Interview with a clinician who worked with Ebola patients in Sierra Leone
Tom Rawlinson is a doctor working towards a career as an academic clinician in the field of tropical infectious diseases. His medical background is diverse, ranging from single-handed General Practice on Hebridean Islands to treating a wide variety of tropical diseases in South America, Africa and Asia. In June 2015 he received the Ebola Medal for Service in West Africa awarded by the UK government. He is currently a Wellcome Trust Clinical Research Fellow and DPhil candidate at the University of Oxford, working on a vaccine against P. vivax malaria.
Q. How did your involvement with Ebola come about?
Having previously worked in Sierra Leone, it was a place I knew and through friends and colleagues still based there I had an ongoing connection with the country. This, combined with my being in the field of tropical infectious disease, led me to join the effort against the epidemic.
In late 2014 I was invited to join a team from Oxford who were running a clinical trial of an antiviral drug against Ebola.
Q.What was the reaction of your family and friends when you told them you are going to an Ebola hotspot?
When Ebola first starting making headlines, in the summer of 2014, my mother called me for reassurance that I was not about to jump on a plane to West Africa. In all honesty, at that point, I reassured her that I had no immediate plans. However, as the situation worsened and I heard reports from friends out there, I felt a growing compulsion to volunteer.
When I did accept the offer to join the Oxford Clinical Trial group and leave for Sierra Leone, it of course triggered concern among family and friends. I was able to reassure them that the group I was going with were with highly organised, with meticulous contingency plans and the highest levels of precaution.
Compared to my previous work in Sierra Leone in 2008, communication with home was much easier and while out there I was able to send regular messages of reassurance to family and friends back home.
Q. What specific training did you undergo before travelling to SL?
All UK healthcare workers going to the Ebola region were offered pre-deployment training. Those who trained us, primarily in infection control, were staff who’d just returned from the epidemic region and were well aware of the current reality on the ground.
We were drilled over and over again in how to safely put on and take off the personal protective equipment (the ‘Ebola suits’) in a super-heated hotel room in the Cotswolds, but despite their best efforts nothing prepared us for the oven-roasting we got in those suits in the West African heat.
Q. Can you describe working in an Ebola treatment centre?
The Ebola Treatment Centre (ETC) I worked in was on scrubland on the edge of Port Loco, a dusty crossroad town with around 20,000 people about 2 hour drive from the capital Freetown on the main road to Guinea. It had been built by the British MOD to a standardised plan designed to minimise transmission of the virus.
The ETC was run by an Irish Non-Governmental Organisation (NGO) called ‘Goal’. As the epidemic exploded, more and more international NGOs and national delegations arrived in the country. As one of the World’s poorest countries with some of the worst health statistics, there were already many aid groups in country and most of these diverted their focus to Ebola.
As a clinical trial group we integrated our work with the healthcare staff, both national and ex-pat, who were running the ETC. As clinicians and nurses, we were on a roster to enter the Ebola wards, known as the ‘Red Zone’, and perform various bedside tasks including; consenting patients, drawing blood samples, administering intravenous infusions and monitoring vital signs.
It was routinely above forty degrees Celsius and approaching 100% humidity. A major concern was of staff collapsing from dehydration/heat exhaustion whilst in the Red Zone.
Taking blood samples and setting up intravenous infusions is difficult enough through double gloves and goggles, but when the goggles are half filled with sweat and the patient is delirious it can be extremely tricky.
Individual visits to the Red Zone had to be kept brief (usually under an hour) for the safety of the medical staff.
Q. What was your remit?
I was working as a Clinical Trial Doctor with a group from Oxford conducting a trial of a candidate anti-Ebola drug. The trial regime involved giving a daily hour-long intravenous infusion of the drug for up to 7 days. This was a challenging task. Firstly, the complexities of taking consent from the patients were significant and involved explaining the pros and cons of a complex drug across the linguistic, cultural and educational barriers. The patients were often very unwell on arrival and usually extremely distressed. We spent a lot of time discussing with local colleagues how best to communicate in a clear way with the patients. Secondly, giving an experimental drug as an intravenous (IV) infusion in an Ebola ward is a major undertaking. Patients with Ebola are often agitated or delirious and this, combined with the intense heat and the thick suit, made the normally simple act of setting up an infusion, very slow and painstaking. Once the difficulties of gaining IV access were overcome, the patients had to be observed continuously in case of an adverse reaction.
Q. Tell us more about the protective equipment and the treatment zones.
The “donning” (putting the equipment on) is done with a buddy who checks that you have everything on correctly. It takes around 15-20 min. and includes double surgical gloves, a full body suit, rubber wellington boots, a plastic apron, a respirator, a hood and then goggles over the hood. From the donning station you then enter the Red Zone and move in a one way direction from the suspected to the confirmed wards. Chlorine is everywhere – buckets on stands for washing hands and chlorine baths to walk through at every entry and exit point.
