Consistent with Ebola

Mountain peaks twelve hundred meters high brood darkly over the forests and valleys of the Thai-Burma border. On the Thai side, a single paved road snakes northwestward from Kanchanaburi 210 kilometers to the small town of Sangklaburi. It then goes up over Three Pagodas Pass and on into Burma, following the route of the old Japanese “Death Railway.” It is often said that, in World War II, one prisoner of war died for each railroad tie laid down on that temporary, war-time rail link with Burma.

Nowadays, death comes from the forest itself in the form of falciparum malaria, scrub typhus, rat bite fever, and a host of other fevers still unidentified. They are borne in the undernourished bodies of thousands of refugees fleeing the military dictatorship that has held Burma in its grip for forty-six years. The diseases funnel through the refugee camps along the border, where lone doctors provide rustic medical care in thatch-roofed bamboo buildings, funded by such groups as Doctors Without Borders or the Refugee Consortium.

Other than these small outposts, the first line of medical defense is ten kilometers inside Thailand at the small community of Huay Malai, twenty km west of Sangklaburi town. Kwai River Christian Hospital is a twenty-five-bed facility with a couple of doctors and nine Thai nurses, run cooperatively by the Thai Baptist Missionary Fellowship and the Armed Forces Research Institute of Medical Science (AFRIMS), which in turn is a joint project of the Thai and U.S. military. Here AFRIMS maintains a research laboratory to identify the causes of fever in that part of the world. Most of the years I visited there, Dr. Phil McDaniel ran the clinical wards, assisted by a constant trickle of visiting doctors, medical students and the AFRIMS laboratory staff.

I was substitute doctor in Phil’s absence when, one Friday at 5:20 p.m., a child arrived from the refugee camp at Holokani. Carried in his mother’s arms, four-year-old Hon Side was feverish and convulsing. His feet were dark splotchy red from bleeding under the skin. He had an intravenous line in one arm and a letter from the refugee camp doctor, stating he had treated him for two days with quinine, ampicillin, and gentamycin, and was now referring him as a possible case of meningococcic meningitis
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Two nurses quickly controlled the child’s seizures with an injection of diazepam and established a second IV line, while our current medical student (Pia Sannaraj, a Thai-American from San Diego) and I examined him. Neck a little stiff, a few rattles in his chest, and the ominous dark-red patches. He certainly might have meningitis, and while we waited for the lab’s first blood report we injected artesunate, an anti-malarial drug safer and more effective than the quinine he had received at the camp. While a male nurse-aide held him, gently but firmly bowing the child’s back, I carefully inserted a needle into his back, drew off spinal fluid and sent it to the lab. An hour or so later, the lab reported a normal white blood cell count, no malaria, normal spinal fluid, but noted the presence of blood in his urine and a very low platelet count, one of the factors that helps blood to clot.

That changed our thinking to Thai hemorrhagic fever, where blood and fluid leak out of the vessels causing a rapid downward spiral into irreversible shock and death. The trouble with that was, having had it for two days before coming in, he should either be recovering or dead by now. Nevertheless, Pia and I pushed IV fluids as much as we dared, trying to keep his blood pressure up while not suffocating him from fluid overload. The AFRIMS staff is not there on weekends.

I am a firm believer in coincidences whenever they appear. Dr. McDaniel would be back from his medical conference the next day, but he had sent his new associate, Dr. Kathy Welch, on ahead to escort a visiting doctor from Congo, Dr. Dan Fountain.

Dan and I go a long way back together as teen-age acquaintances in central New York State, same vintage but different medical schools, after which he went to Africa and I to Asia. He went on ward rounds with Pia and me Saturday morning, when we noted that the little boy, Hon Side, was now vomiting blood, and had a platelet count of 29,000, a level low enough to induce panic in doctors. Moreover, the kid’s baby brother had died with the same symptoms—not six months ago, as the original story went, but just last week. His fever was now 103, his hands were turning red like his feet, and his chest X-ray suggested we had better back off on the IV fluid.

When rounds were over and Pia and I were ready to begin work in the crowded outpatient department, Dan took me quietly aside. “I don’t know much about your Thai hemorrhagic fever,” he said, “But there may be problems for your hospital with that little boy. That looks for all the world like the Ebola virus outbreak at Kikwit, near our hospital in Congo back in ’95. It was just a case now and then in the villages until it hit the hospital, and then it spread like wildfire. They soon had 300 cases and about 240 of them died, including many of the hospital staff. You’d better notify Center for Disease Control.”

CDC, in Atlanta, Georgia, maintains world-wide surveillance of dangerous infectious diseases. Ebola virus is one of the worst, with no effective treatment, no vaccine, and an eighty to ninety per cent mortality rate. It took me a few moments for it to sink in. “It’s Saturday now,” I hesitated, “probably the quickest way to get help is when Dr. Miller comes back to the AFRIMS lab Monday morning. He has the equipment and know-how for this. But I thought Ebola only happened in Africa?”

“Monday is too late. Get on the phone now. Pia tells me she has a number for Dr. Miller in Bangkok.”

“You really think this could show up this far from Africa?”

“Who knows how these things show up? Ebola turned up in Reston, Virginia, in the 90’s. The origin was traced back to the Philippines, and nobody knows how it got there.”

We moved Hon Side into an isolation room complete with gloves, gowns and masks, and a bucket of hypochlorite solution to soak everything in. The head nurse reached Dr. Miller and he sent a lab tech to take special blood samples and freeze them. If it is Ebola, the minority of cases who don’t die can take weeks to recover.

“It’s not contagious until you have fever and bleeding,” Dan told us. “Each of you who has had contact with the boy will need to take your temperature twice a day for the next two or three weeks. If you have no fever, you are home free. If you do get fever, take malaria medicine. If you still have fever, turn yourself in at a hospital wherever you are and tell them you may have contacted an Ebola patient. That will get CDC’s attention, I assure you.”

Phil McDaniel had no trouble believing the danger when he got back next day, but we had trouble with the nursing staff, who wore gloves and mask, but would not put on a new isolation gown each time they entered the room, until we agreed to have them check him every four hours instead of every two. And we caught a substitution of Dettol instead of the required hypochlorite disinfectant solution. Danger of one’s own death from a disease never before encountered is hard for anyone to grasp. Americans hadn’t experienced a deadly epidemic in eighty years.

At latest report (by e-mail after I left for America the next day), Hon Side’s platelets had dropped to 14,000, and areas on his hands and feet were turning black.

After I got home two days ago, I thought my fatigue and aching muscles were from jet-lag on the long trip home. But today my throat is sore; I have a fever of 102 and my head is beginning to ache. There is a bruise on my hand; I don’t remember hitting it against anything. But it’s hard to remember anything today; I feel lousy, and just want to crawl into bed and sleep. I wonder what the emergency room doc would say if I tell him I may have Ebola?

How many people here will catch whatever I’ve got?

Tomorrow’s newspaper should be interesting . . .

if I’m around to read it . . . .

(from "After I got home" and onward is fiction.) © Keith Dahlberg, MD