Standing at the Gates of Hell

Yesterday I posted on the Ebola outbreak going on in Uganda with a large portion of the entry dedicated to discussing the fleeing of medical personal from the outbreak. Today, crfullmoon of PFI posted a link to Paradoxuganda written by Drs. Scott and Jennifer Myhre based in Bundibugyo, Uganda. Their recent blog entries have dealt with an on-the-ground-up-close-and-personal account of this team amidst the Ebola outbreak. They have not "fled", instead, they are "standing their ground".

 

There is a Tom Petty song that I am quite fond of:

I Won't Back Down

Well I wont back down, no I wont back down
You can stand me up at the gates of hell
But I wont back down

Gonna stand my ground, wont be turned around
And Ill keep this world from draggin me down
Gonna stand my ground and I wont back down

Hey baby, there aint no easy way out
Hey I will stand my ground
And I wont back down.

Well I know whats right, I got just one life
In a world that keeps on pushin me around
But Ill stand my ground and I wont back down

Hey baby there aint no easy way out
Hey I will stand my ground
And I wont back down
No, I wont back down

 

With those words in mind…

Thursday November 29, 2007:

 

The mysterious disease that has infected people in Bundibugyo was this morning revealed to be Ebola virus (verified by the CDC-Atlanta laboratories). 79 cases have been identified since August, with a 43% death rate. So far all cases have come from a village area called Kikyo, which is 25 km from our mission, or through direct prolonged contact with patients from that area. Ebola is a panic-inducing word. We are treating this news with sober respect,…

 

[a listing of facts on Ebola]

 

Please pray for our doctors and other health workers. Dr. Jonah is in Kampala now, but he saw quite a few cases before he left, as did Dr. Sessanga. Scott has attended to many of these patients already. Pray for us to wisely support the health system in our district, to graciously care for the ill, to be alert to any danger to our team and children, and to advocate for the best possible response that Bundibugyo can receive from international aid workers.

 

Friday November 30, 2007

 

[snip]

 

We're still waiting for the cavalry to arrive.  Meanwhile the MAF pilot has hung out at our house, and I've been at the Nyahuka Health Center.  We had one patient admitted to the isolation ward but she probably just has malaria.  I had an hour-long meeting with the staff, who are understandably nervous.

And with good reason.  I just got off the phone with Dr. Jonah.  He had gone to Kampala on personal business a few days ago.  Yesterday he had a headache, and today a bit of fever, so he admitted himself to Mulago Hospital's isolation ward.  We are hoping that his illness is not related, but I think he was wise to put himself there, so that he does not infect others.  PLEASE pray for him!!!

 

Later in that day…

 

[snip]

 

The WHO rep, a sharp, experienced, epidemiologist emphasized in the first meeting of the day with local govt leaders that this seems to be a new (fifth) strain of Ebola, atypical both clinically and genetically from previously identified strains. A more non-specific clinical syndrome (fewer specific hemorrhagic signs) will make the containment of this epidemic more challenging, he said. That first meeting also revealed a lack of consensus on what public health message should be disseminated to the pubic. Will schools, markets, basic health services be shut down or curtailed? Hand-shaking cease? There was no debate about the answers, only a request from the experts to wait for their final assessments.

 

The visit to the Ebola Isolation Units at Kikyo Health Unit and Bundibugyo Hospital consisted of physical assessment of terrain, potential tent and gate locations, patient traffic patterns, water and latrine availablity, and staffing evaluations. Surprisingly (to me), not one member of the International Team donned protective gear in order to lay eyes on any patient. Their mandate, they said, was logistical assessment not clinical management. At Kikyo Health Unit, the staff and community seem much less aware of the ramifications of the Ebola diagnosis. People milled around the grounds of the Health Unit gawking at the entourage with its six vehicles and foreign visitors.

