Be the change you want to see in the world. ~ Ghandi

Wednesday, January 28, 2015


I wanted to share this picture and story with you for a happy moment.  This man came to us along with his newlywed wife.  His mother had died of Ebola and he fell ill along with his brother, sister and wife.  Unfortunately, his wife was severely ill and died in a couple days despite our and his best efforts.  He and his sibling survived.
Today he was discharged CURED.  He was elated and spent half an hour with us saying thanks, wanting pictures taken (I asked him if I could share his picture with friends and he said yes).  He told us what he remembered during his illness:  how hard it was to drink because he was so nauseated, but he knew ORS was lifesaving so he continued to drink.  How afraid he was in the night that he wouldn't live until morning.  How good he felt every time we went in and told him he was doing well and treated him kindly.  He especially remembered me (I'm sure because the blue eyes are all that show behind the PPE) and that we'd saved his life.
A very happy day.  Unfortunately, some of them are so happy and dancing on their way out, only to find their homes empty, interior sprayed with chlorine and door locked, all possessions burned.  No clothes, no mattress (foam pad), no money to buy new things.  Some of the community councils are doing this which is probably going overboard, but in an effort to stop the spread.
Everything they bring with them into the ETC is burned.  Cell phones (we can wash the SIM card in chlorine), belts, shoes, clothes - everything.  Logistics buys clothes at the market and shoes so we try to outfit them in a dignified way for going home after a shower at the exit.
Today we have two little ones in Suspected that I admitted yesterday who are not doing well.  One seizing all night despite a whole lot of valium IV.  Both initially tested negative for Ebola, but symptoms began only 2 days prior, so they have to stay a couple additional days to retest.  Probably malaria causing high fevers, but we're struggling to keep them alive long enough to get that second test - then we can transfer to the pediatric hospital, but not until we confirm it's not Ebola.
A 17 yr old girl in ICU isn't doing well and a pikin of 8.  Two others are OK and we moved one darling boy to Oral Confirmed.  Poor dear was playing all by himself because the other children were too sick.  He is now our resident doctor (he's 5) - started hanging his toys on the IV hook and pretending he was giving himself a drip.  So cute.  Should have gotten a picture of that.
Celebrate the good and move past the sad.
Love to all,

Monday, January 26, 2015

More daily life in Sierra Leone...and Momo goes home!!

Hi All, 

Next pic is of me in Triage today. 

 We stand behind 2 meter barrier fences to interview patients, then come within arm's reach to take the temperature - hence the face shield (and gloves).  It's been decided that we nurses can do the triage, screen patients in or out, write admitting orders, etc.  I normally work ICU, but today and tomorrow am in Triage to cover the nurse who's working overnight shift.  I admitted one man who looked sick and indeed is positive with a high viral load, and a pikin who was limp and had a "convulsion" last night and hadn't woken up.  He might be malaria instead cuz no contact exposure.

We ended the day with 18 total patients - I think it's probably a record low.  YAY!!!  The president of SL said schools will open in late March.  Everyone is counting the outbreak over, but it's not yet.  It's not gone.  Cases are not rising nor falling, more holding steady.  I heard Liberia is doing much much better.  YAY. Today there were lots of celebrations as 3 were discharged cured.  And 5 were "no case" - in the Suspected area and blood test negative.  We all breathe a sigh of relief when a test is negative.

Yesterday I had to pronounce a 7 yr old boy dead.  It was especially sad because I'd been with him a couple hours before dripping ORS into his mouth with a syringe.  Poor little guy.

I have to tell you - I absolutely LOVE my Nokia Lumina phone.  Got it just before coming here to be able to stay in touch.  Well, the camera is amazing and I take pics all over the place, and especially for work.  Yesterday, the ICU nurses made the mistake of putting a patient chart inside the bag of medications and sent it "in.". Well, what goes "in" can't come "out" And they were averting their eyes, heads hung, hoping to not get in trouble.  I had one stand inside and hold it up page by page as I took pictures of it, then sat down with the phone and recreated it.  They saw the amount of work it took and came slinking over to apologize.  I'm guessing that's never going to happen again :)

And a prize to whoever can explain the choice of brand names for the latrine covers.

