Friday...

I can’t believe I have been here for 6 weeks. The end is approaching and it is so bittersweet. Part of me wants to stay forever, the other part of me wants to run and never look back. In my mind I have flashes of dead babies, wailing mothers, blown pupils, bloodied hands, last breaths, and silent chests. I will remember every child whose eyelids I closed. I hope that I have somehow immortalized them by writing their stories and sharing their names.

As for me, I know that I will never be the same. I have seen things here that I never thought I would see and I have learned things that I never knew I’d have to learn. I have stepped out of my own reality and into a world where so much can be lost at the dawn of life.

The people of Cameroon are beautiful and strong and full of faith. They are grateful for their waking breaths and they are mindful of their own mortality. They are welcoming of strangers and generous with no expectation of return.

This morning at the end of Morning Report one of the residents, Dr. Nshom, prayed out loud for me- prayed for a safe trip home, prayed that I find a job that is satisfying to myself and God, and prayed that I would return again to Mbingo Hospital. My time here was short, but it is easy to be melded into a community that is so open-armed. I hope to remember the residents and NPs I have worked with- Kristelle, Alvine, Nshom, Claudette, Albert, Nora, Simo, Kamden, and Edith, and I will wonder where they are in the future. I hope they will be happy and healthy and I hope that they will use their knowledge and skills for the betterment of Cameroon. I hope that their children will be healthy and that their spirits will remain strong despite the things they see on a daily basis. I hope they have learned something from me, as I have learned so much from them.

Dr. Nshom, NP Edith, me, and Dr. Alvine

Mbingo Hospital is doing great things.

Before long I will be back in NYC and my role will be very different than it is here. I wonder how this experience will influence my practice, how I will slip back into a world of excess and entitlement. I am grateful that I live in a country where I can name my child at birth, where doctors don’t have to expect a new empty hospital bed every morning, where parents don’t routinely bury their babies. The pain of the loss of a child is universal, whether you are in West Africa or North Carolina, whether it is malaria or metabolic disease, whether you’ve seen one or you’ve seen one hundred. And I guess that is why we keep doing what we’re doing. Why we go home and scroll through labs and textbooks, why we blame ourselves for progressing illness, why we curse God with one breath and ask for miracles with the next.

May our perspectives remain broad, may we recognize a common humanity, and may our eyes never be dry at the bedside of a child. 

"Children's Ward"

Some random pics

Emmanuel (in yellow) with his mom and sister. Recovering from severe malaria and electrolyte abnormalities, going home today :)

Junior and Bryon, stopping by the house to play cards. 

The peak is called "half dome" and we hiked to the top a couple Sundays ago

View of the part of the hospital complex from the side of the mountain. The white circular dome to the middle left is the main entrance to the hospital. 

Stood on the very peak, did not look down

Took this path almost every afternoon

This is Blessing and her mother, finally going home after 3 weeks of treatment for fevers, malaria, failure to thrive, and eventually Tuberculosis. She looks like a new person. Mom cried on the day they finally left.

The Internet Returns...

I feel so sorry that people were worried about me while our internet was down. It turned off suddenly with the power over a week ago, so I haven't been able to contact anyone. But all is well and I am taking the days as they come! So much occurs in a single week here, I wish I could share it all. I tried to write at the end of some of the days here, but it has been very very busy, and I have learned that it takes twice as long to look things up in a limited number of textbooks than it does on google. It's been a little extra lonely being in this big house with no contact with family/friends, but the ward has kept me busy. The crickets are loud and I keep checking every corner for snakes. Right now the children's ward is completely full, and the babies in maternity ward have been extra sick. We do what we can. I've noticed that things come in waves here. For a couple days we had multiple children in heart failure, then for a couple days all severely malnourished children, now many with complications from poorly controlled HIV. I'm beginning to learn how to take things in stride here, but the deaths are heavy and frequent. On Friday we lost a baby that would have been saved by a small dose of surfactant, on Saturday I was hit in the face by a delirious 12yo boy with blood pouring out of his nose and mouth following a snake bite. But I continue to learn so much every day, whether medical or not. And I've gotten to know the staff very well, it will be hard to say goodbye. We are bonded both by trauma and triumph, all at the bedside of a child. 

So here are some entries from my absence...

3/10/15

This morning over the 2 hour course of rounds we had 4 admissions. One was an 8yo boy who probably has a cerebellar tumor (Ataxia, wide-based gait, dysdiadochokinesia), a 4yo boy neurologically devastated from kernicterus as an infant with new onset seizures, and a 3 yo boy with R arm burns secondary to falling into open flames.  

