When the decision was made to remove all ex-patriots (ie non-Sierra Leoneans) working at the Ebola Treatment Unit (ETU) – ie the Red Zone -, we were reassigned to various other activities in the Port Loko area. My assignment was to the government hospital, which is in the process of being upgraded, and ramped up to full capacity, but I had been forewarned by other volunteers that there were many obstacles in the way. We arrived, and set up a structure for rounding – my colleague who is Med/Peds trained focused on the children, and I rounded on the adults. Our first afternoon there, we saw everyone quickly, and focused our attention on two children who were critically ill, one with cerebral malaria, and another with severe malaria who had just arrived the previous day, and had not received any treatment yet. The first child had been evaluated two days previously, and started on antimalarial treatment, and also empiric antibiotics to cover meningitis (a common strategy, in the face of limited diagnostic testing), but had then not been given any treatment for the subsequent two days, due to absence of doctors to make rounds and write orders. In the US, we expect that when we write orders for a medication to be given so many times a day, for so many days, that it will be given, and we may check the medication record to make sure that it is being given, and sometimes there are missed doses (due to a patient being off the floor, or refusing medications), it is an unusual occurrence. Here at the government hospital, the assumption is the reverse – you can generally count on medications not being given, and this is for a number of systemic reasons. Those are:

1. There is no medication record, so it isn’t obvious what medications are due (an easy systemic problem to fix, and one which we would have liked to get solved)
2. During the time we were there, the hospital pharmacist was away, and the nurses had no access to the hospital’s store of medications (this was a big one, obviously). While we were there, the only medications given were the ones that we personally provided out of the PIH stock of medications.
3. The nursing staff is made up of people with a variety of levels of training and experience, due to the huge number of trained doctors and nurses who have died of Ebola infection. Many of the nurses we worked with were really nursing students, or community volunteers – often with limited reading and math skills.
4. Hand-offs to the evening and night staff seemed particularly unreliable, and I came to understand why my previous volunteer colleagues (many of whom had been evacuated due to the concern for exposure to our infected co-worker) had opted to stay overnight in certain cases, to make sure that medications and iv fluid support was continued during the night. Thus, any medication which required dosing twice or three times daily would be given, if you were lucky, once in the morning, but the other doses simply often wouldn’t happen.

Over the next few days, we fell into a comfortable rhythm – my colleague rounding on the kids, and I working with the adults. We were getting to know the nurses, and figuring out who was skilled and knowledgeable and who needed more guidance and instruction. And, then the word came down that we were no longer allowed to have any direct contact with patients if we had been in the ETU more recently than 21 days. That meant both I and my colleague were no longer able to physically examine our patients, although we were able to monitor therapy, and basically perform telemedicine from our office on the hospital premises, based on reports from the nurses, and vital signs. Not ideal, but we accommodated our care strategies. We also had one Sierra Leonean doctor, who had been present on our first day at the hospital, but had some logistical issues to sort out. Happily, his return meant that at least someone was able to round on the patients, and we could serve as resources for him, and, most importantly, the supply source for medications, since we still did not seem to have a reliable access to the hospital pharmacy stores.

This state of affairs lasted for 2 or 3 days, and then we were presented with the news that we had to leave the hospital altogether, because our organization and the governing body of the hospital had been unable to agree to a Memorandum of Understanding (MOU), so our presence at the hospital was not defined, and we could not physically stay on the premises. So, we had to leave.

Since then, I have been in phone contact with our fine Sierra Leonean doctor, who is staffing the hospital and the outpatient clinic there solo. He is an excellent clinician, and I am deeply admiring of his dedication.

We wish we could be back in the hospital caring for patients, but now our support is even more remote – a phone call to discuss patient management now and then, and I am working on an inventory-tracking system to help our staff who is allowed to dispense from our pharmacy supplies (he is a “national”, ie a citizen of Sierra Leone).