Walking out

Yesterday this little boy’s dad brought him in, begging me to cut off his arm.

                       
It's been getting worse over the last year and parents are afraid that it is going to spread to the rest of his body. I told them to return next Monday for further workup including TB and filariasis, which will have to be drawn overnight. I don't think there is much we can do, but maybe we can stop it from spreading. 

His pinky is purple because it shows he has had a recent polio vaccine. Kids here get them about every month, and the marker on the finger is to prevent them from getting more than one in a month. Parents are desperate for their children to get vaccinated as soon as possible, maybe we can send California's unused ones over here. 

We've been seeing a ton of cerebral malaria recently. These kids come in looking SO BAD. Often completely unresponsive. Thursday evening I was doing a spinal tap on a comatose 7 year old, this morning he was sitting up in bed eating rice. It's amazing what antimalarials can do. It's scary to think that there are places that may not have these medications available. How many of these children die at home?

Often patients go to traditional healers before presenting to the hospital and we're never quite sure of what "country medicine" the patient took prior to presenting to us. On the adult ward they see a fair amount of liver failure attributed to country medicine, often leading to death. Last night we admitted a 6yo boy who looked septic from across the room. Working hard to breath, tachycardic to 200, crying from abdominal pain, I can only imagine what his lactate was. His liver was enlarged, he had crackles throughout his lung fields. LFTs elevated, Albumin 1. Apparently he had started with a diarrheal illness a couple weeks ago and saw a traditional healer who prescribed him some country medicine at that time. Soon after, the parents noted some scleral icterus and felt like he was getting worse. He was admitted to an outside hospital with abdominal pain and treated for dysentary, but was transferred here for increased work of breathing and escalation of care. My thought is that he has acute liver injury from country medicine, but only the mythical toxicology lab will know.  For now we will do what we can.

Rudolf might go home on Monday. I shake his hand every morning and say "soon". He doesn't understand American English, but he understands soon. So does his mother. He has been working on walking  on his own and he is off all antibiotics. His wrist wound is almost completely healed and his mother will continue the dressing changes for his thigh wounds at home. I can't believe that he is the only one of the five boys that I wrote about who is walking out of this hospital healed. I've tried to find peace in that Hilaire and Derrik have escaped their intense suffering. I fantasize that Junior somehow healed at home. I'm not sure how I will ever get over Cedrik's death, but hopefully I will come to some understanding some day. 

As for Rudolf, I feel like seeing him walk out of the hospital will be the most beautiful thing I've ever seen.

Last call, for now

Today is my last day on call for the next week. They are assigning a family medicine doctor to the peds ward so that I can focus on study work in Bamenda for the next week. Then I‘ll be back inpatient for the following two weeks. Four of the American doctors left yesterday and Mollie leaves this Friday—needless to say, we are about to be very short-staffed. I will definitely miss having Mollie around, we definitely do a good job of keeping each other sane. Tomorrow after rounds we are going to a tea plantation—I’m not really sure what that means, but I will be happy to get off the hospital grounds for a day. I heard a rumor that there might be gorillas there; Jonas will be sorely disappointed if I come back from Africa without any exotic wildlife pictures.

The little girl who came in with lethargy and vomiting yesterday with a sluggishly reactive pupil was found to have schizoencephaly on head ultrasound. Thank goodness for Wikipedia in times like these. Apparently it means there are abnormal clefts/slits in one or both cerebral hemispheres. She also has dilated ventricles. Having an answer is all well and good, but here the question of what to do next always trumps a definitive diagnosis. I’m not a neurologist, radiologist, neurosurgeon, or intensivist, but apparently I play one on TV. The surgeons are asking me what I think they should do- if I think they need to put in a VP shunt. I asked them to find me the mythical ophthalmoscope that lives somewhere in the jungle. Maybe then hook me up with an MRI/CT scan and a neurosurgeon. For now, I have some thinking to do and hope she doesn’t herniate in the meantime.

A small blessing yesterday was that the mother of the baby with Epidermolysis Bullosa speaks English and I was able to sit and talk with her for a while about the diagnosis. It was so cathartic to finally be able to communicate with a parent directly. She asked to see the chaplain after I spoke with her, which confirms that she was actually hearing the words that I was saying.

Next week will be nice to get a little break from the wards. I also will need to focus on looking for jobs back home for when I finish residency in a couple months. Being away for these two months has made things a little tricky. I was offered a job a couple weeks ago, but I don’t think they are willing to wait for me to return before I accept the position. I guess it wasn’t meant to be.

I’m learning a little pidgin English. It’s really hard to understand. I have no idea how things are spelled, but people say “Asha” for everything- hello, goodbye, I’m sorry, okay, etc. It has a really nice sound to it. They say chop for eating… “you done chop good today?” The syntax is always interesting. And my personal favorite, “you shiddy wahh wahh?” (something like that) for diarrhea…literally, are you shitting water? Makes me giggle every time.

