On the day I transferred Osman from the Suspect Ward to the Confirmed Ward, he rose from his bed, wrapped a lapa around his waist, looked me right in the eyes, and said, “I’m going to die here.”
I took his arm and supported him as he walked, weakened from days of constant vomiting and diarrhea. “You will NOT die here,” I said. “We will do everything we can to save your life. But you must help us by drinking your ORS, even if you vomit it back again.” We turned the corner and headed for the gate into Confirmed. “If you believe that you will live, and drink your ORS, you will live.”
I showed him to his new bed, mixed a new bottle of ORS, and squeezed his hand. “You must believe,” I said.
And he did.
And he lived.
The day we discharged him was bittersweet, for although Osman lived, his wife did not. She had infected him as he cared for her, and by the time she arrived to our ETU, she was too far gone to recover. She died just hours before Osman himself arrived by ambulance.
Still, he was glad to go home to their son, James, only 14 months old, and pick up the pieces of their life.
The next day, Osman emerged from the back of an ambulance, his son pale and limp in his arms.
Osman cradled his son in the red zone of triage, and tried to get him to drink sips of ORS, formula, anything. Desperately thirsty, James would gulp at the drink, pause, and vomit everywhere. His eyes were dull and sunken into his head, his lips cracked.
When Osman arrived home the previous evening from his discharge ceremony, he was horrified to find his son alone, lying on a mattress on the ground, covered in diarrhea. During subsequent questioning, the contact tracers and surveillance officers for the district swore up and down that they had checked on the child; they swore that a neighbor was caring for him, and that they’d seen him just that afternoon, and he was well and fine.
It was at this point in the questioning that the investigating W.H.O. medical officer stormed out of their office, furious and in tears, rushing to leave before she said something unforgivable.
Our lead triage clinician looked over the fence into the red zone, and said, as gently as she could, “Osman, it is our policy that you should leave your son here, and you should go home. We think that survivors have immunity, but we do not know that for certain. We do not want you to get sick again.”
He shook his head. “I must stay with my son. I must care for him.”
She tried again. “Osman, you must trust us that we will care for him; we will do everything we can for him. But you must also care for yourself.”
He clutched his child tighter, and tears began to roll down his face. “Please, I am begging you. Please do not send me away. I must care for him. He is all I have left in this world.
“If you send me away from him, I will go mad,” and he rested his face against his son’s hair, and sobbed.
She broke, and turned away, and pulled out her phone. “Fuck that policy,” she said, and dialed our Chief Clinical Officer.
I could not hear the entire conversation, but afterwards she walked back into triage, looked over the fence, and said, “Stay with your son. We will take you to a private ward.”
We have a phrase here, that we repeat to each other whenever someone gets frazzled or rushed: There is no emergency in the ETU. We do not run. We walk. We stay safe. There is no emergency in the ETU.
As I left the triage area for the donning station, I was about as close to running as I had ever been.
I met our lead pediatrician in the ward. He had tried multiple times for an IV, with no success. James was too severely dehydrated. I tried three more times, using only guesswork and anatomy, for even with a tight tourniquet and good light, there just wasn’t enough volume in his circulatory system for me to see or palpate any veins. I missed each time.
We’d brought in a single IO kit. An IO, or an intraosseous line, is a metal catheter that is drilled into one of the long bones in the body, and through it intravenous fluids and medications can be infused into the marrow, and enter the circulatory system that way. We frequently use IO needles in the Emergency Department in the United States, as with an IO drill you can have the line in and infusing within 90 seconds.
Here, we had no drill. We had an old-school IO, which we would have to manually screw through the bone, and pop into the marrow. Another clinician had used an IO exactly one previous time before in our ETU, and it had saved the life of a one-year-old girl.
I held his leg, and the pediatrician punctured the skin and drilled the line in. I felt the pop radiate up and down his leg. “I’m in,” he said, and he withdrew the huge needle and tried to flush it.
James moved his leg.
The IO backed out, and the fluid went into the tissue. The pediatrician, who never swore – ever – let loose with a stream of invectives the likes of which I have rarely heard.
