Ventrilocricket

For about a week now, there has been a cricket in my bathroom. He goes on and on all night and I can't find him. At one point I thought he was hiding behind the toilet, so I sprayed a lot of deet back there. Quiet until the next night when he got more obnoxious just for revenge.

Our patients seem to come and go in waves. The number of cases in the country as a whole is going down, and the other ETCs in the area also have lower numbers now. We were quite full for the first month I was here. Then about 10 days ago we emptied out. One day last week, Carrie and I were training the two new nurses (one who grew up in Lancaster - it's so frustrating trying to play the Mennonite game with a Baptist), when the next wave came.

While all the international nurses work 12 hour shifts, the local nurses work 6s during the day. All of our admissions seem to come around change of shift. We knew 6 were coming. Two local nurses triaged the first two, and then the third ambulance came with four patients inside. They're really not supposed to do that, because one of the patients could be negative until you pile two positives in on top of them. That and it's a lot of work and coordination for one team to do that many at once. So Carrie and I each buddied with a new nurse and went in.

We were told two patients were ambulatory and two needed stretchers. Assuming the ambulatories were more likely to be suspects, we untangled them from the other two and brought them through first. The engineering team was doing something to the gate on the ambulance bay, making it impossible to hear, so we didn't get the most thorough triage. Enough to know they met criteria and put them in Suspect. The next two we managed to get out without stretchers, thankfully. As we were hobbling into triage with them, we were told from the low risk side (through the plexiglass) to just take them both straight to Probable. So off we went like a herd of turtles.

The one lady was quite sick. I kept sternal rubbing her and yelling at her to wake up. She perked up a bit after we gave her a liter of fluid. The other lady was older, but she seemed much better. She just sat there waiting patiently for us to draw her blood. She chowed down on the banana we gave her and she fussed with her head wrap.

We finished labs and lines and then doffed and went to the medical tent where we finally got the real stories on our admissions. If they had been truthful right away, all four would've gone to Probable. Apparently, they were all from the same village and had attended a funeral. When the village chief asked them about it, they told him that no one had died, he just wasn't around because he went to Guinea. Then they started to get sick. The chief called an ambulance, and after catching the one woman who tried to run away, all four were brought to us. The first woman who was admitted by the local nurse team had attended a birth and then gotten ill. The following day, the sickest funeral attendee's 1-year-old daughter was admitted.

I switched to nights the day after the women were admitted. We also had 6 or 7 come into suspect. After my first pass inside, our epidemiologist called me to give us lab results (a mere 32 hours later). "You have 5 positives and the rest are negative," she said. "I know which ones they are," I said. I listed the ID numbers for the five ladies, and she confirmed that I was correct. Carrie and I were on with just 3 local nurses that night, so we had to map out quite a plan to get them all moved to the confirmed tent. It only took a few hours. 

Our sickest lady was rapidly declining. She had progressed into respiratory distress. We sat with her for awhile, trying to make her comfortable. At one point, Carrie noted that the other four patients had fallen asleep while we sat there with one awake, and quite likely the next morning four would wake up and one would not. I was too tired to comprehend what she meant at first. It finally came to me when we were doffing later. When they fell asleep, their friend was alive, but the people in suits were putting things in her IV. They were obviously already suspicious of the whole ebola thing. Luckily, our lady was still somehow alive when we made our morning pass.

As we watched her struggle to breathe, I couldn't help but think what a high price she was paying for her insistence on participating in a funeral. She died later the next afternoon, and then another woman died each day subsequently. We have one left now, and I think she'll make it. Sometimes it's worse to know their story. The first woman's daughter miraculously had two negative tests and we discharged her a few days ago. She is cute as a button and was less than thrilled about the chlorine shower she had to take to get out of the ward.

