Pediatric Cases #2

I thought I'd post a few photos of what we've been doing in Pediatrics lately. [And I should have grabbed some photos of our severe malnutrition patients, but these will suffice.]

Let me introduce you to Daouda (David in Bambara). This is truly one of the bravest little kids I've ever met. He's not a big fan of me right now (lots of shots and dressing changes lately...) despite my constant efforts to keep him hooked up with candy and coloring books.

Because of his deformity, he had to wear this ski-hood every time he went out into public. You can imagine how warm this was.

When he was four, Daouda was burned. The resulting scar pulled his lower lip down to his collar bone. This severely limited the movement in his neck, and held his mouth constantly open. It also pulled on his left eye and ear.

This is a picture of Daouda a couple days after surgery. You can see we were able to free up his lip. Though the scarring is still extensive, his mobility has been largely returned. Please continue to pray for Daouda. He currently has an infection in his surgical wounds that threatens to undo much of what we accomplished.

Above is Aruna. He had Burkitt's Lymphoma. We have completed several rounds of chemotherapy for him. At first, Brett and I (with minimal chemotherapy experience between us) had big pow-wows to figure out how to do his chemo and his management afterwards. We've now gotten much more proficient. The last two rounds of chemo I've done all by myself, including the spinal taps. The tumor is completely gone, and we have only a few rounds left to guard against relapse. In the first picture, Aruna at admission. The second picture is Aruna now. His facial bones are slightly displaced because of how large the tumor got (and we are hopeful that the bones will remodel a bit and you'll soon not be able to tell.), but the tumor is gone.

I snapped the picture above right before the family left the hospital, and of course, I forgot to get the kid's name. He was many of our severe malaria cases, but he was particularly bad. He had cerebral malaria and despite our best treatments he was in a state of constant seizing and didn't appear to be getting any better. I was on-call one night, and I went to look at him. He looked terrible; he was tachycardiac, his oxygen saturation was around 80% (normal healthy people should be between 95-100%) even with 5 liters oxgen (the max we can give), and his respirations were irregular and shallow. I figured he would be leaving us in a matter of a couple hours. I called Ecle (A-klay) the Malian charge-nurse, and explained my assessment. I asked if we could talk to the family.

We took the dad into the nursing office, and through Ecle, I explained the situation. In Mali, you don't say someone is dying, because this could be interpreted as cursing the patient. So I said that the child was "VERY sick," and that without a miracle from the Lord, there wouldn't be a whole lot of hope. After I explained all this, and it was translated, I asked the dad if we could pray for him. He agreed, and I asked for one of the nurses to pray for him in Bambara. Everyone was a bit reserved, but Ecle finally spoke up and led out in prayer. I'm not sure what he prayed, but the day this kid was leaving, I grabbed Ecle, took him to the bedside, and said, "This is your miracle kid. Proof that the Lord is responsive to our prayers." I also brought Mama Germaine, one of our older, "motherly" nurses who has a direct but gentle way of explaining things to the bedside and told her to express to the family my personal feeling that this kid was a miracle, and that they needed to thank Jesus for His work.

And what would another pediatric case update be without a picture of Miriam. She has gone home with her caretaker, Elizabeth. She made a recent visit to the hospital to see us. She is still cubby and now she is regrowing hair. Above she is pictured with Elizabeth (her temporary caretaker) and her "adopted brother" Abou. (You can see "before" pictures under the post "Medicine in Koutiala: Case Updates.") Continue to pray for Miriam and her safety. In another month or so, she is scheduled to return to her grandmother (who got her into this mess in the first place...).

Follow-up on Malaria Post

I'm currently reading the book, "The Shackled Continent," by Robert Guest. This passage, I thought, went well with what I had written last week about malaria:

"One problem that Africans are almost powerless to solve, at least in the short term, is that most medical research is done in rich countries for the benefit of rich people. The fattest profits are to be made tackling chronic conditions that affect lots of Wsesterners, such as heart disease and cancer. The ills of the poor are neglected: of the 1,223 drugs introduced between 1975 and 1996, only thirteen were aimed at tropical diseases. In 1998, the world spent $70 billion on health research, but only $300 million of this was directed at developing an AIDS vaccine, and a mere $100 million was devoted to fighting malaria." (pg. 202)

Medicine in Koutiala: Malaria Bites

I was working late in the office one evening, when my phone rang. “On a besoin de toi, tout de suite au Rea,” (“we need you, stat, in reanimation”) said a voice on the other end. “J’arrive,” I replied, rising, hanging up, and throwing my stethoscope over my neck. I jogged down to the Rea to see what was going on. I could hear the kid breathing before I entered the room. A four-year old boy lay on the bed, chocking on his own spit and vomit, after having just seized. I grabbed a suction machine and tried to clear his airway. After four or five passes, the rasping and bubbling in his throat cleared. I positioned his head and neck to allow him to breathe more clearly. Even with these interventions, his breathing was labored and you could feel the rattle through his chest from the stuff he had aspirated into his lungs.

