Dispatch from Guinea: Containing Ebola

UNC’s Dr. William Fischer II has been working in an isolation area in Gueckedou, Guinea, since May 28, 2014, as part of a team from Doctors without Borders (Médecins Sans Frontières/MSF) to try to help reduce mortality from Ebola Virus in rural communities. Dr. Fischer was recruited by the World Health Organization (WHO) because of his critical care medicine expertise. With Dr. Fischer’s permission, we are posting his descriptive emails, that give insight into the experience of a frontline effort to contain the deadly pathogen.

 

May 28, 2014 

Everyone,

I have just received orders from WHO and its country office to head to Gueckedou tomorrow by plane. It is in the southwestern part of the country right next to the Sierra Leone and Liberian border in what is considered the Forest region of Guinea. It is also the epicenter of the Ebola outbreak.

Two weeks ago everyone thought the Ebola outbreak was over and there was a problem with contact tracing (involving who would pay the people for tracking down contacts). As a result, there are now multiple foci of Ebola outbreaks across the entire country and now into Sierra Leone.

Gueckedou is likely the safest place to be as an isolation zone is already in place and a standardized system of caring for patients.

More later. I love you all!!

Billy

Jun 1, 2014

Everyone,

I'm sorry for the delay in correspondence - we are truly in the middle of the bush and water, electricity, and internet are extremely limited.

There is quite a lot of despair in and around the Gueckedou.  Unfortunately the epidemic shows no signs of slowing despite heroic efforts by both Doctors without Borders [Médecins Sans Frontières/MSF] and WHO. 

I'm typing as quick as I can right now as there are five new admissions and very little chance I’ll get this off before I lose the connection. 

FischerThe continuing epidemic is really a result of significant distrust between the local population and treatment/epidemiology teams, as well as, the non-specific nature of the symptoms.

Hemorrhagic complications occur only 50-60% of the time and many of them are mild (bloody diarrhea and hematemesis [vomiting of blood]). It is different than what the movies and books have projected although I suspect that early descriptions came from end stage cases that received little care. 

The isolation zone/treatment center really serves two purposes - to isolate patients in an attempt to stop the train of transmission and to provide what little care we can. As you can imagine we have limited resources for treatment. My role has really been to try to provide critical care clinical guidance to see if we can improve our mortality rate but to be honest we are truly limited by the personal protection equipment (PPE).

The PPE consists of scrubs, a pair of gloves and large rubber books both covered by an impermeable tyvec suit then covered by an impermeable full-length apron.  A mask covers your mouth, goggles cover your eyes and an impermeable hood covers your head so that there is not a single inch of skin exposed.  This is all in 30C [86F] heat with >90% humidity. [Editor's note: The PPE described by Fischer, and pictured here, is a variation on the WHO's recommended PPE. PPE had to be adapted for use within the isolation facility.]

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Dr. Fischer, exiting the isolation zone.
I am now starting to acclimate after 3 days with 2 tours in the isolation zone. I had my doubts on the first day. This experience does offer an important perspective on critical care in that one of the most important aspects of what I am able to do at UNC is reassess and adjust my therapy whereas here I have to assess, make a decision, run outside, yell for fluids to be prepared, which are thrown to me, then run inside and set up the IV. Then do it again for the 14 other patients currently in isolation. I’m not sure that I can augment care without the ability to reassess. I had hoped that improving the care of patients might allow us to find some life amongst all of this death but I’m not sure if it will work out that way.

My day starts with rounds at 7:30 a.m. and I usually have to call for another car as the last truck has usually left by the time I’m out of the isolation zone (around 9-10 p.m.) and head back to the hotel. Fantou Rose experienced its peak as a hotel a LONG time ago. Now it’s a shell of its former self without water or electricity but there is a mini fridge and a TV in the room, neither of which work nor look like they ever worked.

But there is nothing quite like a bucket shower after losing 8 liters of sweat in a day.

The hardest part is not being able to talk with Leah and the boys, who I miss dearly. I love you all and will call soon.

Best,

Billy

June 2, 2014

Today was a pretty tough day - one of the first two patients I admitted on May 30 died.  I walked into his room and he was on the floor half naked surrounded by bloody emesis and diarrhea.  I put him back in bed, bathed him, and put fresh clothes on him and as I finished he died. 

It’s pretty emotional to bathe a 27-year- old man who was incredibly strong and rendered completely helpless. His sister is next door and will likely die in the next hour. This is all in front of the other patients in the room, many of whom are family members or neighbors. The despair is suffocating. My computer is running out of batteries. Sorry, more to come.

