Inferno

by Steven Hatch, M. D.

  The drop-offs at Cuttington took about ten minutes, and we headed to our individual flats sprinkled along a half-mile circular road around the periphery of the campus, each a few hundred yards away from the other. The housing was available because the faculty, in whose living quarters we stayed, had fled. I always wondered where they went. After the drivers dropped us off, we tended to go our separate ways. For the first three weeks, I lived alone, but I shared a building with Colin and Steve Whiteley. Steve worked the night shift, so he was always going when we were coming and vice versa, and we tended to see him only at the change of shift, with few opportunities for us to socialize. But after I dropped my stuff off I would often walk to Colin’s place and rap with him about the day’s events.

  My mainstay in the evening, however, was to sit at my dining room table and spend an hour or so on the Internet. As remote and isolated as I was in the Liberian countryside, in some ways, it was as if I hadn’t left. I never lacked for correspondents; even the tedious official e-mails from the medical center back in Massachusetts announcing some new high-level hire or that the main visitor parking on Level 6 would be temporarily closed for repairs, became a source of small comfort. I got an e-mail from a colleague at UMass, who asked me whether I thought it okay for a patient to receive a particular drug used in parasitic infections, and when I replied that it sounded reasonable, she asked me if I would mind seeing her in the next week or two. “I’m a little busy as I’m out of the country, but I can forward this along to someone else in the division if you want,” I replied.

  I’d spend some solitary time with contacts back home, idly munching on some Pringles, touching base with friends and colleagues, reviewing the happenings in Massachusetts and beyond, trying to keep my finger on the pulse of regular life that seemed increasingly distant while I was engaged in what I couldn’t stop myself from feeling was a one-way ticket.

  The single best e-mail I received was from a senior medicine resident named Sunkaru Touray. It came several weeks into my tour, when the excitement of the initial experience had faded and the exhaustion of the work had started to set in—just the time when a pick-me-up would hit the mark. Like my boss Doug, Sunkaru thought I was in the midst of a psychotic break when I told him I was going to go to Liberia. Doug, however, didn’t really take me seriously until I was already on a plane, so our conversations tended to have a dismissive tone to them. By contrast, Sunkaru knew me well enough to know I wasn’t kidding when I told him of my plans, and before I left he spoke with me at one point and I could see genuine fear on his face. But I had left, and now there I was, checking my e-mail weeks later. He apparently still felt the need to express some form of concern to me, even if affectionately, even though the die had been cast.

  “Doctor Hatch,” he wrote. “How’s the suicide mission going?”

  For the most part, I slept like a baby during my time in the ETU. I needed stamina and focus to work inside the high-risk area, so I made a point of going to bed no later than eleven in anticipation of a six o’clock wake-up. There was no air-conditioning, but because we weren’t fully into the searing temperatures of the dry season, the room was comfortable, and a decrepit but functional fan did the rest. During the first two weeks I had a recurring dream of waking up in the confirmed ward wearing a pair of jeans and a shirt, but without any PPE, standing there in my bare feet. It wasn’t a long dream, and it wasn’t a nightmare. I would wake up from it, jolted, but not in a soaking sweat feeling my heart pounding. It felt more like an electrifying curiosity than anything else, a little like how the astronaut Dave appeared at the end of his journey in 2001: A Space Odyssey. With his space suit, however, Dave would have been adequately prepared if he found himself on the hall of the confirmed ward, so the simile ends there.

  I could afford to be amused about the time that I received that e-mail, because we were seeing survival. Our ETU’s mortality rate, which started out at about 70 percent, looked like it was slowly trending down to about 50 percent. Sean mentioned in one of the meetings that this wasn’t isolated to just Bong County, since other ETUs across Liberia as well as Sierra Leone and Guinea were reporting similar numbers. Nobody had any clear explanations for why this was happening. One of the survivors was Siatta.

