Be the change you want to see in the world. ~ Ghandi

Thursday, February 26, 2015

Stairway Troll

Written Wendesday, 2/25

I am currently taking up residence on the stairway landing between the third and fourth floors of our guest house, where the wifi has been most reliably good today. It’s a nice way to meet all the PIH-ers I don’t know yet, as they pass me on the way to their rooms and laugh knowingly at the lengths it sometimes takes to get a good signal. One of the long-term staffers jokingly calls us “stairway trolls.”

Blogging in the stairway. I go where the wifi is!
Blogging in the stairway. I go where the wifi is!
It’s late and I’m still a bit jet-lagged so I know I should go to sleep, but I am bursting at the seams with new information and experiences and I’m afraid that if I don’t write it all down, little details will start slipping away. The past two days of training have been fascinating.
We spent most of Tuesday learning the case definition of Ebola, which sounds boring but turns out to be the bedrock of everything we do here. Patients will show up to triage at an ETU with a variety of symptoms, and it’s our job to decide who should be admitted to be treated for Ebola, and who should be sent to another healthcare facility or home. Sounds easy, right? From what the news tells us, it seems like turning up at an ETU with a fever would be an automatic admission.
The trouble is that there are several tropical diseases here that have similar symptoms to Ebola (Lassa Fever, for example, looks very much the same with the exception that Ebola patients commonly have hiccups). So why not just admit them to be safe, and then figure out what they have for sure once you have them quarantined in the ETU? Because of the nightmare scenario of admitting a person with suspected Ebola who turns out to only have malaria, but then they catch Ebola from having some contact with another patient while they waited to be diagnosed.
Patients who are admitted to an ETU through triage join the other non-confirmed patients in the “suspect” ward. This means they automatically live in the Red Zone, the high-risk area that we healthcare workers can’t set foot in without being completely suited up. As much as we will try to keep suspected Ebola patients separated from each other before they are confirmed, it’s not possible to guarantee that one won’t infect another. One of our case studies described a patient in the suspected ward (who turned out to be Ebola positive) who was delirious, ripped out his IV, and wandered into other suspected patients’ rooms, spreading his blood everywhere.  If any of those other patients had turned out to be negative, now they were at serious risk. Essentially, it would be horrible if patients came to the ETU Ebola-negative, and then caught it there.
We don’t want to admit non-Ebola patients to the suspect ward if at all possible, but we also don’t want to send someone home who turns out to have Ebola after all. Here’s another nightmare: You triage a patient and wrongly decide that her symptoms don’t meet the case definition for Ebola, and she goes home and infects her entire family.
If Ebola tests were instantaneous and 100% accurate, we wouldn’t face scanarios like this. Unfortunately, they aren’t.  The amount of time it takes to get results on a PCR (the blood test for Ebola) has decreased during this outbreak in many cases from days to hours, but many places don’t have a lab that is sophisticated enough to handle blood samples as hazardous as these. And even if your patient’s Ebola test comes back negative, they don’t get an automatic ticket home. In the first few days of the illness the viral load may not be high enough to be detected by the test, so they’ll have to remain in the ETU for a few more days and re-test, to make certain that the initial PCR wasn’t a false negative. One of the national nurses told me today that she felt their most egregious mistake at the start of the epidemic was that they sent patients home after one initial negative test. She was clearly upset as she recalled that they had sent home one of their health workers despite his symptoms because his Ebola test was negative, only to have him return a few days later and die shortly thereafter.
Now I’ll complicate things even more. It would be easier to adhere to the case definitions that guide us to admit a patient if we were certain that every patient was being perfectly honest. But people who don’t want to be admitted to an ETU often hide their symptoms, denying that they’ve had diarrhea or vomiting and insisting that they feel fine. You may also triage someone who has no fever, which lowers your suspicion, until you ask the right question and find out they’ve been taking Tylenol in order to bring their fever down.
Many of the examples I’m using have come from  real case studies that we discussed in small groups in class, which for me has been the most valuable part of training so far. You think you’re somewhat prepared, until you find your group split down the middle trying to decide what to do with the case you’re discussing, which is an actual situation that clinicians faced in an ETU.
We were faced with another sobering reality today, as Ebola survivors had been invited to our training to share their experiences with us. They sat in a row at the front of the class, bravely recounting the hell they had somehow managed to survive. While one survivor took his turn to speak, others stared blankly at the floor as if re-living their experiences. Another leaned back and covered his face with his hands, seemingly willing himself not to remember what he’d seen.
