Amanda Judd tells about her mission with Refuge International

We arrived excited to get the San Raymundo temporary hospital up and running. We had lost time with flight delays and reroutes due to Hurricane Patricia, which was pounding Dallas with an unexpected wallop and caused baggage to be delayed and people to be stranded. Fortunately, thanks to the well-oiled machine that is Refuge International, we were up and running by Sunday afternoon. 

The San Raymundo facility is run by a local group of citizens who open up the compound about every 2 months to Refuge International's medical staff and alternately with a group of Italian medical staff who helps in the San Ray facility. While unpaid volunteers provide all of the care, the local group charges a very nominal fee to the patients to cover the costs of the building, maintenance, and upkeep. Having vested interest in the medical care for the community, the locals seem to respect and appreciate the volunteers from Refuge International. The community organization provides Refuge with a locked storage room to keep supplies safe when Refuge is out of the country. This was a good thing, too, since many of our supplies were delayed for 5 days with all of the reroutes. 

This is a view from the roof of the temporary hospital, overlooking the cafeteria, the adjacent school (in green), and some of the sleeping quarters.

Early morning OR setup.

This is me, ready to go on day 1.

As an ICU nurse, I was assigned to the PACU, and I was able to observe some of the earliest procedures prior to having patients. I was lucky enough to be on a mission with Dr. Cockburn, a urologist, and his lovely wife Judy. Judy was such a warm, inviting person. She managed intake flawlessly while Dr. Cockburn did consults and surgeries. 

One of the first patients to get a procedure was done by Dr. Cockburn and had a softball-sized fatty tumor removed from his buttock. Dr. Cockburn and the patient allowed us to watch the procedure. The patient was numb but awake. He remained very stoic throughout the procedure and was hesitant to admit that he could feel the removal, at times. It's interesting how different pain is perceived culturally. As Americans, we would probably yell out and make them stop the procedure until we were completely numb, this patient tolerated it until we asked him and was grateful once the procedure was done.

Dr. Cockburn operating.

We did many procedures throughout the week. Of course, the kids always capture your heart. The little boy seen below was named Franco. He awoke quite confused from anesthesia but was quickly captivated by one of the games on Eleanor's phone. He was excited to tell us a story about his "pets". He has 2 chickens and 3 fish. One day he decided to take one of his chickens to school for show-and-tell, but was bemused to find that the chicken had laid an egg at the school. In some ways, I think that it's the sharing of experiences that may have a more lasting impact than the medical procedures themselves.

Franco with Eleanor, the NP who worked as an RN in the PACU, and Ashley, the translator. 

A beautiful little girl who had a tumor behind her ear removed. She and her mother were an absolute joy to care for. She awoke from surgery happy, smiling, and full of giggles. 

San Raymundo at sunset.

Of course, there are stories that are gut-wrenching, and make you wonder if our best intentions are not always in the best interest of the people.

With the exception of my luggage showing up, this day was fairly routine in the way that medical clinics become very routine after a few days when everyone knows their places and jobs. I had retired early to enjoy a shower with my own bath products and had crawled into bed to read my newly arrived book when Nancy (the trip leader) came in and asked Dr. Janet Sweetman, ER doc, to please come to the PACU where a baby that had just been delivered today was retracting with an SpO2 of 50%. For those that don't know this is bad, very bad. 

Evidently, the baby was not trying to latch a number of hours after she was delivered by c-section. Eleanor, the NP working in the PACU, is a lactation specialist at home. Her gut told her something was wrong, so the baby was hooked up to a pulse oximeter. That was when the dangerously low O2 levels were discovered. 

This is when teamwork and ingenuity become really important in a resource-poor environment. 

We managed to get a modified O2 hood on the baby, but had to figure out how to transport the baby to the nearest hospital for more intensive care. Someone was able to get an ambulance, which was more of a regular vehicle than what we think of as an ambulance, to transport the baby The final piece of the puzzle was how to keep the baby warm on the 20 minute transport to the hospital. We all looked at each other and collectively said, "Skin to skin, " but who was going to do this? The mother was unable to travel with the baby because she was still recovering from her c-section. One of the midwifery students immediately volunteered and we quickly moved to the other room where I held up a sheet for her to tuck the baby into her shirt and they were off in the night to the hospital.

____

It is a very helpless feeling to do all that you can do and still know that it might not be enough. To know that the randomness of birth would likely give this baby every chance in the world at home but here life hangs by a thread. That Guatemala has the worst newborn mortality rate in the Western Hemisphere and how none of that matters when the mother is looking at all of us wondering if her baby will die and all there is to do is pray. And you pray regardless of what you believe because that's all that you can do. 

When a nurse volunteers to take the baby to the nearest hospital on her bare chest because that's the best chance to keep the newborn warm and alive until it arrives. And it is all that we can do to not break down and cry because of the life that hangs in the balance. 

We were all restless in bed while holding our breaths waiting for news of the baby. 

I always think of things that I have read when I have experiences like this.

"so much depends
upon
a red wheel
barrow

glazed with rain
water

beside the white
chickens."

-William Carlos Williams

____

In the morning, after transferring the baby to a local hospital, along with some of our L&D and neonatal nurses who stayed for a few hours, the baby did well and was nursing. 

____

This baby was the 7th daughter of a couple who had so desperately hoped for a son. The only son that they had was stillborn. You couldn't help but notice the tears and ambivalence of the father when he found out that it was a girl. The mother had opted to have a procedure so that she would no longer get pregnant, so this baby was their last chance for a boy.

A few days later, the father came back to the hospital desperate because the nearest hospital was a private hospital. The hospital was pressuring him for money that he didn't have before they would release the baby. The baby wouldn't have survived to make it to the government hospital over an hour away. We couldn't help out the father with money because that would set a bad precedent and be unethical. 