Also, another case for which I need the help …

4mosM who presented to OSH with bronchiolitis, but transferred here for jaundice and hepatomegaly on exam. Per mother, child has needed transfusions twice in the past. After his 2mos vaccinations he developed a large hematoma in his thigh that needed to be drained, after which they transfused him for the first time. At OSH before transfer he had a Hgb of 5, so was transfused again. Per mother, has been jaundiced his whole life, but only recently she noticed the “swelling” in his RUQ. Had one sibling who died at age 11mos due to unknown causes (per mother was crying for a week, they never sought out medical care and she died at home). CBC here is 17>14<196, BMP normal, AST/ALT 152/68, Alk Phos 986, Alb 5.1, total bili 9.4, PT 24, INR unreadably high, sickling test negative. 

Abdominal ultrasound revealed homogenous hepatomegaly with normal biliary tree. Mother is HIV negative and HepBsAg neg, but unsure of other prenatal lab results. Malaria NEG. In addition to the hepatomegaly, the baby has some periorbital swelling around the right eye with some proptosis and a dilated non-reactive pupil. The left eye exam is normal. I need to track down and ophthalmoscope but I am concerned that the baby has retinoblastoma. Or maybe rhabdomyosarcoma? Neuroblastoma? Retinal hemorrhage? Is otherwise feeding well and active.

But how do we put all this together? Our differential include infectious hepatitis (but the LFTs don’t seem elevated enough), obstructive jaundice 2/2 choledochal cyst or biliary atresia (not consistent with US, but high alk phos), hemoglobinopathies (could explain need for transfusions and hepatomegaly), hemophilia (but with hepatomegaly?), malignancy… There seems to be some disruption of hepatic synthetic function with an elevated INR, but I can’t explain the normal albumin. 

And what about the eye findings? Retinoblastoma? Can a baby be this well appearing with malignancy? There is so much going on with this kiddo, I’m not sure I can come to a unifying diagnosis. What am I missing??? Are the findings unrelated?

Ophtho saw the child this afternoon and noted a retro-bulbar mass and neuropathy and ?central retinal vein occlusion and retinal hemorrhage (r/o polycythemia vera, r/o leukemia). Stay tuned.

 3/11/15

The hardest part of being here is hitting the end of the road. Whether it be exhaustion of resources, lack of funds, limitations in diagnostic workup, or the finality of diagnosis itself, the hardest part is realizing there is nothing else we can do. I’ve hit this dead end more times that I can count since being here, and it has never gotten easier.

If you remember, the first patient I was ever called about when getting here was a young baby with a webbed neck and complete AV Canal defect. The baby needed surgery, but the family couldn’t afford it. The baby was in complete heart failure and there was little we could do at that point. I intubated him and coded him for over an hour before he died. It seems like so long ago. If I were faced with the same patient today, I would know much better than to push epi or start chest compressions. I’ve learned the futility of coding people here. I would have given the baby to the mother and let him die in her arms. The way that Derrik died with his hand in his mother’s, the way many of the children take their last breaths within the warmth of a mother’s hug.

There is one cardiac center in all of Cameroon and it is a couple hours from Mbingo. You can either afford the high price of cardiac repair or you can’t. Our patients can’t. No payment plans, no exceptions. And so these children come to Mbingo for affordable medical care even though we can’t provide them with what they truly need- heart surgery. Currently we have two young girls on the ward dying of heart failure. One is a 12yo girl with severe mitral regurg- in desperate need of surgery, but the parents can’t raise the money. I’m not used to managing heart failure because the children in the states who need repairs get repaired. I’m trying to make her comfortable, maximize her meds, but I fear that I am only providing palliative care. What else can I do? We have an 8yo girl who presented 2 days ago in florid heart failure with dilation of all ventricles, severe pulmonary hypertension, and calcifications on her aortic valve (with a murmur so loud you can practically see it). Surely she also needs a valvuloplasty, but the family can’t afford the bills. So I am here playing cardiologist on these tiny tachypneic girls, knowing sure well that they will both likely die on my watch. So here I am, again at the end of the road. Bed 5 and Bed 10, I am hesitant to learn their names, but today I will.

