Nights

With my foot healed, and around a week left in the ETU, I was put on night shifts.

Nights are a completely different beast than days at the ETU. While Days consist of frequent frantic admissions, blood draws, lab runs, and guests from dignitaries. Nights tend to be longer periods of slow time, with short bursts of activity.

The shift starts off with report, and medication preparation before you head in, which is no different than a day shift.  The difference starts with the complete lack of people. There’s seemingly half the number that are on days, and those that are there are quickly sleeping or lazily watching movies on their laptops.

Normally on nights you would go in around 9pm, stay for an hour or two, then go for a quick walk through at 5am to see if anyone had died.

Our situation was different. We had a 3 month old baby in the confirmed ward, and she required fluid every four hours. Normally a baby this young wouldn’t stand a chance against Ebola.

Bong has had one under five survivor -she was three years old, not three months.

This child had one thing going for her, the fact that her mother was an Ebola Survivor. The hope was that her breast milk would contain enough anti bodies to keep the child alive.

A normal gravity IV would give fluid to fast, so IMC “Acquired” tubing normally used for blood transfusions. This allowed us to measure down to the ML of  much we were giving.

We’d suit up, head into the hot zone, draw up the fluid into a syringe, and place it into the chamber. (60 of Ringers, 50 of D5, 10 of D50).

And we’d wait.
And wait.
And wait.

Forever will I change “watching paint dry” to “watching fluid drop”.  The IV itself was small a 23G (In IV’s the larger the number, the smaller the needle, 23g is quite small),  and it was positional, so every time the baby moved, the fluid would stop. We’d have to go over there, try to hold her arm so the fluid could continue.

We were in there once for two and a half hours, waiting for 120mls of fluid to go. To put that in perspective for my fellow freedom loving ‘Muricans, a can of coke is 355 mls.

I remembered an old game we use to play in the Army. As we often enjoyed(endured) the Army’s hurry up and wait policy, and without cell phones we had to actually look and talk to each other like a bunch of barbarians.

I present:
The Name Game
To start, you say the name of someone famous say, ” Jake Gyllenhaal”
The next person has to come up with a name that starts with the first letter of that persons last name -fictional or real.
So a proper response would be,
“George Costanza.”

I don’t like it Jerry, these Ebola wards have no pillows. How can you call yourself a hospital with no pillows? It doesn’t make any sense JERRY.

A reply would be
“Charlie Chaplin.”

And so on, and so on until you finish what you’re doing. The heat, and PPE made it quite the challenge. Normally you can spit out names without a problem for the first five or ten minutes, this time we were struggling. After awhile you get stuck on letters, and god help you if you land on X or Z.

Sometimes during this time the mother would breastfeed. We had to explain to her that her “Titty Water” (Their name for breast milk) would help keep the baby alive. Each day we would encourage her, and each day the baby would latch a little better. Her temperature maintained relatively stable, and she seemed to have more fight.

One night the IV wouldn’t push, and putting in an IV to a 3 month old dehydrated baby wasn’t any of our specialties, so it had to wait till morning. Each time they stuck the kid during the day, it would work for a few hours then give out. She was on her last scalp vein she spiked a fever of 40.9C (105.6) one day. Luckily the fever came down, and the baby was stable the last I heard.

After dealing with the fluids, we would doff, change into a new pair of scrubs and try to lay down for awhile.

Normally until around 1am, the staff would play a movie for the patients in confirmed. It really depended on who was more in confirmed, if it was kids, they’d try to play Disney films (The Lion King was a hit), adults preferred Nigerian films.

Which
Are
Terrible.
The projector cast the film on a sheet hanged between laundry and the doffing station, it being a sheet, meant that any wind would distort and contort the film. Combine the fact that the speakers were blown, and you have a near IMAX experience.

Mr. and Ms. Ibu was about a cross dressing Nigerian man who attempted to change is genders in order to avoid losing money, or to get money, The costumes and set design were quite well, but the dialogue and plot left much to be desired. 2/10 Wouldn’t make Ebola itself sit through it.

