Rage

Several days ago I stood in the Green Zone of triage, watching over the fence as another clinician stood in the Red Zone, digging through the “supply bucket.” We keep IV start supplies, IV fluids, and IV tubing in the bucket on a tall stand. Green Zone clinicians can carefully reach over the fence and drop supplies into the bucket, and then Red Zone clinicians can go to the bucket and pull the supplies out.

She reached her hand in, pulled out some extra packs of tubing, glanced down into the bucket again, and froze.

“Martha,” she said, her voice oddly strained. “There’s a needle in here.”

I couldn’t say anything for a moment.

Then, “You’re fucking kidding me.”

She carefully put the bucket down, and took an instinctive step away from it. “No, I’m not. There’s a used, bloody IV needle in here.”

– – –

The IV needles we use here would not be stocked by any healthcare facility in the United States. There is no safety device of any kind built into it. I have used a dozen types of safety IV needles back home. I have used needles that retract into the plastic handle at the touch of a button. I have used needles where the plastic base can be slid safely over the needle without getting my hands near it. Even at my last facility, there was a simple spring-loaded device that was activated as the catheter – the flexible, plastic tube that remains in the vein – slid off the needle.

Here, in the middle of the worst Ebola epidemic in history, in a place where a needlestick injury with Ebola-positive blood guarantees you will be infected with the virus, a virus where the fatality rate is about 60%, here — here, we have a needle with no safety device of any kind.

– – –

“Are you ok? You’re not stuck?”

She shook her head, “No, I’m ok. I saw it first. I never got near it.” She looked up at me, and her eyes were wide behind her splash shield. “But, holy shit, I just had my HAND in that bucket.”

We shared the same thought, and we let it hang silently in the air between us.

What if she’d stuck her hand back into the bucket again without looking first?

– – –

She was able to safely retrieve the needle from the bucket, and dispose of it in the sharps container. We threw away everything in the bucket. She triaged the patient, admitted them to the Suspect Ward, and doffed safely.

I stood in triage, seething with rage.

Who could have been so fucking stupid as to leave a bloody needle in a clean bucket? Who could be so selfish and uncaring and ignorant? Who the hell does something that dumb?

I stood in triage, and imagined screaming at the invisible, absent perpetrator; I imagined firing them; I imagined physically striking them.

One of the most important things I’ve ever read in my life was an explanation what anger is. It is the emotion we experience when we encounter obstacles, obstructions, or challenges in our lives that we do not and cannot control. Anger is our response to our lack of control.

I took a few deep breaths, shook it off, and went back inside and got back to work.

– – –

We have a national nurse assigned permanently to triage. He is an outstanding technical clinician, and can start an IV effortlessly on almost all patients. He is also an incredibly safe practitioner. The sharps container is always next to him when he starts an IV, and once he pulls the needle out from the vein, he immediately places it into the sharps box. He follows protocol to the letter.

But standard practice in most of Africa is to ignore the needlebox. And truly, in most countries with weak, understaffed, and undertrained healthcare systems, needles go straight into the garbage. Or they are made “safe” by stabbing the dirty needle into the mattress beside the patient. Or sometimes stabbed into the wooden window frame above the patient’s bed. Another expat practitioner once described a window frame in another country in Africa that resembled a porcupine, the hubs of hundreds of used needles framing the view.

We’d had the same problems at our ETU when our first team arrived. We’d worked hard to teach, encourage, and enforce needle safety. And things had gone relatively well.

Until now.

Sick to my stomach and ashamed of myself, I watched our triage nurse like a hawk that afternoon. No cues, no body language to indicate that something was amiss. Just a normal triage process; him in the Red Zone, myself in the Green Zone, passing medications and fluids over the fence.

He was perfect. On both starts, the needle went straight into the sharps box. His hand hygiene was perfect. His medication administration was perfect.

I spoke to our clinical lead later that night.

“It’s not him,” I said.

“I know,” she said. She knew him better than I.

“So who is it?”

She shook her head. “I don’t know.” She glanced at me. “I just can’t believe it’s an expat.”