Worked on Arts and Crafts between patients in Triage today - trying to create a new system for stocking/inventory control for the items we need at a moment's notice inside ICU.  So I cut up empty gloves and masks boxes and taped them together to create my masterpiece.  Tomorrow will talk with The Powers and see if we can trial it.  Also working on a training for nurses of how to mix IV meds, hang them, count drip rates, etc.  Amazing that they don't uniformly know this stuff, but ... One of my daily lectures is about 3 way stopcocks..

The last picture is to make you smile.  This little girl was sent home yesterday cured.  All possessions taken inside are burned (including cell phones, clothing - anything that can't be sterilized with 0.5% bleach), so they shower and we give them clothes and shoes to go home.  She and her mother were admitted when I first arrived.  Mother died within days, but the pikin survived.  She will now be cared for by an uncle and his family ...

Wish I could have been there to cheer when Momo went home, but it was on my day off.

Thanks to all of you for writing and sending your encouragement and positive thoughts our way.  Day by day, we do the best we can.

Much love, 

Saturday, January 24, 2015

Another day in Sierra Leone - and some good news too

Hi All!
Plan for the day:  
1.  Sleep in.
2.  Go to "Super Market" - can't wait to experience a Sierra Leonean super market!
3.  Have lunch with an old Ethiopian pal from my mission there in ... 2008?  He was a lab tech and went to med school and is now in Freetown working in a pediatric hospital.
4.  Skype with Pete in the evening (morning in Seattle).
5.  Go to bed early and start 6 in a row before another overnight on Super Bowl Saturday (Go Hawks!)
Two pieces of GREAT NEWS!!!  Our 5 month pregnant patient was successfully induced and survived!!!  HURRAY!  She is the 19th documented pregnant Ebola survivor for MSF since the outbreak began nearly a year ago.  She is glowing, happy, laughing and thankful.  
Second thing - Momo tested Ebola NEGATIVE yesterday - WAAAAAHOOOOO!!!!!!!  He's still a bit foggy and rummy - I think still a bit fluid overloaded and perhaps a bit tox from liver and kidney failure.  His hands and feet are still swollen, so I can imagine his brain is as well.  But he's asking to move to the other tent (they all know going to the other tent is a step in direction of survival and going home) and is eating, drinking, walking without staggering, making sense, following directions and even initiating conversations.  Thanks to everyone who has sent such strong positive vibes his direction and prayers - it's all worked and he's improving right before our eyes.  From being chased back into his room with a stick to survivor.  Wow.
A couple pics to share with you - one of a survivor hired as a caretaker to watch/feed/clean the pikins (small kids).
  And one of a ladder - there is lots of construction going on.  Amazing these men can do hard physical labor in this heat.

We are now up to about 60 survivors since this ETC began Dec 10.  About 300 total patients, about 30 still in now.  The 300 includes patients that are brought into "suspect" but get ruled out with lab tests.  Probably half are discharged as not Ebola.  Some are malaria, some are just symptoms we don't diagnose a cause.  We are not a hospital nor do we diagnose or treat anything other than Ebola.  No meds, no time, no space.  We try to get the "negatives" out of the facility as quickly as possible so as to not expose them to the virus in any way.  There is always a risk.
Still teaching at every opportunity and enjoying seeing the nurses get a bit more empowered every day.  After all, we will leave and they will stay.  One gift is to leave behind as much knowledge as possible.  
Hope all's well at home.  Keep sending your happy thoughts to these people.  Keep spreading the word - Ebola is not over.  We have hope.  We're all working hard to overcome.
Love to all,

Tuesday, January 20, 2015

Go Hawks!

The good news:  I got to sleep in til 9 today! 
The bad news:  I have to work a 12 hour overnight shift for the first time in 32 years.

It's now been a week working at the MSF Switzerland Ebola Treatment Center (ETC) and I'm feeling pretty comfortable.  Whereas in the training in Geneva I felt like a zombie-like Frankenstein monster moving in the PPE suit, I'm relatively comfortable in it now.  "Comfort" is a relative term, of course.  I'm getting used to drops of sweat running down my back, legs, neck, face (especially upper lip into my mouth!).  I can even safely dance a little jig in it. :)

Your Krio lesson of the day (with a nod to Heather) :

"De pikin (pronounced pee - keen and accent on the 'keen') de suck bobie?"
Translation:  "Is the baby breastfeeding?"

