doctor

Liberian official speculates on how to fight ebola

An unfiltered, direct comment on how to control Ebola, from a person currently working in Sierra Leone

This comment was posted in the Financial Times this morning by John Galani. Source: steamguy


As a person working in Sierra Leone and directly impacted by it, I can say first hand the issues are both complex and varied.

First, the issue of leadership: the problem is that you are dealing with governments in West Africa that are months behind salary payments, not staffed with knowledgeable public servants in the Western sense of the way, but “bureaucratic employees” and a merry-go-round of politicians, who are untrained in the field of public services to say the least.

It does not mean there is no goodwill, just that the machinery of government is dysfunctional at the best of times; let alone in such a major crisis.  Imagine a horror movie where the actors were oblivious to the mounting threat and then belatedly the government driver is now desperately trying to start the car when the epidemic is surrounding the broken down vehicle… and you get the picture.  Giving money to such institutions, although required, will not achieve immediate results, and even less the required one, hence why so much current funding is indirect.

The second issue revolves around the wider implications of Ebola, akin to firefighters destroying a building by dosing it with water trying to put out the fire on the top floor: medical facilities where doctors and nurses are neither trained for, nor equipped to combat Ebola, and have even collapsed as some of them were infected.

The medical map is now of major hospitals with Ebola wards and minor ones closing.  The population at large does not wish to use hospitals with Ebola screening and treatment wards for obvious reasons; therefore multiple health problems go untreated.  Food in locked-down areas is hard to come by and certainly more expensive, and this in a subsidence economy which cannot afford such price rises.

Seasonal planting, schools, jobs related to all these sectors and the wider public sector whose meagre funding is now being shifted to Ebola fighting, all these conspire to a breakdown of central governance.  It is also rather unfortunate, but true, that the local population has lived through such times in the past, and can bear it better than we in Europe could, but still.

Now what does one do about all this?

The solution is actually quite simple, as it is in most major cases: you use a hammer:

The base case scenario is for Western armies to step in with the chemical and biological units. A form of martial law needs to be imposed with quarantine areas, and large scale assistance to the local population which will neither be able to feed itself nor continue normal life until this is over.  If we were to do this it would all be over in 3 to 4 months, with certain areas taking less time, and others going to the buffers, and potentially longer but only a regional basis.

Any other way, which would impeded less on the local democratic institutions and would take into account the human rights of the population, would take longer.  How much longer would be linked to the loss of efficiency versus the method described above.

It is for the local governments to decide their fate, but I would urge them to understand they are not equipped, nor could they ever be anywhere quick enough with whatever money could be thrown at them, to deal with the outbreak.  If they do not take such courageous decisions, the world will likely contain their countries rather than Ebola, as is happening now.  This should be linked to long term funding of their depleted reserves and infrastructure once this is over.

I remember conversing with a trauma surgeon who told me when they got an emergency case in their job was to save the live of the patient, nothing else, and if that meant scaring, amputating or any form of “butchering” in order to save a life, so be it…

Ebola through the pages of a Liberian doctor’s journal

Reprinted from Adventist Hospital in Liberia

23,459 words from Aug 15,2014 to Sep 12, 2014 – by Dr. James Appel.

Dr. James Appel works at Cooper Adventist Hospital in Liberia This is his personal journal during the Ebola Crisis. Newest entries will be posted at top. Please scroll down to start at the beginning of his story.

BLUR

I’m losing track of time. Cases and patients are coming in and out of my memory. I can’t even remember sequences of events or what day it all happened. I’m not sure now if things happened all in a day or a week or what. It’s all becoming a blur of images flashing through my mind as I try and grab some food here and some sleep there (and the occasional surf thrown in for good measure.)

A tiny 16 year old referred from an outside clinic after three days of labor. The cervix is completely dilated and the baby’s head very molded. There are no fetal heart tones. I set up for a symphysiotomy. I inject the skin and subcutaneous tissues down to the cartilage of the pubis and then slice down, cut through the cartilage and have my assistants put gentle downward pressure on the legs until the pelvis splits apart a few centimeters. The baby is still having a difficult time coming out. I add oxytocin to the saline drip. I inject the labia and do a mediolateral episiotomy. By the time the huge dead baby comes out she also has a massive periurethral tear up into the symphysiotomy wound.

I’m leaning over from the side with almost no light. Mr. Wezzeh has Gillian’s headlamp which helps tremendously, as long as he’s looking where I’m working. I begin the repair with the sympysiotomy wound which is easily closed in two layers. Then I work on the periurethral tear. The anatomy is distorted and she’s bleeding heavily. I’m holding down pressure as I call for more lap sponges. I’m also massaging the uterus and having the midwives give more oxytocin and ergometrine. I finally am able to pull the urethra back to the side wall and then close the vaginal mucosa. The repair of the episiotomy is easy after that running from inside to out and back again in a continuous suture line.

She looks pale afterwards. Jeff is there since it’s early evening already. He does a hemoglobin. It’s 3 g/dl. She needs blood. The family has gone home. Jeff knows someone who sells his blood. He comes in a gives. Kind of sketchy if you ask me in the days of Ebola. The girl gets one measly bag. The sister refuses to donate. Everyone else is “far away” and of course there’s the curfew. I hope she makes it through the night as I put her on a quinine drip. Did I mention she came in with fever? I’m glad her malaria smear is positive. I’d hate to think she had Ebola with all that blood flying around.

The outpatient department is crowded. I’m called out to see three guys coming from the same neighborhood who’ve all started vomiting now. We’ve built a crude lean-to against the outside wall of the hospital with a tarp stretched over the top to shield the patients from the sun or rain. They have to wait outside often for hours waiting to be screened and seen by a provider. No one seems to be too concerned about the vomiting as people are still sitting in relatively close proximity. I take the first guys temperature: 39.1 C. He looks Ebola-ish with red eyes and a haunting stare with sunken cheek bones. Even though he denies diarrhea I don’t believe him…either that or it’s about to start. I refer all three to the ELWA Ebola treatment center.

I’m called out to see a woman in a black pickup truck. She looks like death warmed over. She’s unconscious and has labored breathing. Her conjunctiva look normal and she has no gingival bleeding. The family of course denies nausea and vomiting. They say she just “fell off” last night (meaning she passed out). I check her temperature: 41.3 C! I’m still amazed at my continuing gullibility as I have them bring her in to the ER. After all it’s probably malaria right? I start an IV on each arm and get Dextrose running in one and Saline in the other. I then start a Quinine drip and have them give Ceftriaxone IV. I go away. They call me from lunch to say she’s vomited. I go in and she’s doing slightly better except still unconscious and lying in her own vomit.

I want to send her away immediately, but the ER nurse says we’ve already started treatment, let’s do a malaria smear and see what it shows. A few minutes later it comes back negative. The truck has left but the caretaker calls them back. They call me when the truck arrives. I explain to the family leader that I suspect Ebola. He says he’s part of the Ebola Task Force and pulls out an infrared thermometer from his pocket. He informs me he checks everyone’s temperature all the time and she didn’t have a fever before. He agrees to take her to ELWA so I prepare a referral form. Then I get protective gowns, gloves, masks, etc. for the two people who will carry her out.

I go and clear the lobby. I have everyone sit over in the corner. I go out side and clear people to under the overhang. Some people are angry and ask who I think I am to talk to them that way. Do I think I can just order them around? I of course don’t bridle my tongue and get into some useless wars of words. I also have the other cars move away from the truck. When the coast is clear I have the team bring out the woman. When Ebola task force man sees that I’ve had everyone move aside he is angry and shouts at me, accusing me of making it out as if she has Ebola already. I can’t help but yell back that this is why Ebola is running havoc in Liberia, when even people on the task force can’t even admit that someone is suspicious and take precautionary measures. He’d have preferred to take her out without gear and through the thick of a crowd to avoid suspicion!

A baby comes in after midnight with stridor. The tiny 5 month old chest is flailing in and out with severe substernal retractions and no air movement in the lung fields. I diagnose croup and give IM dexamethasone and start an adrenaline nebulizer treatment. I have to give treatments for over an hour, holding the mask myself over the tiny mouth and nose before air starts moving past the swollen trachea and into the lungs. The baby is very chubby and the mom assures me that she’s breastfed exclusively. I’m not surprised.

I’m at home. I hear a pounding on the door. Come up to OB! A woman has twins. The first one is breech and half way out and stuck. I pull on gloves quickly and pull the baby’s tiny feet with all my strength and the body inches out until I can hook my index finger over the anterior arm and swing it out. I give the baby a quick twist so the posterior, undelivered arm comes anterior and deliver that with much straining. I put a finger in the baby’s mouth, tilt the chin down and pull even harder and the baby comes out with a pop! He’s floppy and I’m afraid it’s too late but I instinctively start chest compressions and vigorously rubbing and drying. The baby takes a gasp. I keep going and call for the ambu bag and oxygen. Before the midwives can get it the baby is taking small breaths as I continue to suction the nose and throat, stimulate vigorously and pound furiously on the tiny chest. The skin pinks up. The legs and arms start to contract and the boy lets out a lusty yell.

But wait, there’s more. The second twin is still to come. I rupture the membranes and feel that it’s a vertex presentation so I go back home and eat breakfast. That’s right, it was early in the morning. Like I said, it’s all running together in a blur.

PUS and BLOOD

From far away I can tell I will find pus. The young girl’s left jaw is swollen with tense, shiny red skin over the inferior lateral aspect. Her left eye is swollen shut and she is in obvious pain. The mother confirms my suspicions that this is a periodontal abscess by saying it started a week ago with a tooth ache.

What really surprises and embarrasses me is that she came here to Cooper Hospital two days ago, saw a PA and was sent home with oral antibiotics and steroids (possibly the worst medicine to give under the circumstances.) I admit her quickly for an extensive incision and drainage.

I walk her upstairs and Joseph and Mr. Wezzeh help put her on a gurney and start an IV. I have them give Diazepam and then a couple milliliters of Ketamine and she is out. I take a scalpel blade and slice down over the center of the abscess and soon am into thick yellow pus mixed with blood flowing out into the large kidney basin. I irrigate the wound out and then pack it with diluted chlorine soaked gauze. Just then, the midwife comes into the room.

“Doctuh, come see dis woman, she hemorrhaging plenty.”

I go and see a woman who delivered two hours ago. She is sitting in a pool of blood on the post partum bed. I examine her abdomen. Her uterus is so floppy I can’t distinguish it from her fat lined abdominal wall. I examine inside and pull out two large menstrual pads that the nurse had stuffed in just after delivery.

“What is this?”

“To make the uterus stop bleeding.”

“This will only make the uterus unable to clamp down and will hide the bleeding so you will not recognize it until late. Never do this again!”

I then pull out handfuls of blood clots and dump them on the mattress between the patient’s legs.

“Get some more oxytocin.”

I finally am able to massage the uterus between my internal and external hands. The woman screams in pain and wants to grab my hand to pull it away.

“Don’t touch me! Do you want to bleed to death?! I have to do this to help you. I’m sorry, but you have to let me or the bleeding will not stop.”

The nurse gives the extra dose of oxytocin and I continue to massage the uterus until it quickly firms up into a hard ball the size of a grapefruit and the bleeding stops. I go and quickly wash up with chlorine water. The woman will live.

STABBED

After a day of panic, turning away more people than I probably should of just out of fear of lies, Ebola and the unknown, I settle in Friday night for some reflection. I try to calm my spirit with music and reading, nothing works. Then I finally just fall on my face and sob and sob until my shot nerves are exhausted and calmed. Then I sleep. The next morning, despite the vicious rain storm pounding the hospital, I see things clearer. My spirit is back on track and fear has been pushed back again.

Fortunately, there aren’t too many inpatients, only 17 and I quickly go through rounds. Unfortunately, the boy I gave my rare B negative blood to three days ago passed in the night. His cerebral malaria just overwhelmed his internal organs and they all shut down. The man with the liver abscess that I put a drain in has had 400mL of thick pus come out and he’s feeling a lot better. The boy in traction with the femur fracture greets me with a big smile. Always before he’s been crying and whining and begging for us to let him go home to let a traditional healer have at it. I’ve been stalling and cajoling and threatening the family members. I’ve said that if he leaves against medical advice then I won’t pull out the traction pin and then who will do it? That bought me a couple of days and today, his pain is better and he’s smiling saying he’s willing to stay. I’ve also kept him by promising that the instruments and materials to do the SIGN intramedullary nail are on the way.

I go home and relax. I listen to some talks and some music. I read some more in several of the books I’ve been reading. I take a little nap. Then I get called back to the hospital in the early afternoon. A woman is out in the car. She is four months pregnant and they say she has “no blood.” This sounds initially like some sick deja vu, but I go out and this time she looks tired, but not sick and she’s not bleeding from any where. Her conjunctiva are actual pale, as are her palms and soles. She does have a fever but as I listen for any warning signs from my gut, instinct or still small voice I hear only silence encouraging me to admit her. We get an IV going with a loading dose of Quinine and find two donors as well as an extra bag of O+ blood in the lab fridge.

Gillian and I then go out to a cafe to meet with Cameron, a veteran doc with MSF (Medecins Sans Frontiers/Doctors Without Borders). He fills us in on what they’re doing in the fight against Ebola and the grim reality that it’s still on the upward side of the growth curve. He’s with the Parisian section of MSF and their role is to help the health care institutions, especially the hospitals like ours that are still open, to have better infectious control measures. He gives us a lot of good advice and promises to come with his team to the hospital in a week or so.

