How to write a report.

     I am a little brain dead right now as I wait for my Granddaughter Charlotte's fifth birthday party which starts at 11:30 tonight.  Normally this is not a problem and I love that I can stay up for the party.  We are going to try to Skype.  Usually, the Internet can't come close to handling a video stream, but late at night is when it seems to be at its best.  Fewer users, less sun interference with the signal, maybe some space time continuum thing that brings Liberia a little closer to the U.S.  I don't know the real reason, I just learn to appreciate the mystery.  Since the Internet was spiffed up last week (to where is is merely slow and unreliable rather than positively atrocious), I felt it was worth a try.   But I am still brain dead despite my excitement and let me explain why.

     Heart to Heart International helps support it's operations in Liberia with a generous grant from USAID, Humanitarian  Response.   They do require extensive reporting on the grant and rightfully so, it is the US taxpayer money.  Reports are due quarterly.  We had reasoned that since the ETU had only been open for a month, that the quarterly report would be due after three months of operation, so we submitted a request for extension.  Somehow, that request got lost and we were notified of that the extension request had been turned down and that the report was due in two days. Never having submitted a USAID report, I started gathering what I thought was required and we developed the report.  Hoo Boy was I wrong.  So much more was required but no one here had submitted one before.  Thus began a 9 hour thrash in trying to simultaneously develop the additional data and to get the data entered into a persnickety program that was best described (with substantial understatement) as not intuitively clear.  

     Well, we made it through by 7:00 PM but I will admit to being butt sore and brain tired at the end of it.  In a way, it was fun.  It certainly is a challenge when you have to figure out something when the instructions are very little help.  And we did get it done.  But next time, we will know to start a little earlier.  And no, they didn't teach us about this in Medical School.

Tappita Fashion

     Heart to Heart's Website recently featured our ambulance section practicing operations in their Personal Protective Equipment (PPE).  PPE is a subject near and dear to everyone that works in the hot zone of an Ebola Treatment Unit (ETU).  There are very specific sequences and methods which are used to put on (or don) and take off (or doff) PPE.  These methods are taught initially in 'cold training' and reinforced in 'hot training' and shift work in ETUs.  This training is conducted by different organizations in different locations and there are often slight differences in the way it is taught.  Some organizations may teach 3 pairs of gloves, some will teach 2 pairs.  Some will place the straps of the goggles inside the first hood (of the Tyvek suit) and some will place the straps over the first hood and under the outer hood.  Some will seal the cuffs of the outer gloves to the suit with tape, others won't.  These may sound like trivial differences, but they aren't, or maybe they are.  The problem is that nobody knows for sure.  You can always add a little more 'just to be safe', but sometimes that addition may make doffing of the PPE more cumbersome increasing the chance for error.  The majority of identified healthcare worker Ebola exposures have occurred during doffing.  

     You are also much more comfortable with the method in which you were trained.  Standardization of methods helps reduce errors, but how do you accommodate differences in training when the feelings about the styles are passionate.  It isn't surprising that people are passionate when potential problems could mean yours or others survival.  Or maybe not, and you can't know for sure.

     We faced that dilemma in our ETU with two groups that trained under different systems.  Each side felt passionately about their method and there wasn't much inclination to compromise, which was a problem if we were to maintain some degree of standardization for doffing.  We eventually decided, by majority vote, for the less stringent methods, but that left many of our members, including the Liberian staff, very unhappy.  

     The next morning, a team from the CDC arrived at the ETU unannounced.  They had come to investigate reports about the village with multiple unexplained deaths.  That village was in our area so they stopped by our ETU before going to the village.  Providentially, their team included an expert in PPE!  We had a wonderful question and answer period and were able to resolve our disputes.  It felt like a pretty contrived happy ending, but that is what happened.  It was good to resolve this question before we had our next patient, who arrived the next day from the village that the CDC was investigating.  

Do what you can

     Patients are often admitted to an ETU when they are sick with something other than Ebola.  Among the general population in West Africa, a myriad of conditions can cause fever, body aches, stomach pain and headache.  However in the setting of an Ebola outbreak, those symptoms meet the criteria for a diagnosis of 'Ebola suspect'.    First, you have to rule out Ebola and then you can get the patient to somewhere where they can be more thoroughly evaluated and treated.  You just hope that they don't get worse while you are evaluating them in the ETU.  