Our numbers are down.  When I arrived a week ago, we had 20 patients in ICU and about 50 patients in total.  As of yesterday we had 19.  Many deaths, of course, some survivors (I think we're up to around 45 - 50 now since Dec 10).  It's too early to know why the decrease - are there really fewer cases?  Is it because there are more beds available in more centers?  Are people just not reporting because their house will be quarantined by the military for 21 days and no one allowed to leave?  Or is the virus just taking a breath before coming roaring back like it did last summer?  The only time to let down our guard is once 21 days have passed with no cases.  Until then ...

There are survival stories, of course.  Right now we have 17 year old "Momo" who is wild as can be.  One of the features of Ebola is incredible mental confusion.  Despite Valium and Haldol, Momo almost made it out of not only ICU, but out of the Triage area into the "clean" space.  Since we can only touch him in full PPE (and if he rips your PPE, you're at huge risk), so the staff were sheparding him with a long stick.  And a couple days ago, he staggered nearly into the decontamination shower!

One survivor (they have immunity for an uncertain length of time) working for us inside caring for patients was just as wild as Momo and has taken him on for special attention.  He recognizes he was just as confused and even threatening the staff that he would slap them if they tried to start an IV or give him meds.  He's strong enough to manage Momo and get him back into a chair or onto the mattress on the floor.

The confused patients are the hardest to manage.  You work so hard to get an IV into them for massive hydration (5-6 liters of IV fluid per day plus ORS and water) and literally as soon as you turn around, they have pulled it out and water and blood are pouring everywhere.  We can only be inside for one hour and no one is inside all the time, so it can be quite discouraging.

I'm really enjoying the national staff. Some say they are lazy, but I prefer to give them the benefit of the doubt.  I think it must be difficult to deal with all the different approaches by all the expats, not to mention the accents - German, French, Aussie, American, Mexican ... Not easy for them.  Plus, even though nursing school is 3 years, they are not taught critical thinking skills.  Nurses do what they are told to do. 

Every opportunity I get, I start teaching.  Basics, why certain activities (like giving ORS) are so important, how the virus is cured, what the lab values mean, how the body functions, even how to use a 3 way stopcock on an IV.  It's really fun to see the light bulb come on and questions asked.  Once I go over something, I ask them to share with their colleagues.  And they do.  But I keep repeating over and over.  The nurses and aids rotate areas and shifts (ugh) so there are always new combinations to work with.

A couple nights ago the expat nurses met and divided duties.  I am now in charge of ICU.  It's not an ICU in the sense of what we have at home.  There are no machines, no invasive care.  Just patients that need a close eye, can't walk, can't drink by themselves, usually on IVs, children (the under 5 yr olds are especially vulnerable) and older (over 40ish is also higher risk of death).  I like staying busy and having to problem solve and work to instill the notion of critical thinking for the staff.  Yesterday one of the nurses came up to say they are concerned because Momo and one other young man have generalized edema and the nurses are concerned about too much IV fluid.  That's the first time they have come forward like this, and I'm delighted.  I know we'll have steps back, but celebrate the steps forward as well.

Yesterday I came to work pumped up over the Seahawks win.  I couldn't watch the game but Pete and Angela were on Skype voice with me for the first half (I'm 8 hours later here) giving me the play by play.  I told the gathered group of nurses, nursing aids, pharmacy staff, etc. all about American football, the Seahawks and got them all chanting GO HAWKS!  with a fist pump.  I addition to my masking tape nametag I wear each day, I put one "Go HAWKS" and all day, I kept getting shouts across the compound of "Go Hawks" - so cute and another way to bond and have fun.

The second picture above is my daily notetaking sheets.  Crumpled from sweat.  By 7:30 am the backs of my hands are forming droplets.  Inside the first layer of gloves in the PPE, I take them off and they are filled with several mls of sweat in each finger.  Amazing.  I drink about 2-3 gallons of water a day and try to eat some salt at each meal.  The feet are feeling a little better plus I rub a couple times a day when I put on dry socks.  The legs and knees are still throbbing constantly so also try to massage them.  Just hope they will eventually adjust to walking in the gumboots over the rough rocks.

