Friday, 19 December 2014

The Isolation Unit at Connaught Hospital

I’m not quite sure where to start… time passes in strange ways here, I arrived less than a week ago and yet it feels like I’ve seen so much, met many amazing people and beginning, ‘slow slow’, to get my head around the current situation.  I also should warn you that this blog makes for fairly upsetting reading. I promise to try and focus on less gruesome topics in future blogs but I thought it was quite important to set the scene initially.

So I’ve started working in the Isolation Unit at Connaught Hospital. I had 3 days of thorough one-on-one training about PPE and the how the unit runs from Tom, an HIV Consultant from South Africa, who has been here for about a month. We talked through the PPE training together in a classroom, then practiced putting it on and off in the correct 22 steps and order. On Friday, I walked through the unit for the first time for an induction. Eyes wide open, blinking through the foggy visa of my mask, hands clasped firmly at my waist in a surgical pose, not touching anything but just allowing it to sink in. I then continued to shadow and work with Tom for another couple of shifts until now it feels like I’ve always known how to wear PPE.  

Getting into PPE
We have 16 beds and 2 cots in our unit. All patients coming to the hospital are screened outside the front entrance with a questionnaire. If there are any suspicions that they have symptoms of ebola (fever and 2 other symptoms) they are then isolated in a tent outside the hospital gates. Once there is a bed available in the unit, our role as doctors is to take a patient from the tent into the unit to have their blood test taken to confirm ebola or not. We try to take the sickest patient first; Tom tells me an easy way to triage is to do a very crude visual check; the sickest (and therefore most infectious) are first to get in the unit are those usually lying on the floor, then those sat on the benches and finally the least unwell are standing.  The first day I arrived there were about 10 patients in the tent, some had been there for more than one day. The alternative is to send patients home with a self-isolation pack and tell them to come back tomorrow – a less than ideal situation given the risks of onward transmission. And yet, this screening tent is the reason why Connaught Hospital has remained open for non-ebola medical care compared to most (if not all) other hospitals. Without a screening process, the patients all sat together in the A&E waiting area and the staff would have no idea until it’s potentially too late whether someone is a suspect ebola patient or not. This is the way healthcare workers get sick and fear spreads causing doctors and nurses to quit - something I can completely understand. As it is, at the moment, the rest of the hospital (300 beds) has only one doctor (Dr Terry, a recently retired medic from London).  All the junior doctors are currently on strike and the other few senior doctors have all died of ebola in the last few months – their faces in posters haunt the corridors; a continual reminder of the consequences of this devastating epidemic in a country that only had about 350 doctors at the beginning of the year.
In full PPE - I'm smiling I promise, you just can't tell!

Back to the Unit… once inside, a suspected ebola patient gets antibiotics, anti-malarials, water, oral rehydration solution and a blood test for ebola. They also get food twice a day from the hospital canteen. We are trialling IV fluid lines in the more stable patients with full auditing of any problems (there had been some previously) as rehydration is the most important intervention available. The blood tests take 1 – 2 days to come back so our 16 patients are told to stay in the beds, pee in one bucket next to their bed, poo in the other, and wait. There is plastic sheeting hanging between beds to prevent cross contamination. There’s a stench of chlorine (even through the mask) from the buckets in every room where we wash our hands between patients as we do all we can to try to prevent those negative patients becoming positive during their stay in the unit. When the test results are available, we give the negative patients a shower, a set of new clothes, a certificate and a bit of money for transport home. The positive patients get taken in an ambulance to a treatment centre – often Kerrytown, which is about an hour and half drive away.

There’s a fantastic team of local nurses and cleaners who we work alongside. They are often in full spirits and have been really friendly and welcoming to me. Inside the unit we all work together, helping patients to drink, giving medicines, washing down the beds, clearing up diarrhoea, vomit and blood and putting deceased patients in body bags and into the mortuary. It’s gruelling, hot work and exhausting in full PPE. In the decontamination room, we take off our PPE in the specific way required including the ‘shrug and wiggle’ move to get the suit off.  Lastly, we all compare sweat patches! Luckily this last week has not been so hot as the Harmattan has started (a West African dry wind that lasts for a few weeks).

