October 11, 2014 Webb Worldwide No Comments

My thoughts on the virus and experiences while there.

In early June 2014, the city’s first patient with Ebola arrived at Liberia’s county hospital, Redemption Hospital in Monrovia. As tensions grew around the city of Monrovia, hospital administrators at John F. Kennedy hospital (also in Liberia and where I spent most of my time), began to devise plans for handling patients with suspected Ebola.

While there, officials from the Centers for Disease Control and Prevention (CDC) came to Liberia and gave us lectures about the deadly Ebola virus. They discussed prevention of spreading and what our plans would be in the event of a potential outbreak.

Before that moment, there were no clear plans for what to do if a patient presented with symptoms of Ebola. No plans for isolation. No plans for treatment. To make matters worse, the scarcity of gowns, gloves, and personal protective attire presented a big problem.

At that point, we never imagined that Ebola would become so deadly and devastate a country so quickly.

ebola  Our grand rounds lecture on Ebola from the CDC

“Hi Dr. Solomon, I’m Antonio Webb, I’ll be helping out today.”

“Ok great! Since you are here, I am going to head home and get some cashews.”

I was taken aback as he quickly left and headed out the ER back door.

My first patient was a 40-year-old diabetic female who came to the ER for a foot ulcer, likely from uncontrolled diabetes. The surgery team already had started antibiotics, but could not take her to the operating room because the schedule was full that day. I glanced down at her foot and then looked up at her. She was tearful and seemed embarrassed about waiting so long to come to the doctor. Her foot was mottled in appearance – she’d probably had the ulcer for some time. She had obviously waited until it started draining fluid and looked infected before she came in to get seen.

lib4 The Emergency Room

The nurse walked up to see what was going on. “Can I get a pair of gloves please?” I asked.

She looked at me, rolled her eyes, and walked away. Ten minutes later, she returned with two gloves balled up in her scrub pocket and even then, hesitated about giving them to me.

Should I not be wearing gloves? Are we conserving them? I thought.

Nonetheless, I left to search for supplies to debride her foot. Supplies were limited, so I was forced to improvise and use whatever I could find. I found a surgical blade and pair of scissors, which were all the way on the other side of the ER.

Most patients with diabetes develop a condition called peripheral neuropathy, in which the high glucose levels damage small nerves that provide sensation to the foot. This creates a problem when patients bump their foot and then don’t realize they have a wound, because they can’t feel it. As I scraped away at her ulcer with a surgical blade, that I rigged onto a pair of scissors with tape, I realized that was the case. The lady’s peripheral neuropathy was so bad that she didn’t feel my blade as I cut into her skin.

“I am going to be honest with you and I want you to listen very carefully. Things like this can cause you to lose your foot. It is important that you take care of your health, eat right, and exercise,” I told her.

She nodded her head and quickly looked away, as if she was embarrassed for letting her diabetes get out of hand.

Without time to even catch my breath, I overheard a nurse screaming to get my attention. A patient who was admitted the day prior with liver failure wasn’t doing too well.

“Help, she’s not breathing!” screamed the nurse.

I ran over to see what the was going on. The patient’s oxygen saturation was in the 60s (normal is 90-100%). Her breathing was irregular, often a sign of impending death, called agonal breathing.

I checked her heart rate and could not feel one. She was essentially dead at that point.

“Start CPR,” I yelled.

The respiratory therapist climbed on top of the bed and immediately started pumping on her chest.

I ordered the nurse to give 1mg of epinephrine and instructed another nurse to grab the defibrillator. I rechecked her heart rate and still felt nothing. By that time, the respiratory therapist was drenched in sweat from doing CPR. The hospital had no AC, and I was told to hydrate at every chance. Everywhere I went inside the hospital, I carried a fresh bottle of water to avoid drinking the Liberian water.

We stopped CPR to check her rhythm on the monitor: Ventricular fibrillation (V-Fib).

V-fib is when the heart does not pump properly and just quivers. It is an indication for defibrillation and is an life threatening arrhythmia. I grabbed the two defibrillator paddles and told everyone to stand clear. I shocked her with 200 joules of electricity. When she jumped from the electricity of the defibrillator, I jumped as well, startled. Even though I saw it during medical school, I never had to shock a patient back to life myself and had never run a code blue alone.

I glanced over at the monitor: Flat line____________

At that point, I knew what we were doing was futile and, had the patient survived the cardiac arrest, she would likely have died from liver failure. In addition, the hospital was devoid of Lactulose, a medication given to patients with hepatic encephalopathy.

Even though she had flat lined, and I knew it wasn’t indicated, I wanted to shock her again. What would we lose? I thought.

This time, I used 300 joules of electricity. She jumped. Still nothing.

The flat line remained_________

Even after everything we had done, nothing would bring her back.

Time of death: 10:15am

Minutes later, an older gentleman with a history of a heart condition, called atrial fibrillation, came in with right-sided weakness and slurry speech. Instinct told me he had likely had an embolic stroke from his heart condition. He admitted to taking his aspirin that morning, but may have not been taking it regularly.

We learn in medical school that, ‘time is muscle.’ All we had at that point, however, was time. In the US, we send suspected stroke patients immediately to the CAT scanner and then activate a stroke team. Then, we administer medication to restore blood flow to the brain.

There was no such thing in Liberia. No stroke team. No CAT scan machines. No medication for strokes. Just time.

