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!
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