Inferno

by Steven Hatch, M. D.

  What you see of this country when you take that one-hour, bird’s-eye-view trip is a lot of jungle. Small villages dot the landscape, but there is hardly any large urban development once you get past the outskirts of Monrovia. Every few minutes, a part of the jungle would suddenly assemble itself into improbable order. At first I thought it was a trick of the eye due to my exhaustion, but I kept seeing this repeated pattern in the canopy where the trees aligned perfectly into a grid. It reminded me of cornfields, but why would Liberians want to harvest trees in the same manner? The answer is that they were rubber trees: The tire corporation Firestone, which has been in Liberia for nearly a century, owns a significant amount of land in the country.

  We landed on the soccer field of Cuttington University and, under the watchful gaze of curious onlookers, loaded our bags onto a waiting bus. Cuttington had been founded by the U.S. Episcopal Church in the late nineteenth century and over the past century had been the training ground for much of the Liberian elite until the Civil War tore the country apart in the 1990s. The school reopened at the end of the Civil War in 2004 and now found itself closed again a decade later, this time because of Ebola. IMC had commandeered some of the student and faculty dorms to house the staff.

  Not having ever been involved in a disaster situation and not having ever worked with IMC, I hadn’t really thought through the point of flying by helicopter. That flight wasn’t cheap—money was time—and the money was being spent so that we could go to work immediately. Yet all I was thinking about was to catch a nap and put my luggage away somewhere, so I was taken by surprise when the bus drove straight through the campus and headed out to the main road. We were bound for the Hot Zone right away.

  *

  The International Medical Corps Bong County Ebola Treatment Unit sits atop a hill in the middle of the jungle, off the main road that links Bong’s capital, Gbarnga, to Monrovia. It’s pronounced BAHN-gah. Liberian English seems to have an often apathetic relationship with its consonants, frequently dropping its g’s and k’s so that, for instance, the tribal language of the largest ethnic group in Liberia, Kpelleh, is pronounced something between “peh-leh” and “pay-lay.” The one-lane muddy road knifes through the jungle for a little over a mile and emerges into an open area where the forest has been torn apart, leaving a bald gash about two hundred meters across. From the bottom of the hill, you would be struck by the wound inflicted on this patch of earth by humans, and your eyes would scan from a dense green to a gap marked by dozens of people scurrying about a bare landscape, and back to the green as if the jungle were heroically trying to ignore its unwelcome neighbors, hoping that they might yet go back to wherever they came from.

  The barren nature of the ETU becomes even more pronounced as you move closer to the gate. The ground is entirely gravel; an incredible amount of it must have been trucked up to this site, for its length is nearly a quarter mile. Many separate, small buildings dot the landscape—so many that it wouldn’t be immediately apparent which buildings constituted the patient care area. But what would grab your attention even more than the hive of human activity, the staff darting to and fro among these buildings, is the unnatural amount of blue pouring in through your eyes. The buildings are, in fact, little more than hastily hewn two-by-fours hammered together, placed on concrete floors, all wrapped in ocean-blue tarps. Once you are inside the compound, you cannot escape the color.

  Despite the number of structures, the layout of the ETU is very simple:

  The vertical rectangle on the left represents the staff area. One building housed the changing rooms, a pharmacy, and a storeroom; a second, the medical staff workspace; a third, the administrative offices; and so on. This was formally known as the low-risk area, although I sometimes called it the “Warm Zone” to distinguish it from the other two rectangles, which were the high-risk areas of the Hot Zone. The only problem with my “Warm Zone” term was that it implied that beyond the gates of the ETU was a Cool Zone, and in the Liberia of October 2014, there was no such thing as a Cool Zone. The virus could be anywhere, and the fear was that it was nearly everywhere.

  The bottom-right rectangle represented the area where the suspect ward building and its patients were housed. This was the way station for patients who came to the ETU with various symptoms or contacts that were suspicious for Ebola but whose blood tests had not yet returned. If the test returned negative, patients were discharged back to the community. But if their tests did show infection with Ebola, they were transferred into that final rectangle, the confirmed ward.

  These were not hermetically sealed places, of course: Doctors, nurses, and patients all flowed through these areas. Structures dotted the boundaries. Patients entered the suspect ward through a triage building (the box at the bottom) that was attached to a driveway where the ambulance dropped the patients off. The staff met them by entering through the “donning,” or gowning, station, thus:

  Once inside the Hot Zone, the staff moved in a counterclockwise direction into the confirmed ward, and then reemerged into the low-risk area by means of the decontamination chamber:

  The laws governing the motion of this humanity and matériel were rigidly enforced, and the structures that formed the boundaries between these spaces were always the points of maximum attention, concern, sometimes stress, and occasionally anxiety. Within a few short minutes of arriving at the ETU, I would be directly introduced to that domain and those laws.

