Remember

The Nigerian nurse standing next to me planted her hands on her hips, and stared at the ambulance in the driveway.  She shook her head in dismay.

“They are coming too late,” she said.

We were standing together at a holding center nearly an hour away from the ETU, watching as a sprayer in full PPE slowly and carefully soaked the back door of the ambulance with 0.5% chlorine.  He opened the left door, then slowly and carefully sprayed the inside handle of the right door, and opened the right.

From our vantage point in the triage area, we could only see the right side of the ambulance, and could not see inside at all.  But the sprayer reached inside, grasped the foot of the patient, and shook it, hard.

No response.  The sprayer shook his head.  “Gone,” he said.

A nurse in full PPE entered the red zone of triage a few moments later, and climbed inside the ambulance.  He emerged in less than 30 seconds.  “He’s dead,” he confirmed, and the sprayer slammed the ambulance doors shut.  The ambulance pulled out of the triage driveway, drove around the building, and backed into the driveway to the morgue.

~ ~ ~

This was the second time in two days that a patient had arrived dead to triage at this holding center.  Far from the main ETUs in the district, it served as a transport point for the tiny rural CCCs in a district on the porous border with Guinea.  Patients crossed the border freely through a network of rivers, swamps, and tiny paths, and when they got sick, they hid until it was much too late.

A crack team of Nigerian doctors and nurses worked at the holding center, almost without break or relief, and the care delivered there was on the level of – or exceeding – the care delivered at our large ETU.  The team rounded frequently, started IVs, administered aggressive intravenous fluid, antibiotic, and antimalarial treatment, even started IOs on desperately ill children.  They had unquestionably saved lives, but even they could only do so much when someone waited too long to seek help.

~ ~ ~

The ambulance was unable to back up all the way to the morgue; the van of the body collection team was already there, taking a body out of the ward.  The ambulance driver shut off his engine and hopped out of the cab, which was just a hair across the line in the green zone.  The nurse and I wandered across the holding center grounds towards the fence in front of it.

“Why do they wait so long, do you think?” I asked her.

She shrugged.  “I think they know how this place used to be.”  At the fence, she ignored her natural impulse to lean against it, and instead crossed her arms across her chest, hypervigilant of any area bordering the red zone.  She sighed, staring at the four men carrying the body bag out of the morgue and into the back of the van.

“They remember,” she said, “and they are afraid.”

~ ~ ~

More than two months ago we were asked by the Command Center of the district to evaluate the holding center.  The Nigerian team had arrived to help, taken one look at the center, and immediately refused to go in.  It was dangerous, they said.  It was bad.

Really.  Really.  Bad.

Our team arrived to find complete and utter chaos.  No equipment.  No PPE.  No chlorine mixed and ready to go.  The Sierra Leonean staff, terrified of Ebola and completely untrained in how to deal with it, would open the door to the ward, push food through to the patients with their feet, and immediately slam the door shut again.

No triage, no rounds, no medications, no IVs, and no help.  The grounds were an old polio hospital, and the patients were locked inside behind heavy metal doors.  It was a place where Ebola patients went to die, and non-Ebola patients entered a living, waking nightmare from which they could literally not escape.

Two of our clinicians got into PPE, and entered the center.  They walked the wards and the grounds, doffed safely using equipment they’d brought themselves, and rejoined the team.

“There are dead bodies piled in the courtyard,” one said.

Said the other, visibly shaken, “Shut it down.  Now.”

The W.H.O and the Command Center pulled every ambulance in the district, and emptied the center of the remaining living patients that night.

~ ~ ~

After two intense weeks of rehabilitation, the center reopened, fully supplied, decontaminated, renovated, with a highly trained staff and an international leadership presence.  But the legacy of the center persisted.

We watched as the body team slammed the doors of their van closed, and then headed towards the ambulance to pull the corpse out.  They sprayed the back of the ambulance again, and opened the doors.  They took out a leak-proof body bag, and placed it on the ground, and unzipped it.  They sprayed the bag with chlorine.  They sprayed the body inside the ambulance with chlorine.

And then two of them reached inside, and grabbed the corpse by its ankles.

Suddenly, I realized what they were about to do.  And in that same brief second, I realized that there was nothing I could do to stop it.  I was in the green zone, on the other side of the double fence.  I was wearing no PPE.  The corpse team was totally focused on their work.  And even if I had screamed at the top of my lungs, nothing could have stopped what gravity was about to set in motion.

They grabbed the body, and yanked.

BLAM, went the head of the corpse as it slid off the gurney and crashed onto the floor of the ambulance.

WHANG, went the metal bumper of the ambulance, as the head slid out and smacked against it.

And as the body fell to the ground, I realized it was facedown.

The face hit the ground with a sound that I cannot express in written words.  It was a sound that, when I remember it even now, makes me feel as though my spine is twisting around upon itself, trying to escape.

It was a sound I will never, never forget.

~ ~ ~

There was a cry of distress, and I looked up.  To my horror, I realized that because of the position of the body van, the ambulance was far enough forward in the morgue driveway that it was no longer behind the privacy fence.  A group of villagers stood on the other side of the drive, staring in shock at the gruesome tableau before them.

This hideous, inhumane, disrespectful corpse transfer had been done with an audience.

“Get them away from the fence!”  I screamed, pointing at the crowd.  I signaled to the ambulance driver, the driver of the support van for the body team, the national nurses standing alongside me.  “This is not right!  They should not see this, THIS IS NOT RIGHT!  GET THEM AWAY!”

They leapt into motion, screaming at the top of their lungs, racing around the fence to opposite side to chase the crowd away.  The crowd scattered, running as fast as they could across the fallow field where they’d congregated.  Some kept running until they were out of my eyesight, but some stopped a little way away, and looked over their shoulders again.

The van driver reached down, picked up a rock, and threw it at them.

They fled.

~ ~ ~

And as they fled, I knew they carried the story of what they had seen back to the village.  And in the village, it was told to a visitor, who carried the story to another village, where it was told to two more visitors, and so on and so on, until the story became a memory in and of itself.

That memory will go like this:

When you come to the holding center, they will open the ambulance, and a nurse will look at you, and decide that it is time for you to die.  Then they will spray you with poison until it drips out the back of the vehicle.  Then they will open a bag on the ground, and spray it with the poison, too.  And then, if you are too weak to exit the ambulance yourself, they will pull you out, and drop you into the bag.  And every bone in your face will shatter, and then they will spray you with poison until you drown inside the bag.

And your family will never, never, never see you again.

~ ~ ~

I sat on my patio tonight, gently scratching the ears of the house dog, a mangy, limping, adoring beast.  My phone rang.  The nurse from the holding center greeted me.

“How was your day?” I asked.

She sighed.  “We had one patient today.”

The dog bumped my hand to encourage me to keep scratching.  A breeze blew over the gate, giving us some relief from the steadily increasing heat of the dry season.

“They’ve died?” I ask, even though I know.

I can just see her nod, her phone to her ear, staring at our shared sunset, an hour away from each other.

“They came too late.”