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| Life, Death and Careful Routine Fill the Day at a Liberian Clinic | |
| (35 minutes later) | |
| SUAKOKO, Liberia — The dirt road winds and dips, passes through a rubber plantation and arrives up a hill, near the grounds of an old leper colony. The latest scourge, Ebola, is under assault here in a cluster of cobalt-blue buildings operated by an American charity, International Medical Corps. In the newly opened treatment center, Western volunteers and Liberian workers identify who is infected, save those they can and try to halt the virus’s spread. | |
| It is a place both ordinary and otherworldly. Young men who feel well enough run laps around the ward; acrid smoke wafts from a medical waste incinerator into the expansive tropical sky; doctors are unrecognizable in yellow protective suits; patients who may not have Ebola listen to a radio with those who do, separated by a fence and fresh air. | It is a place both ordinary and otherworldly. Young men who feel well enough run laps around the ward; acrid smoke wafts from a medical waste incinerator into the expansive tropical sky; doctors are unrecognizable in yellow protective suits; patients who may not have Ebola listen to a radio with those who do, separated by a fence and fresh air. |
| Here are the rhythms of a single day: | Here are the rhythms of a single day: |
| Soon after their arrival, about a half-dozen doctors and nurses gathered near whiteboards for the handoff from the night shift. There were 22 patients, and no deaths overnight. The center — which includes a triage area, a restricted unit for patients suspected of having Ebola infections and another for those in the grip of the disease — is not teeming like some clinics in Monrovia, more than four hours west. It is designed to accommodate up to 70 patients. But with about 200 workers, it is still scaling up after opening a few weeks ago, and has just two ambulances to ferry patients. | |
| An 8-year-old boy had been too weak to lift a liter bottle of oral rehydration solution to his mouth through the night. Bridget Anne Mulrooney, an American nurse, reported that she gave him a smaller bottle and sheets to keep warm. A woman who had lost both her baby and husband to Ebola and was suspected of having the disease herself was refusing food and medications for symptoms and other possible illnesses, such as malaria. A man in his 70s, a talkative staff favorite, was now confused, his sheet covered in blood. He had been admitted four days earlier, but laboratory tests confirming an Ebola diagnosis had not come back yet. “I think he’s positive,” said Dr. Colin Bucks, an American. “I think this will be an end-of-life event.” | An 8-year-old boy had been too weak to lift a liter bottle of oral rehydration solution to his mouth through the night. Bridget Anne Mulrooney, an American nurse, reported that she gave him a smaller bottle and sheets to keep warm. A woman who had lost both her baby and husband to Ebola and was suspected of having the disease herself was refusing food and medications for symptoms and other possible illnesses, such as malaria. A man in his 70s, a talkative staff favorite, was now confused, his sheet covered in blood. He had been admitted four days earlier, but laboratory tests confirming an Ebola diagnosis had not come back yet. “I think he’s positive,” said Dr. Colin Bucks, an American. “I think this will be an end-of-life event.” |
| Eight patients needed intravenous fluids to combat dehydration. One patient was described as happy. Another was playing cards. | Eight patients needed intravenous fluids to combat dehydration. One patient was described as happy. Another was playing cards. |
| Morning devotion began with a song and clapping, performed in triple time. About 18 local workers, most wearing rubber boots and blue hospital scrubs bleached so often that they were now pastel pink, danced and then prayed for God’s mercy on the treatment unit and those who worked there. Some folded their hands, sheathed in bright-colored gloves, at their heart. In unison, the Liberians sang, “Cover with your protective arms, O God.” | |
| Sean Casey, an American who is the center’s team leader, gathered his department heads for what became a conversation about patient flow. The head of the ambulance crew said five patients with possible Ebola infections were awaiting rides to the center. But the ward with suspected cases was full, Mr. Casey said, and needed to be cleared first. Lab results were required, so patients without Ebola could be discharged and the confirmed cases could be moved to the other ward. The center also had some patients who were ill with other maladies. They should have been transferred to the local hospital, but it offered only limited care since reopening after six nurses died of Ebola. | |
