By Dr. James Appel - August 20, 2014

The baby is back, little baby Moses who can’t peepee.  Of course, the catheter I put in yesterday came out.  The mother brings it with her.  

I sterilize it in diluted bleach water and reinsert it into the tiny bladder.  Now that the staff is all back to work, I admit the baby so we can keep an eye on the catheter and put it back in quickly if it comes out.  We want that distended bladder to shrink back down to normal so Moses will feel the urge to peepee before his bladder gets ridiculously huge.


Yesterday, we had a staff meeting with almost all of the 90 or so staff.  It seems there was confusion about a lot of things.  But in the end, the leaders were inspiring and everyone’s questions were answered so most have returned to work. It’s such a different feel with a full staff. I don’t feel so alone and running around like a chicken with its head cut off.


Gillian and I continue to share the load of screening patients outside.  I happen to be outside when a yellow cab pulls up and about 5 people pile out, including an obviously pregnant woman howling in pain.  I ask her the typical screening questions and that combined with her obvious health (despite her screams of pain) lead me to quickly admit her to labor and delivery.  It’s her second pregnancy.  The first was delivered by c-section for having cephalopelvic disproportion (pelvis too small, baby’s head to big.)  This will be a perfect case for a pubic symphysiotomy.


The midwives get her set up in labor and delivery, start an IV and try to get in a bladder catheter.  Gillian gets the instruments, suture, scalpel blade and lidocaine.  I put in the foley catheter by pushing up on the head between contractions. The head is very deformed and the cervix is dilated completely.  Ideal indications and conditions for the symphysiotomy. I clean the front of the pelvis and groin with chlorhexadine and inject down to the cartilage holding the pelvic bones together in front.  I slip my fingers inside to displace the foley catheter (and thus the urethra) to one side and also to give me a sense of depth perception so I don’t cut too deep. With my right hand I make a skin incision and then cut down directly to the cartilage.  Slowly and methodically I slice through the cartilage layer by layer.  It’s all by feel and I stop periodically to feel where I am with my index finger.  Finally, I have the two assistants pull the hips up and out and the pelvic bones separate 2-3cm. “Stop!” I order, and then stuff an open compress into the bleeding wound for hemostasis.  The baby’s head has already descended and with 3 good pushes the bay comes out looking like a cone head and eyes bulging from being compressed in the narrow birth canal so long. I suck out the gunk from his mouth and nose and then put him on mommy’s belly where I clean and dry him before cutting the umbilical cord.   His eyes are open and he’s breathing but kind of floppy and not as pink as I’d like.  And his cry is weak.  We stimulate, dry, suck and finally take him to the OR for oxygen before I’m happy with his skin color, muscle tone and cry. I gently pull out the placenta and Gillian sutures up the wound and the mother keeps smiling and thanking God. I go back to the Outpatient Department and see a few patients.  One of the Physician’s Assistants calls me in to see a patient.  He’s had severe right lower quadrant pain since yesterday morning.  He hasn’t been vomiting but otherwise his history and physical seem to confirm the PA’s suspicion of acute appendicitis.  The weird thing is he came in yesterday afternoon and the PA told him to come back today since we were all in a meeting.  I would’ve been fine seeing him yesterday evening.  Oh well. I ask Gillian to confirm and she agrees and takes him to the OR. I go back to screening patients.  Just as we are about to close another cab pulls up.  Inside is an unconscious man with labored breathing. He has a history of hypertension and yesterday received a call that his son had died in another town in the hospital.  He kind of went crazy and started to go downhill culminating in a coma since this morning.  He doesn’t look otherwise sick and the family denies fever, vomiting and diarrhea so I admit him.  Our lab can’t even check a blood sugar but I think he might be hypoglycemic so I give him Dextrose right off the bat.  His blood pressure is surprisingly not that high.  His malaria smear is negative.  Then he starts seizing.  I suspect he’s having a hemorrhagic stroke and I know there’s really nothing to do.  But I give him some diazepam to stop the seizure, put him on IV fluids and leave him in the hospital bed, sending a quick prayer his way as I leave.


Just as I was getting the older man into the hospital in a wheelchair, a group of women come running up with the lead woman holding a floppyinfant in her arms.  I quickly examine the conjunctiva with a gloved finger: white.  He’s anemic and after quickly determining he hasn’t had vomiting or diarrhea and that he’d been seen last week in a health center and told he had anemia and malaria but was only given pills, I admit him for ablood transfusion and appropriate malaria treatment.  The ER nurse quickly finds and IV, the lab is on the case and quickly testing some of thewomen for potential donors and an Artemether shot is given while the Quinine drip is being set up.  The case is pretty hopeless but I’ve seen many similar cases pull through in Chad.


I go home, exhausted, more emotionally than physically.  Having the spectra of Ebola hanging over us is a weighty affair.  Just yesterday, a groupof thieves looted an Ebola isolation unit, stealing mattresses and linens and causing 26 suspected Ebola cases to flee into the city.  People have written me saying nothing should really be done because compared to the big killers—malaria, TB and HIV— Ebola is barely killing anyone. What people aren’t seeing from the comfort of their faraway living room chairs is that schools, businesses, government offices and hospitals areclosed.  Money is getting scarce.  Our hospital hasn’t been paid in months by the insurance companies and is running low on fuel for thegenerator and supplies.  People are dying more than necessary of treatable diseases because the hospitals are closed and they are afraid tocome in to any that are open (like ours) for fear of catching Ebola so they are waiting too long and then running around getting refused by mostclinics and hospitals until they arrive at death’s door here if they arrive at all.  The country is about to fail financially because of this.  As if theydidn’t already have enough problems.  But we shouldn’t do anything about Ebola because only about 1000 people or so have died.  I wish I could bring whoever wrote that article here for a few days, I think he’d be singing a different tune!

See the excerpt from “The Economist” below that I received by email.



Unseating the first horseman

The price of global health is eternal vigilance


WHAT should the world do about Ebola? A rationalist might say: nothing. Rich countries with decent health infrastructure are  not at risk because—unlike airborne viruses, such as influenza, or mosquito-borne ones, such as yellow fever—the disease can be isolated if treated with sufficient care. In the poor countries that are infected, the thousand-or-so lives this irruption is believed to have taken so far are fewer than the slaughter inflicted every single day by malaria, by AIDS, by tuberculosis or even by diarrhoea. In a world of limited resources, then, it is arguably best to concentrate on those big killers, whose treatment and prevention are well understood, rather than chase after an illness that is incurable and, on a global scale, trivial.