Liberia Week #8

December 23, 2014

The days seem to be blurring -- not a real busy day but I was able to get the first draft of the medication order sheets finished and off to KC for formatting.  Also, have the formulary in transient to get cleaned up.  We still have problems with the wells and are getting no response from the well digger who was called Sunday evening. We continue to move on with unpacking, sorting and distributing.

Worked on resetting a large storage tent so it will be more accessible, began having morning staff meetings, prepared for community open house, etc.  At 5:00 PM the new arrivals requested a meeting to voice concerns after a meeting the previous night.  All the complaints were items that were being addressed, but being newcomers, they were not aware of the previous discussions.  Rene and I then met with the physicians and their concerns were mostly based on the unknown -- reasonable and not much different than our team when we first arrived.  A lot of "What ifs?" For tomorrow’s Community Walk Through, we have teams assigned to different stations so will let everyone see what we are doing. It will be much like what was done for Senator Coons.

Tomorrow I will meet with the new Pharmacist and talk drugs and help her get started and then after lunch meet with the physicians and also talk about drug management of patients.

Good phone connection but still no Viber.  I will call tomorrow afternoon and hopefully hear what everyone got from Santa.  I'm assuming that Christin, Ken, et al. arrived from Colorado OK, just too bad it is so late.  Jim is working on a "Goat Roast" for Christmas day, even with a few Club beers and banana wine (local brew).  And there is rumor that the Army is going to send up a Christmas Dinner as well -- we shall see.

Talk to you Christmas day –

December 24, 2014

A very productive day.  In the morning I met with the new PharmD who is going to be with us for three weeks.  She was very energetic and when I explained the drug protocol, formulary, order process, she seemed very engaged.  She saw her "pharmacy" and as the day went on, the construction people cleared out their stuff and she began moving in drugs.  Still missing a lot of promised drugs, almost all IDA drugs out of Holland, but we talked about filling deficiencies through the hospital pharmacist.  I finished the order sheets, sent to KC for formatting, and they came back absolutely perfect. After lunch, one more "walk through" which didn't happen but we did get 20 banana trees at my request to spiff up the place.  We will plant Friday.  In the afternoon, I met with the MDs and had a really good discussion of medical records, standard drug regimen, order sheets ( not quite ready), and formulary.  They were very engaged and really appreciated being introduced to the reality of medical issues that they will face -- lots of people sick with tropical illnesses but not likely ebola.  This is a great learning experience for those new to tropical diseases.

Just as were leaving, a guard showed up with two 5' long green mamba snakes they had just killed in the drainage ditch on one side of our ETU.  I'm ready to come home!  

We ended the day with a trip to the "Club House" for a Christmas Eve celebration before dinner.  Tomorrow is a day off so I will do laundry and actually think about preparing to leave.  Rumor is that we have a goat roast in the afternoon with palm wine.  Jim and I both agree that on Saturday, we will get up early and leave as soon as daylight.  We don't want to drive in the dark.

Hard to believe it is Christmas Eve - 90 degrees at 5:00 pm -- stinky, sweaty clothes and a cold shower before bed.  Another day in paradise!

December 25, 2014

It started with one more walk-through with the inside construction team - and every time we walk through, we change something so I am sure they are totally confused.  At least it will be my last time.  We got 20 banana trees, at my request, so will plant them tomorrow.  The rest of the morning was about cleaning out the pharmacy, getting printer cartridges, soap for the kitchen -- just busy stuff. After lunch, I read for a while then walked by the lab and was given a big piece of pecan pie that they had left over from their Christmas meal flown in at noon!  All of the military personnel are told not to leave the hospital grounds and to only eat MREs -- no local food or drink.  And they are here for 3-4 months, ouch.  At 4:00 we took parting photos of Merry, our pet goat, (bought for $60 earlier in the day) and at 6:00, we were told that we couldn't have our Christmas Evening Goat Roast without beer.  So we drove downtown and bought three cases of cold beer, with a case going to the cooks, a case for us, and one in reserve.  Then the roast began -- very flavorful but TOUGH and CHEWY.  It was supplemented with grilled chicken and fish, on the bone.  There was a lot of greasy finger food but good.  Unfortunately the Bush Devil did not show, the traditional equivalent to Saint Nick - a very tall person on stilts in wild clothing and mask.  He appears for celebrations -- but later we found out you need to book him a week in advance. Who would have guessed?  Then around 8:00 the cooks started singing Christmas Carols - they knew them all!  This was the only real sign of Christmas. I did get a puzzle from home but only one day to do it so may have to take it home with me.  I will be leaving all of my work clothes, shoes, underwear behind to give to patients coming out of the Hot Zone.  Mine are stained with chlorine burns but is better than some of the clothes they went in with and had to have burned.

One more day in Tappita and then to Monrovia and Home!

December 27, 2014

Just arrived in Monrovia - left at 8:00 am and in at 4:00 pm.  Eight hours of roller-coaster ride but not a lot of traffic even on the better part.  Our back window blew out in the first hour so we are covered in red dust.  We are getting cleaned up and then going out for early dinner since no lunch.  I will try to call when I get in.

December 28, 2014

They plan to turn the generator off from 10:00 to 4:00 so I will lose the router and Wifi.  I will call on the team phone - 24 min. for 50 cents.  Not much happening -- a rest day from eight hours of bouncing in a car and preparing for eight hours of airplane sitting.   My itinerary came through so you can follow on it.  I will let you know when I arrive in Brussels and DC - my only challenge will be getting through the DC customs in time for the RDU flight.  It looks like I have almost 3 hrs so I should be good.  I am the only Tainted One from my group going through DC so maybe I will be the only one on the Brussels flight from West Africa.  