I go back just in time for the security to call me about an emergency. A tall man is standing in front of the main entrance clutching a bloody shirt to his neck. His shorts are spattered with large patches of drying blood. His shorter brother is anxious and quickly states that he was stabbed in the neck about half an hour ago. I bring him in, holding pressure myself with a gloved hand. A nurse comes down from the inpatient ward and starts an IV. He appears to be hemodynamically stable, lungs are clear and his conjunctiva are a normal color meaning he probably hasn’t lost too much blood. Once the IV lines are in and fluids running fast, I gently take away the shirt and a pool of dark blood wells up. I quickly put more pressure on with some gauze, directly over the wound and the bleeding instantly stops. I have the nurse’s aide hold pressure while I go tell Gillian. It’s her day off and she’s with her “adopted” baby that she watches every Saturday. She states we can explore it under local anesthesia.

I go back and we have the man walk upstairs. I’ve already got the OR ready, turning on the lights, putting a drape on the OR table, unlocking the anesthesia cabinet, starting the A/C and putting on my hat and mask. We lay the man down and I pump up the bed so it rises to a comfortable height for me. I get the local anesthetic ready, give him some Diazepam and then take off the gauze. Having had about 10 minutes of direct pressure, the bleeding has stopped. Maybe it wasn’t that serious after all. The wound looks shallow and wide, like a glancing blow. I infiltrate the skin with Lidocaine and then prep it with Betadine. Apparently, I’m too rough with my application of the Betadine as the venous bleeding starts pouring out of the wound again. I quickly apply direct pressure again with one hand as I anesthetize the small laceration on his lower sternum that I’d noticed earlier but that was very superficial and barely bleeding.

I drape the neck and sternum with sterile towels, put on sterile gloves and then have the nurse’s aide remove the gauze. The bleeding has stopped again. I raise the lower skin margin with forceps and see a decent sized superficial vein running along the platysma muscle that was lacerated but is currently not bleeding. I do a figure of eight stitch around it to make sure it doesn’t re-bleed then close the subcutaneous tissues and skin with running sutures. I close the sternal wound after irrigating thoroughly and exploring it to find it goes down to the sternum but didn’t damage it. I’m about done with the man shows me his right thumb which also has a 2 cm knife wound on it that I suture.

I’m cleaning up when I notice crepitus under the skin over his left upper chest. Could the knife have gone down and punctured his left lung? I don’t have x-ray but I have the nurse’s aide bring me a stethoscope. He sounds like the breath sounds are equal on both sides. Also, his O2 sats have remained 99% on room air the whole time and he’s been breathing easily. If it is a pneumothorax, it’s small and asymptomatic so I elect not to put in a chest tube.

I then go and Skype for over an hour with my family and enjoy watching my kids run around and play and act silly.

The next morning, Sunday, I awake with a bit of a panic. What if the man got worse overnight and no one noticed? I get up, even though I’m exhausted and it’s supposed to be my day off and go up to the hospital. I go in and see the man lying comfortably in the bed. He’s breathing normally and his lungs still sound symmetric and clear. I breath a sigh of relief and go home, ready for my day off.

DECEPTION

Once again I find myself ignoring my initial instinct and letting myself be convinced by a good story.

As usual, the security guard calls me outside. “Emergency in de car,” he says. I walk outside, pulling on gloves with a snap as I go. The woman is lying in the back seat of a beat up yellow taxi with 5-6 family members crowded around all eager to tell me the “story.” I glance in and see a very critically ill patient with labored breathing and semi-conscious, her head flopped back on the seat being held by a female relative.

As I piece together the story from the different people all trying to talk at once she had malaria 10 days ago which was treated with a three day course of Artemether/Lumafantrine, a common first-line therapy. Then four days ago she had a miscarriage and bled heavily that evening. Yesterday, she went into the Benson Hospital where a doctor told them she needed an emergency D&C. The father paid the $US 200 and the procedure was done. She stopped bleeding afterwards. Today, however, her breathing got heavier and she started to fade in and out of consciousness. They were told by the doctor she needed a blood transfusion and that their lab couldn’t do it and they needed to come to Cooper SDA Hospital.

In the back of my mind a still small voice is trying to whisper “where’s the referral slip?” but that quickly gets suppressed by the good story I’ve just heard. How could they make all that up? I ask the typical screening questions about vomiting, fever, diarrhea, etc. and they all adamantly shake their heads “No, she doesn’t have any of that.” So I motion them to bring her in. She kind of stumbles up the steps, supported between two relatives. I have her wash her hands and I see her kind of slump as they now drag her through the door, past the benches in the waiting room and into the first exam room on the left.

As they lay her on the exam table, she starts to seize and then stops breathing. The family starts to wail immediately and I roughly push them away shouting “Let me do my job, will you?” and I start doing CPR, half-heartedly I admit. But I then stop and check and she does have a pulse, albeit a weak one. So I keep pushing on her chest to force air in and out of her lungs. Not deep and rapid like compressions of the heart, but enough to get some air movement. I start calling for nursing help and they struggle to get an IV. I figure if we can just get some IV fluids in her and then some blood maybe we can save her.

All along her arms are deep purple bruises. It wants to set off some alarm bells in my head, but I quickly silence them and keep up the resuscitation efforts. We pull the bed away from the table so the nurses can look for IVs on both arms. I then have one of them take over chest compressions while I search for a femoral vein. I find it but have to hold it specifically in position or it stops. I get a dose of adrenaline in and then it moves and stops working. But her heart is better now and she’s having some sketchy spontaneous breathing efforts.

I’m calling for oxygen. At some point, Gillian shows up after finishing an appendectomy upstairs. The oxygen tank is missing the handle to open it. They run to get another one. A nurse’s aide, Habakuk, finally finds a small IV and we start running in some fluids. The lab tech has now arrived and there are two new nurses as we have passed change of shift. I think maybe she’s still bleeding from her miscarriage so I order some oxytocin to be given intramuscularly. We’ve finally got oxygen going and she’s breathing on her own with a good pulse. Two bags of blood are available and the first one is almost in.

“Bring in a family member,” I ask a nurse. Just as the sister walks in the door the patient seizes again and stops breathing. “Get her out of here!” I point to the sister and we restart our efforts. Finally, we succeed in getting her breathing and oxygenating well with a strong heartbeat and pulses. I call in the father. He is overjoyed and thanks us profusely. I’m happy. This is why we still do this CPR stuff, because sometimes it actually works. The second bag of blood is in, a recheck of her hemoglobin finds a stable 9 g/dl. We’ve been working on her for two hours. The sister comes back in. We start talking. I ask some more questions. Suddenly, she starts talking about how she’s been vomiting and having watery diarrhea and fevers at home. I nervously look at the patients arms with the huge bruises and then notice all the IV puncture sites still oozing. I pick her her wrap and see that there’s oozing from where we gave her the shot.

I go ballistic. “What are you trying to do, get us all killed?” I scream. “Lies, all lies! Why didn’t you tell us the truth.”

The sister and father weakly try to give excuses “We didn’t know, I wasn’t there, etc.”

“Everyone was there when you were denying vomiting, diarrhea, and fever…don’t lie! It won’t help you or her! Take her out now!” I’m sure she has Ebola! I’m starting to freak. I’m exhausted and feel like I’ve now put how many staff at risk? How could I ignore my instinct? If a staff member dies of Ebola, I’m responsible. I feel like for the first time I’ve had a serious exposure and my stomach is in knots. I rush home, take a shower and soak my scrubs in a red, hospital smelling disinfectant I find on a shelf in the shower.

The patient dies almost immediately on being carried out the hospital doors. The father comes back to the steel bars now keeping him out.

“You did your best. I’ll come back tomorrow to settle accounts on our deposit.”

I want to scream, “Is that all you can say after lying and exposing us all to a deadly plague!”

My sleep is troubled by fearful dreams and I wake up with my heart beating out of my chest and it still dark outside. I kneel with my face to the floor and sob out as I cry to God for mercy, mostly for the staff and also that he will spare my life.

INTERROGATION

I feel like I’m in some movie.

I’ve been called over by the Department of Defense to testify. A uniformed woman leads the way as the hospital’s van transports Dr. Sonii and I to the walled compound of the military. We walk past a seriously black and shiny SUV, coming out of the pouring rain into the lobby and past the camouflaged guards. Down a couple hallways, past large photos of soldiers doing humanitarian tasks like helping out in schools, battling floods, etc and up to a double door with a full length mirror to the right. Above the mirror it says “watch your uniform”. Our escort pauses briefly to make sure her uniform is up to standard and we walk in, me more than a little embarrassed in my jeans and t-shirt, which is the best clothes I brought to Liberia. Why didn’t I think to plan about coming in to a room of well-dressed civilians and military types? Silly me.

A tall man with a big smile welcomes us and asks us to take a seat. The rest of the men in the room are more somber and intimidating. The man, who appears to be the head of the commission, informs me that they’d like me to give a statement about the patient we operated on a few Fridays ago with the alleged gun shot wound.

First I am called to the middle of the U-shaped formation of tables. There is a single chair there facing the chief who is flanked by two other well-dressed men not in uniform. I’m asked if I will take an oath. I agree and am motioned over to my left where a Bible, a Qur’an and another book I don’t take the time to identify lie. I’m asked to choose which I would like to swear on. I briefly think of the Qur’an but place my hand on the Bible instead. I’m informed I can pick it up if I want to and the way it’s said makes me want to, so I do.

The classic formula of “I swear to tell the truth, the whole truth and nothing but the truth so help me God” is read out to me in brief spurts which I am told to repeat, which I do. I then place the Bible down and return to my small chair in the midst of important men.

I’m told to begin and I start describing how I first saw the young man, what I observed and then what kind of surgery we did and once again what I observed. The man to the left of the chief is smiling and nodding and encouraging me so I start to loosen up and talk mostly to him. The man to the right of the chief keeps a scowl on his face the whole time. When I’m done, the chief smiles again, warmly and thanks me heartily. In fact, everyone is thanking me. I kind of like that about the Liberians. I’m then taken to an empty office and asked to write out my statement, similar to what I just said. I finish quickly, but then think I must have put the wrong date. Surely it can’t be the 22nd, it has to have been longer then that, so I try to call Gillian to confirm but I can’t get through. So I just change it to the 15th (later I learn it really was the 22nd, but so much has happened in that time it’s seemed like a lot longer).

I’m brought back in and they laugh and joke about if they’ll be able to read my doctor’s writing. I’m starting to feel really comfortable. The man does have some difficulty and so another man goes over to help. They finally get through it with me having to decipher some of my own writing in the process. Then they ask a few questions such as the following:

“Have you ever removed a bullet form someone?”

“No.”

“Was the colon touched?”

“Just the rectum which is the last part of the colon.”

“You mention that the holes in the intestines were caused by a projectile such as a bullet, have you dealt with ballistics before?”

“Yes, I’ve treated gun shot wounds, just never taken a bullet out as it’s not always necessary. Can I draw on the board?”

They agree and I trace out the digestive tract and point out why I think it was a bullet and how that could pierce the skin, go through the small intestines and enter the rectum and why the shape and size of the holes makes me confident it was a bullet because a knife or an arrow would leave a different type of wound.

Now they are really happy and say that’s enough and “thank you’s” come from all around and repeatedly. I’m kind of embarrassed about how thankful they are, and yet it’s nice too.

We go back out in the rain to the van and drive back to the hospital. The boy who had been shot is released that same day to go home, having recovered completely.

EBOLA-ICULOUS

We’ve been seeing so many kids with severe malaria and anemia that I let my guard down. Because of the Ebola epidemic, parents are waiting till the last minute to bring in their children. Fortunately, so far we’ve been able to save most of them with blood transfusions and Quinine drips. So, when I go out to see this 10 year old girl, in my mind I’ve already decided she has malaria. I go through the motions of asking all the screening questions and she sounds like she has malaria: headache, fever, loss of appetite, no vomiting or diarrhea. Instinctively, I check her eyelids to see if she has anemia like everyone else. Most of the kids have had very pale palpebral conjunctiva, but this girl’s are bright red. It sets of warning bells in my head, but I ignore my instinct. It’s probably malaria I tell myself. I don’t want to send her to certain death of malaria by refusing her, so I let her come in against my gut feeling.

I hope the mistake doesn’t turn out to be too costly.

We bring her into the ER and the nurses find an IV. As the nurse is taping the catheter in place she asks me if I’ve noticed the rash. She has a raised rash all over her arms and trunk and face. It doesn’t look like anything I’ve seen before. I just gave her an Artemether shot in her muscle. There was no bleeding. Now I look back and some blood is pooling over the injection site. Jeff from the lab is right there. I ask him to go get a rapid malaria test and do it here at bedside. Meanwhile, we start the Quinine drip. I look again at her conjunctiva…they really are more red then normal. I’m starting to get a suspicious feeling. Sure enough the malaria smear is normal. And where Jeff pricked her finger is also bleeding more than normal. And she has a high fever. There’s a reason they call it Ebola Hemorrhagic fever. Of all the suspicious cases we’ve had here, this is the first I’ve seen with bleeding. Of all the cases, this has to be the most suspicious for Ebola I’ve seen yet.

I call in the mother. She’s dressed in some kind of police or security uniform. I explain that I’m suspicious of Ebola and they should take her immediately to either of the Ebola Centers: JFK government hospital or EWLA Hospital where Doctors Without Borders has set up shop. They leave immediately. We wash down everything and through away anything that we may have touched. I run home, take a shower and wash my scrubs and put on new clothes. I feel this is my closest contact with Ebola yet.

A few hours later, the mother is back with the girl in the back of the car.

“Dey look at de IV and say to take her back to where she bein’ treated…”

Are you kidding me!? It turns out that neither place would take her. Both are overrun. Dr. Martin comes out and tries to call some colleagues who work at the Ebola treatment centers. No one is picking up. There just aren’t enough isolation beds or tents or personnel or supplies or anything. They are turning away patients left and right. But to not even test? And to use the excuse that she is being treated elsewhere and turn her away because we left the IV in to help them out so they could treat her without the risks of starting another IV?