Third pic above is in the "Suspect" area.  Patients who present to Triage with symptoms + or - fever are admitted here. The Ebola blood test is taken (above).  Lab draws it, dressed in full PPE.  Imagine.  You must write patient information on the blood tube first, then take the sample, spray the outside of the tube, spray the inside of a zip lock bag, drop in the tube, spray the outside of the bag, spray the inside of another zip lock bag, drop in the tube/first bag, then spray the outside of that second zip lock.  All this goes into a solid blue container with chlorine solution inside and is hand carried about 2 blocks to the lab at the entrance to our ETC (by the way, if you read about the Freetown response, we are the Prince of Wales School ETC).  Imagine doing all of that in the heat and humidity of this place. 

Thanks to all of you who have written and who continue to follow our progress.  Don't believe the media accounts of "it's getting better".  It's not better until Ebola is GONE and no new cases for 21 days.  Only then can we stop these massive efforts.  The world turned away with disinterest last summer and it came roaring back.  Keep reading, keep interested, keep donating and keep sending positive thoughts and prayers to these people and those of us here to help.  We all need your support.

Much love to all,

Reflections on a first medical mission

-Approximately how many patients were served by your team?
-580 patients were seen in the clinic over the course of 5 days.

-What I enjoyed the most:
         -How a team of professionals could come together to serve so many people in such a short amount of time – very fulfilling.
-How humbling the experience was, giving me a new level of appreciation for the simple and important things in my life
-Learning of the vast cultural differences, but also seeing how we aren’t so different in many ways.
         -Brushing up on my Spanish!
-The feeling of fulfillment I had knowing we helped so many people, while also learning and growing so much myself.

-What I enjoyed the least:
         -It was hard to see the extent to which some patients’ conditions had progressed without getting adequate treatment.  It was also difficult to try to manage patients the best we could within cost- and resource-constraints, while thinking of all the labs, tests, meds, follow-up, and therapies that we might treat the same patient with in the U.S.

-What cultural differences I observed:
         -The medical culture is generally quite paternalistic.  Patients are told very little about their diagnoses and treatments are often inappropriate or poorly explained to the patients and families.
-Women’s roles within society and family are more rigid, and this can impact their health: for example, they have quite a different culture surrounding birth, including who should be present/assisting and how they assist.  They also most commonly work in the home.
-Some of the folk remedies were interesting, for example, one patient mentioned that one relieving factor for his musculoskeletal pain was putting lemon juice on his head.

-One to three examples of “memorable moments”:
1.  My most memorable group of patients were 4 generations of women/girls of the same family.  One day I saw a young mother and her 3-year-old daughter.  The mother had been having occasional seizures for several years, and had never been told what was going on!  The next day I saw the “next two generations up.” I noticed a familial pattern of migraines and neuro issues.  The family sticks in my memory because they were so endearing, and also because even though I couldn’t do as much as I wanted for their more complex issues, they were incredibly grateful (as were all the patients I saw!) for the migraine meds and other therapies that I provided.

2. Watching the sunrise from the roof of the clinic before having breakfast and starting our day, hearing
the roosters crowing (and a turkey joining in, too!), and taking that moment to reflect.  It was a quiet, peaceful moment I had just to myself, before the busy-ness of the day set in.  From up there, you can also see all the patients lined up waiting to be seen that day and it really gives you quite a sense of purpose.

-What impact the medical mission will have on your nursing career:
         -This was my first medical mission, and I have a feeling it won’t be my last!  Here at home, I’ve already benefitted from a renewed perspective and passion for nursing.  Next to that “warm fuzzy feeling” you get from helping those with limited access to care, the biggest takeaway, as an NP student, was the confidence I gained in seeing large volumes of patients with limited resources.  In the Guatemala clinic, I couldn’t always make referrals I might have here, or rely on X-rays and other diagnostic tests to help me make certain decisions; instead, it was back to the basics with my history taking and physical assessment skills.  Furthermore, we had a limited formulary to work with, so it meant working with what we had and being flexible.  It’s amazing how much more confidence I have as a practitioner after working with such clinical challenges.