Following your Red Zone shift, you would enter the “doffing” station to begin the slow process of decontamination. This involved walking through a series of chlorine baths to decontaminate your boots, then, arms aloft and legs spread, being sprayed head to toe, back and front with a spray jet of chlorinated water. As one by one, each layer of protective equipment was carefully peeled off at the command of your ‘doffer’, you were re-sprayed.
The whole process took about 15 minutes and was observed by monitors for any potential breach in protocol. Everything apart from the rubber boots and goggles was then incinerated.
Q. Can you describe a typical day?
We would meet in the very early morning, so as to get as much done as possible before the afternoon heat made entering the Red Zone almost unbearable.
A daily rota of Red Zone entries was drawn up depending on how many patients we had that day. We would always enter the wards in pairs, never alone.
If there was a newly-confirmed Ebola case patient, two of us would go in to explain the trial and discuss consent with the patient. If the patient consented to the trial and the paper work was completed, another team would then go in to take baseline blood tests, set up the infusion of the drug and monitor the patient every 15 minutes for the first hour (heart rate, blood pressure, temperature). Another team would then go in to monitor the end of the infusion, take further blood samples and observe the patient during the immediate post-infusion period. There would be a number of review visits; at 1h, 2h, 4h, 6h post-infusion. These were hot and exhausting 12-hour days, but despite the fatigue it was crucial to remain focused whilst in the Red Zone to minimise risk of transmission.
When not in the Red Zone with the patient, we would be closely observing our colleagues from the “spotting” areas - the wards were large open-ended tents to allow observation from outside, in case they got into difficulties. The main risks were of health care staff collapsing due to the heat or from agitated patients leading to breaches in the protective equipment.
There was also a lot of trial data to process and many meetings, both over Skype to our Oxford colleagues and with various local groups.
Q. What was happening in the rest of the community?
We were staying in a large tented compound built by the Danish Army. It felt like being in a military camp and reminded us of the American TV series M*A*S*H*! There were many different groups of aid workers in the compound, including the UN, MSF, Partners In Health etc. The camp was on the outskirts of Port Loco; the surrounding region was a hotspot for Ebola transmission.
My memories of Sierra Leone, from six months spent there in 2008, were of a vibrant, noisy, tactile place. But in this visit, in the time of Ebola, there was an eerie silence. All public gatherings were banned, schools were closed and there was a ‘no touch’ policy throughout the country. There were regular road blocks where you would have a temperature gun pointed at your head. We stayed mostly within our compound so it was hard to get a sense of life in the community, but from what we heard the country was in a state of shutdown.
Despite being banned there were reports of traditional funerals still happening in certain areas and some of these led to large clusters of Ebola cases. There were many conspiracy theories at large among the population about the origins of Ebola and in some cases suspicion of the intentions of the foreign aid workers. Many, many delicate discussions had to take place with local chiefs and community leaders to get across a clear understanding of the nature of our trial and control expectations in what was a time of panic and fear.
Q. What was the most difficult aspect of your stay?
Physically, it was the heat. Working safely and effectively in an Ebola suit at 40 degrees was exhausting.
Mentally, it was the sense of impotence. As a doctor you can normally offer some hope to your patients. But for Ebola victims there was little to offer. Many died, a lot of them children and often entire families. For this reason I was glad to be there as part of a clinical trial – at least there was the hope of an effective treatment.
Many medical staff went in and out of the wards, but this was not like a hospital ward elsewhere where relatives and friends are by the patient’s bed. The patients were dying alone. Their last human contact would be with a foreigner in a space suit. A terrifying and lonely way to die.
It was bleak to see a country normally so vibrant in a state of fear and paralysis.
Q. Were there any positive experiences?
Among all the despair, there were of course moments of joy. When a patient was declared recovered and free from the virus, spontaneous singing and dancing would erupt as they left the ward.
Among survivors and relatives of those who died I saw great resilience and strength. You have to recalibrate loss in a place like Sierra Leone. In the West losing a child is a life defining tragedy, but there it is unusual if a mother hasn’t lost at least one child. The way people cope with loss is different because it is much more an expected part of life, so in some sense they are perhaps more resilient.
An Ebola survivor from our ward whose whole family had died from the disease and had nowhere to go on discharge, was taken in by the family of another survivor from the same ward. I heard many stories of similar acts of kindness to strangers: a kind of solidarity among those whose lives were ripped apart by Ebola.
Q. If there was another similar outbreak, would you go again?
With a vaccine now available we all hope that there’ll never be another epidemic on this scale, but if there were to be then yes I would consider going again.
A huge amount has been learnt from this epidemic about what was, until last year, a little known disease. If this acquired knowledge turns into solid contingency planning then any future outbreaks should be stamped on before they spiral out of control.