Putting on and taking off a biohazard suit — the protective armor in the battle against Ebola — is no simple task, as Audrey Rangel, MIPH, RN, learned during 10 days of intensive training at a hospital in Liberia. A co-worker must be present to make sure the suit is not damaged or improperly donned or removed. There are inner gloves, outer gloves, a gown, an apron, a mask and goggles. When removing the suits, workers are sprayed with chlorinated water at all steps. Nurses write each others’ names on their hoods because that’s the only way they’ll know who’s who under the layers.
”The whole process takes about 10 minutes to get it on and 15 minutes to get it off,” said Rangel, who recently responded to a call for nurses to work in West Africa in response to the Ebola crisis. “They don’t want anything touching your skin.” Rangel spoke to Nurse.com by Skype from Monrovia, the capital of Liberia, where the disease has hit especially hard. The next day she was leaving with her team for Bong County, about four hours away, to join Liberian colleagues in setting up a 10-bed Ebola treatment center run by International Medical Corps, a global nonprofit humanitarian organization.
The layered, complex suits, which must be changed every hour or so, are themselves only one layer of complexity in dealing with an outbreak of a hemorrhagic virus that, as of Oct. 8, has infected about 8,000 people — including many healthcare workers — and caused more than 3,800 confirmed deaths, and probably many more unconfirmed ones, health experts say. The epidemic has been growing exponentially, and the World Health Organization has predicted it could infect more than 20,000 people in West Africa by Nov. 2. The Centers for Disease Control and Prevention project a worst-case scenario of 1.4 million cases in four months. WHO has asked for international healthcare workers to help treat people in overflowing centers in Liberia, Sierra Leone and Guinea, the countries most affected by the crisis.
Rangel, who trained as a nurse in Australia after getting a master’s degree in international public health at George Washington University in Washington, D.C., had finished a two-year nursing job in East Timor. She and her British husband, a water sanitation specialist, were trying to decide where to go next when she saw IMC was recruiting nurses to work in West Africa. Her husband is waiting in London until she finishes her mission. “They needed people to start right away, and they made me feel comfortable about the work they were doing here,” she said.
Not your typical catastrophe
Much of the nursing care Rangel and others have provided involves keeping patients comfortable and hydrated. Although some medications have shown promise in treating it, at this point Ebola is incurable and there is no proven vaccine against it. “You have to have a good [clinical] skill set, but I think it’s more about being mentally strong,” Rangel said, especially because many patients don’t survive — the overall death rate for this strain of the virus is roughly 70%, slightly lower for hospitalized patients, according to WHO. Nurses give pain medications, antibiotics to prevent secondary infections and malaria pills to patients. At the treatment center in Bong, Rangel will also be giving IV fluids to replace those lost through bleeding, vomiting and diarrhea, which can happen in later stages of the illness. By using IV therapy and offering treatment early, healthcare workers hope to bring down the death rate from the disease.
Fighting a rapidly spreading infectious disease that kills more than half the people who contract it is much more involved than responding to natural disasters, such as the 2010 earthquake in Haiti or typhoon Haiyan in the Philippines last year, say those who have coordinated responses to past catastrophes. “This is not a typical emergency, but the only models we have are for a typical emergency response,” one that relies on two-week volunteer stints and efforts by individual organizations, said Sheila Davis, DNP, RN, ANP-BC, FAAN, CNO for Partners In Health, a Boston-based international nongovernmental organization that provides care to poor people in 12 countries, including the U.S.
”Getting people out there [to West Africa] has been entirely different” from other emergency responses, said Brandon Berrett, director of international human resources and recruitment for International Medical Corps, based in Los Angeles, which is operating Ebola treatment centers in Liberia and Sierra Leone. The organization plans to gradually expand the center in Bong to 70 beds. It wants to hire 200 international nurses to work in Liberia and Sierra Leone in six-week stints through February, Berrett said, but finding people able and willing to go and getting them there has been challenging.
U.S. hospitals, universities and some humanitarian organizations have been reluctant to send teams to West Africa without having a secure system to protect their staff — although that could change after President Obama’s announcement Sept. 16 that 3,000 U.S. troops will travel to Liberia to help with the crisis. Some affected countries have closed their borders, and flights in and out of the country are limited only one airline serves Liberia and a different carrier provides air service to Sierra Leone. The length of deployment — six-to-eight weeks, plus a possible three-week quarantine after returning — is a deterrent for many. Even when nurses are willing to go, family members may be alarmed by highly publicized news of infected healthcare workers — including at least four from the U.S. Rangel said her greatest fear was not of catching Ebola, but telling her family in Seattle she was going to be caring for people who had it.
