BEYOND THE TICK BOX

Me: “This patient does not have Ebola. You can’t isolate them.  You need to treat the child’s malaria. If you isolate, nobody will treat them” 

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House Officer: “But Dr Smiti, the parents could be lying.  They have come from out of town.  He has fever and bleeding, we don’t know if he is Ebola positive.  We are scared.”

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Me: “He does not have a positive contact history; he is very unlikely to have Ebola.  He has a positive RDT (malaria).  He has Malaria.”

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It is early June 2014. It is 3 am in the morning.  I am carrying the on-call consultant phone, talking to the on-call house officer.  I am half way through a 6-month placement, working as a senior resident at Ola During Childrens Hospital (ODCH), Freetown, Sierra Leone as part of the RCPCH Global Links Volunteer programme.  The current West African Ebola Outbreak had started in Guinea 3 months ago, 2 weeks after my arrival.  Since then we had been on high alert for the spread of the outbreak. Two weeks ago Sierra Leone started confirming the first few cases and things were getting worse.  Back in April, I myself faced a tricky situation where I had unsuccessfully resuscitated a young girl.  Her face inches away from mine as I managed her airway.  It was only after her death that we realised she fit the case definition for possible Ebola virus disease and I subsequently ended up discussing the case with the late Dr Sheik Umer Khan.  During the early days of the outbreak, before anyone could know how devastating this outbreak would become and before the international response truly kicked in, trying to manage situations like the ones described whilst working as frontline clinical staff, was far from straightforward.

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A big part of my role as one of the few senior paediatricians in Sierra Leone’s only Children’s hospital was to support the house officers who essentially ran the hospital.  Reassuring them in the middle of the night, when they were faced with a sick, febrile and bleeding patient was a challenge.  I didn’t blame them.  In the end I couldn’t reassure the house officer and asked him to called Dr Konoyema, a Sierra Leonean senior paediatric registrar and one of only two local qualified paediatricians at the hospital.  He was a similar age to myself and had been given the overwhelming responsibility of Ebola coordinator for ODCH.  He was also someone who had become an incredible source of support for me during my placement.

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Despite working on the frontline, under the constant threat of Ebola, life in Freetown went on and so did my work at ODCH.  I was in charge of the Intensive Care Unit – a ward with no ventilators or CPAP, just partially functioning oxygen concentrators and very, very sick children.  My day would start at 7 am, making the journey across town to ODCH in the minibus.  Handover began at 8 am, starting with the total number of deaths from that night and a summary of the critical patients.  More recently, handover included an Ebola update and a discussion of how we were preparing for potential cases whilst keeping our patients safe.   My ward rounds started at 9 am and lasted around 2-3 hours, I took time to teach the house officer and nurses during these rounds, they in turn would teach me about local practices and how to speak Krio.  Most of my patients had TB, severe malaria, tetanus, measles and pneumonia. Most of them were less than 5 years old.  After morning rounds I would check in on other busy wards.  There were often not enough senior doctors to be in charge of each of the 8 wards and up to 250 inpatients. I would then review any CXRs that had been requested; I would often play what I called the ‘TB or no TB’ game.  I don’t think I saw a single normal X ray. During the afternoons, I would attend various management meetings, teaching or work on my objectives, aimed at helping build capacity at ODCH.  These objectives included a malaria quality improvement project, taking a lead on developing the in house postgraduate training, teaching the house officers clinical governance skills, developing hypoglycaemia guidelines etc.  Around 2 pm my afternoon ward rounds would begin, making sure results were chased up from the morning, the very sick were reviewed and any new transfers were sorted before I left at 5 pm, I would often arrive home around 6-7 pm.  And then the day would start all over again.

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It was hard work.  Mortality was high in the hospital, and  I lost many of my patients on ICU, some were quite difficult to accept. It was one of the hardest rotations I will ever work during my paediatric training and even though it was an unpaid placement, it was also one of the most rewarding.  I truly loved the clinical work.  My patients, their mothers, my ICU ward, were always worth the effort.

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By the time Ebola made an appearance in Freetown, we had almost become accustomed to the news.  It was another part of life there.  Chlorine buckets outside restaurants and shops was the norm.  The radio blasting the tune ‘Ebola in Town’ was a familiar sound.  Dr Konoyema and the rest of the staff at ODCH, including myself, continued to work hard trying to keep the hospital and patients safe whilst continuing with our clinical duties, this included setting up an initial isolation unit on hospital grounds, organise Ebola teaching and training for hospital staff, encouraging hand washing with the new chlorine buckets.  Trying to implement a system for the screening of all patients presenting to the hospital was a particular problematic area. I attended many meetings including a WHO scientific update on the situation.  My main concern was for patients who did not have ebola but were suffering as a result, as health care systems were crumbling and children were dying needlessly.  ODCH was vulnerable.

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All too soon suspected cases were being isolated in the unit.  The situation was escalating with no end in sight to the outbreak.  Stress levels were high.  Everyday myself and my fellow doctors would have to assess our own risk of contracting Ebola as we continued to work as frontline staff, treating the sick that entered the hospital.  ODCH was not a treatment centre.  We did not have even basic PPE kits to keep us safe nor did we have the money or resources to acquire them easily,  we were still many months away from the peak of the outbreak and the subsequent international response. News of health care professionals contracting the disease continued to filter through and I suddenly found myself working as ‘high risk’ health care staff, living in an extreme environment where decisions could mean life or death for yourself and not just your patients. Abandoning my work was out of the question but the decision to keep working kept getting harder and harder, and with active transmission of the virus in Freetown, a positive case at ODCH was imminent.  At the time every 1 in 6 positive case was a child.  Once it was very clear that it was no longer safe for me to continue clinical work, I stopped.   Even now, more than a year later, I still feel sad about having to make that decision.  I had hoped to stay till the end of my placement, which was not too far away, despite pressure from others to leave, even after my flight out from Sierra Leone was cancelled because of the outbreak.  Unfortunately things were changing fast. Dr Sheik Umer Khan had died, and the president of Sierra Leone had declared a state of public health emergency; the disease by this point had spread to all districts in Salone.  Not long after I found myself on the penultimate BA flight heading out of Freetown before they suspended their flights.  My departure was sudden, but staying was no longer an option. The flight home was difficult and not a single day since arriving back as gone by without thinking about my time there.  I watched, from a far, the outbreak destroy everything I had worked for before finally coming to an end, officially today.

My placement turned out to be quite different to the one I anticipated but I have no regrets and a lifetime of precious memories.    I had the privilege to work with some of the most hardworking and dedicated doctors and nurses I will ever meet and treated some pretty amazing children, and to them I say Plenti Tenki.

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Dr Konoyema, passed away in December 2014. He was the 10th Sierra Leonean doctor to die from Ebola. The first paediatrician.  News of his death broke an already battered and bruised heart.  His death means that after Ebola, there is now one less doctor to care for the children of  Sierra leone.  The declaration of the end of the outbreak today has been a long time coming for me, for Salone and for ODCH.

 

The RCPCH Global Links programme has recently re-established links with Ola During Childrens Hospital.  For more information: 

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Visit the RCPCH GL webpage: http://www.rcpch.ac.uk/global/programmes/volunteering-programmes/global-links/global-links-programme

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