 

This brought up many ethical questions. Should we have even tried to help the baby, if the parents couldn't afford the care and we couldn't give them money to help? Had the baby taken an anoxic hit that would cause complications for life? The issues of ethics comes up in one way or another while doing medical work in underserved areas. It is a tough thing and lends itself to criticism and the concept have having an overall code of conduct on these trips.

Guatemala is such a beautiful country but it's tough here. Really tough. We have people coming from Altaverapaz- a few hundred miles away. The national cancer center is not functioning. Treatable cancers are now a death sentence in Guatemala. People in government hospitals are expected to pay for and bring their own suppose including sutures, etc. If you cant afford private care, you are up a creek without a paddle.

____

And then there is happiness:

One of the days midweek was a 14 hour day today with one amazing highlight. A woman walked in with imminent labor and delivered her baby within about 20 minutes. She rested in recovery for about 3 hours and she walked home with her husband, mother, and healthy baby. This was a picture of the beaming abuela with her new grandson.

Joy is contagious. She hugged and kissed all of us even though we had nothing to do with the delivery. This work is the antidote to compassion fatigue. 

I thought of a book that I read, "Maybe that was how to heal. I told myself stories and learned that I could be made of the ones I chose to tell, not simply the ones that life had laid haphazardly around me."-Francisco Goldman, The Long Night of White Chickens

Abuela with her newborn grandchild.

San Raymundo, Guatemala

San Raymundo, Guatemala

San Raymundo, Guatemala

San Raymundo, Guatemala

San Raymundo

San Raymundo

The improvisations:

One of the nurse anesthetists had to give a patient a nerve block. He rigged a machine that was like a train of four to a long needle to locate the nerve. He injected the patient and it worked beautifully.

We needed some y-tubing in the PACU because we had only one air compressor and 2 patients that needed O2. Some tubing, a syringe, and a few minutes later, we were in business.

The last day during the last surgical recovery, the power went out. Cell phones lit the OR. Iphones were finally used for a greater good.

We wrapped up after 4.5 days of clinical. Hopefully some lives were changed and maybe made better with this Refuge Mission. The team was a huge part of the success of the visit. It was a great experience and I hope to do it again.

Final tally:

And a great team:

Thanks to One Nurse at a Time for giving me the scholarship and the opportunity to participate in this great mission with a wonderful organization. I will definitely work with Refuge again and I would highly recommend them for future scholarships.

Happy Thanksgiving,

Amanda Judd

Jo's Nurses work in Chocola, Guatemala

2015 Jo's Nurses with Refuge International

Chocola is a remote village in the mountainous southwestern region of Guatemala where there is no government assistance in education, health or roads.  Sadly because of the country's political climate there is no help for the indigenous people.  They're abandoned.

Dr. Sergio Castillo and his wife Veronica first visited Chocola about 15 years ago.  They were shocked to encounter villages in deficient conditions with advanced illness including malnutrition, infection, and waterborne illness.  They found an abandoned building in the heart of the community and started a hospital catering to the indigenous Mayan people.  In 2005, after the devastation of Hurricane Stan, Dr. Castillo partnered with Refuge International to help expand the care to the region. "To have a complete team of surgeons, nurses, anesthesiologists armed with medicine was like the answer to our prayers.  For me, it's an honor to be able to help our people.  Refuge allows me to help others.  I'm like a bridge for the people with extreme needs and the services of Refuge." Says Dr. Castillo.

Dr. Castillo is a very positive, inspirational, humble man.  He remembered all of our names and always greeted us with a big smile, thanking us constantly for helping his people.  I will never forget our second night there.  It had been a busy day, the usual torrential thunderstorms where playing their symphony on the tin roof.  After a delicious dinner cooked by Veronica we made our rounds in the hospital.  To our surprise the Inn was full.  Dr. Casillo had invited all the families to spend the night because they live so far away and the thunderstorms were so bad.  We had families sleeping in preop, postop, and even in the courtyard.  It warmed my heart to see such a gracious, giving spirit in action.

I would have to say that our first case was one of the most memorable and inspirational to me. He was an 80+/- (they don't know their exact age) old hernia case.  Hernia's are very common because they work so hard and do a lot of heavy lifting.  While I was caring for him his son came back and told us through the interrupter that he walks 8 miles two times a day to carry wood back to the village for cooking and their campfires.  Wow, was he in good shape.  He always smiled, never complained, took no pain meds and was so grateful for all we did.  On so many levels I feel that the indigenous Mayan people of Chocola have a lot to teach me.  They are truly an inspiration.  They are intelligent,

hard working, disciplined, humble, respectful, compassionate, loving people with a strong sense of family and community.  I feel that as we work together we can learn and help each other.  We can help them with our medical/ surgical and technical expertise and they can help us take a step back and realize what is really important in life.

Thanks again One Nurse At A Time for the scholarship that made this amazing opportunity possible to serve the people of Chocola, Guatemala.  Thanks also to Refuge International for their wonderful work in helping to provide healthcare, adequate nutrition, clean water and education to those in need.  I hope that other nurses will hear the call and want to help with the wonderful work that Dr. Castillo and his family are carrying out in Chocola.  Thanks again 

Bonnie Madeja

Update on Emily Scott's experience in Sierra Leone

Filling In The Blanks

My colleague who was infected has tested negative for Ebola and been discharged from the National Institutes of Health. The 16 Americans being monitored as “high risk” contacts have all passed 21 healthy days. My cohort – the clinicians with whom I trained, traveled, and worked – are all home and well past their 3 weeks of monitoring. I am back at my day job. By all accounts, my experience as an Ebola responder has finally come to a full stop. But issues still linger, and details of what we went through are still coming to light. I know a lot of you have questions, because I’ve heard them from you, the most common one being: “All of a sudden you just stopped writing… What happened?”

Since many of the details have come out in the news, and because all of the clinicians involved are home and healthy, I think now is an appropriate time to fill in some of the details. I would never endanger the privacy of anyone I worked with, so some aspects of the story will be vague. Most of it you could piece together by picking through the news over the last several weeks, but I can share with you how it felt to be in the eye of the storm.

