Tuesday, January 13, 2015

Fear and Loathing in the Ebola Unit

I was sitting in my tent in a small northern Liberian town called Zorzor when the fever hit. 

My cheeks felt hot like fresh sunburn though it was still a mountainous morning cool in this town near the borders of both Guinea and Sierra Leone.  I’d felt tired and cranky for the previous two days, but attributed it to sleeping on too many floors and too much hard travel through Liberia in the past month.   I’d only taken one day off in the past thirty.  We were moving through the country opening up new Ebola Treatment Units (called ETU’s) and training hundreds of Liberians to run and staff them.  I put my phone camera in selfie mode to look at my face.  My cheeks and nose were bright red and the whites of my eye were sick and glassy.  I looked as old and tired as I felt.  Wow, I thought as calmly as possible:  this is really happening.

I called my friend “Sumo” who’d been hired as the camp manager for the Zorzor Ebola Unit. I’ve known Sumo for nearly ten years as a trusted friend and a skilled paramedic.  I asked him to grab one of the thermometers packed in the storage containers and bring it to me.  I suppose he heard the concern in my voice and asked what’s up.  Just bring it to my tent I said.  He came by five minutes later.  He opened the zipper to the door of my tent and started to step inside.

“Stop.  Just wait at the door, dude.  Don’t come in.  Did anyone see you bringing this?”

“No.  What’s wrong?” he said

“Just toss me the thermometer.”

Don't shoot!
I ripped the box open and took out the Thermoscan.  These are the gun-like thermometers used outside every establishment in Liberia, Sierra Leone and Guinea to check the body temperature without having to touch another person.  Medically these are not the most reliable devices to check a temperature as they sometimes under-read the actual temperature. They are certainly the safest though during an Ebola epidemic.  I fumbled with the batteries, checked the calibration and pointed the gun to my forehead.  I pulled the trigger and held it down.  One beep says no fever - you are clear to enter.  A string of beeps says you have a  fever and you risk quarantine in an Ebola Treatment Unit.  I got the menacing string of beeps. I looked at the screen on the back of the device.  It read 39 degrees Celsius (102.5 degrees Fahrenheit).

“Dude, I have a fever.  I’ve been working in Ebola Units and I have a fever.  I gotta figure this out.”

“Take it easy,” Sumo said, “don’t let your imagination run away with you.”

“It wasn’t until you said that.”

Critical glove check
I’d been providing medical care and training in over twenty countries in Africa and Asia and Europe for the last fifteen years.  I’ve worked through all kind of epidemics including big hitters like HIV, Hepatitis, Tuberculosis and dysentery.  There’s been fears and issues along the way, but never like this.  I had to calm down and work through this logically. The ripple effect if I had Ebola was going to be huge.  My first concern was for the people I’d interacted with in our makeshift tent city camp during the last twenty-four hours.  We lived elbow to elbow.  The number would be in the hundreds. I was going to be the Typhoid/Ebola Mary of camp Zorzor - trigger immediate pangs of guilt.   Ebola can only be spread when an infected person shows symptoms.  I figured, at the latest, my symptoms really started two days before.  Next I would have to sort out my evacuation options.  We’d flown to Northern Liberia on a Russian M8 transport helicopter—a veritable city bus of a helicopter that can carry twenty people and tons of supplies.  To evacuate me from Zorzor to the Monrovia Medical Unit—an Ebola Unit designed specifically for health workers who’ve caught Ebola on the job—would require a monster effort of personal protection, decontamination and would take this vital helicopter out of service for a long time during a lengthy decontamination process.  Last, but certainly not least, would be a difficult conversation with my wife whom I convinced at great length that there was nothing to worry about when I took this job.  I’d told her it was relatively safe and as one of the directors of the project I’d barely have patient contact--which wasn’t exactly true. 

I was still calm.  Ebola, while horribly lethal and easily spread, follows certain rules.  I’ve been teaching these rules to nearly five hundred international health workers over the last month all over Liberia.  To catch Ebola there has to be an exposure beyond the constraints of one’s Personal Protective Equipment or PPE—the biohazard suits, boots, multiple masks, gloves and aprons and goggles that have defined the media’s symbolism of the Ebola worker.  

I’d had one such episode.

