August 22-23

In two days, for better or worse, the newness is wearing off.

 

A day in the life includes rounds from 8-10am, and a 30 minute break from 10-10:30 (for which I am usually late as I have had a lot of patients to round on), and then clinic from 10:30 to 1 and 3 to 6.  The two hours from 1 till 3 are for lunch and resting.  I also don't often finish at 6, but go back to the hospital to check on labs and sick patients.

 

I had another patient die last night.  That is one nearly every night, and most didn't even look that sick when I admitted them.  Last night's death was a strikingly beautiful young girl, about 2 years old.  She had a special light in her eyes, plump cheeks and a wonderful smile, when she felt well enough to use it.  She came in for fever, like every other kid, but she had a swollen elbow and couldn't extend her arm.  She also had sickle cell.  And malaria.  It is crucial to remember that it is sickle cell trait that offers some protection against malaria, not sickle cell disease.  In sickle cell disease, they get malaria, and then they have hemolysis from both sources, irregular blood cells that are distorted in shape, causing problems everywhere they pass, and it is a recipe for a quick death.  Literature on the topic also recommends that patients with sickle cell disease be on malaria prophylaxis for life, but I haven't seen enough patients to know if that is being done, and the cost of that would likely be prohibitive in itself.  The patient that died was pale and I wanted her in the hospital, and also getting antibiotics for whatever was going on in her elbow, although the Xray showed no evidence of osteomyelitis (infection) or fracture.  Mom said that she had to go home, and she did.  At some point the next day she returned.  That night the baby died.  I had filled out the admission form when I saw her in clinic.  Maybe I shouldn't have done that, so that someone would have had to see her again (after another 24 hours of hemolyzing her blood and dropping her circulating volume).  I hate that death is such a normal part of life here.

 

Last night Lisa and I went to a campus bible study on 1 Peter 1.  Lisa was in her element; sharing her wisdom and insights!  She has shared her insights with me weekly for the past year, but last night was different; amazing.  My main insight was when the question was asked, what does it mean to love?  My gut instinct was, "to save these children; to not let them die."  Then I wondered, what if that is just the easy way.  It's easy to wave and smile and say "Sannu!" when the kids are getting healthier, and going home.  It is miserable to look desperate parents in the eyes and beg them to be patient while we hope and pray that their child will respond well to our medicine, and to see the child lay lifeless in bed, day after day, practicing somehow for death, the only connection to life being some primitive habit of letting the heart beat, the lungs move inside the body, and the pupils respond to light.  What if that is like how easy it is for everyone to love their friends, but the true test is to love your enemy.  What if the converse is also true here?  What if love is not just preventing children from dying, but loving the family at their time of devastation and disbelief?  And yet the deaths happen at night, with a family member nearby, but no nurse or doctor to know or even attempt anything heroic , in the not-so-quiet hallway, with the lights still on from the busy day that came before.

 

I made a cognizant effort today to try not to admit every kid I saw today, like I did two days before.  There were some that needed admission, and accepted.  Others needed admission and said they couldn't.  (Whereas in Kenya, patients had to pay before they were allowed to leave the hospital, in a sense, being held hostage for the cost of hospitalization and treatment since there is no billing department.  However, here, the "flight" risk is high, patients have to pay before they are admitted, and as I saw today, many don't have the money.)  Others seem to want to be in the hospital, but returning home with a medication and hope that their kid will get better is sometimes acceptable. 

 

One child whose family couldn't afford to pay lived close by, so we were able to treat with an injection today, and do injections until the patient is well enough to tolerated the oral medication, or sick enough to require hospitalization and blood transfusion.

 

The other child is from Nigeria.  Her ear is nearly falling off.  There is no necrosis per se, and it seems to have stuck to fascial lines.  The smell was foul, and there was sign of infection, but it was a relative clean wound with no massive amounts of pus or drainage.  The wound extended from the top to bottom behind the patients ear, and from about 1 cm proximally from where the ear should attach all the way to about 1 cm from the distal edge of the ear.  The ear seemed to be flayed open almost, allowing a good visual, but probably not a good prognosis.  The patient had had intermittent fevers over the month since this appeared, and it started, by report, as a simple bug bite.  Thankfully there were no other such lesions on her body, except for behind the other ear.  If anyone has contact information for an ENT (like an email address) please let me know...I have a picture that might take me the next month to upload, but I am willing to try!