From kisses to weeping...

Lucia, the child with cerebral malaria that received the blood transfusion yesterday, died during rounds today. She died 10 minutes after we rounded on her. I was there 10 seconds after her heart stopped beating. And there is nothing to do....futile to try CPR because what comes after CPR? And so her parents went from kissing me on the cheek yesterday to weeping on my shoulder today.

Most mothers won't touch their children. This mother took off the child's poopy pants, ran outside to scrub them, came in to wash the child, then picked out the child's best dress and jacket. The head nurse and I dressed the child for the mother as she was crying very hard during all of this.

This is when one of the two doctors in the hospital came over. He had come to the wards this morning to "help". He told me I needed to get back to work. I told him no, this is where I needed to be. He told me that the children still needed help while this one couldn't be helped. This was all said in front of the weeping parents with the dead child in front of us less than 10 minutes after she had died and the doctor had not even acknowledged the parents. That was it...my breaking point. I told him how I come every single day twice a day to take care of these children and that the rest of the children I would see later today. I told him that this child should not have died and how the parents needed to be comforted. When he disagreed, I listed off the long list of every mistake made and time the child was ignored when should have been seen. It was a very long list that makes me angry so I wont discuss the details. He still disagreed with me and stalked off.

The parents made some phone calls while the grandmother stayed with the body. And then more family arrived. Then the grandmother put little Lucia on her back, as all children are carried. And the parents and the family walked behind crying and praying in Tonga, as they walked through the hospital to go to the truck or donkey cart that would take them back to their village. It was funeral march in the realest of sense. She would be buried today directly next to the hut. Then most likely they would build another room over her grave site.

The rest of rounds were hell. The doctor yelled at nurses, the nutritionist, and argued with me on almost every patient. And the ward was over-flowing today. We had children in rooms that aren't even used for patients. At the end, the charge nurse and I agreed that the problem is a lack of compassion and unwillingness to learn. And I have no idea how to change that.

Metrude

Metrude is a little girl who presented with "she won't walk" and she would cry and refuse. I first saw her the day after she was admitted. They had stuck a needle into her hip and didn't get anything. They really didn't have any other ideas. The differential for a child not walking is big, but they couldn't name any other reason or idea. So over lunch I researched and went back to the doctor and taught him the main causes, what would indicate one over another and what you would order to tell. I still thought she had a septic hip. They were skeptical....so I taught them how to tap a hip. The trick is not to do it blindly...Ultrasound that hip! They were able to tap it and get the pus out easily. Two weeks later it is still healing but now she is running and skipping around the ward.

Pictures of the hospital!

Abcon

Abcon is a child I met not on the pediatric ward. He is on the men's ward because he is over 6 years old (Yes, thats right...pediatrics is under 6!). So anyways, I met him when he was crying in the middle of the hospital last week. And by middle of the hospital, I mean outside, on a dusty cement path connecting the different wards. He was wailing away, saying something in Tonga, as everyone stopped what they were doing, stared and did nothing. He didn't stop, so I walked up rubbed him on his head. Then he gave me a big hug, crying into my white coat. I made him a balloon and by that point someone told me he was crying because his dad had just beat him. He settled down a bit and a nurse came to take him back inside. That was last week.

On Sunday, he came running up to me chatting excitiedly in Tonga when I walked into the hospital. So I played with him and tickled him and then continued on. And he followed. He followed me for over an hour as I worked in the pediatric ward. He would hold the charts, look at xrays, and peer at the babies. And then when I was done, I walked him back to the men's ward. As we walked back, he started chatting happily in tonga. I wonder what he thought of the day. :)

By the way, for those wondering, he is admitted for a burn on his hand and arm that is infected.

Blood Transfusions

After this you should appreciate when you go to the hospital.

This morning, a little girl with malaria started seizing. When I opened the chart to write the orders for the phenobarbital, I noticed that some lab results had come back. Her hemoglobin was 3.5. That should cause a panic inside of you....that is a dangerously low level of blood cells. Especially in a child who is continuing to drop from the malaria. The lab was so concerned they had someone run over with the results and told one of the nurses. She just wrote it in the chart and didn't tell anyone. So I ran the order over to the lab for the transfusion. But it still took 1 hour to get the blood.