Most of the survivors we heard from contracted Ebola while caring for their ill family members early in the outbreak. In one case, a patient was sick in a government hospital but the nurses refused to care for her because they feared Ebola. When her family came to the hospital to do what the nurses wouldn’t, they all became infected. In another case, an ill woman refused to go to the hospital, so her family members who were health workers cared for her at home. They started IVs on her with their bare hands, and of course infected themselves.
One man told us that when he went to an ETU his family had no hope for his survival, and that “with every tick of the clock, they called me to ask, ‘Are you ok?'” Their experiences in holding centers, which screen patients for Ebola and transfer them to ETUs if necessary, were horrific. One man recalled sharing a toilet with 10-15 people, diarrhea and vomit covering the floor, leaving anyone who didn’t already have Ebola to almost certainly be infected. The medics were so terrified of their patients that they handed them medicine through a barbed wire fence. “Nobody helps anybody,” he said. “It’s like the day of judgment.”
Once they were transferred to an official ETU, many described how grateful they were for the competent care they began to receive. One survivor explained that healthcare workers in the ETU were confident in their PPE, and therefore not afraid to enter the ward and care for their patients. They repeatedly thanked their Sierra Leonean caregivers, insisting that “the staff are making so many sacrifices.”
When they were asked what the worst and best moments of their experience had been, I was certain they would all say that their best day was when they were pronounced Ebola negative and discharged. But most of them described that moment as conflicted; although were overjoyed to have survived, they knew they had to return to lives in which many of their family members, including spouses and children, had died. One man’s wife died of Ebola on the same day that he was discharged home cured.
Surprisingly to me, most of them described their “best” moment as an experience with a healthcare worker. It put faces to the constant message we are hearing that providing quality, humane care in the ETUs is essential. At the beginning of the outbreak, the care in ETUs was horrible and degrading (how many photos did you see in the news of patients dying alone on a cement floor?). Many people chose to keep quiet if they were sick, terrified of what would happen to them if they turned themselves in. Our trainer told us of one case in which a patient’s mother was told that he had died in an ETU, only to have him return to his village cured a week later. His neighbors ran from him, believing he was a ghost. After thinking that her son had gone to an ETU and died, the mother refused to seek treatment when she fell ill, and she died of Ebola at home few days after her son returned.
Enough Beds For Everyone
Although ETU care has greatly improved (and it is now criminal to remain at home if you have Ebola), some people still resist seeking treatment. Confirmed Ebola patients are interviewed to determine who they have been in contact with since showing symptoms, and those contacts are actively monitored for 21 days. Community health workers visit them at their homes to check their temperatures and ask about symptoms, but it can be difficult to get the true story. Our trainer encouraged asking the families to step outside of their houses to take their temperatures, using the example of an old woman who told the health workers she felt fine, but was unable to stand up when they asked. In other cases, people who are aware of what time the health workers are coming have removed their sick family members from the home to hide them. There has been a big push to involve local leaders in the process of monitoring; as our trainers pointed out, the villagers will never trust us as much as they trust an authority figure they already have faith in.
There is also an intense focus here on safe burial practices. Since an Ebola patient’s viral load increases the longer they are sick, corpses are extremely infectious. Studies have shown that the virus can live on dead bodies for 6 days. In a culture where washing the body of the deceased is a common and important ritual, that spells disaster. We were told that some burial practices include mourners washing their faces with the water used to clean the body, or in extreme cases even drinking it. While that may seem abhorrent to us, try to imagine if a stranger from another country wanted to take the body of your child from you without a funeral or a coffin. It’s easy to understand why many Sierra Leoneans refuse. Unfortunately, this can mean that a single funeral can set off a chain reaction in which everyone who attended contracts the virus.
I could go on and on, but I should follow the health workers’ cardinal rule (to take care of myself first) and go to bed! It has been a fascinating few days. I take notes furiously and hope that it’s all sticking in my brain somewhere, ready to be called forth when I need it in the coming weeks. I’m excited to get into the mock ETU tomorrow and start practicing getting my hands dirty (or rather, my outer layer of gloves. Never, never my hands).
Yep, that's me in there!
Yep, that’s me in there!