Another part of night shift, that day shifters don’t have to worry about are the bugs. With sun down, and the lights on inside, everything with more than four legs decides to hang out. Now these aren’t your normal moths and mosquitoes of the United states.
These are African moths the size of your hand, wasps an inch long, and whatever this thing is-
(Highlighter for scale)

Damn Africa you scary.

While the light is on, they dominate  the place, they outnumber us 100-1, if they wanted to revolt and take over the ETU, they would have the numbers to do so.  So as soon as were done going in the first time, and have finished any work we need to in the office, we turn the light off.

The office area had a cot inside, and we would clear off one of the tables against the wall to lay on, which often left the third person faced with a choice- Try to sleep sitting up, stay up, or lay across plastic tables. I would say that medical professionals are above childish games such as rock paper scissors to determine who would get the cot, but I will say that-

Always put your money on Rock if you want a good nights sleep.

I think that laying on that Army cot, with my eyes closed and listening to the African rain patter the tin roof- hearing the occasional rumble of thunder above will always hold a place with me.

(Bit loud)

(Rains looking outside our office)

You’d drift off to sleep, just to be awoken by the doc or other nurse telling you it’s time to go back in for the walk through or to give fluid.
During this time, the sprayers would start what I like to call,

“The Ritual Bathing of the Rocks.”

Every morning, they would fill up buckets with 0.5% chlorine and throw them over the whole compound. Every square inch would be covered. If you have to kill every living cell around? except no substitution. Chlorine is the way to go.

Here’s a sprayer making sure every filthy rock got what what was coming to it.

It also had the added effect of recreating a World War One battlefield. The air became incredibly hard to breath, it burned your throat, and there was no where to escape to to make it get better. They sprayed the inside of buildings, they sprayed the latrines, they sprayed the walls, they sprayed the sprayers and then did it all over again.

You don’t have really any choice but to accept the punishment, and hope that one day a lawyer will run an add on TV promising you part of a class action law suit if you were apart of “Ebola aid” and suffered from injuries related to chlorine inhalation (1-800-coughalot)

Day shift would soon come, you’d change into your civilian clothes, let them know if anyone died, who did well, who took a naked a walk down the ward and had to be corralled back under promise of FuFu in the morning. Then hopefully, you’d make it home by 8:30, be asleep by 9, to wake up and do it all over again.

The Slow Time

We got word on Friday that K would be okay, and two of our nurses went in the Friday we got the all clear.

I was instructed to wait until Saturday morning shift, and head in then.  I was excited to get back to work, It was now Friday, and I hadn’t worked since Monday night. Plus being trapped in the house was starting to give everyone a  bit of cabin fever.

On Friday, I noticed that there was something wrong with my left foot. The top of my foot had a open blister/sore about the size of a half dollar. It was very painful to touch, and any sort of pressure on it, and the pain would become nearly unbearable.

But, I came here to work, not to sit in a house.  So I went in for my shift at the ETU. Even putting my socks and shoes on quite painful, but I sucked it up and headed in. We still had a moderate patient load of around 13 or 14, and I’m sure they could have used my help.

Working in the ETU was painful., The gum boots rubbed against the wound constantly when I walked, I didn’t want to get a bigger size due to the possibility of tripping on something and ripping my suit. So I toughed it out and went in and did my shift. After little more than an hour in the ETU I was limping, and as we watched the last of the IV fluids finish administering I hobbled out to doff.

The doctors  took a look at it, and determined it was either a spider bite, or I had killed a Nairobi fly in my sleep, and then put on shoes and socks. The rubbing irritated it and led to the wound.

However I was told that I can’t work in the ETU itself until it heals. I was to wear flip flops and avoid irritation.

Little bugars have an almost acid like solution in them that can cause severe irritation when coming in contact with the skin. and I don’t like it.

One day back in the ETU and this thing set me back a few more days.

So after 6 hours of work, I was sent back to the guest house.

Three days of sitting around and doing nothing awaited me. I did what I could to keep my self entertained, movies, some games, went on a couple short walks. But not being able to wear shoes was a hindrance.

I did go into the little town near here with some of the IMC staff. We walked through the market, and picked up a few needed supplies.

