Liberia #8

administrator Greg No Comments

Liberia #8
I awoke at 6AM with a bursting bladder.  realizing I had hardly drank any
water during the day and sweat profusely with all the protective gear on
in the OR and also in the outpatient department, I had lost a lot.  so in
the evening I loaded up eating and drinking about three liters of water.
After I was up i had my daily devotions and went into the hospital
devotion.  After a reading and singing and prayer, the medical director
admonished everyone to always be vigilant about ebola and that in some
areas near Sierra Leone the rate was increasing.  he also admonished
everyone to verify that there were minimal people in the hospital and to
make family members stay outside- other than one person taking care of
the patient.  A little reality check!  He also mentioned that if they
planned on leaving work and starting to work for an ebola treatment unit,
please inform the administration.  apparently staff at an ebola unit make
10 times more than the locally paid staff.  So the 3 PA?s and many
nurses, haven?t turned a resignation. If they do it is the day before
leaving, but many just leave and never say anything.  This leaves one
nurse and an aid for the 10-40 patents.  And these people are working a
lot.
I made rounds starting at one end again, this time making it through
three group rooms before meeting the patients that Gillian had already
rounded on.  the prostatectomy patient from yesterday is doing well.
The urine coming out is clear with out blood, wonderful!  the guy with
the second and third degree burns had stayed NPO so we could take him to
the operating room and decide wether to debreed and skin graft or not.
the guy with an infection around his lung (empyema) is still draining a
lot of pus out of the chest tube, but the amount is lessening and seems
to be less viscous too.  the baby that was delivered by C-section still
had not drank any breast milk.  I asked the mom if she had milk and she
said yes, pulling up her shirt and squeezing her breast to show me the
nipple with a little dot of milk coming out as she did it. I am in
Africa!  here, like in most third world countries, breasts are a
functional body part only.  Another guy had a distended abdomen that I
was worried about, but after consulting with Gillian, who admitted him,
he was apparently much better, so we will continue to monitor him.  He
has sickle cell and malaria.  Next another patient with abdominal pain.
And more.  the abdominal pain is difficult to assess.  We have only
ultrasound as a means of evaluating the abdomen, other than physical
exam.  so much treatment is done based on suspicion. the possibilities
are many, and we try to narrow the possibilities some by physical exam,
history of the disease, and area of the abdominal pain.  And also look
for the local common reasons of typhoid and malaria.  I redrained a guy
with cirrhosis and ascites.  That means- taking a iv cannula and IV
tubing and sticking the cannula into the abdomen, and running the tubing
down into a collection bowl.  later when it stopped draining the nurse
removed it.  Only about a liter today.
We took the burn patient to the operating room to decreed and possibly
skin graft him.  Fortunately i was able to buy some dermatome blades just
before coming, that fit their machine, otherwise a large skin graft
wouldn?t be possible.  The patient waddled down to the operating room.
Upper thighs and both arms are burnt from about shoulders to wrists, and
neck and face.  So it?s painful for him to move.  I gave the anesthetic
ketamine.  Because of the areas he was burned, and already having had his
feet poked many times, we were unsuccessful at getting an IV.  So I gave
it to him in his muscle.  In about 10 minutes he started going to sleep,
and was relatively calm till the end.  Ketamine can make one hallucinate
and move a lot, salivate, and sometimes thrash around.  He was still most
of the time.  after taking off all the dead tissue, it did not appear
that a skin graft would be needed, so we redressed all his burns with
honey, and wrapped them in gauze.  gillian mentioned that on her burn
rotation, they had started using slices of raw potato on burns with
similar antibacterial effects.  I guess potato are not real cheap here,
unless sweet potatoes.
After that I went to the outpatient area and saw about 7 remaining
people.  Children and adults with pains, fever, cough, anemia
At about
6PM, i saw the hospital driver Robert.  I asked him where the nearest
store was, and he decided to take me.  Just after i changed cloths, they
called me to see another patient in a car out front.  i looked in on a
woman 60 year old woman who had spilt boiling water on herself 5 days
ago.  Because of her rural location she couldn?t come in till her sister
here in the ?city? heard about it and went to get her.  she?s burned on
her left arm, and left leg- hip to ankle, and right thigh.  They appear
to be pretty deep, but it is sometimes misleading until after debredement
or a few days time.  After asking questions about the different symptoms
of ebola and other burn related questions, i admitted her and went to the
store.  It was a mini supermarket.  They had quite a variety of stuff,
all priced in US dollars.  I guess in most major stores here, things can
be purchased in US dollars or Liberian dollars.  I bought some bread,
peanut butter, jam, toilet paper, ramen noodles.
After finishing and bringing my stuff back, I went into the hosptial.  A
10 year old girl who was breathing rapidly with cerebral malaria had just
died.  So I filled out the death certificate.  Another near by was
unconscious with malaria and vomiting rice and breathing poorly.  We
tried to get a suction to work quickly, but after about 15 minutes go it
to function.  He was breathing better then, but Im not surprised if he
aspirated a lot.  We will know if he becomes more short of breath.  No
chest x-ray- so all auscultation and coughing to tell.
I came back to my room and fixed PB and jelly and ramen.  then I realized
I was almost out of water.  So I?ve been boiling batch after batch to
make it safe to drink.  Hopefully Ill get some in the fridge, for some
cool liquid tomorrow.
i was able to Skype with Audrey yesterday, which was awesome, today it
wasn?t possible as the internet wasn?t working at that time.  i think Ill
dunk my scrubs in bleach water and hand wash some tonight, before i run
out of clean ones.  please continue to pray for the safety of all the
hospital workers.

