Liberia Week #3

I am sharing George’s week #3 in Liberia one day early.  By tomorrow night, we will  be focused on Thanksgiving -- family and food. 

If you have a moment, do send a greeting to George and his team.  I know they will all be missing the big family holiday.  gpoehlmanmd@gmail.com

Betty

November 20, 2014

So glad to finally get emails in and out.              Today was very busy starting with moving all of the pharmacy packages from IDA to the pharmacy area.  Then, the clinical team practiced admission triage followed by an hour in PPEs in the heat of the day.  The IMC PPE is a little different than the WHO uniform we trained in, but actually more protective so no complaints - just very hot.  Sweated through my cargo pants and had water in my glove tips.  

After lunch we spent the rest of the afternoon stringing lines to hang IVs over the individual patient rooms in each of the ETU units.  The rooms are actually just stalls with open front and top.  All of the walls are covered in plastic so that they can be sprayed down with chlorine when the patient leaves.  It has been a bit frenetic but I think we will be ready for Friday.  Many, many details and this is with a crew that has run an ETU in Bong - I'm not sure how Tapita will pull it off in the time remaining!  I may be happy just to stay here for the next four weeks and actually see patients.

They worked on doors until after 11:00 pm last night but now we each have our own room, pretty basic but actually nicer than our guesthouse in Malawi.  There are lots of flying insects with the overhead light on, despite screens.  The big fear here is the Nairobi Fly - it looks like a three colored ant but when it lands on you and you kill it by brushing it off, it leaks a fluid on you that burns the skin, leaving a blister and sore.  Apparently, they are out in full force and about half the staff have blisters on their necks from swatting them.  That actually takes the fun out of having the light on because it attracts these bugs.  

Got to turn of the light - bugs all over the place - Kindle time.

November 21, 2014

Not so frantic today - it seems we have everything pretty much set to go.  The word, though, is not until Saturday because the "dignitaries" aren't available for the grand opening until then - Ebola can wait!  That gives us an extra day to clean up details in the hot zone, because once we have patients, it is closed to anyone not in PPE.  So any maintenance workers are also going to have to learn how to fix problems in the hot zone in full PPE.

Having seen how complicated it has been setting up this unit by an experienced staff who have all worked in an operating unit, I am not sure how HTH will get Tapita running.  We all kind of hope we just can stay on and work here but we also realize our experience will be invaluable in setting up a unit.

This morning we had a team meeting of all "staff"  - 15 total, seven of which are expats.  One is from Australia, one from France, and five US.  And three of the five are the Heart to Heart providers who are really there as guests and not part of the IMC staff.  There are only two MD's and two PA's and I followed one PA on the mock patient today, and I believe he is more of a nurse than a clinician - so maybe only three to write orders.

We all spent the rest of the morning assembling our desks, made with Chinese craftsmanship and assembled with three hours of US ingenuity - no directions, broken pieces, missing parts!  After lunch, we all assembled outside when an "ambulance" pulled up and honked its horn -- two individuals in the back.  We quickly assembled a team of sprayer, triage nurses, PA, clinician and nurse and started to admit them - a live fire training by staff.  It went sputteringly well.  We will need more practice but at least the system worked.  Then, it started to shower and cool down so I am in my room.  I taped all of the screens with duct tape, electric crew in this morning so I have a light in the bathroom and a wall socket, a new wastebasket and soap, and a great desk.  

Have just tried twice, just no Wifi.  Probably done for the day and will rest and read- hopefully less bugs tonight.

I hope you have had a good day / week.  I can't even imagine cold let alone 72" of snow.  I am glad that you are coming to pick me up in DC.  What I hear is that once you clear customs with a temperature and review of systems, you are released and on your own.  Again, I would like to slip under the radar.  I know that there will be concern even in Weldon Downs, but unless I am symptomatic and with fever, I am at no risk to others - hard to sell though.  Also really glad that you are going to Christin's for Thanksgiving - I don't think they celebrate here so eat some turkey for me.  We are still rice, with chicken or fish and a dende - but hot!

Nora just walked in and asked if we could go to Bong and pick up the correct medical supplies.  So on the road for an hour or two and maybe Wifi.

False alarm - Bong is sending a truck down tomorrow so no road trip.

Later,

They have set the Hotspot up on the second story balcony, so much better reception. It is actually going to be our lounge area so quite nice and convenient. With all of the major work on the facilities done, the hoards of day workers will disappear and only the staff working that day will be around. It should be a lot quieter with down time when you are off.

It just started to rain so much cooler. I thought it was the end of rainy season but it is raining for a few minutes every day. It is still very green and lush here with gentle rolling hills and lots of palm trees.  Also, for as far as you can see on the way into Monrovia were rubber trees. Apparently, Firestone owns thousands of acres here.

I just heard that the rest of our team is going up to Bong to help backfill the loss down to here. I think Tapita may be a long way off - I am quite content where I am.

Just got word that dinner is ready. It looks like Jungle Oats!  I bought some peanut butter and crackers today so will need to supplement since I didn't get lunch.

