Updates from West Africa
Ebola emerged in West Africa in late 2013 and has spread across borders, killing thousands and leaving behind survivors and shattered families. Partners In Health has helped respond to the epidemic, aiming to address not only Ebola but also the "staff, stuff, systems, and space" challenges that hamper containment efforts. PIH has recruited and trained American volunteers, many of whom are now working to curb Ebola alongside West African partners in Liberia and Sierra Leone. Several share their reflections below. (Patient names have been changed for privacy. Posts have been edited for space.)
March 2, 2015—I arrived for my evening shift at Maforki on Monday anxious to hear how my patients had fared since I’d last seen them 24 hours before. I expected (and part of me hoped) to hear that Foday had passed away and was no longer suffering. No one I worked with could remember seeing a patient recover after progressing to the bleeding stage, so it had begun to feel like we were simply torturing him. I dreaded the thought that Abass might have died.
I immediately scoured the whiteboard with patients’ names and breathed a deep sigh of relief to see that Abass was still on it. When day shift reported that he had seemed a little better to them, I told myself it was because he was on the upswing; that the worst hadn’t killed him, so he would survive.
Monday night taught me that you can’t make predictions about Ebola. Another patient in Abass’s room, a 36-year-old woman named Mariatu, had been looking comparatively well when I met her on Saturday. She was sitting up in bed, eating and drinking and completely lucid, unlike her roommates Foday and Abass. Although she had diarrhea and vomiting the last time I’d seen her on Sunday, she still seemed to be in better shape than the others. When we reached her bedside during our first round in the Red Zone, she was moaning with pain and laboring heavily to breathe. Since we hadn’t anticipated Mariatu being in so much discomfort, we hadn’t brought any pain medicine into the Red Zone for her. We had used our last dose on a patient in the previous ward. She would have to wait until our next round in a couple of hours before we could get her some. Promising her that we would be back to take care of her, we left Mariatu in bed moaning in pain.
When we returned for our second round at 9:45 pm, it felt eerie in the dim fluorescent light of the Red Zone. We found Mariatu lying on the ground just outside the door of her ward. I suddenly remembered another nurse checking under the beds while he was giving us a tour of the Red Zone, and telling me about this “weird Ebola thing” – that patients often crawl out of bed near the end and die on the floor.
But Mariatu was still alive, breathing hard and looking at us with wide, terrified eyes. I helped my coworkers sit her up against the wall, then stepped into the ward to check on Foday and Abass. When I turned back to the door a minute or two later to ask if they needed help getting Mariatu back into bed, they told me she was already dead.
I couldn’t believe I’d heard right. I started to take a moment to process it, then looked around at the rest of my team who were moving forward with the job at hand. With only 90 minutes in the Red Zone, we don’t have any time to waste. Mariatu’s body was left where we found her and covered with a lapa. Ebola is extremely contagious in the bodies of the deceased, and it wasn’t our job to care for her any longer. The corpse team would be called after we left the Red Zone, and they would come the next day to move her to the morgue so the specially-trained burial teams could come to pick up her body. Nowadays every death in Sierra Leone (whether Ebola-related or not) is handled by the burial teams in full PPE, just to be safe.
With nothing left that I could do for Mariatu, I walked back to check on 10-year-old Abass. He and his 25-year-old neighbor Foday were now both lying on mattresses on the floor; they’d been moved out of bed when they were agitated and the clinicians worried they might fall. Abass had pulled his IV out since we’d last seen him, and another team member felt he would die overnight if we didn’t get another one in him. In the poor light, no one felt excited about attempting it: An accidental needle stick injury to one of us is statistically a death sentence. One of the national nurses stepped up without missing a beat, and had a beautiful IV in Abass’s arm before the rest of us could even tell her to be careful. We hooked him up to a bag of IV fluid and were feeling pretty good.
Then the lights went out.
I won’t pretend it isn’t scary to be the the Red Zone of an ETU at night with no lights. You become extremely aware of all the infectious material around you that you suddenly can’t see. I hate to be dramatic, but it does feel a little like a horror movie. Unfortunately power outages aren’t an unusual occurence, so our more experienced coworkers had warned us beforehand that if we found ourselves in total darkness in the Red Zone, we would have to stop whatever we were doing and leave. I knew we had to go for our own safety, but I wanted to scream out of frustration, since we’d just arrived and had barely started caring for our patients. I was fortunately still holding the battery-powered LED light I’d shined on Abass to help the national nurse get more direct light to start his IV. We all agreed we could take a moment to unhook his IV fluids, otherwise he would tear his IV out again as soon as we walked away.
As soon as we had unhooked Abass’s line and resolved ourselves to leave, the ceiling lights sputtered and flickered back to life. The Red Zone is not a comfortable place to be, but I silently cheered that we wouldn’t have to leave. We restarted Abass’s fluids and decided to try to feed him since he was awake and calm. Fortunately some formula had been left in the Red Zone, so I drew up a few mililiters in a small syringe, squatted on the floor next to his mattress, and held it to his lips. I knew he had painful mouth sores and I worried that he’d refuse it, but he silently swallowed the tiny amount that I squirted into his mouth. I flicked away an ant that skittered across his mattress. Another nurse sat above him, stroking his head. We both encouraged him to eat and cheered him on every time he swallowed a few drops. His eyes met mine while I told him how well he was doing, and I felt sure he was lucid. I tried a silly little dance and suddenly he was smiling. His grin was weak but wide, and his eyes were bright, and all of a sudden I could clearly see the little boy he was before he was sick. I laughed and smiled back at him as hard as I’ve ever smiled, certain that he would see it in my eyes if I could just smile hard enough, even though my mask and hood covered every other part of my face. He babbled at me in a language I couldn’t understand, then called out “Auntie, auntie!”
I don’t know how long my friend and I sat there, entreating him to swallow drops of formula, rubbing his head and his bare chest, dancing and singing in our suits, hoping to elicit another smile. We were rewarded with a few more beautiful grins before Abass shut his mouth and refused to eat any more.
