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Seven or more health care workers, including two workers whose sole responsibility is spraying 0.5% chlorine to maintain control of infectious body fluids, enter the Ebola treatment unit’s hot zone together, operating as a single unit and often exiting as a group. Each team has a delegated leader who allocates clinical responsibilities. The leader also monitors the health and well-being of each member during rounds and while working within the Ebola treatment unit (ETU), often deciding when a rapid exit and doffing, or removal, of personal protective equipment (PPE) is necessary. Failure to appropriately assess or anticipate the status of staff can have potentially severe consequences—for example, a weakened worker might stumble or fall in an Ebola contaminated environment.
Recently, one member of our team felt dizzy after spending less than an hour in PPE. On cue, we exited the ETU as a group, and quickly directed her to doff. Such an occurrence isn’t unusual: Inside PPE body temperature easily reaches 1000° F, which, coupled with humidity of 100 percent, leads to heat exhaustion and poor judgment. At night, health care workers have to contend with insects flying around and within the PPE, even swarming behind goggles. Often personnel are the worst judge of their own vulnerability and need an expedited ETU exit before an emergency exit is required.
As health care workers, we spend less than two hours in PPE—this equates to 100 minutes seeing patients and the last 20 minutes doffing. The tasks of physicians mirror those of other health care workers in the ETU. For all our training, the list of practical skills is modest: administration of fluids and medications, observation based assessments in the absence of blood pressure cuffs, estimation of fluid input and output, respiratory status, state of dehydration and mental status. Practically, we place urinary catheters or change diapers of terminally sick patients, draw blood and handle blood samples and urge patients to eat. The larger task that we quietly perform is paying mind that our patients die with comfort and dignity from an otherwise devastating disease. Contrary to expectation, the wards are not malodorous and full of human congestion. Instead units for both confirmed and suspected Ebola cases are clean and odorless with the exception of the penetrating smell of chlorine. Chlorine collects in small pools along the irregularities of the concrete floor.
Dr. Majid in training to use the personal protective equipment (PPE)
The hot zone contains the patients infected with Ebola. The hot zone exacts an unexpected emotional toll, far more than the physical or physiological. As health workers, we must brace ourselves for its unedited cuts from happy to heartbreaking without compromise to self-control or analytic observation. Occasionally, I find myself broken and paralyzed and must hurry to remind myself why I have come to Liberia—this is what drives me back on my feet.
With these limitations in mind, bedside rounds must be both fast and efficient. Goggles often become foggy, obscuring vision, and PPE allows for limited dexterity in actions such as placement of intravenous lines in Ebola patients. Such fumbling opposes the unalterable rule—that any needle puncture incident is one too many. The injection of Ebola-infected blood is one of the most frightening infectious disease emergencies.
After performing duties in the ETU patient care area, we must doff the PPE systematically, strictly adhering to the directions of a doffing manager. This step, if nothing else, is the one in which medical providers must be most proficient: No matter the heat, discomfort, and anxiety, speed is dangerous. In a deliberate, slow and steady manner, we remove layers of protective outerwear and eye protection, with every action aimed at avoiding self-contamination.
After doffing, the medical group has a joint debriefing session in a tent located in the low-risk zone. Documentation of the patients’ clinical information is essential, but correct and complete information is difficult to collect. With only chlorine-soaked sheets of paper, and without access to medical records outside the hot zone, how can one recall those precious clinical details when our memories are distorted, and it all becomes one vast, swarm of bodies, some wandering, some playing, others already lost, within the hot and wet PPE.