By Dr. James Appel - August 23, 2014

I don’t know if I’m just getting more stressed and sensitive (which is definitely true in a sense) or if everyone else is also really starting to feel the pressure, but patients seem more on edge, more pushy, more panicky.  As usual, I go outside the hospital early to screen patients.  There are more and more of them everyday.  As people have been afraid to come in to the hospital, they are waiting till the last minute and come in on death’s door.  We have many patients who are dead on arrival and many others who die shortly after admission.  In all my 10 years in Africa I haven’t seen death this frequently except the one Saturday back in Chad when there was a small war between the agriculturalists and the cattle herders.  So many people here have severe hypertension, and at a young age.  Strokes come in, several a day, and often in a coma.  They usually die in a few days.

Now, people are impatient. They are clambering to be seen.  They are annoyed and yelling, not the majority of course, but enough to set my already frayed nerves on edge.  The security personnel leave their posts on innocent missions and people take advantage to go in without washing their hands in chlorine water or being screened.  Then when I try to get them to come out, some resist and argue.  I can feel my stomach in a knot, squeezing and making it harder to breathe.

An ambulance pulls up.  It looks just like the ones we just shipped to Chad.  The driver says they have a man who was walking in town and fell down with a seizure.  He opens the back door to the ambulance and inside are two EMTs covered from head to toe in protective gear, looking like they are about to handle radioactive material.

“What’s happening?” I ask.

“He fell down and seized.  He ha’ preshuh.”

“What is his pressure?”

“Don’ know.”

“Do you have a blood pressure cuff?”


I bring them one and hand it in with a gloved hand.  They take his pressure.


“What? His pressure is zero?”


“Does he have a pulse?  Is he breathing?”

They check.  “No.”

“Well he’s dead then, take the body away.”

They seem surprised and move quickly back from the body.  I fetch a basin of chlorine water.

“Put the stethoscope and BP cuff in here.”  They comply and begin talking agitatedly amongst themselves in Pidgin.

The driver grabs a bottle of some disinfectant solution and pour it over their gloved and gowned hands.  As I step back from the ambulance and look around I realize that all the patients that had been crowding around the entrance to the hospital have all pulled back and a crowd is watching from a respectful distance, but no one wants to come near.  They all dread what I suspect:  Ebola.

About 15 minutes after the ambulance leaves, I come back into the lobby from my office and am accosted by a belligerent man.

“Weh dey take da body o’ da man in da ambulance? Gimme his numbuh.”

“I don’t have a number. And you need to go outside and not come in here without being screened.”

He get’s more insistent and finally I have to shout at him and almost forcefully expel him from the lobby.  There are 2-3 others with him.  They don’t seem to get it that I don’t have any info on who the ambulance people are. One of them shoots back a dirty look as he walks away from the door and shoots off some venomous words in my direction.

“Wha’ you doin’ heuh man.  Dis fo’ dee Liberians.  Wha’ you want heuh.”

I start to sputter something off but everyone else around me is calming me, smiling and saying to just ignore him.  I’m stressed out and my temper is short fused.  Things that normally would wash over seem like fighting words.  I need a break.  I go home and make myself some ramon.  I chop up some tiny little eggplants and cook them with the noodles and some dried fake meat.  I always feel better when I’m not hypoglycemic.

I go back out and they have another emergency.  I go outside and there are two cars waiting with patients inside.

“Who’s first?” I ask.  They point me to the car to my right. Inside is an elderly man in a coma with drool and froth coming out as he gurgles when he breathes.  I can guess but I ask anyway.

“What does he have?”


I knew it.  I can’t believe how severe hypertension is here.  The story comes out that five days ago he couldn’t move his left side.  They didn’t take him anywhere, afraid of going to a hospital with the Ebola epidemic going on.  Then yesterday, he stopped moving his right side and went into a coma.  I explain to them that he’s had a severe stroke and we could admit him but even if we were able to get his pressure down and he came out of his coma, he’d still be paralyzed and probably die a slow painful death of aspiration, malnutrition and bedsores.  Here there just aren’t rehab facilities for strokes.  But considering his condition, he’d probably die in the hospital anyway like several others already this week.  I suggest they take him home.  I give them a few minutes to think about it and go see the next patient.

“What’s going on?” I inquire.

“He fine yestuhday. He feel tinglin’ in his hans and take Amodiaquine fo’ da malaria. Today, he don’ eat, he feelin’ weak, reauhl weak.”

