By Dr. James Appel - August 25, 2014

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.