Ebola Treatment Center, Day One

After a few days of training with MSF in Geneva and a grueling journey to Sierra Leone, I entered the Ebola Treatment Center in Freetown where I will be working for the first time on Monday. Here are my observations and impressions from day one, before all of these little details become part of the norm and don’t seem so important:

At the entrance to the Ebola Treatment Center (ETC) compound, we get out of the car, wash our hands with 0.05% chlorine water, spray the bottoms of our shoes, and have our temperature taken. All visitors, staff – EVERYONE – goes through these steps before entering the center from the outside.

Once allowed inside, we proceeded to the entrance to the low risk zone – again, washing our hands and spraying our shoe bottoms. Then on to the dressing rooms, one side for men and one for women (we have been warned to only wear discreet underwear into the ETC, as you often sweat so much inside the suits that when you remove them, your sticky scrubs come right off along with them – so no thongs for us!). In the dressing room you find a pair of scrubs, which are being washed constantly all day long and hung out to dry, and hopefully a pair of heavy plastic gumboots that fit. These are also washed and dried throughout the day, but after lunch there were no more boots to be had…

From there we headed over to the medical “office” tent – one area for administrative work, one where there are white boards detailing patients and needs, etc. A second space is set up for work – mixing IVs, nursing roster, etc. The third space is for the pharmacy folks who pack the med bags. The ground inside the ETC is covered with heavy, broken sharp grey rock. As you’re walking in your gumboots, it’s a bit uncomfortable and sloppy, but I’m sure I’ll get used to that quickly.

Since we were on orientation, we spent the day doing various things. I spent the morning in triage, which I really liked. However, it’s not triage OUR way; we don’t respond quickly to the sickest patients. Here, we respond first to the NOT sick, and get them out of the center with a certificate that says they do not have Ebola. Hospitals and clinics won’t allow them in for care without this. Plus, people are worried about little things and want to be sure they don’t have Ebola.

This is how it works: People come in (after washing their hands, spraying their feet, and having their temperature checked at the entrance) and sit in a holding area consisting of plastic chairs 2 meters apart, the safe distance. We healthcare workers stand under a shade, behind an orange double fence blocking off 2 meters’ distance from them. No confidentiality at all. We get their demographics, register symptoms, and begin to make a determination about whether or not to admit. Today many had vague symptoms, but were relatives of confirmed Ebola patients – a husband, sister, and baby. I guess that’s not unusual. We also know the “hot spots” where many cases are coming from, to raise the suspicion level in certain cases.

Today we admitted about half a dozen people. As we’re doing their paperwork, we give them a bag of water and a sachet of Plumpy Nut (a peanut-based paste for treatment of malnutrition) and ask them to eat and drink. A psychologist comes and asks the patient about who they can call to advise, what they need done, finding a caretaker for their children, etc. There is also a Health Promoter who talks to them about what’s happening.

Oddly, enough, the new patients are stoic. No comments, no questions. They just sit there across a far divide from us. I would be screaming and crying and begging if it were me being told I was to be admitted to an ETC!  The patients are then moved to another holding area and a nurse in full Personal Protective Equipment (PPE) comes to get them, take them to a bed, and get them settled.

The ambulances also come in the triage area, and we have a whole procedure there are well. First, they back halfway into the orange double fence area, then wait for the hygiene team to come spray the vehicle, remove the patient/stretcher, spray again, spray inside, then bring the patient to triage, where we do our work from across a 2-meter table-like barrier. The only time we get any closer is with goggles or a face shield, when leaning close enough to take a temperature with the little electronic gun from 6 inches away.

Things are separated here into areas for suspected and confirmed Ebola patients. In the ward for suspected patients, they are given a bed in a private “room” consisting of a concrete floor, walls of vinyl tarps, roof, sun shade, buckets for Oral Rehydration Solution (ORS), vomit, washing, and stool. The suspected area is separated from the confirmed, and they try to put the “not highly suspected” as far away from the sick ones as possible. You don’t want someone who just has malaria to be exposed to Ebola in the ETC.

The confirmed section has bucket showers for patients, and male and female latrines. This confirmed area also has a separate section for those with the highest nursing/medical needs. It is known as “ICU” even though it really only means IVs versus simply oral medications. Today I got to don full PPE and go into “ICU”. I think I’ll be doing that a bit more often because I can start IVs.