Our time was up anyway. I knelt beside him and told him he was strong. I promised we would be back for him soon. Maybe he didn’t understand, but I think some things don’t need to be translated. I reluctantly stood up and walked away, leaving him alone with his neighbor Foday struggling to breath, and the body of Mariatu just outside the door. As we were leaving the ETU later that night, one of the other nurses told me she thought he had a shot.
Abass died the next day.
I don’t know if he was afraid, or in pain, or even if anyone was there with him. I hope someone was. I hope I made his last night a little less frightening. I think I brought him joy and I have to believe that matters.
I wish I could find the right thing to say to make his death meaningful, but I don’t think there’s any meaning in a 10-year-old dying alone on the floor. I could rant about how he might have been saved if he’d had access to the best medical care in the world, but I’d rather just let him be a sweet little boy than an example of all the injustice in the world. Even though it was only for a fraction of the time I spent with him, I’ll always think of him as Abass with the big contagious grin and the bright eyes, not as one of thousands of children who have died of Ebola. I didn’t know him very well, but now you all know a little piece of him too, and I think that counts for something.
March 2, 2015—The only word I have been able to find to describe this experience so far is surreal. Today it became real. Today Ebola ceased to be a faceless mass of African suffering and became two individual human beings.
I’ll give you all the lay of the land at Maforki before we get much further. Maforki ETU belongs to the Sierra Leonean government, and is built out around what used to be a school. The patient wards are the old classrooms, large concrete buildings painted red on the outside, with several beds in each. When it was turned into an ETU, additional basic structures were added at the periphery: a triage area, nurses’ station, meeting room, areas for donning and doffing PPE. Nailed together out of mismatched wood and blue tarps, the whole thing looks a bit ramshackle, but the center is known in the area for giving excellent care. Port Loko residents who fear they have Ebola ask to be brought to Maforki because they have heard they’ll be treated well.
To enter, you must dip the bottoms of your shoes in a bucket of chlorine, wash your hands in chlorine, and have your temperature taken at the gate. The whole center is divided into two main areas: the Green Zone and the Red Zone. The clinicians’ areas are in the Green Zone, so we can have meetings, draw up medications, eat meals, etc. in an area that is not contaminated with the virus. The patient wards are in the Red Zone. No one steps one foot into the Red Zone for any reason unless they are in full PPE, and nothing you take into the Red Zone is allowed to come out.
At the beginning of each shift, the staff gathers in front of the large white board that shows the names and medical information of each of our patients. Today there were ten (five confirmed Ebola, and five suspect). We discuss how each one fared overnight, and divide them up between the nurses. My group of nurses was assigned to the confirmed Ebola patients, so we huddled at the nurses’ station to make a plan.
Because we are limited to 90 minutes in our PPE, we need to decide everything we’re going to do before we enter the Red Zone. We also need to be deliberate about gathering any supplies we might need, since there’s no way to step back out of the Red Zone to grab something once you’re inside. The Suspect Ward does have a wooden slide from the window of the supply room in the Green Zone going over the fence into the Red Zone, so if we need something we can ring the bell on the Red Zone side and someone will slide whatever we need down to us. But again, that just wastes time in your suit.
So my team drew up all of the medications we thought we’d need--IV start supplies, plenty of bags of IV fluid, rags, and lapas (beautiful African fabrics used for just about everything, but in this case as sheets). I found myself giving doctors tips on how to draw up meds, since at home they are normally the ones writing orders, while nurses carry them out. Here in Maforki, it’s all hands on deck and the doctors gladly do nursing care with the rest of us. One of our patients had just been confirmed Ebola positive this morning, so we would need to move him from Suspect to the Confirmed Ward. We had been told he was too sick to walk, so we brought a body bag to put him on so we could carry him.
Then it was time to don our PPE. I hunted for two pairs of gloves in my size, as well as a pair of black rubber boots that fit me, out of the many drying on a rack in the sun outside the nurses’ station (exposure to sunlight kills the virus, too). Then I joined the rest of my team in the donning room, the last stop before you enter the Red Zone. A few Sierra Leonean staff double-checked us as we donned our suits. We were ready to go in.
As we walked through the doorway into the Red Zone, I took up the “Ebola pose” that we had been taught in training – interlocking my fingers in front of me at about the height of my navel, to discourage me from reaching up to touch my face or anything else around me. One of the Maforki nurses told me that when he’s in the Red Zone he pretends he’s playing a giant game of Operation, trying not to touch anything around him that he doesn’t have to. He assumes that every surface is contaminated with Ebola.
The Red Zone is designed to flow from lowest to highest risk, so the first ward we came to was Suspect. The Suspect patients (who have Ebola symptoms but have not yet had a positive test) are divided between those who have dry symptoms (fever, headache, hiccups, weakness, etc) and those who have wet symptoms (vomiting, diarrhea, and bleeding). The idea is to decrease the likelihood that one patient will infect another with Ebola. “Wet” patients produce a huge amount of highly infectious diarrhea and are often too weak to make it to the toilets. Many wards have old cholera beds, which have a large hole at the center that patients can position themselves over, with a bucket on the floor underneath to catch their waste.
Unfortunately Maforki does not have its own lab, so we send our blood samples to another nonprofit which runs our lab tests and emails us the results. The process can take 12-36 hours. In the meantime, all suspect patients must be housed within the Red Zone in case they do turn out to be Ebola positive. We don’t get many patients who return after they’ve been discharged negative, which is reassuring.
One of our patients today was not so lucky. Foday was brought to Maforki yesterday already very ill, and his test came back positive this morning. We needed to move him from Suspect to the Confirmed ward. When my team of four entered the Suspect Wet ward, Foday lay curled up in bed in his own waste. We carefully cleaned him up with the help of a sprayer who followed us with a tank of chlorine on his back, rinsing our outer layer of gloves whenever they were visibly soiled. Once Foday was as clean as we could get him, we rolled him onto the body bag we had brought with us and lifted him out of bed. Communicating with each other the entire time, we made our way out of the Suspect ward, through the gate into the Confirmed area, and lay him down on a bed in a room with the other Confirmed patients.
