In and out.

I have been in the Bong ETU twice now.  We did a night shift last night and then got up and did a morning shift.   Yesterday was a group tour by Audrey, the nurse who has been teaching our training.  I can't say enough good things about her- good teacher, fun, VERY knowledgeable.  She's been here since the beginning of this ETU and plans to stay to the end.  I haven taken any pictures of this RTU because there is no secure place for us to put belongings, but if you want to see what it is like visually Google the Ebola Sixty Minutes segment from a few weeks ago.  It is the same unit.  The tour began with the grave yard.  This ETU is lucky to have land.  Burial is extremely important to the Liberians and the ETUs in Monrovia just don't have any, thus they have been cremating bodies.  This doesn't sit well with the Liberians strongly enough that folks have refused to go to the ETU for fear of no burial.  The Bong ETU has never had that problem.  There are somewhere around 130 graves to date down a long path cut into the jungle from the ETU.  The unit is not a quiet place but the graveyard is serene.  There is much care taken to keep the area spiritual, peaceful and honorable.  Families are invited to come to the burials so even though the bathing and preparing of the body is not possible due to its incredible viral load and, therefore, infectivity, the families can see the graves and, if they can get there in 24 hours, watch their loved one be buried.  

The ETU is a crazy place there was a lot of noise even at night.  There was a massive TV screen playing an angry, violent movie at a decibel level that made it hard to hear people talk.  It was an odd thing to have in an atmosphere of illness and hopefully healing.  The suspect ward has individual rooms in which the lights stay on all night.  No switches were installed.  There is no such thing as sterile, only relatively clean.  The units are made of rough 3x3 timbers covered with huge blue tarps.  The water system is rudimentary in some ways but there are dozens of spigots all supplying water pumped from the ground to huge water tanks on a high platform.  There are red ones for 0.5% chlorine (for equipment cleaning), green for 0.05% chlorine (for hand washing), and white which is pure water (for rinsing).  Everything is sprayed with chlorine constantly.  Every time you move in or out of a building or area you wash your hands in chlorine and dip (or step if you have boots on) your footwear into a big basin of chlorinated water.  And there is NO touching anyone.  Except if you have PPE on in the confirmed ward.  There you can touch, hug, shake hands as long as you are protected.  In the suspect ward the patients are separated.  In the confirmed ward they can socialize and visit.  Families stay together in one room.  

Today we participated more. We were led initially by Kelly, another totally kick ass nurse.  She was the nurse I reviewed in the 60 Minutes Segment.  After general instruction I went on rounds with a doctor and a Liberian PA.  It is imperative to have a national with you to ease communication. Liberian English has little use for vowels and so is fast and percussive sounding.  It is very hard to understand.  We rounded on the ten patients in the confirmed ward (there were no suspected cases when we went in).  It was confidence building to see the medical people in practice.  I can do this.  Today I am finally sure I will be able to do this medically!  Yeah!  Most of the patients are getting better.  There was one who looked worse to me.  She is still bedridden with some diarrhea.  She also has some Nairobi fly "bites" on her back.  Apparently the Nairobi fly is harmless until you squish it and release the toxins.  If that happens the toxins burn the skin and ulcers can result.  This poor woman must have gotten a fly in her sheets and rolled over on it.  

At the end of our time there two women came in by ambulance.  The ambulance is a pick up truck with a vented compartment in the back.  It never goes out after dark and never takes a trip long enough that it won't be back before dark.  The roads are just too treacherous.  These women were from Taylor Town, a community in which the epidemic was triggered by one man who got sick in Monrovia but was scared of the ETU there because of the cremation.  He came home to Taylor Town to recover and eventually die.  Since then this ETU has seen upwards of 40 cases from that community.  These particular two were the wives of two men who recovered and returned home.  We know that men stay infectious through the semen for 3 months after recovery.  Not saying that's how these women got infected if they turn out to be positive, but sex as a means of women's infection is growing in Liberia.

I enjoyed these shifts.  I will enjoy this work.  I had to leave the high risk area first before my colleagues today because the yellow plastic suit I had to wear was so much hotter than their white tyvek ones.  I made it out before having trouble, but not by much.  I have to say that everyone we have met in this work in training and at the ETU from the national sprayers and WASH guys to the nurses and doctors to the Country director for the NGO running the ETU have been fabulous- welcoming , kind, generous, patient.  There is a real feeling of team.  We are all here to try to beat this thing.  Sorry for the run-on, picture less diatribe, but I guess I had a lot to say.  Two more shifts and we go back to Monrovia.

Heats up tomorrow

Today we finished our cold training.  Tomorrow we go into the hot zone!  I am not scared of the disease as I am comfortable in and have full faith in the PPE.  I just hope I can contribute medically or socially or janitorialy (I think I just made that up) or somehow.  Tomorrow is just a lengthy tour so no pressure.  We had a psychosocial lecture session today in which it became abundantly clear that we expats are doing a good thing, but it really pales in comparison to what the Nationals are doing.  They have survived an incredible upheaval of their entire society over this and while we get to feel good about ourselves and go home, they will be sticking around for the long term consequences.  These are humans dying and that affects us all, but it is their families who are sick and dying and that easily trumps anything we are putting out in this ordeal.  In our class we have a survivor.  He is a young man from this area who showed some of us pictures of his 6 and 10 yo boys and the beautiful young woman who was their mother.  She died in July of Ebola.  Another young girl lost both her parents and two brothers early in the epidemic.  She briefly became ill while caring for her father, but spontaneously recovered without treatment or testing of any kind so it is likely but uncertain whether or not she is an Ebola survivor as well.  She now lives with her sisters.  Both of these young people will be working as psychosocial officers (lay mental health workers) in an Ebola unit beginning next week.  Amazing.  I am humbled.