Transfusions are risky here for children. Not so much for the risk of disease transmission. But because of how hard it is to control the rate. In modern hospitals, IVs have computers attached that you can program the rate into. Here calculate how many drops a minute you want, adjust the dial, count how many drops, adjust it again, count, etc. There have been a few children who have died from fluid overload from getting their transfusions to quickly (over 1 hour rather than 4!).

So anyway, this little girl is still in a coma, is urinating blood, receiving her blood transfusion, but no more convulsions and her fever has come down a little bit. And so we wait and hope and pray she comes out of the coma.

Ahhh frustration

This will be a quick rant.

So yesterday I got sick...vomiting and stomach pains that kept me in bed all day. Which means I did not go to the pediatric ward. So today still feeling sick, I dragged myself over to damage control.

How can things go badly so quickly? There were a bunch of new admissions that had wrong diagnoses, wrong treatments, or no treatment at all. A blood transfusion given inappropriately. Severely dehydrated baby only given fluids for 4 hours. It goes on and on. I could only work for 3 hours before I was feeling too sick and couldn't hide the dry heaving.

Just as I was walking out to go back to bed, I saw Joe, the little boy with the burns. He told the charge nurse to ask me to stay for the cleaning of his burns. This is one of my least favorite things to watch and listen to. But I stayed... He's such a sweet sweet boy.

Relaxing Saturday Night

So tonight we went out to the dam to watch the sunset and then the stars. There are no lights out there, so the stars are breath-taking. Absolutely amazing. We bought some beers at the illegal store and sat around to have a great night. Mark's, a dutch medical student, parents are visiting for the weekend and came with us. It was nice to just sit back, relax, and breathe. I haven't been sleeping well since being here. I haven't got more than 5 hours in a night, often less. Part of it is from nightmares from the malaria medication. Part is just from the stress of the hospital and worrying/thinking about everything. So it was good to relax.

Tonight one of the girls, who is just doing research, was asking me about the hospital and how things were going. I told her a lot of the stories. She has been on the wards twice now and she says she still can't believe it. Mark's parents walked through the hospital today. His mom cried when she was in the pediatric ward. It is so hard to describe how awful things are here. It is difficult to comprehend for anyone, even me. Some nights I wonder if events really happened during the day. Sometimes I reread my blogs or the diary I keep, and I can't believe it. Things are much worse than you could imagine, than pictures or stories could convey. Just walking on the wards would bring you to tears.

So you can see, I needed the beer tonight. :)

Victoria Falls

I forgot I hadn't posted this from last weekend! So Miranda and I went to explore Vic Falls, the largest waterfall in the world, last Sunday. Well we could barely see it! The water is at one of highest levels ever and there is so much "mist" you can't see anything. I put mist in quotations because I laugh as I write it. It was more like a torrential downpour. I couldn't wear my sandals half the time because the path was a flowing stream of water. It was fantastic! We also saw Zimbabwe but didn't the time (nor the patience) to cross the bridge into and deal with visas again. Then we heard about the boiling pot which is whirlpool at the bottom. So we asked around and figured out the trail to hike down. I ran into 2 guys from Spain I had met when crossing into Botswana the day before so they hiked with us. I don't think we ever got quite far enough but we forged rivers, boulders, and logs. And there were 324 stairs to get to the top of the trail: I counted! And afterwards, pizza and milkshakes! bad pizza but still, normal food!!

Child Abuse

So there is a lot of child abuse that I have seen. But it is never discussed. If I bring it up, the other doctors or medical students seem clueless that the injury was from child abuse. They also show no interest. Here are two examples that are on the ward right now.

Milness: Her story is that she fell into the fire. But she only has burns on her bottom and genitals. None on her arms or hands. When a child falls in a fire or scalding water, there are always burns elsewhere that occur as the child is trying to get out. Burns on the bottom only occur when someone is holding a child over a fire and the child is holding their legs out of the way.

