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Ebola: Working in the red zone

Dr Clare Warrell volunteered at Save the Children’s Kerry Town Ebola Treatment Centre in Sierra Leone. Patient names have been changed to maintain confidentiality.

Dr Clare Warrell at the Kerry Town Ebola treatment centre

As the sun rises over the spectacular Western Area Rural mountain range, our bus carefully picks its way along the Waterloo highway.

With liberal use of the horn and brakes, we negotiate goats, women carrying huge buckets of produce on their heads with enviable ease, cars stuffed with firewood and, most regularly of all, police Ebola checkpoints.

The rope festooned with rags jerks to the ground as the familiar Save the Children logo on the windscreen comes into view.

Entering the green zone

After 35 minutes, patchy forest gives way to a huge clearing filled with an island of orderly rows of white and blue tents and floodlights, surrounded by a sea of grey gravel.

We line up at the gates to the green zone, washing our hands in chlorine solution and awaiting our temperature check with a thermal radiation gun held inches from our right temple.

The security guard waves me through, showing my reading on the screen. Anything greater than 37.5oC requires further action.

We wash our hands twice more; on entry to the changing rooms, and then the nurses station, before we huddle, not touching, to receive the ward-specific handover from the night team.

Hawa and Sia

A Sierra Leonean clinical health officer (CHO) eloquently negotiates her way around the whiteboard of patients for the women and children’s ward.

Among the patients is Hawa, a 7-year-old who was brought in a week before, alone and critically ill. We were waiting to hear what had become of her family.

She responded to IV fluids, antibiotics and painkillers and had made steady progress. We’re now waiting on a second  Ebola test – if negative she can be discharged.

At the other end of the ward is Sia, a 19-year-old on day 10 of admission, whose entire family had been affected by Ebola. Despite aggressive fluid management (minimum 5 litres a day) and antibiotics, she was deteriorating fast, and had been agitated and confused overnight.

International team

Dr Warrell with the rest of her international team at the Kerry Town Ebola treatment centre
Clare with the rest of her team

My team is made up of Sierra Leonean staff (CHOs and nurses), two Cuban nurses and an A&E nurse from London.

Planning what to do before we go in is essential to optimise efficiency inside. We quickly put together management plans for each of the patients, and create a rota for staff buddy teams to go in at regular intervals.

Updating the Cuban team, my GCSE Spanish is dredged from the deep recesses of my memory and combined with international medical sign language (freestyle) occasionally leading to comical consequences.

Lance (CHO), Nancy (nurse) and I decide to go in first to do a ward round, while the Cuban nurses do blood tests.

The red zone

Working in the red zone (the area with Ebola-infected patients) is an intense and scary experience.

We want to make the most of the coolness of the early morning before the outside temperature climbs to over 30oC. We collect and check our equipment before the 15-minute process of ‘donning.’

Once the protective suit, wellies, mask, hood, apron, three pairs of gloves and goggles are on, I would be interested to know what temperatures we are enduring.

Working in protective suits

We check each other’s PPE (personal protective equipment) a final time, for potential breaches such as tears or exposed skin. Then our names are written in cool strokes of permanent marker on our already sweating foreheads, and the time is inked onto our shoulders.

Working in PPE is surreal at first. All your senses are numbed. Looking through goggles feels like virtual reality or an out-of-body experience.

All you can hear is the sound of your breathing, and the thumping of your temporal artery beneath the tight goggle strap. We reaffirm our plan before plodding along a long white corridor and through the orange netting into the red zone.

Meeting Hawa

As we approach the ward Hawa runs outside to greet us and holds my hand impatiently guiding me to her bed to show off her new Winnie the Pooh colouring book and some as-yet-unused crayons.

Bridget, a fully recovered patient who has volunteered to delay her discharge to look after Hawa, looks on protectively from her bed opposite.

She glances apprehensively in the direction of Sia’s bed space, before meeting my gaze and looking hurriedly away again. She calls Hawa over to finish her breakfast.