The word is that the official opening will be on the 5th.  That seems about right -- still a lot of work in the next week.  There is no chlorine to set up the different chlorination washing, the drugs are not all up, no training of the sprayer teams, etc.  but I think these things can be resolved in a week.  

I am very happy to be leaving and really look forward to getting home.  Wish I were flying tonight but I am glad to spend the day here and have the ride behind me versus traveling from Tappita today and flying tomorrow.  I have washed all of my dirty clothes and am sorting out what I plan to leave behind - pants, shirts, underwear, and shoes.  I will be light on my way out - I was actually the lightest on my way in.  Don't count on souvenirs - there is nothing to buy or bring home!

We did go to an Ethiopian restaurant last night. Jim was raised in Ethiopia, and it was very good --my first meal in two months that did not include a large helping of rice.  No meals today in the guesthouse but we will go out tonight.  

December 29, 2014

Pretty low-key weekend.  After the eight hours of driving on roller - coaster roads, having the back window blow out within the first hour and covered in red dust from there on, we made it safely to Monrovia.  Over the eight-hour trip, it was interesting to see the landscape change.  Tappita is truly jungle - tall mahogany and rubber trees, palms and banana trees, thick, green growth everywhere with almost no inhabitation along the roadside – here and there a rare collection of mud and stick houses with straw roofs.  No fields or crops - I can't imagine what they subsist on.  The women were all straight legged and bent at the waist cooking over a small fire or doing laundry in a pan and washboard. Kids were everywhere in tattered clothes but no sign of the men. Sometimes there were small paths into the underbrush going to where?  I guess the income is from rubber.  Then at Ganta, it begins to clear up and there were rows of planted rubber trees as far as you can see.  Much more signs of civilization on the road-side and the road is even paved and pot-holed all the way into Monrovia.  The houses now are mud brick with tin roofs and there are frequent small tuck shops with basics for sale. There still is no major commerce except for the rubber plantations.  Apparently Firestone owns most of this land -- thousands of acres.

Once we got to Monrovia we cleaned up and went to an Ethiopian restaurant.  As I mentioned, Jim grew up in Ethiopia, son of a missionary family.  His father was the water engineer for the area and sounds a lot like the Jim McGill of Malawi. Can do everything and is asked to.  The Ethiopian portion of the meal was very authentic and good but there was also some Liberian food mixed in.

Sunday washed clothes and packed, and I am leaving behind my chlorine burned pants, shirts, underwear, and shoes.  When you enter the ETU with street shoes, you have to dip the bottoms and this destroys the glue holding the sole to the shoe -- so eventually your shoes come apart.  Mine have begun to separate but are still functional.  If you are a patient in an ETU, all of your clothes are burned before leaving and you are given clean clothes so mine can be used as replacements.  The shoes can be re-glued locally.  In the afternoon we went to a small hotel on the beach and I sat in the shade and read while Jim was in a meeting on security.  From there we went to a small Lebanese restaurant where Jim and I split a pizza - my first in two months.  I am being reintroduced to Western food.

Later. . .

It is almost time to leave for the airport to come home.  Looking back on the time, did I do the work I set out to do? No. Did I do the work at hand? Yes.  I came to care for ebola patients -- the highest priority at the time.  The country of Liberia was being overrun by ebola and there were few willing to step forward to stem the flow.  And, with all the concerns in the US, the best way to protect our country was to stop it at its source.  If not, it would grow to be a major global-health crisis -- for us and every other country.  

Liberia had done a miraculous job of meeting the challenge.  Initially, in August and September, there were people dying on the streets and healthcare workers were dying, too.  But, Liberia started a nationwide public education program that included closing schools, stopping large group meetings, providing “no contact” warnings, and, most importantly, implementing safe burial practices.  The tradition of the family bathing and kissing good-bye to the dead loved one was banned.  At first, cremation was the recommended alternative, but this was so foreign among Liberians that it gained no acceptance.  

Then, community-based burial teams were created and no-touch burials were begun.  Likewise, health care workers were taught to practice universal precautions.  So by the time foreign aid workers showed up in the form of new ETUs, the rate of spread had already started to decline.  By the time I arrived in the first week of November, the occupancy rate in ETUs had dropped to less than half and once I started seeing patients, it was a trickle.  The remaining cases were basically in Monrovia where people lived in close contact.  So providing direct care to Ebola patients was not a necessity. Yet, I had the opportunity to diagnose and treat many suffering from the tropical diseases I have previously seen in Africa and ones not always recognized by my US colleagues.  We saw a wide variety of illnesses - from terminal TB to progressive liver cancer, even a lady with diabetic coma.  Everyone was sick, just not ebola.

But ebola is not eradicated.  What we are seeing are small outbreaks in more and more isolated settings.  There remains a need for Fast Response teams to go out and cast a broad net in these areas and pull in locals  for evaluation as many individuals have signs or symptoms.  The threshold for admission is much lower in order to catch any who might have the disease in order to not let them stay in the village to die and expose others.  So the role of the ETU went from a care facility to a screening facility.  

After working for several weeks in the Kakata ETU, it was the experience and the recognition of this shift in pattern of care that I felt would be beneficial in the setting up of Heart to Heart’s ETU in Tappita.  The unit was designed in the US, construction was assigned to a private international construction firm, and oversight was provided by the US Army. This was to be a new model for care funded by USAID.  Therein lay the problem -- four agencies trying to work together, none with any experience with ETUs.  We had no one on the ground with more experience than three days in an ETU.  So I volunteered to use my experience and insight for the final phase of construction.  Thus, this was not the work I had come to do, but it was the work at hand.  