Tuesday, February 24, 2015

National Ebola Training Academy Begins

We made it to Sierra Leone! It was touch and go for a minute in DC, where we sat on the tarmac for 3 hours while they plowed the runway and de-iced our plane. As we watched the time for our layover in Brussels trickle away, I started to get pretty nervous – flights into Sierra Leone only leave twice a week. Fortunately we landed in the nick of time, and the wonderful flight attendants made an announcement that there were some humanitarian workers trying to make a tight connection to West Africa, so everyone else kept their seats so that we could get off first!
Something like 30 hours after we left Boston, we finally landed in Sierra Leone on Sunday night. The same smells I know from East Africa made me feel at home from the moment I stepped off the plane. Even after so many hours of travel and sleeplessness, I knew I was exactly where I was supposed to be.
The reality of the Ebola outbreak hit us as soon as we walked across the tarmac and reached the door to enter the airport. Chlorine hand washing stations awaited us outside, and everyone was made to wash their hands before being allowed to enter. After reading so many news stories about it over the past several months, it was surreal to be actually washing my hands with chlorine to prevent spreading Ebola for the first time.
Once inside, it was probably the most fun I’ve ever had in customs. We were surrounded by other humanitarian responders from MSF, World Health Organization, Direct Relief, you name it. It was lovely to chat with them all as we waited. After clearing customs, I waited in line to have my temporal temperature checked (another surreal experience). It’s an odd moment, if you let your imagination run away with you and start to wonder what might happen if your temperature comes out high… Fortunately, I was a normal 36.3 C and was waved right on.
A short bus ride, ferry trip, and another bus took us to the Partners in Health guest house, which is lovely. We were met with another handwashing station at the front door, and had our temperatures checked and recorded, as we will every time we enter the building. We are sharing an apartment with electricity by generator, running water (though not hot), and wifi that comes and goes. We even have a washing machine! My coworkers are laughing at me right now as I sit on the couch, blogging beneath a line of drying scrubs and underwear.
These handwashing stations are at the entrances to most buildings
These handwashing stations are at the entrances to most buildings
Our first day of World Health Organization training was today. It was clearly well-run and fascinating since I was able to stay awake for 8 hours of class despite some serious jet lag! We PIH-ers are just about the only non-Sierra Leoneans there, which is lovely because we get to interact with national staff, who have been fighting Ebola much longer than us and living the reality of this outbreak every day. Most of the Sierra Leoneans I’ve spoken with there have been working in ETUs for several months and are attending training for the third time. Since protocols change quickly as research and experience grows, they are encouraged to take the training again every few months. We of course all took advantage of the hand washing station before entering the building, and had our temperatures checked and recorded by the staff.
Washing my hands before entering training on Monday morning.
Washing my hands before entering training on Monday morning.
Our first lecturer wished us all a good morning, and chided our lackluster response with, “That ‘good morning’ has Ebola!” We were reminded of the huge importance of infection control and prevention among healthcare providers, not only to keep ourselves safe, but because of the role it plays in public perception here. We were told that, “You have not come here to die,” which is always reassuring! At the beginning of the outbreak, hundreds of Sierra Leonean healthcare workers contracted Ebola due to poor infection control measures; 221 have died to date. To the public it seemed like the situation was hopeless: Why would you come to an Ebola Treatment Unit for care, when those who are caring for you are dying themselves? To put it simply, dying sends a bad message. Fortunately this perception has shifted as infection control measures and patient care have improved, but we as healthcare workers play an important role in continuing that momentum. Ebola survivors are also pivotal in instilling hope and proving that admission to an ETU is not an automatic death sentence. Because they are immune to the virus for an unknown period of time, many survivors have also been helping to provide care in ETUs.