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Thanks to everyone back home and abroad for all the well-wishes, concerns, kind words of support and understanding, middle of the day can-you-look-this-up-for-me text responses, overseas consults and advice, reassurance, worry, prayers, messages, and an overall presence from far away. I feel very lucky and blessed to share this story. This is an opportunity to learn and understand and widen our world lenses. It is taking a moment to evaluate our faith and mortality and an opportunity to recognize a common humanity. We are all brothers, sisters, children, mothers, fathers. Let it be empathy and not guilt that enables us to remember our global families. 

The Hopeful Trip to Mbingo

Lots of new patients today. One little girl came in today, minimally responsive aside from occasional vomiting. No fever per mother. WBC normal. On exam her fontanelle is tense and her left pupil is sluggishly reactive compared to the right. I don’t want to tap her, for fear of herniation, so we are treating her with meningitic doses of antibiotics and treating for cerebral malaria. Without a fever, however, my main concern is that she has a space-occupying lesion (brain tumor) for which we can do nothing. For now we will add on some steroids and pray.

Since I’ve gotten here, I’ve been seeing more and more patients in the outpatient clinic, although I have been assigned to the inpatient wards. It usually goes like “…but the parents heard that there was a pediatrician in Mbingo and they traveled many hours to get here…” No pressure or anything. So as the news spread, I’ve been seeing more and more patients in between more and more patients. It’s mostly a sea of hopeless diagnoses that have been seen by many doctors before me. I wish I had something more to offer, but my hands are tied as much as everyone elses.

Today a mother brought in a 3mos baby girl for a “rash” which has been present since birth, but recently has been getting worse. Now with fevers. I undressed the baby and the skin was peeling off with her clothing. She has what is known as epidermolysis bullosa, a congenital deformity of the skin. I confirmed with my stateside consults that bone marrow transplant is the only cure; so again, there is nothing much we can do aside from hydration, antibiotics, and education. Apparently the skin breakdown of the fingers can get so bad that the fingers can fuse together (“mitten deformity”), so at least we can try to prevent that. The overall prognosis is not so good.

The baby in a coma for 4 days took a couple sips of water today. A little blessing! Rudolf may be able to go home tomorrow if he is able to start walking on his own. We have another new girl name Ntoh who came in with a spleen that was so big that it was protruding through her shirt. Everyone here has at least one enlarged organ, I swear. Sure enough on CXR she had some pretty impressive cardiomegaly. So, correction, everyone here has AT LEAST one enlarged organ. You just hope it’s not the brain.

And so life goes on after death. We salvage what we can and have to let go of what we cannot. It’s not that we shouldn’t lose sleep over the ones we could not save, it’s just that we need enough sleep to think clearly for the ones that we can.

A sister and her baby brother <3

The dust settles

The wards felt strange today, no Cedrik tagging along, Derrik’s bed already occupied with an unfamiliar face. Cedrik, Hilaire, and Derrik are dead, Junior left AMA (I’ll pretend he’s still alive, though unlikely), and now we are left with only one of the five boys I wrote about. Rudolph is looking good, but still unable to walk due to deconditioning. Maybe he can go home on Friday…

I ran into Derrik’s mom today and she said “hello dokitah, good morning” and smiled and shook my hand like it was any other day. This place confuses me so much sometimes.

Cedrik’s mom is still sleeping in his hospital bed.

The ward is full again, with lots of children who came in way later than they should have. There is a 2 wk old baby who has been having bilious vomiting since 3 days after birth and has never passed a stool. She weighs 1.5kg and is so malnourished that she just flops in any position you place her. She’ll need surgery for likely duodenal atresia, but I doubt her little body can take it.

We have a 14yo with huge splenomegaly that we’ve been working up over the last week for TB vs Tropical Splenomegaly (chronic malaria) vs sickle cell sequestration vs malignancy. Today she had a bone marrow biopsy done at the bedside with the biggest needle I have ever seen and the loudest screams that she has ever made. I can guess what the results will show.

The baby who was in a coma for 4 days secondary to severe dehydration and probable cerebral malaria is actually looking pretty great. Mom is begging us to allow him to eat by mouth, but it is still too unsafe. Part of me is thinking you should be happy he is alive, but the other part of me is thinking I can’t stand to hear the sound of another distressed child. But I will stand my ground.

We have a 15yo boy with TB pericarditis, 3 failure to thrive children, another few with sepsis/malaria, a 12yo with horrible looking chronic osteomyelitis of the hip, a 2yo with a facial abscess, a 5 yo with probable Burkitt’s Lymphoma, etc etc etc. Who knows what will come in tonight.

I feel a little numb today and spent most of the night staring at the blurry ceiling. This is what these people endure on a daily basis. Death is so much a part of life here, I can’t believe it. We are so so naïve. I appreciate all the support that people back home and elsewhere have given me, but I am only a tiny window into much more horrible things. In 3 weeks I will pack my bags and be back where the water is clean, the medications are in stock, and where I can continue to take everything for granted. 