  *

  As I walked into this blue world, I had two competing sensations. One was of wonder that I really had arrived in this place, had come to the end of the world, and was about to engage in the battle of a lifetime. The more pedestrian feeling was one of such utter exhaustion that all I really cared about, Ebola or no, was to curl up as soon as possible at the most convenient location and take a nap. Since nobody was explaining to me the schedule, I thought that perhaps this was a quick tour of the facility, after which we would be taken back to the Cuttington campus, put up in housing, and be allowed to take the day to acclimate ourselves and get some sleep. I was rudely disabused of this notion when Pranav Shetty, the chief medical officer with whom I had spoken two weeks before, had just completed introductions and then asked Steve Whiteley and me if we were ready to round on the patients.

  I had gotten about five hours of sleep over the past forty-eight, having hopped through four countries and a quarter of the earth’s circumference. I felt dirty, I was exhausted, and I hadn’t had a chance to settle myself. Now I was being asked to do some extremely dangerous work for the very first time. I shot a quick glance at Steve, whose travels began in California and were even longer, but he was expressionless. I felt the urge to voice some concern about this plan. I had to make a quick decision.

  “So, what are we waiting for?” I asked, with a let’s-rock-and-roll tone in my voice.

  It was the right move for more than one reason. First, I was about to get one hell of a jolt of wake-up that would sustain me well into the evening. More important, I would come to learn the critical importance of having a positive attitude. That little piece of Dale Carnegie may sound painfully banal, but in a disaster environment, where there is so much chaos and suffering, being chipper and staying upbeat with a Here we go! attitude is that much more important. When everyone is stressed and stretched to their physical and emotional limits, a sour attitude doesn’t poison the well—it poisons the fishbowl, as the boundaries are that much more constrained. Everyone’s working on top of everyone else, and nobody’s going be getting away to a nice restaurant, movie, or bookstore for a little mind clearing anytime soon. Not that I understood this at the time; I was just following my intuition.

  I went to change into scrubs and boots in the dressing room, and then we entered the donning station. I had performed the gowning process three times at the CDC training course in Alabama. Now, however, it was for real. It isn’t exceptionally difficult to put on PPE, but it does involve several small steps, all of which must be perfect, lest one create a situa
tion where exposure to the virus can occur inside the Hot Zone. Three times is plenty to learn to wear PPE; one of the main points of the training is just to become sufficiently familiar with the procedure that you aren’t paralyzed by fear when you enter for the first time.

  First come the gloves: a pair of regular exam gloves overlaid on surgical gloves, with the inner pair protecting the skin to the mid-arm and the outer pair providing stability, as exam gloves can more easily tear. Next comes the suit itself: a sun-yellow outfit made by DuPont Corporation known as Tychem that zips up from the crotch all the way to the top of the neck. As I put this on, by the time the zipper was midway up my chest, I could already feel the sweat beads form on my head, neck, arms, and back. I never failed to marvel at how quickly I would break into a sweat after I put on the suit.

  After zipping up, we put on small face masks to protect our mouths and, after that, a white hood that covered everything except the eyes. The hood was, for me, the moment of real transition, as I couldn’t get past the idea that it represented some kind of a shroud: I could only see that white go over my eyes momentarily, but I could feel my head and neck become encased in it, like some pharaoh of ancient times getting wrapped in linen to help the journey into the next life. After that hood went on, I was in the land of death, and later, when it came off, that marked the moment when I returned to the land of the living.

  Then came a large plastic apron to provide an extra shield against body fluids laden with Ebola; an outer pair of surgical gloves, which we wrapped up with duct tape; and finally, we put on the goggles, marking the moment where we completely sealed every surface of our bodies from the outside world. It wasn’t designed to be airtight, but you could get pretty far into a pool before you ever got as wet with anything other than your own sweat, although you would produce a shocking amount of that.

  The total time to put on such gear, if only one person were being tended to by the gowning team, was about ten minutes. However, nobody ever goes in alone, and typically there are upwards of six people donning gear in the cramped station, which is not much larger than a decent-sized walk-in closet, so the entire process usually took more than twice that. When it is your first time going in, the anticipation is a bit breathtaking. This wasn’t a typical inaugural session for a new job.

  In we went.

  The one-foot journey from low risk to the Hot Zone was like stepping onto the moon. Suddenly all my senses were operating at full throttle—the sensation made stranger still because all my sensory organs were trapped behind various layers of petrochemical polymers. The hum that I felt was not just a first-time experience. Although I would gradually normalize many of the tasks I performed in the high-risk area, I never quite lost that sense that I was moving around in a place not of this earth, one with rules so different it was almost like gravity didn’t exist. Those differences required a recalibration of how I moved about and my general level of attention to my surroundings. Every sense was heightened in high risk, even during my most pedestrian moments and even when the work, at first so electrifying, turned into routine, as it inevitably does in any job. Ultimately, I came to see that as protective, and I didn’t try to suppress it. Vigilance was required in this place. There wasn’t anything casual about what I was doing.