| The managers also discussed labor issues involving the 175-member Liberian staff, some of whom had walked out days before in one of the pay disputes common among the country’s health workers. The leaders and those who abandoned patient care would not be rehired because it was crucial to have a dependable staff, Mr. Casey said. Then he sent everyone off. | The managers also discussed labor issues involving the 175-member Liberian staff, some of whom had walked out days before in one of the pay disputes common among the country’s health workers. The leaders and those who abandoned patient care would not be rehired because it was crucial to have a dependable staff, Mr. Casey said. Then he sent everyone off. |
| “Go forward and do well,” Mr. Casey instructed. | “Go forward and do well,” Mr. Casey instructed. |
| 8:40 A.M. A Liberian woman scooped steaming yam porridge out of a blue bucket — breakfast for the patients and staff. The food is prepared off-site, at a university that is closed because of the outbreak and houses many of the staff members. The center has people working as cleaners, sprayers and waste removers — part of the so-called WASH (water, sanitation and hygiene) team — who continuously disinfect the site and remove contaminated material. Still, the sight was a little jarring: The woman was putting the food into plastic foam plates just a few steps from the dressing rooms for staff members coming out of the decontamination areas, the pharmacy, and past a refrigerator with a sign marked, “Ebola blood tests. NO FOOD.” | |
| 8:45 A.M. The medical staff — including an American doctor, a Spanish nurse and a Kenyan nurse, along with a Liberian physician assistant, nurses and other workers — put on protective equipment piece by piece to enter the treatment areas. Gloves, Tychem suits, masks, hoods, aprons, goggles, the ensemble checked in a mirror to ensure no skin was showing. The process took about 20 minutes. | |
| A doctor, Steven Hatch, entered the ward of patients with suspected Ebola infections and asked them if they were hungry. “How do you feel?” he said to one. A woman in a T-shirt walked stiffly behind him carrying a plastic chair, which looked heavy in her weak hands. Staff members outside the patient area dropped in bottles of water and pitched plastic garbage bags over a gate from the gowning room, never touching. Cleaners had gone in ahead of the medical team and were spraying the ground with chlorine solution and picking up garbage with buckets that looked just like the ones that held the yam cereal. | A doctor, Steven Hatch, entered the ward of patients with suspected Ebola infections and asked them if they were hungry. “How do you feel?” he said to one. A woman in a T-shirt walked stiffly behind him carrying a plastic chair, which looked heavy in her weak hands. Staff members outside the patient area dropped in bottles of water and pitched plastic garbage bags over a gate from the gowning room, never touching. Cleaners had gone in ahead of the medical team and were spraying the ground with chlorine solution and picking up garbage with buckets that looked just like the ones that held the yam cereal. |
| Staff members observing outside debated whether a set of wooden game tables with dice could be given to patients in the suspect ward. Mr. Casey decided against it, for fear of sickening someone not infected; only those confirmed Ebola patients could safely play together. Friederike Feuchte, a German psychologist, understood but was disappointed. “They feel bored,” she said of the patients awaiting their test results. | Staff members observing outside debated whether a set of wooden game tables with dice could be given to patients in the suspect ward. Mr. Casey decided against it, for fear of sickening someone not infected; only those confirmed Ebola patients could safely play together. Friederike Feuchte, a German psychologist, understood but was disappointed. “They feel bored,” she said of the patients awaiting their test results. |
| One of them, Kolast Davies, 45, agreed. “Being here is stressful and very boring, especially when you don’t know your fate,” he said in an interview. He was admitted after managers of the steel production company where he works, ArcelorMittal, sent him when he returned from a vacation in Monrovia. Now, three days later, his test results were not back. He looked healthy, and the medical team wanted to make sure he did not contract Ebola from the other patients. “They told me I should be very mindful of others. No touching,” he said. His bed, like the others in the unit, was in an 8- by-10-foot space separated from others by wood-framed walls of tarp, and he shared a latrine with other patients. | One of them, Kolast Davies, 45, agreed. “Being here is stressful and very boring, especially when you don’t know your fate,” he said in an interview. He was admitted after managers of the steel production company where he works, ArcelorMittal, sent him when he returned from a vacation in Monrovia. Now, three days later, his test results were not back. He looked healthy, and the medical team wanted to make sure he did not contract Ebola from the other patients. “They told me I should be very mindful of others. No touching,” he said. His bed, like the others in the unit, was in an 8- by-10-foot space separated from others by wood-framed walls of tarp, and he shared a latrine with other patients. |