I was so surprised when I went upstairs for breakfast and the portable Hotspot was working.  I downloaded all the mail and I saw it uploaded my mail.  What a great way to start the day!  Then it was time for our 8:00 am staff meeting and end of Hotspot.

Slept well last night having read until 9:00 with the lights out except for the Kindle, so no bugs - maybe taping the screen helped.  I was up around 7:00 and breakfast and then staff meeting.  We have the luxury of an extra day since the Grand Opening and turnover is not until tomorrow at 10:00 with dignitaries and speeches -Yawn!   

After the meeting Nora came up to John and me and asked if we would go into Monrovia with a driver and purchase last minute medical supplies - IV angiocaths, blood giving tubing, sterile gloves, and adult diapers (for the severe diarrhea).  So we were off at 10:00 over rutted, potholed roads to Monrovia. Downtown Monrovia is the usual African city of confusion.  After going to five pharmacies, we got everything and headed home.  Back around four and now my update.  

Yesterday’s meals were interesting.  For breakfast we had tuna sandwiches with a pita bread, lunch was a hot green stew with fish and chicken over lots of rice, and dinner was cream of wheat.  They had breakfast at dinner time and dinner at lunch time - it was decided to talk to the caterers, especially as one of the servers was seen taking a bite of fish and then putting it back in the stew!

Just got word that the Hotspot was working so will sign off.  Ready for tomorrow and hope the ambulances bring some patients.

Later,

They have set the Hotspot up on the second story balcony so much better reception. It is actually going to be our lounge area so quite nice and convenient. With all of the major  work done, day workers will disappear and only the staff working that day will be around. It should be a lot quieter with downtime when you are off.

It just started to rain so much cooler. I thought it was the end of rainy season but it is raining for a few minutes every day. It is still very green and lush here with gentle rolling hills and lots of palm trees.  Also, for as far as you can see on the way into Monrovia were rubber trees. Apparently, Firestone owns thousands of acres here.

I just heard that the rest of our team is going up to Bong to help backfill the loss down to here. I think Tapita may be a long way off - I am quite content where I am.

Just got word that dinner is ready. It looks like Jungle Oats!  I bought some peanut butter and crackers today so will need to supplement since I didn't get lunch.

November 22, 2014

Told that Wifi was working but, so far nothing in or out. I will text this, as well. Am trying with phone.  

First patient a cute 62 y/ o man with no fever, vomiting, diarrhea, or contact with Ebola. Should not have been admitted. I went in this evening to exam him and found a big liver, ascites, leg edema, and clear lungs. This guy does not have Ebola but he needs a doctor!  If test negative, we will send him to the hospital tomorrow.  Great one to start with.

Nothing is going out - sorry.

Later. . .

Nothing really new since yesterdays email that just went out.  The ambulances don't go out at night and rarely on Sunday - no case workers to identify patients. We do know there were two that they were not able to pick up yesterday because the road was blocked, so they are going to investigate this am - otherwise it may be a slow day with the same one patient. and now a staff of 200. Great provider to patient ratio.  It will pick up! I am the physician again today so will see the new admits and maybe discharge the one patient  but I hear that if we keep him until tomorrow, we will drive him, with a referral, to a hospital.

Breakfast and waiting for 10:00 to go back in to hot zone with head nurse - a national.  Then I will nap and read and if we get two new patients, going in later today to see them.

Even later. . .

I just can't believe Viber worked!

I will email later after I see how the day turns out - I am on 7:00 to 7:00 and will have turnover at 7:00 pm but think I am also on call for the night!  So a 24 hr shift, then probably back on at 7:00 am.  I have nothing else to do and no place to go!

I will try to send a picture of the unit.

November 23, 2014

Not much to add to this morning’s missive.  Good Wifi off and on - I don't know what's different.  I see that I even got my pictures out.  The cute little man does admit that he was a "drinker" until three years ago so that may be part of the answer.  He turned out Ebola Negative so, to date, 100% of our pts are survivors! No ambulance traffic on Sundays - an off day for Ebola I guess!  The dispatcher, however, said he would load us up tomorrow.

After going in this morning, I worked on my shower ( a loose sprayer head) and managed to tape it to the water pipe so I now have a real shower. Yahoo!  After lunch, napped and then the three of us went into Kakata, but because of Sunday Blue Laws, the only real store open was the Total gas station where I bought a small box of Laughing Cow cheese, a can of chile sardines, and a Club beer. Drank the beer as soon as I  got back, before it got warm, so now I have nothing to go with my delicious snacks.  May save them for an off night.  I have spent the rest of the afternoon reading from the iPad and have the speaker on the iPhone.  I cut a water bottle in half and cut the front out to magnify. so now I have a mini stereo while I read.  

Since it appears that the Wifi is working, I will send now and then read some more.  I also figured out why I was having so much trouble downloading - I had the Photo Stream on so it was continuously exchanging photos.  I had to turn it off so I can make better usage of the Wifi.

I am attaching a photo of breakfast - hard boiled egg, plantain, cassava, and some hot red sauce with sliced hot-dogs in it.  Not bad!

Sent young George a picture of me in my Storm Trooper garb!

