Pictures of the Peds Ward

Educational Experiences Pay Off!

As part of our month at Mbingo, we have been giving afternoon lectures to the residents on medical topics. Mine of course all have to do with peds!  When I first arrived, I noticed that we were missing signs of dehydration, sepsis and shock.  Children can die if they are not resuscitated appropriately and I witnessed this happen the first few days I was here.  Yesterday I gave a talk on recognizing and treating dehydration/hypovolemia in children.  I really emphasized the signs of a sick child - poor pulses, cool extremities, high heart and respiratory rate and the importance of ongoing assessment and fluid management so they do not deteriorate.  Today Promise, one of the Nurse Practicioners, found me because he had just admitted a "child with severe dehydration".  We went to see him together and he pointed out all the things that we had talked about that indicated the child was severely dehydrated and hypovolemic.  The anterior fontanel was depressed, the eyes sunken, the skin was dry and tented when pinched, the hands and feet were cool with rapid pulses.  He had written orders to give a 20 mL/kg bolus of NS and for ongoing fluids and had planned to switch to oral rehydration fluids when the child was resuscitated and able to drink.  I agreed completely with his assessment and plan.  His recognition of how sick this child was and how to treat will hopefully save his life.  It's hard to come in as a foreign doctor for a month.  You have to quickly build trust with your colleagues at the same time you are trying to share information and knowledge that will better the care given.  It's important not to be too aggressive or arrogant or you will destroy that trust.  I feel very thankful that I have been able to create good relationships here and was able to teach such important concepts that made a direct difference in a practicioner's and a patient's life.  

Another beautiful hike...

Update on My Child with the Asthma Attack

The little girl I wrote about who was admitted in severe respiratory distress due to an asthma attack is greatly improved and was able to be discharged home yesterday.  It was a very reaffirming moment!  What's even more exciting is that when I came into round yesterday morning, one of the nurses had gotten a water bottle and was making a spacer for her to take home with a salbuterol inhaler to use when she had another asthma attack.  I was so impressed that they observed what we did and applied it to the patient.  It will definitely help keep her safer in the future.  And hopefully they will be able to do that for more patients with asthma.  The little girl is now a wild woman (probably from the exorbitant amount of steroids we gave her) and is running around the ward laughing and playing.  It was a great outcome.

Breathing better and running at the camera!

Making a spacer in the pediatric ward

It's moments like these that help remind me why I went into medicine.

How to Treat an Asthma Attack in Africa

We have had a tough and busy last few days working in the Pediatric Ward.  We are full beyond capacity and have admitted lots of sick children who we don’t know the diagnosis.  I woke up this morning and secretly prayed that we would have smooth rounds, that children would be improved and things would go well.

We had rounded on the first 5 beds when they wheeled in a little 2 yo girl on a stretcher.  She was laying very still under the covers and my first thought was that she was dead.  I came over and pulled back the covers and found a lethargic, unresponsive child who was working very hard to breathe, harder than I had seen before.  She had pulses, but would not respond.  When I listened to her lungs, she was not moving much air in and out and had a very prolonged expiration.   Her mother told us she had been healthy and started to work hard to breathe over last night.  I thought she was in respiratory distress due to an asthma attack.  

We put oxygen on her, and started breathing treatments with salbuterol and gave IM steroids.  After the second treatment, she started to wake up and push us away.  She was still working very hard to breathe but was moving more air and her oxygen saturation had improved.  I smiled both inside and outside in relief.  Finally something I knew how to treat and could help the child. 