It rains, it pours

1pm

In 29 years, this is the worst day of my life.

“He’s not doing well” they said, “the surgery went fine, but when they closed him up, his heart stopped…”

“…The machines weren’t reading correctly, they couldn’t pick up any blood pressures”

“…no spontaneous respirations, they can’t figure out what is going on”

“…the mom is with the chaplain, do you want to talk to her?” they asked, “do you want to go in there?”

“…he tolerated the procedure well until closure…”

“…the surgeon are sitting at the bedside, the anesthesiologist is manually breathing for him”

“…do you want to see him?” they asked, “…can anyone find his mother?”

“…nobody wants to call the death…”

The whole episode is such a blur, I don’t know who is talking to me, I don’t know what just happened. I have never felt so much like I couldn’t breathe, like I couldn’t gasp a single breath, like I was suffocating in my own body. There are children who are chronically ill, their deaths come as a slow and painful decline into the inevitable. There are the children who come in acutely ill, the ones who we throw all of our tools at, but their fates are determined before entering our doorsteps. All are horribly painful, so we mentally prepare for the chronic deaths and we mentally detach from the acute ones.

Then there are the children like Cedrik who walk around the sidewalks with goofy grins on their faces, with basketball bellies under their shirts. They giggle at the sound of your stethoscope in their ears and they share their fufu with you. They play “slap hand” before rounds and explore the compound in the afternoons. They have a mother and a baby sister who sit at the edge of a hospital bed at all hours. They enrich your life, your every morning, with an infectious crooked smile; they lighten your heavy heart when they walk up behind you and grab your hand.

Cedrik is the best thing that has happened to me since coming here, a youthful light in so much pain and darkness. I vomited when I heard the news, felt a deep squeezing pain in my chest. I can’t talk, I can’t think, I can’t eat. I can’t bear to see his mother, hear her wails. I am nauseous, defeated, overwhelmed, paralyzed. I’ve had the horrible misfortune of enduring far too many childhood deaths, but this one has truly shattered me.

I can’t believe that I won’t see his smiling face ever again, hear the sound of his giggles. So outwardly healthy and full of life, so much of a mischievous future he would have had. It is too painful to even think about his mother. He will never be a teenager, he will never fall in love, he will never know the joys of being a parent. I just can’t wrap my head around it. Playful and free this morning, lifeless by afternoon.

I didn’t see it coming.

I think it will be a while before I catch my breath, before I can pull the knife from my stomach. No one will make eye contact with me today. The surgeons look at the ground when they see me coming. Last night at dinner I told them, “be careful with him, he’s my favorite patient.” I wish I hadn’t said that.

And so this is life, I suppose, just a pericardium away from death. It’s cruel and horrible and unfair at times. Admittedly beautiful at others. But right now I’m having trouble seeing the rainbow through the monsoon.

3pm

Called to Derrik’s bedside—complaining of headache and then unresponsive. This morning he was fine, yesterday he was up in a wheelchair. Lifted his eyelids and felt my heart drop to the floor. Fixed and dilated right pupil. He had herniated- with no mannitol, no vents, no hypertonic saline, there was nothing I could do. I had to tell his mother that he was going to die soon and there was nothing we could do to save him. I held his hand and sat between the sounds of his agonal breathing and the wailing of Cedrik’s mother. All the children stared at the one child who was dying and the empty bed where another child used to be. Cedrik’s mother threw her body on the bed and refused to move. Derrik’s mother sat silently at the bedside with tears running down her face. The chaplain came and we prayed. I thought of the words my bravest friend had written to me:

God, grant me the serenity to accept things I cannot change,

The courage to change the things I can,

And the wisdom to know the difference. 

I will try to remember this, now more than ever.

Some news is good

Today will be good news only...

There are eyes and they are beautiful.

This 32 week baby went home today. 

Her mother cried when I told her that it was safe to start breastfeeding.

The pathologist is back.

In a coma for 4 days, he is awake and snuggling with mom today. 

Be still my heart, he grabbed my hand.

And...Cedrik is going for pericardial stripping tomorrow morning... prayers!

A Day of Rest

Hilaire die last night. It was quick and peaceful and there was no wailing. He took one large gasp and closed his eyes, and his mother was at his side. Just two days before his pathology results. It’s so hard to walk by his empty bed, but I’m sure that it won’t be empty for long. The last thing that he said to me was that he was hungry. Only in Africa is there a child gasping for air, keeled over in pain, paralyzed by fatigue, burning up with fever who is asking for food.

The ward was peppy this morning, despite the events of last night. Bed 14 was clean and empty for the first time since I’ve been here. Derrik is still spiking fevers, Cedrik is going for pericardial stripping on Tuesday. The baby in Bed 1 is slowly coming out of a coma.

