Liberia Week #4

November 26, 2014

Sorry the communication is so bad.  I can be in the middle of an email and internet disappears.  George R. [fellow team member] is doing fine, up and about with all symptoms resolved so just a matter of getting a second negative ebola  at 72 hrs from onset - tomorrow.  I'm guessing he will go right back to Bong and back to work.  

Yesterday was very busy with eight new admissions, all at 4:00 pm but they all seem to have an enterovirus, not an Ebola, virus.  Today, all of their nausea, vomiting, diarrhea, and fever seemed to have resolved.  They have eaten breakfast and since symptoms for all but one are over three days old,

if they are test negative, they will go home.  The 14 y/o boy who is an Ebola survivor unfortunately looks like an encephalitis or meningitis.  He is negative for malaria so we are covering for bacterial meningitis but doubt he will make it through the day.  The controversy is over whether to transfer to the local hospital where he will not receive any better care or should we keep him despite the fact he is ebola negative.  

The word on Tapita is for opening the 5th but that is "soft" according to Rene, and he said he wouldn't know until he goes up next week.  So it looks like we are at Kakata for at least another week. Everything here  is very comfortable except for two bitchy staff women who are getting on my nerves.  It seems like the less you know about something the more vehement your opinion.  You know how I am sort of a consensus guy and bossy or condescending people rub me the wrong way.  They remind me of the Colonials of times past, talking down to the Nationals.  Oh well, that may be the leadership necessary to make this place run.

Later,

Not much during the rest of the day.  The 14 y/o with encephalitis / meningitis died.  He tested neg for active Ebola which everyone expected since he is a survivor,  but then the question: is the encephalitis active virus or post viral inflammatory?  I convinced them to start him on Decadron, but I think it was too little too late.  We had four admissions but three don't appear sick and the sick pt has been ill for a month and is confused with anemia, a very large spleen and liver, and appears wasted.  Until Ebola came along, we would have admitted her as probable AIDS , which is what I think she has.  No test for it here so if she is neg. I will refer to the local hospital.  The poor people of Africa never can get away from suffering.

November 28, 2014

Well, my Thanksgiving day meal - a drumstick, two dry slices of bread with white cheese in between, and cold french fries.  bon apetite (sic)!  It actually was not bad.

Not too busy a day, admitted a mother with a 1 y/o and a 3 y/o whose husband died 10 days ago of a fever - no diagnosis  of cause of death.  This qualifies as an Ebola contact and, with a fever, warrants an admission.  All three have had cough, runny noses, and diarrhea, so could be a cold or ebola.  Also, there is a 14 y/o girl who has been oozing blood from between two front teeth and and has fever.  Unexplained bleeding qualifies her as a rule out ebola, though on exam of the two teeth shows loose teeth,  and where we drew her blood, she did not bleed at all.  So clotting functions seem OK, question a dental cyst, tumor (though no palpable mass), draining abscess, etc. Probably needs dental exam and xrays more than an ETU.  Last gentleman is a 34 y/o with a very firm bladder, and he is a rice farmer so in swampy water.  Probably schistosomiases, not ebola.  So far, a lot of fascinating pathology - but no ebola!  That is good though because more and more suspects are getting screened instead of staying home.  All it takes is one case to stay home and die, and then you will have ten new cases.

I have really enjoyed working with Dr. Freeman, the Liberian doctor.  His father is an internist who went to Kenya for a Masters in epidemiology and has worked  in epidemic management for WHO until he retired.  Freeman went to medical school in Monrovia for five years, then a one year rotating internship and then was hired to work at the hospital at Bong Mine Camp, about 20 min. north of here.  He has been out of training for one year and was very busy doing mostly surgery until ebola hi,t and they basically shut down the hospital.  The mine is one of two iron mines in Liberia, initially built by the Germans who ran the mine and hospital until recently when it was taken over by the Chinese.  He started working with German doctors but now Chinese, but they all left the country when ebola hit.  Freeman has offered to take us up to Bong Mine Camp this weekend to see the hospital, iron mine, and then over to the private hospital on the Firestone estate for Firestone employees only and run by mostly expats - apparently very nice in a country club setting! I think we will go tomorrow since there is a meeting in Bong for the IMC staff on Sunday and they need us here to cover.

Great to get to talk to everyone - and actually only 15 cent minutes so we have another $20 on the phone.  I will suggest we all call home again next week.

