Monday, May 25, 2015

These are the days of miracles and wonde


The kid with the glasses kills me

Kids of Bopolu

Off to Bopolu

The Ritz....

Ensuite bathroom

The mess tent
Meal rations for the trip

My morning latte
I’ve spent New Year’s Eve in fancier places and more elegant surroundings but never before in a place more filled with wonder. I am in a village called Bopolu. Say it out loud and smile. The ETU in Bopolu is slated to be open for business starting January 4th. I am here to make sure my clinical team is ready to take care of patients. That means we go through patient care scenarios, know how to triage and test, confirm we have the necessary supplies and drugs, know where everything is, know how to put on and take off the personal protective gear known as PPE, know how to enter and exit the red zone, know how to document. The list is endless. Just a quick aside on documentation. No electronic medical records here. Paper charts return. And no charts in the red zone. We keep a record on a white board and then through fogged goggles read, shout actually, any data back to colleagues several yards away back in the green zone. Old school rules.
The classroom lectures are over thank God. Our training teams are true stars. The instructors are all ETU veterans and a mix of locals and expats. Power point is kept to a minimum. Classroom size is not. Yesterday there were 144 students by my count. Some 30 or 40 true clinical staff, 30 or 40 local support staff and the rest I think were just there for the show. It was ungodly hot and by midafternoon the funk quite simply burned your eyelashes off. Today the students are run through all the PPE on and off rituals or more correctly called donning and doffing.  Sounds like two of Santa’s reindeer actually. We keep them in the suits throughout the patient care training – up to two hours at a time – and I promise you it is NOT comfortable. Critical yes, comfortable no.

We had a new teammate join us yesterday. His name is Eric Dieudonne. There’s a picture below. He’s from Chad and an expert in water and sanitation and has already built and worked in a number of successful ETUs. He’s just a young kid but a wealth of knowledge and experience. His formal training is in civil engineering. He went to school in Tunisia, lives in Chad but travels the world for causes like this. His flight itinerary here was the stuff TSA nightmares are made of - Chad to Mali to Casablanca to Dakar to Monrovia. Within a few hours of landing in Monrovia we had him in a helicopter to Bopolu. Let’s talk about the helicopter. Pictures below. There is no more essential piece of equipment given the terrain and timeline. We have two repurposed Russian MI-17 aircraft from Afghanistan I think. They are ugly, noisy and smelly but get people and stuff from point A to point B with a degree of safety. The flight to Bopolu took only about 45 minutes but it was 45 minutes at high speed straight into the middle of nowhere. We passed over countless miles of untouched jungle and yes I know it’s a cliché but the shades of green seemed too numerous to name. The pictures just do not capture the electric shimmer some of the green presents.

Once landed, offloaded and officially welcomed by all the kids we settled into our new digs for the next couple of weeks. Comfortable enough with a tent, floor cushion, pillow and blanket but someone forgot food. Oops. Flights are dedicated to essential medications and materials so food will wait. Dinner last night for a group of 30 or so was 4 tins of sardines, a few pieces of flat bread, 2 cans of mackerel (no can opener) and a jar of jam. Believe me, I saw some very interesting deconstructed cuisine. The Jenny Craig plan has nothing on the Liberia weight loss plan – less in up top and more out below. And speaking of below, the toilets are actually pretty good for field toilets but they look a lot like the little shower tent. As such, a lot of the locals mistake the shower tent for the toilet tent. Again, oops.

While we weren’t able to conjure up a miracle with the fish and loaves of bread I do see evidence of amazing things everyday. Team members continue to pour in from all around the globe. Heavier than air machines bring them to sites carved out of virgin forest. Local villages step up with everything they have and more. We’re only missing a soundtrack. For now, I can’t get the old Paul Simon album Graceland out of my head. Looking up at the stars last night I kept hearing the verse from one of the songs…the way we look to a distant constellation that’s dying in the corner of the sky…these are the days of miracles and wonder so don’t cry baby don’t cry don’t cry.