The time spent was very worthwhile since I had much to share.  The Tappita ETU is now scheduled to open in one week and I believe the facilities will be operational and the staff properly oriented.  Is the ETU now needed? Definitely. There is still the need to screen and look for the isolated case of ebola as well as train National staff on proper precautions.  Ebola will be back; as long as there are porous borders with Guinea and Sierra Leone, there will be a flow of ebola into Liberia.  Nimba County borders both countries, so it will remain a future route of ebola as Tappita sits right at the crossroads. Just last week, four cases came from Guinea and three of those have died.  One victim was the motorcycle transport that carried the others across the border.  What if he had been coming on down the road to Tappita?

Is ebola the worst disease ever? Seven thousand have died from ebola but malaria kills two million a year.  Is it to be feared because of its death rate or speed of death?  With good care, many can be saved and we have moved towards giving that level of comprehensive care -- not available at the onset.  For speed of death, I have cared for many in Africa that died faster from malaria  -- a child playing in the morning, onset of fever at noon, seizing and dying at 5:00 pm. And, the mother who is induced by the Gogo and put into premature labor for 48 hours, eventually coming in for emergency care in shock from a ruptured uterus. And, AIDS is not called slims disease by accident – it is the long, slow, but too often certain death of African men, women, and babies.  Death and dying are not uncommon when working in Africa.

Maybe the speed and coverage by our news media of ebola has made it so feared.  With good resources, it is a manageable disease.  Unfortunately, the impoverished countries of Africa do not have the resources to stop ebola completely unless they build/rebuild the entire healthcare system.  I do believe that this is one of the US governments’ commitments and I know Heart to Heart, my sponsoring organization, is interested in moving into that phase of providing better health services to the people of Liberia.  

Maybe I can come back and be part of the future.

Thank you to everyone who has supported Betty and me in this endeavor.

Signing off from Monrovia –

George Poehlman, MD, MPH

Liberia Week #7

Liberia Week #7

December 17, 2014

Yesterday mostly about getting the guest house open, meeting with the head of PAE (Pacific Architectural Enterprise) who will be providing our security, internal construction, and overseeing grounds maintenance i.e. the hygienist staff - sprayers, dressing and doffing monitors, trash haulers and cleaners in both the Hot zone and grounds, etc.  We started the day by giving his security team of over twenty a guided tour of the entire facility.  Then worked on staffing for hygienist and clinical personnel.  

Jim arrived in the afternoon and is now my new roommate (on the top bunk). Very nice to be around - very task oriented but friendly to staff and workers. We had a nice group meeting and discussed "next steps" with the OK to start planning the interior and operational issues.  

This morning Jim, Rene,and I met with the site construction team and PAE staff to layout internal construction.  We walked through step by step each building with me showing many of my pictures from Kakata. This lasted until almost 1:00. Lunch and rest and then back down for a walk through again.  A couple of the nurses came along and have been a bit bothersome, going directly to the construction team and telling them what to do here there and everywhere - bypassing Jim and Rene.  I have been impressed how well Rene has managed this continual problem - he just asked the construction staff to agree, say they will look into it, and then ignore them.  It has become almost humorous because most of the decisions were already made during the morning planning session. Unfortunately they are not real good listeners or good at understanding  consensus so they have not been asked to be part of the planning group.  They are annoyed by this and don't have enough insight to understand why they are being excluded.  Every time we add more people, the more complex the dynamics get -- I will be glad to leave by the time we have our staff of 20 expats here!

This afternoon we met with the CEO of the hospital, who is also deputy-chief of the Liberian Task Force on Ebola.  He had been the County Health Director of Anson County, NC but came back to Liberia three years ago to run the hospital. Very impressive gentlemen and physician.  He reports that new Ebola cases dropped to 23 last week!  We may have worked ourselves out of a job. We are now in Rapid Response mode to the scattered outbreak hotspots.  I asked him what he attributed this success to, and he said the change in burial practices, isolation of the sick in ETUs, and symptom awareness.  They had planned on going door-to-door to every house in Liberia to identify any sick during the first week in November but couldn't get the funding to train and pay 8,000 health workers.  They predicted that this would stop all Ebola in Liberia by the first of the year. Maybe the money spent on our ETU could have funded that!

The real big news is that a Senator from Delaware and a two- star General are flying in Sunday to tour our site since it is almost finished. This has actually expedited the delivery of goods!  We are going to have a walk-through Friday and make a punch-list and then the construction company is going to correct deficiencies Saturday and the Sunday - the big tour.  Hopefully next week will be training, internal construction and maybe grand opening Sat or Sun.  I might or might not be here to see it.

The Monday group did get out of Morovia on Brussels Air to Brussels but we don't know if they were able to leave Brussels this morning because of the strike.

Still no HIGH SPEED internet.  It appears that it is up and running across the road but not up to us behind the hospital.  We were told that it would cover 5 KM but so far not even 500 ft

We are supposed to have "turn over" tomorrow from the contractor but it is not ready.  The two star General is coming to review so maybe we will get the support we need to finish. Then Sunday the Senator arrives - the contractor did say they will have the Hot Zone done by then but we will not have gotten beds in, partitions up, or supplied the tents.  That is for next week.  We are putting together a "mock" patient arrival for the Senator so we will be training Nationals for much of the roles.  The problem there is that Saturday is National Election and everyone needs to go back home to vote.  So we may not even have any Nationals!

Rene has assigned supervisory roles to the nurses and they seem to be functioning in their roles and interacting well with the National nurses.  The difficult issue is how to divide up the work - shift hours, assignments, rotations.  It is easy for the Physician staff - there will be three and Rene and I have determined it will be a 24 hr first call, daytime 2nd call and third MD off. Rotating through call days.  

We really expect the census to be stable at around 10 patients, but can't be sure. We now see our role as lowering the threshold for admissions, assuming that almost all will be non-Ebola but not wanting to miss a single probable or real case.  Our mission will be to Evaluate, Stabilize, Triage, and Refer according to our findings - and obviously, if Ebola, manage the Ebola.  We are very fortunate to have a very good relationship with the adjoining hospital who will accept our referrals.

