By Dr. James Appel - September 12, 2014

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.

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