  But even as those numbers seemed genuinely encouraging, the more we worked in Liberia, the more it became clear that Ebola’s toll could not simply be measured by the numbers it killed directly. The tree in Meliandou had died from Ebola though trees aren’t infected by it; the boy shot by Liberian soldiers as part of the West Point riots in September had died from Ebola without having it; the dignitaries who traveled to Womey had died from Ebola even though they were trying to help eradicate it. All these indirect casualties meant that Ebola’s impact was much worse than what was even being reported, and those numbers were unprecedented.

  One of the most important ways in which Ebola killed indiscriminately was by the simple fact that it had completely shut down the health-care system. ETUs were open for business, and that was about it. Local doctors and nurses did not want to risk their lives caring for patients, and so clinics and hospitals throughout the region shuttered their doors. Even those that stayed open were often avoided. JFK, for instance, never officially closed, but its census remained low. If medical professionals could not know who had Ebola, they would be risking their lives each time they evaluated someone, since adequate safety measures were only in place where people had been properly trained. So even matters like routine trauma could be deadly if they could not be evaluated or treated.

  One of the groups most affected by this shutdown was young women, especially if they were pregnant. Vaginal bleeding during pregnancy is a very common problem, and sometimes it indicates a life-threatening condition that requires immediate medical assistance. But bleeding from anywhere at all in an Ebola outbreak all but guarantees that a patient will not be evaluated. So what happens to these patients? They get referred to the ETU, which can do nothing for them except prove that they don’t have Ebola.

  One such woman came to us around this time, in obvious pain, lying in the suspect ward. A doctor named Rene Vega came up to me while we were rounding to tell me something shocking: He thought the woman had an ectopic pregnancy—a condition in which the fetus develops not in the uterus but farther up in the fallopian tubes. Rene was part of an early class of physicians bound for other ETUs whom we had begun to train on-site to help bypass the bottleneck created by the fact that there were only two other places in the world where organized training was taking place: the MSF course in Belgium and the CDC’s Camp Ebola in Alabama. Sean Casey had taken to calling our site in Bong County “Ebola University,” which, given the comparison to Camp Ebola in Alabama, seemed reasonable, since although the course would be the same in the essentials, our location was in the middle of an actual outbreak. Rene worked for a group called Heart to Heart, and their ETU would be going up in neighboring Nimba County.

  Ectopic pregnancies can rupture, and if emergency surgery is not performed, the patient usually dies. Rene’s history and examination, despite the limitations of PPE, suggested that at the very least an ultrasound was in order. We had no ultrasound, and even if we did, what would we do with that information? We decided to give our colleagues at Phebe Hospital down the road a call. Phebe was a typical example of why any doctor or nurse not working in an ETU was wise to close up shop for the outbreak. Their first staff member, a nurse there, had fallen ill in June. By the end of September, six of seven full-time nurses were dead, and the sole survivor, a woman named Comfort Harris, was just coming out of IMC’s ETU as the first person to be discharged from our facility. The staff at Phebe were terrified, and they declined to evaluate virtually everyone, with good reason.

  But once this woman’s test returned as negative, our reasons to have them evaluate her were actually better. It took some complex negotiations that would have made the U.S.-Iran nuclear deal look easy, but with repeated reassurance, along with a second negative test, we
eventually managed to convince the docs at Phebe to take a look at her, providing many outfits of PPE to help them in their efforts. The night after that second test came back, the surgeon and anesthesiologist reluctantly agreed to take her to the OR to remove the ectopic pregnancy that Phebe’s ultrasound machine proved was there. I am fairly proud of my work in the ETU, but Rene Vega managed to do something incredibly rare during the outbreak: He actually saved someone’s life.

  But she was the exception who happened to be lucky enough to have a savior like Rene Vega cross her path. Ectopic pregnancies aren’t the only potentially deadly routine complication associated with obstetrics, and there must have been hundreds of women who had these kinds of problems in the middle of the outbreak, with nowhere to turn. Their lives, some unknown number of which almost certainly ended as a consequence of not having proper medical attention, will never be reported when the final numbers are chiseled.