We see educational Ebola signs all over the city. This one reminds people that Ebola isn't a death sentence, and encourages them to call the emergency Ebola number early if they're ill.
We see educational Ebola signs all over the city. This one reminds people that Ebola isn’t a death sentence, and encourages them to call the emergency Ebola number early if they’re ill.
It has quickly become clear that habits I live with in the US will need to be broken ASAP. One of our trainers stepped into class this morning to let us all know that they had been watching us for 15 minutes, and we each touched our faces an average of 3.4 times per minute. Considering Ebola enters the body through our mucous membranes (eyes, nose and mouth), I’ll just have to learn to put up with the itch on my nose. We also don’t shake hands when we meet someone new; instead, we offer to touch elbows. It’s hard not to feel rude at first, but the stakes are too high to care really.
The basics are essential here: We all re-learned how to wash our hands today, the Ebola way. I’m certain I have never paid such close attention to a person washing his hands as I did at that moment. It takes a full minute, with maneuvers to make certain that we clean every centimeter of our hands. We practiced in a group, everyone nit-picking each other’s technique because it will likely be the thing that keeps us Ebola-free.
The hand washing technique we'll use in the ETU
The hand washing technique we’ll use in the ETU
Next we tested our ability to remove dirty gloves without contaminating ourselves. After dipping our hands in mud, we each SLOWLY removed our gloves, careful not to snap them and fling infectious material, and making certain that no part of the outside of the glove touched our skin. Our trainers inspected our hands and declared, “Quarantine!” to anyone with a speck of mud on their skin. It’s excellent practice for when our gloves will be covered with bodily fluids, and it’s no longer a game.
And finally, it was time for the infamous suits. We refer to them as Personal Protective Equipment (PPE), and we’ll need to know exactly how to don and doff them in order to keep ourselves safe in the hot zone. Today was just a test run, with trainers walking us through the correct procedure for putting on each item – rubber boots, suit, fist pair of gloves, hair cover, mask, face shield, hood, apron, and second pair of gloves. Another surreal moment, to be completely encased in the suits I’ve been seeing on TV for months. Between the mask, face shield, and hood, my visibility was incredibly limited and I struggled to hear what the nurse next to me was saying. We then took a lap around the building, getting a feel for how we would react to the PPE. My lovely African teacher acted as my buddy (everything in the hot zone is done in pairs), and kept asking me, “How are you doing, buddy?” every few minutes. It’s hot in there, for sure, but I didn’t feel faint or claustophobic. We’ll see in the coming days if that changes when it’s an hour and a half, rather than five minutes, that I have to work inside the suit.
The moment you remove your PPE is the highest risk time for contaminating yourself, so this skill is crucial. My buddy walked me through each step, as the support staff will do in the ETU. The motto is “There is no emergency in Ebola,” meaning that we do everything at a snail’s pace to ensure we are doing it safely. We remove each part of the PPE carefully, with a minute-long hand wash in between each piece. It’s a long process. I’m actually looking forward to getting more practice tomorrow; I’d like it to be muscle memory by the time I’m doing it in real life.
We wrapped up the day with a temperature check, the staff scurrying around to make sure no one left without recording theirs in the log. After a delicious dinner of rice, fish and plantains, I’m now off to bed to get a handle on this jet lag before more training tomorrow. Lots of love to all of you!
By the way, a PIH staffer told me that they get more volunteer clinicians from Washington than anywhere else. So way to go, Washingtonians!
Our suits waiting for more training tomorrow
Our suits waiting for more training tomorrow

