Liberia #23

Liberia #23

So what kind of work are you applying for? I ask.  Is it manual work or a desk job?  “It is both manual and desk werk” What will you do?  Oxfam, do community education and I will help wiff dat.  And I will haf workers working for me and desk werk.”  From yesterday when I saw 4 people needing history and physicals filled out by a physician, the word must have gotten around, and about 9 others came in today for a H&P.  Each one was essentially the same.  Guy and gals applying to get jobs at Oxfam and needing this paperwork filled out and sent in, so that they could have documentation that they were healthy enough to do the job.  I would think an employer would want to contract with one doctor to do all of theirs the way they wanted, but apparently not.  The ones that the PA had seen, got lab work with hemoglobin, blood type, syphilis, malaria, urinalysis, random glucose.  None based on any suspicion, but just because.   The ones I saw were rather healthy, by their own description and my physical exam, so I didn’t order these tests.  Later I was questioned by the administrator as to why I hadn’t ordered tests, guess it is the thing to do even though it wouldn’t change my recommendation or not for work.

“Doc, der tree emergency in de car”  Where? “Outsite” I am very frustrated, by then having spent all afternoon doing H&Ps.  People milling about outside are in an uproar, as they have been waiting in the sun all day to see the PA, who after working 7 hours is still on the 11th patient.  I don’t see how many numbers there are, but plenty of people milling about.  As soon as I walk out a mob of different people start pointing toward their car indicating I should see them first.  A mini verbal battle ensues.  Eventually I see the red car first and walk that way.  Another man is still not satisfied, said that I had seen them Monday and recommended surgery and now they are back and ready for it.  I realize that he is referring to the woman who had a gangrenous foot that I told needed an amputation THAT DAY, and they left because they didn’t want it.  So in my current, annoyed state, I tell him he will be last!  In the red car, there is a woman who has a history of hypertension who “fell off” yesterday afternoon.  This means she passed out, or became unconscious.  They said she had a headache for three days.  Hadn’t taken her antihypertensive meds for three days and has a cough as well.  I ask if the cough preceded the headache, no.  Does she cough by herself, or when you try to feed her or give her a drink?  With food or drink.   Before yesterday while unconscious or after that, like this morning?  Yesterday evening and this morning.  So they are trying to feed and give water to an unconscious person, and they are aspirating it- thus the cough!  I discuss the grim prognosis with them, and explain what we can do is supportive.  Place a nasogastric tube and get her blood pressure down, and see what happens.  They are content with that and want her in the hospital.

Before I see the next car, I am pulled back into the outpatient tent to see a chactetic woman who looks like she is almost dead sitting in a chair.  She is 34 and has been unconscious for 3 days.  Before that, she has had black stools for a month, and throat pain for a month, now cannot swallow her own spit.  I look at the labs.  She is HIV positive, and it seems since everyone has been interested in Ebola, that HIV meds are not being taken care of as before so the HIV patients are coming down with all the opportunistic infections that immunosupression can give rise to.  I suspect she has HIV related encephalitis causing her unconsciousness.  Her glucose is normal, so that’s not it.  Gillian says she’s not seen anyone survive with encephalitis here.  And considering the patients state, she will not last long either way.  I tell the family that whether I admit her or she goes home, either way she will likely die.  They decide to talk about it.  Later after hearing that they would have to pay a hospital bill, they decide to go home.  I’m relieved a little; I think she would die before making it up to the floor anyway.

I go to the second car.  Again the same other guy tries to pull me to his car first. I tell him he is last.  The other car has a heavy set old woman sprawled out on two peoples laps.  Story is similar to the first.  One day of headache then loss of consciousness.  History of hypertension and diabetes.  I ask the usual Ebola questions- all negative per the bystanders.  I put on gloves and reach in and look at her eyes, pale.  I rub hard on her sternal bone- she retracts up her arms, but doesn’t grab my hand.  Not a great sign.  I write admission orders for her as well, telling them the same grim prognosis.

I go and see the last car waiting.  It is the woman I saw 3 days ago with a huge hole at the base of her big toe and rotten tissue oozing out of the middle of her foot.  She is now taking very slow breaths, and is unconscious.  So now he brought her in, because she is dying, or nearly dead, now ready to do the amputation.  She appears to be in her last agonal breaths.  I tell him to go home, she is dying, and that at this point, it’s to late for her.