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Liberia#9

administrator Greg No Comments

 

Liberia#9

 

Sitting in morning worship, they just had begun, when we found out that a lady in labor had a baby that the heart rate was low for that past 2 hours.  The nurse reported that she had contacted the doctor, which wasn’t true.  The baby was still alive but with a heart rate about 80, normal is about double that.  The anesthetist is only here Tuesdays and Thursdays.  So this being a Thursday, they would be here sometime after 9AM.  It was too long to wait, so Gillian asked me to do anesthesia for her.  I prefer to do the operating, but doing anesthesia sure beats doing rounds on all the medical patients (which I did later), or going to clinic to see the outpatients!  So was happy to do it.  A nurse got a functional IV canula in and then I started pouring in the fluids.   The delivery room is a room with one bed in the center, and another against the wall, if there are two women delivering at the same time, or not enough time to clean the central one before another baby is born.  Since being here, there always seem to be 2 or 3 women in labor that are waiting around for the delivery.  Though come to think of it, I haven’t yet heard screaming coming form there, maybe a few moans.  Most seem to be silent.  And of course after the delivery, they clean themselves with the nurse’s help and walk back to their room.

So I took the patient to the operating room.  Drew up my medicines.  After enough fluid had gone in, I cleaned her back with iodine, and placed spinal anesthesia.  Her pressure dropped a little, as expected, but was never low.  Dr. Gillian prepped her.  We gave her a little nausea medicine, and then the operation began.  The mother did great.  After entering the abdomen, the anesthetist came.  So I left the operation and went to do floor rounds.

Many of the same people were there as I described yesterday.  I did see some new ones.  A very thin lady lay on her cot next to the wall.  Her breaths were rapid and shallow.  Hollow eyes looked at me.  She complained of being to weak to eat, and not feeling like she was getting better.  I looked at her lab results, and she was malaria and HIV positive.  Black dots and patches marked her already black skin.  I found a stethoscope and bathed it in the chlorine solution.  Then went back to the room and listened to her.  It sounded like water bubbling inside at every breath.  I though of a lung infection common to HIV people, so I started her on high dose septra and steroids.  She was already on treatment for malaria.  So many things here are treated on suspicion alone; I hope my suspicion for her was right, as it may then help her.

I later heard that the baby that Gillian delivered did survive, it had been to long.  I found the lady I admitted yesterday laying on her bed mostly exposed.  It apparently hurt too much to touch the cloth at the burn areas, which was most of her lower body and left arm.  The family had gone out to get honey as requested yesterday.  So I had to wait to do her dressing later (done at 7PM when I got my first break in more urgent things).  Gillian saw a patient in the “ER” (a room downstairs with a bed and a nurse, without any other equipment) that had an axillary (arm pit) abscess.  So she took that patient to the OR while I continued rounds.  I was called out to see a sick person in a car.