In the bed next to Foday lay 10-year-old Abass. When we visited him yesterday he had barely responded, and we worried over the bleeding we saw at his gums – a late sign, and not a reassuring one. Today he was reaching out for something with both hands, probably a family member whose presence he was hallucinating. The team before us had given him his meds, but I couldn’t help walking over to him to try to give him some comfort. When I entered his field of vision he recoiled. Between the language barrier and his delirium, I couldn’t explain to him why his family wasn’t there to wipe his face and hold his hand, and he was instead being cared for by a stranger dressed like an alien.
Having used up a lot of our allotted time already, we went to work giving Foday his medications. At Maforki we are aggressive with IV fluids, although it’s difficult because we can only give them while we are inside the unit with the patients. Experience has shown that if we hook up an IV line and leave it hanging, we will return a couple of hours later to find that the patient has accidentally ripped it out and bled everywhere. So we did the best we could with the time we had left, giving Foday IV fluids, antibiotics to prevent secondary infections, artusenate for malaria, and paracetamol for his fever. Although we had cleaned him up after he’d soiled himself again, by the time we had to leave he was already lying in his own diarrhea for the third time since we’d arrived about an hour before. With no time left, we had to leave it for the next round of clinicians.
Although we technically can spend 90 minutes in the PPE, a good chunk of that is taken up by the doffing process. As I’ve mentioned before, removing our PPE is the point at which we’re most likely to contaminate ourselves. We have infectious body fluids all over us, and we have to get out of our suits without getting a speck of it on ourselves. Once we do, it’s almost noon, and we head to the nurses station to re-hydrate and have a snack before our second round in the Red Zone. I’m feeling fine physically. I seem to be one of the lucky ones who is surprised when our time is up, and I come out of my PPE almost as dry as I went in while others return with their whole scrubs a shade darker from the sweat. Emotionally, it’s harder.
By our second round in the afternoon, Foday was looking worse. He was having pretty much constant diarrhea, rolling over to vomit into a bucket next to his bed, and dripping blood from his nose. His fever had risen and he was tachycardic. Dried blood was caked all over his nose and mouth. We started a second IV and rushed fluids into him, and tried to clean him up from head to toe. At some point he decided he was done putting up with all of these white-suited monsters poking at him, so he rolled over and tried to stand up, clearly agitated. With two IVs hooked up and blood running down his face, any quick movement on his part would mean spraying infectious blood all over the place. As a nurse, everything in my heart wanted me to go rub his back, help him back into bed, and calm him down enough that we could continue to care for him – while everything in my brain was shouting, “Get away from him!” Suddenly my PPE seemed so fragile. He eventually calmed himself down and crawled back into bed, and I was left feeling surprised and ashamed at how afraid I’d been.
Most of the clinicians who have been here a while think he’s too far gone to recover, and I hope if they’re right that he passes away soon. I’m heading back to Maforki shortly for an evening shift, and I know we’ll do everything we can to make him comfortable. Even if he is going to die, he doesn’t have to die in pain and covered in his own mess.
Night shift tells us little Abass is looking better today, and I’m looking forward to seeing him for myself.
I hope that telling Abass and Foday’s stories stories has put faces to the outbreak. The numbers we hear on the news are PEOPLE, every one of them just as important as us and our families.
You Can Get Blood Out of a Stone
February 27, 2015—Those of you who know me know that I’m always freezing, so maybe I have the ideal constitution for working in an ETU. On Thursday and Friday we donned full PPE and trained in the mock Ebola Treatment Unit. In an effort to prepare us, our instructors had described in great detail the science behind what we all know already: That it is really dang hot in there. Inside the PPE is a micro-climate of 40-50 degrees Celsius and 100% humidity. This is, as our trainers put it, an “un-compensable” environment – meaning that our normal heat dissipation mechanisms (i.e., sweating) won’t work. We were repeatedly admonished that there is NO HURRY in the ETU. If we over-exert ourselves, core temperatures can reach critical levels in under an hour. They key is to pace ourselves.
A couple of members of our group did overheat during our training in the mock ETU. Although it’s awful to watch someone you’ve grown close to as they struggle against the limits of what our bodies are capable of, it was nice to see our little family rally to help each other out. If someone starts to feel unwell in their PPE, the most important thing is to admit it and get out of the red zone asap. If someone faints and goes down in their PPE in a real Ebola unit, we’ll have a whole new set of problems. Fortunately my friends headed straight to the doffing stations, and with a little fluid and electrolytes, ice packs under the armpits, rest, and kind words, they were right as rain.
While the heat turned out to be the least of my problems, I was struck by just how restricting the PPE is once I tried to do my job from inside it. Between a hood, face mask, and face shield, my field of vision is pretty restricted. And if I don’t get my mask on just right, my breath fogs up my face shield and suddenly everything is a blurry mess. The first time I donned the full getup, I pulled my hair up in a tight bun, thinking it would be best to get it out of the way altogether. I discovered quickly that with the big lump of hair at the back of my head, if I tilt my chin to look downward, my hood pulls back from my face mask, leaving a strip of completely exposed skin on my forehead. One of the lovely Sierra Leonean nurses, who probably knows more about working in an ETU than I ever will, told me that a braid down the back works best and I was happy to follow her advice.
Another restriction to adjust to is wearing two sets of gloves on top of each other. This is great from an infection control standpoint, but garbage when you want to start an IV. Most nurses I work with in the States will throw on a tourniquet and run their bare fingers over a patient’s arm to feel for the best vein – it’s usually a better bet for finding a good one than just looking. Here, we will be hunting for shriveled veins in severely dehydrated patients, with two layers of gloves between our fingers and their skin. I’m told that this is one of the areas that the Sierra Leonean nurses excel in. While we try over and over to get an IV in, another PIH-er told me that the national staff “could get blood out of a stone.” So I’ll be keeping an eye on how they do it!
As we acclimated ourselves to the PPE, we split up into teams to do rounds in the mock ETU that is set up at the training center. Ebola survivors were stationed in each ward to act like patients, and we were expected to manage their care as we will in the real world. I know I just missed the Oscars, but in my opinion every survivor we worked with should get one. As we approached one man who seemed to be unconscious, he suddenly leapt up and lurched towards us, ripping out his fake IV and trying to escape. Even though I knew there was no real danger, no actual Ebola blood spurting all over the room, it definitely got my heart pounding.