     We had a patient admitted to the ETU after having a cesarean section in the neighboring hospital.  Initially, she had been doing well then she suddenly turned worse.  The hospital staff became concerned about a possible Ebola infection and unfortunately, she meet the case definition and we had to admit her.  We quickly tested her, found her to be negative and we returned her to the hospital.  Over the next day, she did better, but then she suddenly turned worse and died.  To make sure, we tested her again for Ebola which was again negative.  She had probably died of a pulmonary embolus, but she left a 6 day old baby girl.

     This is a problem.  The baby's father isn't married to the mother and there is no tradition of wet nursing in Liberia.  A baby's chance for survival in Tappita is somewhat compromised anyway with the poverty and disease prevalence, even with an intact family.  The situation is so much worse with a baby is so young and without support.  We have no technical obligation to help the baby.  She wasn't our patient and there was no diagnosis of Ebola.  There was even some question about what we could officially do for her.  But we couldn't just not do anything.  We passed the hat and collected enough money for formula and will continue to provide that for as long as we are here. The sister of the baby's father agreed to watch her since she has no girls.  We arraigned for multiple 'community outreach' visits to the home to weigh and check on her every week or two.  Yes, we will only be able to help for the next three or four months.  Yes, we are well aware that even this effort is Quixotic and that the child still faces long odds of making it to her first birthday.  But despite the odds, we are called to care and we are called to at least try.

What Ebola does

     Ebola has so many effects outside of the damage that it does on the human body.  It can injure people psychologically, economically and socially.  We evaluated an Ebola suspect in our ETU whose test came back negative.  We returned him to his community, but they wouldn't accept him because they were afraid that he still had Ebola.  We had told his family about his negative diagnosis and provided him with an official certificate, but his neighbors still wouldn't allow him near.  Our psychosocial team had to go to the community and work with the patient's neighbors to finally get them to accept him back into the community.  

     That fear of being quarantined by neighbors can work against measures used to control the disease.  Last night we were notified that a nearby village had had eight deaths in the last 3 weeks due to 'magic' and that two bodies were still on the ground.  We notified the Nimba County Ministry of Health and they dispatched a burial and contact tracing team the next morning.  We also sent our laboratory technician to collect tissue samples to test for Ebola.  When the team arrived in the village, the Headman told them that there were no bodies and that they had already been buried.  He further said that all the people who died were old (in their 50's and older-ouch) and that they had simply died, without any symptoms of Ebola.  Unfortunately, villagers will often lie about Ebola.  If Ebola is believed to be in a village, the surrounding villages will blockade all the inhabitants until they are convinced that the village is Ebola free.  That creates terrible hardships for a village, sometimes leaving them without access to food or even water.  I understand the village Headman's dilemma, I just hope that he was telling the truth.  In this case, eventually, time will tell.

Tappita

Tappita is a city of around 90,000 people but with a interesting way of doing things.  Here you see a typical gas station.

No this isn't unusual and yes that is gasoline in the glass jars on the shelf.  You may consider this a bit inconvenient, but where else can you get a service station that actually pumps gas?

And if you get impatient, you can always visit Starbucks, or the local equivalent which is the Tea shop in the center of this picture.

     I tried to inject a bit of levity but from the pictures, you might begin to appreciate the material destruction of infrastructure that occured through 15 years of civil war.  However, you can only begin to appreciate the loss of human infrastructure that the war has caused after talking with the people who survived the war.  That was even worse and that was before Ebola.  While the situations in the pictures look pretty primative, the people are recovering better than one might expect.  They are hopeful, bright and industrious.  They still have a very long way to go and our hope is that we can help them get at least a little farther along on that road.

An observation

     A random observation while I have decent internet and am waiting for the meeting this afternoon.

     Driving down the road, we passed a Liberian carrying a stalk of bananas over his shoulder to market.  He was of interminable age and could have been anywhere from his early 20's into his 40's.  From the route, we knew that he still had several miles to go to get to the market and we had no idea of how long he had been walking.  Bananas are a commodity, but banana trees are widespread and that stalk of bananas couldn't have too much value.  

     It makes one reflect on the monstrous inefficiencies in the developing world.  The man that we passed will have invested a whole day in carrying a heavy stalk of bananas to the market, selling it for a small amount of money (or bartering for something of similar value) and then walking home.  While this may produce enough money to meet his needs, it also results in higher prices for commodities when the only way that you can obtain them is through an inefficient manner.  Eggs in Tappita cost around $1 US per egg.  

