Liberia Week #7

Liberia Week #7

December 17, 2014

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

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

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

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

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

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

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

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

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

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

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

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

December 20, 2014

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

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

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

December 21, 2014

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

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

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

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

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

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

December 22, 2014

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

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

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