My first shift proper, on Saturday, felt like a bit of a jump in the deep end, but actually I’ve come to realise it was probably fairly representative of an average day in the unit. Arriving at the main entrance of the hospital, I noticed an elderly woman slumped in a wheelchair that not many people were taking notice of, people just walking past her on the way to A&E and other parts of the hospital. Her relatives were sitting on the bench waiting for her to be seen at A&E themselves. I had no idea how long they had been there. However, it was quite obvious to me that she had died. I don’t know how long ago – whether she’d arrived at the hospital alive or even had been transferred to the wheelchair already dead. A nurse walked by in gloves & apron and, as I had no protective clothing on myself, she confirmed the absence of pulse but she didn’t want to tell the relatives. So I broke the bad news to the daughter, slowly, giving a warning shot, careful to use those good communication skills that had been drummed into us at medical school, even though we were stood there in front of her dead mother. She was upset but did not seem too surprised. Informing Tom of the situation, it was only then that I realised all sudden deaths had to be treated as ebola suspects. This woman’s daughter had told me she had a history of high blood pressure so I had just assumed she’d had a stroke, maybe she had, but the nature of the ebola epidemic is that you can never be too cautious. So all sudden deaths have to be dealt with full protection.  That had not occurred to me at all. Within, a few minutes, in full PPE we wheeled her into the mortuary, took an oral swab for ebola, covered her in chlorine and put her in a body bag with a nametag for an unmarked, unceremonious burial. There was simply no time for the family to grieve.  
A pretty blue wooden house we pass on our
way to the hospital each morning.

We then went to one of the open wards, where the nurses were concerned a patient had ebola and wanted him taken to the unit. Walking into the ward in full PPE, you could see the fear and silence descend amongst the other patients and their relatives (a surgical ward - patients with awful third degree burns, broken legs, head injuries etc). We transferred him to the unit and placed him in the only free bed, next to a young boy who lay curled up at one end of the bed facing the wall - the boy was the same age as my eldest nephew. Sadly, the man we had transferred died a few hours later before he had his ebola blood test taken so we took swabs instead. Again we put him in a body bag and transferred him to the mortuary. All the while I was thinking that poor little boy is witnessing such horrible scenes, how can he comprehend it all? He must have been so scared. In the isolation unit the scene can vary drastically day to day. The sickest patients nearly always end up lying on the floor, confused and too weak to move. They are also sometimes found lying in pools of diarrhoea and/or blood just next to comparatively well patients sitting quietly on their bed looking fearful.  On Saturday, one agitated patient, muttering to herself, had actually pulled herself towards another patient, holding onto his bed linen. It’s difficult to give any sort of reassurance through the barriers of the PPE and the patients unhelpfully just have to wait and sit it out.

The busiest time of day is when results are available and there’s a mass change over of patients in the unit. Yesterday the little boy, who had been curled up facing the wall, was discharged because he had tested negative. He was given new clothes, some jeans that were far to big for him, a yellow t-shirt and new flip-flops. He left the unit via the clean entrance where I was ready to greet him with a certificate and 10,000 Le (£1.30) to get the bus home. He was quiet and I’m not sure if he really understood the situation. With my arm around his shoulders, I gave him a big squeeze – the first human contact he’d had in 3 days, I tried to make him smile and reassure him that everything would be ok. We contacted his family and they came to pick him up an hour or so later. I was worried that this would be the first time I would witness first-hand stigma from his family, but thankfully I was pleasantly surprised.  His mother and grandmother arrived, all smiles, gave him a big hug and took him away. We are all thankful for those moments of happiness which so important to hold onto in such terribly difficult times.

1 comment:

  1. Dear Claire, Thank you so much for writing. Very interesting and wild reading, and I'm very glad to have the chance to hear it all first hand. Please write more when you have time. My very best wishes to you.
    Rick Yoder, Hackney