Then there is the end of the road when you’ve exhausted your meds and exhausted your workup and a young mother has exhausted her funds. There is a sweet 2yo girl named “Blessing” who came in about 3 weeks ago, tiny for age and visibly afraid of my white skin. She was admitted for fever and failure to thrive. She was started on NG tube feeds and our full nutrition protocol. No obvious source of fever could be identified at that time, but we covered her with broad spectrum antibiotics. Over the following weeks, she failed to defervesce and failed to gain weight. Some days were good and some days were horrible. We exhausted our stock of antibiotics, our battery of tests. We even treated her for both malaria and TB despite a negative workup. Yet she continues to be a sickly-looking 2yo in bed 6, with the developmental milestones of a 12 mos old. I suspect a primary immunodeficiency, but I can’t put my finger on it. She is HIV negative, but she is acting otherwise. Yesterday mother told us that she can’t afford anymore workup and I can’t say that I blame her. Here we are, almost 3 weeks later, and the child has barely gained any weight and is still spiking high fevers. And mother’s whole family is broke. I can’t help but feel that we have failed this child, but I’m not sure what else we can do? I believe that she will die at home and no one will ever have the answer. It is a hard pill to swallow, a lump resting in my throat. We could not help this child, but still we took what little money they had.

So we meet the end of the road, for cardiac patients, for elusive diagnoses, for my dear friend Cedrik.

3/12/15

I’ve spoken again and again about a mother’s love, let me mention a father’s love that is just as sweet. The little boy’s name is Gabe and he is 4years old. When he was an infant he has severe jaundice leading to brain damage (kernicterus). Now he’s 4 yrs old and in the body of a 1yr old. He doesn’t speak, he doesn’t walk, he can’t even chew his food or control his bladder. His father brought him to us, desperate, not because he wasn’t doing what other 4yr olds were doing, but because he felt that his son was in pain every night. “Every night he wakes up screaming, like something is hurting him, and his whole body goes stiff. I grab his body and place him on my chest until he stops screaming and his body loosens up.” Turns out the child is constantly having seizures, but he has not been seen by a doctor since he was an infant. Like many children with cerebral palsy, he is severely contracted and with minimal interactions. But the father loves him with a love that is a privilege to witness. He carries the child everywhere, he exercises his stiff limbs, he speaks to him lovingly without ever expecting a response. “How do you feed him?” I ask him when it hits me that the child doesn’t have a feeding tube. “I mash up all our food until it is very smooth and then I hold his tongue down like this with my finger and drop the food into the back of his throat. He sticks out his tongue when he’s hungry.” The doctor side of me shudders with the thought of aspiration pneumonia, but the 29yr old side of me thinks it’s the most beautiful thing I’ve ever heard. It is the love of a father for his son, complete dedication. I can’t bring myself to try to change this practice. Your son will probably never walk I tell the father. Our job while you’re here is to try to help decrease his seizures so that he is more comfortable and to help you learn more exercises you can do with him to help loosen some of his contractures.

Two days later was the first night that Gabe did not wake up screaming and the father was the happiest father in the world. I told him that the blood work looking at his liver and kidney looked good and he said, “Praise the Lord, bless you Dokitah”. I certainly cannot take credit for a healthy couple of organs, but I can appreciate the heaviness of a praised Lord in the setting of a vegetative state. Gabe and his father will likely go home tomorrow, but it will not be an easy road for them. But one thing is for sure, that child knows true love and a father who would give the world for him.

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3/13/15

We lost our internet earlier this week and probably won’t get it back before I leave. I feel so bad having no way to reach my family/friends and let them know that I am okay. I know my parents are probably very worried because I stop contacting people so suddenly. It’s not the best time to lose internet, alone in West Africa, responsible for all the sick children in the hospital, no way to look things up, no way to cry to my boyfriend at the end of a rough day. The house feels even larger now that the only person I can have a conversation with is myself. The power keeps going out because of the start of the rainy season and the bugs have all taken shelter inside. It’s a Friday when I am writing this, I missed dinner because I was trying to save a baby that I couldn’t save. She was one day old and her mother’s name was Silvia. Silvia had been pregnant 7 times, but all of her children had died- either by spontaneous abortion or died in infancy/childhood. When I saw the baby last night I thought, this could be it, this could be a child that lives. No pressure or anything. The baby was delivered early at 34wks due to placenta previa and was in respiratory distress and blue when I met her. She had been born floppy with apgars of 5, 8, and 5. We set up a poor man’s bubble CPAP machine with an old water bottle and she seemed to be making improvements in saturations and work of breathing. No murmurs, good pulses. TTN, I thought. This morning she looked a little worse, with O2 sats in the low 80s and still with some grunting. Good air movement, no crackles, lungs didn’t sound wet. Pushed the tubing a little deeper into the water bottle, started antibiotics, crossed my fingers when I should’ve been saying my prayers. Went back to my ward of sick children, stopped by the ICU to check on my 12yo s/p emergency craniectomy, inquired about the existence of surfactant, checked to see if the internet was magically working again, and then got called back to see the baby. Silvia’s baby was dusky, O2 sats 50s then 30s then in the teens. No spontaneous respirations, heart rate dropping. She looked horrible. The nurse called the chaplain and I told her to let the mother know that the baby was dying. I asked if she wanted to hold the baby or be in the room with the baby, but she did not want to see her. And so we went through the motions of giving her breaths and gentle chest compressions, but there was nothing else we could do. The baby had been too long without oxygen. Her tiny lips were purple and her delicate fingers lay limp off the side of the isolette. She looked like a doll, laying there pale and perfect. I wanted to pick her up and hold her in my arms, let that be her last moment. I wanted her to feel the warmth of another human being, feel a moment of love in her short life. But I just stood at there at her bedside, sweat running down my face, hearing my own heartbeat instead of hers.

