Okay, so it’s been a couple weeks since the last update. Honestly there hasn’t been a ton going on. Were currently in “Standby” Mode. Which means the level of Ebola cases is so low, that we stopped triaging patients. We can open in an emergency, and our ambulance is still helping take potential cases to the nearest ETU in Ganta (About two hours north).
I did manage to get a video done and uploaded of how the suspect and confirmed wards of our ETU look. So, take a look.
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.
(Note: I’ll write about going in and working in the ETU in a little bit, but I thought I’d share this recent update with you)
I had just finished a 13 hour shift working at the ETU, we had given report and handed off all information to the incoming shift. Myself and another nurse were just waiting for a ride, and I (being in a post 13 hour shift gregarious state) start talking to one of the drivers.
He’s about 6’2 and built like a tank. Instantly I miss the gym, picking stuff up, and putting it down (repeat). He’s friendly enough, he’s wearing a blue International Medical Corps shirt, with a IMC vest and sunglasses.
“What’s your name?” I ask
“Sunshine.” He replies.
“Sunshine?” I ask my head tilting like a three month old chocolate Lab.
“Yes,” He smiled, his hands waving in front of him, “Like the sun, it shines? My name is sunshine.”
He seems friendly enough, and my mind banks it with all the other meet and greets I’ve had recently. Sunshine only difference was the fact he was a tank, and since the end of the civil war – you don’t see a whole lot of tanks in Liberia.
He was also well liked, I remember hearing some jokes between Sunshine and our supply guy about having a pushup and pullup contest.
Well, let’s fast forward a few days. Our chief medical officer comes in one morning fuming. He’s very upset, and talking more with his hands than he normally does.
It turns out our resident Sunshine was never in fact a driver for IMC. He had buffaloed his way into the job, he never had an interview, someone gave him the IMC shirt and gear, and he had just started driving people around. He had no license, and was a convicted felon in the United States who was deported back to his Native Liberia.
Well if this wasn’t enough, it turns out he had stolen an IMC car and crashed it into a tree. (In my head, I like to imagine Rage Against the Machine playing while he does this). He was hurt and sent to the hospital.
Where he proclaimed he would be suing IMC for the medical costs incurred upon him from the hospital.
Were all a bit stunned. He had been a pretty likeable guy, I wonder why he had done it? It’s the main topic of discussion for a few hours, but slowly it fades into the past, another quirky news story at the ETU.
A couple days later I work a night shift, come home and sleep violently. I’m awoken by two of our doctors coming into the guest house in scrubs and their gumboots. I look at the clock, it’s only 3:00 PM, they’re supposed to be working till 7:00 at the earliest.
They sit us down and tell us what happened-
The story of Sunshines return to the ETU.
Apparently disgruntled at his prospects of a successful lawsuit against IMC for stealing one of their cars and wrecking it, he decides to return to the Ebola Treatment Unit. In America in a situation like this, a disgruntled employee might go confront of his boss, or make a, “Whose coming with me man?! Whose coming with me?!” speech.
Not Sunshine, Sunshine has a better idea, Sunshine is going to take matters into his own hands.
He rushes the waist high orange fence in the Confirmed ward and leaps over it.
(Dramatic Reenactment)
Sunshine has just placed himself voluntarily into the confirmed ward of an Ebola Treatment unit. All the staff start freaking out, and they pull everyone out of the unit, one of the Liberian PA’s inside draws up a syringe of Haldol to put Sunshine down if he assaults him, but the risk of getting your mask or suit torn during a confrontation with a angry Liberian tank and being exposed to Ebola is high, so he retreats with the rest. The whole compound- save for 5-10 people are evacuated and sent home.
The police are called, but don’t have the training/refuse to don PPE and go into a confirmed Ebola Ward. I can’t say I blame them. We send in our pyscho-social lady in to try to talk him out. She’s in full PPE -turns out he had laid down on one of the empty beds and taken a bit of a nap. The sleep- combined with her negotiating skills convinced him to take a chlorine shower, change clothes and give himself up.
The whole affair leads to afternoon fluids/meds for the patients being skipped, and we get to clean up all the mess during night shift.
