Liberia’s capital, Monrovia, has come to a standstill as the deadly Ebola outbreak sweeps the region. Cooper Adventist Hospital is the only hospital still open to treat patients with problems other than Ebola.
In mid-August Dr. James Appel, a graduate of the Loma Linda University School of Medicine with years of experience at Adventist hospitals in Chad, flew to Liberia to work at Cooper Adventist, an Adventist Health International hospital with only 25 beds and very little supplies and equipment.
Cooper Adventist does not have isolation facilities, so it refers patients suspected of having the Ebola virus to a bigger government hospital.
The week after he arrived, he told The California Report:
“While Ebola is dramatically killing people in a way that catches the imagination, still more people are dying from malaria or complications from emergency c-sections. With all hospitals shut down because of the Ebola crisis, the death toll would soon far surpass anything that Ebola could do, just due to other normally treatable diseases.”
Cooper Adventist cannot treat Ebola patients because they do not have the isolation facilities necessary. Appel said they refer any suspected Ebola patients to a bigger hospital.
A published author, Appel has been writing harrowing and moving reports of his experiences in Liberia for his family and friends. He has given Spectrum permission to share those reports.
Here are three dispatches from Appel. The first describes his decision to go to Liberia. The next two describe some of his brushes with Ebola.
August 14, 2014
In all my medical training there’s only been one thing that really scared me personally: Ebola. Everyone in Chad is panicked, even though the virus has not found its way there yet.
Apparently, most of the hospitals in Monrovia have closed down because health care workers refuse to come to work and possibly expose themselves to Ebola. At first, it was even recommended that the surgeon at the Cooper Adventist Hospital be evacuated. However, Dr. Gillian [Seton] refused to leave. As the only hospital in town doing surgery, she was being overrun, especially by complicated obstetrics. How could she turn her back and leave?
She soon found herself working 18-hour days and being swamped with cases. So Friday night. . . she told me she’d just met with Dick Hart, Adventist Health International’s president, and he was wondering if I’d be willing to go to Liberia to help for a few weeks to a month.
My first reaction was abject fear. I’d been following the story of the American doctor in Monrovia who almost died of Ebola, and was well aware of its up to 90% mortality rate with no supposed treatment available except supportive care.
But I also don’t believe in giving in to fear. I needed to face this fear, especially since it was for such a good cause.
So [we] packed up the ambulance and started the drive across Tchad on Sunday. Sunday night I spent sleeping on the bench in the back of the ambulance parked outside the Catholic mission in Mongo. We continued on to N’Djamena where I boarded a flight to Ethiopia on Tuesday. There were a few glitches in the plan. First, I had no Liberian visa, and second I had a layover in Addis Abeba overnight.
The second was resolved when I got an email newsletter from Adam and Michelle Yates saying they’d just arrived in Addis to begin their work in Ethiopia. They graciously agreed to pick me up from the airport and let me spend the night. I exited the airport into the cold air of Addis and there were no cars outside, at least not immediately. From way across some bushes and down a hill I saw a tall American jumping up and down and yelling “James!” Boy, was I glad to see Adam!
I spent a pleasant evening. The next morning I finally got the invitation letter from Adventist Health International and was able to print it out at Adam and Michelle’s. I had my boarding pass already for Accra, Ghana, so I boarded with no problem.
But I began to get really panicked on the flight. I knew that Accra would be a challenge. I didn’t have my ticket, I didn’t know if they’d make me get a Ghana visa or not, nor if they’d let me on the plane since I didn’t have a Liberian visa. I was told they were working on getting one in Monrovia to meet me at the airport, but nothing was confirmed. Plus, why would they believe me?
Coming off the plane in Accra, I walked directly into the Customs line. There were no signs for transit. Then I heard someone crying out “Transit! Transit!” I saw a uniformed woman holding a list. I wasn’t on the list but I told her I was on Kenyan Airlines for Monrovia. I was registered by hand in a large book and given a laminated “tourist visa” card which the woman held for me and told me to follow. There was an Indian man also going to Monrovia so we followed our guide around Immigration and Customs where the Indian picked up his bag. Then we walked outside and up a ramp to the entrance to the airport. I went to the Kenyan Airlines counter. At the front of the line, the man asked for my passport. He couldn't find my name on the list. I showed him the email on my computer. He asked about my Liberian visa. I said I didn’t have one. He asked for some kind of paper. I pull out the Invitation Letter. He read it, smiled, said “Very good!” and waved me on.
At the counter, they couldn’t find my name. Finally, they found that my ticket had been voided.