While the mock ETU was invaluable in preparing us for the real thing, I was a bit disappointed to see the national nurses take a backseat role. Our doctors made decisions and called out orders, while the nurses carried them out obediently. One of the things I’m most excited about doing here is helping to strengthen the national nurses’ confidence and critical thinking. The impression I get is that nursing education here is very task-oriented, and they are encouraged to follow protocols without necessarily understanding the reasons behind them. Although many of the nurses we trained with were very intelligent and experts at their job, one of them told me, “The doctor is always right.” In any scenario, that can be a dangerous way of thinking, since nurses should be the doctor’s eyes and ears, their final check before care is administered, and strong advocates for their patients. But in a country ravaged by Ebola where there were hardly any doctors to begin, it will be even more essential for nurses to step up and take a leading role. I do hope that once this outbreak is over, what remains are some newly trained, skilled nurses who are motivated to build their country’s health system back from the ground up.
One perfect example is a young woman I’ll call J., a beautiful Sierra Leonean nurse I met during training. She volunteered to work at a government ETU last September, without asking her family’s permission since she knew they would not approve. At that time, nurses only received two days of emergency Ebola training before being tossed in to work at an ETU. J. has been treating Ebola patients ever since, and only gets to see her husband and child when she travels back home to visit them on her days off. I asked her if she wanted more children, and she told me she does not “because it doesn’t leave time for my work, and I love my work.”
It has been such a joy getting to know the national nurses at training. All of these wonderful men and women showed up to our last day of class on Friday dressed in a gorgeous array of African fabrics. Apparently Friday is “African dress day” which made the Americans look pretty shabby in our old scrubs. Nonetheless, it was graduation day and a festive atmosphere as we all rushed around posing for photos and saying goodbye to our new friends.
Directly from training our group left for Port Loko, a district hard-hit with the virus, where PIH’s Ebola Treatment Unit is located. Here we are being housed at a tent city run by a Danish emergency management organization, which looks a lot like MASH and feels like arriving at a colony on Mars. Several large tents are each separated into six rooms, with a cot, mosquito net, and a light in each. Though it looks sparse, it’s actually quite fancy, with air conditioning, wifi, hot showers, and electricity by generator. Plus the food is fantastic, and apparently there is a clothing-optional tanning area (I’m not kidding). Although I greatly appreciate the hospitality and the amount of organization and effort that it must take to keep a camp like this running so that health workers can do their jobs, I can’t help but feel ashamed at the stark contrast between one side of our fence and the other. It is jarring to sit under a nice tent under bright lights, listening to music and going back for seconds at the buffet, while Sierra Leonean kids walk past the fence in threadbare clothes and stare.
After months of waiting, hoping, reading the news itching to be here, tomorrow is the big day. We’ll go to the ETU in the morning, where we will don our PPE and treat Ebola patients for the first time. Maybe I should feel nervous, but I don’t. I’m just glad the wait is over and I can finally have a hand in the important work that needs to be done.
Catch 22s and Surprises
February 26, 2015—I am currently taking up residence on the stairway landing between the third and fourth floors of our guest house, where the wifi has been most reliable today. It's a nice way to meet all the PIH-ers I don't know yet, as they pass me on the way to their rooms and laugh knowingly at the lengths it sometimes takes to get a good signal. One of the long-term staffers jokingly calls us "stairway trolls."
It's late and I'm still a bit jet-lagged so I know I should go to sleep, but I am bursting at the seams with new information and experiences and I'm afraid that if I don't write it all down, little details will start slipping away. The past two days of training have been fascinating.
We spent most of Tuesday learning the case definition of Ebola, which sounds boring but turns out to be the bedrock of everything we do here. Patients will show up to triage at an ETU with a variety of symptoms, and it's our job to decide who should be admitted to be treated for Ebola, and who should be sent to another healthcare facility or home. Sounds easy, right? From what the news tells us, it seems like turning up at an ETU with a fever would be an automatic admission.
The trouble is that there are several tropical diseases here that have similar symptoms to Ebola (Lassa Fever, for example, looks very much the same with the exception that Ebola patients commonly have hiccups). So why not just admit them to be safe, and then figure out what they have for sure once you have them quarantined in the ETU? Because of the nightmare scenario of admitting a person with suspected Ebola who turns out to only have malaria, but then they catch Ebola from having some contact with another patient while they waited to be diagnosed.
Patients who are admitted to an ETU through triage join the other non-confirmed patients in the "suspect" ward. This means they automatically live in the Red Zone, the high-risk area that we healthcare workers can't set foot in without being completely suited up. As much as we will try to keep suspected Ebola patients separated from each other before they are confirmed, it's not possible to guarantee that one won't infect another. One of our case studies described a patient in the suspected ward (who turned out to be Ebola positive) who was delirious, ripped out his IV, and wandered into other suspected patients' rooms, spreading his blood everywhere. If any of those other patients had turned out to be negative, now they were at serious risk. Essentially, it would be horrible if patients came to the ETU Ebola-negative, and then caught it there.
We don't want to admit non-Ebola patients to the suspect ward if at all possible, but we also don't want to send someone home who turns out to have Ebola after all. Here's another nightmare: You triage a patient and wrongly decide that her symptoms don't meet the case definition for Ebola, and she goes home and infects her entire family.
If Ebola tests were instantaneous and 100% accurate, we wouldn't face scanarios like this. Unfortunately, they aren't. The amount of time it takes to get results on a PCR (the blood test for Ebola) has decreased during this outbreak in many cases from days to hours, but many places don't have a lab that is sophisticated enough to handle blood samples as hazardous as these. And even if your patient's Ebola test comes back negative, they don't get an automatic ticket home. In the first few days of the illness the viral load may not be high enough to be detected by the test, so they'll have to remain in the ETU for a few more days and re-test, to make certain that the initial PCR wasn't a false negative. One of the national nurses told me today that she felt their most egregious mistake at the start of the epidemic was that they sent patients home after one initial negative test. She was clearly upset as she recalled that they had sent home one of their health workers despite his symptoms because his Ebola test was negative, only to have him return a few days later and die shortly thereafter.