I was on the other side of the plexiglass for another admission this week. We were going through the triage questions  and it seemed he would be probable (with diarrhea and hiccups). Then we got to the question about contact with a sick or dead person. He said his wife died. We asked his wife's name, and then we all groaned when he responded. His wife had been our patient. Our first pregnant patient. She died within 24 hours of being admitted. It was no surprise when I got his labs back last night. We moved him into confirmed this morning, bloody diarrhea, hiccups, and all.

On a lighter note, I think I should get some credit from the parents for how I eased them into me coming here. We all like to sit around and tell the stories of how our families took the news. One doctor told her parents the night before she was flying, and then her sister met her at the airport to try and talk her out of it. One of our Kenyan nurses has his parents thinking he's just doing education here. And one of our local nurses told her parents she works at a supermarket. She said that after it's all over, she'll tell them that the money that has been paying for their food is ebola money. She thinks it's hilarious. 

Two nights ago, I was in my room, fed up with the cricket. He sounds like he's everywhere. Finally, I thought he might be behind the sink. It took me an hour or so, but I eventually located him. With the deet. This morning after my night shift, I slept peacefully.

Mythbuster

Sometimes we sit at the ETC and muse about what we'll tell our families about that particular day or week. As in, "What's the good, vague part of the last few days that won't freak anybody out?" (Just kidding...) And sometimes our epidemiologist sits at her desk listening to us talk and laments over how she would love to write down some of the things we say, but no one else would understand. Medical humor, I suppose. This is my lead-in to how I don't know what to post again, but I sometimes get panicky texts/emails/whats app messages if I go too long without writing.

We had a bit of a theme over the last few days: pregnant patients. Ebola is somewhat famous for it's treatment of this type of patient. I tested a story out on a friend the other morning, and we determined it wouldn't do for the blog. So in honor of said friend's love of psychology, and in honor of the abundance of social workers in my life, I dedicate this post to our Psychosocial department.

If you were to visit our ETC, you'd see Psychosocial around, but you'd only be able to pick them out because they have weird scrubs (think 60s...). I've often said that my housemate, Anna, is the most overworked and under-appreciated person at the ETC. As a nurse, I have the glamorous job (so to speak...as some may not consider stepping in 4-5 different body fluids simultaneously glamorous). The medical team gets the most credit. We'll put it that way. But a few days ago, I got to do something new. Anna came into the medical tent looking for a specific chart. The family of a deceased patient was in her tent, and Psychosocial likes to give the family some specifics about the patient's treatment. Since I happened to know the patient's ID number off the top of my head (only because we thought we had a screw up with lab results) and there weren't any doctors around, she asked if I would come speak to the family. I was less than thrilled, but I agreed.

There are a lot of myths and uncertainties surrounding Ebola and treatment centers. Our local doctors were telling us that some Sierra Leoneans still don't believe Ebola is a real thing. Others think that Westerners are at treatment centers poisoning patients. There was one village here where a whole bunch of sick people were just rounded up and taken off to holding centers. Their families didn't hear from them again. Some of these patients ended up at our facility. Two were cured, and on the day of their discharge, Anna went back with them to their village. Basically, she had to read a list of deceased patients while families gathered around to hear if she had any news about their loved one. Her retelling of it reminded me of Gone with the Wind. Anyways, for these reasons and a few more, Psychosocial likes to have one of the medical personnel speak with the family. It kind of helps if the family can see someone who took care of their family member.

As we clunked across the rocks from the medical tent to the family tent, Anna told me what to say. I wasn't sure how much information/detail to give. For this patient in particular, I figured it wouldn't be helpful to say, "Yes, we knew she was pretty sick, but we were all still quite surprised when she died." So, I told them what her symptoms were and how we tried to treat them. Then they asked about this patient's brother-in-law. I remembered the patient, but didn't know that the two had been related. They said that he was the strongest person in their family and they didn't understand how he could have died. I agreed, he was quite strong. That's why he hung on for so long it was almost painful to watch. You knew that he knew he was going to die. I explained how sometimes some patients start bleeding and then there's not much we can do, and I also had to tell them that their brother began refusing to eat. Anna asked them if they had any questions about anything. They said they had two other family members who were sick but didn't come to our ETC and they lived. That makes you feel awesome. But Anna did her thing and explained how there's still a lot people don't know about Ebola, so we do our best but sometimes who lives and who dies just feels like luck. Amen, sister.

