Things are developing well at the centre. More international health staff have arrived and are nearly ready to work in the red zone safely, and a group of 30 Sierra Leonian Ministry of health nurses are on track, so the number of staff available will be much higher . I think another 500 wellies are needed to cope with the throughput.

The most important thing is that we sense a fall in mortality. This could be due to improved care, but also that the message is getting through that we need the patients to be transferred as early as possible in the illness, as we can keep in top of fluid losses better at way.

Manufacturers of PPE suits, hoods, masks, goggles and visors, non latex gloves, wellies and plastic aprons must be having a very good year, though I suspect anyone else trying to get hold of these items is cursing.

We are working hard to make systems work better, so that we can measure the amount of fluid being drunk or infused, ensure that procedures involving needles are safe to do, working harder at providing relief for pain and nausea, and to reliably keep drug regimes working well. It is so much harder to coordinate this between two areas with a one way system in operation; any backwards flow from the red zone would be disastrous.

What else do you need for an ETC? The red zone is a small strip on the edge of the site. There is a huge warehouse, a canteen, an office, a laboratory staffed by Porton down and other lab workers from the UK, a beautifully air-conditioned pharmacy, always worth a visit for 5 minutes, wash houses for the wellies, theatre scrubs and aprons, changing areas, huge firepits burning the huge quantities of plastic material. Then there is the waterworks, providing piped caustic 0.5% chlorine. How the plumbing will hold out against this piped alkaline, caustic fluid I’m not sure.

Then there are the training tents and the best place in the whole camp: the discharge tent. Survivors come here after leaving the red zone, having a shower and being given clothes, all their possessions at entry including mobile phones being incinerated. They receive counselling about what to expect as survivors. Rejection through fear is common, adding insult to the injury of having lost loved ones in the days and weeks leading up to their own illness, or worse becoming orphans. They are given a ration of food to last three months: a sack of rice, a sack of corn meal, cooking oil, a Jerry can, gloves, soap and washing materials, money and the all important certificate to prove that they are cured and therefore not infective. How this is interpreted in small village I’m not sure. Lastly they are given 90 condoms and told its best to abstain for three months as virus can be present in sperm for that long.

Four young girls were in the limelight today. Two were smiling, one was quiet and one was distressingly silent and withdrawn, clearly deeply traumatised by the experience of the past week or so. Three of them gave short speeches expressing their gratitude and then we sang a song, and there was a short dance. I could not quite enjoy it, seeing the one young girl so unwell psychologically, but overall it is a joyful occasion.

We took the handover from the night shift and then went through the patient list again, identifying the tasks we needed to get through. The team comprised myself, national nurse Agnes , Cuban nurses Luis and Niorge, with another UK Dr, James, helping out.

Our most poorly patient remained Mahawa, only six and fighting to survive. It was great to see that she was looking me in the eye, rather than into nowhere, and asked for a drink, so I sang her another song. Early days but she might just make it.

There’s work to do to make the shifts run smoothly and get all the different aspects
of care covered. This requires teamwork between the different cultures, which is complex, and it looks like I am taking on this role in part. I talked to the Save the Children director of humanitarian work who is visiting and problem solving for 3 weeks. It’s clearly been a tough year for the charity/NGO, with the Philippines typhoon, Syria, Palestine and now Ebola and more. People seem only too happy to criticise NGOs for being inefficient, just as clinicians love to blame managers for obstructing what seem obvious and necessary aspects of patient care. What I see is hard-working people problem solving continuously whilst trying to drive strategy, from an open office in a hotel lobby, bringing together many different players. It is a logistics nightmare, and as with much hospital care, one bottleneck can hold up the whole system. So if a combination of water supply problems and cleaning staff not quite doing the job means the wellie washing is not fast enough, the clinicians cannot get into the red zone.

Later on we had 9 or so new admissions, one dead on arrival. I think people are sensing an improvement in survival rates already, so hopefully the hard work will pay off and give more hope to this part of Sierra Leone at least.