I got my keyboard back.

I keep having I do posts in shifts because my keyboard disappears.  Here are more pics from yesterday at the fake ETU.  We are all classroom today so maybe nothing to post tonight.  Tomorrow we encounter Ebola for real.  

Doffing.  This is the most crucial part.  Avoiding Ebola contact while taking off the gear is key to staying healthy.  The sprayers and supervisors guide you every step of the routine correcting you if you do one little thing wrong. 

Doris doffing her goggles.

And after each and every step, "wash your hands!"

Inside the fake ETU. 

Last nights Tday feast.  Eat your hearts out!

Second day in PPE

This PPEstuff is other worldly and fun.  We triaged fake patients today, faked an IV, and talked more about what really happens inside the ETU. I will be behind medically, but I am more confident now there will be a valuable role for me. If I just do triage (which I would be great at) I would be fine with that. The training has been excellent so that everyone feels pretty safe. Found out my glasses work great in the PPE so I should even be able to see.  Bonus round!  Tonight we had a Thanksgiving feast- the usual box dinners of rice with egg and some spiced pumpkin, but Joe contributed wine, corn chips, chez mix, Oreos, and apples.  Dee contributed fresh papaya.  We all met and ate and shared our thanks.  Loved it!  I am with good folks doing good work, and I am so thankful for those supporting me from the U.S.  Thanks so much all of you, but especially Jean!

Dee and me in PPE

Our digs at Cuttington Univ.

Liberian car wash.

Very common transport

Happy thanksgiving from ARC

PPE cont'd

I lost my keyboard so I had to do a new post to continue.  So class was good.  We had a meeting tonight and agreed that at least one fear is resolved.  Damned uncertainty.  It is almost always worse than reality.  We all still have our fears.  One of mine is finding scrubs big enough.  They hired me, they have to clothe me.  Still embarrassing.  Bending over to wash my hands I busted out of my tyvek suit, too.  I have to remember that because that is just dangerous.  I feel humility training coming on.  I hate asking for help but this is all about team. If I drop something someone else is just going to have to pick it up.  Tomorrow we do it again.  Those who know how to start IV's will do so in full gear.  I will be someone's partner to make sure they're safe.  If they are super kind they will remind me how to do it.  We will see.  I am feeling better today. This evening is the first I have felt relatively normal since I got here! Yeah!!!

First day of PPE

Now we know how to protect ourselves. The process of donning and doffing the protective gear is arduous. We didn't even do any work and we were all drenched in sweat when we were done.  We will not be able to stay in the suits long at first.  Doffing is the most crucial part of the procedure.  Screw up there and you could take an Ebola shower.  Donning is important but correctable if it doesn't go well.  Doffing is now or never.  Good news is there is always at least on person guiding us through at every move.  

OK no reason to be afraid, it's only Africa

Too late.  I am afraid.  Afraid of the illnesses, the dirt, the food, the roads, and the tasks before me.  I feel wholly inadequate for this operation.  I don't know shit.  Just listening to these nurses talk has me cowed.  Tomorrow we start cold training.  The curriculum looks excellent.  If it holds up it will be the most structured thing we have encountered since landing.  It is probably has the longest unchanged history of anything we have encountered.  It seems like the emergency medical protocols are solid.  Now that the epidemic is changing they probably will too.  Everything is dirty.  Everyone is dirty.  Up until this trip we have been protected by white folks accommodations.  That ended today.  I've been dirty before.  I can be at the cabin for days and not mind a lack of shower.  I can be on a canoe trip and not mind at all, but this is human grime.  There is nothing that can get this place clean.  It smells like human sweat all the time.  The food hasn't been bad but I woke up nauseous and with a touch of diarrhea.  I immediately popped the antibiotics and will continue popping them the requisite three days.  I took my first dose of prednisone today which was generously supplied by a colleague.  Hopefully by tomorrow there will be noticeably less cough.  I am a walking pharmacy.  Better living through chemistry my dad would say.  The drive to the university was harrowing.  Fast, honking, ridden with potholes on steroids, no electricity anywhere along the way.  Men peeing everywhere.  Yes, we had to finally join them and squat by the road.  We passed two ETU's, a truck wreck and a dead body.  Not sure what belonged to what.  The 120 miles took over 4 hours.  Very glad to be here.  I am a middle class white American citizen.  I have never been this scared or uncomfortable ever, and my situation is luxury compared to those we passed on the road today.  Their only advantage is familiarity.  I hope and pray for some of that soon.

Monrovia suburbs.

The scene really didn't change though the vegetation got more lush and a few of the homes looked as though they took pride I grooming their grounds.  Not this one but others.

Checkpoints along the way looking for sick people.  We went through the famous Firestone plantation.

But this I'd the best picture I got.