Hard to believe it is Christmas - it is sunny and hot with only a few scattered lights at the hospital entrance to indicate Christmas.  I was set back yesterday when I got up to shower and shave at 5:30 am and out the window heard the "Drummer Boy" coming off  the phone of one of our watchmen.  It took me a few minutes to place the tune!

I do feel that my time so far has been very beneficial.

December 20, 2014

I think instead of writing about Friday and Saturday I will wait until Sunday and just write about the Weekend.  It has been frenetic, final work on the ETU, a visit by The General on Friday, another visit today by the head of engineering for the DOD to review for turn over, and a USAID front man arriving to set up the visit by the Senator.  It is Senator Coons of Delaware -- he took Biden's seat, and when you Google or Wikipedia him, it appears he is very pro Africa (went to graduate school in Nairobi) and maybe missionary parents - couldn't tell.  Plus visitors will include the US Ambassador, another General, and an entourage of ten with security. Now it is staged to the minute!  Show and tell - but I hear he is the head of the Senate Foreign Relations Committee on Africa and it is said that he was the one that pushed Obama to "do something!" Now he is here to see what was done.  

On top of that we have three new staff, at least six 20' 16 wheelers with all sorts of supplies and goods, and the final walk-thru with the builders, etc.  Rene and I were asked to meet and walk through the DOD turnover team to outline requested changes and recommend for future ETU construction.  He was totally uninterested in anything we had to offer!

Wifi was turned on!  Unfortunately it only reaches to the upper gate of the hospital and we are 200 yards past that.

December 21, 2014

The past three days have been exceedingly busy -- 12 hr. days.  We started with several trucks (20' closed-in 16 wheelers) pulling in on Friday morning.  We all worked on unloading and since much was medical, I needed to direct a bit.  Then mid-morning,  a two-star General came for a walk through.  Really just a "Yes, I'm on top of this!" but still Rene, Jim, and I needed to follow and explain.  After lunch, we started looking for PPE gear to begin planning for the Senator.  About that time, three new staff arrived as well as another truck and the Public Relations guy for the Senator.  So a lot of "Dog and Pony show” planning.

Sat. at 8:00 we met with the outside guards, gate keepers, and vehicle sprayers and gave a run down on modified PPE dressing, gate instructions for everyone (wash hands in 0.05%, chlorine, dip your feet - bottom of shoes in 0.5% chlorine, have your temperature taken and if > 38 C. retake and if still > 38 C. call the supervisor of if repeat is < 38 C.  take best of three readings).  I had to go through these instructions a dozen times before they "got it".  Then a big walk through to document all construction changes for our unit, or future units - for the DOD inspector.  Rene and I then met with him and spent two hours walking around and in the end he was NOT interested in making any changes for us or in the future.  He said "these are the plans!" end of discussion - he said Ebola is a "dumb" bug and won't live long in water so don't worry about the cleaning run-off going down the hill to the stream below -- even though that is where the locals bath and wash clothes.  Not a very satisfying session.  

Then at 6:00 pm, they fired up the generators and turned on all of the lights for the first time - the tents were so bright you could have gotten a tan.  Fortunately we had asked that they let us turn off a bank of lights on one side and pull the plug on four of six on the other side.  After dinner, Rene and I met with the Chief Medical Officer for the hospital and talked about how we could collaborate on pt. screening and care.  A very delightful meeting and he wants to round in our unit weekly.

Today was all about the Senator -- suddenly all of the work trash disappeared, all of the small projects were completed, we started to populate the tents with beds, buckets for body waste, trash buckets, footwash buckets, sprayer and PPE supplies and our staff stationed for a "walk through" of an "almost working" unit. The entourage landed at noon - Senator Coons, Ambassador Malac,  the General and a collection of others.  One of our nurses and I were asked to meet with them at 12:30 to talk about Ebola care, along with the hospital CMO, a Liberian nurse, and a burial team.  This lasted for about 45 min. with very interesting discussions on the differences between Sept. / Oct. and now, level of care, pt. selection, survivor care, continuation of "safe practices", the future for ETU's, and the need for improving the health care system in general.  As Dr. Kolle, the CMO, pointed out, Nigeria, Mali, and even the US had cases of Ebola --  but no spread because of rapid containment, excellent medical care with appropriate care procedures and available equipment.  Again, the epidemic fire was fueled by poverty - lack of resources.  What was interesting was that on Friday the head of CDC, the head of WHO, and the head of UN, Dr. Moon, met in Monrovia to see if they could decide what worked so well in Liberia!  And actually the downhill curves began before all of the available ETUs so it seems that public awareness and safe burials were the cornerstones. The CEO of the hospital here in Tappita district actually recognized the need for these in April and established an "isolation" unit for any suspected cases and has not lost a single healthcare worker!  He also started outreach programs educating about burial, contact isolation, early symptom recognition, etc. and so far, no Ebola deaths in this district.  It seems that education and knowledge are far more powerful than technology - Jon, this is your speciality!

Anyway, the ETU is almost ready to occupy and set up for business.  We start training as a team tomorrow and I hope to get the medication protocol, order sheets, and formulary finished.  We are planning an Open House for Wed. - Christmas Thursday, and then pack to leave!  I will leave Tappita Saturday morning, spend Sunday in Monrovia, and fly out Monday. Yea!

I really am looking forward to getting home - the Country Director for Heart to Heart offered me a job if I would stay on - but I said NO - time to go home!