Now I'll complicate things even more. It would be easier to adhere to the case definitions that guide us to admit a patient if we were certain that every patient was being perfectly honest. But people who don't want to be admitted to an ETU often hide their symptoms, denying that they've had diarrhea or vomiting and insisting that they feel fine. You may also triage someone who has no fever, which lowers your suspicion, until you ask the right question and find out they've been taking Tylenol in order to bring their fever down.
Many of the examples I'm using have come from real case studies that we discussed in small groups in class, which for me has been the most valuable part of training so far. You think you're somewhat prepared, until you find your group split down the middle trying to decide what to do with the case you're discussing, which is an actual situation that clinicians faced in an ETU.
We were faced with another sobering reality today, as Ebola survivors had been invited to our training to share their experiences with us. They sat in a row at the front of the class, bravely recounting the hell they had somehow managed to survive. While one survivor took his turn to speak, others stared blankly at the floor as if re-living their experiences. Another leaned back and covered his face with his hands, seemingly willing himself not to remember what he'd seen.
Most of the survivors we heard from contracted Ebola while caring for their ill family members early in the outbreak. In one case, a patient was sick in a government hospital but the nurses refused to care for her because they feared Ebola. When her family came to the hospital to do what the nurses wouldn't, they all became infected. In another case, an ill woman refused to go to the hospital, so her family members who were health workers cared for her at home. They started IVs on her with their bare hands, and of course infected themselves.
One man told us that when he went to an ETU his family had no hope for his survival, and that "with every tick of the clock, they called me to ask, 'Are you ok?'" Their experiences in holding centers, which screen patients for Ebola and transfer them to ETUs if necessary, were horrific. One man recalled sharing a toilet with 10-15 people, diarrhea and vomit covering the floor, leaving anyone who didn't already have Ebola to almost certainly be infected. The medics were so terrified of their patients that they handed them medicine through a barbed wire fence. "Nobody helps anybody," he said. "It's like the day of judgment."
Once they were transferred to an official ETU, many described how grateful they were for the competent care they began to receive. One survivor explained that healthcare workers in the ETU were confident in their PPE, and therefore not afraid to enter the ward and care for their patients. They repeatedly thanked their Sierra Leonean caregivers, insisting that "the staff are making so many sacrifices."
When they were asked what the worst and best moments of their experience had been, I was certain they would all say that their best day was when they were pronounced Ebola negative and discharged. But most of them described that moment as conflicted; although overjoyed to have survived, they knew they had to return to lives in which many of their family members, including spouses and children, had died. One man's wife died of Ebola on the same day that he was discharged home cured.
Surprisingly to me, most of them described their "best" moment as an experience with a healthcare worker. It put faces to the constant message we are hearing that providing quality, humane care in the ETUs is essential. At the beginning of the outbreak, the care in ETUs was horrible and degrading (how many photos did you see in the news of patients dying alone on a cement floor?). Many people chose to keep quiet if they were sick, terrified of what would happen to them if they turned themselves in. Our trainer told us of one case in which a patient's mother was told that he had died in an ETU, only to have him return to his village cured a week later. His neighbors ran from him, believing he was a ghost. After thinking that her son had gone to an ETU and died, the mother refused to seek treatment when she fell ill, and she died of Ebola at home a few days after her son returned.
Although ETU care has greatly improved (and it is now criminal to remain at home if you have Ebola), some people still resist seeking treatment. Confirmed Ebola patients are interviewed to determine who they have been in contact with since showing symptoms, and those contacts are actively monitored for 21 days. Community health workers visit them at their homes to check their temperatures and ask about symptoms, but it can be difficult to get the true story. Our trainer encouraged asking the families to step outside of their houses to take their temperatures, using the example of an old woman who told the health workers she felt fine, but was unable to stand up when they asked. In other cases, people aware of what time the health workers are coming have removed their sick family members from the home to hide them. There has been a big push to involve local leaders in the process of monitoring. As our trainers pointed out, the villagers will never trust us as much as they trust an authority figure they already have faith in.
There is also an intense focus here on safe burial practices. Since an Ebola patient's viral load increases the longer they are sick, corpses are extremely infectious. Studies have shown that the virus can live on dead bodies for 6 days. In a culture where washing the body of the deceased is a common and important ritual, that spells disaster. We were told that some burial practices include mourners washing their faces with the water used to clean the body, or in extreme cases even drinking it. While that may seem abhorrent to us, try to imagine if a stranger from another country wanted to take the body of your child from you without a funeral or a coffin. It's easy to understand why many Sierra Leoneans refuse. Unfortunately, this can mean that a single funeral can set off a chain reaction in which everyone who attended contracts the virus.
I could go on and on, but I should follow the health workers' cardinal rule (to take care of myself first) and go to bed! It has been a fascinating few days. I take notes furiously and hope that it's all sticking in my brain somewhere, ready to be called forth when I need it in the coming weeks. I'm excited to get into the mock ETU tomorrow and start practicing getting my hands dirty (or rather, my outer layer of gloves. Never, never my hands).
"That 'Good Morning' has Ebola!"
February 23, 2015—We made it to Sierra Leone! Something like 30 hours after we left Boston, we finally landed in Sierra Leone on Sunday night. The same smells I know from East Africa made me feel at home from the moment I stepped off the plane. Even after so many hours of travel and sleeplessness, I knew I was exactly where I was supposed to be.
The reality of the Ebola outbreak hit us as soon as we walked across the tarmac and reached the door to enter the airport. Chlorine hand washing stations awaited us outside, and everyone was made to wash their hands before being allowed to enter. After reading so many news stories about it over the past several months, it was surreal to be actually washing my hands with chlorine to prevent spreading Ebola for the first time.
Once inside, it was probably the most fun I've ever had in customs. We were surrounded by other humanitarian responders from MSF, World Health Organization, Direct Relief, you name it. It was lovely to chat with them all as we waited. After clearing customs, I waited in line to have my temperature checked. It's an odd moment, if you let your imagination run away with you and start to wonder what might happen if your temperature comes out high.... Fortunately, I was a normal 36.3 C and was waved right on.
