It's late at night, just past midnight on the 19th of January. I can't sleep. I swear I spent the first 2 days home either speaking with Tom or sleeping. I can't remember ever being so tired in my life as I have been working with those poor babies. It may take another week or so before I feel as though I've properly caught up on my sleep. I'm still tired now, just not sleepy.

Tom encouraged me to find a quiet period of time & write this, "this" being an account of my experiences at both the hospital & care center to which I was assigned as Head Nurse. I have mixed feelings about doing this. I suppose I have to get it out of my system; hope that somehow disgorging the words may help me somehow excise the impressions, the sights & smells; the sounds which haunt me when it's too quiet here.

I told Tom I really didn't know what to put down here; what deserved noting in a permanent form. He suggested just sitting here with this journal in hand, pen ready & write it as it comes. Funny, that doesn't sound too organized & that may be the place to start - the feeling that there was no way we could have been organized enough to adequately face this, to treat each patient as they deserved to be treated.

We thought we had a good public health response plan to deal with any major medical scenario. It certainly worked last spring, when that tour bus crashed & we had 60 patients to deal with. We had the callout system started within 3 minutes of receiving notice from the police that a mass casualty situation was coming in. All patients were at hsopital & triaged within 90 minutes & within 6 hours, everything was well under control.

Oh we did the usual post incident analysis & were pretty happy with how it had all worked out. The few problems we ran into, we thought we had ironed out. But looking now, especially in light of what's currently happening & after catchinhg up on some sleep, I see several major errors we made. The awful part is that I'm not sure that knowing in advance what would happen would have been much help.

We always looked at mass casualty, callout situations as "one time only" type of emergencies. Even scenarios where we were looking at major outbreaks of illness such as flu had a terminal point. Scenario 'A' would end on Day 'X' sort of thing. We never looked at open ended situations.

The base assumption was always that supplies could be obtained, be they food, IV fluids, clean sheets, etc. The only real source of concern there came from the accountants who fretted about how we would pay for large orders; they weren't sure our credit limit with suppliers was high enough! The idea that we could run out was never seriously examined.

Staffing; same sort of thing. We assumed, even with staff down with flu or something similar, that within a few weeks, they'd be well enough to return for at least light duties. We never presumed a scenario where staff couldn't get in to us, chose NOT to report for duty or were a large part of the patient load themselves.

And, I don't think any projected scenario ever looked at more than 10% of the area's population becoming ill. We also realized that at 10% of locals sick, we would be seriously hampered in our ability to diagnose, treat & deliver supportive care. Most of us out & out stated it couldn't be done.

On paper, we had a working plan for an outbreak of smallpox, but too many crucial issues had not yet been addressed. I doubt it was ever really taken seriously by those who really could have made a difference in the planning. The lawyers kept grinding the process to a halt anytime we spoke of comandeering buildings & people do the work required in a large scale outbreak. "Illegakl, can't be done, violation of this, that & the other thing"...

Yeah, well smallpox is the grossest violation of anything I've ever seen in MY life & I have no doubt those same lawyers would say differently now. What the heck does property law matter when you risk having few people left to worry about property? Honestly, claims & counter claims in a court of law have no bearing on the current crisis. By the time we get through this, IF we get through this, I don't think any lawyer will have any higher priority than feeding him or herself & their families.

I think Tom was right; sit down with some quiet, pen & paper & eventually the words come pouring out. And, I haven't even begun to speak of the unspeakable. I'm going to get a cup of hot chocoalte first, something soothing... and some tissues. I have trouble thinking of what I've seen & you readers a long time from now, forgive me if my writing gets shaky. These are terrible things to relive, to write about.

I needn't say much about the first few days. Tom says he wrote about how I was called in to discuss plans for the crisis which hadn't yet been publicly announced. What he didn't write, (I hadn't told him), was how full of panic the meeting was. It was bizarre. The youngest & oldest doctors, those who've either had experience with severe outbreaks of anything & the newer doctors who've gone for bioterror training were white with anxiety. I must say, my heart felt like it froze for a moment when the Chief Medical Officer told us what we might be facing.

We must have spent a good ten minutes simply REACTING, filling the air with unanswerable questions, opinions & yes, even some tears. The CMO let us 'vent' for those 10 minutes, then quickly got a grip on the meeting. At that time remember, we had no cases here but he saw no reason why we shouldn't expect any. After all, the CDC was already aware of several index cases in a number of different cities.