I admit, some NON-MISSIONARY WORDS not only came to mind, but a few slipped out at high volume as being the only words worthy of expressing my feelings about the ridiculousness of the situation.

I do what I should’ve done before: I write out a referral explaining why we think she has Ebola. I tell them to go back and persist and don’t let themselves be turned away. Dr. Martin also suggests a third hospital, Redemption which is supposed to be opening or already open as an Ebola treatment center.

Obviously—and rightfully so—the family is frustrated and turns away sorrowfully. Who knows? No one probably ever will. She will probably die without us ever knowing if she had Ebola or some treatable disease. If there were only the resources to isolate all the suspicious cases and test them. Then if they are negative, get them referred to a hospital such as our own which is treating non-Ebola cases and get them the malaria or other treatment they need. And if they have Ebola, there should be personnel, protective gear and IV fluids to treat them, not to mention the availability of experimental drugs known to help certain Ebola patients.

Instead, chaos, fear, suspicion, lies and death abounds in Liberia.

SCARS

A large Muslim woman with a head scarf and long sleeved dress with Middle Eastern patterned embroidery comes into my office. I can tell she is nervous. I’ve sent her to be tested because she is the third wife of a man I just tested and found to be HIV+.

She sits in the chair across the desk, her hands folded in her lap as she anxiously bites her lower lip.

“I have your test results and the HIV test is negative.”

The woman starts to cry and wail.

“Jus’ counsel me, doctuh…tell me de trute.”

“Ma’am, calm down. You don’t have HIV…”

She falls off the chair and starts writhing on the ground wailing. She looks up at me with bleary eyes as tears roll down her cheeks. “Oh! Oh! OH!” She slowly pulls herself together and sits back on the chair.

“Ma’am I don’t think you understood. The test is ok, it’s good. You don’t have the disease…”

“Oh tank God. Tank God. Look at dis…” And she lifts up her sleeve to reveal scars on her forearm and a massive, stellate scar on the back of her upper arm. “I a war victim. Dey torture’ me. I shounnah be alive. Look at dis…”

She lifts up her skirt and shows me an equally enormous scar on her thigh. She raises her hands and eyes to heaven. “God is great! I not wanna marry dis man. My mudduh force me. He own many stores, he rich. He take care of my mudduh and brudduh. I ha’ no fadduh. But I de tird wife o’ dis man. I knew it wasna mah destiny.”

She falls on her face on the ground reciting some words in Arabic “Allahu Akbar…la ila illa Al-Lah” then she gets up. “I knew when they wan’ a take ma blood. I knew the test woul’ be positive o’ negative. So I went to pray and I pray to God. Now I know God love me. I know he love me. I will be free.” And she continues to cry.

“Tank you, doctuh and tank God. He has saved me. I will go back to ma family now. He save me fra’ de war and He save me fra’ dis disease. Allahu akbar. Doctuh, may God protect you and not let anyting’ hurt you. All dis Ebola, may God not let it near you. Tank you. You ha’ been straight wid me. I know God loves me.”

As she walks out I call out to her, “As salaam aleikum…”

She turns and smiles, “Wa aleikum as salaam doctuh.”

NO BLOOD

“He got no blood!” The response is becoming familiar. When I ask the different parents of the floppy children they keep bringing in, that seems to be the most common chief complaint.

I’m sitting in church Saturday morning. We’ve just finished the Bible Study and now the choir is warming up the crowd. It’s Women’s Ministries weekend and the ladies are taking charge with enthusiasm. The choir sways down the aisles singing a song of welcome as they march up to the raised choir loft about 20 feet above where I’m sitting. The service moves along with many selections by the all female choir. On the platform, it’s all women. A lady has just finished giving her testimony about fleeing Liberia to Ivory Coast during the war and how she swore she was going to learn French, change her citizenship and never go back to Liberia….until a friend called and asked her to come help this new organization some Liberians were forming to help the young girl child soldiers to recover from their traumas after the war finished. So she prayed about it and has been helping women and children suffering from violence and abuse ever since in her organization’s safe house.

The choir is just about to let it rip again when I hear an ambulance on the street outside. I have a feeling about where it’s going so I pull my phone out of my pocket in anticipation of the call I expect to come. Sure enough, in the middle of the choir’s number, I get a call. I quickly leave my front row seat, duck under the bar across the open door and outside. I can barely hear over the roar of the church’s generator, but I do catch the word “emergency” so I say I’ll be right there and walk around the corner and up the half block to the Cooper SDA Hospital.

An ambulance is outside the main doors. Inside is a boy about 10 years old who’s actively seizing. I ask a couple brief questions, get the reply of “no blood,” verify by looking at his white palpebral conjunctiva and have security bring the child in. I call for a nurse from the inpatient ward since outpatient is closed on Saturdays and she quickly establishes an IV. I give him some glucose and then a loading dose of Quinine, have the nurse inject him with Artemether in his thigh muscle, give him an antibiotic and, since the lab is fortunately here, have them do a hemoglobin and type and cross for a transfusion. He’s still seizing so I give him so Diazepam in small increments until I’ve given him 20mg. Finally, he stops convulsing and is fortunately still breathing.

He has a hemoglobin of 3 but the good news is that his older brother also has O+ blood and willingly donates. The lab tech only fills the adult blood bag about ½ full. I come in just in time to see her finishing up and tell her to take another pediatric bag from the brother so the kid will get a full adult bag dose of 450ml. It turns out to be a good thing the blood is donated in two separate bags.

I soon get called for another child. This one is about 3-4 years old and also has “no blood.” He is floppy, and appears to be intermittently seizing as well since the mom has put a tongue depressor wrapped in gauze between his teeth to keep him from biting his tongue. He looks like death warmed over. The mom is singing sweetly songs about Jesus as she intermittently prays in a loud voice, mostly repeating the name of Jesus. We get an IV in him, start the Quinine loading dose, give him an Artemether shot and have the lab tech type and cross match his blood. He also has O+ but he looks like he may pass before we can test the child’s young father. I grab the second bag of blood still waiting for the first child and get it running in. They can replace it later with another donor. We take him upstairs in 15 minutes as he is already doing better with the blood. He is no longer seizing and is actually awake.

The first kid, though, continues to intermittently convulse and so I have to keep giving him Diazepam. We keep him in the ER.

Another boy comes in, referred from an outside clinic where they did a hemoglobin since he had “no blood” and found it to be a little over 5. He seems alert, though, and not too pale. I start a quinine drip, give Artemether and send him upstairs. The on call lab tech has now left, so I wait for the evening tech who comes in at five and confirms that his hemoglobin is 7 so we don’t transfuse.

Meanwhile, the next bag of blood is ready for our still occasionally seizing 10 year old so we get that running and send him upstairs where he gets some more Diazepam. In less than 12 hours he’s gotten over 50mg of Diazepam, enough to stop me breathing for sure but he still isn’t completely convulsion free. I hear the mom talking to a relative on the phone: “I put my faith in God…”

That’s all we can do sometimes.

Later that evening, I check up on the Pediatric ward. The girl from yesterday, who also came in almost dead with “no blood” and a hemoglobin of 2.3 is lying comfortably in her bed. She’s been awake and eating all day, looking again like the cute little girl she is. Her second transfusing is running since the first one only got her hemoglobin up to 5. Her mother is just finishing up her prayers, bowing towards Mecca. She gets up, looks at her daughter and smiles.

EYES

I can start to see it in their eyes. They just have that look. Maybe I’m starting to imagine things in my paranoia, but I’m beginning to think I can recognize an Ebola patient on sight. Maybe it’s my intuition. Maybe it’s that still small voice I’ve been praying helps me out. Maybe I’m imagining it. The eyes kind of bulge out. They have a sort of blank stare. The inside of the eyelids are more red than normal. The surface of the eyes, the white part, the scleral conjunctiva seems to be a little edematous and not quite the right color: not quite yellow as in jaundice, but not quite white either. It’s subtle.

Ambulances are starting to pull up more regularly. The first of the day, I find with it’s back towards me, doors swung open and a well dressed man with some kind of badge inside telling me to come and look. I first find the ambulance driver, who I think is the same one who brought the already dead body the other day.

“He’s alive this time, right?”

The driver laughs nervously, and nods. I turn to the heavyset woman who seems to be the spokesperson for the family.

“What’s happening?”

“He walkin’ along an’ he just start convulsin’. He bite his tongue and his arms shakin’ like dis.” She gives me a visual of arms pumping up and down.

“How long did it last?”

“An hour.”

“Did he come to…was he conscious afterwards, or sleepy?”

“He not wake up.”

I climb up the rear step of the ambulance and gingerly crawl in, trying not to touch anything. With my gloved hand I pull down his eyelid. He has a blank stare and is in a coma. I can’t see his pupils. His eyes seem slightly edematous. I open is mouth…all his teeth and tongue are covered with old and new blood, like catching the look of a hyena in your spotlight as he lifts his bloody mouth from his prey and laughs at you. I instinctively pull back. I backstep out of the ambulance.

“You’re not telling me the full truth,” I inform the large woman and the well-dressed man as I peel off my gloves and go to wash my hands and arms in chlorine water. “Take him to EWLA Hospital to see Doctors Without Borders. He needs to be tested for Ebola.”

I go inside to check on the two patients I’ve admitted earlier. One elderly man is having an acute exacerbation of his heart failure. His lung bases are filled with fluid and his lower legs are tense and shiny with pitting edema. He has gotten his first dose of Lasix but the foley hasn’t been placed yet. It’s the same nurse who didn’t give most of the medicine to our administrator’s husband the first day he was hospitalized. I go off on him and he scurries to put in the foley and reports back to me that there is 700mL in the bag.

The second man has probably been having a heart attack for the last 3 days. It certainly sounds like typical chest pain which now occurs even at rest. I gave him an aspirin when he walked in the door. Without an EKG or any other way to treat a heart attack definitively, I admit him for accelerated medical management. His pain is a little better after a shot of Pentazocine, the closest thing we have to morphine.

I go back downstairs and the ambulance is still there and the fat woman and distinguished man are inside. I’m getting the idea the man thinks that just because he’s someone important he can make us take this patient. I ask them to please go outside. There is resistance but I insist and finally the grudgingly go outside. The man is obviously upset, muttering something about being in law enforcement or something. I have to stand at the door and keep insisting before they finally drive off.

Paul, the PA, is falling behind in the screening process. There is a crowd inside that’s already been screened, but another, even larger crowd waits outside. I start helping him screen patients. Mrs. Wennie motions me over into her office with her hand.

“Can I speak wid you a minute, doctuh?” I go into her office, right next to the pharmacy off the waiting room.

“Yeah, what is it?”

She shows me a slip of paper with a last name and then two different first names separated by an “or”. Underneath is written “yellow shirt, black jacket and blue jeans”.

“Dat man sittin’ outside, over der…” She points to the right side of the courtyard. “…someone call and tell me he suspicious for Ebola. One o’ his relatives died o’ Ebola.”

I go out and ask the man some questions. It sounds like he has malaria. He doesn’t look sick. But it could be early Ebola. I prescribe him some medicine, find out how much it will cost and take his $US 15 inside to pay for his consultation fee and meds. I bring them out to him, explain how to take them and then warn him if he doesn’t get better in a couple days to go get tested for Ebola.

After lunch and some more screening, I start to see patients since Dr. Martin is falling behind with the sheer number of cases. I see a young boy with a hernia and a middle aged man with a huge inguinal scrotal hernia that I schedule for surgery tomorrow.

I’m up on the wards, seeing how the two patients I admitted earlier are doing. The man with heart failure has now put out a total of 1900mL of clear urine after two doses of Lasix. The man with chest pain is lying comfortably in bed. I go to the nurses station and we hear another ambulance pull up. I go down and out to investigate.

This ambulance is parked parallel to the hospital with the side doors open. The patient is sitting in the paramedics chair and quickly gets up and drops his pants to show me why he came. He has a large mass in his right scrotum extending up into his inguinal canal. He states it came out earlier today and is getting more painful. He vomited once. No fever or diarrhea or other problems. I have him come in. I call down the nurses and Gillian comes as well. The nurses start an IV while Gillian dons gloves and starts gently squeezing the mass to get the air out of the intestines so the hernia will reduce. I give the man Diazepam and Ketamine to help relax him and relieve his pain. He tenses up, his arms rigid, a typical Ketamine reaction. I give him more Valium and he relaxes just as Gillian pops the intestines back inside the abdomen. He has no one with him and is out cold from the meds, so we leave him in the exam room, hoping family will show up or he can contact someone when he wakes up.

Gillian meanwhile has gone out to see another patient. I’m sitting him my office and she comes in.

“I’d like you to see this patient. The woman says she is 6 months pregnant, doesn’t feel the baby move, has fever and diarrhea and vomiting yesterday but none today. Her conjunctiva are very red though. Supposedly she got 5 days of malaria treatment already and her normal hospital, JFK, refused her because they don’t take patients at night.”

I go out and look in the back seat of the car. The woman is semiconscious, her eyes kind of swollen with an abnormal color to the white part. I peel down her eyelid and the conjunctiva are really, really red. I suddenly get inspiration.

“How many times did you go to toilet today?”

“Two times.”

“How many times did you vomit today?”

“Four times.”

“She is very suspicious for Ebola. We cannot take her. She needs to go to EWLA Hospital and see Doctors Without Borders and get tested for Ebola.”

The woman next to the patient speaks up “But she pregnant…she don’ ha’ Ebola…”

“Pregnancy is not a vaccine against Ebola. She needs to be tested. We cannot take her.” And I walk away.

THANKS

I’ve just come back from another, mostly fruitless attempt to surf here in Liberia. I was outside in the car by 5:50AM, waiting for the curfew to lift before racing through the streets of Monrovia to Oddny Beach. The surf was still big and rough and I couldn’t even get past the break. After finally succumbing to exhaustion, I caught some white water in which formed back up and allowed me a few brief seconds of actual stand up surfing before I was back on the beach. I got a call from the nursing station just after getting out saying that our patient with Alcohol withdrawal syndrome just passed. Their way of phrasing it is “There’s no vital signs.”

