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

Abass’s Smile

 by Emily Scott

I arrived for my evening shift at Maforki on Monday anxious to hear how my patients had fared since I’d last seen them 24 hours before. I expected (and part of me hoped) to hear that Foday had passed away and was no longer suffering. No one I worked with could remember seeing a patient recover after progressing to the bleeding stage, so it had begun to feel like we were simply torturing him. I dreaded the thought that Abass might have died.

I immediately scoured the whiteboard with patients’ names and breathed a deep sigh of relief to see that Abass was still on it. When day shift reported that he had seemed a little better to them, I told myself it was because he was on the upswing; that the worst hadn’t killed him, so he would survive.

Monday night taught me that you can’t make predictions about Ebola. Another patient in Abass’s room, a 36-year-old woman named Mariatu, had been looking comparatively well when I met her on Saturday. She was sitting up in bed, eating and drinking and completely lucid, unlike her roommates Foday and Abass. Although she had diarrhea and vomiting the last time I’d seen her on Sunday, she still seemed to be in better shape than the others. When we reached her bedside during our first round in the Red Zone, she was moaning with pain and laboring heavily to breathe. Since we hadn’t anticipated Mariatu being in so much discomfort, we hadn’t brought any pain medicine into the Red Zone for her. We had used our last dose on a patient in the previous ward. She would have to wait until our next round in a couple of hours before we could get her some. Promising her that we would be back to take care of her, we left Mariatu in bed moaning in pain.

When we returned for our second round at 9:45 pm, it felt eerie in the dim fluorescent light of the Red Zone. We found Mariatu lying on the ground just outside the door of her ward. I suddenly remembered another nurse checking under the beds while he was giving us a tour of the Red Zone, and telling me about this “weird Ebola thing” – that patients often crawl out of bed near the end and die on the floor.

But Mariatu was still alive, breathing hard and looking at us with wide, terrified eyes. I helped my coworkers sit her up against the wall, then stepped into the ward to check on Foday and Abass. When I turned back to the door a minute or two later to ask if they needed help getting Mariatu back into bed, they told me she was already dead.

I couldn’t believe I’d heard right. I started to take a moment to process it, then looked around at the rest of my team who were moving forward with the job at hand. With only 90 minutes in the Red Zone, we don’t have any time to waste. Mariatu’s body was left where we found her and covered with a lapa. Ebola is extremely contagious in the bodies of the deceased, and it wasn’t our job to care for her any longer. The corpse team would be called after we left the Red Zone, and they would come the next day to move her to the morgue so the specially-trained burial teams could come to pick up her body. Nowadays every death in Sierra Leone (whether Ebola-related or not) is handled by the burial teams in full PPE, just to be safe.

With nothing left that I could do for Mariatu, I walked back to check on 10-year-old Abass. He and his 25-year-old neighbor Foday were now both lying on mattresses on the floor; they’d been moved out of bed when they were agitated and the clinicians worried they might fall. Abass had pulled his IV out since we’d last seen him, and another team member felt he would die overnight if we didn’t get another one in him. In the poor light, no one felt excited about attempting it: An accidental needle stick injury to one of us is statistically a death sentence. One of the national nurses stepped up without missing a beat, and had a beautiful IV in Abass’s arm before the rest of us could even tell her to be careful. We hooked him up to a bag of IV fluid and were feeling pretty good.

Then the lights went out.

I won’t pretend it isn’t scary to be the the Red Zone of an ETU at night with no lights. You become extremely aware of all the infectious material around you that you suddenly can’t see. I hate to be dramatic, but it does feel a little like a horror movie. Unfortunately power outages aren’t an unusual occurence, so our more experienced coworkers had warned us beforehand that if we found ourselves in total darkness in the Red Zone, we would have to stop whatever we were doing and leave. I knew we had to go for our own safety, but I wanted to scream out of frustration, since we’d just arrived and had barely started caring for our patients. I was fortunately still holding the battery-powered LED light I’d shined on Abass to help the national nurse get more direct light to start his IV. We all agreed we could take a moment to unhook his IV fluids, otherwise he would tear his IV out again as soon as we walked away.

