Bridget Mulrooney, 36
American nurse working for the International Medical Corps in Bong County, Liberia
I was working as a travel nurse at a children’s hospital in California when I got an email from International Medical Corps asking if I was interested in deploying to Liberia to help fight Ebola. I wanted to go immediately but I was locked into a contract at the time. The more I heard, the more excited I got. Within three days of finishing my contract, I was in Alabama being trained in how to treat Ebola patients safely and within a week I was in Liberia.
I have now been at the Ebola treatment unit (ETU) for two weeks and what an incredible experience it has been. This week, I am on the night shift so my working day starts at 7pm. Tonight, we have 12 patients in the unit who are confirmed as having the Ebola virus. One of the patients is a nine-year-old girl who came with her mother when they were both sick. Her mum tested negative for Ebola but unfortunately the girl tested positive. Her mother opted to go home, leaving her daughter behind. She is very weak and really scared now that she is here all alone, so I am going to spend some extra time with her tonight, feeding her to try to get her strength back up.
Our personal protective equipment (PPE) suits get really hot. We spend up to two hours at a time in the ETU with the patients, which is about the longest you can comfortably remain inside the suits without a break.
Everyone I know is very supportive of me being here. I have been doing this type of volunteering for organisations such as IMC for a while. My family are used to me announcing that I’m off to some place where there is a disease outbreak or some other risk to my safety. I guess they were more worried than usual about the risks associated with Ebola, but they are still totally supportive.
I am worried about the backlash against healthcare workers who are responding to the crisis in West Africa. I have heard media reports calling for people such as me who have been treating Ebola patients to be quarantined for 21 or even 42 days. These ideas are not based on the medical facts. People only need to be quarantined if they are showing symptoms and if you do not have a fever, there is no risk of you transmitting Ebola to someone. We work really hard here, the hours are long and the work is physically and emotionally tiring. When we get time off every six weeks, I would like to think I can travel anywhere I want to but I suspect we are reaching a situation where I am not going to be welcome in many places.
Four new patients arrived at around midnight in ambulances. Tonight we saw a father and two sons: the dad is really very sick, throwing up every few minutes. We gave him and the other patients plenty of fluids and medicine to help with the vomiting and then we took the blood test that would confirm whether or not they had the Ebola virus. After triaging the patients, we made our way to the confirmed ward to carry the body of a patient who had died earlier in the night to the morgue.
The sun comes up around 6am, and the team on the nightshift often get together to watch it. Our Liberian colleagues will start singing and we will have a dance around for a few minutes. It’s a small thing but after a long night, when you have had patients die, it is a very emotional time.
My shift finishes at 7am after I have handed over to the daytime crew. We will be back doing exactly the same again tomorrow night. That is a fairly typical night in the ETU: not too scary, at times even fun, and hopefully we are doing great things.
Watching a life drain away
Ebola is mean. It’s harsh and it can tear families apart one by one, or take them all out together. We recently had a teenage girl bleed to death over two days of IV-site oozing. Sounds easy to fix, right? Pressure dressing, elevation, blah blah. Sorry, that’s not how things work in an Ebola unit. You do all the normal interventions but a 20-gauge needle hole in a hand can slowly and fully drain the life source out of someone. Walking into a room that is covered in blood, finding a semi-conscious girl face down on a bed pooling with barely congealed blood is hard. It’s harder the second day when you know all your efforts couldn’t slow that life destruction. I cleaned her up, and put her in a pair of still-tagged jeans. She half smiled and took some medicines. I won’t forget her smile. Nor her soft moans as her body was fading away.
This morning, I carried a baby to the tent morgue. The baby’s father had died days earlier in the ambulance ride to our ETU. The baby tested positive for malaria. We are still waiting for Ebola tests to come back on the mother and baby. The floppy, listless baby seemed to be turning a corner last night at 10. He smiled and took medicine willingly. His mother, lying near him, was vomiting and too weak to care for him any more. We went back inside a second time at 4am and stayed a while. Baby drank and we tried to get him to learn how to drink from a bottle so he could fend for himself. I came out joyed at baby’s bounceback! At around 5.30am, the mother came out crying. Baby had died. It was a shock and a testament to how rapidly situations can change. On the trip in to get the baby, two more patients had expired.
The high elation for our recovered patients is what it is because of the contrast of the deep sorrows of the many lows.
Ebola is not slowing down yet. I am trying my hardest to encourage everyone to drink through the nausea and vomiting, to eat, and to try to have hope of recovery. Nursing wise, we are doing high-level care. But the focus is getting OK care to more people than good care to just a few.