Love y’all,

B


June 3, 2014

Each day has its bright and dark moments.  There are two people in the “treatment center” that are improving.  One is a young man who has started helping us encourage the other people in his room to drink more and to keep fighting.  It is inspiring to say the least.  The other is an older man who claims to be 35 but is more likely 85 and every time I walk into his room he acts like he is doing calisthenics - it provides a moment of levity against all of the struggle that defines the isolation zone.

Unfortunately we also have an 18-year-old woman who is 5 months pregnant, has Ebola, and malaria. I thought being 18 was tough - I can only imagine being pregnant, infected with a near uniformly fatal virus, having malaria, and being in an isolation zone treated with people in space suits. The clinical course of pregnant woman with Ebola is not good, to say the least, and unfortunately she began having contractions overnight and we “helped” her deliver a non-viable fetus this morning. Miserable.

Fortunately we found some oxytocin in the village and were able to give it to her but she has had significant hemorrhage. There is no blood to be given and no family has shown up who could potentially donate. I’ve been trying to resuscitate her with LR [Lactated Ringer’s is a fluid used as a blood substitute when a blood transfusion is not possible] but it feels like I’m trying to put out a fire with squirt gun.

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Dr. Fischer (third from left) and the clinical team.
Relations with MSF are excellent and we, along with 3 local physicians, are working well together and supporting each other.  The one or two patients who are showing signs of life motivate me (us) to continue to push for every inch. I’m hoping that we can discharge the older gentleman today as a cure which would be great for him, us, and the rest of the patients!!

Yesterday, I went into the isolation zone carrying a small thermometer in my pocket to measure the temperature in my suit - 46C or about 115F. We spend between 1-2 hours in there at a time, typically, 2-3 times per day. You lose all sense of time once you're inside, but have to pay very close attention to your breathing and heart rate and head out when they start to increase, as it takes 10 minutes to actually get out. 

Today there is a big meeting between the Gueckedou team and teams from Liberia and Sierra Leone. In addition to losing my sense of time, I have no idea how the epidemic as a whole is doing because I’m so focused on the clinical work. At night I try to get updates from the WHO epidemiologists and it all sounds very discouraging. Each day there is a new report of 10-15 deaths in a particular village. It is pretty amazing, however, to link the patients and risk factors together in an attempt to understand and stop transmission.

What else can I tell you other than I’m happy, healthy, miss my boys and Leah. I do worry about how to transition back to academic life and how to build upon this experience.

Love y’all,

Billy

June 4, 2014

Part of what makes Ebola so devastating in addition to the manner in which people die, is that this virus wipes out families.  It penalizes those families who are close and transforms tradition into transmission.  The 18-year-old pregnant woman that I wrote about yesterday died.  After delivering she continued to hemorrhage despite oxytoxin and uterine massage.

When her husband was told about this he responded with, "ma vie est fini" (“my life is over”). Ebola has killed his mother, his mother-in-law, his wife and their unborn child.  I worry that when the fight leaves a person the body is quick to follow.  Similarly, when a woman died last week, her mother, who was also a patient and improving, soon followed. I'm not sure that there is anything worse than dying with despair after watching your child die.

Despite all this suffering there are moments of hope.  There is one older man, who, as soon as I walk in, starts doing calisthenics to demonstrate his clinical improvement.  I can't help but smile and he has started doing them when he sits outside and we walk by - he is the first person I look for when I arrive at the isolation center.  Another younger man has started to do well and I anointed him team leader for his room.  He has embraced this role brilliantly by helping the other patients in this room encouraging them to drink and helping to translate Kissi into French for me.  

People in Gueckedou are incredibly kind and seem so happy though it is hard to think that life is fair given the juxtaposition of excess in the developed world and need in resource-constrained environments.  Despite this inequality, we are treated so well by our hosts and by the patients and that kindness is incredibly motivating.

My role as a physician has also changed importantly.  Here, in addition to treatment plans, I clean, bathe, feed, change IV lines, and teach.  Clearly, I'm more proud of the comfort I provide than the treatment that I lack but I'm more hopeful today than yesterday that critical care management will save some. 

Love you all!!

Billy


June 7, 2014

Ebola Chicken and Transmission

The MSF operation is impressive. It’s composed of many different subgroups including physicians, nurses, staff who clean the personal protection equipment and scrubs, hygienists who direct the PPE removal, the European lab group, epidemiologists, anthropologists, contact tracers, community outreach/educators, and others. Each one has a different coping mechanism to deal with the duress of this work. The physicians argue about when to retest those that are doing well because once they are symptom-free for 3 days and have two consecutive negative tests separated by 48 hours they can be discharged as cured. The hygienists listen to music although this week they've been on a Celine Dione kick which requires its own coping strategy. However the Euro lab strategy is the most amusing - they want to test the Ebola chicken. Although the isolation zone is designed to separate those who are suspected of infection, those who have confirmed Ebola, and health care providers, it is practically impossible to keep the free range chickens from running where they want. There is also a rabbit that pops out around the suspect tent every day. It’s a bit concerning from an infection prevention and control perspective that these chickens can get in and out of the isolation zone - it brings up the constant concern for transmission of Ebola and the perceived need for such intense personal protection equipment.