My last good day in Sierra Leone was a Tuesday, the day before I found out that our colleague had Ebola. It was my first day off since arriving in country, and I had plans to meet some friends from my cohort at the beach. After a few days of training and working at Maforki Ebola Treatment Unit, the twelve of us had been split up to work at different facilities based on where Partners In Health clinical leaders thought we would be most useful. Most of my cohort had remained in the Port Loko district to either continue working at Maforki or to help out at Port Loko Government Hospital, where patients with non-Ebola related health issues were treated.

While it may seem like Government Hospital would be an ideal place to work since you wouldn’t have to worry about Ebola, in reality many of us felt that working there seemed more dangerous than suiting up at Maforki each day. In an Ebola Treatment Unit, at least you know for sure that your patients have the deadly disease, and each time you interact with them, you take the proper precautions. Government Hospital was more of a gray area. It was expected that no patients with Ebola would enter the facility, so clinicians had no need to don their full Personal Protective Equipment (PPE) when entering the wards. Just like in the States, if you’re treating a patient for cancer or malaria, there’s no need to wear a hazmat suit to do it.

But what if a patient slipped through the imperfect triage system and was admitted to the hospital with Ebola, under the assumption that it was a different disease? Or, what if someone was admitted while incubating the virus but before becoming symptomatic? Ebola has a 21 day incubation period, meaning that if I am exposed to the virus, I could walk around for up to 21 days without showing symptoms and without being contagious. I often wondered how strictly the patients at Government Hospital were being re-screened after admission. If a patient was admitted with malaria and a few days later started showing symptoms of Ebola, would it be caught in time to protect the clinicians who had been treating him without full PPE?

I never worked at Government Hospital, so I really can’t say for sure. I have heard varying opinions from the doctors and nurses who served there: Some say they felt perfectly safe, and others say they had serious concerns from their first shift there. It was at Government Hospital that our colleague who turned out to have Ebola collapsed, and several other clinicians came to his aid, assuming he had fainted from heat exhaustion.

I never saw Government Hospital for myself because, as you know, I was sent back to Freetown to work at Princess Christian Maternity Hospital, the Ebola Holding center for pregnant women. I loved the work. The plight of pregnant women in Sierra Leone was like nothing I’d ever seen; I felt my skills were sorely needed, and I woke up excited to go to work each day. I noticed imperfections in infection prevention and control policies from day one, but I did my best to protect myself while I worked with my colleagues to address them. While I wished my concerns had been taken more seriously, my desire to continue my work completely outweighed the level of risk I felt I was taking.

So when my day off coincided with that of a good friend who worked hours away at Maforki, I jumped at the chance to meet him at the beach to decompress and share our experiences. It was a fantastic day of swimming in the surf, sunning ourselves on the beach, and unloading difficult stories of our work over a healing beer or two. It was jarring to turn back from the gorgeous turquoise waves and think that a short drive away, people were fighting a deadly disease in horrific conditions. But we put Ebola aside just for the day, and lingered as long as we could while the sun sunk lower and lower toward the water, until we knew it was time to head back to reality. I felt recharged and excited for the next day at work.

Among the stories my friend shared with me that day was the news that our colleague had collapsed while working at Government Hospital. To be honest, we thought nothing of it. Sierra Leone is very hot and clinicians are working very hard; it didn’t surprise me to hear that one of us had passed out from the effort. If you’re used to working in an air-conditioned hospital with plenty of staff, it would be a shock to the body to run from one emergency to another in a poorly-ventilated ward in 90-degree heat. I told my friend to give our colleague a hug and a stern talking to about taking better care of himself when he saw him next. Without going into the details of his situation, I simply did not feel we had any reason to worry about him.

I was still in my pajamas the next morning when a PIH staff member knocked on my door and asked me to get dressed and come downstairs for a meeting. Again, I thought nothing of it. It wasn’t until everyone was assembled and leadership started telling us that in four months of working in West Africa, PIH had never had a clinician become infected with Ebola yet, that I started to feel the weight of what was coming. It settled in heavy on my shoulders, and I knew what he was going to say before he said it. Our colleague had tested positive for Ebola.

It was a difficult moment to process because most of my friends were hours away in Port Loko. Almost everyone else in Freetown at that time was from a brand new cohort that had just arrived in country. I was one of only a few people there who even knew who the infected clinician was, and I certainly wasn’t going to share that information. I went back upstairs, put on my scrubs, and went to the unit to work. I donned my PPE and went into the Red Zone, trying to focus on the task at hand rather than the questions swirling through my head.

The next few days were a whirlwind. I don’t feel it would be helpful right now to share every detail of how things played out, or to pass public judgment on how PIH handled the situation, whether positive or negative. As you know from the news, one of PIH’s Sierra Leonean clinicians fell ill with Ebola shortly after our colleague was diagnosed, and in the end 16 American clinicians were sent home on chartered flights after the CDC deemed them “high risk” for having had physical contact with the infected clinicians after they became symptomatic. It was a frightening few days, and more than a few times I thought to myself, “Am I next?” I have complete certainty that our American colleague followed procedures exactly, just as I felt I had. Where was the breach that exposed him? Had he and the Sierra Leonean clinician made the same mistake without realizing it? Had I?

An investigation into infection prevention and control procedures at PIH facilities was of course initiated by PIH leadership. My colleagues and I stepped forward with issues and suggestions, while we waited to see what the next step would be. After a few days, myself and several members of my cohort reluctantly decided that it was no longer safe to continue our work there. Please don’t think for a moment that we took this decision lightly. I can say with certainty that absolutely no one I worked with wanted to leave. Least of all me. I felt that the work we were doing at PCMH was incredibly important, and I honestly wish I could still be there. In dark moments I think about the women I could have helped if I had stayed longer, and hope I didn’t abandon someone to die because I wanted to protect myself. Again, I won’t go into the specific details of what made me feel I needed to leave, but I was (and still am) confident in my decision, although it broke my heart to walk away.