POSTSCRIPT – I did not have internet access the last few days – so much for miracles and wonder – but do now that I’m back in Monrovia for a bit. I’ll send this off and post again in another few days before I head to Zor Zor.
These signs are everywhere in the country

Learning to put PPE gear on correctly

More PPE instruction
Eric from Chad

Classroom lectures

On earth peace, goodwill towards men…

Christmas Day in Liberia starts the same as Christmas Day in Hawaii Nei – sunrise, peace and palm trees. It changes quickly though. A pleasant sunrise turns to a blast furnace and the morning peace becomes chaos as the workday begins. Organized chaos yes but chaos nonetheless. I spent all morning at Spriggs airfield getting a contingent of our docs and nurses on to helicopters bound for the ETUs in Bopolu and Gbediah Town. I love saying Bopolu. I’m not sure whether I’m imitating Fats Domino or Ricky Ricardo when I sing it. Aerial pictures of both sites are attached. The livin’ ain’t easy on either site but will get better over time as the sites develop. Over the next week I send teams out to even more remote sites that make these two look like the Four Seasons.

It’s just after lunch and our next pow-wow isn’t until 3. Time to get this out. I thought a Christmas playlist delivered in a low tech setting in high tech fashion (via Bluetooth and JamBox) would be just the ticket. Wrong. I start off with Nat King Cole. I can remember my dad playing it through enormous speakers in the impossibly small living room where I grew up. Within seconds the tears well up. I switch to Frank Sinatra (Jessie’s favorite Christmas album) – mistake. A fast-forward to Windham Hill selections should dry me up. Nope. How about Hapa? Arrgh. Only makes me miss Hawaii more. I give up, switch it off, blow my nose and resume typing. Jeez. Keep it together. Stop slobbering. Any minute I expect to have someone open the attic access on me and I fall through the roof like Chevy Chase in Christmas Vacation. Where are the Moose Cups when you need them? I am fahklmept.

Finally, a special Merry Christmas to Jessie, Haley and Piper. You three are the greatest gifts I could have ever hoped for. To the rest of you a very Merry Christmas as well. Treasure your time with each other today. Treasure your family. Treasure your health. They are all gifts. And speaking of gifts, I am gob-smacked at the level of generosity displayed here by the responding community, the local Liberians and a very special group of locals – the Ebola survivors. There is no harder working group here. They teach us how to take better care of the current victims. They work in the hot zone caring for the infants whose mothers are too ill to do so. They play with the older children in the same situation. They take home the orphans who’ve lost everyone and everything. They even give of their own blood. It’s called convalescent serum and does appear to help improve survival when transfused into infected patients. Now that’s a gift. They are defining examples of what Christmas was, is and should always be about. And on earth peace, goodwill towards men…

And so it begins…

I’ve been here in Liberia for a few days now and would like to share some thoughts and observations. First off, despite countless previous deployments, trips, and missions I am shocked to realize just how much more I miss my family and friends. My heart just aches at times. Could be that it’s Christmas-time. Could be that I’m just getting older and it’s cumulative. Could be that my girls are growing up so fast. Could be the fact that Ebola is scary. Could be all four. I miss Jess and Haley and Piper and all of you dearly.

I was asked to be the Chief Medical Officer for a US State department funded assistance effort helping mitigate the Ebola crisis in West Africa. More specifically, I am working on a day-to-day basis recruiting, organizing, training, budgeting for and deploying hundreds of international and local health professionals to staff the Ebola Treatment Units (ETUs) we are in charge of.  Other daily duties include validating the clinical care protocols and perhaps my biggest job of all is keeping the peace (at least our part of it) with the various partners we have ranging from the US government and US military to the Liberian government, the multiple NGOs and private sector concerns and even the occasional church group here to save a few souls and hand out some medicines. I work on an hourly basis with Brian who is our Liberian contract manager and Erik my assistant medical director. Their talents and enthusiasm make up for my shortcomings. My clinical work and wearing of the bubble suit is limited. The larger effort is a bit colonial with the US taking the lead for Liberia, the UK for Sierra Leone and France for Guinea. I help run the Liberian part. My colleagues at Aspen in Australia are covering the Sierra Leone part under the auspices of the British government. I am lost as to what the French are doing in Guinea.

