Friday, January 30, 2015


This week I had the privilege of talking about Ebola virus disease (EVD) and my experiences in Sierra Leone with a bioethics class at Pacific Lutheran University. The students had covered ethical issues around EVD the previous week and some of them had read my blog. I presented a (relatively) brief PowerPoint and then had a question & answer session. Although I had been reluctant to talk publicly about some of the things I saw in the Ebola Treatment Unit, it did not seem to me that any of the students were uncomfortable with what I told them.

A number of the students asked questions about the welfare of the survivors after they had been discharged. I knew that there is a survivor program in Sierra Leone that helps people reintegrate into their communities but, since I spent nearly all of my time in the country working inside the ETU, I couldn't tell them much about the program.

I was very pleased that a couple of students asked about long-term health care goals for Sierra Leone; what is needed to prevent an epidemic like this from happening again? What happens when the aid workers leave? What sustainable health infrastructure will we leave behind?

I was particularly grateful for this opportunity because many of the people in the class are nursing students. I used the opportunity to ask the students to consider working in developing countries and was pleased that a couple of them seemed interested, even staying after class to discuss it with me.

When I speak to young people, as I will again in a few weeks, I encourage them to consider a career in health care and in nursing in particular. The nursing shortage in the U.S. is worsening. As baby boomers reach retirement age, our population is becoming older and there are more people with chronic conditions who require medical care. Nurses are getting older too. Over the last four decades, the age distribution of nurses in the U.S. has shifted to the right. More of us are older and approaching retirement age.

Age distribution of Registered Nurses in the U.S.
Health Resources and Services Administration, 2010
To satisfy the demand for nurses in the U.S., English-speaking nurses are aggressively recruited from countries with their own shortages of health care providers.

I decided to become a nurse after spending 10 months hitchhiking in Africa. I fell in love with the continent and its people and wanted a career that would allow me opportunities to return to Africa and work toward improving the health and living standards of Africans. Ultimately, I would like to teach nurses in Africa; something I was able to do in Tanzania and, to a lesser degree, in Sierra Leone last year.

Algeria, 1988

Nursing has provided me with endless opportunities for learning and a high degree of mobility. I've held licensure in four different states and two African counties. I've worked in acute care, critical care, and currently work in public health. I began my nursing career working neurology/neurosurgery and have held neuroscience nursing certification since 1995 (it will expire the end of this year). Over the years I've had countless nurses tell me, "I hate neuro!" I can understand the sentiment; neurological insults are devastating and leave people with life-altering deficits, but I loved working neuro. Caring for patients with neurological deficits can be challenging, but the goal is helping people achieve their highest level of functioning.

I spent most of my bedside career working in critical care and enjoyed caring for the most complicated patients I could find. I worked in units where we saw neurotrauma and multisystem trauma; people who had gunshot wounds, had fallen, or been in motor vehicle accidents. Critical care can be a highly stressful environment but, for me, it was exciting! (For what it's worth, I found working in emergency departments to be boring.)

I've also enjoyed my volunteer work, not just in Africa, but also in this country. I volunteered with a mobile medical clinic in the Lower 9th Ward of New Orleans and St. Bernard Parish after Hurricane Katrina. I've volunteered in shelters and clinics in which most of the clients we saw were homeless. I loved listening to people tell their stories. I still volunteer at a clinic here in Tacoma.

There are, of course, a lot of negative aspects to nursing. It can be physically and emotionally demanding. Working in hospitals usually means having to work weekends. I spent too many years working nightshift. Taking care of sick people can be a dirty job. I've had to clean up almost every fluid and excrement that the human body produces.

Then there's the abuse; abuse from patients, abuse from patients' families, abuse from doctors, and, worst of all, abuse from other nurses (horizontal hostility or lateral violence). Health care providers are at high risk for being assaulted in the work place. I've been punched, slapped, kicked, bitten, spit on, and called every name in the book. Fortunately, I've never been seriously injured. Some of my colleagues weren't so lucky.

Nevertheless, I love being a nurse. It's a profession that allows me to put my Christian values of service and social justice into practice. Since graduating from nursing school in 1992, I've never had to worry about being unemployed. I enjoyed being at the bedside, but I'm very happy to be in public health now. I sometimes miss patient care, but volunteering allows me to do that.

