We started the day at the Kabudula hospital shift hand-over. Basically run like "morning-report", events from the previous night are recited in narrative form by the night nurse. One child with severe malnutrition that lead to total body swelling, or kwashiorkor, died overnight. Aubrey, who was senior clinician and second on call, was not notified at the time. One thing that I hope to continue to emphasize is the need to call the most experienced, at any time, when a patient's condition is deteriorating.
After sign-out, Aubrey rounded on some patients. We came to the crib of a 2 year old girl with HIV who was breathing about 60 times per minute. She appeared half awake and was grunting with most breaths. Bacteria had infected part of one of her lungs, and pus, a by-product of the immune system's fight against the infection, was filling up her lung and keeping oxygen from reaching her vital organs. She was hooked up to an oxygen concentrator machine and was using the device donated by WAM that splits the o2 supply between patients. She had just started receiving chloramphenicol, the recommended antibiotic per Malawian guidelines, but an antibiotic that I have only seen in Africa since it was discontinued in the US due to side effects. They had also started her on presumptive treatment for PCP pneumonia, a disease that only affects those with very weak immune systems. Seeing that she was already on life-saving antiretroviral meds for HIV (meds who's supply are threatened due to cut backs in global health funding) and prophylactic treatment for PCP, and had an exam that was more consistent with a typical bacterial pneumonia, we stopped the PCP treatment doses and later added penicillin per the local HIV guidelines. A child that sick would probably be in a pediatric intensive care unit in the US. When we checked on her later in the day, she was looking a little stronger.
Next we saw a beautiful young woman who had labored for 2 days with an infant that probably wasn't meant to come out vaginally. She went to another hospital where she delivered a still-born infant via cesarean section. Some time later, she noticed that she had started to leak urine from her vagina. Due to the prolonged pressure of labor causing tissue damage, a fistula, or abnormal connection, had developed between her bladder and vagina. Now, as urine enters her bladder from her kidneys, it constantly trickles out via this connection. I was happy and somewhat surprised to see that her husband had not left her, a fate faced by many with this avoidable affliction. Aubrey referred her to the central hospital for corrective surgery. As she stood to leave, a plate-sized damp spot was left on the wooden bench where she had been sitting.
We also saw a woman with a history of cesarean section who had labored 3 days at home with her 12th child. She came to the hospital when the fetal heart beat could no longer be found. A cesarean section by the new clinical officer quickly got out of hand and Aubrey was called in. After extensive repair of lacerations and stoppage of life threatening bleeding, the woman was saved. With permission from her husband, her tubes were tied. She is alive and well, and ready for discharge today.
These are the cases that Aubrey sees day in and day out, working without complaining. It is, as he says, his calling.
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