--Nora Maynard

Saturday, January 17, 2015

It's not about the numbers

Once again, it was a very rewarding trip to the tiny town of San Raymundo, Guatemala.  Having been there last year, I pretty much new what to expect; long days, tired feet, less then ideal working conditions, and the opportunity to make a difference in the lives of some Guatemalans.  Our group of 43 nurses, NP’s, Dr’s, and helpers was less then what we had last year but we all expected to work just as hard.  As you can see in the first picture, “it wasn’t about the numbers” but they showed just how much we accomplished in such a short time. 43 surgeries were performed (orthopedic, GU, GI, and GYN), 580 patients were seen in the clinic, 1,444 medications were given out, 227 labs were performed, and 11 minor surgeries (mostly debreeding wounds) were performed. 

I worked in both the pre-op and the post-op areas on this trip.  Pre-op consisted of getting a brief medical history from the patient, getting an IV started, and answering any questions I could about the procedure.  I was also able to help intubate a couple of patients prior to their procedure.  Post-op consisted of making sure surgical sites were
clean and dry, the patient was kept comfortable and free of pain, and that they understood how to take care of themselves when they went home.  This of course was an excellent opportunity to teach good nutrition and the importance of cleanliness.  The biggest obstacle to overcome was the language barrier.  Although I speak a little spanish and some of the citizens understood a little english, the translators that accompanied us on the trip were invaluable.  Because of them, I knew my patients would be able to take care of their wounds and understood our discussions.  

Most memorable moments for me were helping a 77 year old hip surgery patient walk,  intubating a patient before surgery, and meeting some wonderful people from all over the country who, like me, believe in helping out their fellow man.

This mission has made me appreciate the benefits we have living in the USA.  From our hospitals to the latest technology and equipment, we have the best at out fingertips.  Working in a third-world country and seeing what they have is an eye opener.  That being said, I hope to continue to be a part of the Refuge International Team and travel with them each year to help the people of Guatemala. 

Susan Callen

Friday, January 16, 2015

Keep Calm and FIGHT Ebola!

Thought you all would enjoy this pic after I came "out." Card from a cured patient - I want to make it into a t-shirt!!! Scrubs are saturated with sweat although I have yet to experience literally pouring half a bootful of sweat like one of the doctors.

Today our numbers dropped. No new admissions, a few discharges CURED! Happy dance. And several deaths. Our rate since opening Dec 10 is about 1:1, cured to died. Really quite remarkable but still so much more to be done.

I'm enjoying getting closer to the national staff, teaching at every opportunity, learning the ins and outs of the ETC, adjusting to the heat, drinking at least 2 gallons of water a day if not 3 ... and now in the nice hotel where my old body can sleep on a good mattress, cool down in AC, have a real shower at the end of a long day and sleep til the last minute. So far I'm scheduled for 8+ shifts in a row of 13 hours ... And then a night shift :( 

Hardest thing to manage right now is my feet. Wow. Those damned rubber boots are necessarily loose so no support, worn the full 13 hours (except to change to go for lunch) and my feet and knees and legs ache til the next morning despite tylenol and ibuprofen. Another expat said it took her a month to stop hurting.

Team is generally really nice with a couple marginal personalities thrown in :) People always coming and going. Swiss, Mexican, German, Swedish, French, Italian and a couple Americans.

Today I went "in" in the morning, but must have washed my face a little too vigorously cut I had a teensy nick on my chin, so couldn't go in again. It will be healed
 tomorrow, and we usually go "in" three times for an hour each. I'm getting more comfortable in PPE, sweat trickling down even in places you never sweat. It's a bit of a struggle to get undies and scrubs back up after squatting over a pit latrine when they are soaking!

Happy to be here. Doing my best. Yesterday I was accused of being an optimist by a sourpuss and with a laugh said YES! 

Sending love to all and virtual hugs. Time for a long shower and bed.