So, I’ve just pulled up in front of the gate to the hospital compound. I turn off the car and walk towards the main entrance so I can go through and open the gate from inside. I see the young man who’s been staying with our administrator, Mrs. Carter’s husband while he’s been hospitalized the last week.

“Morning, how are things?” I ask.

“Fine,” he says with a half smile.

I walk past but here another voice behind me.

“Doctor…” I turn and see another relative of Mrs. Carter’s getting out of the car I just walked past.

“Yes…?”

“I jus’ wanna tank you fo’ yo’ efforts for de ol’ man.”

“Ok, no problem…” I get a sinking suspicion that I confirm in the hospital later: Mr. Carter died overnight.

I go home, take a cold bucket shower and go into the hospital. As I open the door to my office I see another young man who’s been faithfully by the side of his aging diabetic father who came in with severe anemia and cerebral malaria. We’d transfused him several times and had been treating him for several days with not much improvement. The man stops me.

“Tanks, doc, yo’ done yo’ best fo’ ma fadduh. He was jus’ his time. Tanks fo’ everyting…” And I know he would’ve shaken my hand if Ebola hadn’t made that ancient ritual suddenly obsolete.

So death continues to stalk us: not just Ebola, but those patients who wait till the last minute to come in because they are afraid of going to the hospital where they are afraid they might catch Ebola. Yet, in spite of it all, the thankful, generous spirit of the Liberians shines through.

SUDDEN

The man is complaining of abdominal pain like pretty much everyone who comes in to the hospital. I often don’t even examine them. For some reason, this time, I put on gloves and have him get up on the exam table. He has a palpable mass in the upper center (epigastrum) of his abdomen. I order an ultrasound. Dr. Martin is in his office, which also happens to be where the ultrasound is, so after the man pays, I take him into Dr. Martin’s office and ask him if he’ll do the scan. He pleasantly agrees. A few minutes later he comes out and gets me to come in. He shows me a well-circumscribed lesion with fluid in it.

“He has an amebic liver abscess here in the left lobe,” Dr. Martin moves the probe around and I clearly see normal liver and then another, smaller fluid collection. “Here’s a second, smaller one in the right lobe.”

Dr. Martin goes to look for a large bore spinal needle and a syringe and a few other things to drain the large abscess using the ultrasound as a guide. He comes back and hasn’t been able to locate a large bore spinal needle. We decide to hospitalize him, put him on IV Flagyl to treat the amebas and try again tomorrow when staff are around to help us find the materials we need.

The next day is really busy, lots of OB patients, lots of out-patients, Dr. Martin does a c-section, etc. So it’s not until the evening that Gillian has a chance to go drain the man’s liver abscess. I’m making supper when she comes back.

“That’s not a liver abscess! That’s a huge abdominal aortic aneurysm!”

“Are you sure? I swore I saw a liver abscess.”

“Let’s go look.”

“Yeah. Let’s.”

We go up and I take the ultrasound and jumping out obviously is an enlarged, calcified, pulsating mass: abdominal and thoracic aortic aneurysm. Not good. There’s no hospital in Liberia equipped to do it. The closest possible place, according to Gillian, is probably Nigeria. Not that they really want to take anyone from Liberia since it was a Liberian who brought Ebola to Nigeria. We explain to the patient and he assures us his employers will be able to arrange things. We tell him to try and relax and we go back to eat supper.

After supper, I go to write emails and Skype with my family. A midwife pokes her head in my office door.

“De patient in N3 goin’ into shock.”

I’m trying to think which OB patient it could be since the midwife is the one getting me. I arrive at the door of room N3 and see it’s our patient with the aneurysm. He is contorting in pain, his legs lifted high up and rocking back and forth. He is moaning and saying “I gonna die! I gonna die!” I try to calm him down as I ask the nurses to bring Diazepam. Getting anxious and increasing his blood pressure will not be good for his aneurysm.

“What is his blood pressure?”

“It wa’ 160/100, den it quickly drop to 80/40 and now I don’ find anyting, doc.” Calmly says the nurse in green scrubs and plastic apron, looking up with a stethoscope still in his ears and the hand pump on the blood pressure cuff still in his hand.

I feel his carotid pulse: nothing. He’s gasping for air. The gasps get less and less frequent as his contortions slow and then stop. His aneurysm has burst, causing him to bleed out in a matter of minutes right before our eyes. It’s an eery and helpless feeling. He has no family with him. One of the nurses takes his cell phone and starts calling numbers trying to find a relative.

I pull of my gloves and snap them into the trash can and go home.

PIT

Today is a holiday in Liberia.  Not that anyone feels like celebrating much with
the Ebola crisis projected to last 6-9 more months. As Mitchell from accounting
tells me later when I ask how was his holiday:

“Boring.  We cannot do anyting.  Everyone afraid to go out.  Before we go see
friends, ha’ some ice cream, but wid dis Ebola ting, we are afraid to go out.”

I admit, I overslept this morning.  I was exhausted.  Gillian has mostly
finished rounds when I get up to the floor. I go see Mr. Carter, the husband of
our administrator.  He has not improved.  When I look at the chart, he has only
received one of the 6 bottles of IV fluids he should have received since
admission yesterday.  And his quinine was only given twice instead of three
times.  I call the nurse in and she quickly starts another IV and tries to make
up for lost time.

The midwife comes up to talk to me about a patient who has been in active labor
since yesterday.  The midwife on yesterday didn’t inform either Gillian or I
that the patient wasn’t progressing even though I was in there for another
delivery and remember seeing the patient already there.  She is now at only 5cm
but has just broken her bag of water.  I tell the midwife we will see if this
spontaneous rupture of membranes can get things going and tell her to inform me
if there is no cervical change in the next couple hours.

Gillian has found a surfboard for me and we make lunch and get ready to go to
the beach.  The sun is finally shining, but there is some wind.  We’ll see how
the surf is.  Just then the midwife comes back.

“Da baby’s heartbeat is 168 per minute.”

“That’s ok, as long as it doesn’t go low.”

“She not progressing.  You need to come see her.”

“Ok.”  I follow the midwife up the two flights of stairs and then down the
stairs from the wards into the labor and delivery suite next to the OR.

I check the woman and she is dilated at 7-8 cm.  The midwife is pointing to the
partogramme and saying we need to intervene.  I really don’t want to do a
c-section.

“How are her contractions?”

“Good, doc.”

I put my hand on the patient’s abdomen.  She is having regular contractions but
not strong enough and they are short lived, lasting only 10-15 seconds.

“Let’s start her on Pit,” I say.  “Put 20 units of Oxytocin in 500ml of
Ringers.”  The midwife sets up the drip and I start it slow and continue to
monitor the woman’s contractions with my hand on her belly.  Within a few
minutes the contractions are getting stronger and lasting longer, but still with
good relaxation in between.  Within 15 minutes the woman exclaims, “I want to
push!”

I check her and the infant’s head has come down and she is now completely
dilated except for an anterior cervical lip that I reduce manually with the next
contraction.  She starts pushing and in another 15 minutes has delivered a
strong boy with a healthy cry screaming his lungs out.

I wash up and head home.  We get in the Gillian’s car with her “adopted” baby.
He was premature and the mother initially abandoned him for several days.
Gillian cared for him and then the mother came back.  Gillian maintains contact
with the mother and baby and takes him from time to time.  She’s had him since
yesterday.  We drive down the main highway in Monrovia which parallels the
beach.  We have been told there is surf at “A La Lagune” resort.  We follow the
signs but find, not surprisingly, a lagoon with no way to the beach.  We ask for
directions to the beach and follow a dirt road to a cement block making business
right on the beach.  Trash is piled high and I have to pick my way through swamp
and garbage to a rocky beach with a tiny stretch of sand.  Plastic waste is
strewn everywhere and a young child is just finishing depositing a poop log
worthy of a much bigger man.  The waves are crazy: a huge swell tossed and
turned by a fierce wind has created a turbulent chop that is positively
frightening.

We go back to the main road and drive south towards the airport.  Gillian says
there’s supposed to be another good spot near a resort that begins with a “K”.
I see a sign that might be something so we turn down a paved road that ends on
the beach near a nice hotel.  The sand is clean and the waves are still crazy
even here.  But I’m desperate to surf.  I choose a place where it’s just choppy
but the angle of the land makes the waves not come in too strong.  I paddle out.
It’s intimidating going up and down and sideways over these huge swells.
Finally, I’m out a long ways from shore.  I paddle over to where the waves are
breaking.  A huge wave piles above me.  I turn and paddle and get caught by a
huge surge.  I get to my feet but there is no wax on the board and my front foot
slips off.  I get tumbled a bit and get back on just in time to catch the next
wave.  They are all breaking and reforming three times so I catch the next two
sections in and jump off right on the beach.  I’m done.

MORE DEATH

 Gillian’s taking the day off.  She hasn’t had one in a long time.  So I start
with rounds on the inpatient ward.  One of the first patients I see doesn’t look
so good.  She came in for an incomplete spontaneous abortion and had a D&C two
days ago.  She’s not bleeding now, but had severe anemia.  Unfortunately, she’s
only got one unit of blood.  We have no blood bank and depend on family members
to donate.  No one has come for her.  She’s breathing shallow and fast, but is
awake and alert.  She complains of upper abdominal pain.  I put on gloves and
palpate an enormous, tender liver extending all the way down to her belly
button.  Not a good sign.  She’s already on Malaria treatment so I add an
antibiotic to cover typhoid and continue the IV fluids and encourage her to
drink a lot of water.

There are 24 patients on the inpatient service.  Many of the postpartum women I
send home, including the Muslim woman who just delivered twins yesterday
morning.  She gets her shot of anti-D Immunoglobulin for having O- blood type
and thanks me profusely, as does her husband.  “Al hamdullilah!” I say, much to
their surprise and pleasure.

I also send home the young boy who had come in Thursday on death’s door.  He is
now fully active and eating without fever or anemia.  Little Moses is still
hanging around to get his bladder intermittently catheterized since we have no
balloon catheters small enough for his premie size urethra.  I spend time with a
fat hypertensive Muslim man with malaria explaining how to control and even cure
his “preshuh” with diet.  He is very receptive.  “As salaam alekum,” I say in
parting as the reply echoes in my ears “…wa alekum as salaam!”

The boy we operated on Friday is doing better, except for periodically pulling
on his tubes.  Today, he’s disconnected his chest tube from the water seal
again.  I reinsert it and try and reason with him.  Otherwise, he is improving
nicely, with clear drainage from his abdominal drain, but no air or stool in his
colostomy bag yet.

I go down to the office.  Dr. Sonni passes by and we discuss how to stream line
the Ebola screening process for new patients.  We decide that the PA’s should
screen.  We call in Timothy, the PA on duty, and he quickly grasps the idea.  We
give him a new toy we just got:  a temporal thermometer allowing us to check for
fever without touching the patient.  Very useful for screening for Ebola.

I go for lunch.  After lunch, I get called by the nurse.  “The patient in M1 is
not doing well.”  I go up.  It’s the patient with hepatomegaly.  She is barely
breathing and unconscious.  Her pulse is rapid and thready.  I open up the IV
running with Saline and give her some D50 in case she has hypoglycemia (we have
no way of testing).  I ask the nurse to start another IV which she does quickly.
I raise the IV pole so the fluids can go in rapidly and raise her legs to drain
blood to her head and vital organs. She starts to wake up, mumbles some words,
moves around and then stops breathing.  I check her pulse.  Nothing.  I don’t
bother with CPR since I know that she needs blood and there’s none available so
resuscitation would be useless… and her enlarged liver means many of her other
vital organs are probably shut down.  I shake my head and offer my condolences
to her sister who is there and then I walk out.

A nurse soon calls me out to see two patients just arrived by personal auto.
The first is a sickle cell patient with severe anemia.  He’d been treated for
malaria 4 days ago with 3 days of Artemether injections.  This continues to
affirm my suspicion that Artemether is almost completely useless as a malaria
treatment.  His dad noticed he was very pale today, called his regular doctor at
the ELWA Hospital who said they didn’t have the supplies to do blood
transfusions and referred him to Dr. Martin, our other doc besides Dr. Seton.
Dr. Martin told them he was in a meeting and to come see me.

The boy is 17 years old, thin and very pale all over.  He is very weak,
breathing shallow and semi-conscious.  My heart sinks.  But I have to try.  We
bring him into the consultation room in a wheelchair and I call Jeff in the lab.
He says he’ll be right in.  I go to see the patient in the other car.  She is a
“preshuh” patient who’s been feeling weak for two days.  She is unconscious, but
the family denies any other symptoms, including fever.  I check her mouth and
eyes with a gloved hand for signs of bleeding.  There are none. I feel her
forehead and it feels hot.  I take her temperature: 101.7.  I refer her to the
ELWA Hospital for Ebola testing.  She’s 74 years old and has already had a
previous stroke.  She’s not going to make it.

I go back in and the father of the sickle cell anemia patient calls me over.

“What’s happenin’? He seizin’?”

I go in and find the boy with an occasional agonal gasp, completely unconscious.
“He’s dying…” I blurt.  As the father panics, I put my finger on his carotid
pulse, it’s still strong, but quickly disappears under my touch as he stops
breathing completely.

“I’m sorry, he’s passed…” I gently inform the distraught father.

“No, no, don’t leave me…after all this…no, no, no!” I turn away, my heart broken
by this man’s sorrow and loss, but feeling helpless at the same time.