The Ebola virus has been isolated from almost every body fluid including sweat, semen, blood, urine, oral secretions and tears. As I mentioned yesterday, this virus has transformed tradition into transmission. Many of the people who test positive have participated in the funeral of a loved one which involves intimate interaction with a body including touching and cleaning the body, and even eating in the same room as the body. Unfortunately, patients with Ebola continue to secrete body fluids after death. So much so, that in the Gulu outbreak (Uganda) they had to wrap the bodies in rugs to absorb the fluids that were released. This virus thus transforms a cultural experience that brings people together into a foci of transmission facilitating spread of the virus to many more people and their families when they return home. Even before death, though, when people become ill, they are cared for by their loved ones as any and all of us do. When was the last time you wore gloves, eye protection, and an N-95 when your son or daughter had diarrhea?

Infected pregnant women create an especially volatile situation as they are often assessed weekly or monthly by midwives who rarely have the necessary protective equipment. The infected midwife spreads the virus to the women she sees clinically. Unfortunately, there has never been a report of a pregnant woman who has survived and our experience in Gueckedou is no different. To make matters worse we admitted a symptomatic midwife who has been working the past week and has now tested positive. In a cruel twist the very centers that promise to provide and protect become those that transmit.

The potential for hospital-acquired transmission coupled with the incredibly high mortality rate of Ebola (and especially the Zaire strain which is the one we are battling here) leads to significant distrust between the community and the treatment center. They see us taking their family members with nonspecific symptoms (fever, diarrhea, vomiting) and returning them in a sealed body bag and robbed of their ability to say goodbye as their culture deems appropriate. Rumors claiming the white people brought Ebola certainly don't help but I also can't blame them as the times that we truly intervene are during moments of crisis. This becomes a circular problem as the later the patients present, the more difficult it is to resuscitate them and the higher the death rate which leads to more distrust, more hiding and more death. The most powerful therapy for this is to save a life and to bring them back to their community. This is called a “sortie guerit “ or discharge cure. Yesterday, we had two and it was pretty emotional - the entire physician and nursing team were clapping and yelling as these two men walked out. Today we have another potential and I'm waiting for her test now.

A truck has just rolled up with a pretty sick woman and child, will write more later.

Love you all!

Billy



June 8, 2014

As the reality of my departure nears I can’t help but feel some sense of guilt—guilt for not having done more, faster, and better. But I think this feeling emanates from the fact that I can leave and the patients in this epidemic can’t. Last night we admitted a young boy who was transported with his mother from Kueldou. They had been locked in a house for four days because they were symptomatic. Unfortunately the delay in presentation was significant as only the boy was admitted because his mother died in transit. A 9-year-old boy sat next to his mother as she died. Now he sits in the isolation ward alone.

His father and brothers walked the 25km today to the isolation ward as the family’s village has rejected them and reported that the father may have symptoms. The MSF team sent a car to pick them up but the father refused to ride given what happened to his wife.

Fortunately, the 3 other siblings do not have symptoms but I’m concerned it’s only a matter of time as the father walked 25km with one of the children tied to his back exposing him to potentially infectious sweat. The estimated 21-day incubation period of Ebola complicates contact tracing given that people can theoretically be symptom free for 3 weeks following exposure. Since we can’t hold the family in the isolation ward for 3 weeks we can only test them now and formulate plans to follow them in case they do develop symptoms.

When the 9-year-old was brought into the treatment facility he barely had a palpable pulse. When I met him he was weak, in pain, but incredibly stoic and most awfully alone. With fluid resuscitation we were able to get a pressure and with that a chance. His clothes were soiled and so we brought a new outfit for him. After some effort I got him to smile and in that smile I found false hope.

With Ebola you can’t have a good death. You are isolated from your friends, your family, your home. You are cared for by people whose primary focus is on stopping transmission from infected to susceptible and from patient to provider rather than comfort and cure.

These people often die without the comfort of a human hand, without seeing someone's full face or even just knowing that a loved one is near. I think of all the death notes that I’ve written in the United States and the bulk of them usually include the sentence, “they passed away peacefully with family at the bedside.”

I didn’t get a chance to write that for this little boy. Despite the hope that his smile brought me, he died overnight. In the void of darkness he converted to hemorrhagic shock with massive vomiting of blood and I’m told he bled out on the floor of the isolation ward.

I can’t help but think about what his last days were like – being locked in a house with his mother by his family and his community out of fear; then watching his mother die in the back of a pick up truck, being placed in an isolation zone staffed by foreigners in space suits, and finally vomiting blood alone.