  *

  Also around that time, we were training a new physician named Kwan Kew Lai, who had joined the IMC group as we prepared for our departures—the first of whom would be Colin, then Steve a week later, and me the week after that. Kwan Kew had done previous stints with MSF in Africa and expressed interest in working in one of their ETUs, but as with other qualified MSF alumni, she had no luck, and so IMC was only too happy to pick her up. She came to Cuttington and began her hot training just as I had done with Pranav.

  During one of her first mornings, the suspect ward was busy, so we didn’t head for the confirmed ward until two hours after we had entered. I could typically feel my body start to get stressed somewhere after one hour, and I got progressively more taxed every ten minutes or so. The longest amount of time I had stayed in during the daytime was three hours, and I was so dehydrated by the end of that spin that it took me more than an hour to recover. So I knew that we would need to move through the confirmed ward with efficiency, and efficiency has never been one of my strong suits.

  Kwan Kew followed along as we entered the confirmed ward. In the first room on the left were three children: a brother-sister pair aged thirteen and eight, and their cousin Tolbert, who was nine. Tolbert’s status had been tenuous since coming to this side a few days before. Neither the diarrhea nor the fever ever stopped, and in the past twenty-four hours he had to be placed in diapers and bathed twice each shift as he could no longer care for himself. The nursing crew had already rounded about a half hour earlier, but when I touched base with them they said nobody had died, although about three or four looked tenuous, and Tolbert was among them.

  When I entered he wasn’t moving. I started with a gentle nudge and said his name. Nothing. Then I moved to the head of his bed and placed my hand on his chest and slightly rocked it, this time cooing his name, “Tolllbert…” Again, nothing. For one instant, I thought of the cousins: Rebecca, who looked no bigger than a typical five-year-old in the States, had been lying on the floor sleeping when we entered, but she quickly moved onto the bed with her brother and clung to him.

  It occurred to me that Tolbert was very likely dead and that the children might be better served by being escorted out while we made soothing noises about taking care of him or some such. I write that now in retrospect and it seems obvious. At the time, though, that thought was only one of many flashing through my mind, and my main focus was on the question of Tolbert’s status. Had he died? The lightbulb had gone out, which was a not infrequent problem that plagued us, so in the darkness of the room small movement could be missed. If he had died, he had just died, since he had been responsive when the nursing staff saw him the hour before. I thought about the rumor we had heard about the woman who had nearly been buried alive; now only days later I faced a situation where I could commit the same error. So whatever thoughts I had about Tolbert’s cousins were quickly chased from my mind as I focused on him.

  First I looked into his eyes, but in the dim light and without a flashlight, there was no way to assess whether his pupils would contract when exposed to a beam of light, which is one of the principal ways medical personnel assess death. I then felt for his pulse on the carotid artery in his neck. A robust pulse hit my fingers, with a bang! on my skin that felt so strong I almost jumped. The rate was somewhere around one hundred. I took my hand off his neck and looked again at the child, who lay perfectly still. How could someone with such a strong pulse look like this? Then, standing there and touching nothing at all, I noticed something in my fingers of which I hadn’t been aware until then: a rhythmic throbbing at the tips. That pulse I felt was almost certainly mine as my heart reacted to the stress of two hours in PPE. I repeated the carotid check a few more times, moving my fingers here and there, growing more frustrated by being unable to distinguish my pulse from what might be his. I felt nothing, but I thought of that woman in Monrovia. Maybe my fingers were incapable of detecting a pulse that distant. I needed to find another way to confirm his status.

  I grabbed the bottle of the rehydration solution at his bedside and shook a little onto his face. Still no movement. It was just then that Kwan Kew, who had been silent throughout much of the rounds, chose to speak. “Don’t you think we should escort these kids out of the room?” she asked reasonably. “I don’t think they need to see this.”