In March 2015, Silvia’s seventh baby died. If the baby was born in the US, I believe that she would have lived. How many of her children would have lived? Her neighbors would have refused life-saving vaccines, scoffed at her 2 years of breastfeeding, but her child would still be alive right now. But instead she will bury her daughter in a tiny grave, next to brothers and sisters that never were. How much pain can one person take? Unimaginable. Take the potential for the most beautiful moment in a mother’s life then replace it with the most horribly tragic turn of events and then multiply it by seven. That is Silvia’s life here in Cameroon.

I’ve seen so many young children die since coming here a month and a half ago, it is something that one would be blessed to never see. I’m always struck by their little mouths, slightly parted purple lips, soft and at rest. It’s amazing how different a child looks from the moment they are taking those last agonal breaths to the moment after I close their eyelids. You would think they are in a peaceful sleep if it wasn’t for those tiny purple lips. But they are not sleeping, their bodies are heavy and their little hands are cold. Their faces take on an entirely different look, as if they have suddenly become a replica of the person who had just been alive. It is the doll-like visage of a person in an open-casket, juxtaposed to their desperate gasping for air. It is quite a phenomenon. And even though all emotion eventually gives way to grief, in those last moments of transition, there is a feeling of intense relief. You have to believe that they have slipped into somewhere that is far better, you believe it because you desperately hope it to be true. Whether this is a justification for Faith or not, it doesn’t matter. It is a necessity here and it is the only way to not crumble with every waking tragedy. Please Lord, bless Silvia’s tiny little girl, show her love, show her comfort, show her happiness. I believe it to be true because I can’t bare it any other way.

There is nothing worse than the death of a child. 

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3/14/15

Overnight, I was called into the hospital where I witness one of the most horrible deaths I have ever seen. It was a 12yr old boy named Caleb who had been outside of his home helping his mother husk corn when he felt a sharp bite on his left foot and it immediately started bleeding. They did not see what bit him, but assuming it was a snake bite, he was brought to a local clinic where his clinical status abruptly deteriorated. He was slightly altered upon arrival to our hospital at ~2am. The resident on call quickly sent off labs, administered antivenin, and started antibiotics. The patient began to have rapid edema of all extremities and within an hour began vomiting blood. The resident called me around 4am, I told him to order blood and stabilize him as best he could, as I frantically flipped through old textbooks and prayed for the internet to return. No such luck. When I arrived at the bedside the young boy was foaming at the mouth, thrashing around on the bed with frothy blood spewing from his mouth and nose. I tried to stabilize him so that he wouldn’t injure himself and he hit me square in the face, busting open my bottom lip. His lungs were completely flooded, he appeared to be drowning in his own pulmonary hemorrhage. Eventually he became unresponsive and frank blood began pouring out of his nose and mouth, saturating the sheets and anyone that was near him. We suctioned a full bucket of frothy red secretions from his airway, but there was no end to the flooding. The initial collection of hemoptysis showed no signs of clotting hours later, his was no doubt in rapid and horrible DIC. It was too late for the blood products as he had begun his agonal breathing. I told his mother that he was going to die and her wails sent lightning down my spine. The other mothers in the room had also started crying, something I had not seen before. I stood there with his cold blood on my hands and my warm blood on my lips and I tried to make him comfortable. His death came quickly and in a moment he was gone, blood still pouring from his mouth and nostrils. It was a scene from a horror film. No wonder people are so afraid of snakes.

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3/15/15

This morning I made a new friend- his name is Junior (geen-yah) and he is 12 years old. After rounds I returned to my house to make some coffee and listen to the Sunday church music. Sundays are nice like that. Around the back of the house came Junior, dressed in a shiny grey suit and a stick in his hand. “Oh hello,” I said as we both startled the other, “are you looking for something?” He told me that he was just walking around while his parents were at chapel and then disappeared around the other side of the house. Not ten minutes later he reappeared on my back porch and sat in a chair across from me. “Do you have any games you want to play with me?” he asked. I told him that I had a deck of cards and we proceeded to play cards over the next couple of hours. He had trouble teaching me how to play the card games as I had trouble understanding his accent, but we soon figured each other out.