I have obviously had a hard few days and I am sorry for being graphic. But this is what it really is like being in Liberia during Ebola.
Sue Ellen Kovack, 56
Australian Red Cross nurse, Kenema, Sierra Leone
At the start of the day, I check my hands for any cuts or scrapes that will bar me from donning PPE. Entering the centre, I must wash my hands in a 0.05% chlorine solution. I balance on one foot as someone sprays the bottoms of my shoes with 0.5% chlorine before being allowed entry to the low-risk area.
I search for a pair of cold wet boots in my size, which have been soaking in chlorine for the night, and I change into my scrubs. I go straight to the whiteboard to see who has passed away during the night; today, it’s one of three nurses who became infected at work. One is on his way to good health, the other is still hanging on.
We need to synchronise putting the PPE on with other team members, because if one is slower than the rest we end up waiting and baking in the sun. We have a dresser to make sure we are completely covered, or we work in pairs and check each other. First on are gloves and a jumpsuit. Then a second pair of gloves, a thick duckbill mask, a hood, and an apron that is tied by the dresser so we can untie it with one pull. Then on go the goggles with a generous drizzle of antifogging spray, a final check in the mirror and a final check with each other. The checking does not stop there, as we must ensure during our time in the high-risk area that we are still covered, that a mask has not slipped, or that a piece of skin has not been exposed. If that happens, we leave the area immediately. We check the time – 45 minutes to one hour is the maximum allowed in the PPE.
We have the luxury of four nurses today. Patients who are feeling well enough are sitting on plastic chairs waiting for a meal. We might offer some pain relief, or a smile from beneath our PPE (yes, you can smile with your eyes).
Hannah (not her real name) is sitting outside, greeting us with a big smile. She has lost all her children to Ebola as well as her husband. And here she is asking me how my evening was. The staff tell me she has had some bad moments, but all they can do is reassure her that she is young and can bear more children.
Others have not fared so well – too weak to sit up, or get to the toilet or the shower block. We do our best to offer fluids, a wash and some paracetamol. The local nursing staff have amazing courage to work in our centre. Their families ostracise them, but they still come, to try to bring an end to this brutal, invisible “war”. In Africa, it is usually the family that feeds, washes and comforts the patients. But no family members are allowed inside our treatment centre.
My three key words are warm, dry and comfortable. Patients who are too weak to move away from their own vomit, faeces and urine need the most help. We clean and care for as many as we can, but if we need to leave the area because of heat exhaustion or feeling unwell, the priority is to get out. You are a danger to your colleagues if you go down in your PPE.
After our nursing team goes in, the hygiene team suits up for their rounds. They clean up the vomit, diarrhoea and urine spills, the garbage and the nappies. Their task is monumental and they can be at most risk.
A minimum of five minutes is needed to undress. We have two tents, where the undressers and sprayers need to be on the ball. The urge to just pull the suit off is strong, but we wait. First, the chlorine spray to the hands. Then, feet apart, arms in the air, we are sprayed from head to toe, first the front, then the back. We wash our hands in 0.5% chlorine. Off come the first set of gloves.
We wash our hands again. Off comes the apron and hopefully it was tied perfectly, as we have to blindly reach around to release the knot; we pull it over our heads. Into the chlorine soak it goes. We wash our hands.
Next go the goggles. We bend over, close our eyes and gently remove them, dunk them three times in the strong chlorine-filled bucket, and then place them in water. We wash our hands.
The hood comes off next. Once again, we bend over, closing our eyes to avoid contamination and dispose of the hood in the garbage. We wash our hands.
Next, the removal of our heavy PPE. Moving slowly – we do everything slowly here – we carefully expose the zipper, hidden under a taped-down flap. We wash our hands. Blindly, we have to find the zipper, as our undressers and sprayers guide us. We wash our hands.
As we shimmy out of our PPE, we are soaked to the bone in sweat, but it feels great. This is the hardest part: to ease off the jumpsuit while kicking your legs back, at the same time standing on it so it doesn’t fly away from you. It’s a balancing act. The sprayer sprays the entire jumpsuit with a stronger chlorine solution and we put it in the garbage. We wash our hands.
Our heavy-duty filtration mask is next. I close my eyes and hope it doesn’t catch in my ponytail. We wash our hands.
The last pair of gloves comes off. Our boots are sprayed from all angles and we have to balance on one foot to cross the line from high risk to low risk. We wash our hands and we are done, stripped down to our scrubs, soaked with sweat.
