Dr. Matthew Waxman: I was on a panel in Tamkin Auditorium in Ronald Reagan UCLA Medical Center in the summer of 2014, and the topic was “Careers in Global Health.” The audience was medical students, residents and some faculty, and what everyone wanted to hear about was, of course, Ebola — the World Health Organization had just predicted the possibility of more than 1-million cases of Ebola in West Africa. It was in the news every day. To my left on the panel was a content, gray pediatrician who left a comfortable practice in Encino to work in rural Africa, returning year after year; to my right, a renowned infectious-disease professor who told the students a moving tale of dragging his young family to Africa decades earlier. The wise pediatrician sitting next to me had whispered, “Has anyone in this building taken care of an Ebola patient?” We both knew the answer — no. After the discussion, a medical student asked me how I thought the epidemic could be stopped. As she followed me to my car, her questions were not about the topic of my talk on my recent work to improve emergency medicine in Bangkok; they were pointedly about Ebola and our response. Why, for example, had so few interested “experts” from major academic centers gone to help? She put me on the spot. I mumbled something about mortgages, shift schedules and childcare. I did not mention the fear of acquiring the deadly virus.
How did that encounter affect you?
As I drove home from campus, I felt vexed by the interaction with this student. She had seen me as an expert in “global health.” Why hadn’t the dozens and dozens of physicians such as myself who are fascinated by malaria and viral hemorrhagic fevers and who are invested in spreading the healthcare advances we practice and teach go to work in one of the treatment units in West Africa? I had helped train physicians and nurses in my department for the unlikely event of an Ebola patient in my emergency department. I had devoured the outstanding journalism about the epidemic in The Guardian, and even had a beer with a mentor who had been in Liberia with the Centers for Disease Control. But, neither I nor anyone within the buildings where I worked or had trained had volunteered to go to care for patients. Would it be fair for me to ask my son’s mother to care for him for two months? Who would cover my shifts at the county emergency department at Olive View-UCLA Medical Center? Could I cover my mortgage if I didn’t get paid for a few months? Could I leave my house if I was under quarantine when I returned? Would the suit that caregivers had to wear actually protect me? What if I got Ebola? Was this something I really could do?
What did you do when you got home, and how did your family respond?
It was a process. I started telling my family that I was considering going to West Africa to work on the Ebola response. I started with my mom, who thought I was crazy — there was silence on the phone for the first 30 seconds after I told her. When the dust settled and she realized that I am a logical, careful person, she ended up being my biggest supporter. I asked my family to tune out the dramatic news headlines and understand the training and mitigation of risks when taking care of Ebola infected patients during the epidemic. A statistic that stuck in their minds was that an Ebola worker might be just as likely to die in a road accident in West Africa as he or she would be from actually contracting the disease. My brother’s response was, “You have a child.” I think he initially looked at it as an irresponsible thing for a parent to do. But when it came time to leave, I really felt his love; he was extremely proud of me being a part of the effort to fight Ebola. Some of my physician colleagues were among the least-aware of the people I talked to of the risks of contracting the virus. Interestingly, more than one seemed resistant to the science behind contracting the virus and thought that this was an exceedingly dangerous thing for me to do.
I contacted International Medical Corps to inquire about volunteering to help treat patients in the Ebola epidemic. I talked with a few non-governmental organizations (NGOs) that were running Ebola treatment centers (ETCs) in West Africa. Besides the standard questions about my educational background, they asked about my motivation for going, and about previous international health experience. I was interviewed by physicians who had worked in ETCs, and they shared their experience with me. The questions all turned on the ability to work in a disaster setting under strict rules and guidelines. At the time I applied, they were being selective to avoid crazies or individuals who did not know what they were getting themselves into. The organizations running the treatment units spend huge amounts of money on our training, flights, food and lodging, and we are representing their organization when working on the ground. So they carefully select folks to work in Ebola treatment centers to minimize it not working out. They talked to my supervisor at Olive View-UCLA Medical Center, Dr. Greg Moran, and some other people who know me in the global-health community here in the United States.
What were your thoughts as you flew to Sierra Leone?
I had on my laptop protocols, treatment guidelines, PowerPoint presentations on security and other information provided by the organization I was working with, and on the flight I tried to learn more about Sierra Leone and what languages were spoken. Most of the country is Muslim, and I had downloaded the Wikipedia article on Islam and started to read it.
Landing in the country was a little anticlimactic. It was late at night, and for insurance reasons Brussels Airlines needed to get the plane out of West Africa as fast as possible. The plane was parked on the tarmac, among towers of pallets of medical supplies to be used in the epidemic, and when we got off we had to walk across another runway and into a large hall. There was sort of a free for all to fill out paperwork and get it processed. This was my first time seeing the ubiquitous white bucket of bleach, in which we had to wash our hands. There was a concern about Ebola being brought into the country so we were checked for fever and previous travel destinations.