As I sat across from him I thought of the little boy who had died of the snake bite yesterday. Caleb and Junior are the same age, the same size, the same stage in life. Junior could just as easily stepped on a snake while helping his mother husk corn and the tragedy would be his own. As he sat across from me explaining how to score the card game, I had a vision flash before my eyes of blood pouring from his nose and mouth. The image shocked me and I quickly snapped back into reality. I imagine this is a shred of PTSD, probably an image that has been defiantly tattooed into my memory. I thought of how alive Caleb must have been the day before we met, his vitality commemorated by my swollen bottom lip and the still open textbooks strewn across the kitchen table. He was no different than Junior is at this very moment.

I was reminded how unbelievably fragile life is, just one wrong step between life and death. It is a snake bite, a car accident, a spontaneous mutation, a misdirected grape, a slip in the bathtub, a misplaced inhaler, a moment too long in the birth canal. I never am more aware of what a blessing a healthy child is than when I am rotating through the NICU. There is nothing more beautiful than a healthy newborn, all the things that must go correctly along the way to a well baby’s nursery. It is a miracle, really. So many people have the luxury of taking this for granted and that in and of itself is a blessing. But anyone who has worked in the NICU is denied this naivety and you begin to ask yourself, “how does everything ever all go correctly?” And for me, this is the foundation of my Faith, the awe of nature, the humbling of science. But I, like many, grapple with the fact that the same God who breathes life into a newborn also creates venom in the fangs of a green mamba. Maybe it is just beyond our human understanding, maybe there is a greater plan that we are not privy to. But I have to believe that God is good because I have to. I can’t devalue miracles for not being able to reconcile tragedies.  

The greatest gift that I have taken from Africa is being able to look across the table at Junior and recognizing a miracle. I can choose to be paralyzed by the walk across a tight rope or I can be thankful for my ability to walk. As I’ve mentioned before, death is a part of life here, but it is a concept that can transcend the continents. By knowing death, we are truly able to value life. By respecting the fragility with which we live, we can appreciate every day that our children are able to play cards with us. Maybe the people of Africa are so devout not because it provides them with strength amidst tragedy; maybe they are so devout because they have a greater ability to recognize miracles. 

Traditional Healers

If I could tease out a single public health issue, in addition to the crippling stigmatization of HIV, it would be the presence of “traditional healers” in Africa. When a person is made to believe that an illness is a curse rather than a medical problem, it is natural that one seeks out a spiritual healer rather than medical care. Twice in the last 2 weeks, I have admitted previously healthy young boys who had been brought to a traditional healer for a minor ailment and came to us in acute liver failure. They don’t know what they took, but soon after they saw this healers the whites of their eyes became yellow and they started having abdominal pain. The first boy I saw walked into my clinic room, crying and complaining of abdominal pain and was dead within 12 hours. Now I have another little boy on the wards with LFTs in the thousands that I am holding my breath for. That’s the thing about acute liver failure. What can we do? Watch for bleeding and infections, hope that they don’t become too altered to protect their airway, pray. It is the worst, not only because there is nothing that we can do, but because someone DID THIS to them. They are just little boys, their parents are well-intentioned, but their little bodies can’t handle whatever toxins they are being fed.

In my idealistic mind, I would like to think that the traditional healers are also well-intentioned and are doing what they believe is helpful. So I asked one of the long-term missionary doctors who’s been at a nearby hospital since 1992—do you think they’re evil? Do you think they are intentionally hurting people? She is a sweet little lady with a huge brain and heart to boost, and she answered me as follows, “I hate to paint all traditional healers with the same brush, but I do believe that they represent all that is evil in the world. They are the evil that lives among us, they prey on the vulnerable for a profit and they manipulate Africans in their most desperate hour.” She proceeded to tell me multiple unbearably horrible stories about local traditional healers and the deaths that pursued. The things the traditional healers have said, the ways which they convinced villagers not to come to the hospital, the way they provide false hope, and in many instances, the way they have brought death to the already vulnerable. And it is a vicious cycle. The patients come to us when all they have left to do is die in our hospital beds, so it is no wonder they associate hospitals with death. And to boot, they will have a large monetary bill from the things we try to do to save them, when previously they paid the healers with chickens and goats. “There is some darkness in that beautiful world out there,” she told me. “They are still making living sacrifices in the bushes, feeding poison to our children, tempting Adam with the forbidden fruit”.

