I am in good health. Many deaths (non-ebola) occurring at this hospital these past two days. Im having significant personal struggles with things unrelated to Liberia. Please pray for me! Greg
Liberia #18
Liberia #18
A mid 50’s European man comes in with hiccups. They have been to a variety of places today trying to get him placed in a hospital. The man has had hiccups for about a month. He says they are worse at night, almost stopping his breath. He is well educated and doing some teaching here. He’s been treated for malaria, and denies any other symptoms other than being weak. I talk to his European boss with him and admit him. His fever is very high at 40.1C about 104F. As I walk him upstairs my differential gets larger. Is ebola a possibility? Fever and hiccups. Doesn’t meet criteria. He has denied all other symptoms and contact with anyone sick. His exam is not specific at all, eyes injected? I know the rate in the country is getting lower. Apparently the only area with new cases are near the Sierra Leone boarder, and last week there were only a few reported cases. I wonder if these are realistic numbers. As the nurses start he IV I ask them to take the necessary precautions. I also inform the patient of my concern and that they will be gowned up. I will check labs, and recheck him in a couple hours when his fever has broken. So though it is much less common now than a few months ago, it is still in the back of all of our minds.
A little while later a European military ER doc comes to see me and ask about him. I explain the symptoms he portrays and he decides to evaluate him in his mother tongue. After that, he concurs that the risk of this being Ebola is very low. At least I have a second opinion now. Have I mentioned, I like surgery a LOT better than general medicine!
I’ve made rounds on everyone. Apparently the nurses do not do dressing changes. When the OR team is here, they will do simple ones, but none today, Sabbath. So I do all the dressing changes too. Just as I am ready to do the dressing change of the 10 year old boy with burns, the nurse asks me to see him. He is laying still without breathing and without a heart beat. I start CPR, copious fluids come out his mouth and nose. They bring me a bag and mask, we give some medicines and continue CPR. I realize it is futile and stop. Did he get an overdose of pain medicine? Aspirate his food? So many questions, and no answers. I suspect overdose. I look for the reversal medicine in the “crash cart bucket”, pharmacy and downstairs storage. No one has heard of the medicine I ask for. I think I will prescribe differently here, from now on. We have been avoiding intramuscular injections, but I think it is harder to overdose intramuscular, so may go that route, or avoid it all together. Another old man is breathing slow after his pain medicine, I can wake him up. He got twice the dose that I ordered. There really isn’t an explainable reason from the administering nurse, I wrote for the lower dose, it was put in nurses medications as the lower dose, but both of these were ignored and the full dose was given.
I go and check on another patient that I asked for a foley to be placed who has been unconscious since admission. To much of the foley catheter seems to be hanging out. I palpate and can feel the balloon, mid urethra, blood is in the tubing. I get all the required materials. I remove the previous foley and reinsert another. It finds a false tract and curls in the urethra. I try a variety of foleys and still none pass. He doesn’t have a distended bladder so I leave him without. If necessary I will place a suprapubic catheter.
The military doc returns with a portable EKG machine. Great! Does an EKG and it shows sinus tachycardia (fast normal rhythm). We exchange phone numbers, and he offers to have me call if I have any questions or problems. I find out that their ETU (ebola treatment unit) is closing because of lack of patients. It will reopen as a severe infection temporary treatment unit. Good news on the ebola front and also a place to send other severe infections or patients. May open in 2-3 weeks. They will even have some ICU capabilities and be run by infectious disease doctors. Seems like a reasonable move forward.
“Doc, Ext bed 4 no pee pee.” I know him as the one I did bilateral hernia repairs on a couple days ago and his catheter fell out this morning. Since then he has been unable to void and is in pain. So I gather the equipment and head down there. I place the catheter and get more than half a liter of urine. He is relieved. Again I could only get in one without a balloon, so I tape it every which way to hope to keep it in place. I’m skeptical, but if he can make it through the night at least.
Liberia #16
Liberia #16
He lays on the operating room table moaning. He’s about 60 and covered in a hospital gown. Below his right knee a hole can be seen that is about an inch and a half wide and an inch deep and is a hole about the same depth. The hole is in his tibia. A terrible odor bathes the room as pus flows out of his bone. The ankle below is swollen to three times the normal size and feels soft and fluctuant. I put a needle in it last evening and got pus out. He told me that his leg has had the hole in it 10 years, and drains small amounts only. About a week ago his ankle became swollen and a couple days ago pus started draining from the hole. A septic ankle and chronic ostomyelitis are my diagnoses. I decide to use cautrey on this case, even though I suspect sterility of the device is suspect. Besides, how much more infected can I make a joint with pus in it? A spinal is attempted by the anestatist student, I seriously question sterility in all places, her teacher doesn’t really use sterile technique! I’ve seen him, dawn his sterile gloves then grab a bottle of rubbing alcohol to put on some gauze. (the outside of the bottle is NOT sterile). Everyone will get a longer course of antibiotics. After multiple bloody attempts, the anesthetist dawns his gloves and helps, getting it in. they patient lays back again. I insert a foley, STERILLY! Then I scrub, and dawn my apparel. I use the cautrey to make a cut vertically over the lateral ankle. Things look fine till I get down to the joint new level of stink, on the already pungent room. I can pass my finger from front to back along the side of the joint. So I open in the back as well. I flush in a liter or two of saline until it is coming out clear. We place a plastic flexible (penrose) drain and suture it in place. In the hole, mid-leg, I see dead bone, and pull out chunks. I bet there is more, but will stop at this for tonight. I suspect a sequestrium (retained dead bone fragment) but would like an xray before progressing. We don’t have one, so when he is a little better, will send him to another hospital for x-rays. (the referral hospital that is sending patients to us, JFK) His leg is wrapped with lots of gauze and then an ace bandage. He goes back to the floor when he is off oxygen and has stable vital signs. He is the last surgery of my day.