It felt different than other trips I have taken to work as a physician outside of the United States. After months of planning, I wanted to get to work, but the Ebola treatment unit was still another five-hour drive away.
What was it like to work in the clinic?
We worked eight- to 12-hour shifts. There were two physicians on duty at any given time. The nurses led rounds on all the patients in the treatment units, and we would go over which patients passed away, how many new admissions occurred over the past shift and which patients had tested negative or positive for Ebola. The laboratory testing took more than 24 hours, and the lab was a three-hour drive away, so results were greatly anticipated each day. The amount of intravenous fluids given, presence of bleeding or which patients needed intravenous access were focal points of our change-of-shift rounds. We tried to anticipate which patients were decompensating and might still have a chance to live. In the Ebola treatment unit, physicians or nurses had to monitor intravenous fluid running into patients, and we could not leave the drips unattended. So planning when providers would enter the confirmed ward was a part of morning rounds.
After rounds, we did paperwork and wrote orders on three different forms for medications for the next shift. Of a 12-hour shift, only a few hours were actually spent in full protective gear in the Ebola treatment unit. We timed entering the unit to give our efforts maximum effect; given the heat and our goggles fogging, one to two hours was the maximum time we spent in the treatment unit at a time. The time and effort getting into our protective gear and safely removing our gear added another hour. In the midday African heat, you are mentally and physically exhausted when you leave the unit.
After being in Africa for several days, you first entered the ward where Ebola patients were being treated.
Yes. Dr. Joel, who trained me and who I wrote about in my article, had at this point in his time at the clinic a somewhat wry take on the situation, and he joked about taking my “Ebola virginity.” Unlike my fumbling efforts with all the necessary gear, he was get-down-to-work efficient, donning his suit, gloves, mask and apron while I was still trying to get one of my legs to come out of the hole somewhere at the bottom on my suit. When we were all suited up, one of the members of the team who is charged with ensuring we are properly suited checked our gloves for tears, adjusted our masks and gave us a thumbs-up to go inside. After splashing our boots in a shallow bath of bleach, we were in.
What was that like, the first time you stepped into the ward with Ebola patients?
Surreal. In contrast to the chatter in Krio, boots crunching on gravel and the sounds of constant construction outside, inside the unit it was eerily quiet. The first time you go into the treatment unit after your are “certified” and have completed your training, you are not supposed to touch anything. Not a patient, not any supplies; it’s enough just to start feeling comfortable in your suit. All the papers about Ebola virus you have read, news articles, preparation over the past couple of months is realized when you take your first steps into a trough of bleach and follow your trainer into the wards. The three wards are organized into “suspected,” “probable” and “confirmed.” Patients awaiting test results who are suspected of having Ebola are placed in the suspected or probable wards. In order not to contaminate the suspected and probable, which have patients, who ultimately will test negative for the disease, you enter the confirmed ward last.
Were you scared?
My first time in the ward, I did feel scared — more that I would make a mistake, knock something over or get in the way of patient care than of contracting the disease. It was not unlike my first weeks as an intern — trying to not do any harm and convincing myself that my being here was not some comical mistake. In the United States, it takes years of residency to become comfortable enough being the only physician staffing a busy Emergency Department; in the Ebola treatment unit, the learning curve is much shorter. After a week or so, touching patients, drawing blood, cleaning up vomit and stomping through the wards feels routine. Unlike at the beginning of the epidemic, we had access to the highest quality personal-protection equipment and the “doffing” procedure where we removed our contaminated gear had been refined. Trusting in the power of bleach to kill the virus, two layers of latex gloves, goggles, aprons and a Tyvek suit do a lot to mitigate the fear.
We did all come to share one symptom with our patients: a chlorine cough. Everything was sprayed with chlorine — including our bodies — in the Ebola treatment center, and both patients and medical providers were constantly coughing from the irritation. One of the physicians came up with the idea that honey might be the ideal remedy, so he bought local honey in the market, strained it and provided it to our pharmacy to give to our patients. It worked!
What was it like after you had gained more experience, and then yourself became a trainer?
The shoe definitely was on the other foot. Toward the end of my time, I trained the British staff from the National Health Service who were working at the Makeni Ebola treatment unit. It was humbling to be in that position. I tried to pass on some of the information that doesn’t make it into PowerPoints, like tricks for removing the duct tape between our gloves and suit, the fact that physicians and nurses do the same tasks in the treatment units — i.e. “everybody does everything” — and of course emphasizing to always wash their hands.
What kind of relationships were forged in this environment?
The camaraderie between my colleagues in Sierra Leone is among the most treasured privileges of my professional life. Living and working alongside them through this epidemic, with each of us having responsibility for the safety of the others, was an incredible experience. It was incredibly difficult at times — our unit’s fatality rate among patients with Ebola was more than 60 percent. Diversion was very important. When we weren’t working, there was near-constant play that on occasion included forging paperwork so we could take official vehicles to pristine deserted beaches on our days off. One of the things we did not talk about, though, was the possibility of contracting the virus. Never.
