Ebola Treatment Center, Day One

After a few days of training with MSF in Geneva and a grueling journey to Sierra Leone, I entered the Ebola Treatment Center in Freetown where I will be working for the first time on Monday. Here are my observations and impressions from day one, before all of these little details become part of the norm and don’t seem so important:
At the entrance to the Ebola Treatment Center (ETC) compound, we get out of the car, wash our hands with 0.05% chlorine water, spray the bottoms of our shoes, and have our temperature taken. All visitors, staff – EVERYONE – goes through these steps before entering the center from the outside.
Once allowed inside, we proceeded to the entrance to the low risk zone – again, washing our hands and spraying our shoe bottoms. Then on to the dressing rooms, one side for men and one for women (we have been warned to only wear discreet underwear into the ETC, as you often sweat so much inside the suits that when you remove them, your sticky scrubs come right off along with them – so no thongs for us!). In the dressing room you find a pair of scrubs, which are being washed constantly all day long and hung out to dry, and hopefully a pair of heavy plastic gumboots that fit. These are also washed and dried throughout the day, but after lunch there were no more boots to be had…
From there we headed over to the medical “office” tent – one area for administrative work, one where there are white boards detailing patients and needs, etc. A second space is set up for work – mixing IVs, nursing roster, etc. The third space is for the pharmacy folks who pack the med bags. The ground inside the ETC is covered with heavy, broken sharp grey rock. As you’re walking in your gumboots, it’s a bit uncomfortable and sloppy, but I’m sure I’ll get used to that quickly.
Since we were on orientation, we spent the day doing various things. I spent the morning in triage, which I really liked. However, it’s not triage OUR way; we don’t respond quickly to the sickest patients. Here, we respond first to the NOT sick, and get them out of the center with a certificate that says they do not have Ebola. Hospitals and clinics won’t allow them in for care without this. Plus, people are worried about little things and want to be sure they don’t have Ebola.
This is how it works: People come in (after washing their hands, spraying their feet, and having their temperature checked at the entrance) and sit in a holding area consisting of plastic chairs 2 meters apart, the safe distance. We healthcare workers stand under a shade, behind an orange double fence blocking off 2 meters’ distance from them. No confidentiality at all. We get their demographics, register symptoms, and begin to make a determination about whether or not to admit. Today many had vague symptoms, but were relatives of confirmed Ebola patients – a husband, sister, and baby. I guess that’s not unusual. We also know the “hot spots” where many cases are coming from, to raise the suspicion level in certain cases.
Today we admitted about half a dozen people. As we’re doing their paperwork, we give them a bag of water and a sachet of Plumpy Nut (a peanut-based paste for treatment of malnutrition) and ask them to eat and drink. A psychologist comes and asks the patient about who they can call to advise, what they need done, finding a caretaker for their children, etc. There is also a Health Promoter who talks to them about what’s happening.
Oddly, enough, the new patients are stoic. No comments, no questions. They just sit there across a far divide from us. I would be screaming and crying and begging if it were me being told I was to be admitted to an ETC!  The patients are then moved to another holding area and a nurse in full Personal Protective Equipment (PPE) comes to get them, take them to a bed, and get them settled.
The ambulances also come in the triage area, and we have a whole procedure there are well. First, they back halfway into the orange double fence area, then wait for the hygiene team to come spray the vehicle, remove the patient/stretcher, spray again, spray inside, then bring the patient to triage, where we do our work from across a 2-meter table-like barrier. The only time we get any closer is with goggles or a face shield, when leaning close enough to take a temperature with the little electronic gun from 6 inches away.

Things are separated here into areas for suspected and confirmed Ebola patients. In the ward for suspected patients, they are given a bed in a private “room” consisting of a concrete floor, walls of vinyl tarps, roof, sun shade, buckets for Oral Rehydration Solution (ORS), vomit, washing, and stool. The suspected area is separated from the confirmed, and they try to put the “not highly suspected” as far away from the sick ones as possible. You don’t want someone who just has malaria to be exposed to Ebola in the ETC.