| One night, he said, someone died under the same roof. “It’s too pathetic,” Mr. Davies said through tears. “I think the world needs to come.” | One night, he said, someone died under the same roof. “It’s too pathetic,” Mr. Davies said through tears. “I think the world needs to come.” |
| 10 A.M. Two men wearing yellow protective suits and thick rubber gloves left the clinic carrying a body bag on a stretcher. As they walked through tropical forest filled with birdsong, another man followed behind, spraying the dirt path until the brown leaves glistened with bleach solution. They were burying a 38-year-old man. In the final stages of his illness, he had left his bed, disoriented, and curled up against a 50-year-old woman who had died. A nurse found them lying together the next morning, a scene Dr. Hatch called “simultaneously touching and horrifying.” | |
| Now, the man’s body bag dripped as the burial team lowered it into a freshly dug hole, across from the grave of the woman, which was marked with a simple wooden sign. His was the seventh body on the grounds of the new treatment center. Ten more holes had already been dug, and four men with shovels stood by watching. No prayers were spoken, no tears were shed in what has become a new, numbed burial rite. As they returned, the team sprayed their path all the way back to the morgue. | Now, the man’s body bag dripped as the burial team lowered it into a freshly dug hole, across from the grave of the woman, which was marked with a simple wooden sign. His was the seventh body on the grounds of the new treatment center. Ten more holes had already been dug, and four men with shovels stood by watching. No prayers were spoken, no tears were shed in what has become a new, numbed burial rite. As they returned, the team sprayed their path all the way back to the morgue. |
| 10:50 A.M. Doctors went over the first set of test results from a new mobile lab that the United States Navy had set up the previous day on the grounds of the local university. It seemed miraculous: Test results would now be delivered in just a few hours instead of the four to five days required earlier, when samples had to be driven to Monrovia and were sometimes lost. Mr. Davies learned that he tested negative for Ebola and could leave. | |
| Encircled by orange fencing, the center looks something like a detention facility. In truth, it would be easy to escape; one confused patient had already wandered onto the driveway and been escorted back to the ward. No armed guards watch outside and the entries to patient areas are not secured. | Encircled by orange fencing, the center looks something like a detention facility. In truth, it would be easy to escape; one confused patient had already wandered onto the driveway and been escorted back to the ward. No armed guards watch outside and the entries to patient areas are not secured. |
| Another patient, Lorpu Kollie, 28, rejoiced after being told she was not on the list of those whose tests indicated infection. She called her parents to tell them she was going home. But a staff member had mistaken her for someone else; in fact her blood sample, drawn nearly a week earlier, had tested positive for Ebola. | Another patient, Lorpu Kollie, 28, rejoiced after being told she was not on the list of those whose tests indicated infection. She called her parents to tell them she was going home. But a staff member had mistaken her for someone else; in fact her blood sample, drawn nearly a week earlier, had tested positive for Ebola. |
| Given the new diagnosis, Ms. Kollie was devastated and refused to move to the confirmed Ebola ward. Dr. Feuchte, the psychologist, went to meet with her. “I told everybody I am coming home,” Ms. Kollie told her, crying. Dr. Feuchte said that she could stay put for now and they would test her again. A fellow patient sought to reassure Ms. Kollie, reminding her that she could be all right. Don’t worry, she said, “only few more days.” | Given the new diagnosis, Ms. Kollie was devastated and refused to move to the confirmed Ebola ward. Dr. Feuchte, the psychologist, went to meet with her. “I told everybody I am coming home,” Ms. Kollie told her, crying. Dr. Feuchte said that she could stay put for now and they would test her again. A fellow patient sought to reassure Ms. Kollie, reminding her that she could be all right. Don’t worry, she said, “only few more days.” |
