Sheffield doctor Charles Heatley kept an online diary of his experiences in Sierra Leone. Here are some extracts from it:
Sunday, November 23:
I’ve just completed a nine-day course at the Royal Army Medical Training centre near York, accompanied by 35 volunteers from the NHS and another 25 Norwegian health workers. We are getting ready to travel to Sierra Leone tomorrow for a five-week secondment from our jobs, funded by the Department for International Development.
The UK response to Ebola is being run by UK-Med, an NGO based in Manchester. After registering my interest they interviewed me by phone and accepted me. I’m not sure how I talked them into it as I have no prior foreign working experience.
What followed was worry, about how my wife would react, how our children, family and friends would react, how I was going to get freed from work, and would there be reimbursement?
The response has been overwhelming. My wife is quietly calm and supportive, and would go herself if she was able, so that was the best start I could hope for. The children took a bit more adjustment but have been wonderful. Friends have been hugely generous, saying that if there is one person they know suited, it’s me. That explains why I am going, it’s about being compelled. None of the people I have come across at the course are courting praise. Many have spent months or even years of their lives working in the most difficult and dangerous places on earth, and come back for more.
Within two weeks, after all the goodbyes, I was sitting in a lecture theatre being told about the epidemic, about Ebola virus, and how to manage patients suffering from the infection whilst keeping safe.
The other crucial part of the training is about PPE, or personal protective equipment. It’s how we put this on and how we take it off, and how we keep ourselves from becoming contaminated by body fluids that will make all the difference between being a safe worker and getting infected.
We flew yesterday evening and arrived this morning at the house which 11 workers will be sharing for the next five weeks.
Monday, November 24:
Today we visited the 100 bed Ebola Treatment Centre (ETC) at Goderich, due to be opened soon. It’s huge, an impressive feat of civil engineering due to be completed under the management of the British army in a total of 31 days.
From there we were driven to the existing ETC at Lakka, apparently built in only four days.
We watched as a suspect case was interviewed at the assessment area, again from the safe distance. He is a 45 year old fisherman whose neighbour had died of Ebola two weeks ago. He was clearly unwell, breathing rapidly, was weak and hiccoughing, a bad sign in this disease. He was admitted and will have been put on a drip, given fluids, antibiotics and other medicines; we will see if the test for presence of the virus, is positive or not. Whatever he has, we know he is very sick, with bloods indicating kidney failure.
Just getting into the PPE gear made us sweat profusely, and we saw people coming out of the red zone with soaking wet scrubs, so much so that they have to take them off and shower before putting on dry ones. We spoke to one pair of young men whose first job this had been ever, at the age of 17 and 19 - I imagine this would not be a popular YTS scheme back home.
Friday, November 28:
I saw up to eight critically ill patients tonight doing a round inside the red zone with the Serbian chief nurse Milos. Most of the population in Sierra Leone are beautiful, young, vibrant and fun loving, but desperately poor, and so the average age is I think 15 and the life expectancy at birth 53 years.
Imagine a healthy 25 year old becoming close to death with pneumonia in the pre-antibiotic era. You went into what was called a ‘crisis’ of sepsis, and if you were lucky you pulled through. That is what Ebola is doing.
I’ve admitted a few to the centre now, trying to find out how they became at risk and it is all too obvious that the message about not having physical contact with those suffering Ebola or dressing and hugging the departed wives, husbands and children is not being taken on board. It must feel inhuman to ask the local Ebola burial team to come and take your closest relatives away without a proper goodbye.
The ethos is to treat as vigorously as you would in Sheffield, London or Glasgow. Managing patients whilst wearing PPE is unbelievably difficult. As soon as you put it on in this heat and humidity you sweat profusely whilst standing still, so after one hour you put your hands down and feel the sweat pour into your gloves.
Monday, December 1:
This illness is bewildering us all. I’m seeing experienced doctors guessing what is going on as they try to catch up with the clinical signs and progress, and with the laboratory results that tell us the body is fighting infection, the blood is thickening through dehydration, the kidneys are shutting down, and the liver is palpably and biochemically inflamed. Then they develop respiratory failure. They are burning up, the virus is burning them.
One young doctor reminded me how unsuccessful Ebola is as an infectious agent - if you kill your host, you cannot get spread around so much.
Today I felt lost in the red zone. We have to prepare carefully so we know exactly what tasks we have to do in the short time we have before the heat and dehydration demand an exit. All I had to do was check on five patients, deliver medication by injection and head out.
I had a plastic bag containing four syringes. The first was malaria treatment for a young woman we think does not have Ebola, but who has to stay in until we get a negative Ebola test 72 hours after symptoms started. Her malaria test was positive. She had her one-year-old baby with her. Imagine being confined to a narrow hospital bed with a baby for several days. There is no complaint from these people.