November 29, 2014

Not a lot of new news.  George was test Neg. so is going to the guesthouse over the weekend and then back to Bong Monday.  We were to go to Bong Mine Camp Sunday with Freeman but there is a staff meeting in Bong Sunday say Pranav asked that we be in Sunday but I can't get Freeman on the phone to change the date.  So far still no positives!  And Bong's census is dropping to eight from over forty this weekend.  They are now bringing in every minimally possible in order not have a hot case still in the villages.  So a lot of screening now of whole families with kids with runny noses and fever.  I just admitted a family of five, though Dad had just died the week before so a strong contact history.  But, they all look fine!  Also a gentleman who ate a monkey a month ago and now feels tired and weak - no fever, vomiting or diarrhea.  So on and so on.

November 30, 2014

Yesterday we only had two admissions and again I am sure non-ebola.  Both very interesting with medical issues, but nothing we will treat.  I talked to Parnav about this issue this morning and he seemed more agreeable to some minimal primary care interventions that previously we had chosen not  to do i.e. treat for worms and giardia since the most common complaint is GI.  

The highlight of our day here was getting the plywood sheets that had been installed to replace missing doors now replaced by real doors.  Also, they are putting up screens over all of the windows - just hammering them directly into the plaster outside walls!  

Every morning for the past week at around 5:00 am, dark clouds with lots of thunder and lightening move over us from the east and then there is pouring rain for about 30 min and then clear for the rest of the day.  Very spectacular light show when it passes over but then very humid for the rest of the day.  True jungle rain forest.  I also  seem to get my best email from about 6:00 am to 7:00 am.

I think you saw all of the emails from George that they are going to pull us back to Monrovia on the 13th and out on the 15th.  I think we will be on Air Brussels and fly into Brussels and out early the next morning - but to where it is unsure. George says that Air Brussels partners with United into Newark, the airport that has had the worst record with ebola exposed pts.so maybe they will separately ticket us back to D.C. -- who knows

Rene goes up to Tapita today so I will call him later in the week and see what his current needs are.  There are now two new US doctors coming in later this week to train and stay on, so we will be doctor rich by next week.  I might be more productive helping Rene set up in Tapita.  If that is the case, I will see if extending two weeks is helpful, and, if not, just come on home.  I look forward to going later to Goma with Mike  to do some hands on teaching where I will  be able to provide total care to pts.  And then try and come back in the spring. However,  I really don't see that there will be any need in Liberia after the first of the year - at least based on the numbers here and at Bong.  They are down from forty confirmed to a total of five and we are yet to have a confirmed after admitting almost fifty pts.  But, we were told they might bring in a group of 10 or 11 today from a village where they had four deaths and burials last week.

A lazy Sunday, and  I don't think I will even get into PPE unless we have new pts to admit.  I will try to read and relax and maybe we will drive up to the Total gas station and buy some snack food, though I don't need any.  I have cut back to two meals a day, breakfast and dinner since they usually include about a half pound of rice with lunch and dinner and I don't need all of that.  Still pretty basic - rice with some side.  Last night, it was a hot pumpkin side to mix with the rice, and some goat,  a drumstick ( I don't know where the rest of the chicken is - we never see anything but drumstick) , or hot dogs.  I have not eaten more hotdogs in my life than here.

December 1, 2014

A little confusing here - Parnav is only going away for 3 days, to Sierra Leone to another IMC camp.  So I'm guessing Jim (the overall boss for HTH) ran into Sean (the overall boss for IMC) and mentioned that George was sitting idle and so Sean said to send him up to cover Parnav.  Now it looks we will have two Georges, Freeman, and two new doctors coming Wed. for Hot Training and then Parnav back so six doctors here.  What a mess when you have all the ramped up staff and now dwindling ebola.   I will be glad to spend time with George anyway.  And WHO has identified a village on the border where they had four deaths and burials about a week ago and now eleven people there are "sick" -- so they are going to bring them in today.  Because of rain, they will have to walk for two hours before our ambulance can pick them up.  May be the real deal.

Sean said that in his discussion with Jim that the opening date for Tapita is now 12 Dec.  It keeps getting pushed back so who knows.

