By Dr. James Appel - August 16, 2014

Here in Liberia things don’t start as early as in Chad, at least not at the Cooper Hospital. After a quick breakfast of yogurt and peanut butter and jelly sandwich I head out the front door into the small courtyard with the three story hospital just to the left. I squeeze through a narrow passageway between the wall and a flight of steps up to another residence. I turn right into a dim corridor with the open air kitchen just ahead opening to the other side of the building.  I turn left half way down and up two half-flights of stairs to the main hallway.  Patients are already lining up outside, but I continue upstairs two more half flights to the wards. I come in just in time for staff worship. When it’s done Gillian and I go downstairs and she shows me the triage area.

Because of the Ebola outbreak, we don’t want to let any cases enter our hospital. Our primary objective is to stay open to take care of the non-Ebola emergencies. There is another hospital in town taking care of the Ebola patients. If we let in one case we not only put ourselves at risk, but our patients as well, not to mention our staff. If this happens we’ll close down like all the others and then no one will have anywhere to go. So, we don’t let patients in. We set up a screen on the front porch. When patients come, we find out where they are from and their names. If they come from a village with a major outbreak that should be quarantined, they are turned away automatically. If not, then we ask them about symptoms that could suggest Ebola: fever, headache, sore throat, vomiting, diarrhea, any kind of bleeding, etc. If they don’t look sick and have less then 3 of the above symptoms we send them in to be registered. Afterwards, they come back outside. When we get their chart with the vital signs taken after registration, we call them in and consult them. The diagnosis is made almost exclusively on history as we try to keep as little contact with the patients as possible.  Then we prescribe meds and they go home.

Shortly after Gillian and I start doing this triage, a cab pulls up. There’s a woman inside, obviously pregnant and obviously not doing well. A man jumps out of the car carrying a note from a health center. It says she’s been in labor 2 days and is bleeding, hypotensive and has no fetal presenting part. We go to the cab.  I don gloves and palpate her abdomen. I feel fetal parts and instantly suspect a ruptured uterus. After asking her our standard Ebola questions and finding her to be low risk, we call for a wheelchair to take her up to surgery.

I’m still not registered with the Liberian Medical and Dental Council so I can’t do the surgery, so Gillian takes on the case and calls in the OR team. I go back down to triage.  I have just started when the administrator and medical director come up. They say it might be trouble if I’m seen working without permission from the council. They suggest I get my papers together and they’ll take it over immediately and see if they can steamroll the process. I find some copies of documents on my computer, others I’ve brought from Chad, still others I write up and print out. I also give them two of the passport photos I’d taken yesterday in the market. Dr. Soni, the Medical Director, takes the whole packet over to the Ministry of Health and soon comes back saying they’ve ok’d me to start working even though they won’t get all the paperwork finished until next week.

So I’m back at the triage. Soon another cab pulls up. A man hurries up with a flaccid preteen in his arms. I now have a nurse’s aid and an intern helping me. The nurse’s aid makes them take him back quickly and put in the back seat of the cab. I put on gloves and go over to see. They are saying he was just hanging up laundry on the line, but that on of the lines was a power line and he was electrocuted. The nurse’s aid steps back and says “He not breathin’, doc.” I verify that there is no pulse or respiratory effort and pronounce him dead. His mother starts flopping around screaming and holding her head. I take off my gloves and go back to triage.

I finish with the outpatients by noon and go to see what’s happening with the c-section. Gillian has just finished and is writing her operative note. The anesthetist and OR assistant are transferring the patient to the gurney. She is still unconscious and floppy. They move her immediately to her room. There is no post-op recovery at the hospital. After she’s in her bed I examine her conjunctiva: white. She has lost a lot of blood. There is no blood bank but

they’ve been working on getting family to donate. They don’t want to. They have gone across town and bought a bag from somewhere. We get that running. She has only one IV, a small one in her left hand. She is still hypotensive at 70/40 and tachycardic at 138/min.  The nurses are trying to find an IV, even on her feet and ankles, but there is no access. The blood is running very slowly. Then it stops. The tubing is clotted off. We get more tubing. We have no central line kits so we are trying to get a regular IV in the femoral vein. I finally get one in the right one but it’s very positional. I have to sit there holding the catheter while IV fluids pour in. Another bag of blood finally comes. The woman is still unconscious. Finally, the pulse slows down some, but still not ideal. Blood pressure is a little better. We call family to try and get more blood. At least we have two good IV’s running now with blood in each. I take a break and go eat a late lunch of spaghetti and cucumber salad.  Gillian stays with the patient.

It’s late afternoon by now and I go relax a little, take a shower and do some laundry by hand. I Skype with Sarah and the kids, the first time I’ve seen them in about a month.  Then I go to bed.

I toss and turn all night.  I’m worried about the woman with the uterine rupture and Ebola keeps lurking in my nightmares as a constant veiled threat. Finally, I fall asleep at about three and wake up after 7:30. Right before 8:00 Gillian comes to the door.

“The woman coded last night. Fortunately, the nurse called me in time and we were able to give her adrenaline and more blood and she came through. I’ve been up all night, though, and am exhausted. There’s two c-sections to be done, can you do them?”

“Sure, that’s why I’m here…”

To be continued...