The market itself was much fuller than the previous time I had been there, sellers hawked their goods as you passed. You were also hit by a unique smell of dirt, humans, fresh fruit, and unrefrigerated meat and fish that assaulted you as you first walked in.

Not my photo, but photo of the Market itself. Notice the cooking oil sold in water bottles on the right. They’ll often take empty bottles out of your trash to use them for this purpose.

Underwear, and fruit sellers were next to each other. Women sold cooking oil from empty water bottles. Fresh and cooked fish dominated another section of the market. Chicken burned black, and forest deer sat on another shelf. The crowds surged in this part of the market, having to turn side ways to head any deeper you were passed by small boys with bags of plastic water.

“Wata, Wata, Wata,” They shouted.

We made our way through the block long market, and emerged next to the street. I had bought a bottle of BBQ sauce for 200 dollars (about $2 American) and refilled the minutes on our wifi hotspot.

We all decided to go get something to eat, and asked our driver to take us to his favorite restaurant. The restaurant was a few blocks away. Like all establishments it had a chlorine 0.05% tank outside for us to wash our hands with before we headed inside. It was small, maybe a dozen tables all together with red and white checkerboard table cloths, and concrete floors.

The five us sat there and ordered, and were handed our very own bag of water to drink for the meal.

I had Goat soup and a side of fufu.What’s fufu you ask? It’s a ball of dough essentially. It has no real flavor, and just acts as a mass that fills up your gut.

Fufu on the right. Similar to what I ate on the left.

The African peppers made the whole soup incredibly spicy, I had to take breaks after a few bites. The fufu itself was flavorless and simply acted as filler. The goat was well cooked, but freshly slaughtered, Some of the pieces were the goats actual skin, and completely inedible

The whole meal cost around $5 American dollars. They often don’t have cash registers, and instead just have a bucket where they keep all of the money.

After that we left, the driver knew of a fresh fruit stand that wasn’t too far away from the ETU.

We headed out down the bumpy road. The “not to far” fruit stand ended up being nearly a 40 minute drive past the ETU and consisted of several stalls along the side of the street.

I bought a pineapple, a papaya, and 80 dollars worth of Bananas (Liberian dollars, but I never thought I’d get the chance in my life to say I bought 80 dollars worth of Bananas)

Nom Nom nom nom

They also had a bowl of live grubs for sale there.
i contemplated eating them, but didn’t have anything to wash them down with.
If anything so I could quote the Lion Kings, “Slimy yet satisfying.” line

We headed back towards our housing and went our separate ways. I waited another day before trying to head back to the ETU. I’ve slowly managed to get back into the hot zone. Each time spending a bit more time in the PPE and gum boots. The foot is healed now, and we have roughly three days left before heading home. All in all, the foot, and K being sick knocked me out of action for nearly a week. During that time our census went from 35 to 12. Now it’s down to about eight.

Only a few more days left, and I’ll be back to the shining Capital of Monrovia, with it’s paved road and and street sign.

A little too close to home

I hesitated for awhile to post this due to the sensitivity of the subject, but I think enough time has passed. I’m also not using any names either.

I had just ended the “Night Shift” when I came home to this situation. I was tired, emotionally frayed and running on an hour of sleep in the past 24 hours.

One of our normally more cheerful docs simply said “Hi” when she got to the ETU and looked very distracted. I didn’t think much of it at the time, but it was quite out of character for her.

I headed back to the guest house to hopefully get some sleep and repeat the process the next day. It was a good tired, the exhaustion of a hard days work.

When I got to the guest house, I was quickly pulled into one of the bed rooms by one of the other nurses.

“K’s, sick.” She said a worried look on her face.
“Sick?” I asked. This wasn’t good news, “What happened?”
“K had Diarrhea last night,  been running a fever of 101, and has body aches.”

“Shit” is the only word I can mutter. K has had close contact with Ebola Patients, is running a fever, and has Diarrhea. K fits all the criteria for a an Ebola Patient…. But also for Malaria, Typhoid, and the Flu.

K is also my roommate.

There’s a chair sitting at the threshold of the door.  People are taking turns sitting there and watching K.  It’s also acting as sort of the demilitarized zone between suspect and non suspect.

