Inferno

by Steven Hatch, M. D.

  Then, and only then, do patient concerns come to the fore.

  There was an extensive network of pipes beneath the gravel surface, all of them leading to clusters of three sets of spigots throughout the compound. These provided direct protection against Ebola and were constantly in use. The first spigot was white, which indicated well water; the second, colored green, was a bleach solution of 0.05 percent chlorine. The green tap was meant for contact with humans: The 0.05 percent solution could deactivate the virus on contact, but the solution was light enough that it wasn’t especially harmful to the skin, eyes, or mouth.

  Finally, there was a red spigot, containing a 0.5 percent bleach solution. The red tap was the industrial-strength deactivator of the virus. Anytime workers were hauling commode buckets filled with fluids containing jillions of Ebola particles or carrying corpses, they would rinse their gloves and some parts of their PPE like their aprons with the 0.5 percent solution. Indeed, once inside the high-risk area, any activity in PPE, even as simple as seeing a patient, was followed by washing with the red tap. The decontamination procedure was done by spraying the 0.5 solution onto providers as they took off their PPE. But this solution was far too corrosive to be used directly on skin; once, one of the members of the national staff had washed part of his face with the red tap, not understanding its strength, and shortly thereafter his left eye had swollen shut.

  Hand washing became an obsession in the ETU. Ebola’s main point of entry to the body is through mucous membranes, mainly the eyes and mouth. Because people incessantly and instinctively touch their faces throughout the day, keeping one’s hands as sterile as possible represented one of the best chances to prevent an infection among the staff. If you had some body fluid containing Ebola splashed onto the skin of your arm, you wouldn’t necessarily become infected—not, mind you, that I would recommend testing this—but if you touched that fluid with your hands and then moved your hands to your face as humans habitually do, this is the most likely way you would allow the virus to enter your body. So the green 0.05 percent tap, in particular, found itself in frequent use at its various locations. It almost didn’t make sense not to splash your hands if you were walking past it.

  *

  I came in the next morning to learn that Aaron Singbeh had died. He wandered the halls of the suspect ward that night in a delirium. On evening rounds, he was found in the bed of another patient, Josephine, the two spooning peacefully. She, however, was already dead, though Aaron was blissfully unaware of this as he cuddled with her. He was escorted back to his room by one of the staff. It was as if he wished to accompany her to the other side in a gesture that was simultaneously touching and horrifying. Soon, he would get his wish, as he passed on in the middle of the night.

  Both Aaron and Josephine, and many others besides, had actually been in the suspect ward for several days. When I arrived, the Bong County ETU had been open for about two weeks, and during that time, only one laboratory in the entire country was devoted to Ebola testing. Located in Monrovia, the lab was operating well beyond its capacity in late September, with hundreds of samples per week pouring in from all parts of the country. It took nearly a day to send the vials of blood from Bong to Monrovia, and because of the backlog it could take three to four more days to receive the test results. That meant that the turnaround time on a suspect case—that is, to actually know whether a person did or did not have Ebola—was roughly five days. And that was under optimal circumstances. As a result of being inundated, tubes could occasionally be misplaced by the lab, or the lab could not properly identify the sample because the chlorine spray used to sterilize the outside of the tube also happened to be effective at washing away the ink used for its identification. During those first few weeks of operation, when the Bong County ETU relied on the Monrovia lab, it was not unusual for patients to linger in the suspect ward for a week or more.

  This delay proved itself to be particularly alarming once it became clear how many patients in the suspect ward did not have Ebola. It would take a few weeks before the pattern became discernible, but about half of the patients were uninfected. No Ebola. This would be borne out by the data from other ETUs run by different organizations. For every patient who came in with the disease, there was another who had some other problem.

  There were at least two major implications of this large number of uninfected patients being brought in for suspected Ebola infection. The first was that there were many other medical problems that might appear at first blush to be Ebola but in fact were different medical conditions. The ETU had one and only one test: an Ebola “PCR,” a test that relies on late-twentieth-century science but has found everyday widespread use since. PCR relies on amplifying specific sequences of nucleic acid, the molecular “letters” that form the design instructions of all living organisms. Ebola PCR merely amplifies nucleic acid sequences specific for the virus. If you weren’t infected, the molecular “primer” (or search string) would not bind to anything, and no signal could be amplified; if you were infected, the primer would bind to the Ebola’s nucleic acid, a signal would be amplified and detected, and the number of virus particles in the blood could even be quantified.

  Beyond knowing whether someone did or didn’t have Ebola replicating in their blood, nothing could be known with anything resembling certainty, and so other diagnoses were mostly based on educated guesswork. In terms of diagnostics, the ETU practiced twenty-first-century medicine for Ebola and nineteenth-century medicine for everything else. At the time I arrived in Liberia, there was no functioning health-care system besides ETUs. Essentially all the hospitals and clinics were closed. So these people in some sense represented all of the other conditions that were being ignored in the midst of the Ebola crisis. It wasn’t merely killing the people it infected; it was killing people who were dying of everything else that could be treated, since there was nowhere to turn.