While another nurse attached monitoring equipment, another helped me ask questions of the parents. The child had been sick for four days and this was his third seizure. Malaria. Not good, I thought myself, you don’t want to fool around with malaria. (It’s not that my diagnostic skills are that good, it is just that 99% of kids coming in right now are malaria cases.) But encouraged by our recent string of victories, I was still very calm. The monitoring equipment seemed to be malfunctioning, so I asked the nurse to go get a new machine. She left, and I pulled the lower lid of the kid’s eye down to look at the conjunctiva. (The third-world version of a quick blood-count.) Where normally you find a rosy red inner eye lid, I saw a pale white. “Oxygene!” I yelled. I sent one nurse running for oxygen and the other for IV start supplies.

In an instant, I went from calm to significantly panicked. Before either of the other nurses came back, I saw the boy’s chest start to move irregularly. Then a pause, and a gasp. I jammed my fingers into his neck to feel his pulse. Bump, Bump…Bump…….Bump……Bump………. The word I screamed in my head at that moment was very unsanctified, very not-missionary; but I hardly know a word that is more sufficient to express my feelings on this disease.

I pulled the sheet over the little kid’s face, and turned to look at the stone-like faces of his mother and father. Sorry, I half-said, half-whispered. Without making a sound, the mother got up and left. The father lingered a moment. I had one of the nurses translate my condolences, and then explained that the malaria had progressed too fast and there was nothing we could do. He nodded solemnly and then walked out.

I made final arrangements with the nurses and then walked out. At first I wanted to play the “what-if” game. What if I had started the IV sooner? What if I had gotten oxygen sooner? I should have looked at his eyes sooner. What if… But my background in critical care medicine has taught me that this is never productive, nor does it represent any form of reality. So I tried hard to stop. I called Brett (the pediatrician), played the what-if game a bit more, and stopped when he spoke the same words that I knew to be true. “The kid just got to us too late.”

And then I got mad.

And I’m still angry. At first, I couldn’t find one direction to point my anger. I wanted to yell at the parents for waiting so long, for not even getting some kind of treatment. I wanted to tell the government that they had done a crappy job at educating their people. I wanted to write the UN and tell them to ship an army here, because we are getting flogged by this disease. But the parents looked poor to me, so I knew that they had waited part because of financial pressure, part from lack of education, and more than likely, they lived in an outlying village and it had taken some time to get to the hospital. The government is already providing free medicine for malaria, and though it is far from perfect, it’s doing a decent job as far as governments go. And the UN…well, whatever…it just doesn’t feel very productive to get mad at the UN.

But I’m still angry. The next day, we lost two more. A little later, I watched two parents throw themselves on the floor in tears as their seven-year-old, their only child, passed away moments after they laid him on our hospital bed. (First Malian man I’ve ever seen cry.) This past week, we’ve had at least two or three new cases a day that we admit. (That’s a lot, considering that pediatrics isn’t even technically open. And that’s not counting the ones seen in outpatient clinic who are sick but well enough to go home on meds.) Some of them get better, some we lose. And all of a sudden this mysterious, tropical disease has an ugly face to go with its name for me.

Isaac, who before the opening of the hospital worked in a rural clinic, told me that during this season every year it is not that strange to have at least one death a day in the village from malaria. Brett has asked, more than once, out loud, “How do any children survive here?” I wonder the same thing. It’s no wonder that some parents stay a bit aloof of their young children. (They often don’t cry at deaths, first because they are so over-exposed to death and second because Islamic teaching says that if a child dies it is Allah’s will; to cry is to tell Allah that you disagree with his will. This is not true of every family.)

The problems are multifaceted. The first is a lack of education. Malians seem to be unaware that their malaria problems have a season. During the dry season, we don’t see malaria, but with the rains come the mosquitoes. So in May, when your kid vomits, you relax and figure it is just a stomach bug. If they vomit in September, you should load them on the moto and get to the nearest hospital. That doesn’t seem clear to them. The seasonal-ness of malaria here may also be part of the problem. If kids were exposed to small numbers of parasites during the whole year, they might form antibodies better. Instead they go through a period of little or no exposure, and then are hit with a wave of parasites.