  Reasonable though the question was, I was not in a state of perfect reason at that point, as my frustration at being unable to assess death—normally not a challenging task even for the stupidest clinician—had left me irritated and testy. “Look, these kids are already gonna have a lifetime of nightmares from their time here,” I snapped in reply. “What the hell does one more moment like this really mean? I need to figure out what’s going on here!”

  I am far from the perfect clinician, although I generally believe that one of my stronger suits is a sensitivity to delicate situations and a knack for using words to heal rather than to hurt. So it shouldn’t come as a total surprise when I say that, in a clinical career that has lasted just under two decades, this is about the most awful thing I’ve ever said to a patient or their family. Kwan Kew ignored my response and silently took Rebecca and her brother by the hand and led them to another room, which was all the more impressive given that she had never been in the confirmed ward before. Meanwhile, I stood there fuming at my ineptitude, though after a variety of maneuvers over the next several minutes I believed I did establish his passing. But it was not a great start with my new colleague, to say nothing of the fact that I probably added to the trauma of two children with my casual dismissal of their fear. The only upside was that they probably didn’t understand my American accent and weren’t fully aware of what was being said. That’s what I tell myself now to find some sort of comfort, anyway.

  Other failures of mine were equally painful. One of the most difficult moments of each day came in the late afternoon when the Navy lab called in the results. Almost invariably the list was a mix of positives and negatives, and the reactions of the patients in the suspect ward understandably ran the gamut. One day, however, nearly everyone was positive, eight patients in all. Organizing that large a group and moving them over to the confirmed ward was going to require some coordination.

  With a smaller group, we would take the patients and their personal effects in one single move as they relocated across the compound. Because new arrivals to the suspect ward would arrive in a few hours and would come to occupy their rooms, we had to make sure no cross-contamination occurred. Everything the newly confirmed patients had touched on the suspect ward was either incinerated, doused in the high-grade bleach solution, or taken with them to the confirmed side. Obviously, we preferred to have as much material move with them, so all their belongings—cell phones, soap, thermometers, toothbrushes and toothpaste, their linens, the medical chart—got placed in their commode bucket after a rinsing and accompanied them across the divide.

  But these people were of course often quite ill. Many were weak, and some suffered the wet symptoms whose severity would likely determine whether they lived or died, so askin
g them to carry a bucket weighing upwards of twenty pounds was asking a lot. Indeed, asking some of them simply to walk the twenty meters from one building to the other, carrying nothing at all, was risky. And nobody wanted to be picking up someone from the ground outside, where the rocks and the wooden posts created opportunities for tears in the PPE, to say nothing of hurting one’s back seriously. So some patients had to be escorted by leaning on the staff. The lighter patients, typically the children, we could carry.

  Yet the ETU rules of movement always dictated that once on the confirmed side, the staff could not return to the suspect ward to retrieve anything. You always moved toward a hotter zone, never backtracking. Most of the time, if we were moving three or four people, we could have one person assist a patient, while another would carry two or three buckets, and the remaining one or two patients could fend for themselves. But eight patients strained our capacities. As I organized the team that afternoon, we had to draw up the game plan on paper to figure out who was assigned to whom, like a football coach drawing up a Hail Mary, down by four with seconds to go in the game.

  As technically challenging as the move could be, we also had to help our patients cope with the psychological distress of that brief walk. It seemed so odd to me: Physiologically, there was nothing different about the infected patients once we gave them the news that most of them already suspected was the case. Whether they were on the suspect side or the confirmed side, they still had virus inside their bodies, replicating at a furious pace and setting in motion changes in their immune systems that would determine their clinical course. There was nothing particularly magical about being on the confirmed side. The suspect patients could see those on the confirmed side during the day, lazing about at plastic round tables in their lawn chairs, listening to Radio Gbarnga, which was most often reporting on the events of the outbreak. Many of those on the confirmed side looked perfectly healthy, as indeed they were, having won their battles with Ebola as they waited for their viral loads to become undetectable. They could chat with these healing patients at the orange-plastic-fenced boundary between the two and take real courage in the evidence that people survived.