K was there, but there was an almost ethereal feel to speech. K was obviously in pain, and grimaced when moving.

“Hey, how are you doing?” I asked,
“Been better.” K replied, trying to force a smile.

When health care workers get sick in Liberia, they are not taken to the ETU as a regular Liberian would be. They are transferred to whats called the MMU or Military Medical Unit – It’s located next to the UN airport outside Monrovia. All the doctors and aid workers that were infected and diagnosed in Liberia, then sent back to the US after being treated at the MMU first.

The weekend before we left for Bong, a large portion of our group went and took a tour of the MMU. I didn’t go, I had no intention of ever seeing that place from the inside.  The others had described it as air conditioned and excellent.

But how exactly did one get someone sent to the MMU? We had been told that it would be handled by those over our heads. The Medical directors of respective ETU’s.

The other nurses in the house wanted me to call our medical director right away and let him know while the other doctor in the house wanted us to wait until she brought back reinforcements.

We discussed the problem for a few minutes before the other doctor and a Liberian national doctor arrived. The national crossed into the room, and started examining K, palpating K’s abdomen and feeling K’s pulse.

Which is NOT what you’re supposed to do with a suspected Ebola patient. You never touch a patient with out being in full PPE.

Wanting to help my friend, I went in and pulled K’s thermometer from their toiletry bag and handed it off.  I then quickly stepped out and bathed my hands in enough Alcohol hand sanitizer to drown a toddler. The doctor followed suit.

There was still some debate on rather or not to call our chief medical officer. I grabbed the phone, stepped in the other room and did this. Had this really been Ebola, we had to get K evacuated and treatment started as quickly as we could.

The medical officer was alarmed at the situation and promised to get working on it as fast as he could on his end. He was only a couple hours away and would head this way as quickly as he could.

The MMU has helicopters outside of it – or it did when our plane landed, at least. The other nurses were questioning why they wouldn’t send a bird to get K.

The next hour was mostly waiting, trying to find out what was going on, and nervously pacing the halls. I made a bottle of Oral rehydration salts for K and tried to flavor it the best I could. K had requested some cold coke from the ETU, but they only had pepsi. We tried to slip a little ORS and ice in with it.

The seconds on the clock came slowly, and our patience for some kind of guidance was running thin. We hadn’t received any word on what to do. I remembered that on our table, there had been a card left on the table. A captain, an aid to the general of the 101st airborn had left it. I called it and explained the situation, he understood and gave me direct contact information for the MMU.

We get word finally that they are going to send a team in to draw some blood for a Malaria and Ebola test, and then send him to the MMU by ground transport.

I think this is when the biggest shock came from. All of us were the ones used to being the ones in the space suit, the ones that received the shocked looks from those looking upon the PPE. To be on the other side, to watch the Ebola shock troops head into your house and into your room was something that none of us expected.

The sprayers came in first, coating everything in front of them with a layer of 0.5% solution bleach, They sprayed the door way, the floor leading to our room, the floor in the bed room, and the entire bathroom. They also filled his Coke/ORS with bleach and rendered it undrinkable (Spraying isn’t a precision art)

You could taste it in the air.  I can understand why those in villages around the country were scared. We knew what coming  and it was scary for us. Imagine yourself being from a village deep in the jungle, and these hooded white figured come in, spraying a noxious fluid over your village and taking your loved ones away. Loved ones who sometimes never came back.

Doctors and Nurses taking some Samples from K for testing

The doctor who had examined K earlier was back with a Liberian national nurse, they were in full PPE this time. They drew a blood sample for a Malaria test and Ebola test, and left the room.

We got a call over the phone that K would be transported with one of the International Medical Corps ambulances down the Military Medical Unit.

The pickup truck with the wooden slat for a back window was the transport vehicle used.

The Ambulance backed up to the door, and K slowly walked into the back and lay down on the mattress. K assured us everything would be fine, and the gate was lowered. We all stood and watched as the trucked disappeared behind the turn, unaware if we’d ever see K again.

The sprayers then return to the house, spraying every step that K had made, and returning again to the bed room, where they sprayed K bed, as well as my bed, and bagged the contents into red bio hazard bags (R.I.P Poncho Liner) they also took the mattresses out of the room to be burned as well.  They sprayed the closet as well, a good amount of my clothes are now ruined with bleach stains and have to be thrown away.

