Lessons from the frontline
Courage to be Kind.
I want to describe three quite different nursing experiences and to discuss the lessons these hold for us as individual health professionals, as a national community and as a world community.
There are times in our careers that are challenging. These are when we learn about our own vulnerabilities as well as about our strengths. These moments also sharpen our understanding of what matters.
Three years ago, there were two events challenging me. I had then been a nurse and midwife for 28 years often working in dangerous or difficult environments such as a remote clinic in PNG and theSudanese civil war. Out of these experiences the only time I found the need to walk away from a job was when I found my colleagues and myself being bullied.
My own experience of standing up to the bullying taught me much.
The other challenging experience three years ago was leading an Ebola team in Sierra Leone.
Whilst these where very different experiences they both led to a deeper understanding of what makes health care work and what really matters in the culture of health care.
Let me start with West Africa 3 to 4 years ago as stories came to us about an Ebola outbreak that had overwhelmed the local health industry and was threatening to become a widespread disaster, perhaps even a world-wide disaster.
The world seemed to stand paralysed in fear and countries set about putting up walls to protect their borders rather than fighting the outbreak at its source. It was like neighbours filling their own fire buckets and waiting to defend their own homes rather than teaming up to fight the fire at its source.
At a practical level this response was going to allow the further spread of Ebola and increased the risk of it reaching countries such as Australia.
At a humanitarian level this was like standing back passively watching a playground bully at work.
We need to ask why so many countries seems to be paralysed at the moment action was needed. We need to ask how we can do better next time.
Fear is very powerful at both the individual and national level. At the individual level many health workers wanted to go and help but feared they would contract Ebola. Perhaps a greater fear among workers was the fear they would not be able to cope psychologically with what they would experience. They feared they would be entering an overwhelming nightmare.
Fear was not only preventing useful actions, it was also paralysing the ability to think clearly.
We should also not forget that fear is useful to some. By increasing fear and then promising to protect us from the things we fear some leaders gain popularity.
During the Ebola crisis they exaggerated risk and promoted isolation of West Africa and the vilification of returning health workers. Some openly discouraged health workers from going to West Africa.
I believe after a crisis such as the Ebola outbreak we need to reflect on how we handled the situation, to prepare to perform better in the next crisis and to understand the emotional responses and emotional manipulation that delayed an effective response.
An example of the sort of reflection we need is the United States presidential ethics commission report, which recognised that it is in the interest of the United States and the world to become positively involved in such crisis.
Courage is the antidote to fear. Courage is not just about protecting our self-interest, it is about kindness to others. I believe through courage and kindness to others we can transcend fear and respond much more effectively to crisis such as the recent Ebola outbreak.
Ban Ki Moon summed it up. “The best antidote to fear is effective and urgent response”.
This Ebola outbreak was larger than all 20 previous outbreaks together. It occurred in countries where the health workforce was reduced by recent war. Ebola was killing many local health workers which made the situation even less manageable. MSF (Doctors without Borders) despite its long history, found this one well beyond its resources. Some countries and organisations stepped forward and my old employer Red Cross was one.
Red Cross provided a boost to depleted workforce, they send battle-hardened teams that could build special field hospitals and the leadership to organise the work. More importantly their presence helped the locals to have courage. Their presence said to the locals they had not been abandoned.
Courage just like fear and Ebola is highly contagious and established itself in our hospitals among our contact tracers and burial teams.
Courage mind you is not the same as recklessness. The people going in were psychological screened and trained in the high-level PPE. (Personal protective equipment).
The space suit of the Ebola worker made treating Ebola patients vastly safer. ½ million suits were required and Estonia proudly donated these, the Norwegian Airforce delivered them and people from all over the world wore them. This was an operation that build a coalition of the courageous. So, when I decided to become part of the solution rather than a spectator I was a minor pawn in a huge operation.