Medicines are also problematic. The government gives out a very good malaria treatment. However, it comes in pill form. The pills work well, if they are started in time, and the kids keep them down. A frequent symptom of malaria is nausea and vomiting. Some parents don’t even have access to these pills. Others try traditional treatments first. Still others try single-drug syrups or injectable quinine, which can work, but malaria often develops resistance to single-drug therapies. The very best treatment (in country) is expensive and is only sold in a box set for adults (making it much more expensive). We offer this treatment much cheaper because we share the vials among our multiple pediatric patients. (i.e. making it possible for the kids to get just the doses they need instead of having to buy a box set that they won’t use all of.) So when a child comes down with severe malaria, parents often waste precious time getting them the very best treatment because they try other options first.

And then, frankly, the reality is that malaria doesn’t exist in first-world countries. We wiped it out with the use of DDT and other extreme measures. We have, however, placed bans on DDT as it no longer affects us. (And I’m not necessarily advocating the use of DDT here.) And this is where my frustration and anger have found roost. How is it that we know so little about this disease in the West?! (And truthfully, care less.) Between 100-300 million people (mostly children) die every year from malaria. 36 million people die from starvation every year. Contrast that with the 25 million HIV-related deaths BETWEEN 1981 and 2006! We hear a ton about HIV (and rightfully so…) but hear little about malaria, even though malaria kills 100 times the number of people! Or, do I dare say it? Yup, the number of world-wide abortions every year is estimated at 46 million. Not saying that HIV and abortion aren’t worthwhile concerns, but it seems like if we wanted the most bang for our buck, we’d go after malaria. I wonder why we have so separated ourselves from this disease. (Grain of salt…statistics taken from Wikipedia.)

I feel a certain moral-outrage about this disease. It is a smear on the face of our world. It is a symptom of our world, corrupted by our sin. It is made worse by our complacency. I’m ashamed that I didn’t know more about it before now. Do what you want…but I’ve asked the Lord to never allow me to become complacent about this disease. As long as He allows me the privilege, I’ll be here kicking back.

Life in Koutiala: Get out of town

It had been a long few weeks. Isaac had been sick with some typhoid/malaria combination and that had left me on-call for anesthesia for a couple weeks straight. Then I added in Pediatric call starting September 2nd, so I was having lots of long days and late nights. So I was quite ready to wind-down into my weekend with no call, and when Paul proposed a trip to the village, I was all over it.

It was, as I’m learning, a typical Malian invitation. I was leaving the hospital just as he was arriving for his night shift. I stopped to talk with him, and the conversation switched to the weekend. He started talking about how he and Eclesiate were going to the village in which Ecle (A-klay; for short) grew up—Zamblala. And then—and this is the problem—some comment or question led me to believe I was invited to come along. But I don’t even remember what it was. It was definitely not a direct question, like “Do you want to come along?” It was way more subtle than that. So subtle, in fact, that driving away, I really began to wonder if I was really invited or whether I had just invited myself. Either way, I figured, their reaction to my “acceptance” (or self-invitation) had been positive.

That evening I ran my trip past some seasoned veterans in efforts to keep unexpected adventures to a minimum. They told me quite a bit about the town. One of the few places in Mali that is predominately Christian, as opposed to predominately Muslim; quite a friendly little town; take your own water; etc. Olive, a 30-year veteran of Mali living, wondered why the two guys were heading back to the village. Probably a young lady was involved, she mused. She recommended being prepared to spend the night. She called Ecle to make sure the road was good since I had agreed to drive. (Don’t worry, Jessica, the road was in really good condition and I took it nice and slow!)

The next morning I was up and preparing when the guys called to tell me they would be ready at 8:30. I threw together a bare-bones overnight bag. Change of clothes, toothbrush, deodorant, diarrhea medication… trying to fit all into a small little backpack. (I really dislike being the “white guy with all the luggage.) I took off, feeling quite ready to leave Koutiala. (I haven’t left Koutiala since arriving here in Mali, except for my wedding trip to Bamako and my vacation to Bobo. I was beginning to feel very confined.)

When I pulled up to pick up Paul and Ecle, I immediately knew something was not as I had expected. They were both dressed in their matching wedding shirts (from the previous wedding). They climbed in and we took off, while Ecle explained that the real reason for the trip to the village today was a wedding of his “big brother.” (Quotes because I think the guy was probably more like a distant cousin…) Sweet…thanks for the heads up, guys. And again, that nagging question, did I invite myself on this trip? Since weddings are more open-invite affairs here, I’ve learned to be a bit more comfortable going with friends to weddings without an invitation in hand, but inviting myself to the wedding of someone I don’t even know, is still a bit uncomfortable.

Luckily, I had packed a boubou (traditional West African formal wear) in case we had spent the night, much better attire for a wedding than my t-shirt. And I decided to trust in the unfailing hospitality of my hosts (self-invited or not). So we turned on the radio and enjoyed the ride. I had the guys help me rehearse my Bambara greetings, since there would be very few French speakers in the village. I’ll admit that my Bambara is terrible. In the hurry to acclimate and get to work, I spent all my energy working on learning other things. It is pretty pathetic that after 4 months in the country I can’t even properly greet people in Bambara (goes against everything I believe…really), but finally, it is starting to come.