It is tough sending people away to die! I know they would die even if I admit them though.  At home, I would admit them, and try everything.  But then again, I have tests, and ICU, a ventilator, continuous oxygen for days if needed, lab tests whenever and however often I need them, other doctors to help manage them if I’m stumped or want assistance, nurses that follow doctors orders to a T… Pretty much none of that applies here.  So I send them home.  In some ways I feel we go to far in the US, prolonging “life” beyond what was meant to be or called life.  Here we are on the other end of the spectrum.  I think some middle ground might be better.

I go back to the floor, to do dressings that haven’t been done this morning.


Liberia #22

Liberia #22

Precious is standing at the nurses station and Bendu walks up.  Bendu says “Doc, der a patient fo ultrasound”.  I’m just finishing rounding on most of the 10 inpatients we have.  And surprising enough they are mostly surgical.  I saw the guy I did the bilateral large hernias on.  The guy who I did a below knee amputation, let me digress and talk about him.

So this man came in with a long standing bone infection and a hole in his leg about mid calf.  The foot was swollen, I opened the joint and pus flowed out.  After many days of dressings, he developed a necrotizing infection that can kill you quickly.  I finally convinced him to let me amputate the leg below the knee.  In the operating room, I asked what saw they had to cut the tibia and fibula (two leg bones).  They had some giant cutters for the smaller bone, and a hack saw for the larger bone.  I did the usual operation of cutting through the muscle with cautery and a scalpel.  Then cut the smaller bone with the cutters, then slowly sawed my way through the tibia with the hacksaw.  It had been autoclaved, but the blue paint on the blade stuck to the cut surface of the bone.  The bone marrow had been replaced by fat- not a great sign.  I used a pitiful appearing rasp to try and get off the blue paint unsuccessfully, but took off all I could.  Eventually I closed it with a drain.  He has been healing well and no sign of infection- in spite of blue paint on his bone!  I am certain that God protects many things we do, especially in these locations where what is best, isn’t available.  Why He doesn’t or can’t intervene in all circumstances- is a question I want to understand some day in Heaven.

So back to rounds.  I saw the old woman with an infected foot, who is slowly improving after debreding off a lot of dead tissue.  I see the burn guy Ernest, that we have been doing daily dressings for my whole time here and slowly is healing most areas.  A young woman with PID (infection of uterus), likely sexually transmitted diseases we don’t have tests for.  I get called downstairs to see a man we did a prostatectomy on.  He wants his urine catheter out.  I go see him, and tell him we cannot take it out for at least a couple more weeks.  He had a catheter placed incorrectly and it all needs to heal over the tube before removal.  He’s not too happy, but will come back on a couple weeks.

I do some ultrasounds.  Most of them are pregnant women who want to know the babies position and sex.  One says she was told she has twins at an outside hospital.  I can only find one 8-month-old fetus.  I look and look and cannot find another.  That is rather disconcerting.  I tell her I do not know why she was told that, but I can only find one child.  Is it my ability to identify the correct findings, or was it the other place?  Either way, I don’t like it!  Another woman has excessive bleeding at her periods.  I find a small fibroid and treat her with medicines to help the bleeding.   Another 18 year old comes in with her mom, to know the sex of the child.

In the evening we hear that there has been an explosion at a rubber plant “in the interior”, meaning anywhere but Monrovia.  And that we will be getting up to 9 patients that have been burned.  Later we hear that this explosion occurred 5 days ago, and that the four most critical went to Firestone hospital (named after the town where Firestone tire company has it’s plant).

