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World Dear Diary: Today I tackled Ebola in Sierra Leone

Gillian McKay, 29, is a registered nurse from White Rock, B.C. She works for the non-governmental organization GOAL at a newly opened 100-bed Ebola treatment centre in Port Loko in Sierra Leone, co-ordinating training of staff who enter the "red zone" to care for patients. Ebola has killed 7,373 people in three West African countries, according to the latest figures from the U.S. Centers for Disease Control and Prevention. Over the past nine days, Ms. McKay has kept a diary of her experiences. Her entries have been condensed for space.

Day 1: I've trained them the best I can

After two months of planning, weeks of training and a few days of delays, I found myself tearing up watching our first two patients being brought into our Ebola treatment centre in Port Loko, Sierra Leone. One older man was wheeled in on a chair, and a little girl of nine or so was supported by two staff members to walk the long, hot pathway to the old fashioned Nightingale ward. I'm not sure if it was the patients I teared up for or the staff. Just 15 minutes prior, I had done a final personal protective equipment check on our staff members who were going to meet the ambulance. As the training co-ordinator for all the red zone staff in the treatment centre, I am accountable for ensuring that everyone is trained to wear the right gear (head-to-toe coverage with impermeable clothing), is practising the right behaviours (no rushing, watch out for your buddy) and is aware of their limits (a maximum of 40 minutes in the red zone in the heat of the day). After all of the drills, the practice and the assessments, the staff were as prepared as they could be – but I still felt afraid for them. With Ebola, any mistake could be your last, and we need our staff safe before we can do anything for the patients.

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Day 2: A sense of normalcy in an abnormal situation

One of the first things I heard walking into the centre today, after I had changed into my scrubs and rubber boots, was the call of a little girl. We have four patients today, a very small number given the large number of staff and the massive facility we have just opened, but we need time for our staff to become comfortable and safe before we can scale up too much. There is an older man, a woman of about 40 and two little girls, aged eight and nine. One little girl, Katiada, has lost her entire family to the Ebola virus. My colleague told me that she had been quite cold overnight, despite the blankets and sheets we had given her, and she wasn't settling in the early morning chill. When I went into the red zone to serve breakfast, I saw Katiada curled up in the bed of the older woman, snuggled in like a kitten for warmth and comfort. It was a beautiful scene. The older woman had never met the child before, but in this strange foreign place staffed by people walking around in moonsuits, the woman had taken on the role of mother, giving herself and a little girl a sense of normality.

Day 3: Of course we will take them

Today I woke up with a cold, a surprising thing given how many hundreds of times a day I wash my hands with chlorine to kill Ebola. (Chlorine is the bullet that kills the enemy we can't see.) A cold means no red zone, and really, not much time even around my colleagues, for if I were to infect any of them we could end up short-staffed. It's critical that anyone working in the ETC environment is absolutely healthy, you can't be getting sick while in your PPE. So this meant I got to spend a day working on our scale-up plans. We took another four patients today, bringing us up to eight. We'd like to be at 10 by tomorrow. By the end of the month, if recruitment and training goes well, we'd like to be at 50, so there is much to do. While at a meeting at the local District Ebola Command and Control Centre, we were approached with a problem. An ambulance with five confirmed patients was sitting outside one of the holding centres, having travelled for hours from a community care centre. But the chlorination at the holding centre had failed, so it was not going to be able to accept the patients safely. Could GOAL take the patients? They knew it was more than we were ready to take, but these people needed somewhere to go. The answer, of course, was yes, of course we'd take them. Our team is ready and wants to help.

Day 4: Connections

So little Katiada, who we thought didn't have any relatives left, isn't so alone in the world after all. Of the four patients we started with, all are still alive, and as we are getting to know them better we are discovering more about them. Katiada is actually a schoolmate of the other little girl, and the older woman is her grandmother. Family connections in Sierra Leone are extensive and convoluted, which can make identifying relationships difficult, but in the end, there's always a way to connect people from a similar part of the country. The older man, our first patient who we admitted on Day 1, isn't doing so well unfortunately. He is getting that "Ebola look" that those of us who know the disease can recognize well. His breathing is becoming more laboured, and he is developing neurological symptoms. Once people get to this stage, it's rare for them to come back from it. I imagine we will have to prepare for our first death quite soon.