I don’t doubt the good intentions of Partners In Health. They leaped into the fray in West Africa several months ago when the outbreak was at its peak, when they certainly didn’t have to. The first teams of PIH clinicians bravely provided care at Maforki when there were 100 patients in absolutely horrific conditions. Having been there when we had 10 patients, I am in awe of those first teams. But could things have been done better, made safer, the level of care improved more in the interim between those first days and now? I think so. The events of the last several weeks have shed some light on those issues, and on what changes need to be made.

Since I left Sierra Leone, I am hopeful that PIH has been addressing infection prevention and control issues and improving the safety of their clinicians while continuing their commitment to the people of Sierra Leone. By their own admission, emergency response isn’t PIH’s specialty; they are an organization that normally works on long-term development projects. As cases of Ebola drop to the single digits in Sierra Leone and to zero in Libera, PIH’s real expertise will come into focus: Health system strengthening. After the last case of Ebola is over and emergency response groups have left, Partners in Health will remain in Sierra Leone and Liberia for years. They will continue to work in government hospitals and rebuild health systems that were ineffective to begin with and completely destroyed by the outbreak.

Here’s a perfect example: In Sierra Leone, when a person is admitted to the hospital a family member normally stays with them. This family member does much of what is considered to be “nursing care” in America: feeding, bathing, turning the patient. Sierra Leonean nurses do not regularly assist patients with these activities because there is always a family member at the bedside to do it. After Ebola ran rampant through hospitals, spreading from patient to patient and killing healthcare workers, no one wanted to set foot in a hospital any longer. No one can sit by the bedside of a family member with Ebola and expect to escape infection themselves. Even when Ebola patients were isolated to separate Ebola Treatment Units, and regular hospitals began to resume care for other illnesses, the fear remained. It will be a challenge to convince Sierra Leoneans that it is safe to bring sick people to a hospital, and to visit and care for their loved ones there.

In the meantime, Sierra Leonean nurses will have to learn to care for patients in ways they never have before. I heard from many American clinicians who were shocked by what appeared to be the apathy of the nurses, who didn’t bathe or regularly turn ill patients, leaving them to develop bedsores. But these nurses have been risking their lives to provide care during an Ebola outbreak in exchange for a pittance from the government that may or may not arrive; they are worn out, and afraid for their own lives. It also helps me to remember that they have never witnessed care being given at the level that we provide it in the United States. They have nothing to compare to. What seems inhumane and unacceptable to us is the status quo for hospitals in Sierra Leone. Education can change this. PIH will tackle these issues, and more, for years to come.

Shortly after I left, I heard that another facility in which PIH works had received its first case of measles. It won’t be their last. With vaccination programs shut down for nearly a year during the Ebola crisis, West Africa is a measles outbreak waiting to happen. Care of pregnant women and newborns was abysmal before Ebola, and even worse now. Everyday illnesses like malaria, typhoid, cancer, heart disease… you name it, and I guarantee you wouldn’t want to be treated in Sierra Leone if you came down with it. PIH is staying in West Africa to try to change that.

For more on what occurred in Sierra Leone surrounding our colleague’s infection, check out these articles. I’ve included one by the New York Times and a couple of others from Partners In Health’s perspective. I find some truth in all of these articles. Very little in global health is ever completely black and white, including my experience in Sierra Leone. My hope is that everyone involved will learn from this situation and continue to improve our efforts as humanitarian responders. I know I have.

New York Times article: Pattern of Safety Lapses Where Group Worked to Battle Ebola Outbreak

Article by PIH clinician: All Lives Matter

Letter from PIH’s founder: Redoubling Our Efforts

Switching gears.

Hi All, we're back in Tegus to regroup for a day - head out on the road again  morning early.  This past couple weeks we've been wandering the north/Caribbean coast of Honduras, visiting hospitals and public health clinics, Garifuna communities, other NGOs and people living with HIV.  It's been fascinating, exhausting and informative.

Fascinating:  Beautiful white sand beaches where mostly Hondurans vacation and not Americans.  The cruise ships call this stop "Banana Coast" probably to not scare people who google "Honduras" and find out it's the most violent country in the world outside war zones.

Exhausting:  we drove TWELVE hours from Trujillo to Tegucigalpa.  TWELVE. I'm tempted to sit on a pencil to retain the crack between my buttocks!

Informative:  The northern communities have an incredibly positive view of MSF - starting 40 years ago with Hurricane Fifi, Hurricane Mitch, maternity programs, HIV programs before they were widely available, and the list goes on.  Rarely did we have to introduce ourselves.

The northern area is lush grazing land for cattle - mostly milk production as evidenced by horses carrying big metal containers on either side of the saddle, going to market?  The vast banana palm farms give way to the "African palms" - native forests (I can imagine what this used to look like when covered with native mahogany and other native trees) now cut down for huge scale production of palm oil ... It's not the "slash and burn" of small subsistence farmers as we were taught in school.  This is industrial scale destruction for economic gain of huge corporations.  Sad really.  We still see butterflies, and all sorts of different birds, so maybe not all is lost yet.

The roads are dotted with fruit stands - coconuts, watermelons, mango, all sorts of fruits - cheap and plentiful.  Fish is only a hook toss away.  Yet in this lush landscape, where food is abundant, people still complain of "lack of economic opportunities" as the reason for migrating to the US.  We don't hear "violence" as a reason in the north.  Yet, it costs about $6000 - 7000 to pay a coyote to take them all the way to their US destination, and that's after riding the train La Bestia all through Mexico.  Most have family members in the US who send for them, and few unaccompanied minors other than those who are going to reunite with their parents.

I don't understand this - everyone talks of how poor Honduras is as a country.  How so much is lacking.  Yet, I look around and see morbidly obese people everywhere (not just Americans!), new cars, tall buildings, food aplenty ... I can't say this country is as badly off as many I've been in.  Yet the statistics say otherwise.  There are lots of foreign companies working here, NGOs, foreign governments donating money for construction and programs ... So where is the disconnect?  Corruption?  Is it any worse than anywhere else in Central/South America or indeed, worldwide?