The confirmed section has bucket showers for patients, and male and female latrines. This confirmed area also has a separate section for those with the highest nursing/medical needs. It is known as “ICU” even though it really only means IVs versus simply oral medications. Today I got to don full PPE and go into “ICU”. I think I’ll be doing that a bit more often because I can start IVs.
There is also a third area for recovering patients. These people are feeling better – they can walk, feed, and care for themselves – and are awaiting tests. Patients must test negative twice in 72 hours in order to be discharged home “cured”. Caregivers for children are recruited from the survivors because they have immunity for an unknown period of time.
We caregivers have one donning room with very helpful people getting us dressed, and two different doffing stations where they tell us step by step what to do as we remove our PPE. We can be inside for only one hour at a time. Today I was only in for 30 minutes, just being shown around, without doing any care on day one. I felt OK, not terribly hot or bothered, but the nurse orienting me was soaked when we came out. One of the docs was in for 90 minutes, and literally poured sweat out of his boot! One style of PPE is lighter than the other, so everyone wants the one with the blue stripe.
There are bags of water at various points, and squat latrines for staff. The spaces everywhere are really vast – lots of room so as not to touch anyone. Things move slowly. Since there is no such thing as an emergency, no resuscitation, etc, we take our time to work out the best plan of action for everything.
Teams go in every hour or so: IV/ICU team, oral med team, admission and discharge team. Nurses (most not very skilled) and our expat doctors go in together. Outside is a group of nurse assistants. Hygiene goes in with the medicals. After the medicals leave, the nurse assistants have their rotation to feed, give ORS, bathe, etc.
One cool thing is that the ICU has a corridor down the middle, with two 1/2 –meter tall plexiglas walls and the patient beds all around, so we can literally walk down the middle, not in PPE, and see and talk with our patients. This minimizes the time we spend in PPE. It’s the same in the other wards, though not plexiglas. Instead they have a double fence 2 meters wide so we can talk to the patients across it without having to be in PPE. There are also slanted “one way” tables so we can pass them meds, food, whatever. We slide it down to them across the 2 meters, or push it with a stick if necessary. It’s the same at the entrance to the ICU: two slide tables so that from the outside you can slide in another IV bag, tape, or whatever they might need that they didn’t take in. Pretty smart system!
In addition to all this, there are more tents for logistics, resting area for staff, and an additional one that just opened today because the number of patients was higher before discharges.
Blood is drawn by the lab team three times a day and there’s an actual lab (not run by MSF, but some other entity). They process the samples in about four hours, so we can clear those who are not sick quickly and send them out with their certificate and a big “congratulations”. They also routinely screen for malaria. Most are positive and so get treated. Admission orders include systematic malaria meds, antibiotics, Plumpy Nut, and Tylenol if fever. IVs are mixed by the nursing staff. It made me a little anxious because I’m not sure they are very diligent about what they are doing. D50 is added to LR, plus potassium if the patient has a lot of diarrhea. IV paracetamol is given if they can’t take pills.
I sat awhile with the Sierra Leonean nursing assistant staff outside of ICU. If find that if you do this in the beginning, they get to know you and word spreads quickly that you’re a good person. One of them said, “Americans are so simple.” I asked her what she meant, and she explained, “You are always nice, always soft in your way, not hard like the Swiss and Europeans.” They had lots of questions and are supposed to be teaching me Krio, the local language. Here are some basics we’ll use a lot:
You belly de run?  or You de gombelly? = do you have diarrhea
You hed de acts?  = You have a headache?
You de feel pen (tapping shoulders)?  You have joint pain?
You de feel weak?
You de eat?  = Do you have an appetite?
You de cough?
I need to practice for tomorrow because I’m sure they will ask and give me more homework.
Oh, and I actually got to be an ER nurse! Two young men brought a boy who had pulled down a container of lye onto his head and face. No one knew what to do. He was not sick, just injured. So I tossed them some bags of water (all of our water for washing has chlorine), and had them rinse him down about 10 liters. Then I got him a blanket so he wouldn’t be wet and naked to take to another facility (we are ONLY an Ebola treatment center and can’t do anything more). I felt pretty good about it, but think he will have some serious eye damage…
Overall, I’m feeling pretty positive about this mission. I think this is going to be good!

No hugs to all.  No touching.  But much love,