Day 5: Safe and dignified

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We had our first death today. While it wasn't a surprise to anyone we are all struggling with it, especially as we know that with a mortality rate of around 70 per cent, we are sure to have many more in the months to come. We had all hoped that our first patient would survive, but the sad truth of Ebola is that people tend to go downhill quite quickly before they die, whereas those who are going to survive take a lot longer to recover. It's nearly inevitable, therefore, that we would see a death before seeing a discharge. The staff are coping well. For our hygienist teams (who manage the dead bodies) it was their first chance to practise this protocol outside of a clinical drill setting. They did very well. Dead bodies in Ebola are highly infectious, therefore our hygienists cannot afford any mistakes when managing a corpse. It's a hard job, making sure that the body is managed in the safest and most dignified way possible. As in all cultures, for Sierra Leoneans taking care of the dead is steeped in tradition. Ebola has severely impacted on how people show their respects, given that any washing or touching of the body can cause many more infections if it is not done properly. I was very proud to hear that the team did it correctly and appropriately. It shows how much they have absorbed from their training.

Day 6: The monsters in the moonsuits

We have a number of new patients admitted into the ETC, including a four-year-old boy. He looks up at the staff in their "moonsuits" with his eyes as wide as saucers, refusing to blink. It's as if he thinks if he closes his eyes something terrible will happen to him. It's hard to know his story, as he doesn't speak, and we have little information about him beyond his name and that he is a confirmed Ebola case from a town along the coast. Our psychosocial team is working to identify where his family are, and to try to figure out where he can go if (hopefully, when) he survives. Many children in this epidemic have been orphaned, and for those who are survivors there has been a lot of stigmatization on their return to the community. Even when a relative can be identified to care for the child, there is still ongoing concern for their welfare, as it is an added burden on whoever takes responsibility to feed, clothe and educate the child. We are working to procure "discharge kits" with mattresses, clothes, food and money to ensure that when they go home they will be comfortable and able to last several months while they reintegrate. When a person has been identified as Ebola positive, a decontamination team goes to the home. They burn the bedclothes, mattresses and other items as these can be infected with Ebola. A discharged patient will usually be returning to a home with very little left inside it. As they haven't been working, money for food and other necessities is hard to come by. So our discharge kits are a critical part of GOAL's package of care.

Day 7: Slow slow, safe safe

We are trying to scale up to take in more patients. The model here is based on cholera care, where there is a "hub" centre that is fed by many smaller "spoke" clinics. Our information from the district Ebola co-ordination centre is that many of the spokes are at capacity, so we need to be able to take in more patients. However, until we are able to do so safely, we need to resist any pressure. The training team and I are currently co-ordinating training for 60-plus hygienists, a burial team, a recently arrived Danish medical team and another 20 or so national nursing staff. If we can successfully train all of these people, we should be able to scale up to 50 beds or so within a couple of weeks. This would make a big difference in terms of capacity for treatment beds. At present, with our 12 patients, things are starting to feel routine, which is exactly what we want. The processes and procedures are in place so that our staff know what to do when an ambulance arrives, or when a patient passes away. The food is going out at the right times and the medications are being administered safely. It might sound a bit boring, but boring is good. Boring is safe.

Day 8: A Return to the basics

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In all the talk of intensive treatment of Ebola patients, it's a joy to go into the unit and be able to provide the basic necessities. Care of Ebola patients is very simple. Oral (sometimes IV) rehydration, good nutrition (when you can get people to eat), hygiene care (massive fluid loss by diarrhea necessitates frequent changes of clothes) and medications for nausea, fever and pain. Even when we lose patients, and we lost three yesterday, we know that they died with dignity, clean and cared for by people who wanted to give them the best care possible in their final hours. It's a return to the basics of good-quality nursing care. Limitations of the PPE mean you often feel frustrated that you can't stay in the unit longer to provide more care, but when every person who goes in helps the patients to sit up, drink fluids and checks that they are clean, we are providing the best possible care in a situation where there are many needs. I particularly love hearing from our physician colleagues, who are loving doing what would often be considered nursing care back home. When there is not much you can do, what we can do we have to do perfectly.

Day 9: Christmas is cancelled

Port Loko is quite a small town, with not a lot to do. Sierra Leone used to be known for the all-night beach parties, but since the state of emergency that was declared in August, that's all changed. No public gatherings are permitted, there is a national "no touch" policy in place and it's not uncommon to hear of villages that refuse admission to strangers when in the past visitors would be immediately welcomed. Furthermore, around Port Loko the epidemic is raging, and there is a four-day lockdown starting tonight, so the streets will be even quieter than normal with no one permitted to leave their homes. Even Christmas (or public celebrations of it) has been cancelled by presidential decree. It's sure to be an odd kind of holiday season for all of us. But we are still trying to have a bit of Christmas spirit, with some lovely decorations we got in from Ireland along with some bunting we had a local tailor make out of beautiful West African fabric. There may be some music. There will probably be beer. And if we can scare one up, there might even be a jar of cranberry sauce to go with the local chicken we are sure to be served.

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