The nurses come to me five minutes later and say there are fluids coming out of
the boy.  I look in the room and he has urinated all over the floor, as happens
often after death when everything relaxes.  But the nurses are a little worried.
Ebola is on everyone’s mind and we all have a healthy fear of bodily fluids now.
I go get some full body isolation suits, one for the security agent, Otis, and
another for me.  We gown and glove up and then wheel the body out to the waiting
Toyota Forerunner.  We dump the body unceremoniously in the back, not bothering
to arrange it since we want as little contact as possible, even with our yellow
and white full body jumpsuits.  I take a final look at the floppy body, legs
sprawled at weird angles and head bent to allow the back door to close…then I
slam it shut.

I remove my suit.  Otis removes his.  We put them in a red, biohazard bag and
Otis takes it to burn it.  The cleaning team is already spraying everything down
with chlorine water and cleaning up.

I go upstairs.  I’ve just come from checking on three patients apparently I’d
missed during morning rounds when people come up excitedly saying “the
President’s coming! The President’s coming!”  For reasons unknown to me, she is
coming to see one of our patients.  Dark suited, large men come up first and
take up security positions.  Then an entourage of equally suited men and smartly
dressed women come up.  In the middle is a middle aged woman with gray hair,
walking confidently with a straight back, wearing blue jeans and a sweater.
It’s obvious by the looks and mannerisms of all around that this is the
President of Liberia.  Mrs. Carter, our administrator, introduces me and we walk
down to see the patient.  She asks about how he’s doing.  I give her an update
and then she spends a long time talking with the young man’s mother.  Then she
thanks the staff and walks out, chatting with Mrs. Carter who has taken the
initiative to ask for government help in procuring some of the supplies we need
desperately in order to stay open.  The President thanks us for staying open
during the crises and encourages us to continue.

I go home, eat leftover rice and curry and crash into bed.

PUSHY

I don’t know if I’m just getting more stressed and sensitive (which is
definitely true in a sense) or if everyone else is also really starting to feel
the pressure, but patients seem more on edge, more pushy, more panicky.  As
usual, I go outside the hospital early to screen patients.  There are more and
more of them everyday.  As people have been afraid to come in to the hospital,
they are waiting till the last minute and come in on death’s door.  We have many
patients who are dead on arrival and many others who die shortly after
admission.  In all my 10 years in Africa I haven’t seen death this frequently
except the one Saturday back in Chad when there was a small war between the
agriculturalists and the cattle herders.  So many people here have severe
hypertension, and at a young age.  Strokes come in, several a day, and often in
a coma.  They usually die in a few days.

Now, people are impatient. They are clambering to be seen.  They are annoyed and
yelling, not the majority of course, but enough to set my already frayed nerves
on edge.  The security personnel leave their posts on innocent missions and
people take advantage to go in without washing their hands in chlorine water or
being screened.  Then when I try to get them to come out, some resist and argue.
I can feel my stomach in a knot, squeezing and making it harder to breathe.

An ambulance pulls up.  It looks just like the ones we just shipped to Chad.
The driver says they have a man who was walking in town and fell down with a
seizure.  He opens the back door to the ambulance and inside are two EMTs
covered from head to toe in protective gear, looking like they are about to
handle radioactive material.

“What’s happening?” I ask.

“He fell down and seized.  He ha’ preshuh.”

“What is his pressure?”

“Don’ know.”

“Do you have a blood pressure cuff?”

“No.”

I bring them one and hand it in with a gloved hand.  They take his pressure.

“Nothing.”

“What? His pressure is zero?”

“Yeah.”

“Does he have a pulse?  Is he breathing?”

They check.  “No.”

“Well he’s dead then, take the body away.”

They seem surprised and move quickly back from the body.  I fetch a basin of
chlorine water.

“Put the stethoscope and BP cuff in here.”  They comply and begin talking
agitatedly amongst themselves in Pidgin.

The driver grabs a bottle of some disinfectant solution and pour it over their
gloved and gowned hands.  As I step back from the ambulance and look around I
realize that all the patients that had been crowding around the entrance to the
hospital have all pulled back and a crowd is watching from a respectful
distance, but no one wants to come near.  They all dread what I suspect:  Ebola.

About 15 minutes after the ambulance leaves, I come back into the lobby from my
office and am accosted by a belligerent man.

“Weh dey take da body o’ da man in da ambulance? Gimme his numbuh.”

“I don’t have a number. And you need to go outside and not come in here without
being screened.”

He get’s more insistent and finally I have to shout at him and almost forcefully
expel him from the lobby.  There are 2-3 others with him.  They don’t seem to
get it that I don’t have any info on who the ambulance people are. One of them
shoots back a dirty look as he walks away from the door and shoots off some
venomous words in my direction.

“Wha’ you doin’ heuh man.  Dis fo’ dee Liberians.  Wha’ you want heuh.”

I start to sputter something off but everyone else around me is calming me,
smiling and saying to just ignore him.  I’m stressed out and my temper is short
fused.  Things that normally would wash over seem like fighting words.  I need a
break.  I go home and make myself some ramon.  I chop up some tiny little
eggplants and cook them with the noodles and some dried fake meat.  I always
feel better when I’m not hypoglycemic.

I go back out and they have another emergency.  I go outside and there are two
cars waiting with patients inside.

“Who’s first?” I ask.  They point me to the car to my right. Inside is an
elderly man in a coma with drool and froth coming out as he gurgles when he
breathes.  I can guess but I ask anyway.

“What does he have?”

“Preshuh.”

I knew it.  I can’t believe how severe hypertension is here.  The story comes
out that five days ago he couldn’t move his left side.  They didn’t take him
anywhere, afraid of going to a hospital with the Ebola epidemic going on.  Then
yesterday, he stopped moving his right side and went into a coma.  I explain to
them that he’s had a severe stroke and we could admit him but even if we were
able to get his pressure down and he came out of his coma, he’d still be
paralyzed and probably die a slow painful death of aspiration, malnutrition and
bedsores.  Here there just aren’t rehab facilities for strokes.  But considering
his condition, he’d probably die in the hospital anyway like several others
already this week.  I suggest they take him home.  I give them a few minutes to
think about it and go see the next patient.

“What’s going on?” I inquire.

“He fine yestuhday. He feel tinglin’ in his hans and take Amodiaquine fo’ da
malaria. Today, he don’ eat, he feelin’ weak, reauhl weak.”

I ask all the other questions about fever, vomiting, diarrhea, etc.  They deny
it all.  I look at him. He’s diaphoretic and cool to the touch of my gloved
hand.  He is semi-conscious and a rousable.  No staining anywhere to suggest
incontinence, diarrhea or vomiting.  He’s a diabetic, they add.  I figure it’s
probably hypoglycemia from the Amodiaquine, possible malaria and not eating.  I
have them bring him in.  The nurses quickly get an IV going and give him IV
Dextrose.  We draw some labs and take him up to the wards.

I go back to screening patients.  A half hour later, the nurse comes from
upstairs.

“De man vomiting bad.”

I go up and find the man I just admitted in his own room to the opposite side of
the stairs from the other rooms.  It turns out to be a fortuitous choice.  I
look in.  The man is lying on the ground, moving agitatedly, a pile of bilious
vomit to the side.  I get the family members some gloves and chlorine water to
clean it up and go down to check on his labs.  They are essentially normal
except for “possibly” some malaria.  Not likely to cause the man’s severe
symptoms in a hyper endemic area.  I’m suspicious and feeling like I shouldn’t
have admitted him.  Maybe it was super early Ebola.  Or the family was lying.  I
go back upstairs and find he has vomited two more times.

“Ok,” I tell the nurse.  “We’re shipping him out to the ELWA Hospital to the
Doctors Without Borders camp to get him tested.”  I explain to the family.  They
call a car while I get them protective gowns, gloves, masks, etc.  Then the four
women (the male relatives have fled) carry the patient down to the car and we
disinfect the room.  I’m thankful that our staff are so careful in having as
little contact as possible and wearing gowns, gloves, boots at all times.

I go downstairs and there’s a man lying in the PA’s office.  He was shot by the
police in the lower abdomen four days ago and has been wandering from hospital
to hospital, getting a few drips and dressings, looking for someone with the
courage to operate on him.  Finally, he went to the government hospital who
brought him here and requested to use our facilities so their team could operate
on him.  Fortunately, our administrator, Mrs. Carter, is a strong woman and a
straight shooter.  She told them no way.  We have our own surgeons and they have
their own well stocked facility.  Either they operate on him at their hospital
or we operate on him here.  They left.

Amazingly, he is able to walk upstairs to the OR with a little assistance.  The
anesthetist hasn’t showed, so I offer to do anesthesia for Gillian.  I give him
a spinal and Gillian get’s operating.  The spinal doesn’t get the upper abdomen
and when he starts flinching I give him Diazepam and Ketamine boluses and start
a Ketamine drip.  Gillian finds five holes in the small bowel and a wound in the
rectum.  Amazingly, after four days, his abdomen isn’t full of stool or pus.
He’s managed to wall off the stool in the left lower quadrant which is certainly
why he’s still alive today.  Gillian inserts a suction catheter into the first
whole in the bowel to clean it out and pulls out a 4 inch long round worm still
wiggling!  She completes the rest of the four hour operation, doing a bowel
resection, side to side anastamosis, rectum repair and colostomy.

When Gillian starts to put the edematous intestines back inside, the patient
vomits, despite having an NG tube in which is supposed to empty his stomach!  I
call for suction, but we only have one machine and it has to be disconnected
from Gillian’s tubing and attached to mine.  Finally, I am able to suction out
the green goo gurgling out his mouth as he desaturates into the 60’s.  The first
thing I pull out is another 4 inch long round worm, also squirming and curling.
I clear out the rest of the gunk and Gillian finishes the case.

He is having a harder time keeping his sats up after vomiting.  I’m afraid he’s
aspirated.  With a lot of oxygen the sats are staying the low normal range, but
not 100% on a couple liters like the rest of the case.  I listen to his lungs as
the surgical team puts on all the dressings and notice he has markedly
diminished sounds on the right.  I percuss and find dullness to percussion.  I
know it might be fluid in the lung from aspiration, but don’t want to miss
something else since we don’t have x-ray.  I take a sterile 5cc syringe and
carefully insert in above one of the anterior ribs.  Just posterior to the rib I
get a sudden flush back of liquify blood.

Gillian ends up putting in a chest tube and his breathing improves.  We take him
out to the ward as soon as he starts to move and come out of his anesthesia.  He
has an NGT, a chest tube, two IVs, a surgical drain, a colostomy bag and a
urinary catheter.  We tie him to the bed to make sure he doesn’t pull anything
out if he gets agitated when coming off the Ketamine (as often happens.)  I go
home exhausted, make myself two peanut butter sandwiches, prostrate myself and
pray and cry a lot and go to bed.

SKETCHY

Gillian asks me to round on pediatrics this morning.  The hospital is filling
back up again.  The first patient is a two year old girl with an amulet around
her neck.

“What is this?”  I ask.

“Oh nutting,” replies the mom with a sheepish grin.

“I have been in Africa for over 10 years.  I know what this is and you know what
it is.”

“Somebody give it to huh to help huh.”

ldquo;Yes, but what gives it its power?  Is it God?”

“No.”

“Then what?  There are only two powers in this world…one of them is God and one
is the enemy.”

“It’s nutting…”

“Every day, our staff prays for our patients, but if God answers our prayers and
heals your daughter, will you thank him or will you think it is the amulet,
charm, fetish, gris-gris?”

Everyone else in the room starts to laugh and chuckle.  The mother looks even
more sheepish and takes off the amulet and holds it in her hand.

“You should get rid of it, not just take it off…”

“I give it to da man who give it to huh.”  Some battles aren’t worth fighting.
The baby is otherwise improving after Quinine and a blood transfusion.  I move
to the next patient.

“His tummy still huhtin’ him,” says the mom.

“It takes malaria a few days to get better,” I’m assuming he has malaria since
he is on a Quinine drip.  He was admitted yesterday by one of the PA’s.

“He not ha’ malaria.  His body not hot.  He drink a bottle of medicine
yestuhday.”

“Oh, really?  What kind of medicine?”

“Blood tonic.”

“What’s that?”

“A medicine.”

“Ok, can you bring it in so I can see it?”

“Yeah.”

I stop the Quinine drip and move on.  The boy looks stable anyway.

The next child is our little anemic boy who came in on death’s door.  I can
barely recognize him now he looks so good.  He still needs one more day of
Quinine perfusion but he’s definitely on the road to recovery.

Finally, I see baby Moses.  Surprise, surprise, the urinary catheter came out.
I repeat our daily ritual of cleaning it in diluted bleach and reinserting it.
This time the bladder is not nearly so distended and the urine is pale and
clear.

I go downstairs and start screening patients.  A woman is brought in who looks
very ill and is gurgling when she breathes.

“What’s going on?”  I ask the family.

“She ha’ tooth pain an’ now she ha’ infection in huh neck.”

I examine her neck with a gloved hand and she does have a fluctuant area just
under her mandible, suspicious for a well-developed abscess.

“Bring her in.”  We get a wheelchair and wheel her into the exam room and put
her on the table.  I order IV fluids and antibiotics.  I get a scalpel, gloves,
gauze and some lidocaine in a syringe.  I numb up the area with difficulty as
the woman jumps when I prick her skin.  I  incise down quickly and thick, bloody
pus wells out as well as a clump of necrotic muscle.  I stick in a gloved finger
and sweep out some more dead flesh.  She starts to really gurgle and yellow
liquid pus starts pouring out her mouth.

“Get me a suction machine!”

Soon the OR tech brings in the suction and continues to suction out massive
amounts of pus.  I pack the neck wound and we send her upstairs.

Another patient is waiting in a car.  The family states he has diabetes and
slipped into a coma.  They took him to the ELWA hospital and was told he did not
have Ebola.  They present a handwritten note on a blank piece of paper stating
he has Diabetes: bad condition, septicemia, no suspicion of Ebola.  Signed Dr.
G_______ MSF (Doctors Without Borders).  It seems suspect to me.  I ask if the
patient is urinating frequently.

