By Dr. James Appel - September 1, 2014

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.