“One hell of a mission to cut your teeth on.”

1 October 2014

Returning Red Cross nurse Donna Collins says the true heroes of fighting Ebola are the national nurses who have lost colleagues, faced eviction by landlords, and have been ostracised by their villages, yet they keep turning up for work each day. Back safely from Sierra Leone, Donna talks to FIONA CASSSIE about the testing, sometimes fearful, but ultimately very satisfying mission to help the Ebola-stricken nation.

Kenema Triage tent“Initially, I was scared witless,” says Red Cross nurse Donna Collins when asked about caring for her first Ebola patient in Sierra Leone.

I looked at this gentleman, and I thought ‘oh my God, you have the ability to kill me if either of us do the wrong thing or if I didn’t have this PPE (personal protection equipment) on’.

“It was one of those life moments when you stop and think ‘far out – this is serious’ and then I thought ‘put your big girl pants on, girl, and get on with it’. So that’s what I did.

“… that poor man was dying of Ebola, so he had more problems than I did.”

It wasn’t the only time that Donna told herself to “put her big girl pants on” or drew on her sense of compassion, strong practical streak, and Kiwi down-to-earthness to get her through her first-ever Red Cross assignment.

“It was one hell of a mission to cut your teeth on,” she acknowledges.

Rather than being intimidated, the Whangarei nurse and her fellow first-timer, Wellington nurse Sharon Mackie, requested for their initial three-week assignment in Sierra Leone to be extended. The pair ended up staying for nearly four and a half weeks, as they weren’t prepared to leave before the Ebola treatment centre (built from scratch by their international Red Cross team) was open and caring for its first Ebola patients. 

After overcoming her initial fear, Donna says she thrived. Luckily her family (she has four children aged 16 to 22) are accustomed to mum and dad’s work (her husband is also a nurse) taking them to exotic places. For example, the family lived in an aboriginal community in outback Australia for five years. “So they take most things in their stride.”

“My youngest one said, ‘I don’t want you to die, Mum’, and I said, ‘don’t worry, babe, that’s not on my agenda, either’.

“My foster daughter said to me, ‘I don’t want anything to happen to you as you are the best mother I’ve ever had’. That really struck me in the heart.”

The 17-year-old focused on the positives and was ‘stoked’ she could use mum’s car while she was in Africa.

Donna and Sharon returned home safely to family and friends in New Zealand at the start of October – after a three-week quarantine period in Morocco – and a week later, they were back in their day jobs.

One of Donna’s three ‘day jobs’ is as a midwife at Whangarei Hospital’s maternity unit, and she found it very tough going from bringing new lives into the world to facing constant death in an Ebola unit. This was compounded by the fact that pregnant woman are very vulnerable to Ebola and no pregnant woman, or her baby, has been known to survive the virus.

“Which is just devastating. I found that very difficult as a midwife.”

 

Claustrophobic PPE in cloying heat

The pair initially arrived in Freetown, Sierra Leone’s capital, in mid-August, and after initial orientation and training, they headed west to the 60-bed Medicine Sans Frontières (MSF) hospital in Kailahun, near the border with neighbouring Guinea, for three days of hands-on, literally life-saving training in how to don and doff the personal protection equipment (PPE) required to safely care for Ebola patients. (See online-only story, Ebola nursing: how to safely get out of PPE at www.nursingreview.co.nz.)

After donning for the first time the multiple layers of PPE – including double gloves, ‘duck bill’ mask, all-in-one suit, hood, and apron all tied tightly around the head and neck area, with ski goggles on top – Donna says she initially felt claustrophobic but got over it quickly as she had a job to do

Worse was the heat. Temperatures were constantly in the 30s and humidity was high. She says her colleague Sharon Mackie’s description of wearing PPE in Sierra Leone as like wearing a personal sauna “was a great analogy”. 

Her first patient contact was having to certify a nine-year-old boy’s death. He’d died in the night.

“Then I was taken by an obstetrician (who heard I was a midwife) to see a 22-weeks-pregnant woman who didn’t look well … she was vomiting blood. Four hours later, she was dead.

“Ebola is a disgusting death – it’s a haemorrhagic disease, so there is a lot of body fluids.

“…people are vomiting, they have got raging diarrhoea, they are bleeding, pregnant women are miscarrying – any body fluid you can think of, it’s there, it’s happening.”

She says nurses don’t end a session covered in blood. If she did get blood on her apron, she would wash it off straightaway under one of the chlorine taps in the unit.

Because of the heat, the nurses and hygienists can only spend up to one hour at a time working in full PPE, “so you get down to it and do your work; you are giving medications, checking ID bands, washing the patients, or changing them”.

She always worked with a buddy nurse for support and safety.

“A high percentage of Ebola patients experience confusion. One of our first patients in the treatment centre was throwing rocks, so we were dodging rocks as well.”