Later,

At the dedication of our ETU 10 days ago, one of the speakers announced that "At first ebola was chasing us but now, we are chasing ebola."  And two days ago, the president also said "We are no longer running from ebola, we are running after ebola."  Today we are receiving a group of 10 patients who were identified by local village caseworkers last week.  The countryside is continuously being canvassed by these trained Liberians who are looking and screening anyone identified as sick within a village, and, if they fit the criteria for ebola, are calling a regional Hotline to transport the patients to ETUs for testing.  The story is that a family member went to market, returned and became sick and died; then three other family members died.  Now, the individual who prepared the bodies for burial is ill.  This, identified as possibly ebola was  related to a WHO team who was called in and drew blood on the one sick individual.  But instead of isolating or removing him, they leave to test the blood and because of heavy rains, the village requires a two-hour walk to the main road before transportation is available. The test returned positive and, besides the one sick individual, there are now nine more people who are ill.  This morning they are walking all ten of them to the road where we will meet them with ambulances and transport to our ETU.  By removing the one positive case hopefully we will prevent further spread and a potential full-scale outbreak.  As for the other nine, one or more might also have ebola or they may just be like most of our other "cases", non-ebola illnesses.  

By removing all potential cases immediately, it  helps prevent further spread if any happen to be positive.  It is better to cast the net far and wide and screen a large number of negatives if it captures the one positive before it spreads further.  It is better to return back to the village nine non-Ebola cases than to leave one positive case in the village to continue the spread.  Two real questions today - why was the one, highly probable case left in the village to continue the spread, and how many of the nine will actually now have ebola.  We shall know the latter in a day or so.  

Great example of how the system has moved to a new level of intervention.  This is very similar to how Smallpox was eradicated in the '70s except, in that case, they vaccinated everyone in the immediate vicinity.  Unfortunately no vaccine for ebola yet.

Later,

So far no patients yet today.  Our ambulance team is out of radio contact so no word as to how many patients  and when coming.  It is getting very confusing here with the sudden drop in census at Bong and low census here.  IMC is like HTH, struggling all at once to keep staff busy!  They have just sent down a Congolese doctor and a PA from Bong, and they have a new doctor arriving today to do Cold training in Bong on Tue  through Thur and then coming down here Friday and George has just arrived.  Parnav is leaving this afternoon to go to Sierra Leone and returning Friday.  So starting next week we will have six doctors.  And right now only two patients!  

George says the word is the "construction" is finished the 12th at Tapita - that doesn't mean it is ready to open.  It will be very interesting to see if they will utilize my offer to help since the only experience they have is Rene having gone through Hot training in Bong a month ago.  I can probably say that there will be almost no need for more volunteers come next spring so my two week offer will be all I have to give.  I will be like everyone else here --  we will have worked our selves out of a job.  No problem, I love spring skiing!

As for the proposed flights home, it looks like Monday the 15th we will be on Brussels Air into Brussels but several people raised red flags about continuing on with United into Newark so it appears they are looking for other options from Brussels.  The rumor is that Marge and Lucille [two fellow nurses] may even leave for home this coming week. They both kind of faded with the PPE heat and local food.

So far a slow day except it is good to have George R. here to hang out with.  

December 2, 2014

Monday was a lot of waiting for not much.  Finally got word back at 5:00 pm that the ambulances had gone and screened the nine pts. in the field and that none of them had any signs of ebola, so turned them around and sent them on a two hour hike back to their village.  In the meantime, we got four different pts., three from the local hospital, which is getting wary about potential ebola and sending for us to do screening first.  I don't blame them.  One is a 23 y/o lady with massive ascites who has already delivered seven times and has four living children - probably abdominal TB since she is really too young to have ovarian cancer.  Then a 44 y/o man with wasting, cough, fevers, sweats, etc. - probably pulmonary TB and / or HIV and maybe ebola.  The other two look fine.  But it was after 8:00 before I got out of my PPE so shower, dinner, and bed.

Great news about Khaki [our Catahoula who had a leg amputation since George’s leaving]!  Can't believe you can be at the Vet's and call Liberia about her meds.  I was just coming out of the shower when the phone kept ringing but in my room no reception so dressed, ran up to the balcony and was able to call back.  I would go with just the Remadyl and Gabapentin - the Tramadol is just for pain and is a narcotic so I think that is what is knocking Khaki out.  We just gave it to a lady here who was writhing in pain.  She sat up and vomited, immediately went to sleep for four hours, and then died during the night.  Not a good test case!

