Hope in Sierra Leone

Regan Marsh wears personal protective equipment to admit a patient.
Regan Marsh wears personal protective equipment to admit a patient.

Regan Marsh, MD, MPH, of BWH’s Department of Emergency Medicine, shares the following update from Sierra Leone, where she is working with Partners In Health (PIH) to care for Ebola patients. Although the situation is dire, Regan says, “There is definitely hope.”

Partners In Health is managing Ebola in 4 regions of Sierra Leone, including an Ebola Treatment Unit, a maternity hospital, two public hospitals and many rural community sites. I am primarily based at the Government Hospital in Port Loko, trying to effectively reopen it in a robust fashion, since it was deeply impacted on all levels by the epidemic.

In terms of my day-to-day, there’s lots of clinical work, as we’re now busier — which is good, the hospital had been close to deserted, which was concerning. People were missing needed care. As Paul Farmer has said, the majority of Ebola deaths won’t be from Ebola; they’ll be maternal deaths, and kids with diarrhea and malaria, and others who can’t find care in the time of Ebola.

At Government Hospital, we’ve just implemented universal screening for everyone who enters the hospital to keep staff and other patients safe. My biggest concern is that an Ebola patient will present to the hospital, be mistaken for having something else, and then infect the staff and other patients.

Photo credit: Bec Rollins/Partners In Health
Photo credit: Bec Rollins/Partners In Health

Ebola can look like a flu or gastroenteritis: vague body aches, fatigue, vomiting/diarrhea, low grade fevers. Bleeding complications are rare and the disease takes 4-7 days to make people really sick, so they’re infectious for a while before they look bad. So now, if anyone screens positive as they enter the hospital, they are isolated in our holding area and either to transferred to the ETU (if they’re very sick and likely to have Ebola) or, if they’re stable, wait there for their ebola PCR results. Our holding unit has 27 beds with a variable number of patients, depending on screening. We’re still working on patient care protocols, improving the lab process, and doing lots of staff training.

Regan Marsh helps an ebola survivor.

The hospital itself was always desperately poor and now has been stripped of resources even more: health care workers who have been diverted to the Ebola response, supply chain which has been disrupted, priorities shifted, etc. There is some frightening data that recent gains here since the civil war in maternal and child health have been reversed — women afraid to come to the hospital for care, or find the hospitals closed, or don’t find a doctor or nurse to treat them, etc. Last month, PIH had to quarantine the neighboring public hospital, because sadly one of its nurses tested positive for Ebola and had been actively working. All staff who had been in contact with her were kept until surveillance for 21 days. It’s a terrible disease because it most infects caregivers — wives, mothers, children and health care workers, all who are trying to take care of the sick.

But, there is definitely hope. We have some amazing Sierra Leonean colleagues who haven’t taken a day off since this started… including an amazing clinical officer, Jon Martin, who helps to run the ETU and works tirelessly day and night. Every morning on rounds he knows the status of all 60 to 70 patients. He cares deeply. And our Ebola holding unit at the maternity hospital in Freetown is run by a 25-year-old British nurse and former Afghan paramedic paratrooper, named Andy. He has gone from being a trauma nurse to essentially a midwife for women with Ebola — and is also so compassionate and wonderful. He has personally seen over 1000 patients with Ebola (20 percent of all total Sierra Leonan patients), having worked as an unpaid volunteer with another organization in Freetown for 6 months. He has done an amazing job of training the local nurses and midwives in the critical infection protection and control, so they are safe.

Photo credit: Bec Rollins/Partners In Health
Photo credit: Bec Rollins/Partners In Health

In other good news, we’re up to 124 survivors (as of last week) and we believe our mortality rate has fallen below 40%. In the last weeks, we’ve implemented a new clinical protocol based on some positive evidence from another unit in Freetown. It’s essentially just good early sepsis care for everyone with possible ebola: volume resuscitation, antibiotics, vitamin K, zinc for diarrhea, empiric potassium, and malaria treatment. The previous “standard” was to offer only limited care or wait until people were sick to provide more treatment. We’re working to maintain the highest safety, while improving scope and quality of care to provide Ebola patients the care they need and deserve.

Survivor Tree
A Survivor Tree where all the patients who are discharged tie a piece of cloth to symbolize taking off their name band and going home.

Even though things are difficult at times, there is also real joy and happiness too — in our team, volunteers and patients. We find the recovering patients sitting outside their ward, playing cards in the sun, waiting for the time when their tests come back negative and they can go home. They help to take care of the sick, as well, and look out for those in need. Our goal is to improve care for the individual patients, so they can survive Ebola, but also to work longterm with our Sierra Leonean colleagues to strengthen places places like Government Hospital, so they can provide the desperately needed health services to the people.