Monday, February 23, 2015

And We’re Off!

Our stateside training is complete, our passports have arrived complete with our visas just in the nick of time, and today we begin our long trek to Sierra Leone! I’ve utilized all my packing prowess and succeeded in whittling my belongings down to carry-on luggage only, which I’ll admit I’m pretty proud of! I even FedEx-ed my one set of winter clothes back to Seattle, and then sprinted back through the snow to the warmth of our hotel :)
My luggage for 6 weeks
My luggage for 6 weeks
When we arrive in Freetown, we will have a week of World Health Organization training complete with a mock Ebola Treatment Unit and survivors acting as patients, then real hot zone training in an ETU before we are sent to our respective assignments. It has been an absolute pleasure spending time with the rest of my group; there’s nothing like hanging out with a bunch of like-minded people who “get” why you do what you do, to really light you up. I think we are all itching to get started.
LOVE this kiddo on the wall of PIH's office
LOVE this kiddo on the wall of PIH’s office
Partners in Health has taken great care of us and treated us like part of the family, which makes it easy to entrust ourselves to them. Yesterday we had a session with PIH’s occupational health doctor to discuss the protocol if we become ill in the field. PIH has not had any clinicians contract Ebola (knock on wood!), but it’s common to experience diarrhea or other illnesses that could mimic some of the symptoms. We’ll be checking our temperatures twice a day, reporting any issues, and isolating ourselves if necessary. Which I explain only because I think it’s interesting, not because I expect it to happen!
Of course, we have also spent plenty of time discussing the surveillance process that we will experience when we get home. I’ll explain a bit now, just to soften the ground for when it’s my turn!
Regulations for returning Ebola responders are set by the COUNTY in which they live. The CDC has guidelines, but states are not required to follow them, so it’s up to each county to decide how they want to do it – which is why some of our clinicians are being told they can’t leave their homes for 21 days (the incubation period for Ebola), while others have much more reasonable restrictions.
Unfortunately, some counties are basing their requirements on public perception, rather than actual science. I understand that people are terrified of catching Ebola, but acting on irrational fear rather than proven facts simply doesn’t do anyone any good. The fact is that Ebola CANNOT be transmitted by someone who is not showing symptoms. It is NOT like the flu, for example, which someone could spread to others before they even knew they were sick (by the way, thousands more Americans will die of the flu this year than Ebola, so if you’re freaking out about Ebola, get your darn flu shot). This is the exact reason that returning clinicians check their temperatures at least twice a day and monitor themselves closely for any symptoms. Even if we had somehow been exposed and contracted Ebola, we can’t give it to anyone else until we show symptoms.
Secondly, Ebola is only passed through direct contact with the bodily fluids of someone who is ill – it is NOT airborne. “Direct contact” includes physical touch but also contact with infectious droplets. The common confusion that I have heard is that Ebola could, in certain cases, be transmitted through a cough – so doesn’t that make it airborne? Not in an infectious disease sense. To clarify, for this specific example to happen you would have to be in close proximity to someone who is already sick with Ebola, and they would have to cough in a way that their saliva or blood landed in your mucous membranes (eyes, nose, mouth). The difference with airborne viruses (like a cold) is that the virus can hang in the air in a lingering cloud. So if I have a cold and I cough, you could walk through the room a few minutes or even hours later, after I’m long gone, and still catch my cold. That is not possible with Ebola. I know it seems like a fine distinction, but it’s an important one. I mean, you usually notice when someone coughs their bodily fluids onto you, and it’s easy to prevent, whereas you don’t have any idea when a virus in hanging in the air that you walk through.
Still don’t believe me? Let’s get real, and imagine how many more infections there would be, not just in West Africa, but everywhere, if Ebola was airborne. There’s a reason Ebola has been referred to as “a disease of caregivers”: most people who have contracted it have done so while taking care of someone who was ill. They don’t catch it walking down the street, or hugging their healthy friends. Family members and healthcare workers catch it while caring for someone who is very ill and losing a lot of highly infectious bodily fluids through huge amounts of vomit and diarrhea (sorry, non-medical friends!) Remember Thomas Duncan, the Liberian man who died of Ebola in Dallas? He was misdiagnosed and sent home with Ebola for DAYS. He lived with his family members while he was actively ill, and NONE of them caught it. If Ebola truly was airborne, how did they come out unscathed?
Another HUGE factor in the spread of Ebola which must be mentioned is the sanitary conditions in West Africa. Imagine caring for a family member who is losing liters of fluid through diarrhea and vomiting, in a hut with no running water or flush toilet or washing machine. Now compare that to the United States. Though of course I don’t know for sure, I would guess that Mr. Duncan’s family avoided close contact with him and washed their hands a lot, as any of us would do if our family was sick with anything. There’s a reason Ebola spread like wildfire in West Africa and was stopped in its tracks in America.
So please excuse the long rant, but that brings me to me. My plan is to live in my house with my husband for 21 days, see my friends and family, and (just to be extra safe) to refrain from swapping bodily fluids with anyone. It shouldn’t be terribly hard – I rarely lick strangers or uncontrollably release bodily fluids at the grocery store :) So let’s say, in theory, I’m at home with my family a week after I get home from Sierra Leone, and I develop a fever. I’ll immediately self-isolate, alert public health, and if I meet the criteria, I’ll be taken to a designated hospital for treatment before I am a risk to anyone. And fortunately I will have been keeping my bodily fluids to myself in the meantime anyway, so there’s no way for anyone to get sick. This is, by the way, all in line with the regulations that King County Public Health has set for me.
Questions about this? Ask me! It is hugely important to me to make this clear so that the public isn’t living in fear for no reason, and returning clinicians aren’t stigmatized.
Please feel free to impart this information on anyone and everyone! I know plenty of Ebola responders who are doing this work in semi-secret, for fear of how their friends and neighbors will treat them if they find out. I believe that is truly a shame, and they deserve better. While I completely respect everyone’s choices regarding how much of this experience they want to share, I’ve been very open about what I’m doing in the hopes that some simple conversations and education will turn the tide. If all of the scientific data doesn’t convince you, take a moment and really ask yourself: Do you honestlybelieve that humanitarian responders would put their lives at risk to save strangers on the other side of the world, and then come home and knowingly put their friends and family in danger?
There’s so much more to say about what we’re expecting to see on the ground, but I’ll report back to you when I’ve begun to see it for myself. I promise my next post will be more about what we’re DOING, and less lecturing :) We arrive in Sierra Leone on Sunday night but I’m not sure exactly when I will have internet access again, so hang tight for a few days!
To end on a happy note, I’ll leave you with this link that was shared with us in training: “The Boy Who Tricked Ebola”. He’ll put a smile on your face!