Donna says the time it took to don the PPE and to methodically take it off under careful supervision (ensuring skin did not come in contact with PPE contaminated by the deadly virus) meant most people could only squeeze three one-hour nursing sessions into a shift.

 

DonnaCollins fullPPETriage tents and the ‘happy shower’

The base for their Red Cross team’s assignment was Kenema, the third biggest city in Sierra Leone, with an estimated population of around 190,000. There, they supported the government hospital that had early on been overwhelmed by Ebola, with the loss of nearly 30 staff to the viral haemorrhagic disease. The team was made up of 28 Red Cross personnel from across the globe, including Spanish architects, engineers, and builders, to doctors and nurses from Finland to Colombia. The team’s mission was to set up a two-stage triage tent outside the city hospital, and at the same time, build, equip, and staff from scratch the Red Cross’s first ever Ebola treatment centre – a 60-bed unit being built on a cleared piece of jungle about 18km outside the city.

Back in the city, the triage tent was used to screen for Ebola in the up to 100 patients arriving each day at the hospital grounds, and so leaving hospital staff to concentrate on providing essential non-Ebola health services, which had largely gone “by the by” for the sizable city during the peak of the outbreak.

Staff in the triage tent wore scrubs, gloves, and gumboots and were separated from their patients by a 1.5m fenced-off gap (see photo) over which the hospital nurses would hand the patient a digital thermometer.  After recording the temperature, the nurse would verbally assess for Ebola, and if they had no fever (defined as 38 degrees or above) and no symptoms, they were allowed to continue on into their hospital for their outpatient or maternity appointment. 

But if they had a fever or other symptoms, they went on to triage 2, where an epidemiologist would take a more stringent history and they would have a blood test, which could confirm within about six hours whether they had Ebola or not. While the patients waited for results, they were further triaged into either ‘suspect’ or ‘probable’, depending on the severity of their symptoms. If a blood test was positive, they were moved into ‘confirmed’ – which Donna is quick to point out did not mean an inevitable death sentence, as at least 30 per cent of people survived.

“People who had gone into ‘confirmed’ sick walked out alive after a week or two. We still don’t know why some people survive and some people don’t. We just know that people with a low viral level initially … if we fed them up well, gave them antibiotics, and wormed them, they survived and walked out happy people.”

“We used to have a shower at the end that was called the happy shower, which was for people who were leaving from ‘confirmed’. Their clothes would be burnt and we would hand them a new pack of clothes, their money (disinfected in chlorine), and they would leave, but usually with a social worker to escort them back to their village and reintroduce them after the stigma of having Ebola.”

 

Humble and dedicated

Donna says they worked 12–14 hour days as they not only did a morning or afternoon shift at the hospital triage tents, but they were also ‘jacks-of-all-trades’ on setting up the new treatment centre, with jobs from interviewing new graduate nurses eager for work, to taking the ‘wheel barrows’ of cash needed in inflation-hit Sierra Leone to buy centre supplies. They also had to train the new staff in PPE and infection control and be team leaders as the novice staff worked in the newly opened treatment centre.

“It was a big responsibility, but I loved it. I thrived on it.”

Donna also developed huge affection and respect for the Sierra Leone nurses and hygienists she worked with.

“These are the true heroes of this whole Ebola response,” she adds. “People keep saying ‘oh you are amazing going’ but it just embarrasses me as the true heroes were the national staff because they are ostracised within their own community for working with Ebola patients.

“Some of the nurses were evicted by their landlords, who said they didn’t want Ebola in their house. They also had to deal with a lot of myths and ignorance about Ebola.

“Most, if they had not lost family members, they had lost extended family members or neighbours and workmates … they had initially been losing huge numbers of nurses.

“They were brave, brave nurses that kept coming to work every day.

“The most humbling thing for me was that they often thanked us for coming to help. My team of workers – that I’m just absolutely in love with – often said to me ‘thank you, thank you for coming and leaving your family to help our family’.  At the end of the day, that’s all you need.”

 

Mates in the worst circumstances

Donna saw death and dying in Sierra Leone on a scale she had never seen before.

“It’s a terrible way to die – it’s actually the fastest death I have ever seen.”

The medical team meetings each night were a chance to debrief with people who could understand.

“You would never do it at the whole team meeting because the builders would have looked horrified if we said what we’d seen.”

The medical team of nurses and doctors were “astounding”, and Donna had the added good fortune to have the “fabulous Sharon Mackie” to “sound off at”.

“We’ll be lifelong mates.”

Would she go back to West Africa to help the fight against Ebola?

“Absolutely, I would!” is the instant reply.

An abridged version of this article went online at www.nursingreview.co.nz on October 10. Also online is full description of the “life and death” method of getting safely out of Ebola PPE (Donna, right, pictured  in last stages).