If I can figure it out, I'll let you know :)

We were able to have a little down time - the beaches along the coast are spectacular.  Chockablock full over Holy Week/Spring Break, but otherwise solitary.  Trucks are overloaded with sacks of plastic bottles to be recycled (into what?).  A first time greeting, even with a person you don't know is with a kiss on the cheek and handshake.  Radio music is 80s - Queen, Christopher Cross, Air Supply.  The alternative is the one and only CD in the car which is an oldie of Jose Miguel wailing love songs in Spanish that, after the 50th play, I DEMANDED be removed!  Then turned on my iPod and listened to the entire podcast of Serial.  Saved my sanity!

Hugs to all - I leave you with the beach at Trujillo ("Banana Coast") and a Garifuna woman making and selling pan de coco (bread made with coconut oil that is absolutely delicious).

Sue

Dora the Explorer Returns to Honduras!

Hi All, 
 
I'm in the midst of a 2 month mission with MSF/Doctors Without Borders to explore the health situation all over Honduras.  With my partner Edgardo (who I met in Uganda in 2006!) and a driver, we're visiting all of the hospitals in the country, some smaller health centers, community leaders, other "actors" in health ... And looking at what might be good interventions for MSF future projects.  
 
So far, it's been fascinating!
 
The country is lovely:  rolling hillsides of banana trees, sugar cane, corn, "African Palms," seaside communities.  Highrises and places where horses still do much of the work.  Claro phone satellite dishes on top of tin roofs and communal wood fires and cooking ovens.  Eating fresh fish and shrimp/conch every day along with fresh hot rolls sweetened with coconut oil.  Edgardo tucked into a bowl of stewed iguana (yes, I had a taste - not bad) and iguana eggs.  Birds of prey that look like small vultures scour the fields for dinner.  There are pine forests and cactus and pine forests.  Herds of cattle graze on the sides of roads and amble down the middle of traffic.
 
People have been very friendly everywhere and certainly stare at our Toyota Land Cruiser covered with the doll figures in the picture (MSF has long worked here with the street population, HIV, violence, etc).  
 
So far we've been mostly in the north/Caribbean coast and the past few days have been meeting with Garifuna leaders.  Garifuna are ethnically different than native Indian/Spanish mixed folks - they were originally black African slaves taken to the island of St Vincent, escaped and settled all along the Carib coast of Central America.  They retain their own language, customs, music (Punta) and traditions. Our interest is to see if they have unique health needs - as a people, they are reputed to be more sexually active, have higher STI and HIV rates and have more young pregnancies (as young as 12 and 13).  From their perspective, they are simply more open about speaking of sexuality.  However, government statistics show double the rates of STI/HIV as the regular population and a UNICEF study showed average age for boys and girls becoming sexually active is NINE.
 
It's also been interesting to see the conditions of and in the hospitals.  The two main tertiary care hospitals are huge, sprawling, disorganized, smelly, and would be a nightmare to try to become involved in.  Both hospitals' ERs are chaotic, patients lying on gurneys lining the hallways unattended with blood hanging, open wounds, smell of infection, no cardiac monitors or IV pumps, crowded, no triage, armed men everywhere ... A real mess.  
 
Yet, here in Tela, their 10 yr old hospital is clean, neat, good equipment in working order, new mattresses, paint ... The only thing I can attribute the difference to is leadership.  Management that cares, is engaged and involved, with vision and pride in quality of services and facilities.  
 
So far the ideas we have are three:
 
1.  Provide HPV vaccine to children age 10/11.  There was one pilot program of about 30,000 doses done a couple years ago, but the government doesn't have the funding to continue.  We feel this would have a HUGE impact on the health of the next generation and an organization like MSF could pull it off ...
 
2.  A smaller community hospital Puerto Cortes has new leadership and desire to fix up their neglected facility.  With a staff who is eager for improvement, and without a lot of bureaucratic hang ups, we could rehab their ER, provide equipment and training plus get involved in their newly created Adolescent program so we could touch on all aspects of Sexual and Reproductive Health.
 
3.  Provide an interim physical space for a large hospital Pediatric ER - they are in the process of rebuilding but have no plans for what to do with the patients while the construction is being done (they say 6 months, but realistically 2 years!).  We could provide modular spaces or inflatables, take over the care and improve systems, training, etc.  and have a hand in the construction of the remodel.  Then once they are ready to move back into the renovated space, they would have had a couple years "doing it right" and would keep those new ideas and systems as MSF withdraws.
 
These are just ideas we're throwing out as we move along our journey.  It will be up to the coordination team and Geneva to make decisions about next steps.
 
Now it's Holy Week and the country is on vacation.  We're taking advantage of being on the coast to enjoy a few days of rest.  We'll do the same in our next weeks - work 5 or 6 days and have a day off in a lovely spot:  Copan, where there are Mayan ruins on the border with Guatemala and the islands to the south off the Pacific Coast bordering El Salvador.  What a wonderful adventure this is!
 
I'll be home soon,  ready to have a lovely summer in Seattle.  Hope all's well in your world.  

Much love,
Sue

Save the Date: Saturday May 30!

Posted on March 26, 2015 by Emily Scott

Transitioning to home life has been a bit strange. In my heart, I wasn’t ready to leave Sierra Leone. I wish I could still be there doing good work, falling exhausted into bed each night and looking forward to helping my patients again the next day. It’s an abrupt change: I went from feeling like there weren’t enough hours in the day to help everyone I wanted to help, to suddenly being back at home on my couch, not allowed to touch a patient for 21 days. The best thing for me right now would be to dive into another mission, but nobody wants me traveling to the developing world while I’m self-monitoring for Ebola. Fortunately, I have One Nurse At A Time to keep me busy!