  That lesson became clear immediately when Pranav, Steve, and I entered the hallway of the suspect ward. There, lying in front of us, sprawled lengthwise, was a patient, delirious and shaking. When we approached him, it was clear that his pants were soiled with diarrhea and his shirt stained with vomit. He was covered in his own body fluids. The moment that I saw him, my mind simply went blank except for the word Ebola. It was not totally dissimilar to the sensation that Phil Ireland had when he realized that he wasn’t infected with malaria, although because he was infected, that word must have seemed like a roar. I thought, You asked for this assignment, Steven, and now you have your wish. We had been in the high-risk area for maybe five seconds.

  But it’s actually what happened the following second that marked the moment when theory turned into practice and I started to learn the art of Ebola care. Pranav surveyed the situation, walked directly to the patient, whose name was Aaron Singbeh, and tried to get his attention. Aaron wasn’t responsive, however. Steve and I walked over, and Pranav said that we should get him back to his bed, change his clothes, and wash him up, and without more than a moment’s consideration, the three of us picked him up and carried him back to bed. My mind was still very much in Ebola mode—here was a guy who was covered in billions if not trillions of copies of the virus, now only a few millimeters from my skin—but I was also aware that suddenly Aaron had magically transformed into something with which I was much more accustomed, namely, a patient for whom I could give something known as care.

  But how to care for a patient with Ebola beyond just standing there in PPE and cleaning him up? As if to answer this question that I hadn’t actually asked aloud, Pranav walked to the next room, which had served as the ward’s medical supply closet, and started looking around for something. I asked him what he was looking for, and he said, “Valium.” That simple, matter-of-fact reply almost made the ground shake under me, for the drug Valium is commonly still used in the United States and Europe for delirious patients. We didn’t have much to offer, but we did have something specific for a specific problem. In short, we had medicine.

  I was even more flummoxed when Pranav thought of a solution to the problem posed by the Valium itself, which was how to get it into Aaron. Because he was delirious, we couldn’t give him the pill to swallow, since he’d most likely either let it just sit in his mouth or possibly choke on it. We couldn’t give intravenous Valium because Aaron had no IV catheter. So he took the Valium pill, crushed it, poured the contents into a water bottle, and then took one of the IV bags and cut the tubing used to infuse the fluid into the veins, fashioning a crude straw out of it. Aaron would be offered a little Valium juice. I was simply amazed at Pranav’s ingenuity. And because of it, the shock was starting to wear off, and I was beginning to think like a doctor again.

  Not that it made much of a difference to Aaron, who was unable to sit up and sip from Pranav’s ad hoc straw. As I looked at him, I thought that he would not survive the night.

  *

  An ETU is, at its barest, nothing more than a hospital: If you looked past the hasty construction, it would fit the image that most people around the world conjure up when they hear that word. There are patients who lie in beds, and there are doctors and nurses who come to round on them. There are medicines dispensed from a pharmacy, which are given for various conditions. There’s a laboratory for testing, although in our case the laboratory was off site (at first, very far off site, then blessedly closer). There is charting and paperwork—the bane of any medical staff, and no different here. And finally there is a morgue. The structure of the facility is similar in all the essentials. As I took my first walk rounds that day, I had the dawning realization that, despite the fact that this was where Ebola was being treated, it was an environment with which I was intimately familiar, and its structure and rhythms would provide a great deal of comfort in the weeks to come.

  Although an ETU is a hospital, it is unlike any other kind of hospital. Normally, people conceive of hospitals as places where they go for care. This is no less true in an ETU, but Ebola changes the playing field between patient and provider, so that the rules governing the relationship between the two become inverted. For instance, the first rule of an ETU is, quite simply, protect the staff. Although patients are there to be treated, they themselves constitute a threat to others because of their contagiousness, so every detail of the ETU is designed to minimize their ability to infect anyone who has come to care for them. In every Ebola outbreak since its initial discovery in 1976, one of the most important features has been the infection rate among health-care workers: Sick patients, naturally, come to clinics or hospitals, and without adequate protections from the virus, the staff become infected and are oft
en among the hardest-hit groups. This was no less true in the West African outbreak, as hundreds of doctors, nurses, and other health-care staff became infected and died.

  Thus, staff safety reigned supreme in an ETU. While patient care was obviously central to this hospital, it was not the highest priority, so that if the two were in conflict, safety would trump it. What does that actually mean? Picture the following: An Ebola patient has a seizure. A seizure is typically a grade A emergency in health care: Every available member of a medical team would come running as fast as possible to administer whatever care was needed. But if a patient with Ebola seized, you would not come running. Instead, you would get into PPE as slowly and methodically as you did any other time. That could mean that the patient would have an uninterrupted seizure lasting as long as ten to twenty minutes, which given the other ravages of Ebola could easily lead to death. But no staff member ever enters the high-risk area without adequate protection; there are simply no medical emergencies in an ETU.

  Moreover, an ETU is designed as much to treat the surrounding community as it is to treat the patients. That is, patients are just that—people harboring an infection—but due to the nature of the disease, infected people pose considerable risk to everyone around them. They are, from the standpoint of outbreak epidemiology, storehouses of virus that can keep the epidemic spreading. Thus, the ETU is designed to get as many copies of virus out of circulation as possible. It exists as much for the people who will never see the inside of its walls as it does for those who become its temporary residents.