I finish what I’m doing and Dr. Seton needs to go the store, so I ask to go along to get some bread, lentils, and drink mix (Fosters).  Just as we are ready to go, the “ambulance” arrives with the 9 guys.  I grab a bunch of blank paper and head down there.  A quick glance, and I observe a group of guys that look tired but not severely ill.  Most have bandages on arms and legs.  One has a cast on a leg, another with his arm in a sling.  At least they don’t appear to be dying in front of me.  So I take my time and go one by one.  Dr. Seton helps when she is free.  Of course, whatever x-rays they have had- they did not bring with the patients.  And as I’ve mentioned before, there is no functional x-ray here.  The reference form for the guy with his arm in a sling- says that he has a posterior dislocation of his shoulder!  For 5 days no one has put it back in it’s socket after a diagnosis?  He will be one of the first I deal with once he gets to the floor.  I question the guy with the cast on his leg.  He says a piece of metal hit his leg.  I think he says that his skin is not broken, but I will have to verify this later by cutting his cast off.  I’ve seen to many open fractures that don’t heal or pus out, for lack of appropriate care.  So will not just take his word.  Besides, I’m not entirely convinced that he said there was no break in the skin, even with the translation of one of the other guys.  Another guy has total hearing loss after the explosion.  He has no visible injuries, and nothing draining from his ears.  We do not have even an otoscope to look in his ears.  Wish I had brought my personal one.  He motions and “reads” lips.  Others have blisters on their arms, where steam burned them.

Later on, we go back and change all the dressings and look at each burned area.  I give the guy in the arm sling a slug of Ketamine and he goes out.  Then with traction and counter-traction, I am able to get his arm back in socket.  It feels a little different than before.  I wait till he is awake later and confirm that he can move it all over, without pain.  Surprised that it went back in so easily after being out of joint for 5 days.  The guy with the cast, I cut in half along either side of his leg.  After taking off the top half, I inspect the lower leg; it is swollen and tender in the lower half.  I move the bone and see a place where it is moving but shouldn’t be.  No break in the skin.  I replace the half I removed and then replace plaster of paris cast material to solidify it again.

During the course of the day we admitted 3 others.  So we went from 10 yesterday to 25 patients today in the hospital.


Liberia #21

Liberia #21

There is good news! As I was talking to Audrey this morning on Skype, she looked up Ebola and Liberia. Apparently the news this last week from the health minister, was that there are only 5 confirmed cases of Ebola currently in the country. A few months ago, there were around 300 new cases, in a week or maybe more. So that is encouraging.

I rounded quickly this morning in hopes of going to church, as it is Saturday. We have 10 patients currently. It is nice to have a little reprieve. Rounds took about 40 min. It is amazing how fast things can go when I do not have to document in a computer. And when there are so few labs and other things to follow up on, that speeds it up as well.

At midnight last night, I’m called to see a Lebanese man in a car outside. He has been short of breath for three days. He got a pacemaker somewhere outside Liberia a couple years ago. I felt his pulse with my gloved hand, irregular. I listened to his heart and lungs. It was difficult to tell what the sounds were from all his groaning, that apparently he couldn’t stop. As we have no EKG or chest x-ray. I recommended that they go to another hospital. Maybe ELWA or the catholic hospital. They were hesitant, but eventually I convinced them that he was better served elsewhere. The other man was pleased and put up his hand for a fist bump- seemed a little strange, but we bumped fists, his and my glove. They drove away in their Subaru legacy.

Sabbath afternoon, I came “home” from church and took a nap. In the evening Dr. Seton and I went to meet dr. John Frankhauser from the ELWA hospital for supper at the Sajj restaurant. He has been here for a little more than a year and had a leadership roll in starting the first ETU (Ebola treatment unit) at the ELWA hospital. This is the same hospital that Kent Brantley, Rick Saccra, and Nancy ? were from when they contracted Ebola. It was nice to sit and talk with him. Apparently they have a 40-bed hospital and besides Cooper Hospital are the only other hospital fully functional. He and one other doc, swap call every other night to take care of patients. Apparently they do many C-sections for obstructed labor, while on call. The Sajj was lovely, I had a vegetarian pizza, and it tasted great! That is the same place I got a falafel sandwich last time.

Later in the evening we were invited to Peter’s place for a barbeque. He runs an NGO that manages and equips all the burial teams in Liberia, 60 in number. The compound was lovely. A series of apartment buildings, with guards. A flower garden out front, with a huge pool overlooking the ocean. There were about 15 people there, all from different NGO’s. Apparently Peters NGO is turning down donations, because they have so much money. Wish that Cooper Hospital had that problem. Then maybe we could get some reasonable blood work, get an EKG, and maybe have a functional X-ray! Hard to diagnose things with only ultrasound, and suspicion! I had a nice time talking to different people and finding out about their NGO’s and what they were doing here. Got back late and hit the sack, after my bucket bath.