As soon as we had unhooked Abass’s line and resolved ourselves to leave, the ceiling lights sputtered and flickered back to life. The Red Zone is not a comfortable place to be, but I silently cheered that we wouldn’t have to leave. We restarted Abass’s fluids and decided to try to feed him since he was awake and calm. Fortunately some formula had been left in the Red Zone, so I drew up a few mililiters in a small syringe, squatted on the floor next to his mattress, and held it to his lips. I knew he had painful mouth sores and I worried that he’d refuse it, but he silently swallowed the tiny amount that I squirted into his mouth. I flicked away an ant that skittered across his mattress. Another nurse sat above him, stroking his head. We both encouraged him to eat and cheered him on every time he swallowed a few drops. His eyes met mine while I told him how well he was doing, and I felt sure he was lucid. I tried a silly little dance and suddenly he was smiling. His grin was weak but wide, and his eyes were bright, and all of a sudden I could clearly see the little boy he was before he was sick. I laughed and smiled back at him as hard as I’ve ever smiled, certain that he would see it in my eyes if I could just smile hard enough, even though my mask and hood covered every other part of my face. He babbled at me in a language I couldn’t understand, then called out “Auntie, auntie!”

I don’t know how long my friend and I sat there, entreating him to swallow drops of formula, rubbing his head and his bare chest, dancing and singing in our suits, hoping to elicit another smile. We were rewarded with a few more beautiful grins before Abass shut his mouth and refused to eat any more.

Our time was up anyway. I knelt beside him and told him he was strong. I promised we would be back for him soon. Maybe he didn’t understand, but I think some things don’t need to be translated. I reluctantly stood up and walked away, leaving him alone with his neighbor Foday struggling to breath, and the body of Mariatu just outside the door. As we were leaving the ETU later that night, one of the other nurses told me she thought he had a shot.

Abass died the next day.

I don’t know if he was afraid, or in pain, or even if anyone was there with him. I hope someone was. I hope I made his last night a little less frightening. I think I brought him joy and I have to believe that matters.

I wish I could find the right thing to say to make his death meaningful, but I don’t think there’s any meaning in a 10-year-old dying alone on the floor. I could rant about how he might have been saved if he’d had access to the best medical care in the world, but I’d rather just let him be a sweet little boy than an example of all the injustice in the world. Even though it was only for a fraction of the time I spent with him, I’ll always think of him as Abass with the big contagious grin and the bright eyes, not as one of thousands of children who have died of Ebola. I didn’t know him very well, but now you all know a little piece of him too, and I think that counts for something.

Foday and Abass

Posted on March 2, 2015 by Emily Scott

Written Sunday 3/1

The only word I have been able to find to describe this experience so far is surreal. Today it became real for me.

Today was our first day actually treating patients in Maforki, PIH’s Ebola Treatment Unit. Yesterday we set foot there for the first time, donned and doffed our suits twice to get a tour of the Red Zone, but didn’t do much actual patient care since we were still getting oriented. Today we were buddied up with a more experienced clinician and assigned specific patients to care for during our shift. Today Ebola ceased to be a faceless mass of African suffering, and became two individual human beings.

I’ll give you all the lay of the land at Maforki before we get much further. Maforki ETU belongs to the Sierra Leonean government, unlike many Ebola centers that were constructed from the ground up by the nonprofits that came to run them. When PIH arrived in Port Loko at the peak of the outbreak last October, they were the only international health workers in the entire district, which had 150 confirmed Ebola cases and zero adequate facilities in which to treat them. The Maforki ETU had been converted from a school and was overflowing with patients literally dying for care. When PIH staff came to tour it to learn about how to construct an ETU, the Sierra Leonean health minister stopped them in their tracks. He was tired of international groups coming to tour government ETUs, telling them what was wrong, and then leaving to build their own instead of fixing the existing centers from the inside. He insisted that his people could not wait 8 weeks for care while PIH constructed their own center. He wanted them to start working in Maforki the next day. PIH could see that he was right, and they have been doing the best they can with what they have at Maforki ever since.