     But what would efficiency add?  If someone set up a Walmart in Tappita, what would that do?  Immediately, people would buy their bananas from the Walmart at a much cheaper price and not buy from the man walking down the road.  People in the market would no longer have 'jobs'.  Then, how would resources be distributed so that the man earns enough money to feed his family?  The efficiency of a Walmart could mean starvation for the people on the margins.  

     I am certainly not advocating continuing the inefficiencies in the developing world. But I do think that we need to be very careful with 'top down' solutions.  Programs such as education, improved communication, improved infrastructure and access to capitol could produce more lasting progress with much less disruption.  They would be tools by which that man could produce more bananas and more efficiently bring them to market.  He could then sell a greater number of them at a lower price and make enough money to improve his familiy's situation.  We need to have a more organic program of development that facilitates the people in the developing world in finding their own better paths forward, rather than top down solutions that can hurt as much as they help.  At least most of the time, in most situations.  Nothing is universal.

     Thanks for your prayers.  After I return to Tappita, I may have a harder time posting due to the bandwidth of our internet connection.  However, improving that is one of the projects that we are working on.

   

Our first patient.

     Sorry for the delay in posting.  We have been busy and this is the first time in several days that I have found enough bandwidth to load Facebook.  

     We had our first patient.  He was a sick older man who had a fever and three of the constellation of symptoms that gave him a diagnosis of Ebola suspect.  We dispatched our ambulance, picked him up and transferred him to the ETU.  After our triage we tucked him in overnight with antimalarials, antibiotics  and fluids pending the blood draw the next morning.  By noon, we got his blood test back and he was negative for Ebola.  Given his constellation of symptoms, I wonder about Dengue fever or pneumonia but we don't have X-rays or any blood tests besides Ebola and Malaria in the ETU.  He certainly was too sick to send home so we transferred him to the neighboring community hospital in Tappita.  

     Overall, it was an excellent opportunity to work out kinks and minor coordination issues.  Trying to learn little things like who calls the drivers, how we get the sprayers who clean the ambulance in full PPE back into the ETU to doff their PPE, etc.  I learned that, when I wear them for extended periods, the triple gloves that we wear in PPE are a little too small for my hands.  After one half hour in PPE, the fingers of my right hand were going numb from lack of circulation.  And of course you are not in a situation where you can just take off the gloves.  Many if not most of the health care workers who become infected with Ebola, for whom you can document a route, became infected during the removal of the PPE.  You just finish the rounds and make a note to get supply to get bigger gloves.  

     I am off to Monrovia today to attend one of the WHO meetings.  Not the most fun part of the job, but it is very important to 'show the flag' and to meet the main players.  Who knows, maybe I'll find better internet!

Serving With Others

One of the more interesting things about this assignments is the diversity of the people who are here.  The Liberians are dedicated, intelligent and they pick up the system very quickly.  The expats though, are a really heterogeneous group of people who are united in a desire to help people at the edge of what most will tolerate.  After that, not so much unites them.  We have physicians who run clinics in other developing world countries, administrators who have worked in a series of positions and organization scatted across Africa or in South and Central America, nurses who have served in a wide variety of developing world countries for shorter or longer periods, people who hitch hiked across Europe for 6 months and many, many more.  Relaxing over a beer at a restaurant (that popped up across the street after the opening of the ETU), talk goes on about adventures covering 6 continents.  The discussions of what we have eaten or things we have done are not the sort of thing you would hear at a bar in Johnson County Kansas.  Of course, strong people often come with strong personalities and that can make things interesting as well.  Thus the 90/10 rule.  The bulk of the people working here are on 6 month or duration contracts and they have all given up their jobs to come here and fight Ebola.  They are a great group of wonderful people and we are grateful for their service.  Even if they are a bit challenging at times.

Waiting patiently

  I have started running over here.  I am not in as good of shape as I usually am and I won't embarrass myself by saying how slow or short the runs have been but at least the weather is great for running.  Low 50's I would guess by the coats, hats and mufflers on the Liberians.  Part of my speed issue may be the gerbil wheel aspect of running the 1/4 mile loop around the hospital.  Once I build back my speed and endurance, I will reward myself with longer  runs out of the compound.  