On Sundays we only round on the very sick or unstable patients. I briefly examined the new patients--- one with a huge facial mass that I’m assuming is Burkitt’s Lymphoma, another probably with malaria, and another with fevers and splenomegaly. Everyone is stable for now and I am not on call tonight, so we’ll see what tomorrow brings.

The way that the hospital is set up is fee for service. The patient/patient’s family is responsible for every lab test, every imaging study, etc. If they are unable to pay, they have to stay on the compound until the family provides enough money to foot the bill. There are tons of people sleeping on benches, in the grass, along the sidewalks, hanging laundry on posts and cooking in a community kitchen. I’ve really learned to think long and hard before ordering routine labs and ask myself “how will this result actually change management?” The charges add up. We order so many labs back home, do we really need to trend a hemoglobin every day? If a patient needs a blood transfusion, it is the family’s responsibility to find someone to donate a unit of blood for replacement. The parents hold down the children for IVs and administer the oral medications. The mothers and siblings sleep on the floors under the hospital beds. But you walk through the wards and the mothers thank you like you are giving them a gift of gold. It’s a far cry from the patient who walks into the ER back home and not only doesn’t pay, but simultaneously exudes a sense of entitlement. I don’t mean to rant, but practicing medicine in the U.S. does a good job of jading you. I could go on, but I won’t.

Today I saw one of the mothers chewing her food and dropping it into her baby’s mouth. It struck me as sweet as opposed to gross. I think that means I’m getting used to this place.

A few young boys

If you look to the right when walking onto the children’s ward, you will notice that there are five young boys, all ages 10-14, eyes wide as the other children come and go. I wonder if they are horrified by the deaths that occur bi-nightly or if they feel defeated as the other children heal while they are nailed to their beds. I wonder what is going through their heads when there is a mother wailing one bed over. I wonder if they are thinking about soccer or holidays or catching lizards.

I wonder if they are aware of each other. Do they track each other’s progress or demise? I wonder if they would be friends in other circumstances. The truth is that they are all very different, bound by the same terrifying experience, caught somewhere between being a child and trying to breath.

And so I have gotten to know them all over the last week. To speak their names and write their stories will perhaps immortalize them in some way. If I can paint their pictures in the minds and hearts of strangers, then they have transcended their little corner of the world and maybe they have a fighting chance.

In the far end of the room is CEDRIK, who struts around the ward with a basketball under his shirt, not a care in the world. He doesn’t seem to notice that people stare at his enormous abdomen, he doesn’t seem to notice that he even has one. He has a crooked mischievous grin and always looks like he just put a bug in someone’s sandwich. He giggles when I let him listen to his own heart. It is the same heart that has grown stiff with tuberculosis, the same heart that is at risk for tamponade. But he cares more about “slap hand” than heart failure, as every child should. Of all the boys, he’s the one that hasn’t yet realized that he’s sick.

One bed over from him is DERRIK, he is quiet except for when he screams during dressing changes. He is on every possible antibiotic, but his fever continues to climb. Today he started the hospital’s only stash of Vancomycin. Stay tuned. He is stoic, never complains, barely ever smiles. His face is young and soft, with big eyes and long eyelashes. He has both pericardial and pleural effusions, on top of all his abscesses. He hates the oxygen that we make him wear, but he wears it because his mother will kill him if he doesn’t. His mother and baby sister sleep on the floor under the hospital bed. He has difficulty breathing due to the accumulation of fluid in his abdomen, and he isn’t able to get out of bed much. Half of his head is shaved for an IV placement. This evening he had a temp of 40, sweating from head to toe, breathing heavy and with his heart making visible beats against his thin chest wall. I placed a cold compress on his head and propped him up against my body, one hand on each side of him. I could feel the heat radiating from the back of his head onto my face and feel his sweat soaking the front of my shirt. Then he took his tiny peeling hands and put them on top of both of mine. Such is a thing that a small child does. Still wanting that human touch, a mother’s coddle, a warm embrace. Then I placed him back down on his bed and fanned his face with my notebook until he fell asleep.

RUDOLPH is closest to the door. His mother is strict and gets him out of bed every day whether he likes it or not. He is finally looking a bit better, despite all his bandages and occasional fever spikes. He is dark and thin and wears a red soccer jersey instead of the hospital gown. It’s funny how his face has begun to looks softer as he has begun to heal. It strikes me that you have to transition from patient to child for that to happen. Perhaps I will encourage Cedrik to play “slap hand” with him.

Next to him is JUNIOR- tricuspid vegetations, DVT, polymyositis, severe pulmonary HTN, you name it. He has these transient episodes of severe abdominal pain that are quite alarming when they happen. My guess is that he is throwing septic emboli and possibly having small infarcts in his bowel, but who really knows. These kids are so sick and unpredictable, any day without a major event is a good day. Two days ago I didn’t think that he was going to make it through the night, today he was sitting up eating mango, tomorrow he may be gasping for air. It’s a rollercoaster, you learn to take one turn at a time.