In the entry to the hospital I put on the gown and gloves and walked out with the guard to the car.  He took the temperature with the infrared thermometer, and then I examined the woman.  She had generalized body aches and nothing else.  I did the few labs that were remotely possible, that I could check.  Malaria, typhoid, syphilis.  She had just finished treatment for typhoid, but I understand that there is a bit of medicine resistance here, because it’s treated so often.  Later on, when I had finished with some operations, I was asked to see her again.  All the tests were negative.  So I didn’t have much to offer her.  I gave her ibuprofen and multivitamin.  It seems like most people here (as in Cameroon) feel that a multivitamin will give them strength and a better appetite.  They seemed content and drove off in their car that resembled a Nissan Altima.  I stripped off my protective cloths, dumping them in a trashcan, bathed my hands and arms in chlorine from the bucket with a spicket, and dripped my way inside.

Next were two people who wanted ultrasounds.  One thought she had been pregnant for 8-9 months, and was told the baby was only 5 months at some clinic.  She felt the baby moving too.  I did an ultrasound, and she was NOT pregnant.  All looked normal, but for a small uterine fibroma.  She seemed content with my explanation and left.  Next another gaunt woman with a large belly.  Said it had been that way a long time. And she could eat hardly anything, because if made her belly feel very bloated.  I looked and couldn’t easily find intestines, just a lot of fluid.  Finally after some time of looking, I discovered it was a huge cyst, going from the pelvic bone all the way up to the sternal bone.  The intestines, liver, spleen, everything was up above it in a little tiny space.  I suspect an ovary as the origin.  I’ve scheduled her for removal next week.  Her labs looked OK (Hemoglobin, malaria, and HIV).  So much fewer that we evaluate in the US where we have much more possibilities!

Gillian found me and asked if Id do the next two surgeries.  OF COURSE!  The first was a young woman who had had a C-section about three weeks ago, got an incision infection, and came in today with a gaping wound with intestines visible (wound dehiscence).  The second was a woman who has been her a couple days, and it turns out has been leaking amniotic fluid at term, and was not progressing at all, or not even in labor that she could tell.

While I was waiting another person was downstairs that needed to be seen.  This time I saw a 3-week-old baby who was breathing fast with a distended belly with a temperature of 104.9 F.  People don’t live long with a temperature like that.  Grandma denied that the baby had any vomiting, nor diarrhea. The eyes were normal, and he hadn’t eating since yesterday.  I admitted him and asked them to start a quinine drip for malaria, while I did the habitual few tests that are available.

The anesthetist student put in the spinal with much difficulty and then the anesthetist offered to put in the Foley (urine) catheter so I could wash my hands and get my sterile gown over my other protective gown.  I walked back in as he put on his sterile gloves, then proceeded to unwrap the Foley catheter, open the legs, grab the betadine bottle, open the container with the gauze then grab the Foley to put it in.  I said WAIT!!!  YOU’RE NOT STERILE!!!!! “Oh, you want it in sterilely?” (The answer to that question would ALWAYS be YES, so no one has every asked that of me before!)  YES!! STERILE!!!!!!  So he put on a new set of gloves and placed a Foley.  My confidence plummeted! He works here and at the ministry of health so I wouldn’t have anticipated that.  (I sure hope not in infection control!) I decided then, that I would put all my own Foley catheters in from now on in the operating room.  I prepped the abdomen with betadine and sucked residual puss from around the exposed intestines.  They had already stuck together in such a way that it was difficult to see lines between them.  Some seemed like one big surface, though that wasn’t possible.  I decided, if there were that much infection on the outside, there would be some deeper inside too.  So I opened the incision up passed the umbilicus.  Next I slowly separated each stuck piece of intestine.  As I did this, more and large quantities of pus flowed out as I would enter pus pocket after another.  Eventually all the loops were free.  I was grateful that I did not make a hole in any piece of intestine.  We washed and washed till all fluid coming out was clear, then I closed the fascia (deep layer), leaving the skin open and packing it with a dressing.

I wrote a short operation note, then back to the floor to see patients with problems. And another new one.

