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!