An Ebola Doctor's Impossible DecisionsBy
There’s just no getting around it—the past few days have been rough.
“I wish I had something more positive or humorous to share, but I just don’t right now,” says Dr. Darin Portnoy. “We are still seeing a decline in new cases where we are, which is welcome, but this disease—it really challenges your clinical judgment. We’re figuring out how to improve the protocols and to recognize where we can help someone most,” he adds, “but it doesn’t go one way. It’s not without pause. Sometimes we’ll have a patient bounce back, only to collapse the next day, and they’re gone.”
Portnoy and I were speaking via Skype for the third time in three weeks since he arrived in Liberia to treat patients at ELWA 3, a Ebola Treatment Center operated there by Médecins Sans Frontières/Doctors Without Borders, or MSF. Portnoy, 52, who has also served as the president of MSF in the U.S. and on MSF’s international board, was an important source for the feature in this week’s Bloomberg Businessweek on the Nobel-winning aid group and why the nonprofit was months ahead of the rest of the world in responding to the epidemic.
Active with MSF since 1997, Portnoy has been on aid missions to Uzbekistan, El Salvador, and Darfur, among others. He’s treated victims of violence and natural disasters. He’d been to Liberia previously, too, toward the end of its long-running civil war. The biggest difference this time, he says, “is that we have to assess every time if we’re going to respond to a patient in need. Are we going to suit up?” It can take half an hour to get all that sorted and into the high-risk ward, and as long or longer to remove the suit safely. There is a limited amount of time to do all this in addition to rounds. So he has to decide: Does a patient really need him now, or can it wait?
“This is something you’d never do in a normal hospital setting. Someone would go and find out directly from the patient what the matter is,” he says. Given the high risk of contamination, he can’t go in as often as he’d like. Patients are in “rooms”—spaces under a broad tent that are separated by fencing. “Patients with more strength will come to the dividers and tell us what’s going on—someone’s vomited, say, or is having a hard time breathing, and I’ll try to get a look from the side or ask them more questions about what they see before going in.”
Thursday morning, two patients became alarmed about a third, and it was hard for Portnoy to determine what was happening. “One told us he was breathing fast. Another said his breathing had become really slow. We couldn’t put it together.” So Portnoy recruited a buddy, a nurse, and they suited it up and went in. He sighs. “He died before we got to him.”
Prior to arriving in Monrovia, Portnoy had been preparing his mind for a situation in which he couldn’t use all the tools he normally has to save a patient’s life. For example, MSF doctors do not perform CPR on Ebola victims. It’s too dangerous for the caregivers and, says Dr. Armand Sprecher, who has helped MSF continually revise its protocols for the disease, futile. “If a patient stops breathing and has no pulse, they have died, and this is what happens to more than half of Ebola patients,” Sprecher says. “These patients will not have the reversible causes of cardiac arrest that would make CPR an appropriate action to take.”
Last night, after his rounds, Portnoy attended a presentation by an epidemiologist, Hans Rosling, a Swedish statistician who has volunteered to help Liberia’s Ministry of Health. (Rosling, not to be confused with Gosling, Ryan, is a celebrity in his field, and gave one of the most popular TED talks ever posted.) Rosling, MSF, and others are focusing now on how to create rapid response teams to contain clusters of new cases wherever they turn up. “We need more flexibility—this is what we’re telling the U.S., too,” says Portnoy. “It’s great to have the new bed capacity that’s coming, but the sense now is that we’re going to need fewer large centers and more smaller ones.” The idea is to race to the hot spots, rather than trying to get patients to travel to the existing Ebola centers, potentially exposing others en route.
Portnoy says his colleagues are holding up well enough. A favorite nurse finished her tour this week, and he was sorry to see her off. “Critical to our success is how the international staff and national staff get along. And if you have a new head nurse coming in every month, it can feel to those who’ve been here all along like it’s a new boss who has to have it done her way. This woman was very good at making everyone understand the value of changes she suggested.” His Italian supervisor remains. His mortadella finally ran out, so he broke out a salami. A highlight of the week had been a visit from a survivor. He told Portnoy that unlike many, he had not been stigmatized in his village, and he was holding a letter inviting him to tell his story on Liberian national radio.
Trials of three drugs will begin at MSF Ebola centers—including ELWA 3—later this month, but not before Portnoy’s term is up. He says it’s “enormously frustrating and shameful” that no treatment has been developed for the virus, given that we’ve known about it for decades. “Between us, I wish I were going to be here for that, to see how that will go,” he says. “I wish we had it now. We should have had it by now.”