| Even with the new lab, something as basic as blood tests still posed outsize challenges. The intense disinfecting process sometimes erased or eroded patient identification numbers from tubes and paper, making them difficult or impossible to read. Each blood draw was risky for staff members, particularly because the syringes were difficult to manipulate with triple-gloved hands. “It would be inexcusable for us to have to take blood again and get a needle stick,” Dr. Bucks had said during the morning shift change. Within hours, he and others devised a better system for identifying tubes and discussed ordering a different blood-drawing system that would be safer to use at patient bedsides. | Even with the new lab, something as basic as blood tests still posed outsize challenges. The intense disinfecting process sometimes erased or eroded patient identification numbers from tubes and paper, making them difficult or impossible to read. Each blood draw was risky for staff members, particularly because the syringes were difficult to manipulate with triple-gloved hands. “It would be inexcusable for us to have to take blood again and get a needle stick,” Dr. Bucks had said during the morning shift change. Within hours, he and others devised a better system for identifying tubes and discussed ordering a different blood-drawing system that would be safer to use at patient bedsides. |
| NOON Lunch arrived; the heat was stifling. The blue buckets that served yam porridge at breakfast were now filled with rice. Workers set out food on plastic foam plates in the staff sitting room, waiting for doctors and nurses to wolf it down when they found a free moment. | |
| 1 P.M. A staff member returned from the local market with bags of second-hand clothing, items to replace patients’ clothes that were discarded because they were soiled or possibly contaminated. Among his haul: 20 lappas, local batik wraps worn as skirts; 20 bras; 30 pairs of socks; and piles of battered jackets and pants. “This is 10th-hand,” joked Eric Diudonne, a civil engineer, who sent the clothing over to the laundry staff to wash. | |
| The cleaners in the laundry room disinfected and washed the staff members’ scrubs, goggles, rubber gloves, aprons and boots in vats of diluted bleach, and then ran them through a washing machine. The items were taken outside to dry; stiff aprons hanging from a line and boots propped upside down on poles. Some patients passed the time by washing their own clothing by hand, but all patient bedding and clothing was burned after they were discharged or died. | |
| 4:30 P.M. Nurses gowned up to give afternoon medicines, run intravenous fluids and draw blood from new patients and three who had to be retested. And the new results arrived. Ms. Kollie was now negative, meaning that she had recovered from Ebola or her first sample had been mixed up with someone else’s. “Thank you, thank you!” Ms. Kollie rejoiced when she was told the news. She danced and reached out her arms as if to hug the staff, who were separated from her by plastic fencing. “I’m coming home,” she told her parents on the phone. | |
| She stepped into a shower for 10 minutes of scrubbing, with a nurse giving instructions. She dropped a handful of belongings, including money, a small change purse and a cellphone, into a bucket of chlorine for disinfection. (She said she did not care that the phone might not survive.) Someone handed her a bag with a fresh set of clothing and $10 for transportation. | She stepped into a shower for 10 minutes of scrubbing, with a nurse giving instructions. She dropped a handful of belongings, including money, a small change purse and a cellphone, into a bucket of chlorine for disinfection. (She said she did not care that the phone might not survive.) Someone handed her a bag with a fresh set of clothing and $10 for transportation. |
| It had rained briefly. Looking out from the hilltop, Ms. Kollie saw a rainbow. | It had rained briefly. Looking out from the hilltop, Ms. Kollie saw a rainbow. |
| 7:10 P.M. The day team handed off the patients to the night crew. Several patients appeared to be doing better. And some whose tests turned out to be negative would be going home the next day. | |
| But, a nurse reported, one man had vomited in the yard. Others had found a sheathed knife under his pillow, and he explained that he would rather die from a knife than from Ebola. Two days later, the disease killed him. | But, a nurse reported, one man had vomited in the yard. Others had found a sheathed knife under his pillow, and he explained that he would rather die from a knife than from Ebola. Two days later, the disease killed him. |