You are right, I doubt that HtH will extend me - it sounds like tickets are purchased and that is fine with me.  Marge and Lucille came by yesterday on their way to Monrovia and are leaving sometime this week.  Marge, I think, had a lot of problems with both the long hours in the PPEs and the devastation of loosing so many confirmed cases.  And Lucille said, “. . .you’re not sending her back by herself, I'm going with her”.  It's nice to have George here to talk with.   and he warned me that one of the new nurses who was still in Monrovia was insufferable!  Knew something about everything and imposed himself into every conversation.  Also he said that another two that came right after us continually complained about the conditions at Bong such that they was about to get sent back to us.  So if I extend two weeks, that is who I will be working with - maybe not such a great idea.  I am definite I will not come back in the spring - it's two weeks or nothing.  Nine weeks for four weeks of service isn't worth it.  I would much rather think of helping out Mike this fall for a couple of weeks in a setting where I might be able to use more of my skills i.e. a full care setting.  We will let it just unfold.

Later,

It is becoming a little clearer how the process is sorting out.  This is all evolving as we speak and is requiring several joint meetings to work out details.  As soon as a potential outbreak site is identified by the Community Health Worker by calling in a possible ebola patient, CDC sends a team to evaluate and test.  They, however, provide no care.  If they feel it is a potential pt., one of two things happens - the pt. is immediately transported to an ETU and all contacts are identified and placed on surveillance, or, if it is impossible to immediately transport, MSF fllies in via helicopter and sets up temporary isolation tents for the suspected case(s) but does not remove pts.  Further arrangements are then established for eventually removing the suspected to an ETU.  

To remove a pt. by helicopter will require a dedicated helicopter specially set up to allow for full decontamination after each extraction of a pt.  This will be the next step and it  has been funded to contract for a helicopter and our ETU will be the home base for the helicopter and recipient of all pts.  This should be in place by the first of the year. Truly "chasing" ebola!

In the cases yesterday, CDC identified eleven potential cases with one of them confirmed.  MSF flew in the isolation tents and today at 10:00 there will be a meeting as to how to remove the patients since it is a two- hour walk to the nearest road.  Now, unfortunately, two patients are too weak to walk so what to do with them?  Our ambulances went yesterday and waited and in the process screened several concerned individuals but deemed none needing ETU care.  So we may still get up to eleven pts. today but probably only a few at a time.

In reviewing our schedule with Nora, she said that Maurice, the Congolese physician, is not here for clinical services so it is only George and me.  Therefore we will alternate 24hr coverage days.  The one "on call" will be available all day as well as at night and will round with the PA at around 10:00 am on existing pts., and then we both will round at 5:00 pm with the PA on new pts.  That way, one of us will not always feel the need to be hanging out in the clinical area all day but we can share ideas on pts. at the end of the day after evening rounds.  This will work fine and even with Parnav back, I don't think he wants to be part of the rotation because he is very busy with administrative details.  We will get a new MD on Friday to put through Hot training and where she will fit in next week -- I don't know.

December 3, 2014

I just got a call from Rene - he says they really need my experience in Tapita to set up and operate.  His proposal would be to take me up to Tapita next week and I can stay on as long as I want. I have really mixed feelings.  I really want to come home!  But I also realize this may be the most valuable thing I have to offer - the experience of helping set up, start up, and work in a real ETU.  Let's not make any decision until after your visit with Dr. Euard and see where we are with Khaki.  

I told him that if I did stay on I would still want to be home by the first of the year so that would be two weeks at the most.

Later,

Interesting visit - two or three days ago a young man named Khakie was getting dressed in PPE's at the same time I was and when I saw his name I said "That is the name of my dog!" and then everyone in the room laughed and started calling him a dog.  I felt really bad about the response and told him I said that with real affection.  I then went and got the iPad and showed him pictures of Khaki. Apparently a dog doesn't have much value in Liberia!  

It turns out he is an ebola survivor whose father was a healthcare worker and died from ebola in Sept. as well as one sibling.  His mother died when he was four so he now is an orphan with a younger brother to support.  He came by this morning to get my email address so I gave him a card.  With further questioning he said that he was a fourth year student at the Technical School outside of Bong and is training to be a lab technician.  He said his goal was to set up a comprehensive laboratory testing center and I asked if there were international agencies that would help support the cost.  I suggested that he needed to finish school first but since schools are closed because of ebola,  he is working for money to pay fees and support his brother.  When I asked how much fees were, he said $100 / term and the had two terms left.  He did not ask for money and I did not offer but think I will leave him $200 to finish his schooling.  I told him that it was so important that he finish school first before he think of setting up a laboratory and he said he had good grades and was sure he would finish but still had this dream of a "good" lab to help others (maybe a bit unrealistic).  

You used to refer to the "path" in Embangweni  [crossing paths with someone that resulted in an opportunity to make change for that person[.  This is not so different!