That room was locked, and placed off limits for the rest of us while we waited for the results.

It’s around 1300 at this point and I’m near the point of delirium. the past day, from the death during the night shift to K becoming ill had left me drained and exhausted. I collapsed on a very uncomfortable love seat and slept for several hours.

The next three days we were held in isolation in the house.  Since K had only shown the first symptoms during the night,  and Ebola is only spread after a patient becomes symptomatic, we all felt pretty safe. I had worked the night when K’s illness had began so I hadn’t been directly exposed.

I think we were all affected by this. K had been very diligent in the use of PPE. No breeches, no close calls or anything, if K could get it being that careful, whose to say the rest of us couldn’t get it either? K had been feeling tired and lethargic for a couple days prior, had K been symptomatic then? Were we exposed then?  Being isolated in a house for a couple days you tend to have a lot of these conversations.

Word came back the first night that it wasn’t Ebola, and it wasn’t Malaria. The Malaria test was good news, but K’s viral load for Ebola could still be low enough that it didn’t show up on the test. However, we took what good news we could get.

Every step in the process of transferring a potentially infected healthcare worker had been followed as it should have been. Both organizations responded quickly and did exactly as they should have.

We get a call the next day saying that K’s is feeling better, and that the anti-biotics they were giving were working. K thought it might have been typhoid, . However, we still needed another negative test to clear us for leaving the house. The whole ETU during this time was worried, they had some idea of what happened, but had less details then we did. We passed the time by watching movies and reading, I think two of us managed to watch a good 16 hours of game of thrones during that time (Winter is coming).

Finally, on the third day we get word that they’re taking K out of the MMU, the Ebola test came back negative. K would get some well deserved R&R in Monrovia and then head up.  It was a collective sign of relief, and just drove home how scary this virus could really be. I sometimes think what would have happened had it been positive? We were all pretty sure K could beat it, strength and determination had never been short, and K had no intention of letting this thing get them, regardless of the illness. Would we have been pulled out ? Would another one of us had been infected? Me, being is roommate had slept in the same room and used the same bathroom, what if he was infected and symptomatic and didn’t know it?

Luckily, all of these thoughts are just speculation and never came to fruition. K was fine, we were all fine, and we got to enjoy a free freshly cleaned floor and bathroom.

Into the Hot Zone

The first time I stepped into the donning room I was pretty nervous. Alright, that’s a bit of a an understatement, my stomach was in my shoes, and each step of donning felt slower and slower.

We had some patients who were just getting admitted from triage, we were gonna draw blood and  check on some other patients.

Slowly, over the course of ten minutes, you put on your gear, it’s called Personal Protective Equipment, but we just call it PPE for short.

Each step is checked and double checked to make sure its on right. There’s always a couple nationals in there to help you tie your hood, defog your goggles, tie your apron and hood. It’s oddly reminiscent of Knights suiting up for battle.  You stand their and look at yourself in the mirror as layer and layer of protection is applied and checked by the nationals.

You cease being who you are as an individual and become an Ebola Storm Trooper. The uniform of mad men and women either brave or foolish enough to work here.  The nationals  write our names on our foreheads so we can tell each other apart.  They also write the time we went in on our arms. They do this so someone coming in can tell if you’ve been in to long and need to go out. It’s sometimes easy to lose track of how long you’ve been working.

This is also the only place in the whole of Liberia where you can shake hands and touch other. Once you go inside, you cant due to the  risk of putting Ebola on someone, the same outside, but for those few minutes you can shake hands, hug, whatever you want. You’re pretty well protected in your full body condom.

Your senses are dulled as the suit goes on. You are suddenly aware of how heavy your feet are, where the straps touch your head – the placement of the mask on your nose – if the mask is high too high, if its too low.

You have to fix all these things before you cross over. If your mask slips, if something is wrong and uncomfortable – you can’t adjust it. You can not ever ever touch your face once you cross that line. I made the mistake of having my mask to low one day, and couldn’t breath through my nose for over an hour. You only do that once.