And lastly, there is HILAIRE. I have a heavy heart for this child. When he rolled onto the floor last week, I knew that he had either AIDS or Cancer. Fever, night sweats, weight loss, abdominal distension—multiple palpable masses in his abdomen. Completely cachectic, I could see every rib, make out the full skeleton of his face. His legs were swollen with fluid and his arms were as thin as broomsticks. He most likely has lymphoma, but both the oncologist and pathologist were out this week. We took a sample from one of his abdominal masses and mother made a trip to Bamenda to leave it with a pathologist. She tells us that she will pick up the results on Tuesday, but I know that those results may be irrelevant by Tuesday. This morning he awoke gasping for air and I removed two coke bottles worth of fluid from his right lung. He grabbed a handful of sheets and gritted his teeth as I stuck a large bore needle into his rib cage. The kids here are so tough, I wish that their lives didn’t make it so necessary. ECHO today showed dilated cardiomyopathy with an EF of 20%. Started him on Digoxin and held my breath. I know that whatever type of cancer he has, it is probably way too advanced for us to have much to do. The day he came in I told him we were going to take a sample from his belly and when I was walking away he grabbed my wrist and said “you take out the cancer?”. I’m afraid that he is too aware for his own good. It’s a strange feeling taking care of a child that you know is going to die. It’s like I have this heavy knowledge that I am keeping from him. Does he know? Does he think he will get better? He is suffering so much and he is so tired, but he is still alive. He can still say that he is thirsty, he can still sit up in bed, he can still take a deep breath when I listen to his lungs, he can still squeeze my hand when he is getting his IV replaced. I want to capture every movement, listen to every heartbeat, remember every grasp of his hand. I want the suffering to stop, but I don’t want him to take that last breath. But I know that one needs the other. There is nothing else that we can do, and it is the worst possible feeling. He is a child. He is his mother’s son and his sister’s brother. He climbed trees and did chores and went to school. What is he thinking right now? Is he scared? Every time I leave his side I know that it might be the last time I feel his warmth against my body. I dread his mother’s wails and the cold parted lips that I have become familiar with since coming here.

I’ve decided that I can’t avoid getting to know these boys just to protect myself. We have to celebrate their lives rather than fear their deaths. Make them comfortable, hold their hands, fan their faces. There is no greater sadness than losing a child. Is it truly better to have loved and lost than to never have loved at all? It’s certainly harder. But to be a part of a child’s life, to provide comfort in times of fear, well that is a blessing. I am blessed by Derrik’s sweat on my shirt, Cedrik’s fingerprints on my stethoscope, Rudolph’s evening high five, Junior’s tears on my gloves, and Hilaire’s hand in my hand. I am blessed by the triplets, the whimpers of a once comatose child, and the sound of new heartbeats.

And so it goes, on your mind and in your prayers, are the names and stories of five boys in Mbingo, Cameroon.

A little of this and that

Cedrik- 10yo with TB pericarditis. Drained 8 liters of fluid from his abdomen 2 days ago. Didn't even flinch.

Burning of the mountains, to prepare for the new season of crops.

I thought this baby was born with no eyes, but turns out the eyelids were flipped inside out and swollen. Antibiotic and steroid drops and everything will be okay

Pineapple plants!

The women here are rockstars

Keeping track of the boys, like a true pediatrician.

And, lastly, why Sinai is the best program ever...

Three babies and a boy

I’m not sure if I mentioned this in a previous post, but the triplets were born early by emergency c-section due to cord prolapse. I’ve been taking care of them all week before sick ward rounds and it has to be the best possible start to any day. They are doing exceedingly well. The mother is a tiny beautiful African woman, full of energy and excitement. All three are boys and mom is a full time breastfeeder. The mother’s mother is there with her at the bedside and forcing her to eat all the time so that she produces enough milk. Every time I walk over to the bed, the grandmother grabs the babies and places them in birth order so that I can keep straight who is who. Today grandma had stepped out and I was three for three. I discharged them this afternoon, it was bittersweet- I will miss my morning visits with healthy babies and small triple miracles. This mother is more than aware that this is a rare blessing and she is nothing if not grateful. Three whole lives ahead of them.

I’ve been on call every day and night for the last 4 days and it has been brutal. Last night we had 3 admissions early before 8- a little boy needing rabies prophylaxis, a 4mos female with fevers, hypoxia, and respiratory distress born to an untreated HIV+ mother, and a little 1 year old boy completely unresponsive.

The 1 year old little boy was brought in by mother and grandma, completely limp in the mother’s arms. The story is that he had been having diarrhea and fevers for 5 days and first went to a traditional healer before going to an outside hospital/clinic. By the time he got there he was so dehydrated that they were unable to place an IV so they attempted to resuscitate him with an NG tube. Later that evening he had a full generalized seizure and has been completely unresponsive since that time. So here is this tiny malnourished child, laying on the bed like a skeleton, with his tiny heart beating a million times a minute. His lips were cracked and his abdomen was scaphoid. His eyes were rolled back into his head. He had raw flesh exposed over his right arm and hand where he had been burned 2 weeks ago, his fingernails were long and caked in dirt. And so we tried with everything we had to get IV access in this child. Shaved his head, called in reinforcements, frantically texted my PICU attending Cecilia, you-tubed how to put in an external jugular line. Can you use a regular 18 gauge needle to place an interosseous line? I still don’t know. All I kept thinking was if I don’t get a line into this child, he will die. In the end, I A-stuck him for labs and the surgical team was able to do an emergency cutdown.