I began with rounds, right after the morning devotion at the hospital. I saw half of the 26 patients. Then I had to wait a bit till the OR team was ready to start. I did a small (by African standards) inguinal hernia with a bulge out all the time about 2 by 3 inches in size. I do a standard repair using mesh that has been sterilized in the autoclave. Then next one is similar, with two hernias that are larger.
“Doc, cam see emergency!” What’s wrong with them? “Pane to much de belly” As I follow Ruth downstairs to the cot in the room we call Emergency, I’m thinking of the different causes here. Appendicitis, typhoid perforation, ulcer perf, cancer perf, the list is much longer. A 14 year old boy is writhing around on the cot. I put a glove on and touch is abdomen. It’s rock hard and when I push down it causes pain, when I let up my hand quickly, he hollers in pain. Peritonitis! He will be the next surgery. They place an IV there and start Ampicillin and Chloramphenacol. I suspect appendicitis, but have been fooled by typhoid before, so I make a midline incision in the OR. Before the incision, we pray for him as is customary. Right under the skin is the fascia (the strength layer). As I open the peritoneum, pus flows up and drains down either side of his still abdomen. The amount we catch and goes to the suction canister is 250ml (half pint). Eventually I discover a necrotic appendix. I pull it up and tie off the base a couple times. I wash out the abdomen with many liters of saline, till clear. Then close up three layers. He should do much better now!
Liberia #14
Liberia #14
“Docta, ……… ca” Im sorry, repeat that again. “De… bleed…ca”. Slowly the cobwebs of my mind clear and Im able to make out a little more. I understood, bleeding and car. Ill come. I get out from under my mosquito net and head in to the hospital. At the car out front I hear a woman hasn’t had a period for two months and is now bleeding profusely. I put some protective gear on and then peer into the back of the car with my headlamp. A 20 year old girl looks back at me from the lap of another girl. Im praying internally, Jesus, please help me know if this is Ebola. Ive not seen any, and at 2AM I hope this isn’t my first. Does she throw out? (vomit) “Ya, she trow out.” How many times today? “won taim”. How many times did she toilet yesterday, or today? “She no toilet!” Seriously? How long since she had a bowl movement? “She no toilet!” No diarrhea? “Ya” But BM? “Ya, Yestaday” After a long drawn out conversation, they deny headaches, feeling sick in the past few weeks, weakness, being near anyone who died… I have an uneasy feeling. I look at her eyes, they are very pale. I again ask for heavenly help in deciding what to do. No discernable answer. By bringing here in, if she doesn’t have ebola- I can likely save her life, with a curettage and some blood. If I’m wrong she will die, and potentially infect workers and potentially myself. I decide to curretage. Everyone is gowned up to the hilt, to bring her in the hospital and up the couple flights of stairs to the delivery room where I will do the procedure. I go and get on all my gear too. The gown is to short and I have difficulty zipping it up completely in the front. I need the extra length on my arms, so I don’t get a space between my gloves and the sleeves. So I leave it unzipped a little, at least it is really tyvec, the correct material! I place an apron in front and we give ketamine. In seconds she is out. I examine the area of bleeding. There is a placenta partially out the cervix. I remove the rest and use special instruments to scrape any that remains out. I have nothing on me and she is no longer bleeding much. I again pray that I have done what is the right thing to do. I go back to bed, and toss and turn for a while. I wake up early to talk to Audrey, and the signal is good so we skype, that’s always great!
I find out after worship that the vomiting has stopped, the bleeding has stopped, and I am grateful to have done the right thing. I am more comfortable now, and can focus on other things more clearly, even though a bit tired. There are 18 patients in the hospital. So we divide and conquer. Then to the operating room.
Fully gowned and sterile, we pray, then I place the blade on the abdomen, and with a swift stroke, the edges pull apart and the usual bleeding starts. I’ve chosen not to use cautery on this surgery, because I have a suspicion that the cautery cord isn’t really sterilized well. We dab, and put little clamps on vessels that bleed more quickly. There is almost no fat, so right after the skin is fascia. I slowly enter the inner layers, exposing a smooth broad surface. I put my fingers in, and then use scissors to open the rest of the abdomen. It is a huge cyst. It displaces all the intestines up to near the sternum. She hasn’t been able to eat much for a while, as there is no space in her abdomen. I remove the ovarian cyst, about the size of a womens volleyball. Later we weigh it, 2.7kg (6lbs). I think a gallon of milk is 8lbs. She has an umbilical hernia that I repair that in the closure.
The remainder of the afternoon is filled with >15 outpatients. And the occasional “emergency” sick person in the back of a car, 2 of which I admit, one I turn away with horrible edema and liver failure. I have nothing I can do for him. Surprising enough, he had had most of the labs I would be interested in at another place in town. So the labs and the yellow eyes, confirmed that I couldn’t offer much.