Next was an injection of calcium to a young woman about to enter the storm when the virus is inflaming every major organ. She was uncomfortable, but we seem unable to help and have to be careful with drugs.
Next more calcium to an 80 year old man who had passed a lot of diarrhoea. A UK nurse, Pauline came in at this point and I helped whilst her expertise was only too obvious, calmly and competently cleaning him up. That is what people need as much as the intensive medicine.
Next to the third tent where the sickest people tend to be. I had some antibiotic for a man in his 20s, who is likely to die tonight; he was sitting again in diarrhoea, a sea of live virus on the other side of my gloves. He was very restless but had his arms tied to the bed; we have not quite worked out a better way. Without such restraint at times we would have to sedate chemically, which has caused poor breathing in people needing all the respiratory drive they can muster. If they wander in a confused state they could walk back into the suspected tent and infect people with ease.
I was starting to feel anxious at this point; those who know me will find this strange, as I don’t often admit to, or show much sign of anxiety. I think it was a sense of helplessness, which will improve in time as I get a clear sense of what can be done that is helpful, and what is inevitable.
Tuesday, December 9:
On the way out of the night shift, we passed a large group of young men waiting to be interviewed for hygienist jobs. The hygienists have in some ways the most dangerous job, coming into the red zone to clear up rubbish, blood, vomit and diarrhoea, and the bodies of the patients who die. The extra protection they get is that they wear washing up gloves instead of thin surgical ones.
Unemployment runs at 90 per cent here; literacy at 43 per cent. So there were many applicants but with a low educational level, looking for what is by local standards very well paid work with a large meal in the middle of the day. What goes unreported are the number of national health workers getting Ebola from work. Sadly one of our hygienists died in the ETC a few days ago. He had been off with a foot injury, and we will never know how he acquired the infection, whether from working at the centre or outside.
The NHS team at Lakka has moved to the ETC at Kerry Town run by Save the Children. In the hiatus four of us walked to Lakka beach, a beautiful seaside resort sitting behind a long golden sandy beach. You can see the potential for Sierra Leone as a tourist destination, as long as the people are given ten years without another civil war or deadly viral epidemic to deal with. I’m planning to come back for a holiday with my wife when it’s safe, it’s such a beautiful country with peaceful, friendly people.
Yesterday I did a late shift 2pm to 8pm. During two entrances of an hour I tried to encourage a two year old to drink. He was tired from Ebola but not that dehydrated. He was just miserable and asking for his mother. What a lonely place it must be for him. All he really needed was a knee to sit on and someone with a cup. My nappy changing skills at least came back to me! I’m looking forward to seeing him during my night shift tonight.
Thursday, December 11:
The first night shift and another poorly child worrying me through the night. Once we had assigned tasks I went in with one of the Cuban doctors, to find the poor six-year-old Mahawa barely responding to verbal commands, very dehydrated and hard to assess. Our attempt to do the malaria test was thwarted by my rapidly steaming goggles meaning I could not have interpreted the result. We tried to get her 17-year-old sister to help find out whether she was in pain and to encourage her to drink.
We managed to get a finger prick sample and did the tests for both sisters. Mahawa’s test was positive.
The big sister took her medication this morning and promptly threw up on my right wellie! I watched carefully as the hygienist sprayed the wellie down with the ebola killer 0.5 per cent chlorine. It apparently takes six microseconds to do its job, and certainly makes a good job of bleaching any clothes you are wearing, and we often have an end of shift cough from the fine spray.
Back to the chalet along the paradisiacal white squeaking sands and blue sea. There’s a lovely breeze to keep things cool whilst I sleep as long as I can. I woke up refreshed and went for another bout of bodysurfing. It’s not all bad.
I went back to work in the same ward and saw Mahawa again. She’s a little more responsive and less dehydrated but still seriously ill. I think her malaria is probably under control but the Ebola is now progressing. I decided to start singing whilst doing procedures with her, and I think she responded a little more.
Saturday, December 13:
Things are developing well at the centre. More international health staff have arrived and are nearly ready to work in the red zone safely, and a group of 30 Sierra Leonian Ministry of health nurses are on track, so the number of staff available will be much higher. I think another 500 wellies are needed to cope with the throughput.
The most important thing is that we sense a fall in mortality. This could be due to improved care, but also that the message is getting through that we need the patients to be transferred as early as possible in the illness, as we can keep in top of fluid losses better at way.