And so we started fluids. He was barely responsive to sternal rubs and barely withdrew to pain. He had ants crawling all over his body and flies taking breaks on his little shaved head. Couldn’t tell how hypotensive he was because we didn’t have a small enough BP cuff, but his cap refill was almost non-existent. Should I be doing something else? He was nothing but dead weight when I lifted him up from his oversized hospital bed. The other children stared, large-eyed and curious, their mothers looked away, eyes down and horrified. Antibiotics, anti-malarials, fever control, fluids, fluids, fluids. His liver function tests were through the roof, his spinal tap was clean. Made a couple overseas consults, put my arms around mom’s shoulders, sat at the bedside for a couple hours, walked back to my house and stared at the ceiling.

This afternoon I was standing at his bedside, adjusting his oxygen, and he moved his legs and coughed. Best sound I’ve ever heard. I imagine it is a similar feeling to when a mother first hears her newborn cry.

Maybe tomorrow he will cough more and move his arms. Maybe he will open his eyes. Maybe he will cry. Of course there is always the chance that he won’t make it til tomorrow, but I am holding on to that tiny little cough like it is a triplet birth in Africa.

The good and the bad

A little 2 yr old girl presented to the hospital this morning with a 2 week history of bloody diarrhea. Mom brought her to a traditional healer and then eventually to us. She made it to the hospital just in time for us to watch her die on the wards within an hour. I feel bad for the other kids in the ward who have to see kids their age die every day. I can’t imagine what is going through their heads. Another death at the dawn of life.

Aside from a rough start, the day has been pretty good overall. I think I mentioned this before, but the families of the patients are responsible for taking care of and cooking for their loved ones, so there are people sleeping on the ground and sidewalks all over the compound. “Hello Docitah” they say with straight-teethed smiles as you walk by. “Hello, good morning” I say, and they respond with “you are welcome docitah”. And so it goes every morning and afternoon walking between the wards. The youngest children stare at me and touch my skin, wondering how a white person feels. The older kids laugh at the sound of their hearts through my stethoscope. There are many beautifully happy things all around us here, but it takes a conscious effort to avoid the drowning out by a mother’s wail.

The Children's Ward

Junior getting his dressings changed

The moms at the bedside

One of the residents showing me where to stick the needle.

Today a 15 year old girl came in with a spleen that took up her entire abdomen. Could be splenic sequestration due to sickle cell disease or could be something known as Tropical Splenomegaly which, per the residents on my team, occurs after repeated malarial infections in endemic areas. So yes, learning a lot.

Deep Breaths

This morning a 12yo little girl rolled onto the wards in the middle of rounds. She had a frilly purple dress on and a big bow on top of her head. Her lips were abnormally pink and her palms were abnormally yellow. History of Sickle Cell disease, mom said in Pidgin English. Has not been seen by a doctor in 10 years because they lived far and she was doing well. Tachycardic to 160, afebrile, O2 sat was 38% on RA. Sent off a Hgb and it was 1.8. Didn’t even know that was possible. Quickly hung a unit of blood. She became increasingly obtunded, at one point requiring me to lay my entire body over hers just so that she wouldn’t pull out her IV’s. She looked like she was possessed by the devil. I tried to calm her by shushing in her ear and patting her head, but only valium did the trick. She finally calmed down and we continued on our rounds.

Came to see her again after a quick lunch and she appeared much calmer. Was able to tell us her name. Blood was still running, it was starting to rain outside. Went to my house to grab an umbrella and a snack, returned to the most horrendous sound I’ve ever heard. There are a lot of kids on the unit that are at the brink of death, but the wail that I returned to was that of the mother of the little girl in the purple dress. “She just died,” the nurse told me, “she didn’t even fight it”. Within 10 minutes her body was in a bag and I was holding the door as her corpse was wheeled out, purple bow and all.

Death is everywhere around us on this compound. We’ve all had multiple of our own patients die, we hear the wails multiple times per day. One of the docs said to me, “It’s really easy to die in Cameroon”, and I’m beginning to believe him. I don’t know if I’m only seeing the worst of the worst, but it seems like everyone I take care of is walking a fine line. Dying is such a part of life here it seems. You can tell by the way the staff reacts to death- like they’re pros at it. No wonder everyone looked at me like I was crazy when I was running the code on that baby; they knew it was futile. But the truth of the matter is that the baby would have lived if he had had a cardiac repair, and this little girl would have lived if she lived closer to medical care.