I found the experience in Sierra Leone working with aid workers from Sierra Leone and around the globe very positive. There was that positive energy being part of a team that had taken on a massive outbreak. With the predictions that millions of lives could be lost we had a sense of being part of a major front line at the same time it was clearly stressful and deeply sad.
There was positive energy in the individual stories of why people had assembled in an African town to do a difficult task for others. This was inspiring and made one proud to be human. These nurses and other team members coming together in Africa made you realize that we all cared for these people far from our homeland in their time of need.
Each time we admitted a patient we reduced transmission to others. Each safe and dignified burial reduced spread of the disease. Each admission hopefully improved the chance of survival of the admitted patient. These were all positives.
Each admission meant someone may die alone rather than surrounded by family, that was hard. In the first few months of the outbreak 80% would die, thus, many of those admitted died and many of these died alone. Out of fear many patients presented late and were very ill on admission which gave them little chance of survival. We often found ourselves caring for people we had no time to know, before they died an often lonely and painful death.
The first time I dressed in the protective outfit I entered the ward just as two week infant began to fit, he bled to death in my arms. His mother sitting with us had now lost all seven of her children and her husband to Ebola. She saw no reason to go on living. At that moment I realized I had no right to self-pity.
Death was stalking West Africa in the same way it had during the plagues of Europe, it has brought the country to a halt through fear. Schools were closed, many businesses went under and health resources were diverted from other priorities such as malaria and maternal health.
I sat with a 16 year old boy who arrived from Freetown the day before. Ebola had killed his father who was a local doctor, who unfortunately having contracted the disease from a patient had passed it to his whole family. This young man became very ill. I had put up IV fluids with some hope that he might survive. He was scared. So I redressed in PPE to go and sit with him for another 40 mins. Holding his hand, I told him I had come from Australia and that my name was Anne. I told him to fight.
He died.
The next day his brother who was doing well; drinking, eating and talking; died. His mother and grandmother survived.
Each survival was the time to raise our spirits through a little celebration of song and dance; African style.
Most importantly one of the things patients received at discharge was a handshake which meant so much for them as they been unable to touch other people while they had the virus.
The PPE outfits kept us safe and made treating Ebola patients possible. However, PPE in the tropics is hard slog. Taking off the PPE involves taking off contaminated layers without becoming infected and had to be done properly.
It was being done in tropical heat and humidity after 40-60min of being cooped up in a suit that does not let your body heat out. It was always done with a companion present to ensure mistakes did not happen. The PPE was hot and uncomfortable and you only wear it for 40-60 minutes otherwise you would overheat and collapse. It included triple gloves, making it hard to do procedures such as putting in drips and taking bloods. The gloves also made it hard to have the usual physical contact with patients that is so much of the comfort nurses bring. PPE did have another effect, it partially disconnected you from the suffering around you making it easier to cope.
While the initial response to the Ebola crisis was slow and we concentrate on the negative aspects of that response there is a positive message. Some parts of the world recognised an aggressive disease was possibly was going to take millions of lives, some communities did respond in a timely manner and the response was successful.
Red Cross with it valves and commitment to humanity was a significant part of that response. Red Cross showed that without the resources available in our Australian hospitals we could build a simple hospital, supply simple rehydration and save many lives. We could persuade people to enter our hospitals to isolate themselves so others could live.
Organisations such as Red Cross showed the combination of knowledge, humanity, courage and the rejection of pure self-interest could make a difference.
Much more importantly organisations such as Red Cross provided a work environment and work culture that made team work possible in those difficult times. This sort of work does not happen without effective teams. Effective teams involve some simple rules such as people trusting one another, caring for one another, putting the task ahead of their career prospects or their egos. Good workplace culture is the essential ingredient that has to be added to courage and kindness to make an operation such as an Ebola Hospital work.
I look back on two other Red Cross missions that I and my fellow workers would have found overwhelming and impossible if it were not for the team culture that held us together.