The best place in the whole camp is the discharge tent. Survivors come here after leaving the red zone, having a shower and being given clothes, all their possessions at entry including mobile phones being incinerated. They receive counselling about what to expect as survivors. Rejection through fear is common, adding insult to the injury of having lost loved ones in the days and weeks leading up to their own illness, or worse becoming orphans. They are given a ration of food to last three months: a sack of rice, a sack of corn meal, cooking oil, a Jerry can, gloves, soap and washing materials, money and the all important certificate to prove that they are cured and therefore not infective. How this is interpreted in a small village I’m not sure. Lastly they are given 90 condoms and told its best to abstain for three months as the virus can be present in sperm for that long.
Four young girls were in the limelight today. Two were smiling, one was quiet and one was distressingly silent and withdrawn, clearly deeply traumatised by the experience of the past week or so. Three of them gave short speeches expressing their gratitude and then we sang a song, and there was a short dance. I could not quite enjoy it, seeing the one young girl so unwell psychologically, but overall it is a joyful occasion.
Our most poorly patient remained Mahawa, only six and fighting to survive. It was great to see that she was looking me in the eye, rather than into nowhere, and asked for a drink, so I sang her another song. Early days but she might just make it.
Later on we had nine or so new admissions, one dead on arrival. I think people are sensing an improvement in survival rates already, so hopefully the hard work will pay off and give more hope to this part of Sierra Leone at least.
Sunday, December 14:
Amadou is getting better, the two-year-old I thought would die. It’s an achievement as infants generally have a poor prognosis, so this maybe another sign of improvement overall. I talked with Oliver, the new humanitarian director here; the signs are that survival is now above 50 per cent, which is a landmark.
We had a death on the ward yesterday just before the late shift started, a man who was clearly very unwell and getting more agitated. He became a danger to others and had to be sedated, but died suddenly, another feature of the illness.
The six-year-old is still holding on. I had to use a little emotional blackmail with her older sister who is now well, making it clear her sister was very ill and needed her big sister to keep making her drink and possible eat a little.
Wednesday, December 17:
We received between six and nine cases yesterday and today, a pretty chaotic process in which ambulances arrive and we don’t quite know what to expect. On each day one patient was not on the list we had received, and tragically one man died on the trolley whilst we were deciding where to admit him; we did not even know who he was.
They vary from people only a few days into the illness without much vomiting or diarrhoea, to dreadfully ill people with severe dehydration and resulting kidney failure, unbelievable diarrhoea, vomiting, and confusion.
The six-year-old girl on my ward, Mahawa, seems to be turning the corner much to everyone’s surprise. So from getting ready to mourn her loss two days ago we could all be dancing at a discharge in a few days’ time.
Having not felt as upset as everyone seemed to think I would be by all this death and misery for the patients, it has crept up on me at times, I think more because of seeing small children afflicted.
Sierra Leone desperately needs doctors. They have invested in community health officers trained to respond to people presenting with the most common illnesses here: malaria, typhoid, childhood infection and malnutrition. Many of these amazing young people want to become doctors, the barrier being cost - the fees are £2,500 per year, let alone the books and living expenses.
Monday, December 22:
Survival figures are improving. Since the ETC started providing IV fluids more aggressively, we have seen a big improvement in survival especially in those coming in with diarrhoea, vomiting and resulting dehydration.
Mahawa is better! Her Ebola test was negative yesterday and she is now asking for and eating rice and stew, and whatever else we give her. I think many people will want to attend her discharge ceremony and I want a front seat.
Only five days to go for our group. More are coming today and will hopefully be up to speed by the time we go; this is why we need the national staff to take the main role.
Thursday, December 25:
Happy Christmas everybody. Am now looking forward to getting home now!
Mahawa was discharged yesterday and I missed it! Another patient was interviewed for ITV and said all sorts of nice things about us.
My Christmas afternoon was made special by having a number of the community health officers join us. They are a special bunch, the real heroes of this epidemic, in it for the long term, and unrecognised. It is hard to get a scholarship to medical school unless you have the right connections, so these workers do my job with just three years training.
The other good news is the numbers of new cases in this area of the country are reaching a plateau, hopefully a sign that the fire is burning out.
Saturday, December 27:
This morning I went to the ETC one last time to say goodbye to all the friendly Sierra Leonians. I also thanked the Cuban brigade. They have come right out of their shells now and are taking on more and more responsibility.
I headed for the discharge tent and watched a brother and sister go through the process. Both were clearly very poor, were thin even before Ebola, and both illiterate, as instead of signing a form they had their thumbs painted in biro and pasted a fingerprint. I did not see them leave, but left them smiling and clutching their certificates and $750,000 Sierra Leonian dollars (£90). I wonder how the next few days and weeks are going to be for them. There is still a lot of cruelty toward survivors as people fear them.
It’s hard to leave now, but I’ve just had a swim and my head is thinking of my wife, the children, family, home, the puppy and cheese.
To read Dr Heatley’s full blog, visit https://charlesheatley.wordpress.com