November 24, 2014

Just a quick note -  got Wifi again.  We have a patient on the way!  Also, heard from Rene last night that he is coming through tomorrow and will give us an update.  Tapita is opening on the 5th so I think we will be here at least one more week, though they might want to pull us next week to help with the last minute start up.  As much as I would be just as happy staying here seeing patients,  I think all team members will be experienced with the IMC system and will be very helpful with the start up at Tapita since we will all be on the same page.  At least I will have had one week of patient care!

IMC just hired a Liberian trained MD who has been working in a private clinic / hospital at Bong Camp (an iron mine run by the Chinese,) but it is so slow he is bored.  He lives in Kakata and is an absolute delight -- a cross between Arthur and Reggie [medical students, now doctors, who George worked with in Malawi] He is very knowledgeable and skilled – at least I think from our conversations. Pranav has asked me to orient and work beside him until he is comfortable in the system - a real pleasure.  He would be a great doctor to work with at the Bong Camp hospital if that were in the future - real Embangweni-style medicine.

And, later,

Well, we are finally up and running.  The first two patients came in around noon and one had had three weeks of intermittent abdominal symptoms with diarrhea and subjective fever.  Probably didn't need to come in but on exam did have a distended abdomen, with cramps and diarrhea.  My guess is worms and / or giardia - he will probably test negative and we will refer to the local hospital.  The second patient is a heavy 34 y/o female who has had nausea, vomiting, diarrhea, lethargy, confusion and fever.  When John and I went in, she was obviously in distress so we started an IV and gave her 2 liters of fluid in about 30 min. - taking turns squeezing the IV bag.  She seemed to wake up and improve and started to drink.  After we left, someone mentioned that she had been told in the past she was borderline diabetic - I don't think she is borderline anymore!  Whether she has Ebola or not is yet to be determined but certainly could be a significant stressor.  Any way, we have no way to treat her diabetes except force fluids, so she will get 2 more liters at 9:00 pm and maybe at 3:00 am and then we will know about the Ebola tomorrow with her blood test.  We may just be treating diabetes, but certainly we will make her feel better, if so.  The 3rd is just a straight-forward rule out.  The fourth is a 14 y/o boy who was positive at Bong and stayed 30 days, discharged after 2 negative tests.  Now one week later he has nausea, vomiting, and mild diarrhea.  Very unlikely he is Ebola since he is a survivor but we will retest and treat his GI symptoms with IV fluids and hopefully it will just be a case of bad home cooking.

Long, hot day which started with thunder, lightning, heavy rain for about 20 minutes but nice to get actually into the swing of things.  We have two more in triage that walked in so maybe busy again tomorrow. Waiting to hear from Rene tomorrow what the game plan is for us.  It is good to actually be practicing real medicine and actually able to make a difference beyond just having the patients drink fluids - the diabetic lady would probably be dead by morning without the IV's.

I will tuck in early tonight since morning report now is at 7:00 every morning and evening report at 7:00 pm so 12 hour day plus told them to knock if any issues tonight.

November 25, 2014

Just a quick update while I can get email. The diabetic lady died after vomiting blood. Awaiting lab but probably positive. The 14 y/o seized and is negative for malaria probably post Ebola encephalitis and seven just arriving so I will go in as soon as they are admitted by nurses.

Later,

So far no positives but one death and one pending death - still may both be Ebola related. The seven admits today all have symptoms and history of contact with Ebola pts but none of them appear sick. Two kids with bad skin rash (fungal) and one with impetigo. The primary care doctor in me wants to treat everything, yet we are here really to just treat their Ebola. We have no meds for most of these problems and it is frustrating, but I also know we are not really an out patient clinic.

I have an African Memory foam bed that just never forgets -- as the night goes on every place I roll sinks in but doesn't rebound until the next day.  By morning I am sleeping in a large hole!

  

Week 2

George continues to have a good experience.  He is on location – but not in Tapita.  Instead, he has been posted for two weeks in Kakata, not too far northeast of Monrovia. On loan to International Medical Corps, he and two nurses will rejoin December1 the others who are posted, as well, to sites, like Bong, where there are new outbreaks. 

Read and know,

Betty

November 12, 2014

Another great day of training!  They broke us up into clinicians (doctors and nurses) and non-clinicians and our clinician lectures were on medical care of the Ebola patient.  Well done and informative but also you can see where Ebola care has evolved into more aggressive adjunct care.  No longer do we just give them ORS (Oral Rehydration Solution) and they either live or die.  Now everyone, at least in our unit, will get an IV on admission and as much fluids as needed to keep up with the profound diarrhea and vomiting.  Also, we will be giving supportive drugs for the vomiting, diarrhea, fever, pain, as well as empirically treating  suspected concomitant infections such as malaria, shigella, etc.  They will be started on a basic regimen of drugs on arrival and then additional drugs as needed.  This a tremendous step forward in supportive care.  What is exciting is that this is all unfolding just as we arrive and we will be one of the first units to take this approach.  