I am troubled that I’m not better at this - that I haven’t figured out a way to implement more advanced healthcare infrastructure that would allow us to save more. When this epidemic is over I am sure there will be more time for reflection but now there are more patients and more chances to help.

Miss and love y’all

Billy



June 10, 2014

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Dr. Fischer in the village of Kissdougou.
I’ve just made the 2-hour trip by truck from Gueckedou to the dirt runway of Kissidougou and I’m trying to process all that has happened over the past three weeks. I’m told this is the first time that WHO has specifically sent critical care clinicians into the field to try to help improve the clinical care of critically ill patients. They have sent countless physicians into the field as epidemiologists, anthropologists, and infection control and prevention experts who have done amazing work to provide care and stop disease transmission but sending critical care specialists is somewhat new. Ultimately, I think that this has demonstrated real promise and I think we’ve also learned a couple of things:

1. Ebola-related mortality can be reduced immediately with early, aggressive critical care management. While vaccines and specific antivirals would be extraordinarily helpful, the majority of patients are presenting with low blood pressure and shock that is responsive to aggressive fluid resuscitation. 

I believe the key; however, is not just in the recognition of shock and institution of early aggressive fluid resuscitation, but also in the constant reassessment and modification of therapy as needed which is a defining feature of intensive care medicine. 

Additionally, while vaccines and Ebola-specific antivirals are years away, aggressive supportive care is possible now. Improved mortality rates from augmented clinical care will result in enhanced trust between patients and providers and ultimately earlier recognition of those that are sick and decrease transmission.

2. The fear of Ebola is almost as dangerous as the virus itself. I truly believe this is a significant barrier to improving the clinical care of patients infected with Ebola. The most difficult part of this mission for me was the week prior to leaving Geneva for Guinea. I was consumed with how this virus is portrayed (90% mortality, bleeding from every orifice, decimated villages, etc.) rather than what we know about this virus (it is caused by a virus that is readily transmissible, has hemorrhagic complications of varying degrees in 50-60% of the time, and is potentially survivable with aggressive clinical care).

Fear is incredibly inhibiting to both healthcare provider recruitment and with contact tracing – two critical pieces in the struggle to control an outbreak. Patients fear the isolation zone because their experience has been one sided: friends and family members go in with common symptoms of diarrhea and vomiting and leave in a body bag with absolute restrictions on touching the body. 

Additionally, trying to recruit physicians to come to a resource-limited environment to fight a virus that is synonymous with death has been difficult, to say the least. But the data on transmission and our experience with this virus tells us that transmission can be interrupted with effective infection control interventions.

I look back at my own recruitment and remember a conversation that I had with Rob Fowler in which I said, “if you don’t get me on that plane soon I’m going to think my way out of this.” It was mentally exhausting worrying about my ability to contribute, my own safety, and the effect this mission would have on my family. In hindsight, getting on that plane was both incredibly difficult and one of the best decisions I’ve made professionally.
Destigmatizing this infection is just as crucial as providing intensive clinical support as both will lead to patients presenting earlier in their illness and increased numbers of healthcare workers to assess and reassess patients.

3. There is an incredible strength in the combination of structure and flexibility. Healthcare organizations are not only capable of working together but it is abundantly clear that we are stronger together than apart. MSF and WHO are incredibly capable organizations that separately provide great work but together they can be both synergistic and heroic. 

Without the structure of MSF, I would not have been able to solely focus on patient care, and without WHO, MSF would continue to provide great clinical care but hopefully will benefit from subspecialty expertise. There remains; however, a tremendous need for organizational and regional coordination to ensure this crucial synergy.

The location of this outbreak has profound geopolitical implications and as a result I’m concerned that this epidemic is far from over. I’m leaving with both hope that critical care support can improve outcomes of Ebola infection and some sadness that I’m leaving before the end of the epidemic.

Miss and love you all,

Billy

About Dr. Fischer

William Fischer, II, is associate program director for research in the department of medicine’s division of pulmonary diseases and critical care medicine.  Billy (as he is known) grew up in Chapel Hill, N.C., and has always been particularly interested in infectious diseases.  He went to UNC School of Medicine and then was a medicine resident, chief resident, and pulmonary and critical care fellow at Johns Hopkins Hospital.  During his training Billy worked at the U.S. Centers for Disease Control and Prevention and the World Health Organization (WHO). In June, Dr. Fischer was asked by WHO to help work on emerging pathogens and he has been sent to Guinea to work with Doctors without Borders (Médecins Sans Frontières or MSF) to try to help reduce mortality from Ebola Virus in rural communities.

Dr. Fischer lives in Chapel Hill, N.C., with his wife, Leah, and two sons.

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