Africa Notes — A Journal of the Plague Month #2 | Miracle
By Dr. Jon Fielder
Most people associate Ebola with bleeding. That’s not surprising, given how terrifying this complication is. But hemorrhage occurs in a minority of cases, and it is uncommonly so severe as to cause death.
The cardinal manifestations are fever, diarrhea, and vomiting. Another “constitutional” symptom is profound fatigue. Shock can result either from loss of body fluid (through vomiting, diarrhea, bleeding, or a combination) or from inflammation and “leaky” blood vessels.
Mananu is a 20-year-old man whose illness included bloody diarrhea. But what really struck me was his complete prostration. His lassitude was so severe that Mananu barely moved.
The profound dehydration made it difficult to maintain an IV cannula. The nurses did yeoman’s work inserting an IV line again and again. They even managed to place a cannula in the leg.
The Congolese nurses, like the rest of the Nyankunde health workers, were amazing. One day, a nurse said to me, “I am done and ready to go. Is there anything else?” I winced, hating to ask him to stay even longer. “Bed 24 has lost her line.” He immediately turned around and went to insert the cannula. The hot zone is a clarifying place. There is no room for shirking or offloading responsibility onto others.
“Grandpa, were you a hero in the war?” Lieutenant Richard Winters of Easy Company of the 101st Airborne, which dropped into Normandy on D-Day, was asked by his grandson. “No, but I served in a company of heroes.”
Despite these valiant efforts, each line ultimately failed in Mananu’s case. Without an IV cannula, it is very difficult to provide adequate hydration to maintain the blood pressure and protect the kidneys. The only other option was oral rehydration solution (ORS), the special concoction of water and minerals originally developed to treat cholera and severe diarrhea in children.
Ebola patients can easily require three, four, or more liters of fluid per day. Drinking that much ORS would be difficult even for the able-bodied. (It doesn’t taste very nice.) Each patient was given a pitcher and encouraged to drink. “Ni lazima kunywa sérum nyingi kusaidia figo,” I told patients in my mechanical Swahili. “It is necessary to drink a lot of ORS to help your kidneys.”
Fluids constitute the backbone of “supportive care,” which has been associated with improved mortality during Ebola outbreaks. Many patients vomit the ORS. More than once, it seemed that I would help someone swallow a cup’s worth only to watch them vomit out two cups.
Mananu was simply too weak to move, much less sit up on his own and hold a cup. Each team helped Mananu to drink ORS. And drink he did. He was parched. We were able to routinely give him more than half a liter during each visit. I was hesitant to push too much ORS at one time for fear that he would vomit everything and more, leaving him worse off than before.
Before leaving the room, we refilled his pitcher and cup and placed them on a chair. But he was incapable of reaching even a foot away. A blank stare seemed to herald that the end was near.
He was at risk of going down the same path as other patients: profound volume loss, inadequate fluid repletion, low blood pressure, kidney failure, worsening inflammation, and death.
The morning before my departure, we entered Mananu’s room, ready for the same daily routine. Instead, I was shocked to see him sitting on his bed, drinking without assistance. The look on his face seemed to say, “What’s the big deal?”
The lame shall walk. The blind shall see. And the prostrate Ebola patient will sit up and drink.
Mananu made a full recovery and was discharged a few days later. His relative, a 10-year-old girl across the hall, did not make it. Why did one survive while the other did not?
I don’t know.
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