There is also a third area for recovering patients. These people are feeling better – they can walk, feed, and care for themselves - and are awaiting tests. Patients must test negative twice in 72 hours in order to be discharged home “cured”. Caregivers for children are recruited from the survivors because they have immunity for an unknown period of time.
 
We caregivers have one donning room with very helpful people getting us dressed, and two different doffing stations where they tell us step by step what to do as we remove our PPE. We can be inside for only one hour at a time. Today I was only in for 30 minutes, just being shown around, without doing any care on day one. I felt OK, not terribly hot or bothered, but the nurse orienting me was soaked when we came out. One of the docs was in for 90 minutes, and literally poured sweat out of his boot! One style of PPE is lighter than the other, so everyone wants the one with the blue stripe.

There are bags of water at various points, and squat latrines for staff. The spaces everywhere are really vast – lots of room so as not to touch anyone. Things move slowly. Since there is no such thing as an emergency, no resuscitation, etc, we take our time to work out the best plan of action for everything.
 
Teams go in every hour or so: IV/ICU team, oral med team, admission and discharge team. Nurses (most not very skilled) and our expat doctors go in together. Outside is a group of nurse assistants. Hygiene goes in with the medicals. After the medicals leave, the nurse assistants have their rotation to feed, give ORS, bathe, etc.

One cool thing is that the ICU has a corridor down the middle, with two 1/2 –meter tall plexiglas walls and the patient beds all around, so we can literally walk down the middle, not in PPE, and see and talk with our patients. This minimizes the time we spend in PPE. It’s the same in the other wards, though not plexiglas. Instead they have a double fence 2 meters wide so we can talk to the patients across it without having to be in PPE. There are also slanted “one way” tables so we can pass them meds, food, whatever. We slide it down to them across the 2 meters, or push it with a stick if necessary. It’s the same at the entrance to the ICU: two slide tables so that from the outside you can slide in another IV bag, tape, or whatever they might need that they didn’t take in. Pretty smart system!

In addition to all this, there are more tents for logistics, resting area for staff, and an additional one that just opened today because the number of patients was higher before discharges.

Blood is drawn by the lab team three times a day and there’s an actual lab (not run by MSF, but some other entity). They process the samples in about four hours, so we can clear those who are not sick quickly and send them out with their certificate and a big “congratulations”. They also routinely screen for malaria. Most are positive and so get treated. Admission orders include systematic malaria meds, antibiotics, Plumpy Nut, and Tylenol if fever. IVs are mixed by the nursing staff. It made me a little anxious because I’m not sure they are very diligent about what they are doing. D50 is added to LR, plus potassium if the patient has a lot of diarrhea. IV paracetamol is given if they can’t take pills.
I sat awhile with the Sierra Leonean nursing assistant staff outside of ICU. If find that if you do this in the beginning, they get to know you and word spreads quickly that you’re a good person. One of them said, “Americans are so simple.” I asked her what she meant, and she explained, “You are always nice, always soft in your way, not hard like the Swiss and Europeans.” They had lots of questions and are supposed to be teaching me Krio, the local language. Here are some basics we’ll use a lot:
 
You belly de run?  or You de gombelly? = do you have diarrhea
 
You hed de acts?  = You have a headache?
 
You de feel pen (tapping shoulders)?  You have joint pain?
 
You de feel weak?
 
You de eat?  = Do you have an appetite?
 
You de cough?
 
I need to practice for tomorrow because I’m sure they will ask and give me more homework.

Oh, and I actually got to be an ER nurse! Two young men brought a boy who had pulled down a container of lye onto his head and face. No one knew what to do. He was not sick, just injured. So I tossed them some bags of water (all of our water for washing has chlorine), and had them rinse him down about 10 liters. Then I got him a blanket so he wouldn’t be wet and naked to take to another facility (we are ONLY an Ebola treatment center and can’t do anything more). I felt pretty good about it, but think he will have some serious eye damage…
 
Overall, I’m feeling pretty positive about this mission. I think this is going to be good!