I need a rehydration solution or water. No food is allowed in the low-risk area. It is too risky to put anything near your mouth from your hands. But I still see people biting their nails, touching their face, rubbing their eyes – risky but automatic responses. Your hands have been washed a trillion times in chlorine, but still, you don’t know how safe your other colleagues have been. You are literally entrusting your life to your work mates. Before I left Australia, I took to wearing a rubber band and each time I caught myself touching my face, I snapped it painfully so I would remember not to do it.
I hear an ambulance and the siren is going fast – it may pass us and head to the next treatment centre, hours away. But it abruptly turns into our driveway and we run out to greet it. I suit up and prepare for the admissions with a package consisting of a blanket, soap, towel, cup, toothbrush and toothpaste, all in a covered bucket that will be used for vomit/faeces or urine if the person is unable to get to the latrines.
The ambulance door is opened and I can see a man on the stretcher, two legs in the air, stiff as a board. They slowly drop and I realise this patient is dying. But he walked into the ambulance in Freetown. It is a five-hour drive through a dozen checkpoints and deterioration comes rapidly. I pronounce him dead, and move on to the other patient.
The female patient is lying on the floor between the seat and the stretcher, strapped in by seatbelts. She is trapped, a terrorised look in her eyes. She is flailing wildly, a dangerous situation in itself. I try to calm her while maintaining my distance. We move her as best we can, but then I realise that she is just trying to cover her exposed area below her waist. In her last moments, this is her concern. We manage to get her into a tent. We ask her name, if she is married. She responds, “I am married”, looks away and dies. All that struggle and desperation in the ambulance and she only wanted to preserve her dignity. That was a tough moment.
Anine Kongelf, 27
Norwegian Red Cross nurse, Kenema, Sierra Leone
Finally, a happy day: 11-year-old Kadiatu and 35-year-old Osman are being discharged as our first two Ebola survivors. Their blood tests have come back negative – they are no longer infectious and can safely return to their families and communities. For the whole week we have been separated by 1.5 metre-high orange fencing. I have been throwing “plumpinut” [a nutritious peanut paste] and biscuits across the fence to Kadiatu, and we have been talking, singing and even dancing for the past two days – from our separate sides. Today, there is no more fence between us.
My first week as a community health delegate at the centre, run by the International Federation of Red Cross and Red Crescent Societies, has been a surreal rollercoaster between life and death, hope, grief, pain and joy. My first task was to oversee four burials. As a team in full PPE carried the corpses in double body bags out of the morgue, we were there to pay our last respects and to make sure the burial site was mapped and the graves marked. The sad fact is that there will be many more graves as the centre will admit more patients, and some of them will lose the battle against the virus. One of the bodies that day was an eight-year-old boy.
When we returned from the burial site, the boy’s family had arrived to ask for news about him. His father had already died from Ebola, but his uncle and brother came all the way from Freetown, a five-hour drive away. The two men had been in contact with people with Ebola and therefore might be infected and carriers of the virus, so we could not bring them into the low-risk area. Nor could they see their nephew and brother. We brought them instead to the unused triage area, where we could speak in private, with the safe orange fencing between us. They don’t say much at the news of the boy’s death. There is a nod of understanding, but their faces express shock and disbelief. At the end of the day, I wasn’t sure if I’d be able to do this for a whole month.
Kadiatu was one of the first patients at the treatment centre, and because she had been inside the high-risk area she had to go through the “happy shower” before she could be discharged: a chlorine bath followed by a normal soapy shower to remove all potential remains of the virus. Her contaminated clothes were destroyed and she was given a new dress and sandals. When she came out she was clean, uncontaminated and safe. She turned around to wave to Haja – another Ebola patient who has been taking care of Kadiatu inside – and walked out past the double orange fencing.
As we wait for her transport home to Freetown, we can finally sit together. Kadiatu is brought breakfast and vitamins, but the nurses no longer need to wear the personal protective equipment, and the psychosocial counsellor can talk to her in private and uninterrupted. Kadiatu makes us dance for her as she sings, and we can take photos together without being worried about coming too close. Magically, our first survivor is this beautiful, strong 11-year-old with the widest, whitest smile I have ever seen, and as the car drives off I know she will be fine. Her mother and siblings are waiting for her at home, and for us, the staff at the treatment centre, we know that people can survive Ebola and that there will be many more happy days like this one in the midst of all the fear and despair.