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.