The c-section went well, pulling out a screaming baby. (music to my ears!).  Then off to the wards to see more patients and do more burn dressings.  Now I’m tired, and you are to, of reading a long Liberia note.  Thanks for your prayers on my behalf and the workers of Cooper Hospital.

 

Liberia #7

administrator Greg No Comments

Liberia #7           After a short nights sleep I woke up at 7AM to my alarm.  I knew that things started at 8AM.  I knew we had many surgeries to do.  I made some muslix that a friend sent with me, and went to the hospital.   There we stood around the nurses station and had a short worship thought and singing.  After that the nurse on overnight mentioned how many admissions there were during the night, 8 in all.  And then I sterted rounds in one area and dr. Seton in another.  After rounds she went to the OR to start a hernia  surgery.  Then I found out a lady had come in with fetal distress so she was doing a C-section instead.  I initially went to the outpatient department in a tent in front of the hospital.  But no one was ready yet so I went to see how the C-section was going, Id rather be in the operating room anyway.  The baby came out while I was there and was blue and no cry.  You may think, how can a black baby look blue? It’s in the lips, palms and soles of the feet!  Heart rate was 40, we took the baby up to the head of the bed where there was oxygen for the anesthesia and stole it from the mom to use on the baby.  After giving some intracardiac adrenaline and then some more subcutaneous, his heart rate finally picked up.  With oxygen, he eventually started breathing and having pink lips, and started to cry..  Another woman in labor arrived, who was on her second pregnancy- 27 years after her last delivery!  Wow, starting over!  She was not leaking any amniotic fluid, though she said she had a few days prior.  I started her on antibiotics and had the midwife assess her fetal heart tones and cervix dilation.  The babies head was high and cervix still barely open.

I then went to the out patient department (OPD).  I gowned up with PPE and went out so see patients.  They would come into my “office”, which was a tent with a fabric divider and a table with a couple chairs and gurney.  I evaluated each patient and ordered labwork.  They would eventually get the results- usually hours later, and then see me again for treatment.

I was called to see a patient in a car that just pulled up.  He had a headache, body pain and pale eyes.  No vomiting, diarrhea, and no contacts with anyone sick or dead.  So I admitted him for evaluation for malaria and typhoid.

Next there was another woman in a taxi that pulled up.  As I was finishing up the patient I was seeing in OPD, they started wailing.  I went out, and found a cool, still 65 year old woman.  As the other women around shrieked and wailed, I said she was dead and they could leave.

Another car came, this 55 year old woman had fever, vomiting, diarrhea, body pains.  Eyes were normal, but I was suspicious.  So I doffed my PPE then went to ask Gillian her opinion.  She was in the operating room doing the hernia repair.  She said sent them on to an ETU.  They are now treating for malaria and typhoid, so either way they’d be evaluated and treated.

I donned a new set of PPE, and went back to seeing patients.  After each patient I would wash my gloves and stuff with the chlorine water, even though none of them seemed suspicious.

After seeing a variety of things: young woman with vaginal discharge and likely sexually transmitted disease, a thinning middle age man I diagnosed with HIV, a 13 year old girl with typhoid, another man with typhoid, a urinary tract infection…about 15 patients in all.  It was time to do the prostatectomy.

The spinal was put in by the anesthetist, it took a while and I saw a fair amount of blood- guess he wasn’t hitting the right spot.  I offered to help- he didn’t respond, likely offended but didn’t act like it afterward.  The patient lay on the table.  I prepped his abdomen with betadine, then put on drapes.  One of the drapes was moldy and so we threw it away.  I cut through the skin down to the rectus muscle (six pack in some people- unlike me).  Then opening down to the distended bladder.  Opening the bladder we suctioned about 2 liters fo fluid out.  They tried multiple times to get a foley catheter in yesterday, unsuccessfully.  So likely false tracts had been made.  I shelled out a very small prostate.  Then had difficulty passing the foley.  After much time, to pass it from the outside in or the inside out, and much prayer.  I finally got it from the inside out.  I tied the larger foley to the tip of the other and pulled in the larger one in the correct direction.  I was very relieved!  I sewed up the bladder in two layers, then started the irrigation.  Left a drain outside the bladder, closed the fascia and skin.  The man seems to be doing fine this evening.  To be sure his catheter does not come out, I sutured it to the abdominal wall from the inside with a large stitch!  That way it won’t be “inadvertently” removed.  Haven’t done that in this method before, but in the current situation, it seemed best.  As in other third world places I’ve worked, doctors orders to place or remove a catheter are not always done.  (my staff at home are great!)