They send sunshine to the hospital to be quarantined for a few days, and we all breath a sign of relief that its finally over.
OR IS IT?!
The next day we get the news that Sunshine broke out of the hospital quarantine, and headed back to the College campus (Where we all live) Where he broke into his dorm room and –
Took a nap for a couple hours.
He woke up, lazily stretched after his nap and took off, he was spotted later that day drinking a soda on a bench somewhere on campus. We currently don’t know where he is, if he’s infected, or where he plans to nap next.
I keep intending to write about our week at the Department of Defense training, and I will…. Eventually.
However, I don’t really feel like writing about it right now. So I’m to talk about the ETU itself, and how we got there.
We were originally supposed to be at our own ETU on November 16th, however due to construction, and that fact that Liberian infrastructure rivals16th century Turkey- the process has been delayed and delayed…and delayed some more.
We finished our cold training at the DOD on Friday the 14th, and were under the impression that we would start our “Hot” training at bong the following monday. Hot training would last another five days, and each day we would progressively spend more time in the hot zone. First we would do a walk through, then the next day maybe hand out food, the next day draw blood. Each day we would progressively provide more and more care until we were comfortable.
When we got home from our last day of cold training, we were told that hot training was cancelled. They couldn’t find any spots for us at the time.
For how long? They wouldn’t tell us, but it was looking like a week.
Now a week to explore the capitals of most countries is normally seen as a chance to go see the sites, try out the food, and have a good time.
Monrovia, sadly lacks any of these amenities . There is really nothing to do, I don’t know if the city has a bowling alley or movie theater. Well, actually I don’t know if there are any of those in the whole country. But that’s okay. I was alright being at the guest house for a little bit, and we would always take short walks down to the beach or around the neighborhood if it became too boring.
On Monday, our fearless leader came in and announced that there was a sudden need for medical staff. A doctor and two nurses at the Bong ETU, and a doctor and two nurses at the Kakata ETU that was scheduled to open. Three headed off on Monday, and myself, Lucile, and another doc were to head out the next day.
I won’t lie at this point, I was pretty nervous. I know the reasons why I came, I came to help these people, and to make a difference, yet suddenly my own self preservation started barking. Are you sure you want to do this? Are you sure you can do this? Why are you doing this? The whole night the thoughts swirled through my heads, I tried to distract myself by adding some movies to my laptop, and talking to my family back home. But the thoughts followed me to a restless sleep.
The road to Bong was long and often in states of Ill repair . The road went from being well paved and traversed at 60 mph to pot hole ridden dirt, crossed at 10 MPH, what could have probably been a hour, maybe hour and a half drive turned into four hours. We also had to stop at a county line check point to wash our hands and have our temperature taken.
Which was kind of nice to see that containment measures are still in place.
When we got to the ETU we got out and took a photo with the sign.
(There’s me in the back)
The ETU is tucked about a mile and a half in the jungle, through a winding dirt road filled with dips, blind turns, and hills. The jungle swallows you up as you go in, you’re in it You can easily forget the outside world, there’s no evidence here. Just a winding dirt road that could have been made hundreds of years ago.
Soon we make a turn and head up a hill
Blue buildings, two layers of chain link fences. When we got out, renee walked us to meet the docs and nurses there.
When you first get there you wash your hands in a 0.05% solution and dip your shoes into a 0.5% bleach bath. You do this again as you pass through another gate.
The ETU is set up with the confirmed and suspected wards being in the back, with the doffing area in the middle, and the donning area nearest the suspected side. The ground is covered in large rock gravel, pipes with 0.05% and 0.5% bleach sprout up around the perimeter.
A few dozen stakes stand next to the laundry room they’re used as boot drying spikes. And every morning you’ll spend a good amount of time trying to find a pair of gum boots that fits (43 for me).
The jungle surrounds and envelopes the ETU
We introduced ourselves to the staff. The Bong ETU is ran by the International Medical Corps, an American based NGO. They were all friendly and glad we were there. They gave us a quick five minute tour of the area, and sent us on the way to the guest house so we could unpack for the week.
My room for the next two or three weeks.