We really didn't get too much done that first meeting. With an impending crisis of the size we were facing, it makes more sense to have representatives of all interested parties. About all we got accomplished was ackowledging that we needed representatives from the clinics in town as well as the other hospital. Thankfully, we were able to set that up for 3 hours from when we broke up our first meeting.

The second meeting was something else. It took a while just to get everybody settled & ready to 'get real'. Too many still wanting to fight over who would be in charge of different aspects of the crisis, should it hit home. Our CMO finally, disgustedly I'll add; handed it over to the Chief of Medical Operations of the private hospital, adding that he'd be happy at act as his second. That finally got the ball rolling.

In any case, it worked out like this; a central switchboard for calls between hospitals & clinics was organized, in order to minimize confusion. Both hospitals agreed to send home as many patients as possible, with medications, care instructions & written instructions for any minor care procedures their families could carry out. All staff was to stay at their own institutions as they were familiar with procedures & protocols, not to mention the physical layout of their own facilities.

In terms of procedures, all emergency room doctors, clinic doctors & private clinicians were to be provided as quickly as possible with descriptions of early smallpox symptoms & findings. Ambulance services were put on notice that they could possibly expect a large influx of calls. Luckily the 2 companies in town are pretty on the ball & their drivers/paramedics well trained. They assured us they'd be ready within 6 hours, both to recieve patients & to transport them to the proper location.

We agreed to take in all suspected smallpox cases, to evaluate & do the lab work & initially, to provide 100 beds. We all hoped that wouldn't be necessary, that we might perhaps only see a few cases which could easily be isolated & that the public health department would be able to vaccinate any contacts.

There's where things started breaking down quickly. At the time, we had no vaccinia vaccine & we still hadn't heard when we could expect to get any. Heck, state public health was darned near impossible to reach & understandably. Still, we had to plan & we spent long hours trying to decide how best to handle suspected cases & contacts until we could assure a supply of vaccine.

Let me skip forward several days...

You know by now, from your own families & from history classes in school that after that first few days, the situation rapidly worsened. We got cases alright, far more than we could have dreamed of & within the first week, it was clear that we were not dealing with "normal" variola. You probably have the answers to that by now, exactly how it had been engineered, how many end up dead. From this side of the time line, so many questions remain unanswered. I'm not sure I want all the answers still outstanding.

I won't soon forget my first sight of a patient with a full blown case of pox. She was about 25 according to the chart & had a semi-confluent case. I'd seen quite a number of patients with prodromal symptoms & some with early pox, but this poor woman lived alone & had been too sick to call for help. She was lucky a neighbour decided to check on her, although that poos woman payed for her concern later, with her life.

Strange, you train, you prepare, you think you've steeled yourself against the worst possibilities. You have faith in your ability to overcome any fear r revulsion you may feel towards patients. Sometimes the reality is almost overwhelming. I froze, I truly did for about 30 seconds or so & had to fight the urge to run, to flee to some mythical safe place. It was as primeval a feeling as I've ever had; more elemental even, then birthing my children; an overpowering sense of immediate threat to my life. I almost broke right then & there & those first few days, several staff members did.

I can't, don't blame them. Most came back after a few minutes, perhaps a few hours, ashamed of their reactions. Most have never seen horro the likes of which we face now & their reason fled in the face of overwhelming sights. In emergency we often deal with gross insults to the body, horrifying injuries, but we mainly deal with those one at a time & any staff member who has trouble emotionally after working on a tough case can get counselling.

But here we were, constantly recieving a stream of patients we could do little for. Sam told me we have close to 20,000 people sick or dead now, just locally. I find that easy to believe. We saw relatively few cases, considering the scope of the outbreak, but those we saw would break the heart of the most hardened person. Men, women, children; we got them all that first little while, until there were just too many clear cases & no room, not enough people to handle them all at hospital.

I wasn't happy about being chosen to head the nursing effort for the childrens' care center. I've always avoided pediatrics like the plague & children in emergency, especially those with serious illnesses & injuries always made my heart sink. Luckily, I'd never had to care for too many. It's not that I'm not good at it or don't deal well with children. In fact, I'm very good at it. I just can't seem to leave that aspect of work at work, if you know what I mean. Still, the peds people here were already pretty tied up & several showed signs themselves of having contracted the illness.