Treating Sia

We walk over to the end of the ward, to see Sia prostrated on a mattress on the floor. She is naked other than the traditional beaded string around her waist and an adult nappy, and surrounded by a sea of secretions.

Her skin is cold and her mouth is dry. Her eyes are glazed over with a vacant stare, not an unfamiliar sight in Ebola victims. We set about cleaning her up, trying to find out how she is feeling, changing the IV fluids and recording her vital signs.

She appears to be having a lucid episode, and the agitation and confusion of the night have passed for now.

Limply beckoning for breakfast, she tries a few spoonfuls before it re-emerges over Nancy’s apron. I send her to decontamination immediately as she is now heavily contaminated.

Stooping down to the mattress is difficult within the confines of the protective suit. Looking down requires careful head positioning to stop sweat dripping directly into my eyes.The two of us carefully lay her back down again onto some pillows, turning her to relieve pressure areas. The Cuban nurses arrive to take blood samples.

Dr Warrell in her personal protective equipement (PPE) suit
Clare in her personal protective equipment suit

Moving through the ward

We wash our hands and aprons in chlorine solution and re-check each other’s PPE before moving on to review the remaining patients.

Hawa follows us around the ward playfully and occasionally giggling when we turn around, catching her doing impressions of our various PPE postures. We radio the nurses’ station, and arrange to shout the observations over the fence to a note-taker in the green zone.

When focusing on the ward round, and doing tasks, the discomfort of PPE is just background noise.

The hardship of PPE suits

However, by now, after some time I am increasingly aware of the frequency of sweat dripping in my goggles and down my back.

I can’t touch my face or head, despite the pulsating band of pain from the tight straps on my goggles and my heavy laboured breathing. Lance and I review Sia one more time.

Her nappy needs changing again. We agree that we will do this and then leave. Afterwards, we wash our hands again and wave goodbye to Hawa and the others, before making our way back cautiously to the decontamination area.

Highest risk

Here, we are individually hosed down with chlorine solution and painstakingly remove all the PPE. This is, day to day, the most tense and high-risk time of all.

Nothing feels better in the world at that moment than the instant relief when I remove the goggles that have been causing blinding pain, and the sudden return of fresh cool air on my face.

After 15 minutes of intense concentration, we emerge in a sweaty, chlorinated, but clean mess. We head back to the nurses’ station and update the next team, who are already donning to go in for the mid-morning snack round with additional jobs that have been generated.

Changing shifts

After drinking some oral rehydration solution, I enter the ward round findings in the patients’ notes. A spontaneous teaching session ensues when one of the CHOs asks about interpretation of the blood results for a patient on another ward.

Later on, I go into the red zone for a much shorter time with another team of nurses, this time focusing mainly on Sia’s comfort, fluid replacement and symptom control.

We hand over to the afternoon team at 2pm before having a banana-leaf fish curry at the Ebola Treatment Centre canteen and heading back to the hotel.

The day shifts are 6 hours. Short, but physically and mentally exhausting. However, I’m only here for 6 weeks. The true heroes of this outbreak are the Sierra Leonean staff.

True heroes

Their warmth, tenacity and spirit have endured many awful months of this epidemic so far. Most of them have been moved far from home, they’ve witnessed friends, family and colleagues succumb to this deadly virus, and continue to face stigmatisation for working in the Ebola Treatment Centre.

Yet, every day they arrive with enthusiasm and the passion to work hard and learn. I am privileged and humbled to be working alongside them.

The team has given me a Mende nickname; Lobbeh meaning ‘to stay with us,’ although sadly, my time here is coming to an end. I will return to work in the UK with renewed vim and vigour, as I continue to remember, and be inspired by these incredible people.

Hawa was discharged the next day, with Bridget as her carer. Sia continued to deteriorate and died a few days later.

A version of this blog first appeared on the Royal College of Physicians website

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