“No, no.  One to two times a day only.”  I get more suspicious.  I turn to
examen the man and he is not breathing and has no pulse.  Very sketchy.  They
want a death certificate.  I state that I can’t give it and I confiscate the
paper.  This needs to be followed up.  Is there really someone at the MSF Ebola
isolation screening patients and writing on a hand written note that they are
Ebola free without testing them?  It’s suspicious at best.  I call Dr. Sonii our
medical director.  He agrees with me and says we will follow up in the morning.
I don’t want to give them back the paper but they start to threaten so Dr. Sonii
calls back and says to make a photocopy and give them the paper.  They will
probably use the paper to get past police controls and bury him in a normal
graveyard, exposing more people if it is Ebola like I suspect.  One of the lab
techs, Geoff, calls the Ebola hotline and gives them the license plate of the
car.  They take the body away.

PRESHUH

I go out to see the man in the taxi.  He’s young and strong looking.

“What’s his age?” I ask.

“Twenty years.”

He’s looking like death warmed over.  First glance show’s he’s in a coma, with
foamy saliva coming out his mouth and swollen protruding eyes.

“How long has he been sick?”

“Since yestuhday he have preshuh, his head can hurt him, he say he have pain in
his head.”

After confirming he has no vomiting, fever, cough, diarrhea, bleeding or other
signs of Ebola, I call for a blood pressure cuff.  I’m skeptical that a 20 year
old really has “preshuh” and so I need to confirm or I’ll send him away.
Amazingly, his blood pressure is astronomically high: 248/148!  I have them
bring him in.  I suspect he may have thyroid storm, where his thyroid hormone is
raging out of control.  Our lab cannot confirm.  We have no IV medicine, but he
is awake enough to swallow some pills to lower his blood pressure and slow his
fast heart rate as well as some iodine drops to help slow down his thyroid (if
that’s the problem.)  He goes upstairs.  I also order some IV fluids and some
steroids.

Another woman is out in the parking lot in a private vehicle.  She also has
“preshuh,” and is in a coma and foaming at the mouth between shallow breathing.
She has no other symptoms.  She heard that her daughter had died in another
village and became agitated and then slowly slipped into a coma.  Her blood
pressure is “only” 160/92 but I suspect a stroke, possibly hemorragic, with
cerebral edema.  I don’t hold out much hope, but the family is desperate for
something to be done.  They’ve been turned away at several other health
facilities already.  I have them start two IV’s and get her upstairs.  Before I
can even go up and check on her, the nurses come down to tell me she has
“passed.”  I go up and confirm her death, fill out the death certificate and the
family soon brings in a van to take the body away.

I go to round on some of the patients from yesterday.  The boy with severe
anemia and malaria who was brought in almost dead is awake, alert and feeding.
Gillian tells me the little baby Moses’ urinary catheter has come out again and
he still can’t peepee.  I have the pharmacy manager, Mrs. Wennie, try and locate
a small foley catheter with a balloon that will stay in.  I promise to come back
later to put in the urinary catheter.

I go back to screening incoming patients for Ebola.  There are no suspicious
cases.  Another man comes in a yellow cab.  He is elderly, frail, weak, but
alert.  He has some edema in his lower legs and the family says he has “heart
problems.”  He’s followed normally every month at another hospital that is
currently closed.  Yesterday, he started feeling weak.  No other symptoms.  I
listen to his heart.  He has a regular rhythm with some skipped beats and an
impressive murmur suggesting a problem with his aortic valve, probably stenosis.
We bring him in and check his blood pressure.  The pulse pressure is wide at
120/40 in both arms. I’m not sure I can do much, but I order some IV fluids, a
malaria smear, a typhoid test, a hemoglobin and have the family bring me in his
home medications.  He goes upstairs to the wards.  The results of the tests come
back normal.

I go upstairs to check on the young man I admitted with severe hypertensive
emergency.  He looks like death warmed over.  He had gotten agitated and is now
restrained with cords around his ankles and wrists tied to the bed.  He also got
Diazepam.  Now he has swallow breathing and is foaming at the mouth.  His eyes
are still bulging and edematous.  We put in a foley catheter and give him some
Lasix.  Then as I’m palpating his pulse, it disappears.  I call down the hallway
for help and Gillian and a couple nurses come running.  We get the “crash cart”
which is a carton of supplies Gillian has put together for emergencies.  We do
CPR, give him adrenaline several times, bag him, get a heart beat back for a few
minutes with some spontaneous respirations.  Then the breathing goes again.  We
intubate him and continue CPR but bloody froth is pouring out his nose and the
ET tube.  Finally, soaked in sweat, we stop and pronounce him dead.  His uncle
has observed the whole thing.  Gillian asks if he has any questions.  He replies
that he saw the whole thing and seems satisfied that we’ve done our best.  We
pull out all the tubes and IV’s and cover up his face.

I go back to pediatrics and am able to reinsert the urinary catheter and drain
Baby Moses’ bladder.  The urine is now clear and pale yellow only.  His
inflammation from the circumcision is all but gone and he has no more edema.  I
think his kidneys have thankfully recovered.  Mrs. Wennie has searched all
around town for hours with no luck in finding a real foley catheter.

I go into the OR where Gillian is doing her second D&C of the day.  She has
finished but the patient is in respiratory distress.  Her blood pressure was
slightly high on entering the OR.  She is one week out from delivery, maybe she
had pre-eclampsia.  After the case, it skyrocketed to 220/130 and she went into
respiratory distress.  She then told Gillian she has asthma.  She is getting a
breathing treatment and has already gotten several doses of Lasix for pulmonary
edema.  She is sitting on the OR table, morbidly obese, with nasal flaring, sub
costal retractions and labored breathing.  Her eyes are open but staring a
little wildly as she inhales the nebulizer treatment in shallow breaths.  She
also has severe pitting edema of her lower extremities.  I listen to her lungs
and she has tight wheezes, crackles and barely any air movement.

“Let’s give her 80mg of Lasix this time and put in a foley catheter.”  I’m
nervous about a repeat of the young man from earlier.  This time, though, the
Lasix works.  When we get the foley in, 1500ml comes out immediately.  We empty
the bag and give her more albuterol nebulizer treatments.  The urine bag quickly
fills with another 1500ml.  She is breathing easier.

“I want to eat!  I need to drink!”  The woman is insistent, speaking in gasping
breaths.  Maybe she’s hypoglycemic?  We get her some juice which she gulps down
eagerly.  We also give her some water and a sugar cube.  Meanwhile her lungs
start to clear up but her blood pressure stays high.  Finally, 5 minutes after
drinking the juice and eating the sugar cube her pressure starts to come down.
Meanwhile, another 1300ml has come out in the urine bag!  Her leg edema is
starting to go down to.  I’m afraid now of low potassium from all the diuresis.
I go to Gillian’s apartment and get a bunch of bananas.  When I come back she is
stable enough to transfer to the wards.  We get her to her bed and she woofs
down 4 bananas and drinks some more water.

“I need some rice now!”  she demands with a half smile and soon is in a
well-deserved sleep.

SYPHYSIOTOMY

The baby is back, little baby Moses who can’t peepee.  Of course, the catheter I put in yesterday came out.  The mother brings it with her.
I sterilize it in diluted bleach water and reinsert it into the tiny bladder.  Now that the staff is all back to work, I admit the baby so we can keep an eye on the catheter and put it back in quickly if it comes out.  We want that distended bladder to shrink back down to normal so Moses will feel the urge to peepee before his bladder gets ridiculously huge.

Yesterday, we had a staff meeting with almost all of the 90 or so staff.  It seems there was confusion about a lot of things.  But in the end, the leaders were inspiring and everyone’s questions were answered so most have returned to work. It’s such a different feel with a full staff. I don’t feel so alone and running around like a chicken with its head cut off.

Gillian and I continue to share the load of screening patients outside.  I happen to be outside when a yellow cab pulls up and about 5 people pile out, including an obviously pregnant woman howling in pain.  I ask her the typical screening questions and that combined with her obvious health (despite her screams of pain) lead me to quickly admit her to labor and delivery.  It’s her second pregnancy.  The first was delivered by c-section for having cephalopelvic disproportion (pelvis too small, baby’s head to big.)  This will be a perfect case for a pubic symphysiotomy.

The midwives get her set up in labor and delivery, start an IV and try to get in a bladder catheter.  Gillian gets the instruments, suture, scalpel blade and lidocaine.  I put in the foley catheter by pushing up on the head between contractions. The head is very deformed and the cervix is dilated completely.  Ideal indications and conditions for the symphysiotomy. I clean the front of the pelvis and groin with chlorhexadine and inject down to the cartilage holding the pelvic bones together in front.  I slip my fingers inside to displace the foley catheter (and thus the urethra) to one side and also to give me a sense of depth perception so I don’t cut too deep. With my right hand I make a skin incision and then cut down directly to the cartilage.  Slowly and methodically I slice through the cartilage layer by layer.  It’s all by feel and I stop periodically to feel where I am with my index finger.  Finally, I have the two assistants pull the hips up and out and the pelvic bones separate 2-3cm. “Stop!” I order, and then stuff an open compress into the bleeding wound for hemostasis.  The baby’s head has already descended and with 3 good pushes the bay comes out looking like a cone head and eyes bulging from being compressed in the narrow birth canal so long. I suck out the gunk from his mouth and nose and then put him on mommy’s belly where I clean and dry him before cutting the umbilical cord.   His eyes are open and he’s breathing but kind of floppy and not as pink as I’d like.  And his cry is weak.  We stimulate, dry, suck and finally take him to the OR for oxygen before I’m happy with his skin color, muscle tone and cry. I gently pull out the placenta and Gillian sutures up the wound and the mother keeps smiling and thanking God. I go back to the Outpatient Department and see a few patients.  One of the Physician’s Assistants calls me in to see a patient.  He’s had severe right lower quadrant pain since yesterday morning.  He hasn’t been vomiting but otherwise his history and physical seem to confirm the PA’s suspicion of acute appendicitis.  The weird thing is he came in yesterday afternoon and the PA told him to come back today since we were all in a meeting.  I would’ve been fine seeing him yesterday evening.  Oh well. I ask Gillian to confirm and she agrees and takes him to the OR. I go back to screening patients.  Just as we are about to close another cab pulls up.  Inside is an unconscious man with labored breathing. He has a history of hypertension and yesterday received a call that his son had died in another town in the hospital.  He kind of went crazy and started to go downhill culminating in a coma since this morning.  He doesn’t look otherwise sick and the family denies fever, vomiting and diarrhea so I admit him.  Our lab can’t even check a blood sugar but I think he might be hypoglycemic so I give him Dextrose right off the bat.  His blood pressure is surprisingly not that high.  His malaria smear is negative.  Then he starts seizing.  I suspect he’s having a hemorrhagic stroke and I know there’s really nothing to do.  But I give him some diazepam to stop the seizure, put him on IV fluids and leave him in the hospital bed, sending a quick prayer his way as I leave.

Just as I was getting the older man into the hospital in a wheelchair, a group of women come running up with the lead woman holding a floppyinfant in her arms.  I quickly examine the conjunctiva with a gloved finger: white.  He’s anemic and after quickly determining he hasn’t had vomiting or diarrhea and that he’d been seen last week in a health center and told he had anemia and malaria but was only given pills, I admit him for ablood transfusion and appropriate malaria treatment.  The ER nurse quickly finds and IV, the lab is on the case and quickly testing some of thewomen for potential donors and an Artemether shot is given while the Quinine drip is being set up.  The case is pretty hopeless but I’ve seen many similar cases pull through in Chad.

I go home, exhausted, more emotionally than physically.  Having the spectra of Ebola hanging over us is a weighty affair.  Just yesterday, a groupof thieves looted an Ebola isolation unit, stealing mattresses and linens and causing 26 suspected Ebola cases to flee into the city.  People have written me saying nothing should really be done because compared to the big killers—malaria, TB and HIV— Ebola is barely killing anyone. What people aren’t seeing from the comfort of their faraway living room chairs is that schools, businesses, government offices and hospitals areclosed.  Money is getting scarce.  Our hospital hasn’t been paid in months by the insurance companies and is running low on fuel for thegenerator and supplies.  People are dying more than necessary of treatable diseases because the hospitals are closed and they are afraid tocome in to any that are open (like ours) for fear of catching Ebola so they are waiting too long and then running around getting refused by mostclinics and hospitals until they arrive at death’s door here if they arrive at all.  The country is about to fail financially because of this.  As if theydidn’t already have enough problems.  But we shouldn’t do anything about Ebola because only about 1000 people or so have died.  I wish I could bring whoever wrote that article here for a few days, I think he’d be singing a different tune!

See the excerpt from “The Economist” below that I received by email.

Ebola

Unseating the first horseman

The price of global health is eternal vigilance

WHAT should the world do about Ebola? A rationalist might say: nothing. Rich countries with decent health infrastructure are
not at risk because—unlike airborne viruses, such as influenza, or mosquito-borne ones, such as yellow fever—the disease
can be isolated if treated with sufficient care. In the poor countries that are infected, the thousand-or-so lives this irruption
is believed to have taken so far are fewer than the slaughter inflicted every single day by malaria, by AIDS, by tuberculosis or
even by diarrhoea. In a world of limited resources, then, it is arguably best to concentrate on those big killers, whose
treatment and prevention are well understood, rather than chase after an illness that is incurable and, on a global scale,
trivial.

PEEPEE

“She ha’ not go peepee two weeks.”  The father seems to implore me with his
answer to my question as to why they have come to the Cooper Hospital.

We are sitting outside in the screening area to try and identify those with
Ebola symptoms so we can refer them to where they can be isolated and tested
(the ELWA Hospital) without exposing our staff and patients.  This child
obviously has a different problem.