  The second, more unsettling implication in terms of our job, was that the uninfected half in the suspect ward was in perilously close proximity to those who did have Ebola, possibly placing them at greater risk of catching the virus than they were in their own communities. The lag time in the test results only added to the risk; the longer the delay, the longer the Ebola-negative patients in the suspect ward had opportunities to become infected. That also meant that, if such delays were to continue, ETUs across the country had the potential to spread the infection rather than halt it.

  The screening strategy represented the double-edged sword of Ebola epidemic management. If half the patients who came through the suspect ward were uninfected, it meant that the net was being cast wide in an attempt to catch every case and take as many Ebola patients as possible out of circulation. In other words, there was a low threshold to be considered at risk for Ebola. That was good for the community, for the risk of having an infected patient outside the ETU was deemed greater than the risk of having an uninfected person sleep a night or more in a Hot Zone.

  But would you want to sleep in there for a night without any protections if you didn’t have Ebola?

  And how many nights must uninfected patients remain in such a place before it becomes difficult to justify? This was the unpleasant question facing the staff of the Bong County ETU in late September and early October. For it became fairly clear to us after a patient had been admitted to the suspect ward for three or four days whether they had Ebola. A patient whose illness did not progress or, indeed, improve over that time might assume they were uninfected and could minimize their interactions with other patients. But what to do when one encounters Aaron, sprawled across the corridor, his fluids flowing across the floor, teeming with virus? What to do when Aaron, in his delirium, waltzes directly into one’s room?

  Fortunately, we did not have to dwell on such troubling matters for long, for a solution was coming, one that would take that five-day turnaround and turn it into a five-hour turnaround.

  The solution came in the form of about four or five guys who set up some supplies in
an unused part of Cuttington University. They all worked for a gentleman named Barack Obama. They were with the U.S. Navy.

  *

  During my first few days working in high risk, I gradually made the transition from thinking my patients had Ebola to realizing that I was a doctor treating patients who happened to have a viral illness. It was certainly a deadly viral illness, and one that required me to care for them while looking like a space alien, but I understood that what I was doing was more or less what I do back in the States. These were people, like the rest of us, with family and hopes and dreams and all the rest, who through some bad luck were infected with an exotic virus never before seen in this part of the world. Treating them as such, I would realize, became an important part of Ebola care: You ignore the Ebola aspect as much as possible, although not to the point where you risk your own infection.

  Learning to care for these people was like going back to medical school again. The first patients I encountered were quite ill, whether in the suspect or the confirmed ward, and beyond checking their temperatures and looking at their medication records, I wasn’t sure what to do—precisely the feeling that marked some of the more humiliating moments of my early training. I did have a checklist of symptoms to review with them, but it was written in a small font, and my glasses were fogged with sweat, and the goggles over the glasses were misty, so that reading became an exercise in squinting out what material I could.

  Only gradually did I realize that I didn’t need the checklist because I could talk to the patients. It sounds so silly now to write this. But it wasn’t immediately obvious to me in those first few days: I could listen to them explain the recent history of how they became ill and ask questions of them to get a detailed story. It is what all doctors everywhere are trained to do. Just because they did (or might) have Ebola didn’t mean that I had to change the rules about how I interacted with the patients. So as that first week wore on, I settled into a routine that I understood.

  I also needed to learn to do physical exams again. Examining patients in full PPE is an exercise in realizing one’s limitations and trying to glean as much information as possible from what little data can penetrate the goggles, hood, mask, and gloves. First, that ubiquitous tool of modern medicine, the stethoscope, can’t be used, for there was no placing anything from the high-risk world into ear canals where a hood might tear. Any details about the physical exam that a stethoscope helps elucidate could not be easily known to us, which meant that all our clinical work could not be communicated to our colleagues, at least some of whom would be picking up our work in the months to come, and yet others still who would treat patients in the future outbreaks that were sure to arise.2 So our ability to take our wisdom as clinicians—and our training was the product of hundreds of years of accumulated experience of the physicians that came before us—and add to it on this disease was limited in the extreme. It was like being an anthropologist at the astonishing discovery of a first-contact society, only to discover that you have no recording technology, and that you have suddenly gone deaf.

  Mostly, what I would do was look at patients—although I could often see as well as a driver trying to negotiate a country road in the middle of a thunderstorm without windshield wipers—and feel them, or what is known in the business as “palpation.” It was not much.

  Why was it important in the first place to perform any physical exam? Wasn’t this just Ebola anyway, and who cares about doing an exam? The answer relates in part to Ebola’s history. All previous outbreaks were relatively short affairs, and so what was known about the disease was still largely hastily gathered impressions, since the principal goal of the prior outbreaks was simply to stop them. But the West African outbreak was different; as much as containing and eliminating the epidemic was still of paramount importance, the sheer number of cases, and the size of the medical staff tasked with caring for patients, allowed for a more thorough study of the disease.

  To a layperson’s ears, that may sound heartless, with clinicians coldly appraising the precise manner of a victim’s physical decay. But having the ability to recognize a possible Ebola patient before a test, to seek telltale signs that would prompt suspicion by a doctor or nurse in some rural clinic five years from now, when the West African outbreak is only a memory, could be the difference between a mini-outbreak and another epidemic that slays tens of thousands of people. Or, given the speed by which humans can travel around the globe, worse.

