This afternoon the medical team suited up together for what we would call “rounds.” The team today consists of a young Australian doctor, a clinical officer from the local area, like our nurse practitioner, and me. We are never sure what we will find each time we enter the ETU (Ebola Treatment Unit), but we plan ahead as best we can for specific patients who are unstable and should be seen, and for supplies that might be needed. We stagger our entry with the nurses to not over-crowd the unit, and in part, because the dressers and undressers/washers can deal with us easier if we come in and come out in waves.

This afternoon is especially hot so we hope to finish the work in 45 minutes. The PPE is an air tight non-breathing environment. We pour out the sweat but there is no evaporative cooling…just drenching sweat which puddles in my gumboots.

Heat controls us and dictates what is possible. The canvas hospital itself is simmering on hot afternoons. Patients lie still. Those that are outside sit in the shade, fan them selves or mop their foreheads. In this heat we all sweat. Sweat can carry Ebola to every place that skin touches anything. The entire unit is continually being sprayed with chlorine.

Heat means that there is no time to really get to know patients, to sit with them and answer questions, listen to their fears and hopes, hear who they are as people. This distresses me. It is in my physician’s heart to know my patients, to weave in personal and emotional support for their healing. I regret this particularly when I am helping someone who is dying. My desire is to sit down and be present. But with the heat and the amount of work to accomplish in a short time everything has to be done in the briefest of moments. Besides, sitting down is discouraged as it contaminates our backside. A simple press of the hand or murmured kindness is all I can manage as I give the medicines or encourage drinking. The specifics of this illness, its’ contagion, the heat, the crush of patients, make intimacy and the human dimension of healing very difficult.

When we enter we look for what has changed, who is declining and who is feeling better. We use a five point progression scale, a score, to describe how we evaluate patients: 1 means no symptoms, 5 is close to death, unconscious, unable to do anything. We ask each person about his or her symptoms. “Ask” really means shout, so we are heard through 2 layers of mask covering our mouths.. “Are you having vomiting? Diarrhea? Pain? What about fever? Are your symptoms better or worse? Are you stronger or weaker?” We assign a score to each patient and note it on a piece of paper that never leaves this zone.

Everyone works slowly, carefully and efficiently. Our mantra is “Slow, slow. Safe, safe.” Hopefully the nurses have already started or restarted the IVs, cleaned the patients, and done the blood tests, so our team is able to do the evaluations, decide and give any treatments or therapy changes, and encourage fluids and food. In practice everyone on the team does all of the work. So if we see an IV that needs fixing or a patient who needs help or cleaning, we just do it if we can. Since the very ill can experience projectile vomiting and rampant diarrhea cleaning up is constant. We monitor each other and ourselves as to how we are doing in the heat. Getting out takes time so we can’t be working inside the unit until “the last minute” which means just before we feel faint from heat.

Before we leave the high risk zone we go to the orange plastic fence and call out all of the patients’ I.D. numbers, bed number, his or her score, and any treatments. This information is recorded by a nurse 2 meters and 2 fences away in the low-risk area. There is no such thing as privacy or confidentiality. These scores will then be placed on a patient’s “chart”, a big whiteboard with every name, bed number, any treatments needed, and today’s score. We look and see if the trend of the scores is better or worse. In this way we monitor the healing or dying of each patient.

Each patient is given a few medicines every day. These include a vitamin, an anti-malarial twice a day, a full spectrum antibiotic, and panadol, which is like Tylenol. Tramadol, a strong oral narcotic-like drug is given for severe pain, and morphine for excruciating or terminal pain.

Today we find several patients have fallen off their cots. Ebola is so profoundly weakening that patients sometimes slip off and cannot raise themselves. One gentleman could only lift his hand two inches before it fell back. My colleague and I pick him up carefully, but even so it causes intense pain while we return him to his cot. The fog inside my goggles is not from heat but from tears for the suffering endured.

Today I discover a man in the “probable” tent, dead on the floor. He is curled up in a child’s pose, knees tucked up. He has a look of surprise on his face. What killed him we do not know for sure, but probably Ebola. His Ebola test had not returned and his symptoms were not extreme. He looks to be about 30.

As I paused with this dead man I hear wailing and keening outside the unit. Some family has just been told of the death of their loved one. Was it this man? In our culture we rarely hear “keening”. It is a sound of grief so sharp that it cuts the air. It enters your body and rivets your attention. It is raw and unbridled grief. Whoever is grieving will not be allowed to be with the body because it is in death that the corpse oozes Ebola and is the most contagious.

In pre-Ebola times funerals were important tribal and social affairs. Death was a time of gathering of relatives and tribal members. There is singing and dancing, eating and lamenting. The body is bathed, clothed, and laid out with love and tenderness for final goodbyes. The family buries the dead with their ancestors in village graveyards. People know they will always be together in the family graveyard and this brings comfort, a sense of place and belonging.

All of this is disrupted by Ebola. These very practices have fueled the spread of Ebola. The epidemiologists suspect that many hundreds of people suffering from Ebola do not want to come to the treatment units because they know if they die they will not be buried with their ancestors. Many others are in denial that Ebola is real and die at home and infect their loved ones.

I have heard that in some treatment units there is an effort to accommodate one family member to view the dead person’s face. A staff member in full PPE briefly unzips both zippers of the bodybags while a family member peers through a window. But I think this is discouraged as it is risky. And the face is often freightening, frozen in agony.

The body itself is wrapped in material that will absorb 30 liters of fluids. It is put into a body bag. Then it is sprayed with chlorine. Then it is put into a second body bag.

A simple procession of the “sanitation” staff buries the dead in deep graves behind the treatment unit. A wooden sign has a name , and is posted in the soft dirt. The gravediggers keep digging. Their work is assured for a good long time.

In the next “room” someone calls out in a small voice. “Look, Dr. Charles, I’m somehow a bit OK.” A woman in a torn tee shirt raises her hand to signal me, It’s Mary I realize. Indeed she does look better. Her score today is a 3, down from 4 yesterday.

“I’m so happy to see you sitting up by yourself, Mary. Good work. Keep drinking, drinking.” I smile a secret smile inside my PPE. “YES!” I say to myself. Many, with proper care, are living through this hell. This bolsters all of us and keeps us going.

Even though I have the exit steps clearly memorized by now, I am grateful for my sprayaer who yells each step clearly to me. I cross over the “red line” with a sigh and into a chair in front of a fan. I am drenched and tired to the bone.

It was a good day.

I am finishing up my time in this center in Bo. I will join other teammates in Lunsar, where a brand new ETU will open soon. This is an exciting part of the international “scale up” to bring care to all of the areas that have Ebola. The Lunsar staff are being hired now, about 200 people including doctors, clinical officers, nurses, washers, dressers, and sanitation workers as well as all the support people. Most of them need to be trained about Ebola in protocols and procedures, and PPE. The medical staff has to practice working together, imagining emergencies, setting up routines and treatment flow, charting, ambulance and burial protocols, and dealing with families of the sick. We hope to open the doors to the people who desperately need this care in about ten days.

Thank you each and everyone for all of the ways you are supporting me and the work here. It means a lot to read your comments on this blog or on Facebook. I sometimes feel very far away from anything familiar and reading your comments brings you to me. Sending love from Sierra Leone,

Charles