We bandaged the site, and gave James back to his father. We had been in the ETU for almost two hours, and we knew we needed to get out. As a last ditch effort, we gave James a dose of sublingual dissolving Ondansetron, an antiemetic.
“Keep giving him sips of ORS and formula,” we said. “Even if he vomits, keep giving him small sips, all the time. Some will stay in. It will help.”
Osman nodded, and we left.
I saw James again late that evening, and he looked slightly better. Osman was constant and diligent in his care, and James had been able to get some fluids down and keep them down.
On my third desperate try for an IV, I saw a tiny flash of blood along the catheter. I held my breath, and withdrew the needle….and nothing happened. No further blood flow. At the end of my rope, I tried to flush the catheter in with a tiny syringe of LR, and the vein blew.
Again, we handed James back to his father, with no IV.
We left the ward, and in absolute fury at the world I screamed at the pack of wild dogs eating the garbage in the courtyard, sending them skittering under the fence and back into the jungle. The night was still and quiet again, clear and calm under a half moon.
We doffed and went home.
The next day I joined the field team, and was away from the ETU the entire day.
At dinner, I got the updates on James. Yes, he was still alive. No, we did not get an IV placed. Yes, he got IM medications, both antibiotics and antiemetics. Yes, Osman was making him drink fluids constantly. No, he didn’t look good, but he maybe didn’t look as bad, either.
It was a member of the national staff that finally placed the IV line in James on his third day at the ETU. Fluids were started, as were antibiotics, antimalarials, antiemetics. The ORS and formula feeds continued.
We all knew that the fact that James had survived this long was due to the constant attention of his father. Without that, James would have died within hours.
Hope glimmered, faintly.
On New Years Eve, four days after James’ admission to the ETU, I returned late to the dorm, exhausted from a day in the field. I showered and put on comfy clothes, and joined the dinner table.
I took a bite of chicken, and turned to the triage clinician. “So what did I miss at the ETU today?”
She sighed, and took a moment to speak. I knew before she opened her mouth.
“Martha, I’m so sorry. James is dead.”
I looked down the table, and realized that in my exhaustion I had missed the deeply somber pall that hung over the gathering. I looked to my left, and met the gaze of one of the nurses on the pediatric team. She’d been fighting for James’ life, ceaselessly, for four straight days.
She looked down at the table, and then buried her face in her hands and began to cry.
Another nurse told the story. He had entered the ward just to check on them and say hello to Osman, who he had helped to care for during Osman’s own illness. Osman was sitting on a bed, holding his son in his lap. James’ breathing was deep and slow, but he was there.
The nurse swore he turned his back for only a moment, to step away and grab some water for Osman.
And when he turned back around, James was gone.
We leaned against each other for many long minutes. In a time of Ebola, when no one is to touch, we held each other’s hands. We spoke of him, and remembered him, and shared our grief. After a few minutes the triage clinician gathered herself and, for the first time that day, told us all of the private conversation she had with Osman before he left the ETU for the last time.
It was outside the fence, back in the green zone. James’ body was gone, in the morgue, to go to the cemetery the following day. Osman had showered and exited the red zone for the second time in a week.
“Osman, I am so sorry,” she said quietly.
He was silent for a moment. “I had a dream last night.
“I dreamed I was in the ward; for a while I thought I might actually be awake. But then my wife walked through the door of the ward, and then I knew that I dreamed. She came to the bedside, and sat by me, and looked at James. And she said, ‘Osman, I have to take him.’
“I said, ‘Please, don’t take him. Let me have him.’
“She smiled at me then. ‘Osman. You know I will take care of him. Let me be with my son.'”
And then he smiled at our triage clinician, and through her tears, she smiled back. Osman looked to the sky, and said, “So when James left today, I knew it was all right. Because I know he is with her.
“And they will care for each other.”
~ ~ ~
There’s a song that they sing when they take to the highway
A song that they sing when they take to the sea
A song that they sing of their home in the sky
Maybe you can believe it, if it helps you to sleep
But singing works just fine for me…
— James Taylor —