A short bus ride, ferry trip, and another bus took us to the Partners In Health guest house, which is lovely. We are sharing an apartment with electricity by generator, running water (though not hot), and wifi that comes and goes. We even have a washing machine! My coworkers are laughing at me right now as I sit on the couch, blogging beneath a line of drying scrubs and underwear.
Our first day of World Health Organization training was today. It was clearly well-run and fascinating since I was able to stay awake for 8 hours of class despite some serious jet lag! We PIH-ers are just about the only non-Sierra Leoneans there, which is lovely because we get to interact with national staff, some of whom have been fighting Ebola much longer than us. Many haven't received adequate education, so they are just now attending this training with WHO. Of course we all took advantage of the hand washing station before entering the building, and had our temperatures checked and recorded by the staff.
Our first lecturer wished us a good morning, and chided our lackluster response with, "That 'good morning' has Ebola!" We were reminded of the huge importance of infection control and prevention among healthcare providers, not only to keep ourselves safe, but because of the role it plays in public perception here. We were told that, "You have not come here to die," which is always reassuring! At the beginning of the outbreak, hundreds of Sierra Leonean healthcare workers contracted Ebola due to poor infection control measures. 221 have died to date. To the public it seemed like the situation was hopeless. Why would you come to an Ebola Treatment Unit for care when those who are caring for you are dying themselves? To put it simply, dying sends a bad message. Fortunately this perception has shifted as infection control measures and patient care have improved, but we healthcare workers play an important role in continuing that momentum. Ebola survivors are also pivotal in instilling hope and proving that admission to an ETU is not an automatic death sentence. Because they are immune to the virus for an unknown period of time, many survivors have also been helping to provide care in ETUs.
It has quickly become clear that habits I live with in the US will need to be broken ASAP. One of our trainers stepped into class this morning to let us all know that they had been watching us for 15 minutes, and we each touched our faces an average of 3.4 times per minute. Considering Ebola enters the body through our mucous membranes (eyes, nose and mouth), I'll just have to learn to put up with the itch on my nose. We also don't shake hands when we meet someone new. Instead, we offer to touch elbows. It's hard not to feel rude at first, but the stakes are too high to care really.
The basics are essential here: We all re-learned how to wash our hands, the Ebola way. I'm certain I have never paid such close attention to a person washing his hands as I did at that moment. It takes a full minute, with maneuvers to make certain that we clean every centimeter of our hands. We practiced in a group, everyone nit-picking each other's technique because it will likely be the thing that keeps us Ebola-free.
Next we tested our ability to remove dirty gloves without contaminating ourselves. After dipping our hands in mud, we each SLOWLY removed our gloves, careful not to snap them and fling infectious material, and making certain that no part of the outside of the glove touched our skin. Our trainers inspected our hands and declared, "Quarantine!" to anyone with a speck of mud on their skin. It's excellent practice for when our gloves will be covered with bodily fluids, and it's no longer a game.
And finally, it was time for the infamous suits. We refer to them as Personal Protective Equipment (PPE), and we'll need to know exactly how to don and doff them in order to keep ourselves safe in the hot zone. Today was just a test run, with trainers walking us through the correct procedure for putting on each item - rubber boots, suit, fist pair of gloves, hair cover, mask, face shield, hood, apron, and second pair of gloves. Another surreal moment, to be completely encased in the suits I've been seeing on TV for months. Between the mask, face shield, and hood, my visibility was incredibly limited and I struggled to hear what the nurse next to me was saying. We then took a lap around the building, getting a feel for how we would react to the PPE. My lovely African teacher acted as my buddy (everything in the hot zone is done in pairs), and kept asking me, "How are you doing, buddy?" every few minutes. It's hot in there, for sure, but I didn't feel faint or claustophobic. We'll see in the coming days if that changes when it's an hour and a half, rather than five minutes, that I have to work inside the suit.
The moment you remove your PPE is the highest risk time for contaminating yourself, so this skill is crucial. My buddy walked me through each step, as the support staff will do in the ETU. The motto is "There is no emergency in Ebola," meaning that we do everything at a snail's pace to ensure we are doing it safely. We remove each part of the PPE carefully, with a minute-long hand wash in between each piece. It's a long process. I'm actually looking forward to getting more practice tomorrow. I'd like it to be muscle memory by the time I'm doing it in real life.
Of course we wrapped up the day with a temperature check.
Ready to Depart, Thinking About Coming Home
February 20, 2015—Our stateside training is complete, our passports have arrived complete with our visas just in the nick of time, and tomorrow morning we begin our long trek to Sierra Leone! We'll have a week of World Health Organization training complete with a mock Ebola Treatment Unit and survivors acting as patients, then real hot zone training in an ETU before we are sent to our respective assignments. It has been an absolute pleasure spending time with the rest of my group; there's nothing like hanging out with a bunch of like-minded people who "get" why you do what you do, to really light you up. I think we are all itching to get started.
Partners in Health has taken great care of us and treated us like part of the family, which makes it easy to entrust ourselves to them. Yesterday we had a session with PIH's occupational health doctor to discuss the protocol if we become ill in the field. PIH has not had any clinicians contract Ebola (knock on wood!), but it's common to experience diarrhea or other illnesses that could mimic some of the symptoms. We'll be checking our temperatures twice a day, reporting any issues, and isolating ourselves if necessary. Which I explain only because I think it's interesting, not because I expect it to happen!
Of course, we have also spent plenty of time discussing the surveillance process that we will experience when we get home. I'll explain a bit now, just to soften the ground for when it's my turn!
Regulations for returning Ebola responders are set by the COUNTY in which they live. The CDC has guidelines, but states are not required to follow them, so it's up to each county to decide how they want to do it - which is why some of our clinicians are being told they can't leave their homes for 21 days (the incubation period for Ebola), while others have much more reasonable restrictions.
Unfortunately, some counties are basing their requirements on public perception, rather than actual science. I understand that people are terrified of catching Ebola, but acting on irrational fear rather than proven facts simply doesn't do anyone any good. The fact is that Ebola CANNOT be transmitted by someone who is not showing symptoms. It is NOT like the flu, for example, which someone could spread to others before they even knew they were sick (by the way, thousands more Americans will die of the flu this year than Ebola, so if you're freaking out about Ebola, get your darn flu shot). This is the exact reason that returning clinicians check their temperatures at least twice a day and monitor themselves closely for any symptoms. Even if we had somehow been exposed and contracted Ebola, we can't give it to anyone else until we show symptoms.
