Today was a better day. Staff sign out in the morning revealed no pediatric deaths overnight. The sick 6 year old with meningitis and malaria, though still quite ill, was alive. After sign-out, I gave a brief review of post exposure prophylaxis (PEP) for occupational and sexual exposure to HIV. They have a nice section on it in the Malawian national guidelines, though interestingly they don't discuss PEP for hepatitis B virus, an infection that is much more easily transmitted than HIV and has a prevalence higher in Africa than in the US.
Things were busy in the pediatric ward. I'm glad that we discharged about 10 kids yesterday, because 13 new sick children earned a place on the pediatric ward today. Most children were admitted for severe malaria, and many of the kids admitted for other reasons, like pneumonia, also had mild malaria. Two children had kwashiorkor type severe acute malnutrition. Swollen, infected, and miserable, these kids are often the unlucky older siblings in families with pregnancies too closely spaced. Or in other instances, infections with HIV or TB increase their catabolism while decreasing their nutritional intake since they are ill. Luckily these two kids both tested HIV negative, and they still had some appetite, a big bonus since we didn't have feeding tubes to force feed them if that wasn't the case.
*interlude* It is mildly difficult to concentrate on writing this blog entry with the rat scurrying back and forth in my room. He is very clever, somehow only running around when I'm under the mosquito net. I think he is testing me. With the spiders of various shapes and sizes, the ants in the kitchen, the malaria-ridden mosquitos, the gnats that dive bomb my eyes and uvula while on a jog, and the hundreds of flying termites with wingspans the size of half-dollars, I'm feeling rather like I'm camping. Or in an Indiana Jones film.
Ahh, where was I?
Other interesting cases included reducing a woman's dislocated jaw, a child with sickle-cell anemia, a kid with possible post-streptococcal kidney disease causing facial swelling, and a nine month old who has failed to gain wait over the last five months likely due to being infected with tuberculosis by his mother.
Aubrey was called to evaluate a woman who had a history of a cesarean section and was failing to deliver her baby. Initially a surprise to me, the policy in Malawi is to attempt a trial of labor if a woman has no more than one c-section in the past. Even having one c-section increases a woman's chance for rupturing her uterus during labor, and many hospitals in the States don't attempt this, but instead head straight to c-section. This woman had reached 10 cm of cervical dilation two and a half hours ago and hadn't delivered her baby yet. For unclear reasons, the nurses hadn't been pushing with her the whole time, and her pushing efforts weren't maximized. Aubrey applied a Kiwi brand vacuum to the top of the baby's head in the birth canal in order to assist with her pushing, but the suction wouldn't hold and the vacuum cup kept coming off. He had another type of vacuum available that he knew how to work well, but it was dirty and was receiving a rushed cleaning. Thankfully, we had a fresh Mystic type vacuum that Dan Dewey from WAM had sent along from the US just a few weeks ago. Aubrey hadn't used one before, but I convinced him to give it a try and walked him through it's use. With two more pulls a vigorous, 3+ kilogram baby girl with a sore noggin was brought into the world. Our relief was short-lived as the mom started to hemorrhage after delivery of the placenta. Aubrey went through the steps of adding oxytocin to the fluids as well as an intramuscular injection of this potent medication that causes the uterus to contract, hopefully squeezing the uterine blood vessels and stopping further hemorrhage. Still gushing, we did a thorough exam of the birth canal to look for the likely laceration, but none was found. Vigorous lower uterine segment massage helped, and a dose of misoprostol was also given. This life-saving medicine, which costs less than twenty-five cents a pill, is often absent from a clinic's medicine cabinet as a woman bleeds to death after delivery. There are few things more frightening in medicine than hemorrhage that you cannot stop. But in this case, his efforts paid off. The bleeding stopped, and this newborn baby girl will have a mother to go home with.
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