned area.  Sometimes the delivery did not come on a timely manner and so the psychosocial team will have to advocate for them.  However if one person in the quarantined village comes down with Ebola, the rest will have to restart their quarantine period from day one all over again.

Sierra Leoneans treat their sick ones with a lot of care and love.  The sick person becomes like a child, he is washed and fed, made to lie down on someone’s lap while his head and body are stroke and touched.  A dead person has to be washed and touched before the burial.  Ebola has changed all that.  There is to be no washing or touching.  Here in the Lunsar ETC, there is no cemetery, so patients’ bodies are taken away to be buried either in Lunsar or Port Loko cemeteries.  If a patient is from very far away, the relatives will have to make do with a distant burial site.  If they could not attend the burial, they would be given the plot number so they could pay a visit to the grave site at a future date.  I am very appreciative and thankful of the proximity of the grave site in Bong.  
Attending burials of some of my patients and visiting the cemetery to reflect seemed to give me some closure of the emotional aspects of volunteering in the ETU.

Evidently fear and distrust of authority continue to be pervasive.  Accordingly to the psychosocial person in charge here, as recently as 2 weeks ago in a village in Makeni in Bombali District, a couple put their sick child secretly in a separate hut with no care and little food and she died a few days later. When officials came to the village for a headcount, they recruited another girl.  Fearing that they could be found out by the Village Chief and be fined, in the dead of night they tried to throw her body into a latrine which was too small.  In desperation they contrived to dump her body in a well but were caught.  

Despite counseling to abstain from sex for 90 days after being Ebola-free, a young man had sex with his wife who contracted Ebola, he is being held on a charge of intent on an act of grievous bodily harm.

In November of 2014, UNICEF helped to create the District Ebola Response Centre (DERC) for the Western Rural District where the Ebola transmission is still ongoing.  In order to bring Ebola cases to zero, many community social mobilizers have been trained to look out for Ebola cases for prompt medical response.

Finally in the late morning I donned and went into the ETC with two other doctors.  Today there are only 7 patients, 4 in the Confirmed Ward and 3 in the Suspected Ward where Joseph was later admitted.  Mamusa, a young lady in the Suspected Ward, is mainly weak with a fever and has to be encouraged to eat and drink.  We urged the caretaker to help her in our absence.  Here the Ebola tests are sent to Port Loko, half an hour away, but may take up to a day to get the results back.

The Probable Ward remains empty.

In the Confirmed Ward, Fatmata 1’s neck is like a bull frog today with swollen lymph nodes, she is unable to open her mouth wide enough for us to see her pharynx.  We started her on antibiotics: ceftriaxone and clindamycin yesterday afternoon.  Her fever persists.  Because of her pain I am leaning more towards a bacterial than a tubercular lymphadenitis.   

Augusta’s Ebola test turned negative on Valentine’s Day on day 12, she would have to wait for 48 hours to get another test before she is declared Ebola-free.  Sullieu and Gabriel remain stable.
We finished rounds in less than an hour.  Prior to going into the ETC while I was attending the psychosocial lecture, the doctors had gone around outside of the ETC in scrubs to round on the stable patients by talking over the fence querying them about their symptoms.  This helps to curtail the length of time spent in the ETC in full PPE.   The sick ones who remain in bed would be attended to in more detail later inside the ETC.  Here in Lunsar, one is not allowed to stay in the ETC for more than an hour and a half.

The white tents of the ETC are sweat boxes and there are no windows for cross ventilation or fans.  The very sick patients, who stay inside, sweat profusely.  This makes hydration even more urgent.  

After rounds I was shown the charting for the patients and transcribing of the signs and symptoms called over the orange fence in the morning.  There was no such consistent charting in Bong, at least out of the ETU, all our charting was done inside and the charts remained inside the ETU and we could not review them at leisure.  This also made our rounds in Bong much longer because of the documentation and ordering done inside.

Now that I have been through the ETC twice, I will be put on the schedule with the rest of the doctors starting tomorrow.  I am assigned the afternoon shift.

In the late afternoon back in Bai-Suba, I fed the baby lamb some blades of tender grass, she followed me and gamboled joyfully.  I saw her playing with a crow a few mornings ago.  She must be lonesome for a playmate.

Feeding Shikira