  Moreover, doing a reasonably decent physical exam was critically important for those 50 percent of patients in the suspect ward who would turn out not to have Ebola, because it raised the question of what they did have. Any information, even a crude physical exam, when coupled with some clinical reasoning, could lead to a potentially lifesaving diagnosis.

  At the very least, having a working idea of what was wrong with these patients gave us some peace of mind. On my second day, Pranav introduced me to a man in his mid-forties named Ballah who had come in coughing up blood. He was emaciated, probably not much more than a hundred pounds, and hadn’t had a fever—which suggested he didn’t have Ebola—and Pranav figured it was tuberculosis. But when you cough up blood in the middle of an Ebola outbreak, nobody’s taking any chances, so when his family carried him to the local hospital, they referred him to the ETU, and he lingered in the suspect ward waiting for a test.

  Pranav was sure that this was tuberculosis for more than one reason. First, if we weren’t in the middle of an Ebola outbreak, TB was far and away the most likely diagnosis, as the disease is still widespread in this part of the world. Second, he had been having symptoms for a week or two; if it was Ebola, he would in all likelihood have died days ago. But how to clinch the diagnosis? We had only our Ebola PCR test to perform, which told us that he either had it or he didn’t. And since he probably didn’t have it, while we waited, any other diagnosis would have to be made by looking, touching, and making a best guess.

  I thought about this for a moment. Not only is TB widespread in the region, but so is HIV, and TB and advanced HIV could easily go together. As an infectious disease doctor, I saw patients with stories like this even in the States. If he had HIV, the diagnosis of TB in this man was quite probably correct (though not necessarily the other way around). But without an HIV test, how to diagnose HIV?

  “Sir?” I said to Ballah, who looked up at me with tired eyes. He could barely lift his head. “Would you mind opening your mouth?” The question was at first unintelligible to him, partly because of how the thick mask of PPE muffles the voice, partly because Liberian English and American English aren’t exactly the best of friends. But after a few seconds of charade-like gestures that had the appearance of clowns at a circus, followed by a slow repetition of the question, Ballah got the idea, and opened his mouth.

  The inside was coated with a white plaque instead of the normal dark pink that one would expect to see. This was a fungus called Candida that forms part of the normal microbiological ecology of our mouth but runs rampant when the immune system fails and can no longer limit its growth, resulting in the condition known as thrush. That was as good a diagnosis of HIV as one could get in this environment. That also meant that Pranav’s diagnosis of tuberculosis was highly likely to be correct. Chalk one up for the ID doc in his first week, I thought as I made my way among these battle-tested emergency physicians.

  I didn’t just have to relearn how to practice medicine during that first week; I had to learn how to move around in PPE. The limitations imposed by the suit and the apron and the rest of the outfit were considerable. Much of what constituted my vision was limited by mist and the sweat that dripped onto my glasses and goggles. Reading a chart, even if it involved only recording and surveying a patient’s temperatures, became an exercise in interpreting hieroglyphics. Because the blue tarp that formed the walls of the ward kept out light very well, the interiors of the wards were dark places, which made reading the charts that much more difficult. To make sure that I knew what I was seeing, I
often had to move my head to adjust it to the light to get the correct angle on the paper. To an observer, it must have looked like I was a museum curator holding up some ancient artifact, considering it from all angles. I often felt like I was in one of those diving suits from the early twentieth century, completely sealed except for that one shield of glass in front, surrounded on all sides by water. Except in my case, the water wasn’t part of the external environment, it was, until quite recently, a part of me.

  Moreover, the peripheral vision in PPE was nonexistent. Anytime I heard a noise or wanted to grab some item sitting next to me like a medication or a chart, I had to turn to look at it directly. Negotiating narrow spaces had to be carefully thought out lest I scrape up against the wooden frame that had a nail or piece of wood sticking out that could tear my suit. That wasn’t a theoretical concern: Steve Whiteley discovered one such nail sticking out of the construction in the suspect ward during the first week.

  Plus, my hands were sealed in three layers of gloves, and although the layers were thin, it caused enough loss of dexterity that I had to move slowly through any tasks requiring fine motor skills. Among the most important of those, I would soon learn, was hooking up IV lines. I ran more IVs in my time in Bong County than in my entire career combined, and during the first few days it was a matter of getting the muscle memory for the motions. But I also had to keep at bay the extra folds of latex from the outer layer of gloves, as they seemed to be insistent upon trying to tear themselves up when, for example, I would seal an IV cap, only to find a small piece of that third pair of gloves stuck up inside the cap. It was like getting a run in your stockings, but with slightly higher stakes, especially since the IV lines always involved getting blood on your gloves. When that would happen, no matter how much I got used to working in the Hot Zone, bright red blood on my hands always guaranteed a fresh flash of Ebola through my head, producing a small jolt of adrenaline, as if my pituitary gland was sending a chemical memo to remind me where I was.