Our next session was actual case studies – fantastic --  repeated what-ifs such as a one year old with fever and seizures and Ebola exposure.  Just as in the rest of Africa, now think of cerebral malaria, meningitis, febrile seizures, as well as Ebola and treat all of them!  I really hope this comprehensive approach will dramatically improve outcome.  Then, in the afternoon we heard from six Liberian health care workers who had recovered from Ebola and learned their experience in an ETU.  They said personal concern and encouragement by the care takers was so important to keep up their hope.  The initial emotion is "I am going there to die." but once they had the strength to walk again, they realized that they actually might live.  They have all chosen to return to work in ETUs!  Impressive.

The change in Ebola management is evolving as the initiall explosion of cases without adequate beds in ETUs has improved drastically.  Almost all ETUs have empty beds. Now, instead of coming to die, people are seeing that the ETUs ,au improve ones chance to live.  The first units could only provide the most basic of care - fluids and a bed.  But now, with the initial onslaught absorbed and some breathing room, everyone is looking at how to improve outcomes. The big cities seem to have slowed down so the effort is directed at putting out the sudden flairs in the countryside.  With dry season coming, people are moving out of the cities and going to the small villages where suddenly 6,8,10 people are infected from one contact . That is where we come in.  We are the first of 17 one hundred- bed units being built throughout the country to serve as centers for rural care  as well as "fast response" teams to go directly to the small village when a local outbreak occurs.  We will be well equipped and provide much more comprehensive care.  That is why it is exciting for us, because we are no longer following the old care patterns and are tasked with moving care to a higher level.  

When we returned today, we spent over an hour within our group with more what-ifs.  What if a worker in a PPE goes down in the hot unit, how do we extricate them without contaminating ourselves, how do we keep more comprehensive records on weights, I & O's, treatment plans, IV's in, etc in the hot zone as well as a cold charting zone, how do we prepare for a pregnant women, an infant, etc.  Some of this will be more theoretical but it will be the road map for the future teams.  What is also great is that Dr. Vega is behind the effort and pushing us on.  Great to have the support!

Enough - you gave me a book to journal in but this is going to be it, daily emails as long as I have the time.  You may need to edit and shorten, I know I am rambling and will bore most people. Thanks for sending on my emails.

November 13, 2014

Another excellent learning day.  In the morning we broke up into Clinician - Non-clinician groups and practiced interviewing patients as they appeared for triage at an ETU.  Some were very easy - met obvious criteria of contact, fever and other symptoms.  Then some were less obvious - questioning if the patient was withholding information in order to "not have" Ebola.  And the last case was a patient who spoke a different tribal language - how do you work with pantomime and sign language.  Then this afternoon we donned our PPEs and went into a full scale mock-up ETU hot unit built by the US military.  It was hot temperature-wise in the PPEs and immediately my goggles fogged up and, after an hour, sweat was pooling in my glove finger tips.  Some good learning cases - one good point - don't stand between the patient and the vomit / diarrhea bucket!  Tomorrow, more of the same with four cases instead of the one and more time in PPE to help get familiar and acclimatized.  Fortunately, the heat does not bother me much but I will need to stay hydrated.

Back home and two new nurses from the US have joined our team, one from Kansas and one from Springfield, MO.  They are here for six months - great commitment.

Saturday we will tour the MMU (Monrovia Medical Unit), the non-military expat. triage and evacuation center at the airport.  It is next door to the same unit for military personnel. It is manned by the Public Health Service workers from the US and they will treat any medical issue as well as triage and evacuate for Ebola. So far, they have admitted only three Liberian nationals as suspected but not confirmed.  It is believed that if they test positive that it is very likely they were infected from the community, not their work.  Several hospitals and clinics have also begun to open up again and have started seeing walk--in patients which puts them at risk for a walk-in Ebola unless they take adequate precautions.  

Sunday is off and then Monday up to Bong for hot training, assuming all the details are confirmed.  We will know for sure tomorrow.

November 14, 2014

Using a military term in a military setting - today was "live" fire.  We arrived and retook our pre-test, then broke up into our respective groups.  Each group consists of three "hygienist" and four clinicians.  My group is all-Liberian and I am the only MD; the other three clinicians are nurses - two of which have worked in an ETU.  Unfortunately, my group was last so we sat until 11:30 and let the day warm up.  We finally  go to a mock ETU built by the military and start by donning our PPE, entering the unit at 11:50.  I am immediately soaked inside with sweat, and there is no way for it to leave. It is a 120 degrees sauna inside the PPE.  My goggles were better but eventually my vision was the same as in a shower.  We had four cases and the drill is this:  the hygienists enter the room and clean any residue with 0.5% chlorine, empty the waste pail (urine, vomit, stool) for output, then the clinicians enter.  The charge nurse prepares the patient - cleaning the bed, dry sheets, and gown.  Then I interview, examine, and give orders to the IV nurse, and the scribe nurse writes all of the vitals, I & O, and orders on a whiteboard in the room.  Additional nursing is provided asap.

We had four scenarios which provided lots of insight -1) a patient in shock from massive fluid loss (vomiting and diarrhea), 2) a confused combative patient, 3) a healthy nurse who was stable but hiding her own meds, and 4) a patient in a room on the convalescent ward.  When we got there, the hygienist told me there was a dead patient. I went in, pronounced the patient and started to leave when the instructor asked about the other patient.  I was so fogged over by then that I hadn't even seen the second patient.  Anyway, we discharged him with  discharge instructions  and then bagged the dead patient (a mannequin) -  but the learning point was to treat the live first and worry about the dead later. Missed it!