     Still working on setting up programs and procedures and double checking little things (how loud is the ringer for the ambulance phone and where does it ring?).  Things that seem nit picking but can mean a lot to how well everything works. Also working a lot on personnel issues.  That is one thing that I remember well from the military.  The 90/10 rule applies here as well.  

     Thankfully, the situation here is quiet on the disease front.  Cases have been north of us, but none have made it to our ETU.  This has given me a chance to structure things in the ETU as I like them.  If it remains quiet (God willing), we will further expand our outreach activities.  We cannot perform medicine outside of the ETU, but we can teach and mentor.  Our Public Relations crew is sounding out the community for opportunities for teaching and outreach.  Even if we don't treat much Ebola, we will leave Tapeta a better place for our coming.

A new role in Tapeta

     I haven't posted for a few days because the situation here has been a bit unclarified since I arrived in Tapeta.  I came over here with the intent of just 'filling a stethoscope" and simply being a doc in the ETU (isn't that enough?).  Sadly, I had to put on my Heart to Heart Board of Directors hat and assume the responsibilities as the Chief Medical Officer in the ETU in Tapeta.  Sometimes you plan the situation and sometimes you have to react to it.  Things being as they are here, I have extended my deployment through early April which is the end of Heart to Heart's contract with USAID.  Jo, College Park and HCA have graciously (but maybe not excitedly) accepted this extension.  I wasn't exactly packed for 3+ months but that is ok, I can work with it.  I just ask for your support and prayers.

     My duties are much different.  Basically, I am responsible for the smooth functioning of a very complex clinical operation.  I have to approve, modify or establish procedures to ensure that all potential Ebola cases are evaluated and treated in a safe and efficient manner (with much more emphasis on safe).  I am stepping into and operation that has just started and am learning the personalities and evaluating procedures for effectiveness.  I also have supervisory responsibility of all the administrative and logistical aspects which impact our clinical operations (basically everything).  I hate to quote Donald Rumsfeld on anything but he did have a point about there being known unknowns and unknown unknowns.  I am still discovering what I don't know.  But I am getting there.

     I haven't said much about the location.  Tapeta is a city of 90,000 people but no restaurants that an expat could trust.  They do seem to have an adequate supply of Liberian beer.  It can be a bit hazy and cool early in the morning but quite hot and muggy during the day with temperatures in the mid 90's.  We are currently in dry season and it is dusty.  Rainey season starts sometime in April.  

     Our cooking staff provides food for about 150 people each meal and the food is quite good compared to what is available in other ETU's.  I won't say that there is currently much variety, but it is plentiful, safe and satisfying.  Sleeping accommodations are about what you would expect for a higher grade of housing in a poor country.  It works (mostly), but certainly with no frills.  It is very safe and the local population is quite happy that we are here.  Everyone waves at you as you walk around.  

     Liberian English is pretty difficult.  One thing that I have noticed is that it is more difficult the farther that one travels from Monrovia.  I find myself repeating back what a Liberian says as a method to make sure that I comprehend what they have said.  Still sometimes I only pick up half of what they say.  People have discussed how English is becoming a world wide universal language.  Well, I am experiencing the opposite effect, how English is evolving into another distinct language.  

     Again, thanks for your support and prayers.

Arriving in Tapeta

     One of the ETU physicians told me yesterday that they hadn't had a positive Ebola test in Monrovia for over one week.  This is a great sign and a testament to the hard work and sacrifice going on in Monrovia, but people are getting a little complacent.  There have been large crowds at the beach and people were dancing and partying for New Years eve.  While a certain amount of release is expected after getting through such a period, it is a problem when that release also increases the risk of Ebola transmission.  There are no reported cases yet from New Years eve, but we aren't yet near the end of the up to 21 day incubation period.  

     It is a different case outside of Monrovia and in the neighboring country of Guinea.  The main road from eastern Guinea into Liberia traverses the city of Ganta which is 3.5 hours north of Tapeta.  10 days ago, a man sick with Ebola crossed into Liberia in Ganta and died en route to Tapeta.  He had 40 known contacts including 7 health care workers (without protective gear) with 4 confirmed positive tests for Ebola (so far).   On my ride to Tapeta today, I passed the body of a young man, lying on the side of the road 30 minutes south of Ganta.  There was no sign of trauma and there was no one else there with the body.  I did not leave the car to investigate further.  In an Ebola outbreak, an unexplained death meets the case definition of 'suspect case' for Ebola.  While there is no current case of Ebola in Tapeta, we will need to keep a high level of suspicion.  

