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.

Trained and Ready

Written Friday 2/27

Those of you who know me know that I’m always freezing; in the middle of the summer you’ll still likely find me curled up by the fireplace. So maybe I have the ideal constitution for working in an ETU. On Thursday and Friday we donned full PPE and trained in the mock Ebola Treatment Unit, and while I can’t say that it was a comfortable experience, I came out the other end feeling pretty good. One of my team members told me, “You were peppy in there!” which I’ll take as a compliment. When it comes to working for two hours in 80-degree heat completely encased from head to toe, I think getting out of it without heat stroke or a panic attack is a win.

Practicing treating patients in full PPE in the mock Ebola Treatment Unit

In an effort to prepare us, our instructors had described in great detail the science behind what we all know already: That it is really dang hot in there. Inside the PPE is a micro-climate of 40-50 degrees Celsius and 100% humidity. This is, as our trainers put it, an “un-compensable” environment – meaning that our normal heat dissipation mechanisms (i.e., sweating) won’t work. We were repeatedly admonished that there is NO HURRY in the ETU; if we over-exert ourselves, core temperatures can reach critical levels in under an hour. They key is to pace ourselves.

Yikes

A couple of members of our group did overheat during our training in the mock ETU. Although it’s awful to watch someone you’ve grown close to as they struggle against the limits of what our bodies are capable of, it was nice to see our little family rally to help each other out. If someone starts to feel unwell in their PPE, the most important thing is to admit it and get out of the red zone asap. If someone faints and goes down in their PPE in a real Ebola unit, we’ll have a whole new set of problems. Fortunately my friends headed straight to the doffing stations, and with a little fluid and electrolytes, ice packs under the armpits, rest, and kind words, they were right as rain.

While the heat turned out to be the least of my problems, I was struck by just how restricting the PPE is once I tried to do my job from inside it. Between a hood, face mask, and face shield, my field of vision is pretty restricted. And if I don’t get my mask on just right, my breath fogs up my face shield and suddenly everything is a blurry mess. The first time I donned the full getup, I pulled my hair up in a tight bun, thinking it would be best to get it out of the way altogether. I discovered quickly that with the big lump of hair at the back of my head, if I tilt my chin to look downward, my hood pulls back from my face mask, leaving a strip of completely exposed skin on my forehead. One of the lovely Sierra Leonean nurses, who probably knows more about working in an ETU than I ever will, told me that a braid down the back works best and I was happy to follow her advice.

Another restriction to adjust to is wearing two sets of gloves on top of each other. This is great from an infection control standpoint, but garbage when you want to start an IV. Most nurses I work with in the States will throw on a tourniquet and run their bare fingers over a patient’s arm to feel for the best vein – it’s usually a better bet for finding a good one than just looking. Here, we will be hunting for shriveled veins in severely dehydrated patients, with two layers of gloves between our fingers and their skin. I’m told that this is one of the areas that the Sierra Leonean nurses excel in. While we try over and over to get an IV in, another PIH-er told me that the national staff “could get blood out of a rock.” So I’ll be keeping an eye on how they do it!

My fingers after an hour in PPE

As we acclimated ourselves to the PPE, we split up into teams to do rounds in the mock ETU that is set up at the training center. Ebola survivors were stationed in each ward to act like patients, and we were expected to manage their care as we will in the real world. I know I just missed the Oscars, but in my opinion every survivor we worked with should get one. As we approached one man who seemed to be unconscious, he suddenly leapt up and lurched towards us, ripping out his fake IV and trying to escape. Even though I knew there was no real danger, no actual Ebola blood spurting all over the room, it definitely got my heart pounding.

While the mock ETU was invaluable in preparing us for the real thing, I was a bit disappointed to see the national nurses take a backseat role. Our doctors made decisions and called out orders, while the nurses carried them out obediently. One of the things I’m most excited about doing here is helping to strengthen the national nurses’ confidence and critical thinking. The impression I get is that nursing education here is very task-oriented, and they are encouraged to follow protocols without necessarily understanding the reasons behind them. Although many of the nurses we trained with were very intelligent and experts at their job, one of them told me, “The doctor is always right.” In any scenario, that can be a dangerous way of thinking, since nurses should be the doctor’s eyes and ears, their final check before care is administered, and strong advocates for their patients. But in a country ravaged by Ebola where there were hardly any doctors to begin, it will be even more essential for nurses to step up and take a leading role. I do hope that once this outbreak is over, what remains are some newly trained, skilled nurses who are motivated to build their country’s health system back from the ground up.

One perfect example is a young woman I’ll call J., a beautiful Sierra Leonean nurse I met during training. She volunteered to work at a government ETU last September, without asking her family’s permission since she knew they would not approve. At that time, nurses only received two days of emergency Ebola training before being tossed in to work at an ETU. J. has been treating Ebola patients ever since, and only gets to see her husband and child when she travels back home to visit them on her days off. I asked her if she wanted more children, and she told me she does not “because it doesn’t leave time for my work, and I love my work.”

It has been such a joy getting to know the national nurses at training. All of these wonderful men and women showed up to our last day of class on Friday dressed in a gorgeous array of African fabrics. Apparently Friday is “African dress day” which made the Americans look pretty shabby in our old scrubs. Nonetheless, it was graduation day and a festive atmosphere as we all rushed around posing for photos and saying goodbye to our new friends.

Seen on our drive out to Port Loko. I can’t get over what African women manage to carry on their heads!

Directly from training our group left for Port Loko, a district hard-hit with the virus, where PIH’s Ebola Treatment Unit is located. Here we are being housed at a tent city run by a Danish emergency management organization, which looks a lot like MASH and feels like arriving at a colony on Mars. Several large tents are each separated into six rooms, with a cot, mosquito net, and a light in each. Though it looks sparse, it’s actually quite fancy, with air conditioning, wifi, hot showers, and electricity by generator. Plus the food is fantastic, and apparently there is a clothing-optional tanning area (I’m not kidding). Although I greatly appreciate the hospitality and the amount of organization and effort that it must take to keep a camp like this running so that health workers can do their jobs, I can’t help but feel ashamed at the stark contrast between one side of our fence and the other. It is jarring to sit under a nice tent under bright lights, listening to music and going back for seconds at the buffet, while Sierra Leonean kids walk past the fence in threadbare clothes and stare.

After months of waiting, hoping, reading the news itching to be here, tomorrow is the big day. We’ll go to the ETU in the morning, where we will don our PPE and treat Ebola patients for the first time. Maybe I should feel nervous, but I don’t. I’m just glad the wait is over and I can finally have a hand in the important work that needs to be done.