An hour and thirty minutes in PPE and I had soaked through all of my clothes but  I felt OK.  Our work group did very well and our Heart to Heart team all did great. We are ready to go for "hot" training next - with real patients.  The US military should be very proud as  the week was well planned and executed and everyone was extremely courteous and professional.  Proud to be an American!

We bought a case of beer on the way home - but it was still hot so no celebration yet.

And later, on 14^th

Just got word that hot training has been postponed for a week - no available sites.  There is a reported drop in cases in Liberia so everything seems to be in slowdown mode.  They don't think we will be up and running until the 1st of Dec. Nimba county shows between 21 and 50 new cases reported in the past 21 days.

We don’t really know what’s out there. In the meantime, we have talked about putting together additional learning cases  -- basically creating  Standardized Patients!  I hope we get to do more than talk about it, but if not we will have a well thought out unit.

You would of loved dinner - rice and kidney beans just like Mr. K  [ our cook in Malawi] cooks.  Now just kind of hanging out and it is pouring rain outside.  So far have not had any rain during the day.

Nov 15^, 2014

Great rice and beans but after two servings, as well as rice and stew for lunch, and two warm beers --  about 3:00 am a slight rumbling in the stomach and a couple of quick runs to the bathroom.  But, it was all over - whew!  I was afraid the Durham Curse that “bugged” you all at home had followed me.

At 9:30, we drove back to the airport grounds, about an hours’s drive.  There we went into the MMU compound (Monrovian Medical Unit), an absolute state of the art Ebola care center -- everything one would want for in-country care plus they would automatically arrange your transport back to the US ASAP.  They are simply there to stabilize and transport any American and care for any Liberian health care worker suspected of or diagnosed with Ebola.  The Doctors were all PHS but also part of a special Deployment Unit that drops into any stateside or international emergency zone. These were really impressive individuals. I certainly feel that if any of us needed help, we would get state of the art care.  

Back for the rest of the day - big Pow Wow scheduled this  evening with advance group already in Tapita to find out where we stand for planning.  

Nov 17, 2014

Got up, and George R. and I went for a walk at around 8:00 and were back at about 9:30 - showered and cleaned up, expecting a slow day.  I started to create an Operational Manuel for Tapita when Rene came in at about 11:00 and said be ready to travel in 1 hour!  I packed, ate a sandwich and John, Davis and I are off for Kakata.  George, Aaron, and Donna (one of the new nurses) are headed to Bong tomorrow.  Bong got hit hard with new cases this weekend and need additional providers because they have sent one of their Doctors and a RN down to Kakata to help open a new facility on Thursday.  My team of three is to provide the additional coverage.  They are also sending down four more national nurses and two national PAs.   Both units are run by International Medical Corps and seem well supplied and established.

So we will have four teams that will work 12 hr shifts i.e. M - day, T - night, Wed - off, Thr - day, Fri - night and Sat/Sun - off.  That works for the nurses but not sure about the MD' since there are only two of us.  The other MD is from UCLA and trained in ER but since residency has only done international disaster relief for IMC.  His first name is Parnad and is from India originally.  He help set up the Bong unit and is very experienced and busy finishing out this unit.

Most of the unit is done but there is still some work to do.  The Intake / Triage is finished, and the Suspect ward is done with new metal beds in but no mattresses and covers yet.  They are pouring the cement for the Suspect latrines and the patient shower is done.  The Confirmed ward is just about the same.  The Donning and Doffing is finished but the providers workstation has no floor or walls yet.  Anyway, we have people who know what they are doing. There are four ambulances that will be on call and will divert calls from Bong to us starting on Friday.  

For our accommodations, we are in what appears to be a Govt. building with very nice rooms, each with a bath and shower and window.  We are all three in one room tonight (it has a door) and when they get doors on three other rooms, we each will get a private room.  Good breeze but no AC.

Meals will be prepared in town and brought out for staff and patients.  Waiting to see what they bring.  So far so good!

November 18 , 2014

Slept well, mattress very lumpy so rolled in and out of holes.  Slept from 10:00 to 6:30 - we each have a fan and will take them to our individual rooms when they get doors. Waited for breakfast which got here at 8:30 and at 9:00 meeting of all the clinical staff - Liberian nurses, nurses aids, and two PAs.  First we had a tour of the ETU which is bustling with workers to get it finished - I think they will! Then we went over the scheduling, rounding, and general nursing obligations including drugs -- very basic list of 10 drugs - but a lot more than I expected.  Everyone gets treated for malaria and is put on antibiotics daily for five days and, in addition, multivitamins, zinc, Tylenol, and Potassium.  So this is much more advanced then the early days of ORS and live or die.  Then lunch took from 12:00 to 3:00 - our group of about 25 suddenly jumped to about 50 - where they came from we not sure.  Just many got in line, but it may be the only meal of the day.