Finally, as the sweat starts to come out, and you feel like an Asthmatic astronaut you cross the red line into the Hot Zone.

I took a deep breath before crossing that line. Here it was, the whole reason I had came to Liberia, and volunteered for this mission. All the worries and doubts and questions rose up and I anxiety coursed through my body. Man didn’t go to the moon to sit in the Lunar Module and wait did? Not after the journey he took, no he took those steps and did his job.

Standing in my own space suit, I crossed that line. All the self doubt and worry disappeared.

It was replaced with a very itchy nose.

The first day I was working with two other Nurses, a nurse practitioner who is our charge nurse, and another nurse who came up with me.

We only went into Suspect that first day. The building itself is Spartan, constantly wet concrete floors – your boots splash in small pools that gather throughout the building. The building is separated into individual patient rooms. On the confirmed side you can have three or four to a room, in Suspect you don’t want someone who might have Ebola to be in the same room with someone who might not.

The walls are are blue tarp, and the wooden framing is exposed, there are nails jutting out from the walls near the beds (for IV’s to hang from)

The patients each have a plastic mattress, and paper sheets as well an outlet for a cell phone to be charged. There’s  a bucket to urinate/vomit/defaecate into. If they feel healthy enough there are tables and chairs outside for them to gather at. The insects that can fly buzz around above, any unfortunate to be caught in a chlorine sprayers path lay dead on the floor.

There’s a light bulb in every room that’s always on. They have no pillows,  the bed rails can not be lowered  or the beds adjusted.  I imagine the smell of chlorine is nearly palpable.
We had a patient in Suspect that we would later admit, the Nurse practitioner went for a blood draw and missed, then she asked if the two of us would want to give it a try.

I nodded and said sure. He wasn’t a hard stick, but drawing blood from someone with Ebola was particularly nerve racking. One slip, one second of distraction and I could infect myself.  I had drawn blood on maybe a thousand people in the past, but none of them ever had Ebola.  I took a second to settle myself and got the stick.

Remember I said you can’t touch your face? For the first ten minutes I’m in the ward I have an incredible urge to scratch my face or adjust my mask or something. You just have to ignore it and focus on a task,  it does go away after awhile. However, the intense awareness of anything and everything on or around your face doesn’t. Even after your out of PPE, you’re hyper aware of anything touching you or near your face.

The amount of care we can offer is pretty limited. It is in my mind at least comparable to a battalion aid station in the army:

We Give IV’s (A lot of them)
We draw blood
We give IV Meds (Cipro, Flagyl, Ceftriaxone)
IV Pushs (Metrocploromide, Haldol, Valium)
PO Meds
Cleaning patients
Changing beds

That’s really… about it. They’re were two occasions where Foley’s catheters were put in, but they’re really quite rare.  The actual scope of nursing care is pretty limited.

It’s the conditions that make everything a challenge. The suit narrows your field of vision, your hearing is dulled slightly from the hood.  You can’t listen to a stethoscope . We can’t use a BP for a blood pressure. Even palpating for puncture sites is difficult with three pairs of gloves on.

Supplies are an issue as well, if you don’t have supplies in the suspected ward, you just can’t walk out to the supply room and grab them. You yell over a fence until hopefully someone pays attention to you, you stand and wait for five minutes while they go get it, They then throw it over two layers of waist high fencing to get to you. Hopefully they have a good arm, or you wait all over again.

The heat is another factor inside those suits.  During the afternoon shifts it can hit 93*, and with humidity it feels around 110. Walking around in that normally wouldn’t be fun, throw on tyvex or god forbid tychem suit and suddenly you’re facing 100% humidity.  Every activity you do is slower, every step you take has to be for a reason.

Rolling a patient to clean them? Subtract some time you can be in there.
IV? More time
Even handing out PO meds gets you after awhile.  I force myself to walk slow and plodding along like Darth Vader to conserve energy.

If you can be in there for ten minutes or three hours there’s never any judgement for “tapping out” and leaving early. Utmost care and attention is given to your own safety. What would happen if you pass out in the confirmed ward? How exactly do they get you out?  Luckily the situation has never happened, but the risk is always there.