Heart of darkness
The Bo EMC compound is an impressive and foreboding community encompassing around 30 acres just beside the main road that travels east from Bo to Kailahun. The Kailahun region is where the outbreak began and where MSF established their first Sierra Leone EMC. The epidemic is believed to have started in a small village with a young girl (unceremoniously referred to as “Patient 0”) in the Gueckedou region of Guinea that borders Foya in Liberia and Kailahun in Sierra Leone.
The Bo EMC compound is completely surrounded by a high fence with two guard stations. Immediately inside is a large MSF supply tent (in MSF lingo, a ‘rubhall’) that is next to six cottages; the middle four have been taken over by MSF as offices. The 1st is a CDC Ebola testing laboratory and the 6th is a private residence. Behind the offices are a huge water tower and a helicopter pad that has been located a bit too close to the patient tents, such that everything and everyone gets blown around whenever a copter lands. Behind the helicopter pad is the EMC itself surrounded by a second, inner fence that is meant to provide separation rather than confinement. The area within the inner fence is the EMC itself – divided into a low-risk zone and a high-risk zone. The low-risk zone comprises dressing rooms, a nursing station, a pharmacy, a dressing, and an undressing area, several supply tents and a laundry, bathroom, and kitchen. The high-risk zone is separated by a third fence and contains the heavily contaminated areas – the triage area, the ambulance entrance, 4 patient tents and the morgue. Bo has three rubhalls for confirmed Ebola viral disease (EVD) patients and one smaller tent (in MSF lingo, a ‘trigano’) for suspect and probable EBV patients awaiting the results of their Ebola lab test. The confirmed tents each contain 32 beds in 8 cubicles; 4 beds/cubicle. The suspect/probable tent has 8 beds.
There are four connections between the high-risk and low-risk zones – the discharge shower, the morgue exit, the dressing (donning) room, and the undressing (doffing) room. When patients are discharged, they have a thorough shower in the discharge shower room, they receive new clothes (all of their possessions are burnt or buried) and they are serenaded by songs and drums as they dance out of the EMC. In the morgue, dead bodies are thoroughly decontaminated with chlorine and zipped into a body bag. The white, plastic, non-porous body bags have the name of the deceased and his/her Ebola outbreak case number clearly noted in permanent red magic marker on the outside. A burial team that digs the grave, transports and deposits the body, fills in the grave again and marks the gravesite then whisks off the body. All of this backbreaking labor involving corpses that are heavily contaminated with a lethal virus is done over and over again, under the hot sun, in partial PPE and without complaint. One doesn’t have to look far to find unsung heroes in this tragic situation. The ambulance drivers are another.
A hygienist steps in to the undressing tent to begin removing multiple items of protective clothing. The sprayer (left) guides the often exhausted colleague step by step through the undressing process. The protective layers can create stifling conditions that are difficult to withstand for too long. To avoid overheating and fatigue, staff working in the high risk zone must limit the time they spend in the isolation ward. ©Fathema Murtaza, MSF
We ‘go in’ with a partner and we stay in visual range of each other for the entire time. The maximum time in PPE is 1 hour but at midday 30-45 minutes is enough. The undressing (doffing) procedure is controlled by doffing officers who guide us through each step. “Now, remove your mask.” “Now, wash your hands properly.” This is basically donning in reverse plus hand washing with 0.05% chlorine and PPE spraying with 0.5% chlorine between each step. We usually ‘go in’ twice per shift.
The low-risk and high-risk zones are only 2 metres apart. They are separated by a 3-foot high, orange plastic, see-through fence that allows for full visual monitoring of the high-risk zone and verbal communication between the two. For instance, a person in PPE in high-risk can shout across that fence for clothes, a blanket(!), ORS (water mixed with oral rehydration salts) or a medication that can be thrown to them across the fence. Amazingly, nursing rounds occur every 2-3 hours right through the hottest part of the day and all night long.
There are 0.5% chlorine shoe-spraying stations and 0.05% chlorine hand-washing stations everywhere. The soles of the our shoes must be sprayed and our hands washed every time we enter or exit anything – offices, kitchens, bathrooms, compounds, and the low-risk zone. I do not find the chlorine toxic to my hands (except for turning my nails yellow) but I am just recovering from a chlorine chemical burn of my upper and lower eyelids. Luckily, my eyes were spared. I wasn’t aware that the skin of the eyelids was so sensitive. It feels and looks just like a sunburn and I am in the peeling stage. Happily, I didn’t miss any work.