We were given adequate enough facilities thank goodness. One of the local high schools with 2 huge gyms, both of which could be searated into 4 smaller rooms. An adjoining cafeteria gave us even more space. I couldn't have imagined needing all of it though & even overflowing into classrooms the way we did. In my center alone, we ended up with close to 1000 beds, cots, mattresses; all full of kids under the age of 10.

Most of the time I spent there remains a blur. There never seemed to be enough staff, but really, there was little we could do except keep them as clean & dry as possible, keep fluids in them & sedate those who were in the most pain or the most upset. I'm grateful I didn't have the real babies to deal with. It was bad enough having the 2 to 5 year olds. They're old enough to speak, but not really old enough to understand what's happening & definitely not able to understand why mom or dad can't be with them. Some of the doctors didn't them bringing in their stuffed animals, but I put down my foot at that. What would have been the point of excluding them? No one came to us unless we were sure they were suffering from variola & they certainly weren't going to make it worse for others if their teddy bears were contaminated.

So what were we able to do? Frankly, not very much. The worst cases got IV rehydration but for most that was more of a problem than a solution. The little ones often ripped them out or got so restless, the needles slipped out of the veins which at that age, are small & fragile to begin with. It was easier to simply try & get them to drink whenever possible. Food, well most weren't too hungry in any case. They were too sick, too frightened or missed their parents too much. And they were so frightened at the sight of those lying around them. A full blown case of pox, especially on the face looks terrible & these kids are at the age where their fantasies are vivid & they can't distinguish dreams & nightmares from reality.

We had to keep quite a few lights on at night for a child waking & seeing the face of his neighbor, would often erupt into heartbreaking screams of terror. It was hard enough keeping them still & calm, without involving their own terrors. Some, we were able to put loose, soft blindfolds over but even that became a source of terror to many. Young kids are very visual & not seeing was to some, wrose than what they saw.

A no win sitaution all around. Most died within 3 - 4 days & with the death rate so high & so many new pateints coming in after being found alone, we had no way of knowing how long some of them had been ill. We had days where over half the patients in any one room died & no way of giving them any privacy nor of protecting those around them from the sight of death.

And the stench. Even the masks did nothing to keep that out. It can't be masked or eliminated & most likely factored into the lack of appatite many kids suffered from. The smell of an 'accident' was almost welcome. wful as that can be, it's far better than the reek of weeping pustules.

We spent most of our days working in tems of three. We'd go from bed to bed, washing what we could as gently as possible, making sure linen wasn't too dirty & changing it when it was. We'd give them what we could to drink, assess how they were doing, then move on to the next child. Three of us to see to thirty or so kids & it took an hour at best, three at worst. It was actually fastest when we arrived at a cot & find the patient had died. They'd be taken away by oderlied while we did the best we could to disinfect the bed, then change the linen. I don't think a cot or bed was ever empty more than 5 minutes.

I don't know how long we worked. We generally worked until we couldn't see straight, then would go shower out & lie down for a few hours sleep. It was easy to forget to eat & the sights, sounds & smells made it impossible to look at any food with any degree of enthusiasm. I made the mistake of looking outside once. Curfews notwithstanding, many parents stood patiently outside, hudling against the cold & weeping softly in the arms of loved ones.

Every few hours, some poor orderly had to go & read the list of those who had died & eventually, those few who were making a recovery. If you lost track of the time on the wards, you were reminded when the shrieks & wails of anguish could be heard outside. Unfortunately, that generally set the kids off, adding the bedlam we were already experiencing.

I understand why soldiers who have seen war have that empty, far away look in the eyes. There are different wars that we fight & this war we're fighting now, the battle against this scourge, is no less terrible than any WW1 trench or massive artillery barrage. We have been subjected to a bombardment of disease & a campaign that's the result of years of arrogance, of neglect, of assuming we would never suffer such an attack.

And we're paying fullest, fullest price... through the deaths of our babies.

I must stop now. There is more to say, but not at this time. My hands are shaking & I suddenly feel like those children are just on the other side of the living room door. I can't go there right now, not & stay sane.