He never smiled….

By Dr Kalyani

I was in triage that day. There was to be a transfer-in with a Ministry of Health ambulance, maybe late evening. Triage in Ebola requires us to sort out the patient’s symptoms to identify whether they fit our admission criteria – the only clinical evidence most often is fever, which is checked using ‘no touch’ thermometers. At a distance of 2 meters over the orange fences, it is a dilemma fifty percent of the time – headache, fever, joint pains, body pain, diarrhea – any combination of these can occur from any disease like malaria, typhoid, and so on. The only thing that could clinch the diagnosis in favour of Ebola was someone sick or dead in the family: a positive contact history.

In an Ebola epidemic, every fever with non-specific symptoms has to be looked into carefully until proved otherwise. To admit a patient to an Ebola treatment center if they have some other disease is potentially exposing them to an increased risk of contracting the virus. Even though they are still suspects and segregated from the confirmed cases, the risk is always there – contamination by a fellow patient who is still awaiting results of confirmation is a strong possibility.

To wait and watch for the development of symptoms on ambulatory basis is unacceptable, because if the patient has Ebola they could infect others in their home and community. To err or not to err on the side of Ebola? It is a constant dilemma.

A couple of admissions took place that evening and it completely slipped my mind that an ambulance should have come with one patient from a faraway county, travelling six hours to reach us. In the middle of the night, I got a call from my nursing team that an ambulance had arrived.
I hastily arrived at the triage area and found this little guy of 9 years with no one accompanying him, who was ashamed that he had soiled his pants and had no pants on. No papers of referral could be found and we started questioning the boy. He was tired and sick, travelling alone all the way in the ambulance, without a sip of water or food, not knowing where he was being taken to and why.

Any patient arriving in triage is offered a water sachet and biscuits. This not only helps the patients to settle down after their long and weary journey but also helps to quickly get an idea how sick a patient is. The triage is usually carried out by a doctor along with a nurse or assistant physician and the mental health counselor, who explain about the treatment centre’s services, and become the focal point for further communication with family.

The boy in question sipped a little water. He was too tired to eat the biscuits and was holding his hands over his stomach. I started with a couple of questions and he looked at me, bewildered, and said that he felt sick and just wanted to lie down. I asked him his mother’s name, which he answered, but looked around to see why she was not with him. I asked his father’s name and he said he could not remember. He curled up, and we decided to admit him in the suspect area and test him without further ado.

While talking to the driver about referral sheets and late arrival, the driver informed us that the ambulance which they were travelling in had broken down, and they had to switch to another one – hence the delay and loss of referral sheets. About the boy, he was only able to inform us that he was picked up by the ambulance when he was sick on the road. Soon we contacted the district health officer or some official by telephone at that ungodly hour, only to learn that both his parents had already died from Ebola, and that the boy was not yet aware of it. He was found alone and sick on the roadside.

The human spirit has wonderful resilience, and soon the little guy was fighting against Ebola with all the might he carried in his little body. He would never give up, even when he was too weak with diarrhea to move, nor pull out his IV lines in the height of delirium caused by fever. He always endeavored to maintain his dignity in the most isolated and undignified circumstances. He would complain that his medications had not arrived yet, or would inform us that his pants had been soiled and that he wanted a new pair, but never once did he ask the question about his near and dear ones.
 

He recovered soon enough and would walk up to the visitors’ area and sit down with the other recovering patients who came to talk with their family. The mental health team tried to reach out to him by encouraging him to talk and do some activities, which he would comply with, but there was always this unvoiced question in his every look and gesture – why is there no one for me? Why did they not come to meet me? Maybe he was waiting patiently and hoping that someone would explain this to him; maybe he realized the facts subconsciously and was scared, and did not want to confirm his worst doubts.

Both the mental health team as well as the medical teams were afraid for his emotional state – we wanted him to be safe and surrounded, at least by his relatives in his village, before we could explain. But he was in the strange world of Ebola, the reek of the dead before his eyes, far removed from the normality of his life. We simply could not add up to the trauma. 

I was anxious to get his repeat test done to confirm that his body had cleared the viral particles, but the lab technician was having a tough time picking up his veins for blood sample. I was at the end of my rounds, the goggles of my PPE (personal protection gear and equipment which we wear at all times when entering the isolation unit to care for patients) already partially fogged, and offered to do a femoral puncture – a blood sample which is collected from the vein at the junction of the thigh and abdomen – so as to to get the sample to the laboratory by the morning session itself so that we could get results the same day. He was scared to death with all of us around him, performing a procedure that he could not comprehend. With my fogged glasses, sweat dripping into my duck mask, I saw a restless child, pleading with his mother to come and save him from those who were hurting him. It felt like it was doomed to be a failed attempt from the beginning. However, we managed to get a blood swab done for analysis and got the good news in the evening that he had been cured.

The ritual of getting out of the high risk isolation area once a patient is cured is almost like a rebirth. You leave all your possessions in the area for incineration, get a chlorine shower, step into new clothes at the exit area, and feel your first human touch again after being deprived of it for more than three weeks.

One survives Ebola, but must now develop courage to survive the stigmatization it wreaks in the community. A piece of paper certifies that the boy has recovered from Ebola – a life giving certificate. The smile which greets you when survivors have this paper in their hands is more than rewarding for the team.
 

The little guy walked out into the world again, but there were no embracing hands reaching out for him. Like any child of his age, he relished this freedom by asking for his favourite fish, and the mental health department became his abode, where people still continued to counsel and support him in the best possible way, until he could go home.
 

He was such a serious boy, brave through this entire trauma. But we could not make him smile and laugh. We promised that we would take him to his village soon and that kept him from buckling under the stress he was under. When the mental health team addressed the critical issue and asked him if he had any idea, he replied that his parents could not come and collect him because they were very poor.

The ambulance from his county finally came to collect him with none of his family accompanying, and I guess he grew up very fast in the moment he realized his destiny. Ebola had robbed him of his smile and his childhood in a flash, and endowed him with an uncertainty about his future. He left the next morning in the ambulance for his village, a lonely warrior in our eyes, but never smiled, even when he waved back.