If you haven’t asked by now I’m sure you will. What is a plastic surgeon doing in this setting and what do I know about Ebola? The answer to the first question is fairly straightforward. I’ve spent my whole career developing a second skill set where I’ve gotten quite good at managing medical groups in austere and complex settings. Liberia certainly fits the bill. I’ve been a practicing surgeon for 27 years and needed a break quite frankly.  Also, the company I helped start, Aspen Healthcare Services, is the US affiliate of Aspen Medical Global and once we won this contract it became very apparent that it would require my full attention. In a very short time frame I needed to up and go from my day job at Kaiser and head to Liberia. Jess and the family were hugely supportive even given the uncertainties of time away and risk. I cannot thank them enough for their love and support.  The answer to the second question is easy. What do I know about Ebola? Nothing more than anyone else prior to this outbreak. It is not something you learn about in medical school. It wasn’t even discovered until the mid 1970s. Previous outbreaks were isolated and quick to burn out. This one was so tragically different as you all know. Still, the care is not that complex – even a surgeon can get it quickly. It’s all about proper diagnosis, isolation protocols, presumptive care (treat them like they all have malaria too which most do) and supportive care (fluids, nutrition and the like). For now there is no vaccine or direct treatment.

Our job is to provide the clinical staffing and support for several sites around Liberia. We do this in conjunction with our business partner PAE. PAE is a large very well established and preferred provider of services to government missions. In this case they are the prime contractor and provide all the logistical support. Together we are running four ETUs and perhaps a fifth. They range from 25-50 beds and are truly scattered around the country from the remote border regions of Sierra Leone, Guinea and Cote D’Ivoire to the inland jungles and coastlines. We rarely drive anywhere and if you do some of the places are a solid 24-hour drive away. Helicopters serve as the primary means of personnel transport. My clinical teams are comprised of US, Australian, New Zealand, European and African professionals. Just today I took another 20 Kenyans under my wing. My site management teams have the same mix. Some are brand new to this work. Others have the well earned t-shirt logo of been there done that. I learn from both groups.

I live in a base camp in Monrovia the capital of Liberia. I’ve been here before and we have had a primary care clinic here for several months, Aspen Medical Liberia, so I already had some friends and contacts here but it is still so far away. The base camp is comfortable enough with air conditioning and hot water most of the time. The food is OK. The coffee is bloody horrible. Still, I can’t complain. Many of my teammates, especially at some of our newer sites and extra remote sites are basically camping. I get to fly in and fly out a few days later usually. Most of them are on site for 6-8 weeks at a time. I expect to be here until March with a break and then perhaps another tour. When I’m finished with this effort I’ll return to Aspen full time. I may do some clinical work just to keep the hands warm. I do miss my patients and teammates in Honolulu.  A special shout out to Tracy and Brenda. I could use both of them here in a heartbeat.

We are on a crushing 16-hour a day schedule so that’s all for this first missive. I have two teams heading out Christmas day but I promise to get a short note out then and at least once a week after. Please take care of each other and thank you from the bottom of my heart for all the love and support you’ve shown my family in Hawaii, San Diego and Boston. And so it begins. Aloha.

My Stunning Mystery Companion

I know that you don't want me to be
Out here forever on this road
Or live among the boxes
Where all our past lives have been stowed
Maybe you're thinking of our place
With a garden by the sea
Where we could slow down
And you could put a little more work in on me

What with all my expectations long abandoned
My solitary nature notwithstanding
You're the one who pulled me
Out of that crash landing
My stunning mystery companion

Three days and a wake up is what we used to say in the Army. It means 3 sunrises, 3 sunsets and a rooster crow and I’m home. Yes I know the last post was about exactly the same thing but that was a too quick trip home for vacation. I’ve been back a little over a month working on transferring some of the program assets to the government of Liberia. I’m done. Time for a final post. This time it’s homecoming. Home to Piper. Home to Haley. Home to Jessie – my stunning mystery companion. To be honest, taking a break from surgery and jumping into this had all the elements of a potential midlife crisis – uncertainty, unplanned, unexpected. Instead, it was life affirming, wholly absorbing and crazy interesting. And there was a safety net. Jess. I knew she was ever there – no crash landing.

I’ve told you about this place and this disease but not enough about the people I worked with. There was a core group I spent most of my time with on this project and another core group who staffed our clinic in Monrovia. To a person they represent everything one could hope for in colleagues – a great sense of humor, a tireless work ethic, ridiculous competency, selflessness and impenetrable accents at times. More on the last one in a second. We were truly a polyglot tribe. From our Liberian colleagues with their special brand of Libglish and phrasing from the 18th century, to our Antipodean colleagues with their awesome slang, to our South Africans with their very special brand of English that I just could not understand at times, we cobbled together a common tongue and understanding.