It's definitely not for everyone but, if you're looking for a very rewarding career, please consider nursing.
My PowerPoint presentation:

Highline Community College
Associate Degree in Nursing
Class of 1992


U.S. Department of Health and Human Services Health Resources and Services Administration. (2010). Findings from the 2008 National Sample Survey of Registered Nurses.

Monday, January 19, 2015

Ebola: Altered standards of care

I thought I was done talking about Ebola for a while.

I've been preparing to go back to writing about vaccines and vaccine-preventable diseases but was asked to speak to a bioethics class at Pacific Lutheran University about my work in Sierra Leone. I decided to post some of what I plan to discuss instead of writing about another subject that's near and dear to my heart: meningitis.

There are a number of things that I've been reluctant to discuss publicly. I've tried to keep my posts about Ebola relatively positive. I haven't discussed the gruesome scenes and situations that I saw in the Ebola treatment unit (ETU), but it requires no stretch of the imagination to understand that those of us working in the ETU were troubled not only by some of the things we saw there, but also by some of the decisions we had to make.

I went to Sierra Leone because I believed that my clinical and educational background prepared me for that work. I spent most of my bedside career working in critical care units and am comfortable with end-of-life decisions and care. I worked neurology/neurosurgery where I saw people suffer devastating injuries and illnesses that left them with permanent disabilities. I worked in resource-poor settings in Africa. I went to Sierra Leone fully aware that ebolaviruses are highly lethal and that epidemics of Ebola virus disease (EVD) are associated with high mortality. I went with the understanding that I would see people die.

I've also been involved in emergency preparedness planning and am familiar with altered standards of care in mass casualty events. Mass casualty events are those in which the number of people requiring medical care exceeds local capacity. One example that has been used in training exercises in which I've participated is a chemical spill in a small city where the number of people exposed is greater than the number of hospital beds available, ambulances needed to transport the victims to the hospital, and the number of personnel needed to care for the injured both at the scene of the accident and in the hospital. In this scenario the injuries vary in severity. Some people have only minor injuries and do not need immediate medical attention; some people have severe injuries and require immediate medical attention; and some people have severe injuries and are unlikely to survive even with immediate medical attention. In altered standards of care, the focus shifts from caring for the most severely ill or injured first to allocating personnel and equipment to caring for those who are most likely to survive with the goal of saving as many lives as possible. This means that emergency responders and health care personnel must determine who will not receive life-saving care and will die.

There were times when I had to decide whether to spend the limited amount of time I had in the ETU giving oral rehydration solution (ORS) to someone who was too weak to sit up but was able to drink or spend that time with someone who was unresponsive and could not drink. This was not a decision I had to make frequently and, once we had enough people working at the bedside, it was a decision that I no longer had to make.

I can't say I'm sure I always made the right decision. On the other hand, I have no doubt that there are people who are alive today because I stood at the bedside holding patients in a sitting position with one hand and a cup of ORS to her or his lips with the other. My purpose in doing so was not only to rehydrate that patient, but also to lead by example; to establish a standard of care for our patients in the ETU. With good reason, many of our local staff were reluctant to provide hands-on care to our patients. They had watched their friends and colleagues die from the disease. One of the trainers in the Ebola safety course I took before going to Sierra Leone told us that the purpose of personal protective equipment (PPE) is to allow us to touch our patients.

I recently participated in a conference call with some of my colleagues from the ETU, one of whom, a nurse with critical care experience and who had previously worked in Africa, expressed a sense of helplessness at not having the resources needed to provide life-saving care to every patient in the ETU. In critical care and in most patient care settings, our focus is on the needs of the individual patient. For those working in an ETU, our objective is to safe lives, however, in an Ebola epidemic, the primary purpose of holding and treatment facilities is isolation; removing infected or potentially infected individuals from the community to prevent transmission to others.

I'm scheduled to speak to the bioethics class a week from today.

My fifteen minutes of fame:

Agency for Healthcare Research and Quality. (2005). Altered standards of care in mass casualty events.


Two guys at the hardware store
Two guys waiting for breakfast