     Another thing to remember about this country is that it is not far removed from a horrendous civil war.  My driver today survived the civil war by laying low.  The rebels took his wife and left him with two children to raise.  He has never learned the fate of his wife. The forces were tribal based and there is still a lot of animosity between the groups.  After the peace treaty, some of the rebels returned to their villages and were killed for what the did during the war.  You can still see signs on the roadside advocating 'ballots not bullets'.  But even with all of that, people here are making significant progress.

     Tomorrow, I will start working in the ETU in Tapeta.  Please keep all of us in your prayers.

     

Pictures from Liberia

I thought that I would post some pictures as I will be leaving tomorrow for Tapeta (the change is changed).  In disaster response, it is always good to be flexible in your planning.  I am getting to practice my flexibility today.  Since the internet in Tapeta is much slower and less robust than it is in our offices in Monrovia, I thought I would take this opportunity to post some pictures. This is a picture of the MoD1 ETU.  It is fairly typical with lots of tents and a fairly standardized pattern of organization.

This is the classroom in the ETU during a break.  It was pretty warm but the instructors said that it was good practice for being in PPE.  

This is a picture of me donning PPE during the training.

This is the handbook we use as a clinical referance.

This is the 'memory tree' from MoD1.  On it, there are colored ribbons for each survivor and a black ribbon for those that didn't survive.

This is the survivors board from the MMU ETU in Monrovia.  This is the ETU set up by the US Public Health Service exclusively for health care providers (of any nationality) who become infected.

More on Monday after my 10 hour drive to Tapeta tomorrow.

More training - I meant to publish this yesterday.

    One item that I don't think that I have commented on is the the ubiquitous smell of chlorine.  Chlorine is the disinfectant of choice here.  It is inexpensive, easy to handle and effective against the Ebola virus.  Most of the time, it is used for hand washing.  You will see it in front of restaurants, grocery stores and public buildings.  There is a hand washing station at the entrance to our guest house.  Usually you use a 0.05% strength for hand washing and a 0.5% strength for cleaning equipment.  However apparently under the theory if a little is good, more must be better, you occasionally run into more highly concentrated solutions.  You can tell pretty rapidly by the feel and smell.  Hopefully you have some normal water to rinse off with afterwards.    But at least in the ETU, it is the smell of security. 

     Today, we had mock 'patients' in triage.  These were 'patients' who would have just come to the ETU to be evaluated.  The first case was pretty straight forward and we were able to question him and see that he needed to be admitted.  The second case did not speak English and I was without a translator.  After an initial huh?, I basically started playing Charades with the patient to try to obtain the history.  Not my strongest suit but made even more interesting by needing to coach the use of a thermometer and to pantomime diarrhea.  I think the rest of the team was amused but also thankful that this wasn't their patient.  The hardest part was when the 'patient' sat down, the plastic chair collapsed and unconsciously, I reached out to catch him.  Of course, you shouldn't do that since you will only be in light PPE (gloves, apron, mask and goggles) and not fully protected agains Ebola.  But it is just hard to suppress something that happens so quickly that you don't have time to consciously consider.  Structurally, most triage areas are set up with a barrier between the triage officer and the patient.  Originally, I thought that this was to keep the patient away from the triage provider, but I see how that can work the other way as well.   

     The ETU here has a motto:  "We protect ourselves so that we can save lives."  It is interesting that the emphasis is on the protection of the provider first and then on the patient.  This was followed later with the statement that 'A life lost is bad, but a lost health care worker is much worse'.  It is an interesting inversion of many concepts of service in the US.  'Service above self' for Rotary and Jesus' admonition to love your neighbor as yourself.    I certainly see the reason for this from a utilitarian point of view.  The early loss of health care providers has proven disastrous over the course of this epidemic and has cost many more lives.  I have no problem adopting the motto, however it still feels a little funny.

     More training on Friday then a ten hour drive to Tapeta on Saturday.  Thanks for your prayers.

When Healthcare providers get sick

    It is an interesting drill when a health care provider gets sick.  For most of us, most of the time, we can recognize what is going on and make a decision whether to treat ourselves (if minor) or get with a colleague.  It is a little different here.  Certainly, there are a lot of illnesses as one would expect in a developing world country.  But the specter of Ebola distorts the normal way you approach a set of symptoms.

