Honesty and Despair.

Day Fifteen.

Two nights ago, after my second day in the ETU, I was reading a book given to me by an esteemed colleague and loving cousin, Jordan. (He has a fun and very thoughtful blog here.) The topic is about as far away from Liberia as could possibly be imagined in that it deals with writing for comic books. But a particular passage stuck with me, which I think can be applied to many settings:

Write true. Write honest. That in itself is success. – Brian Michael Bendis

I’m about to test that theory here, so let me know if it’s valid or a load of crap.

every inch of you has to be cleaned, top of the head, bottom of the feet

Whenever I tell people my primary job is in Emergency Room nursing, I usually get the same response: “Oh, man that sounds really difficult.” My response is frequently that, yes, it’s challenging and soul-sucking at times, but in other ways rewarding. We have a great team, face challenges not many people get to and quite literally save lives that would be lost otherwise. In short, there’s a sadness and difficulty to what we do, but a beauty that makes it worthwhile.

Finishing up three ETU days, and I can’t really say the same for it. There’s just not much beauty to be found inside. This is not to say that the staff isn’t excellent, the patients aren’t gracious or that the facility isn’t well-run and efficient. All that is true. But in the time I’ve spent here, I think an ETU is perhaps one of the last places on earth I’d ever choose to be, but maybe not for the reasons you might think. Starting with the obvious, the environmental challenges are constantly on the assault: de-humanizing stormtrooper suits, inability to speak or see well through the stupid mask and goggles and blazing sun wringing every bit of moisture out of you like a soggy towel, but really, those parts aren’t as bad as I thought they’d be. The most devastating part is seeing what the virus has stolen away from these people.

hot training, observing triage

We enter the first ward of the day. Everything but the cement floor is covered in white tarp – railing, stairs, walls, tables – so they can be sprayed down frequently with 0.05% chlorine solution: a stream of slimy-feeling, noxious fluid that lingers in the room long after it has evaporated. The long hallways loom ominously, partially because there is no décor, no color, nothing to distract your eye. Just an old clock and a pen hanging on the wall; items which will all be incinerated. In fact, everything will end up getting roasted: dirty bedsheets, pillows, toys the kids play with, the cell phone the patient unwittingly brought. It all gets cooked. It’s really weird to think about. It made me feel like I was living in a lifeless pop-up book; as fabricated and vacuous as if everything were made of paper, if that makes sense.

Getting my bearings, I look and see a row of green military-esque cots against the far wall and a single patient laying supine next to another cot, piled with blankets and rags. The young woman stares blankly at the ceiling. As the team makes its way towards the patient, I determine in my mind to be cheerful and encouraging, even though I feel as far away from it as I ever have. I drew six-pack abs on the PPE of the doctor next to me, just to remind me to relax. She doesn’t look very sick – actually not bad at all – and although she has a sad look about her, it brings me a modicum of optimism. Maybe she’s one of the half that get out of here.

“Zach, where are you going?” our instructor says. I turn to see our group huddled around the cot with the linens on it. Our actual first patient. The source of the barely audible whimpering I can just now begin to make out – the eight-month old, who we soon discover, lost both parents to Ebola and probably weighs less than the bowl of rice I had for lunch.

It’s a punch to the stomach in every way, without the fist. And you can just physically feel your heart scramble immediately, desperate for answers. To somehow make this fit it into your worldview and make it even a little ok. But it can’t. It just can’t ever be ok.

boots dry quickly in the hot liberia sun

Not sure how long I stood there and gawked at this little princess, probably only a few seconds. In retrospect however, I think I have a salty old hag in my heart that I met in the ER. Her name is Nurse Duty (probably RN, BSN, CEN), and she’s rude and morbidly obese. So fat in fact, that when she shows up – as she has many times before – there’s just no room for little Empathy or her sweet playmate Compassion to hang around, so they just get offended and skip away. She doesn’t usually see the patient as a whole – more like a collection of veins to poke and interventions to consider and data to gather. Like a breathing version of the case studies we did in nursing school. But say what you will about obscene, gruff old Nurse Duty. She gets her stuff done; she exists for a reason.

