By Dr. James Appel - August 21, 2014

I go out to see the man in the taxi.  He’s young and strong looking.

“What’s his age?” I ask.

“Twenty years.”

He’s looking like death warmed over.  First glance show’s he’s in a coma, with foamy saliva coming out his mouth and swollen protruding eyes.

“How long has he been sick?”

“Since yestuhday he have preshuh, his head can hurt him, he say he have pain in his head.”

After confirming he has no vomiting, fever, cough, diarrhea, bleeding or other signs of Ebola, I call for a blood pressure cuff.  I’m skeptical that a 20 year old really has “preshuh” and so I need to confirm or I’ll send him away. Amazingly, his blood pressure is astronomically high: 248/148!  I have them bring him in. I suspect he may have thyroid storm, where his thyroid hormone is raging out of control. Our lab cannot confirm. We have no IV medicine, but he is awake enough to swallow some pills to lower his blood pressure and slow his fast heart rate as well as some iodine drops to help slow down his thyroid (if that’s the problem.)  He goes upstairs.  I also order some IV fluids and some steroids.

Another woman is out in the parking lot in a private vehicle.  She also has “preshuh,” and is in a coma and foaming at the mouth between shallow breathing. She has no other symptoms. She heard that her daughter had died in another village and became agitated and then slowly slipped into a coma. Her blood pressure is “only” 160/92 but I suspect a stroke, possibly hemorragic, with cerebral edema. I don’t hold out much hope, but the family is desperate for something to be done.  They’ve been turned away at several other health facilities already. I have them start two IV’s and get her upstairs.  Before I can even go up and check on her, the nurses come down to tell me she has “passed.”  I go up and confirm her death, fill out the death certificate and the family soon brings in a van to take the body away.

I go to round on some of the patients from yesterday. The boy with severe anemia and malaria who was brought in almost dead is awake, alert and feeding. Gillian tells me the little baby Moses’ urinary catheter has come out again and he still can’t peepee. I have the pharmacy manager, Mrs. Wennie, try and locate a small foley catheter with a balloon that will stay in. I promise to come back later to put in the urinary catheter.

I go back to screening incoming patients for Ebola. There are no suspicious cases. Another man comes in a yellow cab.  He is elderly, frail, weak, but alert. He has some edema in his lower legs and the family says he has “heart problems.”  He’s followed normally every month at another hospital that is currently closed.  Yesterday, he started feeling weak.  No other symptoms.  I listen to his heart.  He has a regular rhythm with some skipped beats and an impressive murmur suggesting a problem with his aortic valve, probably stenosis. We bring him in and check his blood pressure.  The pulse pressure is wide at 120/40 in both arms. I’m not sure I can do much, but I order some IV fluids, a malaria smear, a typhoid test, a hemoglobin and have the family bring me in his home medications. He goes upstairs to the wards. The results of the tests come back normal.

I go upstairs to check on the young man I admitted with severe hypertensive emergency.  He looks like death warmed over.  He had gotten agitated and is now restrained with cords around his ankles and wrists tied to the bed.  He also got Diazepam.  Now he has swallow breathing and is foaming at the mouth.  His eyes are still bulging and edematous.  We put in a foley catheter and give him some Lasix.  Then as I’m palpating his pulse, it disappears.  I call down the hallway for help and Gillian and a couple nurses come running.  We get the “crash cart” which is a carton of supplies Gillian has put together for emergencies.  We do CPR, give him adrenaline several times, bag him, get a heart beat back for a few minutes with some spontaneous respirations.  Then the breathing goes again.  We intubate him and continue CPR but bloody froth is pouring out his nose and the ET tube.  Finally, soaked in sweat, we stop and pronounce him dead.  His uncle has observed the whole thing.  Gillian asks if he has any questions.  He replies that he saw the whole thing and seems satisfied that we’ve done our best.  We pull out all the tubes and IV’s and cover up his face.

I go back to pediatrics and am able to reinsert the urinary catheter and drain Baby Moses’ bladder.  The urine is now clear and pale yellow only.  His inflammation from the circumcision is all but gone and he has no more edema.  I think his kidneys have thankfully recovered.  Mrs. Wennie has searched all around town for hours with no luck in finding a real foley catheter.

I go into the OR where Gillian is doing her second D&C of the day.  She has finished but the patient is in respiratory distress.  Her blood pressure was slightly high on entering the OR.  She is one week out from delivery, maybe she had pre-eclampsia.  After the case, it skyrocketed to 220/130 and she went into respiratory distress.  She then told Gillian she has asthma.  She is getting a breathing treatment and has already gotten several doses of Lasix for pulmonary edema.  She is sitting on the OR table, morbidly obese, with nasal flaring, sub costal retractions and labored breathing.  Her eyes are open but staring a little wildly as she inhales the nebulizer treatment in shallow breaths.  She also has severe pitting edema of her lower extremities.  I listen to her lungs and she has tight wheezes, crackles and barely any air movement.

“Let’s give her 80mg of Lasix this time and put in a foley catheter.”  I’m nervous about a repeat of the young man from earlier.  This time, though, the Lasix works.  When we get the foley in, 1500ml comes out immediately.  We empty the bag and give her more albuterol nebulizer treatments.  The urine bag quickly fills with another 1500ml.  She is breathing easier.

“I want to eat!  I need to drink!”  The woman is insistent, speaking in gasping breaths.  Maybe she’s hypoglycemic?  We get her some juice which she gulps down eagerly.  We also give her some water and a sugar cube.  Meanwhile her lungs start to clear up but her blood pressure stays high.  Finally, 5 minutes after drinking the juice and eating the sugar cube her pressure starts to come down.  Meanwhile, another 1300ml has come out in the urine bag!  Her leg edema is starting to go down to.  I’m afraid now of low potassium from all the diuresis.  I go to Gillian’s apartment and get a bunch of bananas.  When I come back she is stable enough to transfer to the wards.  We get her to her bed and she woofs down 4 bananas and drinks some more water.

“I need some rice now!”  she demands with a half smile and soon is in a well-deserved sleep.