Secondly, Ebola is only passed through direct contact with the bodily fluids of someone who is ill - it is NOT airborne. "Direct contact" includes physical touch but also contact with infectious droplets. The common confusion that I have heard is that Ebola could, in certain cases, be transmitted through a cough - so doesn't that make it airborne? Not in an infectious disease sense. To clarify, for this specific example to happen you would have to be in close proximity to someone who is already sick with Ebola, and they would have to cough in a way that their saliva or blood landed in your mucous membranes (eyes, nose, mouth). The difference with airborne viruses (like a cold) is that the virus can hang in the air in a lingering cloud. So if I have a cold and I cough, you could walk through the room a few minutes or even hours later, after I'm long gone, and still catch my cold. That is not possible with Ebola. I know it seems like a fine distinction, but it's an important one. I mean, you usually notice when someone coughs their bodily fluids onto you, and it's easy to prevent, whereas you don't have any idea when a virus in hanging in the air that you walk through.
Still don't believe me? Let's get real, and imagine how many more infections there would be, not just in West Africa, but everywhere, if Ebola was airborne. There's a reason Ebola has been referred to as "a disease of caregivers": most people who have contracted it have done so while taking care of someone who was ill. They don't catch it walking down the street, or hugging their healthy friends. Family members and healthcare workers catch it while caring for someone who is very ill and losing a lot of highly infectious bodily fluids through huge amounts of vomit and diarrhea. Remember Thomas Duncan, the Liberian man who died of Ebola in Dallas? He was misdiagnosed and sent home with Ebola for DAYS. He lived with his family members while he was actively ill, and NONE of them caught it. If Ebola truly was airborne, how did they come out unscathed?
Another HUGE factor in the spread of Ebola which must be mentioned is the sanitary conditions in West Africa. Imagine caring for a family member who is losing liters of fluid through diarrhea and vomiting, in a hut with no running water or flush toilet or washing machine. Now compare that to the United States. Though of course I don't know for sure, I would guess that Mr. Duncan's family avoided close contact with him and washed their hands a lot, as any of us would do if our family was sick with anything. There's a reason Ebola spread like wildfire in West Africa and was stopped in its tracks in America.
So please excuse the long rant, but that brings me to me. My plan is to live in my house with my husband for 21 days, see my friends and family, and (just to be extra safe) to refrain from swapping bodily fluids with anyone. It shouldn't be terribly hard - I rarely lick strangers or uncontrollably release bodily fluids at the grocery store :) So let's say, in theory, I'm at home with my family a week after I get home from Sierra Leone, and I develop a fever. I'll immediately self-isolate, alert public health, and if I meet the criteria, I'll be taken to a designated hospital for treatment before I am a risk to anyone. And fortunately I will have been keeping my bodily fluids to myself in the meantime anyway, so there's no way for anyone to get sick. This is, by the way, all in line with the regulations that King County Public Health has set for me.
Questions about this? Ask me! It is hugely important to me to make this clear so that the public isn't living in fear for no reason, and returning clinicians aren't stigmatized.
Please feel free to impart this information on anyone and everyone! I know plenty of Ebola responders who are doing this work in semi-secret, for fear of how their friends and neighbors will treat them if they find out. I believe that is truly a shame, and they deserve better. If all of the scientific data doesn't convince you, take a moment and really ask yourself: Do you honestly believe that humanitarian responders would put their lives at risk to save strangers on the other side of the world, and then come home and knowingly put their friends and family in danger?
There's so much more to say about what we're expecting to see on the ground, but I'll report back to you when I've begun to see it for myself.
A Valentine's Day Explainer
February 14, 2015—Happy Valentine’s Day, everyone. I have the morning off, as today I am scheduled for my first evening shift. It is HOT – getting up to 100 today – and Port Loko is not, needless to say, entertainment central. I’m planning to read and write and maybe snooze till I have to go in.
It occurs to me that I should give you a clearer description of what exactly we’re doing. So: I am working in an Ebola Treatment Unit (ETU) called Maforki, which is currently the busiest one in the country. The purpose of the unit is to isolate and treat people who either are confirmed to have, or suspected of having, Ebola.
It works like this: People come to the ETU who have symptoms of some kind and/or have an established contact with an Ebola victim – they lived in the same house; they shared a long taxi ride; they took part in the person’s funeral. Occasionally, we have “walk-ins” – people who have decided they might have Ebola. Mostly, though, the patients come in ambulances, and mostly they are sent by contact-tracing teams. These teams are out in the community looking for, and then following the health of, anyone who might have come into contact with Ebola. They are really the front line soldiers in the struggle – the ones getting on top of what could otherwise be an exponential rise in cases, getting any possibly sick person into isolation before he or she can affect anyone else.
Once the person arrives at the ETU, they are screened – by someone from here, who speaks the language, needless to say. We need to see if they “rule in” or “meet criteria” – that is, if they have enough signs and symptoms to make us conclude they might have Ebola. Currently, the screening is “high sensitivity/low specificity” – in other words, we cast a wide net. The thinking is that it would be much worse to fail to identify an Ebola case (who could then go on to infect 20 or 30 other people) than it would be to keep someone in isolation unnecessarily who does not have the disease. But we can’t pretend this is 100% benign – it is completely possible that someone who does NOT have Ebola but whom we bring into the isolation unit will then CATCH Ebola from another patient while they are there. As you can see, we are deciding that risking one additional (and isolated) case is better than risking 20 (un-isolated) cases. But it might not feel that way to the person involved.
When you're admitted, we try to place an IV and give you some basic medications (including malaria treatment for everyone, since it is so widespread). We also take your blood for laboratory analysis. We then move you to the “suspect” ward – where people stay who do not have confirmed Ebola.
