A 34-year-old man enters an Ebola treatment unit speaking another language. He looks cold, sickly and frustrated.
An ETU volunteer is screening a woman for the Ebola Virus Disease and her test comes back positive. She is admitted into the ETU; however, she refuses to go with the clinicians because she has two small children waiting outside. She claims she is their only caretaker.
These are the types of scenarios happening in ETUs, and these scenarios are what ETU health care workers are prepared for during the five-day Ebola Treatment Unit Course led by the U.S. military, Joint Forces Command – United Assistance, at the National Police Training Academy in Monrovia, Liberia.
The curriculum and the students
The Department of Defense Ebola Treatment Training Team offers classes at the NPTA as well as two mobile classes that go out to the more remote locations to train health care workers.
“We’ve been directed to conduct training on how to work in an ETU, in support of [the U.S. Agency for International Development],” said Col. Laura Favand, chief of training for the DET-3, JFC-UA. “That was one of two keys roles for the DoD. One was to build the ETUs that are required and the other was to train the personnel who would work in them.”
“We recognized that education was a key role in managing the Ebola outbreak, and the country did very well before we even got here,” said Favand, who has served for 25 years. “They started doing hand washing; they changed their burial practices; they recognized the need for specific Ebola treatment [units]. However, they didn’t have the personnel to train everybody who needed the training and that’s where we came in.”
The Liberian Ministry of Health and the World Health Organization screen ETU applicants who come from various backgrounds, said Favand. Health care workers come from nongovernmental organizations across the world to include Germany, Nigeria and South Africa. American troops and soldiers in the Armed Forces of Liberia also take the class, but their purpose for being there is for education only.
“Any health care worker can get an entire week’s training to fully understand the things you have to be cautious of with Ebola,” said Favand. “So if they’re in their aid station and somebody comes in with a certain set of symptoms, they have a better understanding of how to identify if it’s malaria, Ebola or Lassa fever. It’s another way to help protect the troops. The AFL soldiers are coming in the same capacity as our Soldiers, but because this is their country and they feel training is valuable, they’ve joined us.”
Clinicians and hygienists are separated for portions of the program and presented curriculum relevant to their role in the ETU. Clinicians include doctors, nurses and physician’s assistants. Hygienists include those who will care for the upkeep of the unit.
“On the clinician side, we do clinical cases and teach how to assess whether or not a patient has Ebola, how to treat Ebola patients and the process to discharge them home or, unfortunately, if they’ve passed away, how to manage the bodies,” said Favand.
Hygienists are taught how to appropriately and safely clean the treatment unit, how to mix bleach and water, and how to manage the bodies, she said.
Using the WHO’s curriculum, which instructors have already successfully completed, service members begin day one with an overview class on EVD and infection prevention.
In a breezeless room filled with little more than tables, chairs and Meals, Ready to Eat, service members train health care workers on how to operate an ETU. In an environment where something as simple as improperly washing their hands can be life threatening, it’s vital these workers learn here rather than in an active ETU.
After an overview of EVD, the class participates in a hand washing exercise followed by an introduction to the mock ETU and the personal protective equipment.
“We teach them what they need to know to protect themselves, to protect their family and get rid of the virus,” said Air Force Senior Airman Kyle Thompson, instructor, DET-3. “A lot of the people here have family or know someone who has died, and they’re just overly grateful we’re here to teach them how to take care of their loved ones. We’re the ones training the Liberians on how to fight EVD, but we’re leaving it up to them to make the right decisions.”
Several Liberians, including medical and nonmedical personnel, are participating in the class.
“To save lives, I’m being trained to protect myself first before helping the patients, and these classes have helped my fear of getting infected with Ebola to go away,” said James Gaylor, social worker and ETU course student.
Gaylor, a native of Lofa County, Liberia, said prior to the ETU course, he wasn’t trained on the proper way to wash his hands or wear the PPE.
“I’m very glad I could be here for this training,” he said. “We were not taught how to use this PPE. That is the first mistake I have seen from most of the health care workers; they were not taught how to wear the PPE or how to take it off. It’s a skill and a gradual process to get used to.”
Although service members had less than a month to say goodbye to family and friends, Air Force Staff Sgt. Dominique Blea, instructor, DET-3, said the mission has been worth it.
“Even though we may miss home, we understand this is what we have to do,” said Blea. “Hearing the locals speak highly of not only the American population but also the Army, the Air Force and seeing how much they look up to us and how much it means for us to be here, makes you feel good.”
The key factor to survival for health care workers: personal protective gear
On days two through four, health care workers practice the extensive and fragile process of donning and doffing – putting on and taking off – their PPE.