Three days ago, 32 witch doctors were arrested in Tanzania where it is a common belief among traditional healers that the limbs of albino children hold magical powers. These traditional healers were kidnapping albino children, killing them, and using the bones of their arms and legs to make potions. In some cases they cut off a hand or a foot and left the child bleeding. One of the doctors here who had worked their previously said the albino patients would refuse to leave the hospital, as they lived in constant fear of being kidnapped or mutilated by witch doctors. Here in Mbingo, there are lots of albino children, they march around in their wide-brimmed hats without a care in the world. The lady that cleans our house has 5 children, one set of twins, and a boy and a girl who are albino. It is hard to believe that had they been born just a couple countries to the east they would have been forced into a life of constant fear. I’d like to think that there are not as equally horrible practices here in Cameroon, but I’d be naïve to think so.

Though maybe there are a few good-intentioned traditional healers out there, the damage that is being done by the ones whose patients I see is nothing but evil. But it is an engrained culture, a constant fight over strongly held spiritual beliefs. Even medical doctors were somewhat of witch doctors at one point, but I would hope that at least our intentions were good and our work was not at the expense of another human being. These are the types of things you read along the lines of holocaust, female circumcision, voodoo sacrifice, infanticide, things that you feel are almost too painful to think about. Things of another world, things of another time. But it is our world and it is our time, and there are many things that we need to believe that are otherwise too hard to believe.

Sick Rounds.

There was a huge thunder and lightning storm last night, but still no rain. The thunder was so loud, it sounded like an airplane was driving through the house, I kept waiting to smell smoke. Today the sky is ominous, everyone is hoping for rain.

We went on a hike yesterday evening and scaled our way to the pinnacle of a rocky cliff. It was scary, but made for a good adrenaline rush. You could see for miles despite the dry dustiness and the pre-rain fires that are set purposefully for the new crop season. I kept my eyes out for snakes, but all we ran into was lots and lots of longhorns.

This weekend I was consulted on a 2 wk baby with a 1kg weight loss (2kgà1kg) since birth, poor feeding, and lethargy. The baby’s blood sugar was so high that it was unreadable on our machines, but after many many boluses the blood sugar finally read as 900. It was the first time I’ve ever started insulin on a newborn, so I had to consult the NICU back home for some Neofax guidelines. My guess is that it is all secondary to sepsis, but I was reading that there is an entity of neonatal diabetes but it is exceedingly rare. I wrote out step by step instructions for the deer-eyed overnight resident, but I didn’t expect the baby to survive through the night. Also, Na 171, K 8.5, Cl139, BUN 281, Cr 4.4. Surprisingly not the worst electrolytes I’ve seen since coming here, but pretty darn close. Imagine my surprise when the baby was looking better in the morning and even able to eat by mouth! Today the baby’s blood sugar is around ~100, but the electrolytes are still pretty abysmal. We started somewhat of a manufactured insulin drip with comes to ~0.1u/h, which we have weaned this morning. I am hoping that it is all due to sepsis and will eventually self-resolve because it will be a nightmare trying to manage neonatal diabetes in this setting.

There was another 3 day old baby girl who came in yesterday, floppy and lethargic, who died before we could even get an IV in her. She had been born at home and hadn’t been well since birth. You can start to understand why mothers are hesitant to name their babies until they are a couple weeks old.

It was nice to be back in the community today. There was a lot of “Good morning Dokitah Britt-anee, You are welcome back”. Rudolf is still here, has some osteomyelitis of the hip and the family is working on raising money for his huge bills. It is nice to see his smile. I called my grandfather over the weekend and his home attendant who is from Ghana answered the phone. He said “how do you like Africa?” I told him that it is beautiful and the people are really nice and welcoming. He said that he was glad to finally hear someone say some positive things about Africa, as it often gets so much bad press about being dangerous and poor and scary.

While there are obviously some very dangerous parts of Africa, the Africa that I have experienced here in Mbingo is filled with good morning smiles, invitations to family homes, welcomings into churches, shared meals with strangers, parades of children on hikes, and music in every corner of the countryside. Of course the hospital is filled with death and despair, but outside of its walls is a beautiful place. The people here are so grateful for the existence of a hospital in their midst, there is no one that takes that fact for granted. They will thank you for doing a spinal tap or bone marrow biopsy at the bedside, just as soon as they will invite you into their family home.

They said that the children ward was not so busy last week, but sure enough I walked in today and every bed was filled. And the kids are VERY SICK.