The suspect ward is, as much as possible, divided into two parts – “dry” and “wet.” Which means what you might imagine – if you are vomiting, have diarrhea, or are bleeding, you go into “wet;” if your symptoms are limited to things like fever, weakness, and headache, you go into “dry.” This is because wet people are more contagious (the disease is spread via bodily fluids, after all), and also probably more likely to actually have Ebola. Separating wet and dry is a way of trying to avoid, as much as we can, any spread from infected to uninfected people in the suspect ward. (For the most part, people are all together in big rooms with metal beds and not much else in them – we are isolating cases from the community but, except in some special cases, we can’t completely isolate patients from each other.)
Meanwhile, the blood we drew is going to a lab, where a little miracle of modern bioengineering called a polymerase chain reaction (PCR) test takes place. The test increases the quantity of DNA in a sample to the point that different DNAs can be detected by different tracer molecules. If you have DNA from the Ebola virus in your blood, the test will find it. In that case, you are “positive” for Ebola, and moved from the suspect to the confirmed ward. If, however, you are “negative” – and, critically, if the blood was drawn at least three days after your symptoms started (three days being the generally understood time it takes for the virus to multiply enough to become detectable) – you are considered Ebola-free and can be discharged. (If It’s been less than three days, you have to stay in the unit a little longer so the test can be run again at the appropriate time.) Some “negative” people are still clearly sick – with TB, malaria, HIV, malnutrition – sometimes we have a pretty good sense of what it is, sometimes we don’t. These people are discharged to Government Hospital for further care. People who are otherwise well get to go home. But, of course, everyone who has been in the unit must be followed for 21 days after leaving, because – see above – they might have picked up Ebola while in the ETU. So the contact-tracing teams I’ve already referred to will add these patients to their list and keep tracking them.
Things are, in many ways, simpler once you go to the confirmed ward. Obviously, we try to maintain basic hygiene as much as possible, but it is less critical to separate wet and dry, since everyone is already infected. Similarly, while we have to be obsessive about hand-washing etc. in the suspect ward – the last thing any of us wants to do is to bring Ebola from an infected person to someone who is not infected – we can be thorough but more efficient in the confirmed unit since, again, everyone is already infected. (For now, there is no evidence that there are multiple “kinds” of Ebola virus – one person’s virus is the same as another’s. So even if one patient receives some virus from another it shouldn’t make any difference, since everyone is full of the same virus anyway.)
As I’ve said many times before, there isn’t a whole lot we can do to specifically fight Ebola. Either your body fights it off or it doesn’t. What we try to do is to give your body the best chance possible of doing this, by keeping you from getting other infections (antibiotics), by keeping you strong (food, if you can eat; vitamins; IV glucose if you can’t eat), by keeping enough water in your body (IVs, oral rehydration solution), and by keeping you comfortable (anti-nausea medications, pain relievers, Tylenol for fever, anti-anxiety drugs, sleep aids). These are the treatments you get in the confirmed ward (and in the suspect ward, too, if you are already clearly ill). There is certainly some debate about the BEST treatment – one ETU has published data indicating a survival rate of over 70%, and, needless to say, everyone is interested in adopting their protocol – but that is more or less the range of things we use.
With luck, after 5 or 10 days, you start to get better! At this point, we scale back your medications and tailor them to what you need – we can take out your IVs if you’re drinking well; stop antibiotics if you’ve received a full course; make sure you have lots to eat. And, once you are without symptoms for three days, we can re-test your blood. If at that point the PCR is negative, it means you have fought off the virus and can go home! You bathe to remove any remaining virus from your skin and go, quite literally, naked into the world – anything that came with you to the unit, clothes, money, cell phone, has to be burned. On the other side of the isolation fence, you are met by people who give you clothes, some money, some basic food, some basic household equipment, and a new phone. If you are a man, you are given condoms and told to use them for 3 months or abstain altogether, since the virus appears to live on in semen for that long. And everyone is given an official certificate establishing that they have survived Ebola, which they can show to people in their community who might still be afraid of them. It doesn’t guarantee you won’t be stigmatized, but hopefully it helps. (These days, you are also met at the gate by other survivors, who can talk to you about what it’s like, how to go back to your community, how you may be feeling if many people in your family have died, etc. It’s a wonderful program.)
That is the flow in the unit, and what I am specifically occupying myself with every day – triage, admission, treatment, discharge. I hope that makes things a little clearer!
Leadership Lessons from an Ebola Treatment Unit
January 17, 2015—I did not arrive to work in Sierra Leone in any kind of leadership capacity.
Prompted by the news and the conviction of faith, in October I signed up with USAID and then with Partners In Health to serve as a clinician caring for patients with Ebola. I was initially scheduled to go to Liberia but with the growing need in Sierra Leone I was rerouted a week or so before my travel date.
We arrived in Sierra Leone on Wednesday, December 3, trained aggressively and began working in the Ebola Treatment Unit (ETU) in the Maforki Chiefdom of Port Loko by that weekend. Providing care to these wonderful people in partnership with the courageous Sierra Leonean nationals and a cohort of exceptional international professionals was one of the true honors of my life.
Although I was not formally in a leadership role until I became ETU clinical lead the last week or so of my time there, I was aware of the challenges and I was very impressed with the leadership team assembled. Applying the critical dyad of “attention and intention,” I discovered that in the ETU, as is usually the case, leadership lessons abound: “If the spirit of the student is in you, the lessons will be there” (Sir William Osler). Here are several of my observations.
Master narratives and names. New expatriate staff arrived at Maforki regularly. It would have been very easy for the “long-timers” (those who had already been there a week or two) to develop the kind of exclusivism that could disrupt team development and undermine the “changing class picture.” One solution was to aggressively learn the new peoples’ names and stories and take the initiative to reinforce that knowledge by introducing them by name and “narrative” to the folks who were already there.
People won’t readily surrender personal identity to take on group or team identity until the former is at least acknowledged. The same practice was an important part of getting to know the local national staff and to build the team with them.
We need to practice “intentional inclusivity.” This follows by purposefully including newcomers into existing rituals. For us at Maforki this meant eating meals together and inviting new colleagues on the morning walk to the ETU through the town of Port Loko. It was a tremendous opportunity to get to know one another and to reinforce our new, shar