IMC needed us in there to help, they got hit with a good amount of patients and a good portion of their staff had departed on holiday, or their contract had ran out. So we were skipping the customary few days of hot training and just jumping into it. Outa- the frying pan into the fire sort of situation. Personally I was fine with it, I was tired of power point presentations at this point, and another week learning how to wash my hands might push me to psychosis.
So on Wednesday we headed for our donning and doffing training. The gear we actually use is different than the what we trained with for the World Health Organzation. While the WHO says its okay to have exposed skin, IMC protocols don’t allow it. Which, while adding a bit of heat, definitely makes you feel safer.
They also promoted me to “RN” when they wrote my name the exercise -When I told them I was a nurse. That’s okay, I only had to come to Africa and fight Ebola for the promotion.
Here’s the order of operations for donning the gear.
Gum boots
Two pair of Gloves
Tyvex or (God awful) tychem suit
N95 Mask
Hood with mask ripped open in the middle to allow you some air passage.
Another pair of gloves taped to your arms.
Waterproof apron.
Goggles. The goggles were a challenge at start, fogging was a big issue with the WHO training, turns out that some dish soap on the inside gets rid of the issue completely,
For those wondering how you get out of all that? Well there’s a process for that as well.
Stand in 0.5% basin for 30 seconds to disinfect boots. Sometimes when there’s a person in front of me, I just stand in the basin for awhile, even if it’s been sitting in the African sun for four hours, it’s cooler than you. You can almost close your eyes and pretend your bathing in the purifying waters of Lake Minnetonka.
Step into Doffing area.
Hold up your hands and wave them like you just don’t care (You could be covered with Ebola, so care and don’t wave them)
The sprayer will spray a 0.5% chlorine solution from neck down, on your hands, apron, legs, and boots. Then you turn around and they get the other side.
Next you wash your hands in a 0.5% solution
Remove the tape from your gloves, and take off your outer layer of gloves.
Wash your hands.
Take off your water proof apron. This part can be a bitch, trying to find the tucked away hidden string that magically causes the apron to fall off you is hard, and on one occasion I just had to push the apron off me and step out of it.
Place the apron in barrel of 0.5% solution
Wash your hands
Bend slightly forward , grab your goggles from the front and pull them off your head. Dip your goggles THREE times (no more, no less) in a 0.5% solution, then toss them through a hole in the wall into a bucket of chlorinated water.
Wash your hands.
Now comes the hood, The hood has three ties in the back, and one at the bottom of the hood that wraps around in front of you. You can untie the strings, but wet gloved hands have terrible dexterity, I always end up just ripping them. Once all the strings are ripped, you bend forward slightly and grab the back of the hood, pulling it forward and off your head. Then you throw it away.
Whats next?
What the do you think is next?
Wash your damned hands.
Now comes the suit. The suit has two pieces of tape on it, one that closes a flap over the zipper, the other over your collar. You “Pop your collar” by peeling the tap off, then pop the tape down the front of the zipper.
Wash your ha…NOPE! (Guys thought you were getting it by now right?)
Now the sprayer sprays the newly exposed area of suit. Which at times can suck, since they start at the top, some 0.5% chlorine can hit your neck and face. This can cause some pretty severe skin irritation and burns. Luckily Mr. Beard protects my face and neck from such a chlorinated attack.
Now you unzip, starting from the top, making sure not to touch the inside of your suit when you grab the zipper at the very top. Unzip it all the way down to your nether relms and then you…
WASH YOUR HANDS YOU FILTHY SAVAGE.
Once that’s done you
Reach on the inside of your suit, making sure not to touch the outside, and pull it off your shoulders. Then you kinda shake shimmy the suit off you. Basically you do the Bernie out of your Ebola suit.
Pulling your hands through it, make sure you only touch clean to clean, or dirty to dirty. Now, pull your suit down your legs, touching only the inside. Yeah, down to your boots, but don’t actually touch the boots while you do it.
Now, stand up and pull your boots out of the suit, this part can be a little tricky to, first you step forward, then you step back, then you lift your leg up, try to step on it with the other foot. Every time I do it, I feel like an idiot, I’m trapped for a good minute trying to step out of the suit, until finally I manage to pop my boots free.
