First day in ETU

February 7, 2015 – It is 100 degrees today. We made one pass through the ETU in full PPE; it was bearable, although, in fact, we didn’t do any treatment of patients. We saw them, though. I am very, very concerned about turning individuals, whom I know nothing of, into emblems or symbols. But - a listless child pulling a grubby pink blanket around him, despite the morning heat, is a very sad sight.

There was also a guy, perhaps 18 or 20, well dressed, bathed, and apparently comfortable and full of energy, who asked one of us to speak with his father. I’m guessing he is about to be released (I know there was one patient today who had recovered). So there is that, too.

The unit makes use of the concrete-block buildings of an old technical school. At least half of the surface area, however, consists of enclosures of one kind or another surrounding the buildings, made of wire fencing and blue tarpaulins. The fences delineate a variety of specifically defined areas – triage; the lab area; the “red” zone; the mortuary – through which patients may pass during their time at the facility, always moving from less-infectious to more infectious zones. Until, with luck, they take their “happy shower” (pre-discharge bath to clean any remaining virus off the surface of their skin) and come back out into the world.

I believe that there were four people to be discharged today (three who turned out not to have the virus and one who recovered); there was also one who died last night. As we were leaving, two ambulances had pulled up – unfortunately at the same time, so one patient had to wait in the baking, non-air-conditioned box while the other was seen. If that represents the total “outs” and “ins” for today (it might not), it means the patient census fell a little. Perhaps you have to be here to realize how fervently I hope that to be true.

In Port Loko

February 6, 2015 – In Port Loko, at this hilarious sort of fantasy-camp for relief workers set up by (who else?) the Danes. Thrice-purified potable water, electricity, wi-fi, showers, air-conditioned tents, three meals a day, and laundry service. It’s really kind of obscene, except the vibe is so good. And we were welcomed by the charming, young, bearded, slightly humorless Danish receptionist with the compliment that “we always love having PiH people here, because they are always so positive.” Well – I hope so.

We drove up here in a bus (see map) over an excellent road – the 75 miles takes three hours mostly because of traffic getting through and leaving Freetown. The morning was spent on an almost-2-hour simulation in the mock ETU, in full PPE. We were presented with five scenarios – the disoriented and combative patient, the self-medicating patient, the relatively stable patient, the patient in septic/hypovolemic (low body water) shock, the deceased patient, the recovered (!) patient. It was actually reasonably bearable to be in the suit that long (we were wearing the lightest of the available suits today), and, again, the work seemed eminently doable. Tomorrow, we get our first exposure to an actual ETU, with around 25 patients.

The epidemic is waning, as I’ve been saying – that is, it is waning countrywide. However, there are still “hot spots,” and we are in one of them here. I believe the unit actually has more patients in it this week than it did last (although a far cry from the 100 patients it was built for). So an overall decline does not mean a resolution everywhere.

By the way, a number of those Salonean heros I spoke of in the abstract in my first post were in our class. One of them particularly made an impression – a woman who seemed tough to the point of being off-putting, until she burst into a huge guffaw, which she did from time to time. (Like when she was flirting with one of my colleagues, a 6-foot-3, 30-something nurse who somehow projects this perfect combination of manliness and boyishness. He was very, very popular at the training!) She’s been working in ETUs for 5 or 6 months, and not just for 4 weeks at a time like us. When she demonstrated putting on and taking off PPE ("donning and doffing," as it is universally referred to here), you knew it wasn’t something she’d just learned. I don’t know if the toughness was something she’s had all her life or something that’s developed over the past half year. It was somehow reassuring….

A report from the real ETU tomorrow.

The camp.

The camp at sunset.

Some Ebola signs you see along the roads

Training day 4

Last night, many of us in the team ended up sitting around the living room swapping stories. The team is gelling very nicely, and I’m struck by how much it feels like – being in a play! You come together with strangers whom you will have to work with for a set period. You feel your way a bit into who they are. You find ways to laugh together. You start to trust each other, and to sense who you can rely on for this, who you might have to support a bit for that. And all for this goal that is bigger than any of you individually. (It might sound strange to compare producing a play to ending an Ebola epidemic, but when you are doing them they can both feel very important.) I guess it’s just the nature of collective undertaking. But it was nice, and both a bit surprising and a bit concerning (because in a way it made me feel young and more fragile again) to find myself coming back around the circle.