At Bundibugyo Hospital a significant portion of the hospital staff have gone AWOL or called in sick. A few brave nurses volunteered to staff the Isolation Unit, previously built by MSF for Cholera Isolation. During our discussion of potential layouts of an expanded unit at Bundibugyo Hospital, I received the short message on my cell phone that Dr. Jonah admitted himself to the Mulago Hospital (Kampala) Isolation Unit with fever, headache, and vomiting (and a history of contact with Ebola cases). Up to that moment, we had all expected Jonah to return today to resume his active role in the assessment and management of this crisis. Not possible now.

 

[snip]

 

I realized this morning that there are, in reality, two related emergencies. The Ebola Epidemic trumps all as the primary crisis. However, there is a secondary Medical Staffing Emergency in this District. Our only two Ugandan Medical Officers lay ill, presumably from Ebola. The official Ministry of Health initial press release revealed 51 cases and 16 deaths. That's a 31% case-fatality rate. Nearly three-quarters of those afflicted may survive (according to the official numbers). So, our doctors may survive, but are likely to be out of commission for weeks.

 

[snip]

 

Bottom line....

We desperately need at least one more physician at Bundibugyo Hospital who can do emergency operative obstetrics. The District has failed miserably in recruiting doctors even before Ebola. The likelihood of a Ugandan Medical Officer volunteering to come to Bundibugyo now seems slim and none. I have appealed to MSF to recruit a doctor from their ranks to come and do non-Ebola hospital work (they are sending two already to manage the Ebola cases).

Please pray...

For Dr. Jonah, Dr. Sessanga, Joshua Kule (a senior Physician Assistant), and Fred (a nurse)--health workers who have all fallen sick with symptoms of Ebola this week.

For another doctor to come in and serve at Bundibugyo Hospital.

For Jennifer and I as we balance the responsibility of leading our team and being involved in District-level response and planning.

For Jennifer and I...for our health. We have personally examined patients (using some protective measures—but not the head-to-toe suits which are on the way), but I do not believe our exposure has been to the level of our Ugandan colleagues.

For Bundibugyo. It's another bad rap for a disdained district. We know, however, that God has a special concern for the poor, the lowly, the despised. He has not forgotten or forsaken us.

 

Sunday December 2, 2007

 

[snip]

 

Admitted at Bundibugyo:  15, including Dr. Sessanga whose sister just came to our house looking for Scott because he's no longer responsive; the matron (head nurse); the nurse who was working in the isolation unit Fred; a clinical officer named Joshua Kule; and an ophthalmic assistant.  Among the other patients are six direct contacts (mother, brother, wife, daughter and two friends) of Muhindo Jeremiah who died just over a week ago.

Admitted at Kikyo:  8 as of yesterday, haven't heard today.

Died:  official number is 18.  Likely higher, hard to say.

Calvary:  Still en route, but expected any minute.  They slept in Fort Portal last night.  There is a 17 person team from combined MSF branches (Belgium, France, Spain, etc.) including the doctor who was in charge of the recent outbreak in Congo.  They have two doctors, four nurses, and a wide variety of other staff who won't see patients but do logistics, education, investigation.  Even an anthropologist.  The CDC lab team arrives in the country Tuesday night.  They say they'll be up and running for labs in Entebbe (Uganda Viral Research Institute) by Thursday, possibly even Wednesday evening.

Jonah:  I just talked to his sister, she says there is definite improvement since yesterday.  We heard he had a positive malaria smear, so it is possibly not Ebola.  But then he developed more symptoms, so we are waiting for a confirmation.  His blood sample is with the CDC in Uganda, not yet reached America.

Team:  OK.  We had a prayer and discussion time this morning.  As team leaders we are leaning towards sending out non-medical staff and children, to be cautious.  Scott and Scott zipped up to Bundibugyo again mid-meeting to do an emergency C section, but by the time they got the mother into the OR the baby had died, and she then delivered the still-born vaginally.  So you could, in a public health sense, count that as another Ebola casualty.  As soon as they got out of that they were called to see a motorcycle accident victim, a lady with severe facial trauma and fractures they need to refer to Fort Portal, but probably can't because she's a family member contact of an Ebola survivor (one of the cases Scott has been following the last two weeks).  He was actually driving the motorcycle when it crashed.  It is incredibly complicated.