You wrote in your article about some of the people with whom you worked. Can you talk about your colleagues a bit more so readers will come to know them better?
It was an incredible cast of dedicated, talented and generous individuals. My African colleagues represented the Democratic Republic of Congo, Sudan, Kenya, Ghana, Nigeria and, of course, Sierra Leone. There also were physicians and nurses from Lebanon, India and Pakistan.
There was a young nurse with whom I worked who was driven to care for Ebola patients by her faith in God after reading of the death of a Catholic priest early in the epidemic. There was a retired surgeon his 60s, Richard, from Oakland, California, who had amazing stamina, worked a large number of night shifts and could drink the rest of us under the table. In addition to other supplies, he brought along an array of sophisticated cocktail mixers. His calm under pressure and experience having worked in Africa made him a natural mentor for many of us. He also was the one who came up with the honey idea, and he and another physician, Jon, from Georgia, even built a beekeeping box and started a colony inside the compound to produce honey.
There were, of course, many others. Our nurse manager, Sarata, a British-Sierra Leonean with a posh London accent, returned home from England to fight Ebola. She was our rock and our cultural ambassador, who always worked with a smile. There was a family-practice doctor from rural Vermont who left a young family and busy practice behind to come to Sierra Leone, and Dr. Mohammed, from Sudan, who had worked for various organizations in Africa for almost two decades and is a world expert on infant malnutrition. There were two nurses, Kelly Suter and Audrey Rangel, both career disaster-response professionals who knew as much as anyone about taking care of Ebola patients in West Africa. Kelly was my first trainer and taught me how to put on the suit, and she was one of the best teachers I have ever met. Audrey is an ER nurse in California, and she is still in Lunsar, Sierra Leone, and is the director of the unit, a job akin to running a small corporation, in the middle of the Sierra Leonean bush.
And there was Sam Kafoe and Brima Sesay, who were two of the fewer than 30 Sierra Leonean physicians who remained in the country during the epidemic; many of Sierra Leone’s doctors had been killed by the disease, refused to work clinically or had left the country. Sam and Brima had both been residents at the government hospital in Freetown and had watched numerous colleagues, professors and nurses die of Ebola in the early stages of the epidemic. Sam and Brima had seen their training abruptly end with the epidemic and, at the beginning of their careers, had chosen to stay and work on the epidemic. I was extremely fortunate to become their friend and colleagues. While they sometimes asked me to explain concepts such as pediatric fever management or antibiotic regimens, they both had extensive experience in pediatric nutrition, malaria treatment and tetanus, and we shared our knowledge freely. On a lull in overnight shifts when rounding and paperwork were finished, Sam and I stood underneath the stars that are visible only in a country without electricity and he talked about his dream of doing an internal medicine residency in Cameroon, and I was fortunate to be able to help him with a letter of recommendation. Throughout my time there, Sam and Brima continued their education by studying medical texts and utilizing access to the Internet to read journals. Their dedication to self-education in the time of Ebola was truly impressive.
What happened when you returned to Los Angeles?
My port of entry into the United States was Chicago — the Centers for Disease Control had designated a few airports in the country for returning travelers from West Africa — where we were greeted by health officers from the U.S. Public Health Service, the CDC and the Chicago Port Authority. I almost missed my connection to Los Angeles because the health officers had to get clearance from the CDC for me to continue on.
When I got home, I was served with a Public Health order restricting my movements. Even as my friends and family showed sympathy about my quarantine, I had a difficult time explaining how luxurious my situation was compared to how my Sierra Leonean friends lived. I didn’t want to mention the guilt I felt when I did not eat much of the expensive sushi or treats from Trader Joe’s that friends brought over. As I continued to stay in contact with my colleagues in Africa, I started to calculate how many hours it would take to get back to Lunsar from Los Angeles. One night, I woke up from a dream and went outside to my car with the ridiculous intention of driving to LAX. It was nice, though, that I was able to take care of my son and reconnect with him during the 21 days I had to stay at home. It is rare in our busy lives that one has that much time off to be at home, so I looked at it as something of a “staycation.”
And now that you have settled back into your daily life of work and family?
I am filled with a lasting gratitude for having had the opportunity to participate and try to make a difference, and I want to get the message out that if I can leave my well-ordered life here to volunteer to help in an epidemic, that many more can, too.
Now that I am back at work, I find that I touch patients more than I used to. I am much more interested now in what our nurses think is needed for our patient in the ER to get better, and how the nursing approach to care looks at the patient more holistically. And I have worked to keep active in the Ebola response and incorporate it into my academic work. I have reviewed scientific papers from the Ebola response, lectured to medical students and residents. I am looking forward to working with International Medical Corps in being part of the effort to publish all of the data that was collected in the heat and chlorine. We all hope a viral epidemic of this magnitude does not happen again in our lifetime. If it does, the data collected and hopefully published will improve patient care and safety the next time around.