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

Doug Demo tells about his experience with Refuge International

Thanks to a scholarship from One Nurse At A Time, which was made possible by a generous donation from Omicrom Delta chapter of the Sigma Theta Tau, the honor society of nursing. I was able to participate in my second medical mission trip with Refuge International to San Raymundo, Guatemala in October 2014. Throughout the week the team provided primary care services to nearly 600 patients, and we were fortunate this year to have the skills of two general surgeons, an OB-GYN, a urologist and an orthopedic surgeon who completed 43 surgical procedures. Although I work at an urgent care center in the US, I was assigned to the OR area again this year as a circulating nurse. From hernias and hysterectomies to cystoceles and lap choles, patients were soon able to have relief from a range of conditions that had plagued them for months and in some cases even years! It was a wonderful opportunity to experience a different side of nursing while simultaneously using my Spanish language skills in the perioperative area.

            In collaboration with the Asociacion Medica Quirurgica de San Raimundo, Refuge International makes three medical mission trips to San Raymundo each year as well as to other sites in Guatemala. The organization also participates in a nation-wide program called “Adios Lombrices,” which aims to rid school-age children of worms, and a clean water project, which involves constructing wells to provide clean water in rural areas. I was impressed by a group of strangers who can come together in such a short period of time and make the best of limited resources to provide much needed health care services. The clinic where we worked is only open when volunteer groups come to staff it, and it may be a month or longer before another group visits the area to provide another round of services.

            Every medical trip has its challenges and frustrations, but they also have special joys and memories. As a healthcare professional I wonder how I am going make a connection with people from a different culture? On this trip, I was chatting with a woman in her 50’s as she was getting prepped for surgery, and I jokingly told her that after the surgery she would feel much better, and then we could have a party and go dancing.  She smiled and nodded her head and then the anesthesia kicked in. Later in the recovery area, she was sitting in a chair and I asked her if she was ready to dance.  Remembering our conversation, she smiled and said, “I’m sorry, but I only dance with my husband.”  We laughed together and I wished her well in her recovery before heading back into the OR for my next case.  Even though I did not perform the surgery, I know that smiles and laughter can alleviate fear, raise spirits and provide comfort. Smiles and laughter transcend cultural boundaries and serve as a reminder that nursing is more than IV pumps, documentation and call bells. When circumstances force you to get “back to the basics” you are quickly reminded that the patient is the focus of your work and that you can make a connection using the most available tool around--yourself.

            Having traveled to Guatemala on several occasions, I do not experience the same culture shock as new travelers, but that does not mean that I am unaware of the poverty, living conditions or social struggles in the region. I make the trip knowing those problems exist and with the hope that my short time in the area might bring some needed relief. There is a quote attributed to Ronald Reagan that says “We can’t help everyone, but everyone can help someone.”  As a nurse I help someone every day as part of my job, but going to Guatemala is a special opportunity to help a different someone, and I hope that my participation in medical missions can inspire other nurses to reach out and find their “someone” to help.

Douglas Demo, RN

New Jersey

Megan Duda R.N. reports on her trip to Ecuador

On Oct. 25, 2014 I led a team of 4 nurses and a pharmacist to Ecuador for a medical-outreach mission trip.  Our clinic was 4 days long we spent 2 days in San Josue, Ecuador and 2 days in Liberador Bolivar. We worked from 9am to 5-7pm. In those 4 days we saw over 700 villagers… absolutely amazing. The needs varied from villagers simply wanting vitamins to needing emergent care. Returning this year to Ecuador was a blessing especially to see the knowledge the villagers retained from last year’s teachings and care we provided.

I enjoyed watching my team grow individually and as a unit throughout the trip.  As a leader I was able to use my knowledge from last year to be there for my team. I enjoyed being able to experience the medical mission to the fullest by having the freedom to be a part of each assessment area for example the triage, in-depth assessment area, pharmacy area, teachings, and prayer area.  Overall, I think I enjoyed being able to pray more this year with the villagers than last year the most, because it created a bond between myself and the villagers that I will hold close to my heart forever.

The thing I enjoyed least was some of my team members being ill, myself included. Some of my team members were ill before we even left the states as was I, some became ill in Ecuador, and after we returned home. I was very worried about them. This was the most challenging aspect because as the leader I felt a little helpless not being able to know why they were ill or being able to relieve their illnesses.

