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Liberia #25           Sabbath morning.  I sleep in a little bit, then get up to go make rounds.  It takes me a while but I round on the 36 patients.  When I’m nearly finished, “doc, der two pasunt outsite.”  Ok, I will see them in a few minutes, when I’m done seeing the last two. “I bring tem insite?”  No I will see them outside. I finish seeing the last two and writing their progress notes.

First there is a little girl.  She can barely stand, but for a few seconds.  She is about 6 and very weak.  I hear that she vomited once about 3 days ago, and has had a fever for a week.  I look in her eyes and they are pale.  I feel her belly, she squirms a little and needs to lay down.  Her liver is large as well as her spleen.  She has likely had malaria for quite a while or repeated episodes of malaria.  As the malaria parasites burst red blood cells, the spleen is the organ to filter the broken blood cells out of the blood stream, this can happen in sickle cell disease too.  So I admit her and start treatment.  Whenever the lab technician is available I will have them check for malaria and the blood count.

I look for the next woman in a car, and the car has already left.

I go change and walk to church.  The singing of the choir is with harmony and mostly songs I know, so it is very nice.  The sermon was well amplified and almost hurting my ears at times.  The church air conditioner quit about 15 minutes after I arrived, so it got quite hot very shortly, and they eventually opened all the windows.  After church I returned to the hospital to quite an uproar.

What happens when two people die, the burial team takes one of the bodies, and the family of that body, takes the other body that remains?  A huge mess, which should never have happened in the first place.  We have been instructed by the minister of health to notify the burial team of all deaths in the hospital so that the burial team can bury them with appropriate precautions.  This has caused quite a problem for us.  A few months ago they were cremating all the bodies, now they will bury them in a cemetery with the family present.  I guess the burial team came last evening and took one dead patient.  The family of that patient arrived early this morning and with the help of the security guards and a couple workers took the body they thought was their family member and drove away.  It was not their family member.  So the second family shows up to request their family members body, and there is no body to be had.  This generates many phone calls and a flurry of anger, and eventually the previous family is on the way back with the other families dead relative.  There was much hubbub as two families and one body were present.  I asked to speak with the oldest guy of the first family and asked the second family to please depart and go outside.  They complied.  As in most cultures, it seems the older people are more likely to be reasoned with than the young men and women.  I explained to them that their family member that had died in the hospital had already been taken by the burial team and that we needed to unload the body they had into our morgue.  After much discussion about them not ever being told that the burial team was called, they eventually allowed us to remove the body out of the car and into the morgue.  So three workers fully gowned up in PPE and took the body bag on a cot to the morgue.  They were unhappy that they spent a lot of money to transport a body that wasn’t their own away from the hospital then back again.  So I told them to come back Monday and we would discuss it further after more details and when the administration was present.  They got a call that the burial team was about to bury their relative, so they eventually left.

I called the daughter and the eldest male member of the other family in to verify that the woman present was their relative.  We unzipped the white body bag and they confirmed that it was their relative.  I re-called the burial team with them present.  They begged for us to let them have the body and let them go embalm and bury it.  I reconfirm with Dr. Seton if this can be done, and it cannot, per the minister of health.  So I recalled in the two people, out of the group, and inform them.  They cry and go out.  The metal gate at the door of the hospital is immediately flooded with many people, shouting and yelling and very angry.  Fortunately there is “security” and a gate.  Otherwise there could be much more problems.  Security has no weapons, but at least have a uniform.  One of the nurses, Odi, is very good at talking at high volume.  She talks and talks to them through the gate.  I am called back tot the gate to go outside to see a patient that just arrived in an ambulance.  With the crowd at the door, I consider that it may be unsafe to venture outside.  Crowds are more likely to do stupid things, than individuals.  So I wait by the inside.  The ambulance realizes that I’m not coming out, so they come up and ask for the referral paper back, and head out to a different hospital.  After about 45 minutes the crowd dissipates to go call the police.  I do not think they will get anywhere with the police, but likely loose more money in pocket change.  The previous family wants to see me Monday to discuss their lost money.  So it won’t be over yet.  Plus the burial team still needs to come and get the remaining body bag.

Eventually they come, and with much more commotion and arguing, they eventually leave with the body.

“Doc kam outsite, der a pashunt in de ca.”  I walk out, around the corner, and up the stairs to the ground level and out the front of the hospital.  I see that the crowd that was there earlier has dissipated.  I go out and see a 34 year old guy in the back seat.  They say he has had a fever for two days, doesn’t want to eat and is weak.  He denies headache, vomiting, diarrhea, difficulty swallowing.  He looks a little weak and I ask if he has passed out.  They deny this.  I look at his eyes and they are normal.  I decide he likely has malaria or typhoid and decide to admit him.  As he walks into the hospital he is weak and squats in the lobby.  I am sitting there writing orders, when the nurse says he is bleeding from his mouth and moves away from him in fear.  He says he had a sore tooth and put aspirin in it, and that is why he is bleeding.  I ask him to open his mouth, and stick out his tongue.  He has a laceration on either side.  It is deep but not something I would need to suture closed.  He still denies, and says it was the aspirin.  I don’t believe this at all so I wonder what else he isn’t telling me.  I tell him to go back to the car, and I will treat him as an outpatient, with oral medicine.  They resist, and the patient starts arguing with me (obviously better off than he was purporting to be), so with more forcefulness I tell them to get out to the car.  They comply.  I continue writing, outpatient medicines now.  The mother comes back in to tell the real story hoping I will change my mind.  She says that he was walking from the beach when he had a convulsion and bit his tongue.  Now that looks like what happened, based on the way his tongue looked like.  I continue writing for oral meds to treat him, and as I  do they get in their car and drive away.  A person outside, heard as they left, that they had already been to a number of hospitals and were turned away.  I think it is unfortunate that people need to falsify symptoms to get what they want.  It happens in the US too, for people trying to get pain medicines.  Here it is to try and get admitted.  But had they been up front with me, the laceration of the tongue would have matched the story, and I would not be hesitant, not knowing what else he wasn’t telling me.