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.