     First you have to start with the WHO case definitions of Ebola.  A probable case of Ebola consists of a known contact with the virus, and usually a fever sometimes with a constellation of symptoms that can include diarrhea, vomiting, fatigue, sore throat, unexplained bleeding, headache, abdominal pain and hiccups.  A suspect case of Ebola will have the fever with the symptoms without a known contact.  A confirmed case requires a confirmatory blood test.

     The problem is that many of the common illnesses that occur here can have those same symptoms with a fever.  Food borne illnesses, malaria and many others can cause some or all of the symptoms, with bacterial gastroenteritis being a particularly common offender.  Particularly for people whose GI tracts are not used to the local bacteria.

     As a health care provider in an Ebola zone, you can easily recognize these symptoms when they occur in you.  The risk is that you could minimize their significance.  Clinically you know that when these symptoms are due to Ebola, they are usually severe, but you also know that all severe symptoms start out as not so severe.  So, you fall back on the algorithm that says;  fever plus 3 typical symptoms without known contact equals Ebola suspect.

     There is the formal algorithm that states that the patient will be admitted to the suspect ward of the ETU until there are two negative blood tests separated by 48-72 hours.  There is also an informal algorithm for healthcare providers that, if the symptoms are not severe, you can have your blood drawn and go into self isolation pending worsening or improvement of symptoms.  Dependent upon how you do, you may need a second test.  Sometimes it is good to be the doctor.  But it is even better to have a negative Ebola test.  To my friends and family:  I have not been ill.

training day 2

     More training today on how to protect yourself while in Liberia.  Some of it was more mundane and directed primarily at the expat personnel.  Simple things such as malaria prevention and rest cycle management.  One interesting change is that no one shakes hands upon greeting each other, whether at the ETU or on the street.  Shaking hands has the risk of spreading Ebola if one of the parties is infected.  Most commonly, people now bump the outside of each other's elbows in greeting.  It gets more natural with repetition but I might still extend my hand if the other did so.  Others areas of instruction were more specific to ETU's such as heat stress.  One thing to realize about the PPE is that it is impermeable and lacks any sort of ventilation.  Once you are zipped in, there is no exposed skin and the effective humidity in the suit is 100%.  Couple that with ambient temperatures into the low 90's yields effective (wet bulb) temperatures in excess of 120 degrees.  This limits the time in the suit for patient care and puts a premium on efficiency to reduce the amount of time in PPE to prevent fatigue induced errors in technique.  Another interesting tidbit is that a common route of infection for health care providers is through the eyes and mucus membranes of the nose and mouth.  Have you ever checked to see how often you unconciously rub your nose or eyes?  This is something that you really have to suppress while you are in PPE since it usually occurs without concious intent.  

     The set up of the ETU is interesting.  It is engineered to reduce the risk to the patients and staff through contamination and cross contamination.  There are many fences with specific gates and procedures so that you can only cross from a cleaner area to a more contaminated area.  Also, you can only exit the hot zone through specific decontamination stations.  Maybe it isn't the easiest system, but it is the safest system for both the patients and the staff.

     Arrangements have been made for my transportation to Tapeta on Saturday.  It will be an 8 to 10 hour drive over some pretty rough roads.  But that is where the action is.  Thanks for your prayers.

Training for Ebola

     We started our official cold training today.  In many ways, it is like a medical conference anywhere.  It has classroom instruction on the Ebola virus, transmission, treatment etc with handouts.  It even has the usual pre conference snacks and scheduled coffee breaks.   But it is also different.  1/3 of the class consists of expats, mostly from Sweden, Germany, Ireland, the US and Australia with the rest of the class from Liberia.  Many different organizations are represented, including the Red Cross, Carnitas, the Swedish Civil Contingencies Activity and local Ministry of Health organizations. The classes are held in a large non air conditioned tent with roaring fans in the second half of an ETU compound that was never utilized.  Overall, it was pretty obvious that we weren't in the US.

     Liberian English is a little difficult.  Not so much the idioms, but the pronunciation and diction are different.  Couple that with some of my high frequency hearing loss, and it can be a bit of a struggle to get the full meaning.  However, it is even more difficult for the Swedes and Germans to understand a different variant of a second language.  Thankfully, there are good handouts and the language does become easier to understand the more you hear.   That and motivated students.