One Nurse At A Time is an awesome nonprofit that helps nurses volunteer their skills at home and abroad. I am lucky enough to be Vice President of One Nurse, and it is constantly inspiring to work with others who share my passion. I have loved watching first-mission nurses light up the way I did the first time I set foot in Kenya almost a decade ago. Because I feel so strongly about the importance of One Nurse At A Time’s work, I have helped organize our first fundraising event for this May. For those of you who have been enjoying my blog and want to support this kind of work for nurses everywhere, this is a way to do it! Myself and at least two other Ebola responders will be there to share our experiences in West Africa. There will be appetizers and drinks, a performance by a Guinean dance and drum group, a silent auction with some awesome items and experiences, and a chance to try on our Ebola suits if you want to!

All of your kind words meant so much to me while I was on this mission, and I would love the chance to see all your faces and thank you in person. You can buy tickets here and please feel free to invite your friends! Here’s the official invitation:

You are invited to One Nurse At A Time’s celebration

Come hear about Sue Averill and Emily Scott’s recent experiences working at Ebola clinics in West Africa

When: Saturday, May 30th at 7 p.m.
Where: Nalanda West, 3902 Woodland Park Ave. N, Seattle, WA 98103

• Appetizers and drinks will be served
• The Message from Guinea drum group will perform
• There will be a silent auction of art, experiences and get-aways

An amazing party supporting a great cause!

Tickets are $30 each.
Sign up here.
Map of event location

Home and Healthy

Posted on March 23, 2015 by Emily Scott

As some of you already know, I arrived home in Seattle a few days ago. It is a bit earlier than I was planning on leaving Sierra Leone, which is deeply disappointing to me. Since one of our PIH colleagues tested positive for Ebola, I’ve been pretty absent on this blog; while I have been writing a lot for myself as a way to process everything, the only experiences I can share with accuracy and fairness are my own.

I have never for a moment been cavalier about the work we were doing in Sierra Leone, but the true cost was suddenly brought into sharp, painful focus when our colleague’s test came back positive. Since no PIH clinician had contracted Ebola yet, it was easy to put the possibility in a back corner of my brain where it wouldn’t be examined too closely or often. Now, it takes up far more real estate in my head than it should. From venting with my colleagues, I know that most of them feel the same way. For the first several days after our colleague fell ill, we were intensely aware of every sensation our bodies experienced – a mild, passing headache; an achy neck after a bumpy car ride; feeling tired in the middle of the day. I’m not a religious person, but I did something close to prayer when I went to the bathroom each morning that what came out wouldn’t be diarrhea (sorry for the over-share!). If I thought too hard about it I’d get a moment of chest-tightening panic: Was this the first sign that I was getting sick too?

My beloved oral thermometer kept my worries in check. I bought it at the drugstore before I left the states, choosing a bright orange one because it was a cheery color. I don’t think anyone has ever gotten so much use out of a thermometer in such a short period of time. Whenever my mind starts to spin, I pop it under my tongue, close one eye, and focus on the digital readout right in front of my nose. I watch the number tick up, slowing down as it reaches my body temperature. I can tell by how fast the numbers change that it’s going to be normal. Three little beeps tell me I’m officially afebrile, and I can take a deep breath again.

Which is why I felt confident facing CDC questioning at immigration in Chicago – I had just checked my own temperature minutes before. I’d sucked down an impressive amount of water and done my best to sleep on the long flight. The last thing I wanted to tell the CDC interviewer was, “You know, now that you mention it, I do have a bit of a headache, feel pretty exhausted, and I’ve got all these aches in my joints…”

As it happened, my colleagues and I had more fun at immigration than we probably should have. Knowing we were nearing the end of a long journey and, for the first time in a while, had access to world-class healthcare should we need it probably made us all a little giddy. I scanned my passport at one of the kiosks and, along with the rest of my colleagues, was rewarded with a slip of paper with a big black X across it since I was coming from West Africa. The immigration officers checked our passports and handed us surgical masks to wear. We gathered in a small group of masked travelers watched over by an official, giggling about how alarming we probably looked to everyone else. We were led to a few rows of chairs and asked to wait, as a CDC official behind a blue curtain called each of us in turn to be questioned about our exposure to Ebola. Friendly airport employees brought us juice boxes and granola bars, and thanked us for our work. Each time one of my friends was called to be interviewed, we could still see their silhouettes and hear them through the thin blue curtain; it looked comically like confession from our side, as though we would be asked to recount our sins of the past few weeks.

We had worried that coming back to the US so soon after an American clinician had contracted Ebola would be unusually difficult (see Kaci Hickox’s experience for reference). In reality the process was completely rational and simple. A CDC employee asked me a series of questions to determine my risk category, went over the process I’d adhere to for the next three weeks, and issued me my Ebola responder goody bag: a chart to record my temperatures and symptoms, a contact list, a card to carry in my wallet, and an illustrated list of Ebola symptoms (as though I might forget!). I even got a cell phone loaded with minutes and the CDC’s number so that Public Health can get in touch with me any time and vice versa. I’ll call it my burner phone and pretend I’m in the CIA.

Before I knew it, I was done. With no time to say a real goodbye to my friends as they were still being interviewed and I had to catch my connecting flight, I joined the everyday crowd of people navigating their way through the airport, none of them the wiser that I’d just returned from fighting Ebola in West Africa. Not that I’m any risk to them at all, of course. But I felt so defined by the experience I had just stepped out of, that it seemed to me that strangers would be able to take one look at me and somehow see it.

The reality is that I’m at no more risk than I was before all this happened. I was not exposed to our colleague after he was ill, and I am confident that I personally followed safety protocols as strictly as possible. There is no reason for me to be quarantined and no law requiring me to do so, as I explained before I left. Public Health started counting my 21 days when I arrived in the US, but on my own calendar I’ve marked my last shift in the Red Zone, and the last time I treated a confirmed Ebola patient, which was a few days before that. I’ll feel safe personally when I get three weeks out from those markers, although obviously I will continue to take my temperature and comply with Public Health for as long as I’m required to. I’ll do my best in the meantime to get back to normal life, although for me “normal” will be a tough bar to reach until everyone I served with is home and healthy.

