A day in the life

I wake up before dawn to the calls of the fishermen on the shore 50 metres away as they arrive home with their catch. Men from the nearby village come and help pull in the nets whilst the woman sit back with their colourful buckets, watching patiently until the fish are flapping on the sand. At that moment they descend in a wild mêlée to get their share of the best fish to sell or feed their families. I can hear the buzz and excitement even over the air-conditioning unit in my room - on this deployment to Sierra Leone with Save the Children we have been very fortunate to stay in a standard of accommodation above that normally expected on a humanitarian mission. For the last 4 months I have lived in a beautiful location on the beach, in a hotel with a swimming pool, where I don't have to cook, clean or do any of my own washing. Not what I expected when I applied to work in one of the poorest countries in the world and certainly in stark contrast to the village located  outside the walls.

The journey to work at the Ebola Treatment Centre (ETC) takes 30 minutes in one of the minibuses that shuttle us to and fro at the start and end of each day. For the first time since I arrived in January this morning it rained. It rained the type of rain you only experience in the Tropics; a sudden, dark, angry downpour of such fury that even the goats took shelter under the plastic sack awnings of the makeshift houses we drove past. Just as suddenly it's over and while the dust is still settling, the humidity begins to soar.

On arrival at the ETC, temperatures are checked and hands are washed in 0.05% chlorine. By the end of the day this routine will have been repeated upwards of 30 times. A temperature above 37.5°C results in being denied entry into the ETC and a sit down in the shade; a second high reading and the doctor is called. Putting on scrubs in the changing room someone will invariably make the standard appeal: "Has anyone got a spare pair of socks?". Nobody wants to go barefoot in rubber boots the whole day.

After opening the pharmacy, greeting the staff, recording fridge temperatures, emptying bins and disinfecting the benches, it's time for the 8am clinical handover where the night team presents how the patients have fared since the previous evening. Requests for further IV fluid for patient A, ceftriaxone for patient B and frequent nappy changing for patient C are noted. I record any new medications that have been prescribed overnight or any drugs not given on the morning round and make sure they are available quickly for the next team preparing to go into the red zone. Having a pharmacist present at the handover gives me the opportunity to intervene on formulary substitutions, advise on correct dosing, draw attention to interactions and suggest treatment options, for example. It is also an opportunity for the pharmacist to highlight their role within the multi-disciplinary team - the ETC is staffed by Sierra Leonean clinicians, NHS doctors and nurses, and the Cuban Medical Brigade - not all familiar with the benefits a pharmacist can bring to patient care.

Morning handover

The pharmacy department is made up of pharmacists and pharmacy technicians from the Sierra Leonean Ministry of Health, Save the Children International and the UK Ministry of Defence. This multi-cultural, multi-sector working atmosphere brings together an interesting mix of experience, protocols and pharmacy practice. The disciplined and comprehensive approach of the MOD pharmacy team combined with the enthusiasm of  the national staff makes for a fantastic, fun working environment.

Phil, Teresa, John, Harold and Al Hassan - some of the pharmacy team

Other morning duties include packing down medicines like paracetamol, multivitamins, and zinc into individual patient doses. These and other common medications are stored in small quantities on the Nurses Station so that they are available 24 hours a day if required. When a team goes into the red zone they take with them any medication needed at that time in the quantities prescribed and administer it to the patients themselves. Drugs required once the team is already inside can be requested via the radios located in the red zone and sent in through hatches in the fence. Pharmacy is responsible for making sure the medicines are topped up twice a day and that the supply of IV fluids is maintained.

Michael, Mary, Sorie, Samuel and Tariq in the pharmacy

Having been trained in Personal Protective Equipment (PPE), I prepare to go into the red zone preferably before the hottest part of the day. With a buddy, usually one of the doctors or nurses, we follow the strict protocol and spend 20 minutes 'donning' our gear including suit, mask, hood, apron, two pairs of gloves, and finally goggles. After checking each other for breaches, our names are written on our hoods and the current time written on our sleeves, and we are cleared to enter. My jobs in the red zone include checking that no medications are being stored on the wards, that syringes of IV drugs have not been left lying around and that there is no glass - bottles or ampoules - inside. Glass equals the potential for cuts of skin and tears of PPE - one of the worst possible incidents in the red zone. All parenteral drugs are reconstituted and drawn up in the green zone to keep the risks to a minimum.

The 'donning' room

Being in the red zone is a physically challenging experience and a very humbling one. Meeting the patients who until then have only been a name on a whiteboard, talking to them, trying to make the children smile - these are some of the memories I will take away with me. Within 30-40 minutes the heat becomes too much. I can no longer see clearly through my misted goggles and the sweat that drips down your face collects in the mask in such quantities that some people have to swallow it just to be able to breathe. The decontamination process is the most important step of all and takes another 20 minutes, so it is important to consider that when judging how long you can tolerate in PPE.  The 'deconners' are amazing men and women. When you no longer have the mental acuity to undress safely through heat exhaustion, step by step instructions are called to you by the chlorine-wielding hygienists, many of whom were farmers, drivers or teachers before the Ebola outbreak.

Hygienists

De-conning

After a lunch of African stew, the afternoon involves stock checks, stock reporting and preparing to place and receive international orders. The most important role of the pharmacist in the humanitarian context is ensuring that the supply chain is intact, reliable and efficient. Managing the levels of medication, IV fluids and medical sundries fall under the remit of the pharmacist. Accurate stock levels must be kept to pre-empt and avoid stock-outs.

Stock checks

Meetings with the health teams and the logistic teams fill the rest of the day along with teaching the national pharmacists aspects of clinical pharmacy, auditing skills and how to use the new pharmacy dispensing programme. On a good day there may be a discharge ceremony to attend for a patient finally clear of Ebola. Having the best air-conditioning at the ETC not to mention a kettle and a cafetiere, the pharmacy is also a popular place for colleagues to pop in for a well-earned coffee and a cool down. I think I can officially add barista to my list of skills gained on this deployment!  

A discharge ceremony

For ten hours a day, six days a week my life is at the ETC. Evenings are spent chatting with new friends over dinner or a drink, using the projector to organise a movie night, or having a beach bonfire. Sometimes it really is necessary to forget about Ebola for awhile.