     One point raised during one of the Personal Protection talks was to remove all rings when working in an ETU.  Anything that can harbor contamination or induce even microscopic injury to the skin must be avoided.  Those could increase their risk of infection if there was a breach in PPE.   I guess I will be ring free for a while for the first time in 37 years (sorry Jo).

     More classes through the rest of the week are coupled with practice in our PPE.  Thank you everyone for your support.

First time in the Hot Zone

     When we walked through the gate, our CDC status changed immediately from 'no identified risk of Ebola' to 'minimal risk of Ebola'.  Today we entered the 'hot zone' for the first time.  No patient care, it was primarily a drill in donning and doffing our personal protective (PPE) with an extensive tour through the 'hot zone' in the MoD One Ebola Treatment Unit (ETU).  Crossing into the hot zone entails potential exposure to Ebola with intact PPE.  That degree of potential contact raised my risk status to minimal.  It will be raised further once I begin patient care to 'some risk of Ebola'.  

     There are exacting procedures for the placement and removal of these protective suits.  Everyone checks each other and there are safety personnel who monitor you while you don the multiple layers of Tyvek, goggles, mask, gloves and boots.  Removal is even more intense as that is the operation which has resulted in the majority of identified Ebola healthcare provider exposures.  You remove the suit as a team with chlorine sprayers a/hygienists directing your actions.  You can't perform healthcare in an ETU until you have completed training.  We will all be paying close attention in class.

     These suits can be quite warm.  With the temperature in the low nineties and quite muggy, these essentially air tight suits can generate temperatures of over 120 degrees Fahrenheit.   Due to this, we are limited to 45 minutes at a stretch in the suits.  While you know you are hot, you don't have a good feel for how much you are sweating.  When in the hot zone, you don't want your hands to go above your nipple line.  Gloves are the most contaminated part of your suit and you don't want your hands near your face.  You also don't want to let your hands drop onto your apron which is the next most likely contaminated part of your suit.  That leaves you hands held with your forearms level much of the time.  That allows the sweat to accumulate in the arms of your suit and to slosh around when you use your arms.  Altogether, I needed to chug two bottles of water when I had completed disrobing.

     We also toured the U.S. Public Health Service ETU which is located near the airport.  It is a more sophisticated ETU which is staffed entirely by Public Health Service physicians and nurses.  It is there solely to evaluate and take care of health care personnel (of any nationality) who becomes symptomatic.  Usually, it is something other than Ebola, but of course there have been positive cases as well.

     Tomorrow is a light day while we wait for our official cold training to start on Monday.  Please keep everyone here in your prayers.

En route to Liberia

     I am in the waiting area for my flight leaving Kansas City ultimately ending in Monrovia, Liberia.  I will be posting throughout my six week stint with Heart to Heart's Ebola Treatment Unit in Tappita, Liberia.  Waiting in the airport is good practice for working in the developing world (for any purpose).  Construction has moved slowly and the overly optimistic start time for the Heart to Heart ETU of the end of November has come and gone.  Expected opening of the ETU is now 1/5/15.  However, good can come from the delay.  With my prior military and management experience, I may be able to contribute in more than just a clinical way.  

     I suppose that I should address why I am here in the first place.  Usually, the question is phased something along the lines of 'are you crazy?'.  No, I am not crazy, but I do feel called to help in places where others can't or won't.  Why in Liberia (or Haiti or Uganda etc) and not locally?  I am not sure exactly why (as I do help locally), but it has something to do with the fact that all my experiences throughout my life have been leading in this direction.  I have always viewed my experiences as a gift of God, not that I necessarily appreciated them when they occurred.  I have often wondered how I could honor those gifts by using them in a way that pleases God.  When you combine my military experience (military commander, medical staff officer, unit chemical defense officer, 5 years in special operations, combat experience), my medical degree, continued athletic involvement and church involvement, I seem to be well prepared for service in difficult areas.  I do feel a peace when I deploy.  Not that I am not a bit nervous (it wouldn't be safe to feel complacent), it is just that I do feel that this is what I was meant to do.  

     I will try to update the blog every day or two.  We do have Internet in Tappita, however it can be intermittent.  God bless you all and thank you for your prayers.

Rick