As we walked back to the medical tent, I thought to myself how glad I was that I don't have Psychosocial's job. I have to talk to the patients' families for 5 minutes a week. I don't have to tell them that we can't unzip the body bag to let them see their family member one last time (or simply to convince them that it really is their family member). I don't have to tell the lone survivor of a family unit, "I'm so sorry for your loss. Here's a bag of rice." I don't usually see the family once the patient leaves (unless they come back as patients...that was a first last week). So here's to the people in the funny scrubs. Quietly taking care of people. Unless, of course, we're discharging a cured patient. Then they break out the instruments and dance.

On a completely unrelated note, I finally had time to take a few pictures (/steal a few pictures from another nurse). Hopefully this will satisfy some curiosities.

My house!

The main walkway. Triage and wards to the left, "offices", pharmacy, kitchen to the right

The medical tent

Doffing area

Donning

Meds waiting to be passed from low to high risk

Because we can't take pictures in the wards...here's the next best thing to seeing the inside

Two nurses calling the vital signs over the fence to the scribe

Carrie and I wanted to take pictures on our night shift. We can't touch, so this is our Awkward [Ebola] Family Photo

Correction: You are allowed to bump elbows with people. But no high fives, handshakes, or any other touching

Donning in the early morning

Tearing the hole in my hood before the dresser gets to me because I don't like the way they do it

The dresser asked my name, said, "Oh, that's my wife's name!" and then proceeded to spell it incorrectly on my head

The nurse Carrie made responsible for taking pictures was a bit overzealous in his duties and wouldn't let us doff until he got pictures

Sunset outside the Lunsar ETC

A Day in the Life

My dilemma is that I feel like I need to write a post before we inevitably lose internet for days again, but I don't have anything really exciting to write about. So on the advice of a friend, I am taking you through a typical day.

Every day I cry a little bit when my alarm goes off at 6:20. Not because I don't want to go to work, but because waking up is hard. So I hit snooze for the next 20 minutes or so and then hope I'm not late for breakfast.

We take a van to the site, hoping all the way that we beat the bus full of national staff. If we get there at the same time, there's no room to change and no hope of finding scrubs that fit. Yesterday, a man without pants handed me my boots.

At 8am, all the nurses and doctors gather around the whiteboards (because no disaster response is complete without whiteboards) to get handover from the night shift. We're still working on how to do a proper handover (i.e. not just reading out loud everything on the board about every patient). We have plenty of handover opportunities to practice. While all the international nurses do 12 hour shifts, the local nurses (and the international doctors...) are split into 3 shifts: 2 6's during the day and a 12 overnight (during which they usually sleep). 

We make several passes through the wards on each shift, so after handover, we have to make assignments. There's usually plenty of chiming in about who wants to do what, or who just did that job yesterday, or who can't go in because they picked open a zit on their face (you can't enter the hot zone with an open cut). The first pass is for patient care (feeding those who need help feeding, changing those who need changed, etc). In the morning we also have a phlebotomy pass to draw labs on patients and start or restart IVs. Not many nurses here have those skills. Or, I get put on phlebotomy with one of our four "lab techs" only to find that he thinks it's acceptable to try to draw blood on a 4-month-old with an 18 gauge needle. We've since introduced him to the butterfly needle.

