Paul Dhillon, MBBChBAO, LRCP&SI, EMDM
University of Saskatchewan, Regina, Canada
|Sinead sitting in PPE Training Tent|
Rubber boots crush gravel underfoot. The generators drone in the background, languid bees in an artificial honeycomb of hospital.
Kerry Town Ebola Treatment Centre in Sierra Leone is a hospital that has slowly morphed into a complex series of wooden skeleton-, metal clad-, and tarpaulin-covered buildings connected by hand-chipped rough gravel in defiance of its surroundings. No building rises to a second story, but the contrast of the complex to its verdant green jungle surrounding is stark, especially when viewed from above and afar.
The institution at its peak capacity, which did not correlate with maximum incidence of disease, consisted of eighty Ebola-patient beds and twenty-two suspect-patient beds. A part of the facility, but apart, sits the British Army's twenty-two Field Hospital; twelve acute care beds and four isolation tents for suspected Ebola patients. It is staffed in twelve-hour shifts by Canadian and British military personnel for any health care workers and international staff in the country that fall ill. The costs of construction, and the ongoing costs of the complex, were realized through the Department for International Development UK, and the bulk of the construction was delivered by the British Army Royal Engineers alongside Sierra Leonean workers. Controversies abounded over the cost of the facility and the speed of construction, the bulk of which occurred in an eight-week period in the autumn of 2014. Also included on the grounds is a laboratory and pharmacy staffed in a tripartite fashion between Public Health England, the military, and international staff from Save the Children UK.
Historically, hospitals are understood to instill hope, to heal, and to be a beacon to people in their darkest and most painful moments. They calm, soothe, and provide a balm to the wounds of fear. They embody history; they hold the last dying dreams and failed aspirations of their patients, their final breath. The Kerry Town ETC, exclusively viral, has valiantly held up these common historical perceptions of the hospital. It is a new hospital, wrinkled and covered in meconium that contains aspirations of healing and hope laid within the shallow concrete of its settling foundations.
The idea of a single pathogen hospital is not new. One thinks historically of the tubercular sanatoria and of leper colonies as examples. For viral hemorrhagic fevers though, this hospital is one of many firsts, and its current life is predicated on the survival of the epidemic. What happens next to this hospital is unknown to all but history and the last living virus.
Passing the last police checkpoint, arrival is signaled by a sharp turn into the hospital. The trip has been on decent tarmac road passing through small villages whose names such as Durham Town and Black Johnson attest to the colonial history of Sierra Leone which has led to the British assuming responsibility for the Ebola response here. Stepping off the bus, each change of shift feeds more staff into the hospital and exchanges them for a satisfied and solemn group returning to sleep and rest.
A journey through the hospital grounds is controlled visually by bright orange plastic fencing declaring different zones of danger. Entrance to the hospital is not permitted for staff without an obligatory infra-red thermometer check. 37.5 degrees Celsius is the magical number above which concern for possible Ebola rises; along with the staff members’ own fears. After the audible beep of the thermometer and a normal temperature reading, staff complete the first handwashing of the shift from the ubiquitous blue cisterns with chlorine-residue stained taps. Change zone, wash hands. These stations are manned by local staff ensuring that none pass without a tepid waterfall of 0.05% chlorine across their palms.
Clinical staff, alongside the Water, Sanitation and Hygiene teams (WASH), then proceed to the changing rooms where all dress in maroon scrubs completed with occasionally matching rubber boots in white, yellow, or black. Staff then head to their respective staging areas to prepare for the shifts’ work. Out of the changing rooms lies an open rectangular space with two round thatched roof structures, for rest from the searing sun and for use in training. One is unofficially the Cuban tent and the other for national staff, at times they remain separated by language and place. However, all come together for handover that contains cultures bound together in a common humanity to fight against a virus that makes all bleed the same blood. The hospital has not only had patient casualties and victories, Cuban and English physicians and nurses have been infected at the hospital. Two have survived Ebola, victory; the other succumbed to cerebral malaria and will remain interred in the Sierra Leone soil for five long years before being repatriated. ¡Hasta la Victoria Siempre!