It happened on my first day in a busy Monrovia Ebola Unit with my first Ebola patient ever.  I’d donned my protective gear and entered the “Suspect Ward” where new cases waited for confirmatory blood tests.  It was a hot mid-day in Monrovia, sweltering in the Ebola treatment tent and ten degrees hotter still inside my biohazard suit.  I was drenched in sweat, my goggles fogged over completely.  My N-95 face mask pushed painfully into my nose to the point where I could only breathe through my mouth.  My first Ebola patient ever sat on the side of his bare green army cot.  I leaned down to speak to him and had to yell through the thick mask for him to hear me and understand my American accent.  I asked how he was doing.  He said he felt well.  He was having no more fevers and was not having any diarrhea or vomiting – the hallmark sings of a new Ebola infection.  I examined him as best as possible in the clunky biohazard suit, wrote in his chart and moved to wash my hands before the next patient. 

Suddenly, THUD!  I turn back and he was having a full blown seizure. He thrashed violently on the small unstable cot.  He’d bitten through his tongue and bloody saliva flowed from the side of his mouth.  He’d also pulled out his intravenous line and blood ran from the hole in the back of his hand and dripped and splattered on the floor.   I called the doctor working with me to help and we struggled to turn his head to the side.  He was in danger of choking on his bloody tongue or drowning in his own secretions.  All this time we had to be careful not to rip our suits or gloves and risk exposure to the surely contaminated fluids now filling his bed.  The nurse went to the nurse’s station to find an injection of Diazepam (Valium).  Hopefully that would break the seizure.  We charged the experienced nurse to  give the injection.  Now there were more fears.  I worried when this big man felt a sharp needle pierce his skin, he was going to react and grab one of us or start swinging.  I positioned the team out of his reach and told the nurse to proceed with the injection, but to do it quickly.  He jabbed the needle into the man’s right shoulder, injected in one move and we all backed away.  The seizure eventually stopped and the man looked at me disoriented from the seizure and the Valium.  I looked briefly into his eyes through the fog in my goggles and saw a look of desperation that I’d never seen even in the Tuberculosis and AIDS dying wards throughout Africa in the late 1990’s.  If there’s a devil, I thought, this is his disease.

Uptown Zorzor
My apron and gloves were covered with infected blood.  Protocol says to clean them with 0.5% Chlorine solution which kills the Ebola virus.  I sprayed down my contaminated suit, washed the blood from my outer second pair of gloves and then decided to throw them away and get a new pair.  I carefully removed the gloves to avoid any fluid splashing  and dropped them gently in the waste container.  Only one box of gloves was left on the nurses table, but they were too small.  They would have to do.  As I struggled to put them on, POP.  My hand poked through my only remaining glove.  There it sat unprotected, exposed to the air on my first day ever in an Ebola unit with the most deadly infectious patient I’d ever seen in a long career of deadly infections.  I called out as calmly as possible, “BREACH!”  The nurse instructed me to clean my hand as thoroughly as possible with chlorine and to put on two fresh pairs of gloves.  As I ran the stream of chlorine water over my bare hand all I thought was: I have two small children and a wife.  What the hell am I doing here?  After a good five minute wash I left the unit, decontaminated the rest of my suit and threw it away to be burned.  I moved into the “Green” uninfected zone of the Unit.  I tried not to show it, but I was shaken.

Tent City, Downtown Zorzor
So there I sat febrile in my tent in Zorzor replaying every moment as vividly as if it happened yesterday.  But it did NOT happened yesterday and here is where the rules of Ebola brought reason to my fear.  Ninety-nine percent of Ebola infections occur within twenty-one days after exposure to the virus.  In my head I counted backward to that day in the Monrovian Ebola Unit.   Twenty-five, twenty-six, twenty-seven…twenty-eight days!  Time was on my side.  I wasn’t showing any of the other signs of Ebola that define the infection…not yet anyway.  I told Sumo that this had to be Malaria.  I was convincing myself as much as him.  I’d been taking Malaria prevention tablets, but it is never one hundred percent effective.  I’d had this before.  This definitely felt like Malaria.

“Sumo, can you grab me a pack of Coartem?” I asked.  Coartem is our effective three day Malaria cure.

“Sure.  Why don’t you just rest and chill out though.”

I took the cure and my fever resolved later that day.  I watched closely for any other symptoms, but none came.  That was 4 days ago. I’m starting to feel better.  I’m fatigued, but I can still work and teach.  I'm trying to rest a bit more,and put back lost weight. I'm still working.  There's too much to be done.

Ebola has changed so many of the ways we in the medical field think about things.  Never in my life did I imagine I would think this:   Thank God I have Malaria.

Goooooood Morrrrrrrning West Africa!


  1. glad you are feeling better Erik! Jami

  2. Dude. We r with you in spirit and thoughts everyday