It was midnight in the US — no way to call the travel agent. I offered to buy a new ticket. It came to $484. No credit cards allowed. I had $400 with me. Then I remembered I had some euros in my wallet. I went to the exchange booth and got $90 for my 70 euros. Just enough to buy the ticket. I finally was able to contact Dick Hart by telephone (fortunately, my Chadian SIM card works in Ghana) and he then called Gillian in Liberia. He then called me back to confirm that they had a visa ready for me and would meet me at the airport!
So I’m off to Liberia!
September 4, 2014
We’ve been seeing so many kids with severe malaria and anemia that I let my guard down. Because of the Ebola epidemic, parents are waiting till the last minute to bring in their children. Fortunately, so far we’ve been able to save most of them with blood transfusions and quinine drips.
So, when I go out to see this 10-year-old girl, in my mind I’ve already decided she has malaria. I go through the motions of asking all the screening questions and she sounds like she has malaria: headache, fever, loss of appetite, no vomiting or diarrhea. Instinctively, I check her eyelids to see if she has anemia like everyone else. Most of the kids have had very pale palpebral conjunctiva, but this girl’s are bright red. It sets off warning bells in my head, but I ignore my instinct. “It’s probably malaria,” I tell myself. I don’t want to send her to certain death of malaria by refusing her, so I let her come in against my gut feeling.
I hope the mistake doesn’t turn out to be too costly.
We bring her into the ER and the nurses find an IV. As the nurse is taping the catheter in place she asks me if I’ve noticed the rash. The girl has a raised rash all over her arms and trunk and face. It doesn’t look like anything I’ve seen before. I just gave her an Artemether shot in her muscle. There was no bleeding. Now I look back and some blood is pooling over the injection site. Jeff from the lab is right there. I ask him to go get a rapid malaria test and do it here at bedside.
Meanwhile, we start the quinine drip. I look again at her conjunctiva — they really are more red then normal. I’m starting to get a suspicious feeling. Sure enough, the malaria smear is normal. And where Jeff pricked her finger, it is also bleeding more than normal. And she has a high fever.
There’s a reason they call it Ebola Hemorrhagic fever. Of all the suspicious cases we’ve had here, this is the first I’ve seen with bleeding. Of all the cases, this has to be the most suspicious for Ebola I’ve seen yet.
I call in the mother. She’s dressed in some kind of police or security uniform. I explain that I’m suspicious of Ebola and they should take her immediately to either of the Ebola Centers: JFK government hospital or EWLA Hospital where Doctors Without Borders has set up shop. They leave immediately. We wash down everything and throw away anything that we may have touched. I run home, take a shower and wash my scrubs and put on new clothes. I feel this is my closest contact with Ebola yet.
A few hours later, the mother is back with the girl in the back of the car.
“Dey look at de IV and say to take her back to where she bein’ treated…”
Are you kidding me!? It turns out that neither place would take her. Both are overrun. Dr. Martin comes out and tries to call some colleagues who work at the Ebola treatment centers. No one is picking up. There just aren’t enough isolation beds or tents or personnel or supplies or anything. They are turning away patients left and right. But to not even test? And to use the excuse that she is being treated elsewhere and turn her away because we left the IV in to help them out so they could treat her without the risks of starting another IV?
I admit, some non-missionary words not only came to mind, but a few slipped out at high volume as being the only words worthy of expressing my feelings about the ridiculousness of the situation.
I do what I should have done before: I write out a referral explaining why we think she has Ebola. I tell them to go back and persist and don’t let themselves be turned away. Dr. Martin also suggests a third hospital, Redemption, which is supposed to be opening or already open as an Ebola treatment center.
Obviously — and rightly so — the family is frustrated and turns away sorrowfully. Who knows? No one probably ever will. She will probably die without us ever knowing if she had Ebola or some treatable disease.
If there were only the resources to isolate all the suspicious cases and test them. Then if they are negative, get them referred to a hospital such as our own which is treating non-Ebola cases and get them the malaria or other treatment they need. And if they have Ebola, there should be personnel, protective gear and IV fluids to treat them, not to mention the availability of experimental drugs known to help certain Ebola patients.
Instead, chaos, fear, suspicion, lies and death abounds in Liberia.
September 5, 2014
Once again I find myself ignoring my initial instinct and letting myself be convinced by a good story.
As usual, the security guard calls me outside. “Emergency in de car,” he says. I walk outside, pulling on gloves with a snap as I go. The woman is lying in the back seat of a beat up yellow taxi with five to six family members crowded around, all eager to tell me the “story.” I glance in and see a very critically ill patient with labored breathing and semi-conscious, her head flopped back on the seat, being held by a female relative.
As I piece together the story from the different people all trying to talk at once, I hear that she had malaria 10 days ago, which was treated with a three-day course of Artemether/Lumafantrine, a common first-line therapy. Then four days ago she had a miscarriage and bled heavily that evening. Yesterday, she went into the Benson Hospital where a doctor told them she needed an emergency D&C. The father paid the US $200 and the procedure was done. She stopped bleeding afterwards. Today, however, her breathing got heavier and she started to fade in and out of consciousness. They were told by the doctor she needed a blood transfusion and that their lab couldn’t do it and they needed to come to Cooper SDA Hospital.