Bed 1: 1.5yoF with vomiting and abdominal pain x2 days, mass in LUQ. ? Intussusception

Plan: Repeat abdominal ultrasound- Go to OR

Bed 2: 4mosM with cough, fever, increased work of breathing x3 days. Transfused x1 at OSH (Hgb5.9), + hepatosplenomegaly. ?Lipoma over left rib cage?

Plan: Supportive care for bronchiolitis. Chem10, coags, sickling test. Abdominal US for HSM and rib mass. Start Fe.

Bed 3: 13yoF with AIDS, CD4 count 4, severe HA and vomiting x1 week. LP shows cryptococcal meningitis. On ARVs x1 mos, Bactrim PPX

Plan: Continue Amphotericin, therapeutic LPs when complains of HA, monitor fever curve, other symptoms

Bed 4: 1yoM with vomiting, diarrhea, lethargy, s/p transfusion x1 for Hgb 4.0. Sickle neg. Likely AGE. Why such anemia?

Plan: Repeat Hgb, ORS, continue supportive care for viral AGE. Start Fe.

Bed 5: 10yoM with fever, cough, tachycardia x4 days, also recurrent epistaxis. CXR with R upper and L upper consolidations

Plan: Continue O2. Ceftriaxone and erythro for CAP, will send aspirate for AFB and place PPD. Follow up Code Status.

Bed 6: 2yoF with persistent fever and FTT. Has been treated by multiple antibiotics in past, as well as antimalarials. Currently on Clinda and Bactrim and Day #2 of TB treatment. Suspect immunodeficiency disorder.

Plan: Will continue TB treatment x1 wk. We are not providing anything new for this child and parents have very large bill. Consider discharge after trial of TB meds.

Bed 7: 3yoF with R leg pyomyositis, s/p I&D. Now afebrile on Clox and Clinda.

Plan: D/c home with continued dressing changes and antibiotics.

Bed 8: 14yo with fevers, huge splenomegaly, pancytopenia. Failed antibiotics, Antimalarials, TB treatment. Bone marrow biopsy inconclusive, Hgb persistently 4.0 following transfusions. Is leaving AMA today.

Bed 9: 14yoF with anemia, bone pain, generalized weakness x3 mos. Has had 4 transfusions in the past, Pancytopenia with CBC last night showing WBC 2.5, Hgb 2.2, Plts 1. Now s/p transfusion x2.

Plan: Bone marrow biopsy once platelets >15k. Send peripheral blood smear and aspirate.

Bed 10: Chemotherapy

Bed 12: 15yoM with abdominal pain and post-prandial vomiting x2 days. ? scleral icterus. AlkPh 646, bili 6.6. AGE versus gastritis, ?superimposed liver injury secondary to traditional medicine?

Plan: Ranitidine. Send LFTs. Abdominal ultrasound

Bed 14: 10yoM with neurodevelopmental delay and full body contractures, present since age 7 after child had seizures x3 days and did not seek medical care (previously normal). Here for PT, also with fever and seizures. Loaded with phenytoin and continued on home phenobarb. Treating also for UTI. Now with cough and concern for aspirations PNA despite CXR WNL

Plan: Continue PT, Flagyl, Cefixime. Follow up antiepileptic dosing.

Bed 15: 8yoF with abdominal pain, fever, and cough x 3 weeks. Febrile with loud holosystolic murmur (new?). + Hepatosplenomegaly with tenderness over liver. Crackles at lung bases bilaterally, 2+ pitting edema of lower extremities bilaterally. Electrolytes ok. Abd ultrasound shows severely congested liver. ECHO show all chambers dilated with severe mitral and tricuspid regurg and significant calcification of the aortic valve. EKG LVH. EF 69%

Plan: ASA, IV Lasix. Start Digoxin? Need to research this more. Talk to Sinai Cards?

Bed 16: 2 wk F with choanal atresia- seen by ENT, can’t determine membranous vs bony.

Plan: Send to Bamenda today for CT scan.

Bed 17: 2 wk F with suspected sepsis and severe hyperglycemia, s/p insulin drip. Still with significant electrolyte derrangements, though better appearing today. Na 183, K 6.4, BUN 245, Cr 3.6, Gluc 109

Plan: Switch fluids to D5 ½ NS and continue to monitor FS q3h. Need to think more about this one. Repeat Chem10.

Bed 18: Rudolf. Has been discharged but parents working on paying bill. Continue PT while here.

Bed 19: 11 day old male with irritability x1 wk, here with dehydrations and electrolyte derrangements. Na 161, K 5.5 BUN 98, Cr 0.7. CSF WNL. Baby improved-appearing. Continue amp/gent, repeat Chem10

Bed 20: 3mosF with suspected HIV, being treated here for CAP, PCP. Persistently hypoxic despite treatment with Bactrim and steroids. WHY?????