The Medical Director, Pravnar, is going to be very busy sorting details so I have volunteered to cover the medical side by myself for the next few days.  I can gown and round around 10:00 am for an hour or so, hang out in the clinician tent until afternoon and then round again around 4:00 pm and come back and maybe round at 9:00 pm and be available all night.  We are about 2 miles out of town (the town people would not let them build any closer - same hysteria as home).  We have four ambulances to pick up suspected patients but they don't run after dark so there really will not be any nigh- time admissions - just problems.  I have nothing else to do and no place to go!

After lunch, Davis and I went to the medical supply room and sorted.  At about 8:00 last night, a big semi came and we all helped unload it.  Medical supplies, PPE's, patient towels, gowns, etc.  As you know I love sorting and stacking so I was in my element.  At 5:00, I was drenched in sweat but I felt good - then found out we had some Wifi.  Yea, until it disappeared, so I will work on getting Mon and Tue out.  Cold water only so a cold shower but it felt great.

It has been hot mid-day,  then clouded over and sprinkled at around 4-5 pm -- the last two days, temperature has been OK.  A cool breeze after the rain and with a fan  make it very comfortable.  Food has been local, rice with a hot sauce and pan-fried fish last night, scrambled egg in a soft roll for breakfast, and browned rice and chicken for lunch.  I am starting to take very small portions because I don't want to come home having gained weight.

Tomorrow we will do some actual gowning and case scenarios with the nationals. A large load of drugs came in from IDA so tomorrow afternoon may be drug sorting time.

Getting ready for patients on Friday.

November 19, 2014

Just got on wi-fi for first time in two days. Practiced triage and in PPE's this am and worked on finishing units this pm. Hot and exhausted but doing fine.

We open Friday.

I won't send much since wifi is very spotty but will do my dailies and hope they get out when I get reception.

Week #1

George left last Wednesday, the 5th, for a 42 day deployment to Tipeta, Nimba County, Liberia -- an eight hour bumpy ride northeast of Monrovia.  The team of  Americans convened at Dulles late afternoon on Wednesday after getting the call for deployment on Sunday, mid-afternoon, from Heart to Heart out of Lenexa, KS, a USAID grantee tasked with organizing teams into Liberia.  George's group is number one of 17 each to roll out at 4 week intervals over the next months.  There are many other agencies also deploying, including Partners in Health.  Interestingly, George has gotten his initial call-up from PIH since leaving for Liberia, saying they will be in touch soon.  The war on ebola seems to have come into full force this past week and while numbers of new cases are momentarily down in Liberia, Sierra Leone's numbers are increasing.

Here is his team at Dulles,  so you can put faces on these health providers.  Please do not post this photo as I haven't asked member's permission for broad dissemination, though I suspect it would be okay.  And, what follows is a log of emails from George this past week.  He very much wants to share his story in order to educate and humanize the work (that's pretty much like preaching to the choir among our dear friends, though the Red Cross nurse received over 200 hate mails in response to a television PSA about her deployment).  At any rate, read and know.  I shall post every Wednesday for the six weeks of his deployment.  

Thanks for so many positive letters, comments, prayers, and support to George -- and to me.  Betty







November 7

Well, it has been a whirlwind week!  Phone call Sunday, Monday and Tuesday doing paperwork for visas, contracts, etc. and then out early Wednesday.  First to Charlotte, then Dulles, and finally on to Dakar on an overnight flight.  We arrived at 6:00 am to an empty airport, hotel bus to the Radisson Blu and checked in.  It was surreal!  It was one of the swankest hotels I have ever stayed in.  Right on the beach, all in marble, a room overlooking a beachside pool and bar, and an endless breakfast table.  We were all disappointed as it was way too nice for the work we expect to do. Slept until mid afternoon, then read a little and early dinner in downtown Dakar.  Again, over the top.  A long wharf over the ocean with a cool breeze and a sunset on one side and a full moon coming up on the other. Great seafood grill and a cold beer.  Dakar is like most African big cities, packed high-rises, half finished high rises, tuck shops all along the road and people everywhere.  Back to hotel and listened to a small band playing at poolside bar outside my room.

Today up at 5:00 am and at 6:00 to airport for UN flight.  There at 6:30 for 9:00 am flight - nobody in sight and airplane locked tight.  Finally at about 8:00 people showed up to check us in and we left at 9:00 on time.  The plane seated about 50 and there were about 20 of us.  Stopped in Guinea, then Sierra Leon, and finally to Monrovia.  Through passport and an hour drive into Monrovia.  Looked very much like Malawi!  Then to guest house.  Wow, a very nice house that they rented for six months and have been frenetically readying.  Room ACs just installed, new water storage just put on line, new Wifi within the hour after we arrived, still unpacking beds, tables, chairs etc.  Great lunch of rice and fish, plantains, fresh fruits, and salad.  Excellent!  Then to grocery store which has more things in it than Harris-Teeter.  Talk first by Medical Director, Rene Vega, an FP who is Medical Director of a healthcare system in Dallas - committed for the full six months.  Very personable and will be easy to work with.  Then the CEO of Heart to Heart appeared, retired from pharmaceuticals and up working on housing for us in Tapita.  Also, very laid back and committed.  Finally time to unpack.