“Me neither,” I said. “It’s too instinctive, we’re trained from our first day of clinical work to use the sharps box.”

We sat in silence for another minute.

“So who is it?”

“…..I don’t know.”

~ ~ ~

The grandmother and her four-year-old granddaughter came in on the same ambulance. They were strong, alert, ambulatory. The grandmother had a mild fever.

Her husband had died several days ago, and she had cared for him while he was ill. She also cared for her granddaughter, who lived with them. She cleaned him up. She made dinner for everyone. She helped him eat, drink. She helped her granddaughter bathe. Maybe the child sat with her grandfather as his illness progressed, perhaps curled up with him to keep him company, to offer him comfort.

Afterwards, after his death at home, someone called the body team, who swabbed his mouth and tested the swab for Ebola. When the test came back positive, the contact tracers drove to their home, followed by an ambulance, and brought them to the ETU.

I was in triage, and a new clinician and I entered the Red Zone together. I was able to start the IV line on the grandmother without difficulty, and as her IV fluids ran in, I focused my attention on the little girl. A national nurse held her on his lap as we tried for an IV.

The little girl cried out as the needle slipped underneath her skin, and tried to move her arm. The nurse kept a firm grip on her arm as I tried to thread the catheter into a tiny vein. And then, unexpectedly, the grandmother reached over to the child, and patted the arm we weren’t using.

I didn’t understand the words she used, but it was the Temne equivalent of, hush, hush, be brave. It won’t hurt for long.

The vein blew. We tried a second time. The child cried.

Hush, hush. It’s ok. They are here to help you. Hold still, now.

No flash. We decided on a third and final try. The child cried out again.

Hush. Be brave, my child. You will feel better. This medicine will make you well. Hush now.

A flash in the hub, and I threaded the catheter smoothly into the vein.

We walked them and their IV bags to the Suspect Ward, and settled them into two beds right next to each other. The grandmother waited until the child was lying down, and we’d stepped away. Then she crawled into the same bed, and curled herself around her grandchild.

I looked back at them from the doorway. The grandmother held her granddaughter’s hand in her own.

~ ~ ~

The day after the needle in the bucket, one of our most experienced clinicians came to the dinner table after helping out in triage. She was furious.

“I found two used, bloody needles lying on the ground today. They’d just LEFT them there, out in the open! Who the fuck uses a needle on a possible Ebola patient, and leaves it lying on the fucking ground?”

I looked at our lead clinician. She looked at me. We looked at the clinician. We put a few more pieces of the puzzle together, and all came to the realization at the same time.  We knew who it was.

One of “our own” was inadvertently, through their own negligence, trying to kill us.

I dropped my head to the table, and closed my eyes.

And seethed with rage.

~ ~ ~

I walked to work, through the morning mist. Down the dirt hill, past the goats, the chickens, the sheep. Past the black car with the broken axel. Past the white LandRover on its side in the ditch. Past the Chinese mining offices. Left onto the paved road. Over the tidal river, roaring over the exposed rocks and fallen trees. Up the hill, past the tree where the fruit sellers gather. Left, past the carpenter. Straight past the burned fields. Up to the front gate of the ETU.

I walked into triage, and over to the patient board for the Confirmed Ward. We’d transferred the grandmother and granddaughter there four days ago when their tests came back positive.

Their names were gone.

I turned to my right, to yet another board. There, under the column marked “Deaths,” I found them.

The night shift clinician saw me staring. He reached over and touched the two pieces of paper gently, as if he could reach through it and grab them back again.

“They died within minutes of each other,” he said, quietly.

I stood there, and stared at their names.

The night before, we’d sat around the dinner table, remarking on the e-mails we were receiving from friends and family, the posts on Facebook, the articles in the news, all with the same theme:

They say Ebola is over. So now what are you doing with your time, are you going to the beach?

I stood there, and stared at their names. They were the same.

They say Ebola is over. Are you watching the Superbowl? Do you have a TV there?

The child had been named after her grandmother.

They say Ebola is over. When are you coming home?

I stood there.

And seethed with rage.