At 6 a.m., our medical team arrives at the Ebola case-management center in the Kailahun district of Sierra Leone to take blood samples. At our 80-bed center here near the borders of Liberia and Guinea, 8 new patients were admitted yesterday, 9 need to have a repeat test 72 hours after their symptoms began, and some we hope to discharge today: at least 18 blood samples to obtain. The center currently houses 64 patients in all, 4 of them children less than 5 years of age. We have already seen 2 patients die today.
I have been here for 7 weeks, working as a nurse and emergency coordinator for the Médecins sans Frontières (MSF) Ebola response. Today we're lucky: it's raining, so we won't be too hot in the personal protective equipment (PPE) we must wear. We control who goes into the isolation area, how often, and for how long. No one should wear the PPE for longer than 40 minutes; it's unbearable for any longer than that, but it's easy to lose track of time, so we have to monitor our colleagues. The process starts in the dressing room, where getting into the PPE takes about 5 minutes. We have a designated dresser, responsible solely for making sure that we are wearing our equipment properly and that not a square millimeter of skin is exposed. In case one layer is accidently perforated, we wear two pairs of gloves, two masks, and a heavy apron on top of the full-body overalls. When we exit the isolation area, we are sprayed down with chlorine solution and peel off the PPE layer by layer. Some of the equipment — goggles, apron, boots, thick gloves — can be sterilized and used again. Everything else — overalls, masks, headcover — is burned.
The center has two sections: the low-risk area, containing the pharmacy, dressing rooms, laundry, laboratory, water-chlorination points, and staff meeting area; and the high-risk, or isolation, area, where patients are admitted and staff must wear the full PPE. Our medical and water-sanitation teams go into the high-risk area with a clear plan: check vital signs, administer medication, serve meals, and clean the 10 tents. There are also teams that help new patients settle in, prepare patients for discharge, and disinfect and remove the dead.
Everyone working in the isolation area must follow the protocols and procedures to the letter. We use a buddy system — we're responsible for ourselves but must also put our lives in the hands of colleagues: one mistake could be deadly. The isolation area is divided into separate tents for patients with suspected, probable, and confirmed Ebola virus infection. Suspected cases are defined by fever and three or more other symptoms of the disease; probable cases, by symptoms plus known contact with someone who's had Ebola or with the body of someone who's died of the disease. There is a clear separation between the tents for these two types of patients, who are given instructions for minimizing the risk of cross-contamination — by washing their hands, for instance, and not touching other patients or their belongings. For the same reason, the staff follows a strict circuit, moving from the suspected-case tents to the probable-case tents and finally to the confirmed-case tents.
The isolation area also contains a waste area, laundry, latrines, showers, and the morgue. The staff works in three shifts a day, around the clock, but everything is organized to minimize the time we spend in the high-risk area. In reality, it's one of the safest places to be during this outbreak, because we know that the patients have Ebola, so every protective measure is in place.
In the suspected-case tents, most patients look quite well, but the probable-case area is a different story. Patients here have fever, pain, anorexia — but these symptoms could indicate malaria. In the on-site laboratory, a polymerase-chain-reaction test can determine whether a patient has Ebola, usually providing results on the same day or the next day. When the result comes in, the patient is either moved to the confirmed-case tents or discharged. Knowing what it means to be moved to these tents, patients are understandably frightened. We have a psychologist, a counselor, and health promoters to help and support patients, but there are just too many of them.
Standard treatment for Ebola is limited to supportive therapy: hydrating patients, maintaining their oxygen status and blood pressure, providing high-quality nutrition, and treating any complicating infections with antibiotics. Supportive treatment can help patients survive longer, and that extra time may be what their immune system needs to start fighting the virus.