The room is stifling and the only relief comes from room-temperature water and sporadic fans. Training must simulate the real deal to better prepare these workers who could be working in ETUs with little more than a roof and four walls. Learning proper hygiene, waste management and memorizing the multi-step process for donning and doffing their PPE are some of the aspects of training.
Correctly doffing the PPE is one of the more essential steps in this procedure because it really takes a lot of focus and attention to detail to not spread the EVD if the gear has been contaminated, said Blea.
The goal of this course is two-fold: teach ETU workers how to stop this virus from spreading and, ultimately, how to stay alive in the process.
“This is where mistakes can ultimately cost people their lives,” he said. “If they unknowingly get contaminated, they could take it back to their communities and infect their loved ones so we really want them to be careful and use the buddy system when taking off their PPE.”
After practicing with their PPE, the health care workers are separated into their respective clinician and hygienist groups. While clinicians learn about methods for providing medical care for patients, hygienists learn how to spray down body bags and safely clean up bodily fluids.
An ETU environment demands health care workers pay extensive attention to detail while working in PPE that covers every inch of their bodies. While health care workers are training for the physical toll, instructors help prepare teams for the emotional toll as well.
John Nell, a medical team leader with Quicksilver Group International, will not be providing direct medical care to Ebola patients; however, he is in charge of a team of doctors who will treat them.
“I think that by being part of the training and going through it with them, I am in a better position to understand exactly what the team will be going through in the ETU,” said Nell, a South African native and attorney by trade.
The student pool includes individuals with various career backgrounds, languages and dialects, but despite the differences, instructors have received positive feedback.
“I’m finding the training to be absolutely awesome,” said Nell. “When we came here, we were a little apprehensive about how we were going to fit in and how things would work, but I find the training is very structured, very informative and it empowers us so that we gain confidence.”
In the beginning, the service members told Favand they were scared of getting infected with Ebola, but now they are glad they came on the mission because they see a benefit of what they do.
“They recognize they’re safe and we see Ebola numbers decreasing in this country,” said Favand. “That’s not just the U.S. military, that’s a combination of all efforts coming together for a community. I think the Soldiers on the ground, for the most part, are seeing the benefit of what they do. I just want to assure family members back home that we’re doing everything possible to keep their service member safe.”
Despite the extensive media coverage regarding the Ebola outbreak, which can include nonfactual information, Thompson said he encourages families to get the accurate information before believing all of the rumors.
Since he now knows how the Ebola virus is contracted and what signs and symptoms to look for, Thompson said he feels completely safe.
Service members are required to carry a set of gloves and facemask on them at all times. Hand washing stations are at the entrance of buildings with a high volume of traffic. Additionally, troops have their temperature checked twice daily and take anti-malarial medication.
“This is not the time to hide being sick,” said Favand. “We address everything early, and we don’t want anybody to hide their illness.”
Day five tests the knowledge and skills the health care workers have developed over the past week.
“Students are tested on the fifth day by going through a mock ETU,” said Favand. “They go through the mock ETU as a team and don their PPE in buddy teams so they learn to check each other for exposed skin. Then they have five patient scenarios to go through in separate rooms, including patients who are combative and a patient who has passed away. From caring for the patient to properly disinfecting the rooms, the teams are tested on their ability to safely handle various situations they may face in an ETU.”
In addition to the feedback instructors give health care workers as they go through the mock ETU, survivors of the Ebola outbreak participate as expert patients.
“The patients who play in the scenarios are Ebola survivors and they give feedback to the teams immediately after each of the scenarios are completed,” said Favand. “They know exactly what should be done to take care of them.”
One perspective these expert patients remind health care workers of is how foreign they look in their PPE to patients, said Favand. They emphasize the importance of showing compassion through their mask and gloves to patients who may seem frightened of their appearance.
The final station in the mock ETU is where the teams remove their PPE. For safety purposes, every ETU requires one supervisor to watch one health care worker remove their PPE.
Helping their own
Part of this mission here is to essentially raise courage and confidence in people to get rid of this virus, said Thompson.
“These people are really wanting to help themselves,” said Thompson. “They’re very proactive. It’s not a lack of want; it’s a lack of know-how. We’re here to teach them how to prevent Ebola from spreading and they’re listening to us and taking those prescribed steps seriously to help their own people recover from this epidemic. I think taking the fight to the main source is definitely key to getting rid of the virus.”
While American troops and volunteers from around the world are helping combat the Ebola outbreak, for natives of Africa, this training and mission hits closer to home.
“There’s a part of me that is here for the humanitarian aspect of it,” said Nell. “I’m from Africa and there are Africans who need our help. For me it’s an opportunity to contribute and improve things and hopefully to leave Liberia a better place once we’ve left.”
“We want to take care of our people and now we have the training to take back to our communities and teach them how to stop this infection from spreading,” said Gaylor.
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