Maforki is a built out around what used to be a school. The patient wards are the old classrooms, large concrete buildings painted red on the outside, with several beds in each. When it was turned into an ETU, additional basic structures were added at the periphery: a triage area, nurses’ station, meeting room, areas for donning and doffing PPE. Nailed together out of mismatched wood and blue tarps, the whole thing looks a bit ramshackle, but the center is known in the area for giving excellent care. Port Loko residents who fear they have Ebola ask to be brought to Maforki because they have heard they’ll be treated well.

To enter, you must dip the bottoms of your shoes in a bucket of chlorine, wash your hands in chlorine, and have your temperature taken at the gate. The whole center is divided into two main areas: the Green Zone and the Red Zone. The clinicians’ areas are in the Green Zone, so we can have meetings, draw up medications, eat meals, etc in an area that is not contaminated with the virus. The patient wards are in the Red Zone. No one steps one foot into the Red Zone for any reason unless they are in full PPE, and nothing you take into the Red Zone is allowed to come out.

At the beginning of each shift, the staff gathers in front of the large white board that shows the names and medical information of each of our patients. Today there were ten (five confirmed Ebola, and five suspect). We discuss how each one fared overnight, and divide them up between the nurses. My group of nurses was assigned to the confirmed Ebola patients, so we huddled at the nurses’ station to make a plan.

Because we are limited to 90 minutes in our PPE, we need to decide everything we’re going to do before we enter the Red Zone. We also need to be deliberate about gathering any supplies we might need, since there’s no way to step back out of the Red Zone to grab something once you’re inside. The Suspect Ward does have a wooden slide from the window of the supply room in the Green Zone going over the fence into the Red Zone, so if we need something we can ring the bell on the Red Zone side and someone will slide whatever we need down to us. But again, that just wastes time in your suit.

So my team drew up all of the medications we thought we’d need, IV start supplies, plenty of bags of IV fluid, rags, and lapas (beautiful African fabrics used for just about everything, but in this case as sheets). I found myself giving doctors tips on how to draw up meds, since at home they are normally the ones writing orders, while nurses carry them out. Here in Maforki, it’s all hands on deck and the doctors gladly do nursing care with the rest of us. One of our patients had just been confirmed Ebola positive this morning, so we would need to move him from Suspect to the Confirmed Ward. We had been told he was too sick to walk, so we brought a body bag to put him on so we could carry him.

Then it was time to don our PPE. I hunted for two pairs of gloves in my size, as well as a pair of black rubber boots that fit me, out of the many drying on a rack in the sun outside the nurses’ station (exposure to sunlight kills the virus, too). Then I joined the rest of my team in the donning room, the last stop before you enter the Red Zone. A few Sierra Leonean staff double-checked us as we donned our suits. They cut thumb holes in the sleeves so they wouldn’t ride up and expose our wrists, and sprayed de-fogger on the inside of our face shields. I felt myself start to sweat as soon as I zipped my gown up. After writing our names and whether we were a nurse or a doctor on the front and back of our suits, they noted the time we were entering the Red Zone on our sleeves, and literally gave us a stamp of approval on our forearms. We were ready to go in.

As we walked through the doorway into the Red Zone, I took up the “Ebola pose” that we had been taught in training – interlocking my fingers in front of me at about the height of my navel, to discourage me from reaching up to touch my face or anything else around me. One of the Maforki nurses told me that when he’s in the Red Zone he pretends he’s playing a giant game of Operation, trying not to touch anything around him that he doesn’t have to. He assumes that every surface is contaminated with Ebola.

The Red Zone is designed to flow from lowest to highest risk, so the first ward we came to was Suspect. The Suspect patients (who have Ebola symptoms but have not yet had a positive test) are divided between those who have dry symptoms (fever, headache, hiccups, weakness, etc) and those who have wet symptoms (vomiting, diarrhea, and bleeding). The idea is to decrease the likelihood that one patient will infect another with Ebola. “Wet” patients produce a huge amount of highly infectious diarrhea and are often too weak to make it to the toilets. Many wards have old cholera beds, which have a large hole at the center that patients can position themselves over, with a bucket on the floor underneath to catch their waste.

