Wednesday, March 4, 2015

Letters from Liberia

By Joe Spann, MD
Austin physician

This article first appeared in the TCMS Journal, a publication of the Travis County Medical Society.

When TCMS member Joe Spann, MD retired in 2014, the last thing he imagined doing was volunteering in the fight against the spread of Ebola. But in November, he joined the humanitarian group American Refugee Committee and traveled to parts of Western Africa to do just that.

Only halfway through his three month stay, Dr. Spann has already had many interesting experiences. Writing whenever he has a few minutes and internet access, he starts each email with “Dear Friends and Family.” Here are a few excerpts from some of his missives.

November 22, 2014
I landed last night in Monrovia, the capital of Liberia, after 9 pm. We stepped out into the warm humid air and were bused to the terminal.

Before we could enter the terminal we had our temperatures taken and were required to wash our hands under a stream of chlorinated water.

The terminal was packed with both Liberian residents and international health care workers. Standing in the long lines I met several individuals working with Doctors Without Borders, the CDC and the United Nations. Many were returning to work in Ebola Treatment Units (ETU) while some were new like our group. Most of the individuals are young and single, but there were a few gray haired individuals like myself.

PS: You cannot enter a store, hotel or apartment without having to wash your hands first with chlorinated water. I suspect I will be drinking it by the end of the trip.

November 30, 2014
Our Ebola Treatment Unit training will last 7 days. We will initially do 3 days of “cold training” where we will have lectures in the morning regarding the history, pathology, epidemiology and treatment of Ebola patients. In the afternoon sessions we practice dressing (donning) the personal protective equipment (PPE) uniforms, triage patients, starting IVs, drawing blood for Ebola testing and removing (doffing) our PPE uniforms. The donning and doffing of the PPE is both a physical and mental challenge.

The training is conducted on a minimally shaded basketball court with a mock ETU build. It consists of an enclosed tent with cots and separate donning and doffing areas. A step-by-step regimen in getting dressed and undressed is drilled into our heads. The entire donning and doffing sequence takes about 10-15 minutes a piece performed in the sun and heat. You wear scrubs and rubber boots to begin with. All jewelry including rings, earrings, watches and necklaces are removed. You climb into the PPE suit that provides the inner layer of the uniform covering your boots and extending upwards to your entire neck, much like a turtleneck shirt. There is a zipper in the front and several tabs on the uniform that are removed and have adhesive underneath to tape part of the uniform over the zipper and around your neck. Three pairs of surgical gloves are put on with the last pair being taped to your sleeve with duct tape. A duck billed type surgical mask is put on covering your nose and mouth followed by a complete headpiece with a second mask that overlaps the duck billed mask. A hole is made in the outer mask, and the bill of the underlying mask is allowed to protrude outwards. A heavy apron is then donned in front and tied behind you by an assistant leaving a free end on the side that can be pulled in the undressing process. Finally, a large pair of plastic goggles is placed over your eyes making sure that no skin is exposed either on your forehead or cheeks. The overall look resembles a Star Wars Imperial Trooper, but instead of a man you are a duck.

Movement in the PPE uniform feels clumsy and restricted wearing rain boots, a heavy apron and constricting clothes and headpieces. I was worried that I was going to panic since I am a tad on the claustrophobic side. (I cannot stand to wear turtleneck sweaters or shirts normally because I feel like I am being choked).

Combine that with the heat, humidity and fear of contamination and you have a recipe for panic attacks. I use mental imaging to project myself to a calmer, cooler location such as Barton Springs to calm my nerves.

We practice the PPE donning and doffing exercises for 3 days. On the third day we discuss what to expect when you enter a functioning ETU with Ebola patients.

Never enter the ETU alone. Always have someone with you, a “buddy,” to look after each other. Do’s and Don’ts are reviewed…don’t touch your goggles or face while in the ETU, don’t allow any sharp objects to be pointed towards you or your buddy. Always wash your hands between patients. Try not to touch any body fluids or surfaces while in the ETU.

Tomorrow we will travel to the Bong County ETU three miles from our campus and begin our “hot” training. Our team has a meeting and we discuss the fear that lies shallow beneath every one of us. The fear of Ebola, the fear of failure to perform our assigned tasks and the fear of the unknown are discussed. We provide emotional support to each other and decide that courage is what it takes to move forward in our mission to help the Liberian people with this awful disease. Let it begin.

December 3, 2014
As we begin our hot training, we are told there are no real emergencies in the ETUs. If a patient arrests, starts hemorrhaging, goes into labor, develops seizures or quits breathing we do not rush in to assist them. This was attempted early on in the epidemic with several worker fatalities. Doctors Without Borders, who has treated more Ebola patients than any other group here, has a motto: “We are never in a rush to die.” Words to stay alive with.

After our tour of the facility we are led by our guide to the outside of the compound. We pass the morgue and a two wheeled elongated cart that is used to transport the bodies. We follow a narrow winding trail that leads us away from the ETU and into the jungle. The sounds of the generator and workmen fade and soon all you can hear are bird calls and the wind rustling the leaves of the trees.

After 200 yards we enter a small clearing and see the graveyard for the Bong County ETU. There are rows of small white crosses with the names, date of birth and the date of their deaths. Most are in their 20s, 30s and 40s, but there are several young children and teenagers also. Many of the deceased are related to one another since one family member will tend to infect another. The sight of this
elicits silence and reflection in our group. There are perhaps 150 people buried here since the unit opened in September 2014.

The last night there is a big party in celebration for finishing our training and making many new friends here. One of the Liberian-American nurses has family nearby and they bring in large quantities of fish, chicken, rice and fruit. Jonathan and I supply the beer and a Kenyan worker brings in a karaoke program on his computer with a speaker. Soon we are taking turns singing various songs, many of them American. A particularly emotional and moving moment occurs when we all sing “We Are The World” together. It is a multinational, multiethnic group gathered here tonight, and looking around the room I see people from Uganda, Kenya, Nigeria, Liberia and the United States. We are the world coming together to fight Ebola.

Tomorrow we leave for Monrovia to have a few more days of cold training and wait to hear when our Ebola Treatment Unit in Fish Town River Gee will be completed. As with most things in Liberia, it is behind schedule and may not open until late December. I feel confident that the training we have received here is the best you could have. The Bong County ETU has a mortality rate of around 60% that, while still too high, is better than the 75-80% mortality figures I have often seen. The doctors and nurses here are truly saving lives with minimal resources. I am honored to have met and worked alongside them.

December 10, 2014
I have been told to pack my bags for deployment to Fish Town tomorrow morning. It will take us two days to travel 300 miles on the torture devices that pass for roads here. I will be the first medical person there from our group. I will be evaluating the layout and functionality of our brand new Ebola Treatment Unit. Of course, all I know is what I saw in Bong County during my training.

December 18, 2014
I have been making the city rounds meeting with the local health authorities, mayor and local engineers and making nice with them. If our Ebola Treatment Unit is ever to get a good start we will need the support of the local leaders and community. Much of the business in Fish Town is conducted in bars… I think they like me because I always make a point to say we are here to assist the Liberian people and not give orders or take control of the Ebola emergency response. And, of course, I always buy them a beer.


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