Kick/slide the suit forward a few feet. The sprayer then gives the Ebola suit another chlorine bath, drowning any remaining ebola’s hopes and dreams in tidal wave of chlorinated goodness.
Now wash your hands.
At this point your wearing two pairs of gloves and a mask, so the next step is to carefully take off the outer layer of gloves.
Now wash your hands again.
Lean forward and pinch the front of your n95 duck billed mask, pull it off your head and throw it away.
(Pictured is a n95 Duck billed mask)
(Quack Quack)
Once that’s thrown away you wash your hands again.
Now you take a step towards the sprayer, and stand at attention. He/She sprays the the front side of your boot
you turn to the left, sprays that side of your boots, (Reverse Reverse!) You turn to the right side and that side is sprayed.
Then you turn away from them, where the back of the boots is sprayed, then you lift up one boot behind you and its sprayed, take a step back and the other sole of the boot is sprayed.
Now you’ve crossed over to the “Clean side” of the doffing area. You take off your last pair of gloves and throw them away.
Congrats you’ve ma…
YOU WASH YOUR HANDS AGAIN
This time with no gloves on, and a 0.05% solution. And normally a good 45-60 second process
(Minus the soap and water part for us)
Next you stand in a 0.5% solution for another 30 seconds as you exit the doffing area.
Right next to the station is some piping with pure water and 0.05% solution. I always cover my face/arms/neck with a good amount of 0.05% solution. Then rinse it off with pure water.
Congrats! You survived donning and doffing!
Now go enjoy a coke.
(Me right after I doffed, notice the moistness)
A sharp cry breaks the stillness of the night, and awakens the staff and I from our short restless sleep.
A women in the confirmed ward was crying out, her whole body shook with grief, and her voice failed her. Distraught is a word too timid to describe the emotion. Her whole world was suddenly gone, twenty years of life, a lifetime of promise was taken away in a matter of days.
Ebola had claimed another, its second of the day, surely Charons boat must be nearing it’s limit.
I went in with Matt, one of the doctors here, and one of the nationals who was acting as a sprayer.
EDIT: One of our nurses was taking pictures during the donning procedure of our gear. She stated that it was an eerie silence as we did it, no one spoke a word. It was almost ritualistic.
She was laying on her right side, a light sheet covering her to her neck. No pulse, no chest rise and fall, and the warmth had left her body. There was no pools of blood, or bodily fluids like many would think, she lay peacefully.
She was dead. We pulled the sheet over her head.
Ebola is at its highest viral load when the person has died, dealing with dead bodies is one of the most dangerous jobs you can have in an Ebola outbreak. In order to prevent the virus from spreading, the body is sprayed with a 0.5% chlorine solution. When we wash our hands we use a 0.05% solution. The 0.5% is used for equipment and our protective suit.
The virus had stripped her of her humanity. We didn’t care about burning her skin, we just needed to stop the virus from being on another surface.
You have to move the people out of the room to do this, the chlorine is high enough concentration that any splashing can cause burns. So her two roommates, a 40 year old women and a –
3 year old girl.
Had to be moved across the hall. The little girl was in there awake and watching as we checked for a pulse and covered her body. I Made two beds in the other room and matt carried the little girl over. We Gave her blankets and toys and tucked her in. I asked her if she was okay and she nodded, her head trying to see what was going on in the other room.
The wailing mother was down the hall, sitting on a chair in a room occupied by two other patients. Matt went in first and spoke with her briefly, giving her some valium to help her sleep.
I walked in and gave mine as well, squeezing her hand trying to offer what sympathy I could, tears were already filling my goggles.
We moved everything we could out of the one room into the other, and the sprayer went in.
I stood in front of the three year olds door, blocking her view in case she was curious. She has already seen to much for her age.
The sprayer worked methodically as he sprayed her body,
Pump pump pump
Spray
Pump pump pump
Spray
Pump pump pump
Spray
Until her body was soaked. We blocked off the door and started to leave, the three year old was already alseep.
It’s raining now, thundering down in great buckets on our tin roof, so loud we can’t have a conversation across the room.
But I can still hear the mothers scream
African Platypus 