The cultural difference that I observed was the male dominant society. One of the village nurses that helped us was not able to do anything like going with a patient to the hospital without getting permission from her husband first. She had mentioned having to ask at the right time, but in the end he still said no. Our translator was a newlywed who was in a more modern relationship; however she still needed to be home to make her husband supper before he came home from work.  Another example was one of our patient’s, Lida, she was a young woman that suffers from a dura tear with excessive cerebral spinal fluid nasal drainage for the past 6 months. She has been waking up in the morning to a soaked pillow in the morning, having frequent severe headaches, memory loss, and other complications. Her memory loss is so excessive she forgets she is cooking something and it burns… in turn domestic abuse is the result. I explained the complexity of her condition and informed her of the need for surgical intervention as soon as possible. She needed to have her husband come to talk with us to decide, for her, what she should do. When the husband arrived and talked with myself, the Pastor Luis, and the Pastor’s wife Karen, the result was unreal; as the Pastor talked with the husband there was no emotion from the husband; then the husband said, “ It is not my problem… it is her and her families problem.”  Tears poured down Lida’s face.  As we talked more with Lida is was clear that domestic abuse was the likely reason of the dura tear.  Although this is sad situation, I remind myself of is that Pastor Luis and his wife Karen are teaching the community how to appreciate your spouse and value equality within marriage as they demonstrate this on a daily basis.

The most difficult cultural difference is the ability to pay for healthcare versus the United States. In the United States we have government funding, foundations, special hospitals, or payment plans to assist with getting the treatment we need when we need it. In Ecuador, they need to pay for clinic visits and specialists. Some hospitals provide free care and procedures, but the patients need to buy the medications, anesthesia, and much more before anything will be done. If the procedure needs a specialist  for the surgery payment needs to be provided before the surgery. For example, Lida, a young women with the dura tear, needs emergent surgery, but is not able to afford to pay for the medications, transportation, or other aspects of care that she needs to have prior to the surgery, so she goes without. Her condition would be a neurological emergency in the United States.  Another example is an 8 year old little girl that has a narrowed airway passage and has seen a specialist that informed her family she needed surgery or could possibly die. The family has no money to pay for this $1000 surgical procedure. In the United States these things would be taken care of right away. I think people take this for granted in the United States. Yet, in Ecuador these people fear for their lives on a daily basis and pray that God provides a miracle.

Another cultural difference is the happiness and love the people of Ecuador radiate to each other as well as visitors.  As a sign of respect when you meet someone new, are greeting someone you have known forever, or when you say good-bye you give them a hug and a kiss on the cheek. This is actually one of the things I miss most when I return to the states from Ecuador.  Similar to the United States, the aspect that is hard to wrap your mind around is the abuse that occurs behind closed doors and the lack of love in some families; however there are organizations that are available for people to utilize to escape these circumstances in the U.S. and in Ecuador there is not.

The people of Ecuador are very kind and understanding. I needed to use my Spanish speaking skills much more this year which was a challenge. I am not a fluent Spanish speaker, but the Ecuadorian people did not criticize, did not laugh at me, and did not judge me as a stumbled with my words or required a little extra time to think of the right word I needed to use.  Instead, they would help me by suggesting words, help teach me proper pronunciation and vocabulary, and laughed with me when I made jokes or said something silly.

My most “memorable moments” are caring for Lida the lady with the dura tear with excessive cerebral spinal fluid leaking from her nose and Rosa Rodriguez an 103 year old lady with extreme pain:

 Lindsay one of my team members was assessing Lida and called me over. Lindsay explained that Lida was having memory loss, headaches, dizziness, and burning with excessive nasal drainage that pours from her nose when she simply looks down. I ran to get a glucometer and asked Lida if she could give me a little sample of the drainage from her nose. She looked down and I couldn’t believe at how fast and how much drainage poured in the cup. I tested the nasal drainage for glucose which is an indicator of a cerebral spinal fluid leak if glucose is present. The test came back positive with a glucometer reading of 241.  Although, this was a very difficult diagnosis to explain to Lida, being able to diagnosis her or at least have a idea of the seriousness of her condition put into action a immediate interventions for Lida. All Lida needed to do was let us know she wanted help and if money wasn’t an issue be open to having surgery. After hours of praying with Lida, providing information of the seriousness of her condition, and informing her of complications she could experience if she did not have surgery, Lida informed us she wanted the surgery, so she could better take care of her kids. Lida doesn’t have support from her family or her spouse. She continues to have to live in an abusive relationship.  The bravery Lida showed at that moment was truly unbelievable.