Off for the weekend (boring but schedule dictated by UN flight schedule on Fridays) and then two days of "cold" training and then three days of "hot" training.  After that we are not sure what next.  The construction of our unit in Tapita is being totally managed by the US military and we are the first of 17 units that they are building so we are the model unit.  But, they have just graded the field!  It will be much like a field hospital with various zones for workers, Suspected cases, and Documented cases.  Actually, a small compound totally enclose with wire fencing.  It sounds like we will be in the hospital grounds. The hospital was built by the Chinese in 2011 and apparently very nice but nobody manning it now.  Unfortunately, I'm not sure it will be ready in one week!  So I'm not sure what we will do if it is not finished.  They did talk of sending us to assist other units.  

The team is very compatible.  An Infectious Disease person from Einstein who has spent a lot of time in Ethiopia, a just-retired Critical Care doctor from KC, an EMT ex-military smoke jumper, a recent graduate of the military nursing program and ex medic, a male ER nurse, and three RNs.  The fourth MD is Dr. Vaga.  We are all chomping at the bit to do something but it sounds like there may be some down time!  O' well.

November 8

The CEO for HTH has been here for about three weeks working on the logistics and said today that the completion date for the ETC has been pushed back to the 23rd and he thinks maybe as late as 1 Dec.  He apologized for getting us here on such short notice but said that for HTH to get the honor of opening the first unit they needed to have troops on the ground.  We will continue to train this next week with "cold" training (classroom) for 2-3 days here and then we move to Bong for our "hot" training - a live unit.  THEN, we may continue to help at Bong, come back here and sit, or go on to Tapita and help set up the ETC.  There is a temporary unit, 15 beds, in Tapita attached to the hospital that we might take over.  But because the hospital is basically shut down, no one with Ebola comes there. So far 10 suspected cases and only 3 confirmed!  They do think that once the word is out that we are there the numbers will increase. And, with dry season now, the roads have become passible so people may try to escape Monrovia and will bring the virus with them.  We shall see!  

This new ETC unit is to be a model for the next 16 -17 built by the US and includes many new features that the existing MSF units do not have.  We don't know what that means.  It will be exciting to be the creators of this first unit - we have already started to explore scenarios - what if a term pregnant lady comes in (Rene or I will deliver), what if a three month pregnancy miscarries and continues to bleed - D & C (no) or what (drugs), HIV pts. on RVU's can have false negative tests, what to do?  (only 1.9% of Liberians have HIV - 70,000 and 40% are on ARVs) not likely to see, etc.  So the discussions have been helpful.  Just today new guidelines for PPEs (Personal Protection Equipment)  full face shield instead of goggles (it won't fog up so easily).  Will we get them with our new equipment?  So far we have stayed busy - but it could get slow.  Well, this will also definitely reduce our risk of exposure!  

Nothing planed for tomorrow and told not to go to town or church since we are viewed as someone who may have had contact with Ebola.  Hang out and read!

As usual, everything could change.  Will keep you up to date.

Photo of our guesthouse


t

November 9
Rene is the leader, a FP from Texas, active practice for about 15 years in California, then into AAFP residency, international medicine, alternative medicine, etc and past several years working for several managed care groups.  Very personable - easy going and knowledgable with lots of international work.  Good general medicine knowledge and skills with OB and minor surgery skills.  Here for six months or to end of crisis.

George, just retired as chair of Dept. of Medicine at UMKC with training in pulmonary and critical care.  Has been to Cameroon twice and has seen the same Africa that we know.  Wife is a Dermatologist and twin sons - one in fourth year of medical school at Univ of Kansas and the other is economic consulting.  Great to be with and we will make a good team.  No technical skills beyond general medicine but knows basic African medicine

Carol, specializes in Infectious Diseases  at Einstein with lots of experience in Ethiopia focusing on Women's Rights and children.  She heads up Einstein's Global Health Initiative, as well. Shehas a son in California trying to get into film.

Davis, ex Army airborne in 70' and 80', Special Forces reservist for several years, then a smoke jumper and EMT.  Is an artist on the side!  Also very easy going but no international experience.

Lucille, a Nurse with the Red Cross. From Rochester and got the hate mail when she did a PR airing for HTH.  They are very chagrined, not expecting that response.  She does not seem to have much international experience but willing to do her best.  

Marge, married 50 yrs.  She and her husband have spent time in Vietnam, Cambodia and Tibet working for Salvation Army.  Still active in nursing, very spry, religious, with a can-do mind set.

John, an ER nurse.  Very quiet and distant with a sort of military presence, though no military background. Probably very good at what he does but no international experience.  Married with two younger children - eight and I think a teenager.

Aaron, the youngest and his only overseas trip was to Israel and Jerusalem two years ago.  Active Army and then reserve where he was first a medic and, I'm not sure, if RN or Nursing assistant.  Very gung ho, always doing exercises, wears military like clothes but wan's to do good.  Really lacks experience and may be a bit green but will work very hard.

I think that is everyone except for staff - more on them later.