When I first arrived at the world’s largest refugee camp Gereida in Sudan a poor team culture had prevailed and the nick name for the post was the gate before hell.
A small group of us over 6 months developed a team ethic of mutual support, kindness to each other, to the local population and at the end of 6 months the change had been acknowledged by a new nick name the gate before heaven.
I again saw the importance of team culture when working in a 600 bed hospital for war wounded on the Kenya/Sudan boarder. At night we would have just one 1 RN and 2 assistance nurses attending 600 patients, some of whom would die each night. During the day the hospital would become active again carrying out operations, chiefly lifesaving amputations.
Despite the awful staff to patient ratio the team managed to do a lot of effective work. Team morale in a situation like this is what matters not resources, not flow charts and protocols just good team culture.
Before I completely leave the story of the recent Ebola outbreak, I would like to pass comment on the role that fear took in our community.
On my first return to Australia public health officials were not focusing on educating the public that returning health professionals were not a serious threat to Australia. Unfortunately, these officials set out to make it appear that I was under some form of quarantine to allay unwarranted fears.
For those who are not aware, the simple reality is Ebola has not been passed on in the first 3 days of fever and so if a returning aid worker were to be infected there would be plenty of time to safely isolate them.
The focus here should have been to help people understand Ebola and to help contain the disease. Our role is not to respond to hysteria our role is to educate so that the public response is calm and rationale.
To share with you an instance of how easily health professionals who were experts on contagious tropical diseases could be reduced to frightened people who could no longer perform their role I would like to tell you a little story.
18 days following my first return and knowing I need a fresh supply of anti-malarial medication and with no evidence I had Ebola, an appointment was made for me with a practice that specialised in travel health.
On the morning of the appointment I was phoned and informed that this practice had held a meeting and decided I was far too great a threat to be allowed inside their doors.
So, I set out in a packed morning train, walked through the streets of Perth, paused for a coffee in a café, and then as instructed made my way to the front door of the practice. I phoned the receptionist and waited for the door to open just sufficient for an eye to look around and a disconnected hand to toss my medication onto the pavement in front of me. The door shut as I bowed gratefully and I collected my package and made my way back through the crowds of Perth.
This brought home to me more than anything else that well educated, knowledgeable, fellow health professionals could be reduced to mere fools by lacking the courage to question fear. We are all capable of panic but we seldom achieve anything worthwhile when we yield to fear.
Situations, such as occurred in Sudan and West Africa provide tests for the moral compass of nations. In the case of West Africa many small countries such as Norway, Finland, Estonia and Cuba took a leading role. By doing so they wrote a page in the national histories that they can always be proud of and which will encourage them to behave with courage and kindness in the future. Countries whose primary response was fear and retreat could do well to examine their moral compass.
These are the moments that build nations and organisations. These are the moments that set the moral tone of societies. They separate the givers and the takers. These moments in a nation’s history set benchmarks and values that determine how other ethical matters are tackled.
This includes how we respond to bullying in the workplace and those who seek our sanctuary from war.
These are the moments when nations and organisations gain the ethical right to pass judgement on others and set the moral compass for their futures. In this crisis Red Cross responded in a way similar to its founder’s actions on that battleground in 1859.
Finally, my other learning experience in health care has been to find myself leaving my role as a public hospital midwife and RN in the face of a toxic workplace culture.
At my age I could retreat into retirement however my experience made me question what has happened to the valves we claim are the moral basis of health institutions.
By allowing poor workplace cultures to go unchecked we guarantee the loss of good clinicians, damage to teams and poorer patient outcomes.
Just because this is an awkward topic for many, is not a reason to avoid discussing it.
Providing excellent workplace culture should be as high a priority as providing excellent clinical care.
I leave it to you all to reflect on how we as a nation responded to Ebola and how we respond to refugees, bullies in the workplace and the injustices we encounter in our society.
I ask you all when you have gone home to reflect on how we can each achieve the courage to be kind.
Copyright: A Carey
1