December 22, 2014

Leave for home one week from today!  I know I won't see the "Grand Opening" but I will have done all I could - time to leave.  It's up to the next team to take possession and run it.  Today started with a longer training of support staff on how to use the PPE.  The problem is that between Rene and myself, we have experienced five different types of PPE and our new suits here are totally different.  As I taught the class, I had to apologize for not exactly knowing how to put on and off in a correct sequence.  It turns out that the nurses were having the same problem so we got together to develop our uniform procedure for donning and doffing.  Then, apparently a new style will arrive in two weeks and it's all over again.  We also had another walk through with the builders to now start the inside construction.  This will take at least a week but hopefully we really will be ready by 1 Jan.  The latest construction dilemma is the well not working - probably needs to go deeper.  Apparently the two star general is flying back out tomorrow and everyone is expecting a real chewing out.  Not our problem - they delivered 5,000 gal of fresh water from the UN so now all of the plumbing is debugged. After lunch, I designed the order sheets for the patients records and  I sent to KC to have them formatted.

One of the new physicians is from the Congo and even practiced in Liberia.  He just married two months ago but has committed to come and fight Ebola - I am very impressed with him and think he will be a great asset in teaching Tropical Medicine to his US colleagues.  And that is mostly what we will be seeing!

Tomorrow more group meetings including the first time we have a physician cadre here so I will talk a bit about our role in the scheme of things, drug list, and treatment plan.  Then Wednesday, we are going to have a community open house and I'm guessing Thursday will be a day off.  Not much time left.

Liberia Week #6

Happy Holidays to all!  I have decided to move these last three installments to Tuesday nights.  Wednesdays, for the next two weeks, are “Eves” – and I suspect all will be way too busy to read these missives once relatives have arrived.  At any rate, George has only two more weeks in Liberia.  I shall ask him to write his last installment on Tuesday night, December 30^th, once safely home.

Many of you have said such kind words about George’s service.  In his behalf, let me say what George would say, that medicine, the art of healing, is the universal language. The transfer from culture to culture, from country to country, is simple, sometimes just the healer’s hand placed on that of the “other”.  George is blessed by his profession’s unique privilege, allowing him to participate in the lives of others, anywhere, at a very intimate level.  bsp

December 10, 2014

Did you see, the Person of the Year are all of the volunteer who have worked in an ETU in the war on Ebola!

Later,

Back to the ETU in the morning to troubleshoot.  It turns out that the electrical supplies that are on hand are all substandard.  The breaker boxes say Snider (a well-known American product) but when you open them, the insides are Chinese but say made in Liberia.  They apparently are not short protected or even have an inspection panel to keep you from sticking your hand directly into the hot wires.  The onsite electrical team refuses to use them stating they are "knock-offs" and are unsafe, pirated the Snider name.  

They have apparently located some left over supplies from other ETUs and are having them shipped up.  Also, we are still waiting for the supplies in Brussels.  Around noon, a full Colonel appeared somewhat in a heat over all of this and said he would resolve the problem.  We shall see.  There is also a shortage of gravel to cover the grounds so that we are not in mud after a rain.  

We did go to the second day of the Community Meeting but today was the gathering of donors - so we paid our fare and immediately left.  We did not wait an hour and a half this time for the meeting to start!

The work on the second guesthouse has progressed amazingly well!  Windows came last night and are already set in place and plastered in.  It actually may be ready by Sunday.  We are expecting three expat nurses Sat so they should have housing ready.  And this evening we received three National nurses who will locate there own housing in town.  They are staying in one of the rooms with four bunk beds tonight and will get a home in town tomorrow.   

I am really touched by TIME's "Person of the Year" award.  I have had a sense that we have been viewed somewhat as pariahs for "subjecting" the USA to the threat of Ebola.  At least TIME is championing for us.  It's a job that has to be done or Ebola will truly be an international threat.  I think we have demonstrated in Liberia that it can be controlled through the hard work of locals and others. It is not going to go away on its own!

Tapita  reminds me of how attached we have been to Embangweni, Malawi, and Africa.  I get the same feeling when I go to these meetings and walk around town. Everyone is so friendly and says, “Hello”, not even "Give me money, give me sweeties."

December 11, 2014

I see that I did not report on the status of Baby Nancy - a two year old whose mother died in an ETU but who wanted to hold her daughter for an hour before she left for the ETU.  Unfortunately, in that hour, or sometime in the previous 24 hrs, the mother transmitted Ebola to Baby Nancy.  Nancy came to the Kakata ETU where I admitted her and one other 23 y/o gentleman with  Ebola - Junior. Junior has done well but Nancy, unfortunately, just died after a progressive downhill course.  

Ebola is especially unkind to the young, old, and pregnant.  It is extremely rare that a term mother with Ebola will deliver a live child, and if it is born alive, that child is destined to die.  It is also a given that mothers with Ebola, in their first trimester of pregnancy, will abort a nonviable child.  Ebola is very much like malari as it seems to accumulate in the placenta and cause first and second trimester abortions and third trimester stillborns.  No Ebola mother will name a third trimester child after delivery, or even ask to hold the child, knowing the child will die.  Likewise, Ebola concentrates in the breastmilk so she cannot nurse - sure death in third world countries from eventual diarrheal disease from unclean water or lack of formula while trying to bottle feed. In Malawi, infant mortality was one in five -- I don't know what this outbreak is doing to Liberia.  In addition, the absence of trained healthcare workers has to increase the probability of infant death with any complicated delivery.  Life is hard here - if its not recovering from a civil war over a dictatorial government, it is a devastating Ebola crisis!

