Disclaimer: I initially sent this out only to my doctor and medical friends. I didn't post it to the blog because it both contains a lot of medicalese (some of which I have tried to translate), and because it is fairly graphic and disturbing. So if you are easily traumatized by medical horror stories, do not keep reading. But the truth is, this is what medical care is like on most of this planet, and I think it is important for us all to realize (debates over single payer vs. public option vs. non-profit healthcare collectives aside) that we are extraordinarily lucky, and that life is a lot harder when you are poor in the developing world.
The clinician on duty walks into the High Dependency Unit (HDU) and begins the day by saying “Is everyone still alive?”. 4-6 children die every night in the hospital’s 200+ pediatric beds, spread over 5 wards. The HDU only has 5 beds, but they are reserved for the sickest, most complicated kids. In any hospital in the developed world, these children would be in an intensive care unit. The fact that all of the patients that were here when we left last night are still here is a small miracle. One is a 16 year old boy who was admitted yesterday in DKA (diabetic ketoacidosis). Or so we think. He has a history of recurrent abdominal pain and vomiting. He is severely malnourished. And his blood sugar was over 600. There is no way to measure pH. STAT electrolytes take 4-6 hours to return (which is amazing, since usually they take a week), and there is no such thing as measuring IV fluid rates or giving meds by drip. His blood sugar has come down to the 300s with IV fluids (measured by drops/minute) and subcutaneous insulin. His mental status has improved. He is lucky.
Next to him is a 10 year old boy who presented with body swelling and respiratory distress. We did a thoracentesis (stuck a needle into the space between his chest wall and his lungs to remove fluid) in the treatment room 2 days ago and got mostly blood. We were thinking that maybe he had some kind of heart failure causing his pleural effusions, ascites (fluid in the belly), and hypertension, but his electrolytes came back showing massive renal failure, revealing his diagnosis of underlying kidney disease. We put him on prednisone (no albumin available here, and lasix might dangerously dehydrate him further). Miraculously, the adult dialysis team comes and says they could manage to do peritoneal dialysis on a child if the surgeon would kindly place the pigtail catheter. Sure, no problem. So far so good.
The 4 yr old patient across the small room in Bed 4 can be heard wailing under the iron cage that keeps the blankets from touching her body. She has full thickness burns covering over 50% of her body, including her face, both arms and hands, and torso. She was burned because some other kids in her village locked her in a thatched hut and set it on fire. There are no plastic surgeons in Malawi, no opportunity for skin grafts or physical therapy or even adequate dressings. Topical treatments include penicillin powder and mashed papaya. We are waiting for her to die.
And yet, it has been a successful morning in the HDU. Labs that were ordered have come back. Consults have been answered. Children are still alive. Then we start rounds on the HIV patients, and we enter Ward A.
Ward A is a long narrow room with 10-15 cribs or beds lining each wall, which are painted with chipped murals of safari animals. There are 2 children in each bed. (And this is the quiet season. When the rains start, and malaria runs rampant, there will be 3-4 children per bed and you won’t be able to walk to the end of the ward). Large cumbersome oxygen concentrators are mounted to the wall and look like prehistoric octopi with as many as 6 different tubes snaking to the many children with respiratory distress. Mothers dressed in the same bright traditional fabrics they have been wearing all week look hopefully up through exhausted eyes, hoping that you, the azungo (white) doctor are here to see their child. Occasionally, the nurses wind the crank on the Grundig radio and some lilting African music or Christian bible preaching temporarily drowns out the crying and coughing of sick sick babies.
Mphatso is almost 2 yrs old. She is HIV +, and has massive generalized lymphadenopathy, Making her neck so swollen that her head is shaped like an eggplant; the lymph nodes so large they are impinging on her airway making it hard to breath. Her saturation today is only 87% on O2 (though the 2 litres/min she is supposed to be getting is being shared with 2 other kids through endless splitting of the O2 tubing). She looks tired, and ready to be done with it all, though she is dressed in her best Dora sweatshirt and shiny pink skirt. We are holding her chemo (Vincristine and Bleomycin are the only drugs available, whether you have KS, ALL, or lymphoma, any of which may be her diagnosis) because she is febrile and neutropenic. She shares a bed in the open ward with two other babies.
We don’t round on George, the 13 year old with relapsed cryptococcal meningitis, because he died overnight. His bed has quickly been filled by someone else. It is unclear who covers the hospital at night. Technically there is a Clinical Officer on call (which is basically the equivalent of a paramedic, but who provide the bulk of the medical care in Malawi). There is no routine taking of vital signs, meds are only given three times a day, and Mums do the vast majority of the “nursing” care. They sleep on the wooden benches or on the floor, so that they can breastfeed their children, and attend to them during the night.
