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.