December 12, 2014

Morning rounds down to ETU construction site.  At around 10:00, we received a truckload of supplies - plastic buckets, foot wash basins, mattresses, etc. Unloaded and went to town to help nurses locate housing and to find a plug adapter so we can run our scanner / copier - which took over an hour to find. After lunch back to ETU - still issues over electrical supplies.  They are supposed to have one shipment up today and flight in from Brussels with second load. When we got back to the house, a list of all supplies, including drugs, arrived so I spent the rest of the day working on our Daily Drug Regimen and our Formulary (one of my goals for staying on).  Next, I will start developing our medical record sheets incorporating these daily guidelines.  Tomorrow, a General is arriving at noon to inspect the project with reporters.  So clean shirt and pants!

December 13, 2014

Rene is driving to Bong to pick up three nurses so I won't have internet all day. His phone is the Hotspot but we may be getting a US Army satellite link in the next few days.  I will be at the ETU most of the day as well as doing laundry and writing some letters.  Might have a printer so can work on developing some of the new records.  I can develop now but no way to print and even then will have to send as an email attachment to a computer that is linked to the printer - a bit convoluted.  

December 14, 2014

An off and on day.  We went down to the ETU and worked with the electricians on light placements and breaker panel placements.  A two star General was supposed to come in at noon and everybody was on edge.  Then at 11:45, they announced that because of bad weather, they had turned back.  So after all this waiting, we left to go eat lunch and see if he would come in the afternoon.  At 2:00 pm, he cancelled.  There is a rumor that some Senator will be coming soon. I could take pictures and save them a lot of money!

I worked on pt. records sheet for the rest of the afternoon, but it is very frustrating -- I can't print from the iPad and I am not good with the iPad word graphs program.  I am then trying to attach to an email and will send to Rene's computer which can then print, butt only when we gets the correct driver to allow him to connect to the printer.  AND, then we can scan the draft page to KC to have them set up and print all cleaned up, return to us, and then copy.  Nothing easy!  

At 5:00 we had a "staff meeting" at the downtown cafe / bar - over a bottle of Club Beer.  Two more National nurses came in last night and Rene is picking up three expat nurses today.  The electrical crates arrived from Brussels today and are to come up tomorrow. I think it will take them the rest of the week to finish the project before it is turned over to us.  Then, there will be another week to finish the interior to our specifications.  But, during that time we can be training and coordinating activities.  We will go from 10 workers (us included) to over 100 in one week!

It is hard to describe what my role is here.  I walk around with Rene and am available for "consultation".  But it does happen!  I worked with the electrical crew trying to lay out lighting and had them move all of the breaker boxes out of the Hot Zone.  I will work with the Pharmacist when she gets here on Thursday on  medication protocols and procedures, as well as medical records.  And, I  have spent time with the HR person outlining staffing needs and job descriptions.  All of this comes from my time in Kakata in the ETU  -- experience that  no one else has done.

Two weeks left - I'm not sure I will see opening day but I think it will be ready to open by the time I leave.  It is probably a good time to slip out of town and leave it to the next team.

Later,

Work on the ETU has been slow but steady.  A big chinook helicopter came in twice yesterday with supplies -- courtesy of the US Army.  I went to the LZ and it was amazing how loud and blowing it was when landing -- dust and rocks everywhere.  Most of the electrical supplies came in so we are off and running on finishing the ETU.  

We took a tour of the beautiful Chinese built hospital next to our ETU.  What is sad is that there are no doctors - with the Ebola crisis all of the foreign doctors (China, Ethiopia, Egyptian, etc) left immediately.  At one point the Chief Medical Officer, a Liberian trained MD who has lived in the US, was the only doctor in the hospital.  He now has four interns from the Liberian medical school covering the wards.  How would you like to have an intern as your primary surgical, obstetrical, medical, or pediatric hospital provider?  Great training for them but without supervision.  

The healthcare system of Liberia has been devastated by the outbreak.  Some of the first people to die were the doctors and nurses who weren't aware of what they were treating.  We were told that one of our Liberian nurses didn't feel well and what should we do?  To us that is a bigger threat than the ETU!  We said to go to the ER and don't come back until you are well.  Our lead cook, Mariah, then showed us a picture on her cell phone of a handsome Liberian doctor and his wife who she knew well and both died in September of Ebola.  There are now less than 50 doctors in the country to treat a population of 4 million.  Even when Ebola is gone, it will take years to rebuild and repopulate the healthcare system. Once again the effects of poverty will express itself in many ways for years after this outbreak.  How lucky we are!   

December 16, 2014

Very busy two days --JIm is now here (my new roommate- in the top bunk) until he and I leave together on the 27th.  We have moved forward on planning the interior of all of the units.  We are supposed to get the shell on Friday after a walk-through with the military.  Then, Saturday to correct the deficiencies, then Sunday a Senator from Delaware and two-star General are coming for a show and tell.  So, there is  lots of planning in anticipation of the turnover.  

Liberia Week #5

December 4, 2014

Not much to report - my 24 hrs in the hot seat.  As you are aware, the biggest issue is the call from Rene asking if I am still interested in staying on for an additional two weeks.  The original plan was for our team of eight six-weekers to be the first "boots (Dunlop Rubber) on the ground" with the new ETU in Tapita.  Our job would be to set up and start running the ETU and then turn it over to a cadre of 3-6 monthers who would pick up from our work and run it as long as needed.  However, because of construction delays, we all are scheduled to leave just as the team of long-termers arrive.  They will arrive with no time in an ETU and there is only Rene who has spent any time (three days) in an ETU.  So I volunteered and he has accepted for me to stay on for two additional weeks to help set up and start up the ETU.  I have agreed to the extension and now he has to get final approval.  Either way, if it doesn't fly, I will be glad to get home, or I would be proud to say I stayed to finish the work we came to do.  

Still no positives, four discharges and four admissions. Two of the admissions are from the "outbreak" at Grand Bossa (the place that we have been following for the past week) but appear OK and were able to walk out. There are still several left behind and the debate is how to go and carry out on stretchers the sickest who may be the most likely positive.  So the question is how to carry out on stretchers for a two hour walk and protect ones self - PPEs, vs. long handles on the stretcher, or face masks, gowns, gloves, etc.  To be decided!