At the end of our last clinic day we were closing the clinic when an elderly woman was pushing another elderly woman in a wheel chair down a dirt road. The lady in the wheel chair was crying and in excessive pain. The woman pushing the wheel chair reported that the lady in the wheel chair was her mother and is 103 years old. Her name is Rosa Rodriguez. The daughter explained that Rosa had broke her left hip a year ago and has had pain ever since.  Recently, she was having increased pain in both hips and her right lower leg. As a geriatric nurse this broke my heart. We immediately gave Rosa some Tylenol and I massaged her lower legs and hips with muscle rub. She continued to cry and as a nurse I have never felt so helpless and useless as I did not have the resources to relieve this woman’s suffering…at that moment I understood completely what these people experience every day.  I tried to comfort Rosa and I held her close as she wept. I could not hold back my tears.  Many people surrounded Rosa and we prayed a long time for her.  After we prayed, it was as if God reached down and placed is hand on Rosa…she finally had stopped crying and appeared settled. Although, she stopped crying Pastor Luis and I kept holding her hands and everyone that surrounded her was silent, but you could feel the empathy for Rosa in the air. We asked her daughter where she lived. She explained to one of the volunteers and we lifted Rosa into the truck and drove them home. Her daughter who was in her early 80’s had pushed her mother in a wheel chair about 2 miles to get her to our clinic. Pastor Luis and I wheeled Rosa into her house and her great grand-daughters helped her into bed. I taught her great grand-daughters how to administer the medications, properly lift her, properly lay her into bed, and provide adequate nutrition as well as fluids. I overheard Pastor Luis say to Rosa, “Do not worry. You are in your bed in your own home.” Rosa looked at peace. I knew we had to get back, but it took everything in me to leave her there… I wished I could stay with her and keep her comfortable. I kissed her on her forehead and hugged her family.  I asked Pastor Luis why he told her she was home. He told me because she thought her family was leaving her with us, which was another reason she was so scared. As we drove away I prayed that God would hold her close to Him and her suffering would be lifted. Rosa Rodriquez changed my life in ways I can’t even express… she has a special place in my heart that I will hold dear for the rest of my life.

The impact this medical outreach mission had on my nursing career is hard to put in to words. I will never be the same nurse or person as I was before this mission. The people I met and cared for changed me and reminded me why I became a nurse in the first place. In the United States, people sometimes take nurses for granted and the passion of nursing sometimes becomes dimmed by this. Sometimes nurses do forget why they became a nurse in the first place because after days, weeks, months, and years of staying late at work, not getting to use the bathroom for 8-12 hours, missing lunches, and being ordered to do things without a please or a thank you in return becomes tiring. However, after my mission last year and this year I have come back to the United States with such appreciation for the things other nurses have taught me, other things I learned on my own, and all the patients/resident’s I have cared for throughout my nursing career. God provided these rare opportunities to me and all I did was say, “yes” and he took care of the rest. Helping over 700 people in 4 days is definitely works of God because he gave all of my team, the volunteers, and me the strength, knowledge, and skills to help each and every one of His people.

I honestly wish every nurse could experience a medical outreach mission trip because I believe our society and health care systems including clinics, hospitals, skilled nursing facilities, hospice, home health care, school nurses, and every other nursing profession would be changed for the better as every nurse would have a renewed outlook and humbling experience to relate to when they are working with others.

I cannot thank One Nurse At A Time and their supporters for the scholarship I received this year.  Without them I would not have been able to experience and learn the things I did. 

Nursing is an extraordinary career and takes very unique individuals…Being a nurse we affect many people on a daily basis within our own communities… Being a nurse missionary we promote change in ourselves, our communities, and the world.

Thank you,

Megan Duda R.N.