Update

Posted on March 16, 2015 by Emily Scott

I apologize for my silence over the last several days. I’m sure most of you have seen in the news that a PIH clinician was infected with Ebola. I have been reeling from the news since it was announced, and struggling with how to continue writing this blog as my colleague fights the virus. I have no information to share that you won’t read in the news, so all I can honestly tell you is how I’m doing.

To assuage any worries about my well being: I am feeling completely healthy and my risk category has not changed. I am not the clinician who is infected, nor am I among the other Americans who were flown home due to possible exposure. I will try to write more soon, but for now please send all of your positive thoughts to my colleagues. Thank you all so much for your concern and support!

Aminata and Baby Boy

by Emily Scott

Written Friday March 6

On the day Abass died, I was on my way back to Freetown where I have been assigned to work at the holding center for pregnant women for the rest of my time here. Let me explain what that means:

With limited resources, it isn’t feasible to have Ebola Treatment Units in every town in Sierra Leone. Ebola Holding Units are used to isolate and treat suspected patients until their Ebola status can be confirmed. EHUs are peppered around the country, and patients with a wide variety of maladies show up there to be triaged to see if they fit the case definition for Ebola. If they do not, they will either be sent home or referred to a government hospital for further care. If they do show symptoms that make clinicians suspect they have Ebola, they are admitted to the holding unit and cared for until their Ebola blood test (called a PCR) comes back. Depending on the center, a PCR result can take anywhere from several hours to several days. The patients whose results come back positive are then transferred to a full Ebola Treatment Unit for care.

The holding unit where I now work is specifically for pregnant women, and it is the only one in the country. Even before Ebola, the state of obstetric care in Sierra Leone was abysmal. In 2010, one in every eighty-three women died in childbirth (that’s forty times higher than in the US). Since the outbreak, pregnant women have been completely abandoned.

The problem is that labor and common complications of pregnancy can look frighteningly like Ebola. If a pregnant woman showed up to triage in America complaining of abdominal pain, weakness, and nausea, we would assume she was in labor. But here, among healthcare workers who have watched their colleagues die, everyone sees Ebola. They also know that the mortality rate among pregnant woman with Ebola is nearly 100%, and with limited resources, a case can be made that time and medicine would be better spent on someone who has a chance of surviving. Add to that the fact that the viral load in the fetus, placenta, and amniotic fluid is very high (and even a normal labor is a very messy processs involving a LOT of bodily fluids), and suddenly a woman in labor looks like a bomb about to go off.

As a result, many pregnant woman have been isolated and essentially left to die since the outbreak began. Princess Christian Maternity Hospital (PCMH) is the only hospital for pregnant women in the entire country, and descriptions of it during the height of the outbreak are horrifying. A New Yorker article from last October makes it sound like hell on earth: “Inside the ward, a woman writhed and groaned on the floor in a pool of bleach and bloody diarrhea, a full body bag lying next to her. Staff entered and exited without properly donning protective gear. There was a shortage of numerous supplies, and used equipment was being discarded in a hole dug outside. A woman wandered between rooms, holding her dead infant.”

Since then, the situation at PCMH has improved, although it is still by no means ideal. On the compound that PCMH shares with the children’s hospital, PIH staff now help run a holding unit to care for pregnant women who would otherwise be turned away. The main hospital now cares only for pregnant women who are clearly Ebola negative; the others come to us.

Our unit is housed in what used to be the radiology building. Like Maforki ETU, the nurses station and donning and doffing areas have been added on to the original structure with tarps and wood. We have enough beds for nine women in three rooms, plus two little rooms with a bed in each designated for deliveries. There are six international PIH staff, and plenty of national nurses. Our family practice doctor leaves tomorrow, so for now we nurses will run the show.

In our small unit next door to the full hospital, we do the best we can to keep these women alive until they can receive proper care. Because we can’t be sure which patients are having common labor complications and which have Ebola, we do all of our care (and if necessary, deliveries) in full PPE. Although some of our patients do turn up positive (one this week and two the week before), we see many more complicated labors than we do Ebola. Unfortunately, the only way to distinguish between the two is to do a PCR blood test. A lab run by the Dutch has recently arrived on-site that can process our samples in several hours, but before that it could take days. On my third day at the holding unit, the Dutch lab’s generator was broken so no tests were being processed.

Unfortunately, the time it takes to get Ebola test results is the difference between life and death for many moms and their babies. If a woman shows up at triage hemorrhaging, for example, in America she would have an emergency cesarean section to save the lives of her and her baby. Here, bleeding is a sign of Ebola, so she must first come to our holding unit. No one will perform a c-section on a woman suspected of having Ebola. It would be too risky for the staff, and if she did have Ebola she would likely bleed to death during the surgery anyway. But for those woman who arrive likely bleeding because of a placenta previa or a uterine rupture, we hope we can keep them stable long enough to prove they are Ebola negative and get them to the operating room.

To make the situation worse, prenatal care has halted along with the rest of the country’s health systems since the outbreak began. Aminata* is a perfect example of this. She was the first patient I cared for at PCMH holding unit, and when I first saw her she was lying on the ground next to her bed, barely conscious. She had arrived at the hospital eclamptic – a condition of pregnancy in which high blood pressure causes seizures (for reference, I usually tell people that eclampsia is what Sybil died of in Downton Abbey, which, it’s worth noting, was 100 years ago). I have never seen an eclamptic patient in America. Because our moms get consistent prenatal care, the warning signs are identified early and I often see pregnant woman with PRE-eclampsia (essentially, we have caught them before the condition is serious enough to cause a seizure). In Sierra Leone, no one is caught at the pre-eclampsia stage.

