Rob is a Canadian intensive care doctor who went to West Africa during the 2014 Ebola outbreak.
“I went to the World Health Organization in Geneva in 2013 on a sabbatical. The goal was do work in international health care; to donate my time in some naive altruistic way. In March of 2014 there came word of an Ebola outbreak in West Africa. Every couple of years there’s an outbreak of Ebola, but West Africa hadn’t seen the virus before, so that was a big deal.”
“The WHO has a usual outbreak investigation process, which is to first do epidemiologic investigations, figure out what’s happening on the ground and help plan a response. Rather suddenly, I found myself in Conakry, the capital of Guinea, to do that. I was partnered with Tom, an infectious disease doc from the UK.”
“Tom and I were tasked with going to local hospitals to see if they had come across any patients that had a syndrome that might be Ebola. One of the first hospitals we went to was a rather nice boutique hospital the Chinese government had set up, mostly for business and industrial clients in the area. Surprisingly, the hospital was empty except for one floor that had seven or eight patients on it who were being cared for by one nurse.”
Because of an Ebola outbreak?
“They didn’t know what it was, but they knew it was bad.”
Two or three weeks prior, a patient had come in with abdominal pain and was taken to the operating room. Within seven to 10 days, the surgical staff all started getting sick. The patient died and then the surgical staff started dying one by one.
“When we got there, the patients on the ward were almost all health care staff. A couple of them were very sick, a couple were in the middle phase of an illness and one was actually getting better. The nurse told us that during the night a doctor had died. He was still in his room, which was a complete mess. Blood was everywhere, and there was no one to help move him out of his room.”
“Tom and I realized that Ebola was already in this large, crowded, poor city — an environment it has never been in before. Very quickly we changed from being part of a small team doing public health epidemiology to being doctors faced with patients who were very sick, being cared for by one nurse. Tom said, ‘Let’s go. We are going to put in IVs and we’re going to treat these patients.’”
Did you have personal protective equipment (PPE)?
“We had a box of PPE that you would never find in our hospitals — almost like a negligee meant to keep stuff off your body. We did have gloves, mask, and face shields, and that was pretty much it. We didn’t have rubber boots; the boots I was wearing are in the corner over there. So we started treating patients, with heavy attention to not putting ourselves at risk.”
“We met with the hospital administrator, who was understandably beside himself. His first question was, ‘Can you take these patients someplace?’”
“We thought there needed to be an Ebola treatment unit set up somewhere. Within a day the Ministry of Health said we were going to use a cholera treatment facility in the middle of the city that had been mothballed. But the place had nothing in it. It was just a single story structure with about 12 beds and maybe six cholera cots with a hole for lots of diarrhea. There were no supplies, no IVs, nothing. So we said to the hospital administrator that we could take his patients if he gave us all the hospital’s medical supplies. We brought two big cardboard boxes to the pharmacy and they dumped the whole pharmacy into them.”
“One by one we started to take the patients over. There were a few terrific Médecins sans Frontières (MSF) nurses in town, and we started the Ebola-treatment facility with them. Our goal was to provide good care, safely, to patients that usually get minimal to no care.”
“The first patient died not long after arriving. He was destined to die and should probably never have been transferred. It was a heavy guy — there were not enough people to carry him out of the room. Eventually we were able to bring him to a Red Cross truck – they do a terrific job in these outbreaks of handling bodies safely, and they started the process of safe burials.”
“It was a huge challenge to provide care that we thought was reasonable quality, because we started with a very small staff. The PPE the nurses and doctors were using was a yellow plastic suit that completely covered them; not a pixel of skin was exposed. They also had to wear two masks and goggles. In the middle of the day it was in the high 30s, and if they spent more than 45 minutes inside the PPE they would get lightheaded and faint.”
“Tom and I were using PPE that most people would now say was inadequate, but it was very breathable and we could stand to be in it for up to four hours at a time. That allowed us to put in IVs and give IV fluids to people who couldn’t eat or drink anymore.”
“Our approach to treatment was at odds with the prevailing philosophy of care in some NGOs. They would say if patients were so sick that they couldn’t eat or drink, they were very likely going to die no matter what, and anything we did beyond basic nursing care was just increasing the risk to health care workers.”
They thought we were cowboys, treating people who were likely to die. But Tom and I thought that even if they had a high likelihood of dying, they still deserved the best medical care we could give them.
“MSF, which is terrific operationally, came in with tents for a pharmacy, better water sanitation, piped chlorine for disinfection and a place where you could get in and out of PPE. It started to look like something you could imagine in ordinary healthcare. Over the next month or so we were usually treating between 20 and 30 patients at a time, with four docs and eight nurses.”
“After we’d been set up for a week or so, we continued to see quite a few people dying despite us giving them IVs and trying to make sure they were not volume depleted. So we said, ‘We need to find out why they are dying.’ We wanted to take blood, but at that point, no lab would process the blood from our patients.”
“MSF found a portable machine and we started to process blood in our facility, which we could only do in the morning and night because in the middle of the day it was so hot the machine wouldn’t work. We had to put ice packs around it to get it to work. When we got the test results, we realized that some patients had specific abnormalities in their blood, such as of their sodium or potassium. That knowledge allowed us to tailor our treatment in a fairly simple way.”
Is there research to show whether your approach of more aggressive management was the right thing to do?
“Community work to prevent infection is the most important, and in the big picture makes the work inside a treatment unit seem trivial. That said, the mortality was around 80 percent at the beginning of the outbreak and decreased to lower than 40 percent by the end. The mortality of folks that were evacuated to Europe or the US was less than 20 percent. Although this isn’t definitive, we feel that over the course of the outbreak we at least helped move clinical care in the right direction. You can’t feel good about an outbreak where nearly 30,000 people got infected and 40 percent of them died, but from a narrow perspective, I think we helped.”
“A week or so after I was in back in Geneva I had a Thursday night hockey game. I didn’t feel very good and sat out a couple of shifts. I finished the game and thought I was coming down with something. It wasn’t horrible, and we had planned to go skiing that weekend. I had missed a lot of family stuff for the last month and a half, so we went.”
On our way to Zermatt I started to feel really bad. Like unusually bad. At that point I thought, ‘If I am rational about this, Ebola would be near the top of the differential!’
“We checked into our hotel and I quarantined myself in my room. I felt like shit for the next 36 hours. I thought it could be malaria or bacterial gastro, so I treated myself for those. And then, slowly, I started to feel better.”
You must have been scared.
“I was very close to figuring out how I was going to get back to a hospital in Geneva that would be able to deal with my Ebola.”
Click here to read part two of this piece, where Rob talks about how this experience affected him and his research after her returned to Canada.