Our second pass is always medications and vital signs (called TPR here, for Temp, Pulse, Respirations). Let me tell you, it is a real treat to try and get heart rate and respirations with goggles. I'm not sure who, but someone thought it would be a good idea to clean all of our goggles with some sort of scratchy device. It doesn't even matter anymore if you put the anti-fog spray on them, because you can't see a thing through all the scratches as soon as you put the goggles on your face. Sometimes if you tilt your head just right, you can see out the top or bottom. But you have to find a clock that's working first. Yesterday, I was helping with medications and I was doing the TPR so the national nurses would have time to hang all the IVs (we can't leave them attached when we aren't in the ward, so we do a 500mL bolus - or whatever can go in - before we have to leave). We got a new expat nurse in a few days ago, so she was following me around. It was her first time in the ward, so she wasn't touching patients, just getting a feel for things. She volunteered to watch the time so (theoretically), we could get TPR done faster and then help with the rest of the drips and meds. As we were in the middle of getting a pulse on one woman, the clock died. Second hand just stopped moving.

With so many fluids, the med pass often takes at least 90 minutes. Then there's yesterday when the national nurses saved the two hardest patients for last (I assume hoping that I would do them), and then they told me that they just couldn't give meds to those patients because they wouldn't cooperate. These women are laying on the floor and I think they ignore us sometimes, but I really didn't have much trouble hooking up their lines. But then I just had to wait another half hour until they were finished.

Anything that goes into the ward can't come out again. So we have to call all of our vitals (and doctor assessments) over the fence to the person posted outside. When the med pass goes really long, it's hard to leave the ward and then know you have another 10 minutes of shouting and enunciating to do while you can feel all the sweat inside your suit ("Bed C7." "C7." "Temperature 38.2" "38.2" "Pulse 130." "113?" "130. One. Three. Zero." "One three zero."). I'm always so thankful when the person outside isn't one who wants to double check every patient after we finish.

The doctors make a round through the ward once a shift with a nurse who speaks Temne. Often they come in during the med pass, tell us to hang another bag on a patient, and then get to leave before us. Something we're going to discuss at our meeting in an hour. Most of them are really good at helping out, though. ("Everyone does nursing care during Ebola!")

Our last pass of the shift is patient care again, which includes passing the next meal. Then we have change of shift and handover, and we do it all again with the afternoon shift. 

We may also have admissions and discharges. If possible, we try to clump the discharges in with another pass. That might mean that psychosocial comes and says that the discharge is ready from their end, so you yell over the fence to whoever is in the ward and say, "Hey, get so-and-so ready to go and send them to the shower!" But sometimes it's a bit more organized than that. Admissions can be a bit trickier, depending on the number of patients and their conditions. If the first patient you triage isn't ambulatory or they're wet (vomiting and/or diarrhea), they go right to Probable. Then if the next patient is better, you have to send someone else in for them because you can't go backwards to Suspect.

So to answer those who have asked what I do when I'm not in the suit: I help to make all of the above things happen! There is a lot of organizing and coordinating that goes on outside the ward, between medical and WASH and/or psychosocial. We have to make sure the labs get collected out of the hot zone, disinfected, and sent to the lab. We have to sign off meds in charts, sign off lab draws, and make sure the local nurses sign off their charts. We also always have a person posted outside each ward that has people in it in case they need something (i.e. "Hey, C16 is vomiting! Get the doctor to write for zofran and then bring it to me." or "So-and-so needs another blanket!").

It all depends on the number of patients and their conditions and the number of staff. Yesterday was so slow. We had so many national staff on in the evening that I didn't need to go in a second time. I ended up folding and organizing all the clothes in the psychosocial tent. I had gone in there to ask for long sleeves and long pants for our patient who also has TB. We had to put her in the convalescent tent all by herself so she wouldn't infect any of the other confirmed patients. 

This woman really amuses me. She speaks English really well, and I saw her very soon after she got admitted, so she has started calling me "My Friend." Any time she sees me (in PPE), she says, "It's my friend! You're my friend!" However, the other day I went to talk to her through the fence when I wasn't in the ward. I said my name so she would know who I was (name is always written on my head, remember), and she said, "Nice to meet you." ... So she recognizes me in the PPE, but not as a regular person. Guess that answers my question about whether or not it's possible to connect with a patient when you just look like a marshmallow with goggles.