November 9. . . later in the day

Well, I guess you saw, we have a week of cold training, 3-5 days of hot training and it sounds like on up to Tapita to set up the ETU.  I sense it may be slow at first but our role is very important because we will start the routine which we will pass on to the next team.  They will do cold training here and come directly to Tapita for hot training and turn over.  Even if the unit is finished by the 23rd, as planned, we would still only get in three weeks.  And, it may not be ready until the first of December - I  believe that we all feel our role is important though.

November 10
I will write about my training later - by military.  The first presenter was an FP doc at Womack doing his residency there. He couldn't wait to come tell me during break how nice I was to his family once when his child was sick.  A really nice young man - you would be awed at how well they ran the training.

November 10. . . later in the day
We left the Guest house at 7:15 after learning that the generator had run out of diesel and therefore no Wifi or water pump for water to shower in.  Drove to the National Police Academy and it looked like a US Army encampment. Tents, water bladders, Humvees, and swarming with US soldiers.  We were ushered to a boma-like classroom with about 100 individuals.  Eight from our team, twenty US from Americare, six Germans, and the rest Liberian.  It was run totally military style - WHO guidelines, with handouts, booklets, slides, pre-test, evaluation, etc.  The initial speaker was the FP who did his residency at Womack when I was there - very nice guy.  Also there was an Infectious Disease / Tropical Disease specialist from the Uniformed Services Medical School who was a true expert. Very impressive!  And out of the hundred, there were our three doctors and one other!  They walked us through the donning and doffing of the PPE (Personal Protection Equipment).  Complicated, but by the numbers and always with an observer.  It sounds like about an hour to one and one-half hours is all one can stay in the Hot ward due to heat.  So in and out of the ward twice a day.  We will continue with the Cold Training for the rest of the week including putting on and taking off the PPE and working in a mock-up ETU.  Very useful training!

Back to the house - new water pump, fuel for the generator - no water in the tank (city water is now off).  So two days without a shower - we went to the hotel where the women are staying and used their showers.

Plans are still to go to Bong, now  for only four days of Hot training, then back here to pack up and move to Tapita.  If it opens as scheduled, our timing will be perfect, but that seems very optimistic.  They now have procured two homes on the hospital grounds for us with AC, electricity and water from the hospital, and are working on Wifi.  So far facilities have been excellent - they have taken very good care of us.

Monrovia looks like most big cities in poor countries of Africa.  Half the street lights are out, endless traffic of beat-up smoking cars, lots of tuck-shops, and then dark side streets with trash and potholes and swarming with people.  The locals are very friendly,  speaking English, so communication is not difficult.  Our cook is local and cooks with lots of local spices - tonight a meat and vegetarian pasts but very hot.  Salad of tomatoes, avocados, and lettuces and fruit for dessert.  

The group has stayed together fairly well.  George, Carol, and I tend to cluster because we are always talking "What Ifs", then the two women nurses, then the other three guys who are less medically inclined and seem to be a bit more loners.  George and I are on the same wavelength about everything so we get along great.  

Please share as you wish, all or parts of my e-mails.


November 11

Another day of exceptional training.  We learned how to put on our PPE - totally encased in plastic.  Hot, but not bad, and immediately fogged up my goggles.  Easy to put on since sterility is not an issue going in but very hard to remove.  Doffing is critical, you assume you are contaminated and have to remove step by step without touching yourself.  I will need, and get, much practice.  Also spent more time on 7-step hand washing in 0.05% chlorine solution.  I smell like a swimming pool.  Then we did some case studies of triage - who needs to be admitted and who is not a case.  All real scenarios and very difficult, still no agreement on some of them between us, but good discussion.  We also queried some of the WHO standards i.e. Why do suits have to be a terrorizing white, orange, or yellow like spacemen.  What about a more muted color for the units - maybe more acceptable to the patient and to be admitted?  What about drawing a unit of blood from each survivor and administering to the marginal patients?   Can we add electrolytes to IV solutions since fluid loss with severe dehydration and shock is the cause of death - not the virus itself?  Etc.

Just back and power off and so I had to start the generator and water pump.  It's good to have a little Malawi experience in such issues.  

November 12

Just got up and starting to move around.  Leave for the training in about an hour.  Slept well and will get breakfast at the training.  I just forwarded the first three e-mails to Mike [ a colleague that George has done work with in refugee camps and they are scheduled in Haiti together in February though Haiti may not be open to George's coming now]].   Isolation begins from the last day I see a pt. with Ebola so it may be over sooner than the 10th - won't know until the next team arrives and takes over.  Everyone on team has said they would stay an extra week if they needed us but so far it doesn't appear that they do.  There will be a new arriving team for cold training here and then they come up to Tapita for their hot training with us.  Patrick's [Craft, MD, one of George's first ECU residents who heads up medicine at Butner Federal Facility here in NC]  Public Health Service  doctors and workers on loan from Butner are our escape route if we become ill. There is a full PHS hospital at the airport along with the Army's and they are the  center for any US person infected - free, solo flight out of the country to hospital of your choice equipped to care for you - so worst case scenario - Duke.  We are going to that facility on Sat for a tour.  More later today.