 

Still Sunday, different post…

 

I am making this two separate posts, to separate the facts from the emotions.  And since my mother and my son both read this from America I probably won't be fully honest.  But I will say that the emotional toll of the last 72 hours has been tremendous.  There is first of all the wrenching anxiety about the patients that we know.  Since about a third right now are hospital staff, they are not mere numbers in a list.  Jonah of course top of the list of people we love who are in danger.  A virus that selectively attacks the people who care for the sick seems positively diabolical.  Then second there is the small but real possibility that one of us, mostly Scott, would fall ill.  Since the only other two doctors who have seen these patients are down, we can not ignore that risk.  We have been careful and pray that we've been careful enough.  The full protective MSF biohazard garb is arriving today, before that we've worn masks and gloves only.  And related to that sobering hypothetical scenario is the responsibility we feel to protect and care for and make good decisions about our children and our team, a third area of gut-twisting thoughts.  It is unbelievably painful to consider that we (Scott, Scott Will, and me) might be dangerous to them.  So over the last day we've been growing in our conviction that we need to get the non-medical team members out of here, away from us.  It is an impossible dilemma, to look at my beautiful three children who are here with me, and think that for their own good I need to send them away from me.  To look at our bewildered team scrambling to make plans and feel that we can't go with them.  So far we are all well, but if our medical exposure stopped this minute it would still be at least two weeks, maybe three, until we were sure we were safe.  Over the last three days since we knew it was Ebola, I have only been with one patient who may have been a case (she died), while Scott has continued to care for the ill until MSF arrives (hopefully soon).  Clearly it would be good to keep one parent healthy, but where does that leave the support we need to give each other?  And if those three areas of stress are not enough, there is the parallel crisis of the collapsing medical system.  Scott has been gone all day again, third day in a row of juggling the medical and surgical emergencies that would have fallen to Dr. Sessanga and Jonah.  How do we weigh ethically protecting ourselves and our children and our responsibility to the community here where we've spent  a large portion of our lives, in their time of greatest need?  

 

I strongly encourage you to visit paradoxuganda to read the heart wrenching account of the Drs. Myhre in full, along with the few recent entries I did not "snip".

If you are a person of faith, your prayers have been asked for, I'm confident they aren't particular as to what faith.

 

Standing at the gates of hell. Afraid, but still standing.

I fervently hope that the Drs. Myhre do not mind me "snipping" such a large portion of their recent entries, I did not bother them with asking permission. I did so to honor their struggles, their fears, their prayers, their courage, their commitment, and above all… their humanity.

 

SZ

Comments

[Readymom]

This story is just 'sticking' with me. Popping into mind at various times, during the day, since reading. It touched my heart.

Today, I saw this on PFI. Apparently the good Jonha has died, along with 2 colleagues. I just thought the up date might be appreciated :

[q]Commentary

Fatal Ebola Infections in Three Health Care Workers in Uganda

Recombinomics Commentary
December 4, 2007
http://www.recombinomics.com/News/12050701/Ebola_HCW_Fatalities.html

"The sad news is that our doctor who was admitted in Mulago died last night and a senior clinic officer who had been in critical condition died this morning," said Samuel Kazinga, district commissioner for Bundibugyo, the epicentre of the new outbreak.

Joshua Kule, the senior clinical officer, and the head nurse of the hospital (Peluce) also died this morning, so with Jonah that brings 3 of 6 health care workers admitted dying within 12 hours of each other.

The above comments describe the deaths of three health care workers in the past 12 hours. One had been admitted to the hospital in Kampala, while two were admitted locally. The high fatality rate for the health care workers as well as clusters of cases, raise additional transmission concerns.

One group was linked to attendance at a funeral, raising concerns of transmission by casual contact. The CDC is setting up a local lab for testing, so the number of confirmed cases should rise shortly, which will help determine the spread of the infections..

The sequence of the virus from patients is said to represent a new species, which is almost certainly a recombinant.

Details on the sequence would be useful. [/q]

[sophiazoe]

Thanks for the update RM. Yesterday was not a good day for me and I didn't manage to get to this item again.