After the second treatment, the nurses placed her in the bed and walked away.  She needed to continue salbuterol to keep improving, so I asked over and over for another treatment.  Finally one of the nurses said, “we have used all the salbuterol, there is none in this town or in Bamenda (the larger neighboring city)”.  I was shocked.  This previously healthy girl may die because we didn’t have any more of the medicine we needed.  It was the most frustrated I’ve felt in my time here.  I kept myself calm and started thinking through all of the other things we could do to treat her asthma.  We gave intramuscular epinephrine that didn’t have the concentration on the bottle or box anymore so I was very unsure if it was the right dose.  We started aminophylline – a drug that can easily become toxic and we don’t use in the US anymore.  All the things I normally use – albuterol, atrovent, methylprednisone, magnesium – weren’t available.  I didn’t have ICU nurses or respiratory therapists to watch her closely.  I didn’t have labs to check the drug levels of the aminophylline.  But we had to do something to keep her alive as she was deteriorating again in front of our eyes, so we did everything we could think of to do. 

Mary and Brian are two family medicine/psychiatry residents that are in Mbingo with our group.  They happened to see me and I filled them in on our situation.  They had a very hard time believing there was no salbuterol and went to the pharmacy to see what other options there were.  They found out we had lots of salbuterol inhalers, just not the nebules.  We use the nebulized form in young children because they cannot inhale on demand to take the inhaler.  But when you attach a long tube called a spacer to the inhaler, you can activate the inhaler into the spacer and then have the child breathe the air with the medicine out of the spacer.  We raced home to make a spacer out of a water bottle and duct tape.   I was very grateful to have creative friends here who were willing to help me find a way to take care of my sick patient.  We brought the homemade spacer back up to the ward and showed the nurse.  She looked confused for a moment and then reached far back into the supply cabinet and pulled out a single spacer, like the ones we use in the US.  We had had one the whole time, but either no one mentioned it or knew what it was for.  It will still be a long night for the child and her family, but I am much more hopeful that now she will survive.  Even though today wasn't as smooth and easy as I hoped it would be, I learned how to quickly work with the resources I had to give care in Africa.  

The Cost of a Life in Africa

Azaelle has sickle cell disease, meaning his red blood cells have a genetic defect that causes them to be sickle shaped instead of round.  The sickled cells can get stuck in small blood vessels and rupture causing anemia, pain, lung problems, strokes, infarctions of bone and lots of other complications.  Azaelle was admitted with a pain crisis in his foot, had been improving and we almost discharged him over the weekend.  When we rounded yesterday, he was requiring oxygen, was very sleepy and looked terrible.  I was very worried about him.  He didn’t have pneumonia or another pulmonary problem to explain his oxygen requirement.  He had a loud murmur and I was concerned his hemoglobin (part of the red blood cell that carries oxygen) was low.  That could explain his oxygen requirement and he would need a transfusion. 

Azaelle is here with his Uncle.  His mother is pregnant and unable to travel the long distance to Mbingo, and his father works far away.  As I was trying to figure out why Azaelle needed oxygen and what to do about it, his Uncle demanded to be discharged.  He said he only had 9000 francs and the hospital bill was already 8300 francs and he could not afford another night.  Everyone treated at Mbingo must pay their bill before they leave.  There are many people that sit around the hospital grounds for weeks waiting for family members to bring more money for their bill.  He said that he had to be at his job tomorrow otherwise he would be fired.  The nurses, residents and I worked all day to explain why his nephew was so sick and needed to stay in the hospital to get care.  When we took him off oxygen he dropped to 68% oxygen saturation and had trouble breathing.  I wanted to scream “look at him, don’t you understand?”  He wasn’t even the child’s parent, what gave him the right to choose to take him out of the hospital and risk his life.  But there was no way he would change his mind; he had to go now.  

Many times during the day the nurses threw up their hands and asked me to write an order to discharge the child against medical advice.  I refused.  The child would die if he left.  I didn’t think there was a choice, he wasn’t going to leave and I certainly wasn’t going to write an order saying that he could.  Even if the order said I explained the risks and benefits and they were leaving on their own will.  I tried to be empathetic to the situation.  Having no money to pay the bill and then loosing your job is a terrible situation.  But loosing a child has to be worse.

