By Dr. James Appel - August 19, 2014

“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?”


“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.


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.