Aminata had come to traige unconscious, and because she was living in a home that was quarantined due to contact with an Ebola case, no one at the main hospital would touch her. She was admitted to our holding center, and the national nurses reported that they had delivered her baby vaginally overnight, while she was still unconscious. Her first PCR had come back negative, but because she had come from a quarantined home, protocol required that she have another test three days later before the main hospital would take her or her baby.

When I found Aminata lying on the floor, her little baby boy was wrapped in a lapa on her mattress a few feet away from her. She was not aware enough to know that he’d been born. My colleague and I lifted her onto the mattress and began to clean her up when I saw her eyes roll back into her head and her eyelids begin to flutter. I knew what was happening only from books, and it took me a moment to process that I was seeing my first eclamptic seizure. A second later her arms began to twitch, and her whole body followed. I turned her onto her side while my colleague shouted out to the Green Zone for medications. A minute passed, maybe two. Aminata continued to seize while we waited for medications to be drawn up and handed in to us. I felt like I was in a nightmare.

Aminata’s seizure spontaneously resolved just before her medications arrived. Among other things, we treated her with intramuscular injections of magnesium sulfate, though in the US she would have been on an IV drip under constant supervision. In an Ebola holding unit, where the heat often drives us out of our suits and away from our patients in under an hour, there is no way to continuously monitor an extremely ill woman. There are also no IV pumps to make sure the exact dose is administered, and no lab testing to check the level of magnesium in her blood.

Despite all this, Aminata has come around. One of the PIH-ers who has been working at PCMH for weeks told me that they often see good outcomes in eclamptic mothers, despite their shockingly late arrival for treatment. When I visited Aminata yesterday she was lethargic but completely conscious, a huge improvement from the day before. I unwrapped her baby and put him on her bare chest, and she stared down at him in wonder.

Unfortunately these two are not out of the woods yet. The little boy is small (to the naked eye, anyway; we don’t have an infant scale) and not interested in breastfeeding. We have been feeding him formula while we encourage Aminata to keep trying, but it’s not a viable long-term solution for a woman who can’t afford the formula, let alone clean water to mix it with. But soon their fate will be out of our hands. Aminata’s second Ebola test came back negative, so we cannot keep her in our unit any longer. The day before, the woman in the bed next to her turned out to be Ebola positive. Every minute Aminata spends in our holding unit puts her and her baby at risk for catching Ebola from someone else. Aminata is no longer ill enough to be admitted to the main maternity hospital, so she’ll go home with her family tonight. In America, I would refer her to a lactation specialist to make sure her baby eats and gains enough weight. Here, there’s no such thing.

The sad truth about this job is that I can take on my own small role, and nothing more. I wish I had the time and resources to follow up on Aminata, but in reality I barely have a moment to chart on the care I gave her, before some other issue falls at my feet. Yesterday one of the lab personnel saw a pregnant woman wandering around alone in the hospital compound, vomiting. Without touching her, she guided her to our holding unit, where the 17-year-old told our nurses that her mother, father, sister, and brother had died of Ebola. She said she had come to the hospital when she started to have vomiting and diarrhea, and had been turned away at triage. For the past three days, she had been sleeping in the hospital compound, being sick in the lab stairwell.

After a fair amount of horror at the idea that an Ebola-positive young woman had been wandering around the compound spreading infectious fluids everywhere, we got to the bottom of her story. Her family had actually passed away three months ago, longer than the incubation period, so she hadn’t really had Ebola contact. If she was going to catch Ebola from her relatives, she would have gotten sick in the first 21 days. The nurses at triage confirmed that they had seen her and turned her away since she didn’t meet case definition: Her vital signs were fine, no fever, just a pregnant woman with morning sickness. She’d told them that the person she was staying with since her family died had kicked her out of the house, and she had essentially turned up at the hospital out of desperation.

We all breathed a little easier knowing that, based on her history, it was unlikely that she had Ebola. Her blood test came back later that day and confirmed that she was negative. Like Aminata, this young woman now poses a problem that we aren’t equipped to solve. She insists that she has no place to go and no one to turn to now that we must discharge her. With no social worker and no idea what options we have, we PIH-ers turned to the national staff to help us come up with a solution for her. The last I heard before I head to leave for the day was that the staff was collecting some money for her. She’ll get her discharge package from us (clothes, medicines, and a certificate saying she tested negative for Ebola) and presumably they’ll send her on her way.

As the Ebola outbreak gets under control and the Sierra Leonean government attempts to return to normal healthcare, the issue of pregnant women will continue to be a problem. No one quite knows what to do with them. Over dinner tonight we got a call asking us to admit a woman in labor coming from a quarantined home. My colleague asked the usual questions, trying to get a sense of how likely it was that the woman had Ebola. As she untangled the story, it turned out that this woman was not in fact in labor – just very pregnant, and looking like she was about to pop. She had no symptoms of Ebola, no fever, no indication that she was sick at all. But she was hours away in Port Loko district in a quarantined home, looking like she might go into labor at any moment and making everyone very nervous. Couldn’t we just hold on to her until she went into labor?

The trouble with pregnant women in the setting of Ebola is that they’re all in a gray area. If this woman had not been pregnant, she would have remained quarantined in her home and only been brought to a holding center if she began to show symptoms. According to case defintion, she has no business being in a treatment center. But when she goes into labor, who will care for her? With no maternity care available in Port Loko, can we reasonably ask an untrained traditional birth attendant to do this delivery without PPE under the assumption that the mother is Ebola negative? If we tell her to come to our unit when she goes into labor, will she get here in time?

No matter what decision we make, it won’t affect just this one woman. We’re told there are actually ten women in quarantined homes in Port Loko in various stages of pregnancy. We can’t take them all at our holding unit. They would more than fill all of our beds, and we would have no space to care for the women from Freetown who continue to show up needing care. Much as we’d like to, we can’t take on all the pregnant women in Sierra Leone in day. We are at ground zero for rebuilding maternal care in this country, doing the best we can one day and one patient at at time.

*Names changed to protect privacy