I take them in to my office and have the mother take off the layers of homemade
diaper (plastic bag covering wrapping cloths).  A boy’s traumatized penis
emerges from the wrappings.  What’s left of the foreskin is ragged, swollen and
bloody with the glans barely peeking through some ratty ends of purple suture.
The abdomen is tense and distended with prominent, dilated veins above the belly
button.

“When was he circumcised?” I ask the father.

“Two week ago,” he replies.

“Since the circumcision he hasn’t gone peepee?”

“No.”

“Was he able to peepee before the circumcision?”

“Yeah, small, small.”

“He does poopoo and breastfeeds normally?”

“Yeah, no problem.”

I find a suture kit and with the scissors and forceps remove the sutures from
the tiny penis.  It starts to ooze from the suture sites.  The suture was
obviously compressing the tip of the penis.  Still no urination.  I gently press
on the distended bladder.  Nothing.  I go to search for a small urinary
catheter.  The smallest I can find is a 10F.  It’s way too big.  With Gillian we
search in the chaotic stockroom.  We find a single use red robbin catheter that
is 8F.  I try it but it’s too big as well.  Suddenly, Gillian remembers some
suction catheters for ET tubes.  We find one that’s 6F.  I take off and cut off
the paraphernalia surrounding the tube and with a lot of lubrication get it to
go in part way.  I twist and turn and gently probe until finally it bursts into
the bladder and over 300cc of dark brown urine comes out.  The abdomen becomes a
normal pudgy newborn belly.  The baby is obviously relieved.

“Tank da Lawd, tank da Lawd!  Tank you Jeeesus!” exclaims the father, a huge
smile on his face.  The mother sits quietly with a silly grin on her face.

Now I’m faced with the fact that this tube has no balloon to make sure it
doesn’t come out.  I decide to see if the baby can now pee on his own with the
release of the suture constricting the urethra.  I take the tube out, give him a
shot of Ceftriaxone (which I administer myself since we have no nursing staff),
and tell them to come back tomorrow.

The next morning, I see the mother sitting out in the crowded waiting room.  It
seems patients have decided to come back.  I have the Physician’s Assistant
screen them for signs of Ebola and the nurse brings me the chart.

“Has the baby gone peepee?” I ask.

The mother shakes her head “No” as she removes the diaper, this time a real
diaper.  The babies abdomen is swollen again, but the edema of the abdominal
wall is gone.  The kidneys are functioning well despite the obstruction!  I
reinsert another suction tube, drain over 300 more milliliters of clearer urine
and this time leave the tube in.  The penis is much less swollen and starting to
look almost normal.  I still give one more shot of Ceftriaxone and tell them to
come back tomorrow.  I hope that if the tube can stay in at least 24 hours then
the bladder can stay shrunken down and the baby will start to feel the need to
pee before it gets too distended.

In the meantime, the PA calls me to evaluate two patients who’ve come by taxi.
The first one is an elderly woman sitting motionless in the back seat, her face
covered by a head scarf.  Her legs are exposed revealing old sores on the ankle
and foot with some edema.  They say she hasn’t pooped in 5 days.  The belly is
somewhat swollen but not tense.  I remove the head scarf and she looks like
death warmed over.  My radar is on high alert.  I can’t take the risk.  I tell
the family there’s nothing we can do.  They try to protest and show me a torn
slip of paper with some doctor’s name and phone number on it with a note in
chicken scratch saying “not suspicious for Ebola.”  That makes me more
suspicious and I insist they leave.  It’s hard to do, my whole medical training
screams “no!” but I know I have to protect the staff and patients and keep the
hospital open so we can help those who can be helped.  If we admit an Ebola
patient, none of the staff or patients will come and many others will die who
could be helped.

The next cab has a middle aged man in it.  He is awake but doesn’t talk or look
at me.  The son tells me he had been having black, tarry stools and then nothing
for the last 6 days.  I look at his conjunctiva with a gloved finger and the
under eyelids are very red.  I also feel uncomfortable in my gut.  Bleeding is a
prominent feature of Ebola.  They may be lying about diarrhea, vomiting and
fever.  I offer to give them some ulcer medicine (in case that’s the cause of
his bloody stools) and some laxatives (in case it’s only constipation).  They
really want to be admitted. They say he won’t eat and won’t take pills.  I say
I’m sorry and send them away with their pills.

I see more patients and then they bring in a 6 year old girl who is obviously
sick.  No diarrhea, but she has fever, abdominal pain and vomiting.  I’m
suspicious but also realize it could be just malaria.  She throws up some thick,
bilious vomit in a small amount into the bed pan.  I’m wearing gloves of course.
I instantly rinse out the bed pan and soak everything in chlorine water.  I
prescribe Artemether IM injections twice a day for her possible malaria and
Ceftrixone IM injections for her possible typhoid.  Instead, I pray that that’s
all it is and that the injections will work.  As soon as she leaves I wipe
everything down with a chlorine soaked rag and have the cleaning team come in
and decontaminate the floor.

I go eat a quick lunch while they are decontaminating the room.  I come back
just in time to see the PA putting in a 10 year old boy who is wearing only a
ragged pair of shorts that are soaked in urine or other bodily fluids.  I
quickly learn that he was brought in urgently by his mom who carried him on his
back and he’s been vomiting with fever.

“GET HIM OUT OF HERE!” I yell.  “THESE ARE EXACTLY THE CASES THAT WE ARE
SCREENING FOR!”

Just then the mother let’s out a wail.  The child is dead.  She grabs the boy
and runs out.  I continue to explain in a loud voice to all the staff that these
are exactly the cases that are supposed to be screened and sent away.  The PA’s
reply is that he was too sick to screen outside so he brought him in on a bed.
I emphasize that those are exactly the cases that should be sent away.  He died
immediately anyway so we didn’t help him, we only put all ourselves at risk.  We
close the room, the cleaning staff dons complete gowns, gloves, masks, boots,
etc and pulverizes and sterilizes the room and we leave it off limits the rest
of the day.

The struggle continues.

C-SECTION

Gillian comes to the door early Saturday morning, “…I’ve been up all night,
though, and am exhausted.  There’s two c-sections to be done, can you do them?”

“Sure, that’s why I’m here…” I finish the one piece of French toast I’ve already
prepared and go up to Labor and Delivery through the same maze that at first was
confusing but is already becoming familiar.

The same midwife is still there.  She’s been on for almost 48 hours since no one
came to relieve her yesterday evening.  Many of the staff refuse to come in,
scared about Ebola. This one is very good and conscientious and I’m glad to see
her.

“What’s going on?” I ask.

“Dis woman, she been he-uh since yestuhday.  She not progressing in huh laybuh
and now dere is fetal distress.  I put huh on huh left side and tings bettuh
now.”

“This is the woman with a hemoglobin of 8 yesterday right?”

“Yeah, dat’s right.”

Gillian has called in the OR team already and they’re on their way.  I go to the
lab to make sure we have blood.  They have one bag already, but it looks like
it’s in a pediatric blood bag which is only half the volume of an adult bag.
Apparently, they are out of adult sizes.  I come back up and the OR team is
assembled in the changing room putting on scrubs.  I reach out my hand and shake
the hand of one of them who introduces himself to me as “Wheezy” even though his
breathing is normal.  A large, stocky man with a weathered face then speaks up:

“Hey man, this is Ebola time.  We don’t shake hands.  Go wash.”

I laugh and comply.  The man then introduces himself as Neal, the anesthetist.
A few more minutes and they are setting up the room.  I pull on my surgical cap
I brought from Chad, put on a mask and head into the OR.  It’s small, but clean
and seems well equipped, although there’s only one ancient OR light and most of
the equipment looks like it may have survived WWII.

“What anesthesia will you use?” I ask Neal.

“General.”

“What about spinal?”  To me it’s a simple question but it brings forth an
aggressive response from Neal as if I’d insulted his mother.  He goes on and on
about how he knows what he’s doing and a spinal would be not right in this case
of anemia and he’s worked in Britain and who am I to question him, etc, etc,
etc.  I’m a bit taken aback by his reply, but bite my tongue.  I’m already wary
of his abilities based on his poor handling of the uterine rupture from
yesterday but I don’t say anything.  I go downstairs and find some long shoe
covers to protect my feet and legs from exposure to bodily fluids and head back
up.  Neal is just coming out of the Labor & Delivery and confronts me again
aggressively.

“Are you happy with my anesthesia or not?  Huh?  Just let me know, ok?”

I motion him over away from the rest of the staff into the changing room where
we are alone.

“Listen, Neal, I’m not sure why you are being so defensive.  I was just asking a
question.  For me, that’s good medical practice, one should dialogue,
communicate and discuss and that’s all I was trying to do.”

“Ok, man, ok. You say you’ve always done c-sections under spinal and you like
them because they relax the lower abdomen.  So will my general.  You’ve never
tried a c-section under general, let me show you how it works.”

Deep down, I’m not satisfied, but it’s not a time to pick a battle.  I nod and
we move into the OR again where the patient is already on the table.  I notice
she just has a small 20G IV in her left hand and an even tinier 22G in her right
antecubital fossa.  I mention to Neal that I’d like at least one 18 G before
doing surgery.  He doesn’t say anything as he hangs up the bag of blood and gets
it ready to give.  I don’t push but watch him warily out of the corner of my
eye.  He doesn’t start another IV and the 22G isn’t working at all.  I
reluctantly don’t say anything.

“Go scrub!” orders Neal.  I comply.  At first, all I see are hard, plastic scrub
brushes used normally for cleaning instruments.  There’s also some old bar soaps
on the counter.  I then see a blue covered dish.  I open the lid carefully and
inside see two used regular surgical scrub brushes.  One seems to still have
some chlorhexadine on it so I scrub with that.  I back through the swinging
doors of the OR, by hands held out in front of my chest high and well away from
my body.  I pick up a small washcloth folded over the surgical gown and wipe my
hands dry.  I then fully dry them in front of the A/C and put on my gown and
gloves in sterile fashion.

The woman’s exposed, very pregnant belly is covered in some kind of substance
that looks like fine wood chips.  I’ve seen this many times in Chad.  It’s some
kind of traditional medicine.  I have the circulating nurse wash it off before
prepping with Betadine.

“Dr. James,” Neal begins, apparently ready with some more advice for me. “The
faster you do the c-section the better for you and for me…”

“…and for the patient and the infant.” I add.

“Yes, of course,” Neal quickly agrees.

“I always consider c-sections under these conditions to be crash c-sections so I
do them as fast as possible.”

“Yeah, and now I’ll show you crash anesthesia too,” adds Neal with a gleam in
his eye.

We’ve draped the patient’s abdomen and I stand poised with the scalpel after
surveying the instrument tray and finding most of what I’d expect in a c-section
kit (although I’d really prefer more than 2 ring clamps).

“Neal, can I start?”

“Of course, I’m just waiting for you.”

“Let’s pray first,” interjects Wheezy who’ll be assisting me. He then rolls off
a beautiful prayer in Pidgin English that I mostly don’t understand.

“Amen!” I state at the finish and slice down quickly through skin, fat, fascia
and peritoneum.  The woman moans and contracts her muscles.  She’s not fully
under anesthesia!

“She’s moving!” I tell Neal.  Then I pull open the wound with my hands, extend
it some inferiorly with scissors and fight against the intestines wanting to
push their way out and the tight abdominal muscles that would’ve been relaxed
with a spinal anesthetic.  I force in the bladder blade but have a hard time
seeing the lower uterine segment as we fight against the contracting muscles.
Finally, I am able to get a bladder flap developed and retract the bladder out
of the way.  I make a small incision in the uterus, poke through with a clamp
and extend it to both sides and superiorly with my fingers and scissors.  The
head is right there.

“Push on the top of the uterus!” I tell Wheezy.  His efforts are less than
adequate so I reach my left hand up and push down hard as my right hand guides
the head out.  A contracting baby with excellent muscle tone who seems to want
to cry emerges.  I quickly wipe him off while Wheezy clamps and cuts the cord.
I hand the baby off to the waiting midwife.  I don’t hear a cry but turn back to
the placenta.  I tug too hard on the cord and the cord pops off.  No big deal, I
reach my hand in the uterus and scrape the placenta off the uterine wall then
exteriorize the uterus.

There is a bleeding artery on the left that I clamp with one of the two ring
clamps and then get the other edges out with some other clamps they have instead
of the normal ring clamps.  I still don’t hear a baby cry.  I look over and the
midwife is bringing a limp baby over to Neal who is getting a bag valve mask
ready.

“Start chest compressions!” I order.

“The baby has a heartbeat, he’s just not breathing,” replies Neal.

“How fast is the heartbeat, if it’s under 100/min that’s not enough.  And chest
compressions will move air into the lungs in the meantime as well.  It certainly
won’t hurt.”

Neal smiles condescendingly and continues doing what he’s doing.  I turn back to
the mother, she’s my first priority. Hopefully, the baby will make it despite
the lack of protocol.  I suture the uterus and after assuring that the bleeding
is controlled replace it in the abdomen.  I verify that there is no bleeding
from the wound and close the fascia.  I finally hear a weak baby cry.  Thank
God!  I close the skin with a flimsy, tapered needle more suited to thin bowel
than tough skin but I eventually am able to finish the job with a very warped
needle at the end.

I scrub out and thank Neal who thanks me back.  As I leave the room I hear Neal
bragging to Wheezy, “See, I told you that general anesthesia was the best…”  I
pretend not to hear.

On coming out, I meet Gillian.

“The woman with the ruptured uterus from yesterday just died.”

Life and death.

