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?”
“Do you have a blood pressure cuff?”
I bring them one and hand it in with a gloved hand. They take his pressure.
“What? His pressure is zero?”
“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
“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
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?”
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
“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.