I enlisted the help of the chaplains and don’t know if they were the ones that talked him out of leaving, or if we argued so long that there wasn’t enough light in the day to travel.  Either way they stayed, and almost 12 hours later, I was finally able to get the hemoblobin level I wanted.   The hemoglobin had dropped from 6.9 three days ago to 4 (normal levels would would be above 12, but many sickle cell patients live at 10).   We gave Azaelle a blood transfusion and this morning he was much improved.  The family is still here because when you receive a blood transfusion at Mbingo, the family must donate blood to replenish the hospital's supply.  The Uncle is not willing or unable to donate blood and they are waiting for a family member to come and give their blood.  I’m just happy that it bought me some time to care for Azaelle. 

There have been many times I haven’t been able to care for a patient the way I would want to; the way I would in the US.  I have had to find ways to work within the system with the resources available.  This is one time I chose to stand my ground on something I believed strongly about.  I have been unable to save or help many children here in Mbingo, but I knew I could help this child and would not make the decision to let him leave.  I wondered if I had made the wrong decision – if the family would be in debt and loose their jobs for my choice.  One of the chaplains who helped talk to the Uncle yesterday stopped me as I walked to dinner tonight and reaffirmed the choice I made.  He said that he was so grateful for doctors who cared enough about a child in Africa to make a hard decision and fight for them to get the care they needed.  I won't always be able to fight for the children I take care of.  Some will be too sick or we won't have the resources available to help them.  But I know that I did the most that I could do for this child and I hope that his Uncle will one day understand.

The Things Medicine Can't Provide

I haven’t made many posts about the pediatric ward and the patients I’ve taken care of. I think the reason is that the first week we arrived in Mbingo, we experienced what every doctor dreads – we had three children die. The first died of Burkitts lymphoma after starting chemotherapy. Another was brought in to the ward already deceased from complications of HIV. The third child died from septic shock despite our best efforts to save her. I can still hear the mother’s wails and the silence of the rest of the peds wards; each mother secretly relieved it was not their own child but fearful they could be next. It was a baptism by fire to practicing medicine in Africa. I pushed my feelings deep inside, as I so often have to do when taking care of sick children, in order to keep working.

Today we visited the peds ward not just as doctors, but as people that cared about the patients and their families. We sat and visited with the mothers. We brought mobiles that the Schlaudecker children made and hung them in the windows. We handed out balloons and crayons with coloring pages to all of the children. One by one, smiles crept across faces, mothers laughed and opened up to us. I learned more about the families I was caring for in that afternoon than I had in all the mornings rounding. And it was therapeutic!

The boy in bed 1 is an adorable 6 year old who has had weight loss and fever for the last 8 months. His mother has been sick with worry watching her son waste away and took him from doctor to doctor until coming to Mbingo. We believe he has TB, though the tests we have are negative, and he started treatment one week ago. He looks fatigued and malnourished and is too quiet and sad appearing for a 6 year old child. As I visited with his mother, the boy sat up in bed and started coloring, which was more than I’d seen him do the whole week he has been admitted. His mother said she was so happy to see him play again.

Another child is an adorable 4 year old recently diagnosed with HIV and possibly TB and is very ill. He is too weak to sit up for long, but when we gave him his balloon he smiled and laughed and batted it back and forth between his mother, both looking like they had forgotten how sick he was for a minute. His mother said she hopes that getting to play will help him build some of his strength back.

Then there’s a 15 year old girl who came in with paralysis of an unknown cause. We suspect that she has conversion disorder (manifesting stress as the symptom of paralysis) triggered by her father getting put into prison. She sat up in bed and smiled for the first time, eagerly waiting for us to come to her.

I’ve seen how even with the best medicines and care, children can be damaged or die, in Africa and America. But the statistics and hope here are even grimmer. I’m not able to make my patient’s TB meds work faster or cure their HIV, no matter how much I want to. But today, I was able to help them play and be kids, which I believe helps them to heal. I was able to look the mothers of the children I cannot cure in the eye and make a connection; to show them that there are people in the world that care deeply for their families. I was able to give them something that medicine alone is unable to give.