So we take a big breath and move on with our day. After all, there are plenty of other patients to take care of, to scratch our heads over, to lose sleep over. 

Whirlwind on the wards

Started the wards today- seeing a ton of crazy stuff. Everything from TB pericarditis to a baby born with no eyes. I have a ton of learning to do, fortunately my residents are really good at getting things done. I also cover all the newborns, and fortunately they seem to be doing well. The triplets were all born overnight because mom had cord prolapse and they are all doing really well. The 32 weeker is almost at full feeds. Selfishly, today I am going to post my ward list that I made to keep track of the patients on my unit. My non-medical people out there will probably find it a bit boring, but I am welcoming feedback/recs/advice from any residents, etc in regards to my plans, workup. Remember, I am pretty alone here. I will spare you all the baby with no eyes, as it is pretty graphic and sad.

Bed 1: “Favour”

2.5yoM presenting with 1 week history of swelling of R humerus, L ulna, R tibia, L tibia. X-Ray shows chronic osteomyelitis. Ultrasound showed collection of pus of L tibia and R humerus, now s/p I&D. No fever, sickle negative, s/p transfusion x1 for low Hgb.

Plan: Continue Cloxacillin and dressing changes BID. Sedation with ketamine for dressing changes.

Bed 2: “Hope”

1mosF with spina bifida, hydrocephalus, and club feet. S/p myelomeningocele repair. Also with bacterial meningitis, s/p 14 days of Amp and Gent. CSF 5 days ago still with signs of meningitis. HC increasing but surgeons won’t place shunt until infection clears. Yesterday with signs of increased ICP and vomiting.

Plan: Repeat LP today, assess for WBC. If clear, talk to surgeons. Follow up HC, continue on Clox. PT to continue with casting for clubfeet.

Bed 3: “Jemina”

9mosF with R humerus swelling x2 weeks, found to have fracture x2, concern for rhabdomyosarcoma or osteosarcoma. CBC WNL.

Plan: Continue Clox, Biopsy of humerus to be performed tomorrow.

Bed 4: “Merciful”

15mosF presenting with 2 days of fever, decreased appetite, vomiting. Hgb 6.2 at that time, transfused 300cc whole blood. Sickle screen positive, will send for electrophoresis today. Malaria negative, BMP ok. Continued on Ceftriaxone and Ampicillin.

Plan: Continue Ceftriaxone and Amp. Send for blood for electrophoresis. Repeat Hgb now.

Bed 5: “Shanel”

2yoF with FTT. Birth weight 3.5kg, today 8.5kg. Started on F-100 regimen. Stool with no O&P, UA WNL. CBC showed Hgb of 6 (MCV 83).

Plan: Malnutrition protocol with mebendazole, folic acid, Vit A, and Zinc. Daily weights. Transfuse 100cc whole blood now. Sickle status?

Bed 6: “Ciemon”

2wkM presenting with fever, irritability, and jaundice. LP WNL. Today is day 5 of Amp/Gent. Bili on admission 20.3, repeat 3 days ago was 14.7 (14.7/1.7).

Plan: Repeat bili today. If decreased, turn off phototherapy. Repeat tomorrow with Hgb. Follow up weight today. Continue Amp/Gent

Bed 7: “Praise”

7mosF with cough, fever, poor feeding, diarrhea, and malaise for 3 days. Weight loss 1.6kg. Irritable. Flat fontanelle. Stool with WBC, malaria neg. CBC WNL. Started on Amp.

Plan: Continue on Amp, monitor fever curve. Send UA. (find otoscope?). If continues to be irritable will perform LP.

Bed 8:

2yoM with bilaterally nephroblastoma, finished chemo 4 days ago, planned for nephrectomy in 3 days. Spiked fever, ANC 530, started on Ceftriaxone. Now afebrile.

Plan: Repeat ANC now and if >500 will allow him to go home and return in 3 days. Will send home on abx if discharged.

Bed 9: “Princess”

2 day old female born at home, found to have bulging membranes from both eye sockets. Does not appear to have eyes.

Plan: Retinoblastoma? Anophthalmos? Look this up. Wet sterile gauze to membranes. Speak with Ophtho.

Bed 10: “Adele” 4yo with IBD? Getting better on antispasmotics. Plan: D/c home today.

Bed 11: Bacterial pneumonia, off O2. Plan: D/c home today.

Bed 12: New patient. 10yo with constrictive TB pericarditis. Re-presenting today for increasing abdominal girth, distention. No respiratory complaints. Need to see patient tonight.

*Bed 13: “Derrik”

10yoM who fell onto left hips 2wks ago when playing outside. Mom took him to traditional healer. Wound up with L leg DVT, confirmed on Doppler. Also with large abscesses on L wrist, R thigh, now s/p I&D. On exam with bilateral 2+ pitting LE extremity edema, significant increased work of breathing (93% on O2, 86% RA), chest pain, significant skin breakdown (SSS?). ECHO shows mild pericardial effusion, no tamponade, EF 70%. CXR with cardiomegaly and bilateral pleural effusions. Started on lovenox à warfarin, paused for high INR. Repeat today 1.83, will re-start Coumadin today. No IV access.