Let me tell you a little bit about the ones I was with almost hourly. Forgive me if some of these comments may have a bit of an inside joke flavor to them. I spent the most time with Brian and Nick. I’ve mentioned Brian before. He served as the program manager and hails from NZ. The success of the Aspen portion of the program is due in large part to Brian. His steady hand, fairness and attention to detail kept it all happening. His tales of Antarctica (Brian is a retired NZ Air Force General and perhaps the world’s most experienced Antarctic helicopter pilot) kept me riveted during countless dinner discussions. His theories of everything from change to Brontosauri were entertaining as well.

Nick or Saint Nick as we called him is from of all places Boston. Boston, England. He served as our logistics manager and made sure the program lacked for nothing but on the rare occasion when it did he could invent anything out of nothing. Of course he was also great at finding things that “fell off the back of the truck”. He will be transitioning to come work with Aspen on a different project as we build a clinic in Freetown Sierra Leone. Unflappable is the best word I can use to describe Nick.

Mike and Muhammad were PAE counterparts for Brian and me. Muhammad while originally from Pakistan has spent years working on USAID development projects across Africa. Mike is from DC by way of LA (lower Alabama) and ran the whole show with aplomb and a focused calm that taught me a lot. Together the two of them kept the program running on all cylinders even when everyone else had run out of gas.

Russ our deputy program manager is a former Australian military officer who now lives in Tasmania. He will likely be the one to turn out the lights on Aspen’s part of the program sometime in the early fall. Katie was our training lead and singlehandedly was responsible for crafting our curricula out of the best WHO and MSF had to offer and delivering it to nine remote sites in a very compressed few weeks. Not a single ETU would have opened up had it not been for her making sure everyone was trained and trained properly. She was also the one to somehow find a blowup Santa and park him in the dining area when most of us didn’t even realize it was Christmas day.

Finally let me tell you a little bit about Kebeh our Liberian admin assistant. She worked directly for Brian but made sure all of us thrived in our new environment. Everyone got paid even though Liberian banks can be challenging to say the least. Everyone got in and out of the country without hassles. Everyone had all the licenses they needed. And, everyone who had a birthday while we were here got a cake courtesy of Kebeh.  There are dozens of others I worked with some of whom I’ve mentioned in other posts. These are the folks though that greeted me on day one and are still here as I exit six months later.

With a mixture of fondness, nostalgia and good riddance I left the Congo Town compound yesterday. While beachside and comfortable enough it just wasn’t home of course. The waves were a constant source of torture to look at but I loved hearing them. The concertina wire that surrounded us gave everything that Martha Stewart minimum-security warm and fuzzy. The food was always plentiful and safe and occasionally inspired-especially the curries-but I cannot wait for a piece of monchong, fresh asparagus and a trip to yogurt mama.

My colleagues at the Aspen clinic deserve a shout out as well. Remember the clinic is a totally separate effort from this Ebola program but it was a place we congregated on an almost daily basis whether to get medications, bring colleagues who were ill or injured, or just sit in air conditioning. Doctor Leon took care of us all myself included. The clinic continues to grow and now that Liberia is Ebola free people and businesses are coming back en masse. We’ve decided to bring an airplane to Monrovia to fill a market gap in aeromedical evacuation, cargo and passengers. My clinic and Aspen colleagues in DC have worked so unbelievably hard to bring this to fruition. Airplane deals are complicated enough but when you factor in three continents, multiple stakeholders, three sets of lawyers and West Africa things get really sporty.

I had a great time. I think I helped some. I learned tons. Jess and I celebrate our 20th wedding anniversary late next month. She’s the only reason I was able to experience any of this and any help I was able to offer the program is because she made it so. The final stanza of Jackson Browne’s Stunning Mystery Companion speaks of a partner sticking it out for 10 years and no more, but then taking another 10 years just to be sure. Ten and ten is twenty. Can I get another twenty more? I’ll see you Wednesday.

Maybe you were joking when you said
You'd take me for ten years and no more
Maybe you've had the best of me
But you could take another ten years and be sure

What with all my expectations long abandoned
And a life that just gets more and more demanding
There's no doubt that you're the reason I'm still standing
        My stunning mystery companion

Congo Town compound

Congo Town sunrise
Note: Words by Jackson Browne