Wednesday, January 14, 2015

Ebola Treatment Center, Day One

After a few days of training with MSF in Geneva and a grueling journey to Sierra Leone, I entered the Ebola Treatment Center in Freetown where I will be working for the first time on Monday. Here are my observations and impressions from day one, before all of these little details become part of the norm and don’t seem so important:
At the entrance to the Ebola Treatment Center (ETC) compound, we get out of the car, wash our hands with 0.05% chlorine water, spray the bottoms of our shoes, and have our temperature taken. All visitors, staff – EVERYONE – goes through these steps before entering the center from the outside.
Once allowed inside, we proceeded to the entrance to the low risk zone – again, washing our hands and spraying our shoe bottoms. Then on to the dressing rooms, one side for men and one for women (we have been warned to only wear discreet underwear into the ETC, as you often sweat so much inside the suits that when you remove them, your sticky scrubs come right off along with them – so no thongs for us!). In the dressing room you find a pair of scrubs, which are being washed constantly all day long and hung out to dry, and hopefully a pair of heavy plastic gumboots that fit. These are also washed and dried throughout the day, but after lunch there were no more boots to be had…
From there we headed over to the medical “office” tent – one area for administrative work, one where there are white boards detailing patients and needs, etc. A second space is set up for work – mixing IVs, nursing roster, etc. The third space is for the pharmacy folks who pack the med bags. The ground inside the ETC is covered with heavy, broken sharp grey rock. As you’re walking in your gumboots, it’s a bit uncomfortable and sloppy, but I’m sure I’ll get used to that quickly.
Since we were on orientation, we spent the day doing various things. I spent the morning in triage, which I really liked. However, it’s not triage OUR way; we don’t respond quickly to the sickest patients. Here, we respond first to the NOT sick, and get them out of the center with a certificate that says they do not have Ebola. Hospitals and clinics won’t allow them in for care without this. Plus, people are worried about little things and want to be sure they don’t have Ebola.
This is how it works: People come in (after washing their hands, spraying their feet, and having their temperature checked at the entrance) and sit in a holding area consisting of plastic chairs 2 meters apart, the safe distance. We healthcare workers stand under a shade, behind an orange double fence blocking off 2 meters’ distance from them. No confidentiality at all. We get their demographics, register symptoms, and begin to make a determination about whether or not to admit. Today many had vague symptoms, but were relatives of confirmed Ebola patients – a husband, sister, and baby. I guess that’s not unusual. We also know the “hot spots” where many cases are coming from, to raise the suspicion level in certain cases.
Today we admitted about half a dozen people. As we’re doing their paperwork, we give them a bag of water and a sachet of Plumpy Nut (a peanut-based paste for treatment of malnutrition) and ask them to eat and drink. A psychologist comes and asks the patient about who they can call to advise, what they need done, finding a caretaker for their children, etc. There is also a Health Promoter who talks to them about what’s happening.
Oddly, enough, the new patients are stoic. No comments, no questions. They just sit there across a far divide from us. I would be screaming and crying and begging if it were me being told I was to be admitted to an ETC!  The patients are then moved to another holding area and a nurse in full Personal Protective Equipment (PPE) comes to get them, take them to a bed, and get them settled.
The ambulances also come in the triage area, and we have a whole procedure there are well. First, they back halfway into the orange double fence area, then wait for the hygiene team to come spray the vehicle, remove the patient/stretcher, spray again, spray inside, then bring the patient to triage, where we do our work from across a 2-meter table-like barrier. The only time we get any closer is with goggles or a face shield, when leaning close enough to take a temperature with the little electronic gun from 6 inches away.