In the back of my mind a still, small voice is trying to whisper “Where’s the referral slip?” but that quickly gets suppressed by the good story I’ve just heard. How could they make all that up?
I ask the typical screening questions about vomiting, fever, diarrhea, etc. and they all adamantly shake their heads “No, she doesn’t have any of that.” So I motion them to bring her in. She kind of stumbles up the steps, supported between two relatives. I have her wash her hands and I see her kind of slump as they now drag her through the door, past the benches in the waiting room and into the first exam room on the left.
As they lay her on the exam table, she starts to seize and then stops breathing. The family starts to wail immediately and I roughly push them away shouting “Let me do my job, will you?” and I start doing CPR, half-heartedly, I admit. But I then stop and check and she does have a pulse, albeit a weak one. So I keep pushing on her chest to force air in and out of her lungs. Not deep and rapid like compressions of the heart, but enough to get some air movement. I start calling for nursing help and they struggle to get an IV in. I figure if we can just get some IV fluids in her and then some blood maybe we can save her.
All along her arms are deep purple bruises. Some alarm bells in my head begin to sound, but I quickly silence them and keep up the resuscitation efforts. We pull the bed away from the table so the nurses can look for IVs on both arms. I then have one of them take over chest compressions while I search for a femoral vein. I find it, but have to hold it specifically in position or it stops. I get a dose of adrenaline in and then it moves and stops working. But her heart is better now and she’s having some sketchy spontaneous breathing efforts.
I’m calling for oxygen. At some point, Gillian shows up after finishing an appendectomy upstairs. The oxygen tank is missing the handle to open it. They run to get another one. A nurse’s aide, Habakuk, finally finds a small IV and we start running in some fluids. The lab tech has now arrived and there are two new nurses as we have passed change of shift. I think maybe she’s still bleeding from her miscarriage so I order some oxytocin to be given intramuscularly. We’ve finally got oxygen going and she’s breathing on her own with a good pulse. Two bags of blood are available and the first one is almost in.
“Bring in a family member,” I ask a nurse. Just as the sister walks in the door the patient seizes again and stops breathing. “Get her out of here!” I point to the sister and we restart our efforts. Finally, we succeed in getting her breathing and oxygenating well with a strong heartbeat and pulses.
I call in the father. He is overjoyed and thanks us profusely. I’m happy. This is why we still do this CPR stuff, because sometimes it actually works. The second bag of blood is in, a recheck of her hemoglobin finds a stable 9 g/dl. We’ve been working on her for two hours. The sister comes back in. We start talking. I ask some more questions. Suddenly, she starts talking about how the patient has been vomiting and having watery diarrhea and fevers at home. I nervously look at the patient’s arms with the huge bruises and then notice all the IV puncture sites still oozing. I pick up her wrap and see that there’s oozing from where we gave her the shot.
I go ballistic. “What are you trying to do, get us all killed?” I scream. “Lies, all lies! Why didn’t you tell us the truth?”
The sister and father weakly try to give excuses “We didn’t know, I wasn’t there, etc.”
“Everyone was there when you were denying vomiting, diarrhea, and fever…don’t lie! It won’t help you or her! Take her out now!” I’m sure she has Ebola! I’m starting to freak. I’m exhausted and feel like I’ve now put how many staff at risk? How could I ignore my instinct? If a staff member dies of Ebola, I’m responsible. I feel like for the first time I’ve had a serious exposure, and my stomach is in knots. I rush home, take a shower and soak my scrubs in a red, hospital-smelling disinfectant I find on a shelf in the shower.
The patient dies almost immediately as she is being carried out the hospital doors. The father comes back to the steel bars, now keeping him out.
“You did your best. I’ll come back tomorrow to settle accounts on our deposit.”
I want to scream: “Is that all you can say after lying and exposing us all to a deadly plague?”
My sleep is troubled by fearful dreams and I wake up with my heart beating out of my chest: it is still dark outside. I kneel with my face to the floor and sob out as I cry to God for mercy — mostly for the staff, but also that he will spare my life.
James Appel, MD, received his BA in Theology from Southern Adventist University in Tennessee and then a Doctor of Medicine from Loma Linda University in California. After completing a Family Medicine Residency at the Ventura County Medical Center, James moved to the Republic of Chad where he was the only doctor in a district hospital for seven years. It was there that he met his wife, Sarah, a volunteer nurse from Denmark. They have two surviving children, Miriam and Noah. Miriam's twin brother, Adam, died of complications of malaria at the age of six months.
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