Liberia #20

Liberia #20

How big does YOUR hernia have to be before you want it repaired? Now Ive seen old pictures in textbooks of men with their scrotum in a wheelbarrow because it is so large with elephantiasis. But for a hernia, not quite that large. How about when your scrotum is the size of a lemon? An orange? A grapefruit? Ive seen all these sizes this past week. Single side, both sides, young men, old men. All with pain that they have supported for months to years.

Im called to see a 14 year old girl in a car. I go out and listen to the story. Her father is well dressed in his slacks, nice shirt and tie. She sits in the front seat of what looks like a Honda accord. She has had rectal bleeding for 2 days. A week ago she had headache and fever. A little diarrhea yesterday. She hasn’t been around anyone sick or any dead people. I determine that she has enough symptoms to warrant an evaluation at an Ebola Treatment unit. I do not examine her. I prescribe some Cipro and Flagyl, in case this is dysentery, and refer her to the ETU.

“Doc, dere a burn” What? “Dere a burn outsite”. Ruth is telling me that there is a new patient with a burn outside. I ask where and she calls the name. A grandma, carries up a 1year old boy with both legs blistered and the right foot, white. I put on my gloves. The boy is not crying. As I touch a couple areas he crys, then stops when I stop. I touch his white foot, nothing. This is likely burned deep enough, that it has burned the sensation nerves. We check his temperature, and ask all the usual screening questions, to which all the answers are no. I have them weigh him and then start calculating how much fluid to give him within the next 8 hours then rest of the day. (there are specific formulas for this in burn resuscitation) I ask the family to find honey, so I can do the dressing with it.

Another girl arrives in a car outside, and Im asked to go down and evaluate by the PA. This week the PA’s are working- so much nicer not to have 30 patients in clinic waiting for me. This girl is late teens, or early 20’s. She has sores all over her body that they say have been there for a couple months. There is traditional “medicine” (looks like dung and grass) on the top of both feet which are each a huge sore. In Cameroon this would be to “draw the pus out” It is very effective. Imagine, you put cow dung on a open sore, and sure enough, pus comes out!!! She has had some vomiting and looks a bit pale, had a fever yesterday. This could all be from the chronic wounds, but Im not taking chances. I decide to prescribe her some medicine and send her home. I tell the family how to clean off that dung, and put honey and a dressing on those areas twice a day. I give her antibiotics and iron. If they do these things, she is likely to do well. If not, she won’t make it. This is the sad reality of living in the land where Ebola resides, everyone is cautious or over cautious. Many hospitals are still not providing any real services, partially because of staffing, partially because of fear…

A man arrives this evening who is short of breath. He has been this way for the past three days. He has a host of labs done at another hospital, and a chest x-ray. The labs show he is HIV positive, and has a high white blood count. The x-ray shows near complete white out of one side and markings of pneumonia on the other. I admit him and start treating for suspected HIV related lung infection. By the time he makes it to the floor he is dead.

I want to go for a run/walk on the beach, but am called to see another boy. He is 22 and has a urine catheter poking out of his lower abdomen from his bladder. It had been placed more than a year ago when he couldn’t urinate. He has been changing the catheter each month as requested, till this time when it has been 2 months. He went to another hospital and someone tried to pull out the old one and put in a new catheter. The old one came out partially. The balloon was outside the skin, but the tip wouldn’t come out. I gave it a good pull, stretching out the tube from 1 inch to 3 inches. The patient was all over the place but the catheter didn’t move. I didn’t have any instruments in my office. So I went to the storage room to look around. The OR was already locked. So I find a pair of clamps and put alcohol on them and poke them one in beside the tube. It was a slow process, causing a bit of pain. A catheter that has stayed in a while develops some hard stone like, buildup on the tip. So I slowly crushed this and eventually was able to get out the catheter. I reinserted another sterilely. He was much happier. I hope he can get a urethrogram and then come back, we may be able to help his stricture.

It is way past dark, so no run on the beach tonight.