I ask all the other questions about fever, vomiting, diarrhea, etc.  They deny it all.  I look at him. He’s diaphoretic and cool to the touch of my gloved hand.  He is semi-conscious and a rousable.  No staining anywhere to suggest incontinence, diarrhea or vomiting.  He’s a diabetic, they add.  I figure it’s probably hypoglycemia from the Amodiaquine, possible malaria and not eating.  I have them bring him in.  The nurses quickly get an IV going and give him IV Dextrose.  We draw some labs and take him up to the wards.

I go back to screening patients.  A half hour later, the nurse comes from upstairs.

“De man vomiting bad.”

I go up and find the man I just admitted in his own room to the opposite side of the stairs from the other rooms.  It turns out to be a fortuitous choice.  I look in.  The man is lying on the ground, moving agitatedly, a pile of bilious vomit to the side.  I get the family members some gloves and chlorine water to clean it up and go down to check on his labs.  They are essentially normal except for “possibly” some malaria.  Not likely to cause the man’s severe symptoms in a hyper endemic area.  I’m suspicious and feeling like I shouldn’t have admitted him.  Maybe it was super early Ebola.  Or the family was lying.  I go back upstairs and find he has vomited two more times.

“Ok,” I tell the nurse.  “We’re shipping him out to the ELWA Hospital to the Doctors Without Borders camp to get him tested.”  I explain to the family.  They call a car while I get them protective gowns, gloves, masks, etc.  Then the four women (the male relatives have fled) carry the patient down to the car and we disinfect the room.  I’m thankful that our staff are so careful in having as little contact as possible and wearing gowns, gloves, boots at all times. I go downstairs and there’s a man lying in the PA’s office.  He was shot by the police in the lower abdomen four days ago and has been wandering from hospital to hospital, getting a few drips and dressings, looking for someone with the courage to operate on him.  Finally, he went to the government hospital who brought him here and requested to use our facilities so their team could operate on him.  Fortunately, our administrator, Mrs. Carter, is a strong woman and a straight shooter.  She told them no way.  We have our own surgeons and they have their own well stocked facility.  Either they operate on him at their hospital or we operate on him here.  They left.

Amazingly, he is able to walk upstairs to the OR with a little assistance.  The anesthetist hasn’t showed, so I offer to do anesthesia for Gillian.  I give him a spinal and Gillian get’s operating.  The spinal doesn’t get the upper abdomen and when he starts flinching I give him Diazepam and Ketamine boluses and start a Ketamine drip.  Gillian finds five holes in the small bowel and a wound in the rectum.  Amazingly, after four days, his abdomen isn’t full of stool or pus.  He’s managed to wall off the stool in the left lower quadrant which is certainly why he’s still alive today.  Gillian inserts a suction catheter into the first whole in the bowel to clean it out and pulls out a 4 inch long round worm still wiggling!  She completes the rest of the four hour operation, doing a bowel resection, side to side anastamosis, rectum repair and colostomy.  

When Gillian starts to put the edematous intestines back inside, the patient vomits, despite having an NG tube in which is supposed to empty his stomach!  I call for suction, but we only have one machine and it has to be disconnected from Gillian’s tubing and attached to mine.  Finally, I am able to suction out the green goo gurgling out his mouth as he desaturates into the 60’s.  The first thing I pull out is another 4 inch long round worm, also squirming and curling.  I clear out the rest of the gunk and Gillian finishes the case. He is having a harder time keeping his sats up after vomiting.  I’m afraid he’s aspirated.  With a lot of oxygen the sats are staying the low normal range, but not 100% on a couple liters like the rest of the case.  I listen to his lungs as the surgical team puts on all the dressings and notice he has markedly diminished sounds on the right.  I percuss and find dullness to percussion.  I know it might be fluid in the lung from aspiration, but don’t want to miss something else since we don’t have x-ray.  I take a sterile 5cc syringe and carefully insert in above one of the anterior ribs.  Just posterior to the rib I get a sudden flush back of liquify blood.  

Gillian ends up putting in a chest tube and his breathing improves.  We take him out to the ward as soon as he starts to move and come out of his anesthesia.  He has an NGT, a chest tube, two IVs, a surgical drain, a colostomy bag and a urinary catheter.  We tie him to the bed to make sure he doesn’t pull anything out if he gets agitated when coming off the Ketamine (as often happens.)  I go home exhausted, make myself two peanut butter sandwiches, prostrate myself and pray and cry a lot and go to bed.