Things are separated here into areas for suspected and confirmed Ebola patients. In the ward for suspected patients, they are given a bed in a private “room” consisting of a concrete floor, walls of vinyl tarps, roof, sun shade, buckets for Oral Rehydration Solution (ORS), vomit, washing, and stool. The suspected area is separated from the confirmed, and they try to put the “not highly suspected” as far away from the sick ones as possible. You don’t want someone who just has malaria to be exposed to Ebola in the ETC.
The confirmed section has bucket showers for patients, and male and female latrines. This confirmed area also has a separate section for those with the highest nursing/medical needs. It is known as “ICU” even though it really only means IVs versus simply oral medications. Today I got to don full PPE and go into “ICU”. I think I’ll be doing that a bit more often because I can start IVs.
There is also a third area for recovering patients. These people are feeling better – they can walk, feed, and care for themselves - and are awaiting tests. Patients must test negative twice in 72 hours in order to be discharged home “cured”. Caregivers for children are recruited from the survivors because they have immunity for an unknown period of time.
We caregivers have one donning room with very helpful people getting us dressed, and two different doffing stations where they tell us step by step what to do as we remove our PPE. We can be inside for only one hour at a time. Today I was only in for 30 minutes, just being shown around, without doing any care on day one. I felt OK, not terribly hot or bothered, but the nurse orienting me was soaked when we came out. One of the docs was in for 90 minutes, and literally poured sweat out of his boot! One style of PPE is lighter than the other, so everyone wants the one with the blue stripe.
There are bags of water at various points, and squat latrines for staff. The spaces everywhere are really vast – lots of room so as not to touch anyone. Things move slowly. Since there is no such thing as an emergency, no resuscitation, etc, we take our time to work out the best plan of action for everything.
Teams go in every hour or so: IV/ICU team, oral med team, admission and discharge team. Nurses (most not very skilled) and our expat doctors go in together. Outside is a group of nurse assistants. Hygiene goes in with the medicals. After the medicals leave, the nurse assistants have their rotation to feed, give ORS, bathe, etc.
One cool thing is that the ICU has a corridor down the middle, with two 1/2 –meter tall plexiglas walls and the patient beds all around, so we can literally walk down the middle, not in PPE, and see and talk with our patients. This minimizes the time we spend in PPE. It’s the same in the other wards, though not plexiglas. Instead they have a double fence 2 meters wide so we can talk to the patients across it without having to be in PPE. There are also slanted “one way” tables so we can pass them meds, food, whatever. We slide it down to them across the 2 meters, or push it with a stick if necessary. It’s the same at the entrance to the ICU: two slide tables so that from the outside you can slide in another IV bag, tape, or whatever they might need that they didn’t take in. Pretty smart system!
In addition to all this, there are more tents for logistics, resting area for staff, and an additional one that just opened today because the number of patients was higher before discharges.
Blood is drawn by the lab team three times a day and there’s an actual lab (not run by MSF, but some other entity). They process the samples in about four hours, so we can clear those who are not sick quickly and send them out with their certificate and a big “congratulations”. They also routinely screen for malaria. Most are positive and so get treated. Admission orders include systematic malaria meds, antibiotics, Plumpy Nut, and Tylenol if fever. IVs are mixed by the nursing staff. It made me a little anxious because I’m not sure they are very diligent about what they are doing. D50 is added to LR, plus potassium if the patient has a lot of diarrhea. IV paracetamol is given if they can’t take pills.
I sat awhile with the Sierra Leonean nursing assistant staff outside of ICU. If find that if you do this in the beginning, they get to know you and word spreads quickly that you’re a good person. One of them said, “Americans are so simple.” I asked her what she meant, and she explained, “You are always nice, always soft in your way, not hard like the Swiss and Europeans.” They had lots of questions and are supposed to be teaching me Krio, the local language. Here are some basics we’ll use a lot:
You belly de run?  or You de gombelly? = do you have diarrhea
You hed de acts?  = You have a headache?
You de feel pen (tapping shoulders)?  You have joint pain?
You de feel weak?
You de eat?  = Do you have an appetite?
You de cough?
I need to practice for tomorrow because I’m sure they will ask and give me more homework.
Oh, and I actually got to be an ER nurse! Two young men brought a boy who had pulled down a container of lye onto his head and face. No one knew what to do. He was not sick, just injured. So I tossed them some bags of water (all of our water for washing has chlorine), and had them rinse him down about 10 liters. Then I got him a blanket so he wouldn’t be wet and naked to take to another facility (we are ONLY an Ebola treatment center and can’t do anything more). I felt pretty good about it, but think he will have some serious eye damage…
Overall, I’m feeling pretty positive about this mission. I think this is going to be good!

No hugs to all.  No touching.  But much love,