Today (2/5/15) we wore the PPE (by the way – I said that meant “personal protective gear,” which might have confused everyone – it is, of course, Personal Protective Equipment!) while treating “patients” in teams inside a mock Ebola Treatment Unit (ETU). I was elected team captain because (to my mild alarm), it turned out I was the only MD on our team. But, once inside, it went very well. I don’t know what it is about medical trainers, in general (this happened all the time in medical school), that they like to put you in situations they have not explained very well and then yell at you when you don’t figure them out the way they want in the time they want - ! There was a bit of that – but, in general, the PPE was bearable, and, when it comes down to it, the treatment of Ebola patients is (as I’ve said) not particularly complicated. I feel like I’m pretty good at supervising clinical people – telling them clearly what I’d like them to do; summarizing information collected and stating simply what we need to do in response – so that’s what we did in there, and the trainers seemed happy. Basically, it’s evaluate the patient’s “fluid status” – how much water they have filling their blood vessels – and, if it’s low (as is very likely in this case), figure out why. It could be due to the patient losing water (vomiting, diarrhea, sweating), to the patient losing blood (the “hemorrhagic” part of Ebola Hemorrhagic Fever – actually, a relatively rare occurrence, though a serious one if it happens), or to the patient having a massive systemic infection (“septic shock”). Once you think you know which one it is, you treat it – although, ha, ha, in this case, all the treatments are all the same, since we can’t give the patient blood, and we give all patients antibiotics whether we know they have an infection or not since it is very likely that they have or could develop one. That only leaves IV fluid, and, whatever the reason the volume status is low, we give a lot of this. Add an antimalarial (many, many people will come in with malaria, whether or not they also have Ebola), some Tylenol for their fever, a multivitamin, and other drugs (anti-nausea medications, stuff for seizures, sedatives…) as needed. Clean the patient up, replace his/her linens, make him/her feel as comfortable (and hopeful!) as possible – then check again in a little while. And hope that, as you do this again and again over several days, their body, in the meantime, will cure them.

By the time we got out, there were little lakes of water in both of my sleeves, my face shield looked like the inside of a kitchen window on a snowy night, but with the help of my colleagues, I got everything on and off, more or less in order.

Interesting to note: While doing “triage” exercises (deciding whether or not a person who comes to the ETU should or should not be admitted as a potential case), if it wasn’t crystal clear what the right answer was, the Sierra Leone colleagues were more likely to say “yes, admit them” than the foreigners were. They’ve been doing this for a while and it’s their country – my guess is that a) they’ve seen how the disease can surprise you, and b) they’re more acutely aware of the havoc than can be wrought by an infected person NOT being isolated. The downside is that you risk giving the virus to someone who in fact does not have Ebola to begin with, if you bring questionable cases in. Which error would you choose?

To Port Loko, and a real, active ETU, tomorrow.

Training day 3

Training, day 3. Most of the day was taken up with very useful and important protocols for treating Ebola patients, but by far the most striking aspect was a panel of Ebola survivors. The first time you hear someone say “I was taking care of my children, and after they all died, I became sick,” or “when I returned home from the treatment unit, I learned that my mother, my father, my brother, and my elder sister had all died” – it kind of takes you aback. I mean, all that stuff you read about, 20 people in a family dying – it actually happened. A stupid thing to say, maybe, but hearing someone sitting in front of you, whose individual face you are looking into, say it makes it more real.

One of our group commented on how traumatized the whole country is, and you begin to see it. To begin with, the survivors themselves – the man whose kids all died said, when we were speaking with him afterwards, that when he’s doing events like this he feels okay, but when he goes home he gets depressed. Yes…. He wished there were more psychological supports. He also said that men need support/somewhere to go when they come out, since they can’t have sex for 90 days after they’re cured because there is still virus in semen. On the one hand, this seems kind of a minor concern – but, on the other, I can imagine that, after you thought you were going to die, were tended to by strange people in moon suits in a treatment area where you knew no one, got unexpectedly better, and came home to find that your partner was, amazingly, still alive – you might really, really want to have sex!

But the entire health system is messed up, too. First of all, any condition that is NOT Ebola has been completely neglected over the past several months, so the general level of health has probably declined, and there will probably be a backlog of people coming in trying to get services once they feel safe (and once normal facilities are open for business). Second, a lot of healthcare workers have died, and as a result of this (and of fear), the system has just come apart in some places. But also – the thing about Ebola’s “presentation” (i.e., what people look like when they come in for care) is that it is more or less the same as “feeling sick.” People have headaches, achy joints, red eyes, abdominal pain, fever. How many other illnesses can you think of that make you feel like htat? If they are a little sicker, they might also have vomiting and diarrhea and feel weak. Again – is there another illness or 50 that makes you feel this way? So imagine what happens in 6 months: A woman has malaria (headache, fever, achy joints) and comes to the hospital. Whereupon everyone becomes terrified she has Ebola (headache, fever, achy joints). Will they care for her? Will they kick her out? Will they run away? Those are going to be the questions from now on.

I’m glad to say that, once the Ebola crisis has been contained, Partners in Health is first and foremost committed to rebuilding the health system. It will need it.