About 7PM, I made ti back to the apartment.  I had seen some ramen and Gillian said she had some lentils left over, so we combined and ate.  Feels good to eat after 12 hours!  We went back to the hospital to do a burn patients dressing change under ketamine at the bedside.  That took a while.  I decided to take call tonight to give her a break after 3 weeks of straight call.  So I saw a few other patients the nurses had questions on then made it “home” at 11PM.  Was able to skype with Audrey tonight!  What a wonderful thing to have some electronics that worked in Africa!!!  Now it’s 12:45 AM.  Guess Ill shower, and sleep.

Thanks for all of your prayers.  I really appreciate it.

Liberia #6

administrator Greg, Shanks No Comments

Liberia #6

I have 6 hours in Brussels. The terminal that I am to leave from is separate. I suspect that there is minimal food or other amenities there. So I confirm this with an agent , and I am correct. So I hang out in the terminal to go other international places. I find a juice bar and get a fresh pressed drink, way to much money, but that is the norm in the airports these days. They know you have to eat, because you’re not getting it on the plane usually. I sleep on a couch that I found, setting my alarm for a couple hours, giving me plenty of time to make it to my gate. I sleep about 2 hours on and off. Then on to the terminal. I start to get my usual anxious feeling when flying into Africa. What will happen at the entry airport? Will I be bothered by the customs officials, wanting to take things out of my bags? Will all my bags arrive? Will someone be there to pick me up? Will I be accosted by many men vying to carry my bags? The “usual” worries, because these issues have all happened before.

After I board the plane, there is an unusual experience. The plane is full of foreigners going to Liberia. Many are greeting each other and asking what they did with their time off. There are numerous languages represented. From what I can surmise, the majority are working in ETU’s (Ebola Treatment Units). We take off on time, heading for Dakar, then on to Monrovia.

Arriving in Monrovia, we disembark to a standing only bus. Then at the airport terminal we have our temperature checked by a woman with a white coat and a mask on (as if we are bringing Ebola INTO the country?!) and wash our hands in bleach water before entering immigration. They didn’t give any problems in immigration. Then on to the customs room. The baggage belt is overflowing and bags are falling off at every turn in the belt. Workers are pulling off bags and placing them aside. I get through customs and they don’t even ask to look in my donation box. So I go outside and many guys are trying to get my attention to take their taxi. Eventually I find the guy with the Cooper SDA hospital sign and ride with him. After the half hour drive at 80mph in the dark and passing on double lines, we make it unscathed. The driver Robert, points out the sites along the way. The ELWA hospital area, the ELWA ebola treatment unit (ETU), MSF, Chinese, and other ETUs as well. He says people are not being turned away from them any more, and that they are not full here in the capital.

Gillian is up seeing a patient, so after they show me my room, I go and see what’s happening. There is a ?12yo girl who has tetanus. What a terrible disease. Back arched in opisthotonis, teeth clenched, and rigid body. We consider cerebral malaria and meningitis and treat for both. They cannot do cerebral spinal fluid evaluation. I brought glucometers, so we check her glucose to verify she isn’t low blood sugar.

A taxi arrives with a man who has had difficulty urinating for 3 months, and hasn’t been able to urinate at all today. We ask the usual questions of fever and check his temperature, headache, nausea, vomiting, diarrhea, body aches… and these are negative- so don’t suspect Ebola. We admit him and have the nurses place a bladder catheter, being sure to ask them to get urine before inflating the balloon, to not create a urethral injury. I didn’t stay to watch how unsterile or sterile their insertion was.

Another guy arrived with headache and neck pain. No other symptoms per him and family. Says he was treated in outpatient clinic today for malaria but had a negative result. Ebola is possible but unlikely, so I admit him for typhoid testing, malaria test, and treat empirically for meningitis.

As I type I hear wailing- I suspect the girl has died. Just outside my window there is the loud noise of a generator, and I heard it over that! Sadness and death are everywhere- and it’s better than it was when James was here!