December 5, 2014

My second day off in two weeks - it is so nice to have George R. here to share coverage.  I finished From Beirut to Jerusalem and Davis lent me Killing Patton so I read off and on most of the day.  Around 11:00, I went into town to try and locate some artesunate, an IV drug for malaria.  One pharmacist last week said he would get it from Monrovia, but he failed  -- but would try again.  Back to the ranch and read some more.

Have been picking everyone’s brains about the details of managing an ETU in case I do go to Tapita.  George and I put together our ideal drug list and talked out some treatment strategies.  George, Freeman and I went into the hot zone at 5:00 to see our two new admissions. One, a 23 y/o, said his Aunt died of Ebola in Oct. and when he had two loose stools yesterday, his Uncle brought him immediately to the ETU knowing that was a sign of Ebola - no other symptoms, so he will be neg.    I don't know if I mentioned another man who took some Dulcolax  and then had diarrhea all the next day, so he came to the ETU. But the word is out!  

At 7:00 pm, we had a surprise going away for one of the staff - the cake said on it "Faware God Bless".  A true African Good-bye!  Then, our on-again off-again Viber.  So funny how it can be so good, then suddenly breaks up.  The only good reception is on the balcony which is where everyone hangs out in the evening and  so that's why all the voices in the background.  We did get satellite TV hooked up. All the Liberian staff immediately turned to  the non-stop soccer station.  To bed. I will let you know as soon as I hear from Rene what my fate will be for the next three weeks.

Later. . .

I just got off of the phone with Rene and he plans on picking me up tomorrow at 9:00 am. Rene says "you will be the number two man here”.  He will be great to work with and I really sense he will be leaning very heavily on me since he did hot training in Bong when it was very busy and did not have a lot of time to absorb the day-to-day workings.  I have been scurrying around taking picture and making notes of the operational side of things here, so hopefully I will be able to share.  Also,I  have talked extensively with George about how we should do "best practice" treatment.  So hope to have a green light on that.

December 6, 2014

We have our first case of Ebola --  young man of about 26 y/o whose Aunt died recently -- first he said September,  then October, but may well have been November. -- he seemed a bit confused on dates. As you know, when every day is the same for young African men without work, it actually is hard to be certain of dates.  Anyway, she had vomiting and diarrhea and he attended her burial.  Then, he developed minimal vomiting and diarrhea, but his Uncle made him come in anyway.  Test positive - but actually today he looks good with only 1-2 loose, unformed stools and no vomiting.  We moved him from the suspect ward to the confirmed ward,  put in an IV so as to be able to keep him well hydrated and then will watch him.  We also admitted a 2 y/o whose mother died of Ebola. Before she went into the Bong ETU, she held the child for over two hours - what a sad parting.  The child is here with grandmother and is very likely to be positive.  And, we admitted a 29 y/o who just buried a close friend and now has vomiting and diarrhea with a fever so I think very likely positive.  So from none to maybe three!

I leave at 9:30 tomorrow am for Tapita to prepare for opening.  I feel like I have learned a lot and have a lot to share, as well as some improvements to suggest.  I think health workers are so immersed with positive Ebola cases that they are simply treating Ebola or discharging - very binary.  Now that we are not so busy, it may be time to try and individualize care to deal more with patients  -- why they come in and hoe they get adequate follow up.  We certainly have treated a lot of non-Ebola enteric viruses1

This may be my last day in PPEs for a while, and possibly my first and last Ebola patients.  I have seen over 100 patients and we have experienced 5 deaths - not Ebola related.

Later,

Delay in vehicle leaving Monrovia so I still haven't left and it is now 11:00

Later,

Jim called at 11:00 and said they were a little behind but would be on the road soon.  It is only about 1 1/2 hrs from Monrovia to Kakata and still not here!  African-time personified.

And our lunch is late so I'll bet they both show up at the same time.

December 7, 2014

The old saying applies aptly in Africa "Hurry up and wait."  I said my good-byes at the 7:30 am team meeting, met with Nora from 8:00 to 9:00 to talk about operations and procedures, carried my bag to the front door, and went to the balcony to wait, and wait, and wait.  At 11:00 Jim calls and says they have just left so would be here in an hour or two.  At 2:00 I called Jim because it had been three hours.  He said that they had "just gone shopping" but were now on their way.  They showed up at 3:00pm for an eight-hour drive to Tapita!

As I texted last night, it was eight hours on the Jenda Road  [our way in and out of the bush when we lived in Malawi] - four hours in dry season and four hours in wet season.  We got to Ganta just at dark, stopped for fuel, taking three tries, then turned to go to Tapita.  So far the road was a mixture of old pavement, no pavement, pot holes, and new pavement - as the Chinese are rebuilding.  At Ganta, there was a spectacular full moon coming up on the horizon until we turned; then, straight ahead was a big black cloud filled with lightening.  The road was now mud and potholes.  Over time we got closer and closer to the black cloud but I thought we would get to Tapita before we hit rain - wrong!  The last hour was in torrential rain, harder than anything I had experienced since arriving.  

At least we were only going 10 MPH as we slogged through water filled pot holes, almost unable to see the front fender because of the rain.  Finally at 11:00 we made it - safe and sound.  The house is nice, construction quality like the guest house, and I have a single room with a double bed and the best mattress yet.  Same old Chinese desk, horrible shared bathroom, but AC and a washing machine. So not so bad!  I will tour the ETU in the am and give you an update.