TRIAGE

Here in Liberia things don’t start as early as in Chad, at least not at the
Cooper Hospital.  After a quick breakfast of yogurt and peanut butter and jelly
sandwich I head out the front door into the small courtyard with the three story
hospital just to the left.  I squeeze through a narrow passageway between the
wall and a flight of steps up to another residence.  I turn right into a dim
corridor with the open air kitchen just ahead opening to the other side of the
building.  I turn left half way down and up two half-flights of stairs to the
main hallway.  Patients are already lining up outside, but I continue upstairs
two more half flights to the wards.  I come in just in time for staff worship.
When it’s done Gillian and I go downstairs and she shows me the triage area.

Because of the Ebola outbreak, we don’t want to let any cases enter our
hospital.  Our primary objective is to stay open to take care of the non-Ebola
emergencies.  There is another hospital in town taking care of the Ebola
patients.  If we let in one case we not only put ourselves at risk, but our
patients as well, not to mention our staff.  If this happens we’ll close down
like all the others and then no one will have anywhere to go.  So, we don’t let
patients in.  We set up a screen on the front porch.  When patients come, we
find out where they are from and their names.  If they come from a village with
a major outbreak that should be quarantined, they are turned away automatically.
If not, then we ask them about symptoms that could suggest Ebola: fever,
headache, sore throat, vomiting, diarrhea, any kind of bleeding, etc.  If they
don’t look sick and have less then 3 of the above symptoms we send them in to be
registered.  Afterwards, they come back outside.  When we get their chart with
the vital signs taken after registration, we call them in and consult them.  The
diagnosis is made almost exclusively on history as we try to keep as little
contact with the patients as possible.  Then we prescribe meds and they go home.

Shortly after Gillian and I start doing this triage, a cab pulls up.  There’s a
woman inside, obviously pregnant and obviously not doing well.  A man jumps out
of the car carrying a note from a health center.  It says she’s been in labor 2
days and is bleeding, hypotensive and has no fetal presenting part.  We go to
the cab.  I don gloves and palpate her abdomen.  I feel fetal parts and
instantly suspect a ruptured uterus.  After asking her our standard Ebola
questions and finding her to be low risk, we call for a wheelchair to take her
up to surgery.

I’m still not registered with the Liberian Medical and Dental Council so I can’t
do the surgery, so Gillian takes on the case and calls in the OR team.  I go
back down to triage.  I have just started when the administrator and medical
director come up.  They say it might be trouble if I’m seen working without
permission from the council.  They suggest I get my papers together and they’ll
take it over immediately and see if they can steamroll the process. I find some
copies of documents on my computer, others I’ve brought from Chad, still others
I write up and print out.  I also give them two of the passport photos I’d taken
yesterday in the market.  Dr. Soni, the Medical Director, takes the whole packet
over to the Ministry of Health and soon comes back saying they’ve ok’d me to
start working even though they won’t get all the paperwork finished until next
week.

So I’m back at the triage.  Soon another cab pulls up.  A man hurries up with a
flaccid preteen in his arms.  I now have a nurse’s aid and an intern helping me.
The nurse’s aid makes them take him back quickly and put in the back seat of the
cab.  I put on gloves and go over to see. They are saying he was just hanging up
laundry on the line, but that on of the lines was a power line and he was
electrocuted.  The nurse’s aid steps back and says “He not breathin’, doc.”  I
verify that there is no pulse or respiratory effort and pronounce him dead.  His
mother starts flopping around screaming and holding her head.  I take off my
gloves and go back to triage.

I finish with the outpatients by noon and go to see what’s happening with the
c-section.  Gillian has just finished and is writing her operative note.  The
anesthetist and OR assistant are transferring the patient to the gurney.  She is
still unconscious and floppy.  They move her immediately to her room.  There is
no post-op recovery at the hospital.  After she’s in her bed I examine her
conjunctiva:  white.  She has lost a lot of blood.  There is no blood bank but
they’ve been working on getting family to donate.  They don’t want to.  They
have gone across town and bought a bag from somewhere.  We get that running.
She has only one IV, a small one in her left hand.  She is still hypotensive at
70/40 and tachycardic at 138/min.  The nurses are trying to find an IV, even on
her feet and ankles, but there is no access.  The blood is running very slowly.
Then it stops.  The tubing is clotted off.  We get more tubing.  We have no
central line kits so we are trying to get a regular IV in the femoral vein.  I
finally get one in the right one but it’s very positional.  I have to sit there
holding the catheter while IV fluids pour in.  Another bag of blood finally
comes.  The woman is still unconscious.  Finally, the pulse slows down some, but
still not ideal.  Blood pressure is a little better.  We call family to try and
get more blood. At least we have two good IV’s running now with blood in each.
I take a break and go eat a late lunch of spaghetti and cucumber salad.  Gillian
stays with the patient.

It’s late afternoon by now and I go relax a little, take a shower and do some
laundry by hand.  I Skype with Sarah and the kids, the first time I’ve seen them
in about a month.  Then I go to bed.

I toss and turn all night.  I’m worried about the woman with the uterine rupture
and Ebola keeps lurking in my nightmares as a constant veiled threat.  Finally,
I fall asleep at about three and wake up after 7:30.  Right before 8:00 Gillian
comes to the door.

“The woman coded last night.  Fortunately, the nurse called me in time and we
were able to give her adrenaline and more blood and she came through.  I’ve been
up all night, though, and am exhausted.  There’s two c-sections to be done, can
you do them?”

“Sure, that’s why I’m here…”

To be continued…

MONROVIA

I step out of the Kenya Airways jet and into the muggy air of Monrovia, the
capital of Liberia.  The sky is overcast with cracks of white letting in a
little sunlight.  The tarmac is wet from a recent rain.  It’s cool and breezy.
Across the runway is a small airport with cracked paint on the walls.  We get in
a bus for the short trip to the door marked “Arrivals”.  A sign half falling off
one of the double doors gives a list of do’s and don’ts for Ebola.

We are let out of the bus in groups of ten. Right inside the door is a short man
in a short white coat with a digital thermometer with which he is taking
temperatures.  As soon as each passenger is declared fever free they move to a
water cooler constantly dripping chlorine impregnated water into a plastic
bucket sitting on a stool.  Hand painted signs point us to one of three lines:
“VIPs/Diplomates,” “Liberians” or “Foreigners.”  I choose the appropriate line,
passport without visa clutched nervously in my hand along with a letter I just
printed off that morning inviting me to come to Liberia a relief physician for
the Cooper Adventist Hospital, one of the few hospitals still open during the
Ebola epidemic.

When it’s my turn, I nervously go up to the Immigration booth and talk to the
woman inside through 5 holes haphazardly drilled through the plexiglass.  “I
don’t have a visa.  Someone’s supposed to meet me here to give me one.”

Without saying a word she takes my passport and letter and walks out the back of
the booth.  Soon another woman comes up and says, “Follow me.” I go into a dingy
back office with a desk piled with scattered papers.  The woman shuffles through
one pile and pulls out an official looking document with the words “Airport
Visa” emblazoned in bold across the top.  I’m relieved to see it has my name on
it.  We go back to the booth where the first woman quickly stamps my passport
and waves me through.  I show my passport to the customs official who waves me
outside where a crowd has gathered.  I see a few people with signs.  None of
them have my name.  A man comes up to me and we start talking.  I explain the
situation, but he says he hasn’t seen anyone from Cooper Hospital.

Just then a large man approaches from behind me and says in heavy African
English “Coopuh ‘ospitawl???  He’s holding a hand written sign that reads “SDA
Cooper Hospital.”  I nod in relief and we weave our way through the sea of
people waiting to leave Liberia and into a fairly new looking Land Cruiser
hardtop with “Cooper Eye Hospital” written on the doors in green paint.  We rush
off on a nice paved road through lush tropical vegetation reminding me of a
South or Central America.  Palms and banana trees poke out amidst the sprawling
jungle interspersed with brightly colored wood or block houses and restaurants.
But it’s obvious for many miles that we are still in the country.  In fact, it
appears the airport is at least 30 miles from Monrovia.

As we approach the city we pass a huge walled compound to the left, just between
the road and the ocean.  “Dat’s da ELWA ‘ospitawl,” says my host, who has
identified himself as an immigration officer but who is an Adventist Church
member.  The ELWA Hospital is where the Ebola cases are being referred to and
where the American Doctor and Nurse stricken with the disease were cared for for
over a week until the experimental drug ZMapp arrived from the US and turned
there cases around enough to allow them to be evacuated to the US where they are
making a recovery.  It’s also where one of my former attending physicians from
residency, John Fankhauser, is spearheading the medical care of the Ebola
patients.

We whiz on by and enter the capital which is like so many cities in the
developing world: crowded, a mix of modern and primitive.  Lots of cars, but no
electricity unless you have your own personal generator.  We stay on the main
road for a long time through town until we turn right on some pothole filled
roads and stop in front of a dilapidated building with “Cooper Adventist
Hospital” emblazoned over the front doors leading from a small circular
courtyard.  All the staff is sitting outside on a low wall.

Apparently, two days previously, the rumor had got out that the Cooper Hospital
also had an Ebola case, so patients had stopped coming.  Today, though, a real
possible case had come through and just died in the hallway.  The patient had
been sick for a week with fever and vomiting and went to another hospital who
saw that he also had an incarcerated hernia, and instead of first checking him
for Ebola, sent him straight over to Cooper.  Dr. Gillian was doing triage on
patients and was suspicious but also felt he should be examined for his hernia.
She took precautions and allowed no one else around the patient, gloved up and
was able to reduce the hernia.  Then the patient vomited on her arm  and died.
The body was quickly doused in chlorine and wrapped in plastic bags and OR wraps
and placed in the unused X-ray room on a bench.  Everything was then properly
dosed with chlorine water and clothes disposed of.

The Ministry of Health was called to evacuate the body and test it for Ebola.
No has come yet.  So, I arrive with the staff refusing to go back in the
hospital and our doors temporarily shut to new patients.  I’m introduced to some
of the staff and then Gillian takes me and shows me my room.  It’s inside the
courtyard under the OR and Labor and Delivery which are upstairs.  It’s a lot of
buildings crammed in a small space.  The rooms were the dwelling of a
Phillippino couple, she was the staff OB/GYN before fleeing the Ebola epidemic.
The cabinets are sagging, half the drawers are swollen shut by the humidity,
small cockroaches abound, and most of the furniture is about to fall over.  The
couch and chairs are nice though, as is the bed and mattress.

Gillian brings me some excellent pasta and a Greek salad from a nearby
restaurant which I devour.  I haven’t really eaten well in the four days since I
left Abeche in Eastern Chad to cross the desert, head to Eastern Africa and then
fly almost the length of the upper horn of Africa to Liberia.  I feel much
better with a full stomach and despite the pit in my stomach from the fear of
Ebola and the unknown I fall into a deep sleep.

The next morning, I awaken, prepare a breakfast of yoghurt, oatmeal and peanut
butter & jelly and go out to the lobby where I meet and talk with many of the
staff.  The body is still in the X-ray room.  The Ministry of Health has shown
no signs of action despite continued calling.  I’m told that in at least one
case, they took 5 days before they came for the body leaving many people exposed
since Ebola is often passed from the dead body to those handling it.  We have
worship upstairs on the wards and in the middle of rounds, we are told the
family has come to reclaim the body.  Our idea is for them to take the body and
then count on the police to arrest them, take the body to test it and then bury
it safely in a secret grave site they have reserved for just that.

The family is obviously Muslim and they pull in a beat up small pickup into the
side yard near the outdoor kitchen where some soup is being boiled over a wood
fire on a grill.  The three pallbearers are called up to the hallway just
outside the X-ray room.  Gillian explains how to put on the protective gear
given us by the Ministry of Health.  Full body suits with hoods are zipped on.
Booties are put over the feet part of the suits. Two pairs of gloves are put on
and we realize the sleeves are too short and pull out easily from under the
gloves leaving the wrists exposed.  Brilliant design!  Gillian solves the
problem with her pocket knife.  We make thumb holes in the sleeves and loop them
over the thumbs before reapplying the gloves.  Now the sleeves stay under the
gloves.  We give them heavy duty masks and then instruct them on how to remove
them eventually and place them in the red biohazard bags to avoid further
contamination.  I see right off this is a weakness in the system and even if we
were there to observe, the likelihood of contamination is high.

The three men go into the X-ray room and pick up the whole bench where the body
has been laid.  Then they take it down the hallway, down a flight of stairs and
through a hallway, past the kitchen and into the open air where the truck
awaits.  I have spread a large impermeable OR drape in the bed of the truck so
they can further wrap the body and hopefully contain the bodily fluids which may
or may not contain the Ebola virus.  They lift the whole bench in the truck and
then slip the body onto the drape, remove the bench and wrap the body.

I look at the bench which has a huge wet spot under where the man’s abdomen and
thorax had been:  bodily fluids soaked into the wood.  The truck drives outside
and Gillian goes upstairs to prepare the death certificate.  I spray some
chlorine water on the bench’s wettest spots and then go upstairs.  A new problem
has arisen.  The head of the family states that they can’t go out dressed as
biohazard personnel.  They’ll be arrested immediately (of course, that’s the
point, but we can’t say that).  So now we have to have them come back in the
courtyard, take off their suits and give them new suits to put on once they get
to the graveyard.  I’m sure they won’t use them.  Even in taking the suits off,
there is a lot of disorder and things touched that shouldn’t be.  They wash in
bleach and take off.  I use the rest of the bucket of chlorine water to douse
the entire bench.  When I’m done with the top, I grab a stick from the ground to
push it over and soak the bottom of the bench as well.

I wash up well and we finish rounds.  There aren’t many patients from the
earlier scare and there will be none the rest of the day.  I spend the afternoon
talking to Gillian about the challenges of the Cooper Hospital and after a hefty
supper of lentils, rice and fried plantains I go to my room.  I wash my clothes
by hand, hang them up in the bathroom and living room, take a shower and fall
into a deep sleep.