A word about Freetown: If it were richer, it would be San Francisco. I keep noticing this. It is situated on these lovely, steep peaks right over the ocean. (And apparently the beaches nearby are BEAUTIFUL, too.) The general sense of poor-country dilapidation changes the impression – although mostly what makes it seem less lovely is the Harmattan (wind carrying dust off the Sahara at this time of year) and the perpetual burning (garbage? Cooking fires? Field clearing?) – also a common developing-country phenomenon. So the air is always kind of brown and hazy (at this time of year, anyway). Still – the views from our hillside house are kind of breathtaking.

A beach more or less in the city of Freetown - nice swim!

View from our apartment - morning

View from our apartment - evening

Training day 2

Another day of training – again, very useful. Today we concentrated on the layout of the Ebola treatment units and the definition of who is and is not a “case” – that is, who needs to be kept for further diagnostic study and who can be let go.

Up to a hotel atop the city afterwards, for happy hour and a soothing swim. Then back home, where we played a game called Pandemic, about trying to save the world from outbreaks of killer diseases. Yes, it actually exists, a commercially produced game about what we are, in our way, actually doing here. Pretty weird. (And fun, too!)

First day of training, Sierra Leone

2/2/15 – First day of training in Sierra Leone! After our late arrival last night (and some watching of the beginning phases of the super bowl by some of us), we got up before sunrise to be ready to go to the stadium by 7. Turned out we were an hour or so early, which gave us time to look over the Olympic swimming and diving pools (unused since at least the start of the outbreak but likely a whole lot longer than that, by the look of them) to the shanties lining the watercourse below. Sierra Leone is supposed to be the wettest country in West Africa and among the poorest countries in the world, and the crop fields along the (trash-filled) stream looked very lush, even if the living quarters beside them did not.

It was clear when we got underway that the training (by WHO and the International Organization for Migration) was not just for us. There were maybe twice as many Sierra-Leoneans (or Saloneans, I think they say), most of them nurses, many of them already working in Ebola Treatment Units (ETUs) and so a great resource for us new folks. A large group – maybe 60 people – but the training was really well run and useful.

Along with briefings on the disease and workshops on useful topics like correct hand washing (you'd be surprised how much of your hand you can miss if you don’t do it systematically!) and how to remove gloves (yes, there is a right way, and it makes a difference!), this was our first chance to actually put on PPE – “personal protective gear,” our new friend. This is the combination of boots, Tyvek suit, mask, face shield, multiple gloves, and hood that is supposed to keep us from contracting Ebola even as we work with patients who have it. You have probably seen pictures – more or less, you end up looking like an Empire storm-trooper from Star Wars, except more colorful.

It’s amazing the amount of anxiety that comes up as you contemplate putting this stuff on. First of all, it makes it 100% clear that you are getting ready to go into close contact with a deadly disease. I think that, as with being mortal in general, it is amazingly easy to pretend it doesn’t really apply to you even though you know the whole time that it does. Second, as you know from every last person who has ever spoken to you about it, the gear is incredibly HOT. I mean, hotter than the 90 degrees hot that the air is here already. Apparently, more like 120 degrees hot. Several people have spoken about feeling faint, feeling like they can’t breathe, having panic attacks, etc. while wearing it. Third – putting it on and, especially, taking it off involve many, many steps which you are supposed to do in the same order every time, while simultaneously keeping in mind adamant prohibitions, such as you are never supposed to touch the outside of the suit and never supposed to touch anywhere near your face. Finally, all kinds of things can happen while you are wearing it which can be anything from irritating to dangerous, and you are supposed to respond correctly to all of them. Face shield fogs up? Can’t wipe it. Mask slides up toward your eyes? You can try blinking it away, but you can’t reach up and touch it. Itchy nose? Try to think about something else, because you aren’t going to scratch it. Tiny patch of skin appears between glove and sleeve? Out you go, no matter what you are in the middle of doing; you have to completely remove and re-put-on the gear, with a good scrub of the exposed skin in between. 

In other words – in addition to the deadly-disease aspect, and the suffocation aspect, there are just a lot of ways you can screw up.

As it turned out, the first run went pretty darn well! You realize that, between you, the “buddy” with whom you are joined at the hip whenever you are in the ETU, and a third person who is there to coach you, it’s not that hard to follow the prescribed steps in order. It is INCREDIBLY hot (it’s like wearing a thick plastic bag) – after 30 minutes or so, my shirt was dripping wet, and we are going to be wearing it for 90 or more minutes at a time. And you do feel like you can’t breathe. But here’s where the three-minute meditation techniques they taught us in Boston come in handy. Breathe, settle down, and you realize you’re not going to suffocate. The shield does fog up – but, at least for those 30 minutes, I always could find some patch that was clear enough that I thought I could look through it to put in an IV. I still worry about screwing up – not pulling my gloves up high enough, touching my hair as I take off my mask – but they’re always telling us to do everything SLOWLY, and I suppose if I can overcome my habitual klutzy haste, I’ll manage to do things the right way.

Don’t know what we’re doing tomorrow, but they ARE giving us a break from putting on the PPE!