And time we were wasting.

He laid on the ER stretcher and stared at the ceiling walls. We could not do anything for him. He most likely suffered continuous brain damage. This likely left him with permanent and irreversible neurological and social economic damage, something that is very much preventable in the US.

While I attempted to gather the rest of his history, a nurse ran over to tell me her patient wasn’t doing well.

Her patient was a 33-year-old female who had delivered a baby vaginally, a few days ago in a back alley, but now had shortness of breath and signs of a blood infection. I instructed the nurse to give her a 500ml bolus of fluid, even though her urine output had been low and her blood creatinine levels were high: signs that her kidneys were failing. The nurse quickly gave her the fluids. It didn’t affect her blood pressure much and instead her oxygen saturation dropped. I glanced over at my colleague, who had just arrived, and we gave each other the same nervous, “I don’t know what to do” look.

“We have to make a decision – now! Otherwise, she will die,” my colleague said.

I ordered the respiratory therapist to gather supplies so we could intubate her. Before that point, I had only intubated patients under the supervision of anesthesiologists in the operating room, on my anesthesia rotation in medical school. But, there was no time to ponder. We needed to act fast!

The respiratory technician returned and handed me an endotracheal tube, which looked like it had been used.

“I need a new tube,” I quickly stated.

“We wash our endotracheal tubes and re-use them,” he responded.

Even though I was in disbelief by what he had just said, I didn’t have time to put up a fight. Our patient was crashing – and crashing fast!

We decided that Marci, my colleague, would intubate while I tried to insert a tube in her nose to decompress her belly. Her belly seemed to be swelling by the minute. As Marci inserted her breathing tube, the patient began to vomit. We suctioned the regurgitated fluid and turned her on her left side. Her oxygen saturation was now low in the 80s and her blood pressure dropped to 40/20.

She was crashing!

I glanced over at the monitor and noticed that her heart rate was zero on the monitor. I felt for a pulse, but it was weak and thready. Without hesitating, I started pumping on her chest as hard as I could, even after hearing her ribs crack between my fingers. I instructed the nurse to retrieve the defibrillator from the other side of the ER. We prepared the paddles with lubrication and stopped CPR to check her heart rhythm. Her heart was beating again, but unorganized, a condition known as ventricular tachycardia. I placed the paddles and shocked her with 200 joules of electricity.

“Give her another milligram of epinephrine,” I yelled out to a nurse who was just standing back and looking on. She appeared to be startled by everything that was going on.

We rechecked the patient’s pulse, which was much stronger now, possibly from the adrenaline we just pushed into her veins. Whew! We saved her life. She was in critical condition, but stable.

Did we do everything right? Did we miss something? I thought.

Sure, she had a blood infection. She had warm skin, low blood pressure, a high heart rate, fever to 102.7, and low urine output – all which pointed to a diagnosis of sepsis. But, was there anything we could have done differently? There were none of the medications we commonly gave in the US when a patient didn’t respond to initial intravenous fluids. Instead, we improvised by injecting 1ml of adrenaline into a bag of 500ml saline and then used that to raise her blood pressure back up to normal range. In medical school, we learn that the mortality for someone who goes into cardiac arrest is very high. But, all that mattered at that point was that we saved her life.

I sat down to catch my breath, my mind running through everything that had occurred during the day. The day had been insane! It was only then that I remembered the ER doctor who left earlier in the morning to get cashews. He never showed back up. I shook my head and thought to myself, “Welcome to Africa!”

jfl I soon left Liberia and was fortunate to not contract Ebola, although I treated several patients with suspected symptoms. Unfortunately, I cannot say that for everyone that I worked with while there. A few weeks after my departure, Ebola became rampant in Liberia. It further weakened and destroyed a country that was already on the verge of recovery from the 1990’s civil war, led by militant Charles Taylor. The virus soon spread to neighboring countries Sierra Leone and Guinea. As of October 2014, the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have reported more than 8,000 suspected cases and more than 3,000 confirmed deaths.

The Liberian medical infrastructure was not ready for such a deadly outbreak. The WHO estimated that the Liberian’s capacity for treating Ebola was insufficient by over 2,000 beds. In some areas of Liberia, protestors began attacking hospitals because they thought the disease was a hoax and the hospitals were responsible for the disease. Many areas of Liberia that were seriously affected by the virus lacked basic supplies and had limited access to soap and clean, running water.

The virus soon took the life of Dr. Solomon and several other physicians that I worked with while there. JFK Hospital closed its doors to patients not much longer after, eliminating what minimal healthcare that had existed.

The WHO later released a statement that said, “The Ebola epidemic ravaging parts of West Africa is the most severe acute public health emergency seen in modern times. Never before in recorded history has a biosafety level four pathogen infected so many people so quickly, over a broad geographical area, for so long.”

Rest in Peace to the doctors who I met while there. They placed their lives on the line and passed away doing something they enjoyed doing: helping others. They cared for patients, despite inadequate and unsafe resources, clean water, air conditioning, supplies, and insufficient training in infection control. These selfless doctors were on the front lines, and died as a result. They continued to sacrifice themselves to provide for others, even after a deadly disease such as Ebola, wreaked havoc throughout their country.

12 GOD BLESS LIBERIA!

“Overcoming the Odds” coming December 2014

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Written by Webb