By Dr. James Appel - September 7, 2014

After a day of panic, turning away more people than I probably should of just out of fear of lies, Ebola and the unknown, I settle in Friday night for some reflection. I try to calm my spirit with music and reading, nothing works. Then I finally just fall on my face and sob and sob until my shot nerves are exhausted and calmed. Then I sleep. The next morning, despite the vicious rain storm pounding the hospital, I see things clearer. My spirit is back on track and fear has been pushed back again.

Fortunately, there aren’t too many inpatients, only 17 and I quickly go through rounds. Unfortunately, the boy I gave my rare B negative blood to three days ago passed in the night. His cerebral malaria just overwhelmed his internal organs and they all shut down. The man with the liver abscess that I put a drain in has had 400mL of thick pus come out and he’s feeling a lot better. The boy in traction with the femur fracture greets me with a big smile. Always before he’s been crying and whining and begging for us to let him go home to let a traditional healer have at it. I’ve been stalling and cajoling and threatening the family members. I’ve said that if he leaves against medical advice then I won’t pull out the traction pin and then who will do it? That bought me a couple of days and today, his pain is better and he’s smiling saying he’s willing to stay. I’ve also kept him by promising that the instruments and materials to do the SIGN intramedullary nail are on the way.

I go home and relax. I listen to some talks and some music. I read some more in several of the books I’ve been reading. I take a little nap. Then I get called back to the hospital in the early afternoon. A woman is out in the car. She is four months pregnant and they say she has “no blood.” This sounds initially like some sick deja vu, but I go out and this time she looks tired, but not sick and she’s not bleeding from any where. Her conjunctiva are actual pale, as are her palms and soles. She does have a fever but as I listen for any warning signs from my gut, instinct or still small voice I hear only silence encouraging me to admit her. We get an IV going with a loading dose of Quinine and find two donors as well as an extra bag of O+ blood in the lab fridge.

Gillian and I then go out to a cafe to meet with Cameron, a veteran doc with MSF (Medecins Sans Frontiers/Doctors Without Borders). He fills us in on what they’re doing in the fight against Ebola and the grim reality that it’s still on the upward side of the growth curve. He’s with the Parisian section of MSF and their role is to help the health care institutions, especially the hospitals like ours that are still open, to have better infectious control measures. He gives us a lot of good advice and promises to come with his team to the hospital in a week or so.

I go back just in time for the security to call me about an emergency. A tall man is standing in front of the main entrance clutching a bloody shirt to his neck. His shorts are spattered with large patches of drying blood. His shorter brother is anxious and quickly states that he was stabbed in the neck about half an hour ago. I bring him in, holding pressure myself with a gloved hand. A nurse comes down from the inpatient ward and starts an IV. He appears to be hemodynamically stable, lungs are clear and his conjunctiva are a normal color meaning he probably hasn’t lost too much blood. Once the IV lines are in and fluids running fast, I gently take away the shirt and a pool of dark blood wells up. I quickly put more pressure on with some gauze, directly over the wound and the bleeding instantly stops. I have the nurse’s aide hold pressure while I go tell Gillian. It’s her day off and she’s with her “adopted” baby that she watches every Saturday. She states we can explore it under local anesthesia.

I go back and we have the man walk upstairs. I’ve already got the OR ready, turning on the lights, putting a drape on the OR table, unlocking the anesthesia cabinet, starting the A/C and putting on my hat and mask. We lay the man down and I pump up the bed so it rises to a comfortable height for me. I get the local anesthetic ready, give him some Diazepam and then take off the gauze. Having had about 10 minutes of direct pressure, the bleeding has stopped. Maybe it wasn’t that serious after all. The wound looks shallow and wide, like a glancing blow. I infiltrate the skin with Lidocaine and then prep it with Betadine. Apparently, I’m too rough with my application of the Betadine as the venous bleeding starts pouring out of the wound again. I quickly apply direct pressure again with one hand as I anesthetize the small laceration on his lower sternum that I’d noticed earlier but that was very superficial and barely bleeding.

I drape the neck and sternum with sterile towels, put on sterile gloves and then have the nurse’s aide remove the gauze. The bleeding has stopped again. I raise the lower skin margin with forceps and see a decent sized superficial vein running along the platysma muscle that was lacerated but is currently not bleeding. I do a figure of eight stitch around it to make sure it doesn’t re-bleed then close the subcutaneous tissues and skin with running sutures. I close the sternal wound after irrigating thoroughly and exploring it to find it goes down to the sternum but didn’t damage it. I’m about done with the man shows me his right thumb which also has a 2 cm knife wound on it that I suture.

I’m cleaning up when I notice crepitus under the skin over his left upper chest. Could the knife have gone down and punctured his left lung? I don’t have x-ray but I have the nurse’s aide bring me a stethoscope. He sounds like the breath sounds are equal on both sides. Also, his O2 sats have remained 99% on room air the whole time and he’s been breathing easily. If it is a pneumothorax, it’s small and asymptomatic so I elect not to put in a chest tube. 

I then go and Skype for over an hour with my family and enjoy watching my kids run around and play and act silly.

The next morning, Sunday, I awake with a bit of a panic. What if the man got worse overnight and no one noticed? I get up, even though I’m exhausted and it’s supposed to be my day off and go up to the hospital. I go in and see the man lying comfortably in the bed. He’s breathing normally and his lungs still sound symmetric and clear. I breath a sigh of relief and go home, ready for my day off.

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