Out of concern for staff safety, the Massachusetts General Hospital Center for Global Health in Boston is not recruiting or deploying clinical teams to West Africa, said Pat Daoust, MSN, RN, associate director of nursing at the center, although it has sent teams to other disaster sites. The center has established eight safety and training criteria for volunteers responding to the Ebola crisis, including evacuation plans that consider possible civil unrest and non-Ebola dangers, as well as how to transport volunteers who might contract the virus.
”We can’t advocate for our staff to be deployed without all of these considerations being assured,” Daoust said. ”This could be another disaster for us if we don’t do it right.”
Berrett understands why people fear Ebola. ”They see a substantial risk, and there is one,” he said. ”But we are very careful.” ICM and Médecins Sans Frontières/Doctors Without Borders, the French-based group that has mounted the largest international Ebola response in West Africa thus far, gives all its workers a 10-day training session like the one Rangel received. Ebola is spread through bodily fluids — sweat, blood, vomit, urine, feces and saliva — but not through airborne particles the way influenza and Severe Acute Respiratory Syndrome are. The groups follow precautions recommended by the CDC, which include using protective suits. If those precautions are followed, the risk is very low, Berrett said. MSF, which has about 3,000 staffers working in West Africa, has reported two Ebola cases among its 300 international workers.
Although Rangel felt nervous when she arrived in Monrovia, she said her initial unease was replaced by a healthy caution once she started her training at a hospital for Ebola patients run by MSF. “Ebola is a scary disease, but as long as you follow the rules and do what you’re told, you feel like you’re in kind of a bubble,” she said.
Rangel and three fellow nurse trainees, two from Kenya and one from Spain, learned to avoid touching their faces and how to watch each other for signs of dehydration or exhaustion. “Caring for patients in 90-degree heat engulfed in the protective suit is as exhausting and sweaty as working out at a gym,” she said. ”If you start to feel tired, you have to stop.”
The nurses also learned the importance of remembering to care for themselves in other ways — avoiding street food, getting enough sleep, taking malaria pills, staying hydrated, washing hands frequently with chlorinated water and not touching people, even when not at work. They take their temperatures twice a day. Anyone who has a fever is isolated until a test confirms or rules out Ebola. If one of them gets Ebola, IMC will arrange to have the person evacuated to a treatment center either in the persons own country or a country that can take him, Rangel said.
Despite stories of panic and healthcare workers and community educators being attacked by people who feared they’d bring the disease, Rangel said she has seen relative calm during her time in Monrovia. There’s definitely fear in the community, she said. She’s heard stories of people getting kicked out of their houses because they had a family member who died of Ebola, and of people asking for treatment when they were not sick. But there’s also a lot of education, Rangel said. Signs are everywhere listing precautions — washing hands, cooking food properly, avoiding touching people who have Ebola and getting to a treatment center if symptoms develop. Radio jingles and talk shows echo the warnings. Storekeepers ask customers to wash their hands with chlorinated water when they come in and again when they leave. Customers entering restaurants must have their temperatures taken with a thermometer that does not touch their skin.
“So far we’ve been very welcomed by the local staff and people in the community,” Rangel said. “It seems like people are glad to have us here.” She heard IMC had no problem finding local people willing to work in the center in Bong, with its procedures and equipment designed to keep staff safe.
“Right now the safest place for a healthcare worker in Liberia to be is in an Ebola treatment center,” she said. But they’re definitely going to need more people.
Federal response to security concerns
President Obama’s decision to create a military command center in Liberia to help coordinate U.S. and international relief efforts and build Ebola treatment centers will offer more security to U.S. organizations who want to send medical staff to the area, said nurses involved in international aid groups. Partners In Health recently started recruiting nurse volunteers to staff a planned 100-bed Ebola treatment center in rural Liberia, but no one will be deployed until arrangements are made with the U.S. and Liberian governments to get people in and out of the country, and to be sure they will be properly cared for if they get sick, Davis said, something she hopes will take days rather than weeks.
Once the government and military support is in place, Daoust and Davis said they expect U.S. nurses to follow. Both have received many calls from nurses wanting to know what they can do to help. ”As nurses, we want to respond,” Daoust said, particularly because Ebola has been so devastating for West African nurses and other healthcare workers. “I think people will be amazed at the number of nurses interested in working on a defense.”
Since she’s been in Liberia, Rangel said she has been moved by the heroic efforts of Liberian nurses and other local healthcare and sanitation workers, who have been battling Ebola for months, even as family members, friends and colleagues have become sick and died. If it were happening in her own country, she said, she isn’t sure she’d resist the impulse to retreat, to protect herself and her family. ”Their resolution to carry on and keep doing something about it, I find really impressive,” Rangel said.