A hard day

Sunday, March 11

It's been a tough 24 hours. Yesterday we were called to see a 6 year old in distress. While he was play-fighting with friends, he was stabbed in the neck with a stick. The cut was over the left side of the front of his neck, and amazingly, it missed his carotid artery. It did however reach deep enough toward the midline to enter his windpipe. He was wide-eyed and breathing fast, and this was clearly an airway emergency. I could tell from his lack of stridor, the wheezing noise made when inhaling through an obstruction in the upper airway, that he wasn't in immanent danger. But I knew that he could turn the corner fast if swelling or a blood clot blocked his lifeline to the world. In the US, he would have been sedated, paralyzed, intubated by an experienced physician, and taken urgently to the operating room. Luckily, we have one of the two anesthetist clinical officers that work for the ministry of health in Lilongwe district, a catchment area of over one million. He could manage the airway on the 1+ hr trip to the referral hospital. The big question was whether to intubate before transfer. In the States, we most likely would have, but I've never dealt with this before (I'm wondering what I would have done if the referral hospital wasn't an option). But here, there's 33 km of unpaved, gutted dirt road and a few water crossings before getting to the paved road that leads to the city. Any one of those bumps could dislodge an endotracheal device and spell doom to a sedated kid. We decided to send him with an IV in his arm in case he needed emergent meds (watching Aubrey place the IV was unnerving - the kid started crying and struggling, coughing blood through his neck wound), and send the anesthetist along for management. I found out later, during one of the overnight cesarean sections, that the child made it OK.

Shortly after that child was transferred, I came upon a 2 year old that was breathing quickly in his crib on the pediatric ward. He had a diagnosis of severe malaria, and this could certainly explain his clinical condition, including the fact that he was near comatose. He was also visibly anemic and needed blood, and we weren't sure if he might have also had meningitis to boot. We performed a lumbar puncture, and found that his spinal fluid was under very high pressure, an ominous sign. Later that night I came back to the hospital and heard beautiful singing coming from the darkened outdoor hallways. The dozens of pregnant patients and caregivers that sleep outside due to lack of sleeping quarters were singing hymns as they lay down on the concrete to sleep. I went to the pediatric ward to check on the sick child from earlier in the day, feeling lucky and peaceful, and found that he had passed away less than half an hour after the procedure.

In the morning I found out that another child, one who's mother didn't allow us to examine the child the night before, had died as well, probably due to malaria or meningitis. As I walked onto the wards, I found a worried mom standing beside her seizing, six year old child. The nurse was off the ward getting breakfast. When he was found, we adjusted some meds and calmed his seizures. After rounds we attempted a lumbar puncture to see if he also had meningitis in addition to malaria. Within the hour, despite our efforts to give him oxygen and assist his breathing, he was gone as well.

There's another six year old on the ward tonight with clear cut meningitis as well as malaria. His chances are slim. Times like this, it's hard for me not to doubt my skills as a doctor. It's also easy to feel like our efforts are drops in the bucket the size of the Big Dipper. The day before, I realized that most wards had no soap, and the one that did was using laundry detergent. It had apparently been like that for weeks. Weeks. And everyone was just used to it. Nurses worked all shift long, clinicians saw patient after patient, and almost no one was washing their hands. I walked the 100 yards to the town shop, bought thirty bars of soap for 10 dollars, and delivered them to the wards.

And the question that keeps nagging at me, the one that I don't really like to think about, is am I weakening the whole system by buying soap? Would it be better for the hospital workers and patients to get so fed-up with the system that they marched on the capital and demanded better conditions? Well, maybe the hundreds of other similar Malawian hospitals that don't have support will get fed-up and rise up. In the meantime, for better or worse, the staff at Kabudula will have soap.