Bed 5-2: 11yoF with severe mitral valve regurgitation in severe decompensated heart failure. Needs surgery but family can’t afford it. On Captopril, Lasix, ASA. +HSM, b/l pitting edema. Very ill-appearing.

Plan: IV Lasix stat, continue home meds. Follow up CMP.

Women's Day

It is lonely here today! I heard from Mollie who said the ride back to Douala was pretty treacherous. The trip itself took 8 hours full of bumpy roads and sweatiness. Then she was dropped off for dinner at a place known for their fine clientele of foreign businessmen and prostitutes. Afterwards, she was brought to the Duoala airport 6 hours before boarding time, where she had to sit on the ground in one small room, surrounded by heat, humidity, and a swarm of mosquitos. I guess I have 2 weeks to mentally prepare.

I’ve been consulting on the wards over the last couple of days, but I will officially be taking over again tomorrow morning. Chapel at 6:30, Morning Report at 7, breakfast at 8, rounds until noon, worrying and admissions all afternoon, on call at night. I am going to try to fit in a short daily hike for sanity’s sake. This shouldn’t be any harder than an 80 hour resident’s work week that we’ve all grown accustomed to, but there is something about the level of responsibility and emotional exhaustion that really puts you over the edge.

Late last night a young boy knocked on my back door and I almost jumped out of my skin. He was trying to sell a small glass craft that he had made, but he scared me half to death. I told him we weren’t allowed buy things from our houses, but maybe if he came around lunch tomorrow then I would buy it in honor of Women’s Day. The house is so big and dark and creepy at night, I don’t want random people showing up and freaking me out when they realize there’s a gullible white lady that will buy your stuff.

I wore my new dress in honor of Women’s Day today. I missed church this morning, but I wish I hadn’t. I can hear music from all angles from the surrounding churches and all the women are dressed in their finest fabrics. The children are so cute in their Sunday outfits- the little boys in their mini suits and the girls in their frilly dresses. Yesterday there was a lot of wailing around the hospital, but today the sounds are so much sweeter. Maybe it will stay this way, but probably not.

Happy Women’s Day!

And then there was one

Black Mamba? The jury is out.

Mollie left this morning and it was pretty sad. We were great support systems for each other and it was nice to have someone my age around. Now it is just me and Dr. Dillon at meals (one of the surgeons), and he is leaving next weekend. They are desperate for doctors here right now, there is one family medicine doctor which is basically consulting on all the wards, as well as running the peds ward over the past week when I was away because that is the ward the residents are most afraid of. The poor internal medicine residents have to cover the peds ward a couple months per year, so there is a lot of learning on the go. I am trying to mentally prepare for plowing through the next two weeks and taking all things in stride.

I can’t believe I left New York over a month ago. I never would have thought I would see the things I’ve seen or been in the role that I am now. They said that sometimes there are as many as 3 or 4 pediatricians here, but somehow I arrived in a time when there was none. I had mixed feelings about mission trips before I came, recognizing that what we do here might not be sustainable and, in the end, we end up getting more out of the trip than anyone else. This may definitely be true, but this experience seems different in that it is integrated into a Cameroonian residency program. The concept is fairly new in Cameroon and still has a long way to go, but is miles ahead of where it used to be. The residents here read up on their patients, do almost every procedure imaginable, attend lectures, and make the big decisions on a daily basis. There are so many cultural differences between residency here and in the US, but the general concept is the same. They don’t have the luxury of smartphones, but they do have textbooks and libraries and experience. When we round in the mornings and evenings, they can teach me procedures and endemic disease presentations and I can remind them how the physiology of a child is more than just a little adult. It is a symbiotic relationship that I do feel is sustainable, as they will carry it with them into the Cameroonian realm of public health. At the very least, perhaps they will face the peds ward with a little less trepidation.

So today I will adjust to some solitude and check under the beds for snakes. Maybe I will look for a job, maybe I will go on a solo hike, maybe I will start a new book. I will enjoy the calm before the storm, again. I appreciate the massive amount of support I’ve received from back home, I am so flattered and humbled by the newspaper article. I am happy that the story can be shared as a window into a world that we are not used to, perhaps not even aware of. It is not about a single experience of someone who comes here for a short time; it is a medium for recognizing and giving a moment’s thought to our brothers and sisters overseas. It is not about guilt, it is about compassion and awareness. It is about perspective and a common humanity. It is a shared sadness for Cedrik and a cheering squad for Rudolf, a reminder that we are all in this together.