Opposite and beyond the thatches, lies the red zone, literally a stone’s throw away, even for a wilting child.
Handover completed in a cacophony of languages and tones, the teams separate and divide into buddied teams; no one enters the Red Zone alone. Leaving the nursing station, staff cross the first threshold and begin to gather the personal protective equipment (PPE) that will become their shielding burka against the virus. Two pairs of gloves, goggles, a hood, a mask, coveralls, and finally an apron. Equipment collected staff move to another room with two doors; one leads in and the other leads to the Red Zone; entrance is one way. Never will anyone venture back through that door. A slow and methodical inspection is conducted of all pieces of equipment. Odd to onlookers, the concentration is intense; a life could possibly rest on the exquisiteness of exam, your life. The protocols for the gear are followed to the letter, to an extent. Veterans, of the hospital are calm and methodical. Newcomers take longer; their fear, yet to diminish, tempers the speed of their preparation.
The last steps are delicate. Goggles cleaned with Clorox to remove chlorine stains and avoid the real threat of fogging, possibly deadly but at the least, dangerous. As they place the goggles on they are isolated, alone. The only window to their soul is through that looking-glass. Another person, perhaps a stranger to them, must then examine the goggles for any breach. If they cannot trust them, if they do not trust the other person, they will never be able to enter the Red Zone. Their voice is muffled by the doubled face mask, but a deep look into their eyes supersedes any linguistic barriers, they hope they are safe. Circulating in the white tarpaulined room are official dressers to aid with the donning of the PPE, a bow here, a tie there and they are deliberately packaged for exit. A tie of the apron across the back and they feel for the dangling knot that is their release, a parachute pull-cord that will signal the start of mental and physical decontamination.
The Ebola Ward is long and consists of a single track of rooms covered in blue plastic, and it is the raison d’etre for the facility. Orange plastic gates are removed and replaced on hung nails as you walk to your ward. Tasks on the ward are simple. There is one diagnosis treated. The differential diagnosis does not exist; admission criteria is a positive PCR test for the Ebola virus. Wards are a mix of male, female, and children, a conglomerate of life all infected with the same virus. Fellow patients must care for the Ebola children as there can be no caregivers on the wards. There is only the latex of the gloves that separates you from the disease, but attempts are made to allow for a semblance of human contact. Diarrhea, vomiting and lethargy overcome patients who lie immobile during their worst days. IV drips, plastic water bottles, and sachets of oral rehydration solution litter the windowless wards. Yellow clinical waste bags await collection and incineration. It is not a happy place, but smiles do occasionally exist on patient faces, yet on staff they are eternally masked.
Hot, sweating, and most likely exhausted after their ward work, they shuffle to the decontamination tent. As they step out of the 0.5% chlorine foot bath they see their counterpart for decontamination procedures. Standing like a starfish, head raised to God, the first cleansing and cool spray of chlorine is felt through the coveralls, sweat collected in gloved fingertips drains slowly down forearms and joins with pooled sweat sloshing in boots. A slow dance then ensues, directed by the chlorine controlling staff. Seven steps of hand washing, again, again, and yet again. First the apron comes off, followed by the glorious removal of the goggles. Cool air tenderly kisses your sclera, reconnecting you with the world. Methodologically, each item of PPE is removed in a controlled and slow fashion. Boots are sprayed on four sides, and then as they raise one foot and dangerously balance on the precipice of the green zone they step back across the threshold. Scrubs dark with sweat, a change of clothes and boots along with a cold bottle of water marks the end of a journey.
As they exit the decontamination area they glance to the right and see the planted forests of drying boots up laid on wooden pegs, strings of protective ski goggles staring back confused at the lack of snow, and the quiet chlorine rain dripping from the crisscrossed lines of drying scrubs.
Everywhere there is a chlorinated humidity. Sounds, previously muffled by your PPE return. Gravel crunches underfoot, again.
Paul Dhillon, MBBChBAO LRCP&SI EMDM CCFP DRCOG DTM&H (Lon) is a clinical assistant professor of family medicine at the University of Saskatchewan.