We move on to the nursery, which is comparatively quiet, with lots of sunlight streaming in through the windows. Beyond the faded, grimy curtains, are rows of laundry hanging to dry, Mum’s washing their naked brown children with swollen bellies, and people resting on the ground in the fresh air. As we try to figure out what is going on with this HIV-exposed infant who has supposedly had fever x 2 weeks, I notice a Mum sitting on the floor holding a tiny tiny infant who looks like he is minutes away from death. He is one month old but weighs 2 kg (less than 5 pounds) and has the appearance of a small frightened aquatic alien who has been thrust into the air and forced to make do with ill-equipped biology. He is severely malnourished, his eyes are wide and unseeing and frightened, his tiny hands are squeezed into balled fists and shaking as if in protest to this cruel cruel world. Someone has admitted him to the NRU (nutritional rehabilitation unit), but failed to notice that he is also severely dehydrated, a febrile neonate, and on death’s door. Or maybe they did notice, but he is not so different from the hundreds of other children that pass through this hospital on a daily basis. There is no triage system here.
I take him to the treatment room and place an IV in his scalp. I give him a 10 ml/kg bolus, not wanting to overload him, since it is difficult to assess for dehydration in a patient that is so severely malnourished. But his heart rate quickly decreases from >200 to 140, and he seems a bit less agitated, though when you pinch his belly skin, it stays tented for a good 3-5 seconds. I run some more fluids, and offer him some oral rehydration fluid through a syringe, which he tries to swallow. Good sign. I let the medical student do a spinal tap, which he gets, but which is grossly bloody. HSV meningitis? Hypoxic brain injury causing a bleed? I will never know, because I can’t order a PCR, and the closest CT scanner is 6 hours away by bus and is currently broken.
Despite a respiratory rate of about 12, the tiny baby seems to be staying alive, and I am relieved. The other children in the treatment room are not so lucky. One is a 7 month old febrile child who has been seizing since this morning. Her fontanelle is so bulging that her forehead is soft and squishy. I give her intramuscular diazepam and try desperately to get IV access. Multiple peripheral sticks, 2 intra-osseous (IO) attempts, 2 femoral line attempts (both IO and fem lines tried using a regular 22g IV cannula) later, I find some Ceftriaxone at the clinic (the hospital has completely run out) and give her a whopping dose IM. One of the medical students has inserted a nasogastric tube, and without IV access, that is going to be her only source of fluids. She is not my patient – she just happened to be in the treatment room (the closest thing to a Peds ER), was in status epilepticus, and I happened to be the only clinician in the room – and so I did the things I knew how to do to take care of her. I write down the lab tests and medications that she will need in her chart, and hope that someone will actually look at it before tomorrow morning.
Another baby, who actually is my patient (being an HIV-exposed infant) has come into the treatment room with one of the clinical officers. He has had fever, vomiting, diarrhea and respiratory distress, and looks lethargic. The CO is working diligently on getting an IV, giving Quinine for presumed malaria, antibiotics, oxygen, IVF, etc, so I focus my attention on the others who are precariously hanging on. The next thing I know, the mother is wailing “lululululululululu” and a blanket has been pulled over the baby’s head. This one didn’t make it.
I look around. It is 5:00pm. There are 10 children on the bench being cradled by their mum’s, holding the IV bags in their free hands. At least 3 of them look like they are about to sink into unconsciousness. There are no other doctors or clinical officers in the room. No nurses to be seen, only the two orderlies dressed in masks, gloves and plastic aprons who have come to take the dead baby to the morgue. I realize that if I choose to stay, I will never leave tonight. Tomorrow is another day. I slowly back out of the room, trying to avoid the pleading but silent gazes of the mums who seem resigned to the inevitability of waiting. Right now, their children are still alive, and that is something to be thankful for.
I may be pan-spritually, ethnically Jewish, but I find my fingers making the sign of the cross as I slowly walk across the yard of the pediatric ward, my eyes raised to the glowing orange orb of the setting sun, silently mouthing a prayer to protect these poor babes and their mum’s; and that if they must die, to let it be quick and painless, without suffering.
But do not fear my friends!! Life in the clinic
The hospital is an unfortunate, sad place that is chronically understaffed, under-resourced, and the referral center for all the district hospitals who send all of the super-sick patients who aren't getting better. We have instituted universal HIV testing for all kids that get admitted, so that if they do get better, they can be identified and referred into appropriate care. I am optimistic about this year, and am looking forward to the challenging work that lies ahead. This week was just an eye-opener into the reality of life in Africa. I am realizing that I am going to forget most of what I learned in residency while I am here, but will learn so so so much more.