So I’m pretty sure she saw a patient, adjusted the height of her chair, cracked her knuckles and starting taking clinical notes. Pulse normal. Fine lanugo hair on the head, which should’ve been replaced by mature hair months ago – indicative of malnutrition. Approximately 6.5 kilograms. Poor neck strength. Decent veins for a scalp IV if needed, etcetera, etcetera. So let’s get it done, right?

Further down the line we encountered a family of patients: a mother, two girls and a boy that ranged between five and twelve. Of course, they can’t be next to, or touch each other. Being the sickest one of all and to protect her children, the mother had to be kept across the hall, where her kids could smile and wave at her. They’d had a close family member die of Ebola and so were all in the Suspect ward, awaiting their final blood test results. I’d go crazy if I was that mom, but I think she was too sick to notice.

“If there is meaning in life at all, then there must be meaning in suffering.”
― Viktor E. Frankl (Auschwitz survivor)

So before I knew it, our two-hour time window was up and we were being hosed down with the potent, chlorine film. Post-class wrap up, a little more study, dinner, home. But perhaps the craziest thing? I didn’t think of that family or the little one even once, after I left. As if the memory was undressed along with the suit. It never reoccurred to me until a friend asked me how my day had been, later on that evening. I started in on the catalogue of the daily events and with no warning, the memory unleashed itself on me. All the injustice and anger and overwhelmingly despairing emotions that I should have felt at the time I saw that helpless baby, just washed over me in an instant. I felt like I’d tossed a boomerang and given up on it returning, until it hit the back of my head.

Side thought: that’s a scary realization. My brain quite literally realized that it couldn’t function with the feelings I was eliciting from it, so it just staged a coup and gave me a new set. I know professional detachment can be necessary, but it is a little frightening how it could happen so suddenly and without my consent. I think people who do difficult things or have painful experiences can put themselves through this, but for far longer than an eight-hour delay. Hiding things away for decades, only to erupt like an underwater torpedo someday all-at-once, unseen yet deadly. If I’m going to do and see more difficult things, I’m going to have to practice self-awareness just as intensely as clinical skills. Back to topic.

supply ward. most of the ETU is made up of these tents, but I can’t take my camera in, so that’s why you get boring pictures like this

The place just steals so much dignity from these patients. They get no physical contact (which in my opinion is essential to being a great healthcare worker) except through 3-4 layers of plastic. Voices are muffled, everyone looks the same, every single thing they touch has to be drowned in germ-killer or tossed in the bin to get incinerated. I think it would be easy to see myself as the disease. It’s hard to express how difficult it is to watch, much less to experience firsthand. The world has some really evil things in it.

But as I lay in my bed last night and tried to find a place for this crazy stuff I’m taking in (self-awareness right?) I realized that as weird as this may sound, I want to see the evil things. I want to find out how dark it can really get. I think I mentioned this in a post before, but at the risk of being redundant: if the way I deal with these senseless tragedies is to put them out of my mind and act like they don’t exist, what good am I? I’m preserving my rosy worldview sure, but to what end? I’m no different than a child who hides by putting his hands in front of his face. How can anyone be proud of a life like that?

I want to be the kind of person who can see suffering and stare it right in the eyes, whether that’s a starving orphan child or a friend who tells me he lost his mother to cancer. And you can’t just decide to do that; you have to actually experience it. We can see that in others that have been there, right? I can. When I read about Hellen Keller (fantastic category of dark humor, nonwithstanding) who made something of her life although deaf and mute; Mother Teresa who spent her days comforting dying people; or Harriet Tubman (a saint here, since Liberia is founded by ex-U.S. slaves.) who risked her life to conduct the underground railroad, I just feel as though they discovered something a lot of people never do. They weren’t perfect, but learned how to go in really deep. To plunge into the swamp of human despair, come up for air, and return to show others the way out.

a lady getting interviewed for triage. notice the two meter distance required at all times, and the tube for sending things to her

So in a really perverse kind of way, I suppose I asked for this. And I just found out that today, the first patient I saw – the one with the sad look; twenty-three years old – asked to adopt our little emaciated princess. She went to meet the mother and requested to keep the child, just before she died. Not a family member, neighbor or even a friend. Though sick herself, she just saw suffering and didn’t back away from it.

When I heard about that, I felt like a deep-sea diver approaching the surface, finally seeing the sunlight glittering through the waves.