December 8, 2014

As you come into town on the road from Ganta, it is suddenly paved and there is this beautiful two story hospital on your right.  It has a front gate with a well manicured lawn and the front building is two storied with an ER on the right and clinics in the rest of the front building.  It is much like Da Yang Hospital in Lilongwe.  Then, there is an attached building going back perpendicular to the front building which is the OR and radiology - with the only CT scanner in the country (broken and not working).  Then that building connects to another building forming an H which has the patients’ rooms, even some with room AC.  The only problem is  there are very few patients.  There are still eight generalist on staff, but all of the foreign specialist have left town because of ebola.  A beautiful hospital in the middle of nowhere.  Next to it is a temporary ETU constructed out of tents, and then next to that and outside the wall is our ETU, a large campus of plywood structures, US Army tents, and two massive USAID tents for the wards.

The ETU still needs work, like faucets for the three systems - water, 0.05 % chlorine, and 0.5% chlorine taps.  There is no gravel on the grounds so there is mud everywhere and all of the units need to be stocked and have basic finish work.  The two patient . wards are these large tents that are empty.  Our job will be to lay out and supply when the grounds are finished next week.  There are two large generators to be put into service and apparently a major shortage of gravel explains why it has not been put on the grounds.  They are just finishing the drainage system --from inside the wards into French drains -- the entire units are washed twice a day with 0.5% chlorine. Beds arrived today and all of the major supplies for stocking are to come this week.  We will be very busy unloading, sorting, and moving around supplies.  Also this week we will develop patient charting, order sheets, etc.  Lots to do but I feel that I have the know how to do it  from my time in Kakata.  

The rest of the staff is to come up next week-end, if housing is ready. They are in cold training this week in Monrovia but having housing for them is really a problem.  Our house has five bedrooms, three baths, a large central room, and a kitchen.  But, they will need quarters for over 10-12 staff so we are working to expand a second unit and put in bunk beds. Rene and I are currently the only expats on site but that will change.  I am lucky to have my own private room!

Then I went into town. What a nice, clean spread out little crossroads. There is minimal litter and all of the shops (basically tuck shops, like the Jeri store in Embangweni) seem well maintained, clean and painted and not too crowded.  It is Sunday and Liberia has blue laws prohibiting shops from opening.  We went out to the helicopter landing zone and passed the outpatient clinics - spotless.  That is also where they do uncomplicated deliveries.  The town reflects the previous influence of the hospital, a cash economy.  Unfortunately because of the low census much of the staff has been cut back / laid off.

We stopped at a little outside cafe at the main intersection and had a local Club beer and watched the world go by.  It was really very peaceful except for all of the little motorbikes that are  the main source of transportation.

It looks like hard work beginning tomorrow.

December 9, 2014

Not a bad day.  Started out with a breakfast of eggs and ham with a Lebanese pita bread.  I went to the ETU and discovered a major glitch - the designers in D.C. decided to code the three wash waters red, white, and blue, very patriotic.  However, the convention is the red is 0.5% chlorine and should only be used on surfaces and never on skin, the green is 0.05% for disinfecting skin, and white is for plain water to rinse with.  They had them all mixed up so it appeared that we would be washing and showering in 0.5% -- this would take our skin off by the end of the day.  I went to town to get white paint to do correction.  Then the electrical supplies are apparently in the airport in Brussels, but the airport is shut down because of a strike - so we are possibly delayed by two or three more days.  We unloaded one of the supply trucks and my great mattress disappeared as I went from a double bed to a bunk.  Also, I started to set up printer / copier but the model not compatible with any of the computers - need to download a new driver but no Wifi to download on -- maybe tomorrow so I can start on medical records.  Lunch consisted of greens with fish on rice - very spicy and last night nuclear hot red beans on rice.  Not our bland Malawian nsema and dende!  

After lunch, we had a meeting of "stakeholders"  -- it involved community leaders and they are going out on motorcycles next week to all of the small villages to talk about ebola and ebola testing - very impressive commitment (plus they get a travel allowance for going). Then, back to the ETU to check progress and it looks like, except for the electrica,l most of it is finished.  The patient tents, however, are empty and we will have to contract separately with carpenters to create personal spaces - cubicles, tables for donning, stands for chlorine wash between patients, etc. so completion and turn over may still be the shell.  As we get our supplies in this week, will start to sort and assign i.e. pharmacy, pt. supplies, office supplies, pt. rooms, etc.; then we will move them in the next week after internal construction is complete.  It sounds like three nurses will come up this weekend to work with Rene and me, and the rest of the crew will come later next week.

December 10, 2014

Not too busy a day.  Went to the ETU and no progress on all of the electrical supplies that are frozen on the tarmac in Brussels -- due to a transportation strike.  The electricians say four days once they arrive but Brussels Air only flies on Mondays and Fridays.  The broken cable in the crane has been repaired and they were able to unload two empty shipping containers for storage and set the 5,000 gal fuel tank in place.  So just about everything is done except for the electrical and the interiors of the patients’ units and ancillary facilities.  We have carpenters coming next week to do all of the interior finish. A one-star General flew in to review and would like to come back for a grand opening on the 19th. It looks like he has set the Drop Dead date -- fine with me

After our ETU tour, we went to a meeting where we were told they would discuss going to local communities regarding messaging about ebola.  The meeting was to start at 10:30 but only four people were there.  Then the PA system man arrives at 11:00 and has it set up at 11:30 at which time about 30 women in local colors came dancing and singing up the road.  At 12:00, the MC hands out the program "Fund Raising Initiative for the Renovation of the Palava Hut and the completion of the Statutory Superintendent's Residence".  Nothing to do with ebola - we quietly excuse ourselves.

And the windows just arrived for the second guest house so it should be "finished" by Sunday which means adequate housing for all. Maybe they will take back my bunk bed and I can get my double bed back.

Mariah, the cook in Monrovia, has just arrived so food quality should improve dramatically.