After 15 kilometers on paved road, we pulled off onto a dirt, donkey-cart path and went another 10 kilometers. The road was narrow and surrounded by shrubs and millet and corn fields, but the surface was even and the going was smooth. We had to stop several times to figure out how to get around an on-coming donkey cart. And the best was when we came around a corner and stopped suddenly in front of an on-coming cattle plow-team, led by a boy that couldn’t be more than 7. It took him a full five minutes to get the team off the road, being less than 1/8 the size of even one of the cows. We probably should have helped, but we were too busy laughing and digging out my camera to take a picture of him pushing and pulling with all his might on the stubborn beasts.

[This picture made possible by me sitting in my car laughing, instead of helping the poor kid!]

Pulling up to the village, we had to drive over the narrow dam that has created rice fields for the village. The village itself is little collections of houses, interspersed with huge mango trees and fields of corn, millet, and cotton. Healthy looking chickens, pigs, and goats were everywhere. I’m not an expert on village living, but I would say this village was doing well for itself.

We parked the car in front of the compound of Ecle’s grandfather. The compound is a large, walled-in area that has houses for the grandfather and his sons. There were easily 80 people in the compound that morning. And the greeting began. And the greeting continued. This is what we did for the vast majority of the morning. We greeted, we sat for the appropriate length of time in their presence, and then we were off to the next family. We traveled the village on foot, meeting countless people, visiting the schools, the small health clinic, and the church. At each place, there was the rush to find chairs for us, to properly welcome us.

After our first few stops, Paul and Ecle began to explain that the village was very on-edge that morning because the bride had not shown up. (She was from a village a ways away.) Normally she should have come the day before, in order to have been there for the all-night party. They had thrown the party anyways, but preparations for the wedding were at a stand-still that morning. Some imagined an accident, others that the parents of the bride were playing some trick to get more gifts and money from the groom. A delegation had been sent to find her.

This was eliciting complaints from everyone, at every stop. Some of the concern was for the groom—the shame and disappointment of a failed wedding. Some of it—coming from the women—was over when to start preparing the food. And some was over the delay of an anticipated event. These events are clearly a highlight of life in the village, and people wanted to get on with the party. Paul and Ecle, who had worked all night, wanted to get on with it so that they could get home and sleep.

It was while walking around the village, visiting, greeting, and guessing with Ecle and Paul what had happened to the bride that the reality of my situation washed over me. I would occasionally get a similar feeling in Utah. It would come when I was driving on the interstate with a clear view of the mountains, I would suddenly catch my breath, and it would wash over me again—their grandeur, their majestic beauty—as if I was seeing them again for the first time. It was the same here. I looked at the blue sky lit up with a blazing sun, the palms and mango trees framed with white clouds, and the red dirt of paths and mud huts. And I felt like I should pinch myself. “I’m in Africa,” I thought. I’ve dreamed of this all my life, and here I am. I felt very blessed.

Around noon, the bride finally arrived. The story I heard is that a car was supposed to bring her to the village, but there were too many people wanting to go, so they had to take two trips. So they left the bride and her attendant and took the other people first. Very funny, but strangely not surprising.

We retired to Ecle’s compound. We sat in the shade of a room and talked for a while, not knowing when the wedding would start. And here I observed yet another fascinating thing about village life. All of a sudden, Paul and Ecle got up and said that it was time to go to the church. No one had come in to announce this. There was no ringing of bells or PA announcement, no phone calls, no text messages. I can only assume they heard people talking about it outside. We took off for the church and were some of the first to arrive, but less than two minutes later, the whole village was there. Much like the beats in music that they hear and I don’t, there is some kind of rhythm in the village life that I just am not tuned into.

We all entered the church just as the rain began to fall. And it came hard. The racket made it hard to hear the service, but Paul, sitting right next to me, was translating most of it into French for me, and he seemed to be able to understand enough of what was going on.

The ceremony was shorter than the one in Bamako. And after the service, we all made mad dashes back to the village for cover. Paul, Ecle and I ate in a back room of one of the houses. The food was excellent. A rice-and-sauce dish with pork and noodles with chicken. We ate and then brewed tea to drink. The rain continued to fall hard. I began to have fears that the road would wash out and that’d we would be stranded.

The rain slowed towards the evening and so we said our goodbyes, picked our way through the mud to the car, and took off. The road was very muddy on the way back, but still very much intact. We made it back without problems, and I dropped the guys off at their home. I thanked them for a great day, and they promised we’d do it again soon. I look forward to it.

[Ecle and I eating dinner.]

[Ecle and Paul]