Unfortunately Maforki does not have its own lab, so we send our blood samples to another nonprofit which runs our lab tests and emails us the results. The process can take 12-36 hours. In the meantime, all suspect patients must be housed within the Red Zone in case they do turn out to be Ebola positive. We don’t get many patients who return after they’ve been discharged negative, which is reassuring. We did have an 11-year-old girl in the suspect ward today who was here for the second time. She came to triage once before and was admitted to Suspect because her symptoms met the case definition for Ebola. She turned out to be negative and was sent home after a few days, but because she spent time in an ETU, she had to be followed as a “contact” for 21 days. At some point during that monitoring period, she spiked a fever again and was brought back to us. A fever by itself isn’t cause for alarm, but fever plus a history of contact with an Ebola patient is one of the case definitions that makes a person an Ebola suspect. Since she’d had contact with Ebola patients in the last three weeks, we had to re-admit her and test her again. On my first round of the day, I found her sitting in the alone in the courtyard of the Suspect ward, where I imagine dozens of children used to play during recess at school. We brought her a fresh bottle of cold water and encouraged her to drink but she refused. All I wanted to do was comfort her, but it’s incredibly hard to connect with a child from inside a suit that makes you look like a monster. Fortunately her test came back negative today, and we sent her home for another 21 days of monitoring.

Another one of our patients today was not so lucky. Foday (names changed to protect privacy) was brought to Maforki yesterday already very ill, and his test came back positive this morning. We needed to move him from Suspect to the Confirmed ward. When my team of four entered the Suspect Wet ward, Foday lay curled in bed in his own waste. We carefully cleaned him up, stepping over to a sprayer who followed us with a tank of chlorine on his back to rinse our outer layer of gloves whenever they were visibly soiled. Once Foday was as clean as we could get him, we rolled him onto the body bag we had brought with us and lifted him out of bed. Communicating with each other the entire time, we made our way out of the Suspect ward, through the gate into the Confirmed area, and lay him down on a bed in a room with the other Confirmed patients.

In the bed next to Foday lay 10-year-old Abass. When we visited him yesterday he had barely responded, and we worried over the bleeding we saw at his gums – a late sign, and not a reassuring one. Today he was reaching out for something with both hands, probably a family member whose presence he was hallucinating. The team before us had given him his meds, but I couldn’t help walking over to him to try to give him some comfort. When I entered his field of vision he recoiled. Between the language barrier and his delirium, I couldn’t explain to him why his family wasn’t there to wipe his face and hold his hand, and he was instead being cared for by a stranger dressed like an alien.

Having used up a lot of our allotted time already, we went to work giving Foday his medications. At Maforki we are aggressive with IV fluids, although it’s difficult because we can only give them while we are inside the unit with the patients. Experience has shown that if we hook up an IV line and leave it hanging, we will return a couple of hours later to find that the patient has accidentally ripped it out and bled everywhere. So we did the best we could with the time we had left, giving Foday IV fluids, antibiotics to prevent secondary infections, artusenate for malaria, and paracetamol for his fever. Although we had cleaned him up after he’d soiled himself again, by the time we had to leave he was already lying in his own diarrhea for the third time since we’d arrived about an hour before. With no time left, we had to leave it for the next round of clinicians.

Although we technically can spend 90 minutes in the PPE, a good chunk of that is taken up by the doffing process. As I’ve mentioned before, removing our PPE is the point at which we’re most likely to contaminate ourselves. We have infectious body fluids all over us, and we have to get out of our suits without getting a speck of it on ourselves. Here’s the process:

I approach a national staffer in full PPE who has a tank of chlorine on his back attached to a sprayer, and as he sprays I wash my hands (or rather, my outer layer of gloves) for a full minute. He then sprays the whole front of my suit, and then asks me to turn around so he can spray the back. When he’s finished, I tear off my apron very carefully so that the pieces don’t snap and flick any fluid at me. Then I wash my gloves with the chlorine sprayer for a full minute again. Next I move to my doffing station, where I stand in a bucket of chlorine and shuffle my feet for a full minute, to kill the virus on my boots. I step out of the bucket and into my doffing station, where a bucket full of chlorine awaits. I open the tap and wash my gloves again for a  full minute, making sure to keep some chlorine in my hands at the end to splash on the tap, so I don’t pick up any virus that I left there when I turned it on. I step over to a full length mirror leaned against the wall, and slowly, carefully unzip my suit and then pull the hood back off of my head. I wiggle the suit down my torso, past the top of my boots onto the ground, making sure to only touch the outside. I then pull my hands forward, letting my sleeves roll off and my top layer of gloves with them. Now my suit is off except for my feet, so I do the Ebola dance and shuffle my boots out of the legs of my gown. Then I carefully nudge the suit over to a sprayer on the Green Zone end of the doffing station, who waits until I turn away to spray it down with chlorine (we don’t want anything splashing into our eyes). While he sprays my suit, I step back into the chlorine bucket and clean my boots again. Once my suit is sprayed, I pick it up with one gloved hand and deposit it in a large trash can (I still have my inner layer of gloves on at this point). I return to the chlorine station and wash my gloves for a full minute. Then back to the mirror, where I ever so carefully grasp my face shield with both hands, pull it as far away from my face as I can, turn my face the other way with my eyes closed, and remove it. Back to the chlorine station to wash my gloves for another minute. Next it’s the same process with my face mask, pulling it far away and turning my face so that if anything splashes, it won’t go into my mucous membranes. Then another minute of hand washing. All that’s left at this point is my final layer of gloves, which I remove at a glacial pace. The goal is to never touch my hands with the dirty outside surface of the gloves. Try putting on some gloves, dipping them in mud, and then getting them off without getting ANY on your hands. It’s tougher than it sounds. My buddy clinician, still in PPE, stands in the Red Zone and supervises me through this entire process to make sure nothing is missed. Once that is done I turn to the chlorine sprayer, who sprays the front of my boots, asks me to turn, sprays one side, asks me to turn again, sprays the other side, then asks me to turn so they can spray the back. I then lift one foot at a time while they spray the soles of my boots as I slowly back out from the Red Zone into the Green Zone. With all of my PPE finally off and my boots clean, I wash my hands for a full minute with chlorine, and then again for a minute with soap and water. To be extra safe, I’m not supposed to touch my face for then next half hour.

By now it’s almost noon, and we head to the nurses station to re-hydrate and have a snack before our second round in the Red Zone. I’m feeling fine physically. I seem to be one of the lucky ones who is surprised when our time is up, and I come out of my PPE almost as dry as I went in while others return with their whole scrubs a shade darker from the sweat. Emotionally, it’s harder.

By our second round in the afternoon, Foday was looking worse. He was having pretty much constant diarrhea, rolling over to vomit into a bucket next to his bed, and dripping blood from his nose. His fever had risen and he was tachycardic. Dried blood was caked all over his nose and mouth. We started a second IV and rushed fluids into him, and tried to clean him up from head to toe. At some point he decided he was done putting up with all of these white-suited monsters poking at him, so he rolled over and tried to stand up, clearly agitated. With two IVs hooked up and blood running down his face, any quick movement on his part would mean spraying infectious blood all over the place. As a nurse, everything in my heart wanted me to go rub his back, help him back into bed, and calm him down enough that we could continue to care for him – while everything in my brain was shouting, “Get away from him!” Suddenly my PPE seemed so fragile. He eventually calmed himself down and crawled back into bed, and I was left feeling surprised and ashamed at how afraid I’d been.

Most of the clinicians who have been here a while think he’s too far gone to recover, and I hope if they’re right that he passes away soon. I’m heading back to Maforki shortly for an evening shift, and I know we’ll do everything we can to make him comfortable. Even if he is going to die, he doesn’t have to die in pain and covered in his own mess.

Night shift tells us little Abass is looking better today, and I’m looking forward to seeing him for myself. I hope that telling Abass and Foday’s stories stories has put faces to the outbreak. The numbers we hear on the news are PEOPLE, every one of them just as important as us and our families. I will never understand why some people’s lives seem to matter more than others; why if I get sick I’ll be flown home to receive the best medical care in the world, while Fuday is dying in his own filth while we do what we can for him with the little we have.