Peter: His story is that he has spiral fractures of both legs from a bicycle falling on top of him. Maybe he could break his leg if he was ran over by a bicycle. But not spiral fractures. Spiral fractures are 95% of the time from child abuse...someone yanking and throwing the child. Peter has to be in traction like this for 3 weeks.

Isambe

Isambe is one of the malnourished children. He has Kwashiorkor, which leaves the children very small but swollen with ulcers all over their bodies rather than looking like a skeleton. He had been doing fairly well and gaining weight. Then over a period of four days, he became lethargic and started losing weight despite continued ng feeding. This happened over the weekend while I was gone. The notes in the chart said “consider treating for TB if survives” and provided no other treatment. So yesterday, I took over his care when he was unresponsive. He went downhill so quickly, I thought I might be able to reverse it. He was already on the best antibiotic we have: Ceftriaxone. All day I worked on him…I started him on fluids (difficult to do here…can’t be through IV, only thru ng tube) and ordered a lot of labs and tests. Half the tests didn’t get done because people went home early. I still had no clue what was wrong with him by the end of the day… I came to work early this morning to see if he survived and to talk to the night nurse.
Isambe died in the night. The nurse said he pulled the ng tube and then couldn’t get another one in. So that meant we couldn’t give him any more medications or fluids. I didn’t even want to ask why they would pull the ng tube.
The reason I fought so hard for Isambe was that his mother told me that her only other son had already died earlier this year.

The pictures are of other malnourished babies and their moms. Two are blind: one from Vitamin A deficiency and one from tribal medicine.

Joseph and his leg

2 physical therapists held down a child a put traction on a broken femur. The child, Joseph, screamed when even his other leg was straightened because it moved his left leg. I asked them as soon as I heard what they were doing to stop and bring him to the operating theater to put him under anesthesia. They laughed and said no. I explained how painful it was and how they need to give him something. They said they could reset the leg just fine without it. I kept working on a child two beds away. But the screaming got too awful. The entire ward stopped and turned to stare. I went back over and pleaded again. I told them that this is wrong and they were torturing the child. They laughed again. After they were done, one of them came to find me and said “see I reset the leg just fine without any pain medication”.

Jester Went Home!

Jester was discharged yesterday! She looks amazing! She was admitted for three weeks. When I first met her, she was barely conscious with gangrenous infection from armpit to her stomach. Now she is a playful happy toddler walking around. Her mother thanked me for saving her daughter's life. I will always treasure this family. Thank you for your prayers.

Joyous and Joe

There are twin brothers: Joe and Joyous. Both have extensive burns due to a pot of porridge being spilled. I don’t think that could be true. Not with the amount of burns on both boys. Its likely child abuse. Joe has the worst burns. Burns on both legs and his right arm. His right arm is also developing contractures so its hard for him to straighten it. Joyous just has burns on one thigh. When I saw them, their burns were very dirty and had flies sitting on it. The burns are left uncovered but also the windows are left open and the beds they sit on are dirty. Joyous is on antibiotics but Joe, the one with more extensive burns, was not and had high fevers. When I was there, the charge nurse said he was going to clean the burn s. I wanted to see how they were doing it since the burns were so dirty. They don’t give the child any pain medication. None. Not even Acetaminophen. And to clean a burn, you have to scrub it. Joyous went first. He sat on his mom’s lap and four nurses held him down as they scrubbed the burns with saline water and gauze. He screamed and screamed. Not a normal child scream, but blood-curdling scream. He fought to get away from the nurses. The baby on his mom’s back also joined in, screaming as well. The whole ground was slippery with blood as it splashed down from the burns. It was too much for me to watch after an already difficult morning, so I turned to leave. As my hand turned the doorknob, the screaming stopped and Joyous began crying out something over and over. The nurses stopped what they were doing and looked at me. Then the charge nurse said “Joyous says he doesn’t want you to leave him”. So I stayed, stroking his head as he screamed staring into his dark brown eyes filled with pain as mine were filled with tears.