Plan: Resume warfarin. Repeat INR with next CBC. Start Lasix 40mg PO BID. Continue clox, flagyl, ibuprofen, PPI. Think about this kid a lot.

*Bed 14:

14yoM admitted yesterday for increasing abdominal distention and LE swelling x3 months. Also with anorexia, watery diarrhea, night sweats, muscle wasting. Paracentesis done at outside hospital and was told he had liver cancer. On exam is cachectic, with significant abdominal distension and significant hepatosplenomegaly, as well as multiple palpated irregular masses. 2+ pitting pedal edema bilaterally. L leg >R leg. Abdominal ultrasound shows bilateral echogenic kidneys, bilateral pleural effusions, mild ascites, hepatosplenolmegaly (homogenous liver?), and multiple hypoechoic antra-abdominal masses. CBC WNL. Na 120, ALT/AST 23/39. HIV neg, malaria neg. Albumin 1.6.

Plan: Send UA, stool. Doppler US of L leg. Tomorrow will do ultrasound guided FNA of abdominal mass, as well as obtain ascetic fluid- will save sample for pathology and send the rest for TB testing. See is mom can bring path to Bamenda. Discuss with nutritionist what to do for low albumin.

*BED 17: “Junior”

11yoM with L leg DVT in left common femoral. Also with cellulitis and pulmonary embolism. ECHO shows severe pulmonary hypertension and “strands” on tricuspid valves, as well as tricuspid regurg. Started on Lovenoxàwarfarin. Held for high INR. On Clinda, clox, ceftriaxone. Lots of chest and leg pain- on paracetamol, NSAIDs. O2 93% on facemask. Hemoptysis x1 today. CBC WNL. HIV negative.

Plan: Restart warfarin if INR is okay. Continue antibiotics, Follow up CXR.

BED 18: “Rudolf”

15yoM with multiple abscess- L thigh, L wrist, R thigh, R paraspinal- s/p multiple I&D (although not on back). Fever trending down on Clinda, Ceftriaxone, clox. Also with PNA.

Plan: BID dressing changes, sedate with Ketamine. Thoracic x-ray.

BED 20: “Ngen”

1.5yoM presenting with stridor, found to have large retropharyngeal abscess, now s/p I&D. Afebrile. Received decadron x2.

Plan: Continue amoxicillin, nebulized epi prn. Follow up with ENT.

Hike of all hikes

We hiked for 4 hours today, it was by far the hardest and coolest hike of my life. I went with Mollie and one of the general medicine doctors who has been here for a while. Walking across tiny bridges, scaling sides of mountains, crawling marine style under barbed wire fences, crossing wild horses and longhorns, sliding down steep inclines on our butts only holding onto vines, wading and then swimming to the foot of a waterfall, making human chains to get up steep slopes, the list goes on.

taking a break

Walking to the base of the waterfall

Fondom of Bafut

The baby died this morning, about ten minutes after we left the ward. I asked the nurse if the family was there and she said nonchalantly, "yes, they took the corpse already". It struck me as a strange choice of words. 

We spent the day in a town called Bafut, about an hour and a half from the hospital. It is actually the Fondom of Bafut which is synonymous with a Kingdom, as the king of Bafut is known as Fon. The kingdom is over 500 years old and has had 11 Fons in its history. It was taken over by the Germans after a 10 year war in 1911, but was eventually returned to a Fondom after the Fon was released from prison. Prior to Germany's acquisition there were some pretty unsettling practices taking place.

One of the princes gave us a tour of the kingdom (one of the present Fon's many sons) and the first place he took us was a field of stone structures. The first was a large and a small boulder. This is where people with high crimes were punished-- these crimes included fornication and adultery- the large rock was for the men and the small stone was for the women. They would be tied to the structures to die and if they were hungry they were fed their own flesh and if they were thirsty, they were given their own blood to drink. If they were taking too long to die, they would be given to the lepers (or leopards?) to be eaten. There was another structure close by with to cylindrical stones where two virgins were sacrificed every year as they felt that it would keep the Fon powerful. The prince clarified that in present time they sacrifice animals instead.

Where the Fon pays respect to his ancestors, built ~500 years ago.

Huts where the wives live

Taking a break in the market

Walking around the Fondom was very cool, there are a lot of huts where the Fon's wives live and tons of kids running around. The current Fon has 8 wives, but apparently some Fons had 100 wives and fathered close to 500 children. Twins were sacred and triplets were a curse. When the Fon dies, his will is opened for the first time and that is when his successor is named.

There was a small museum where we weren’t allowed to take pictures which had tons of German guns and Bafut war equipment. The Germans fought with guns and the Bafut fought with bow and arrows dipped in snake venom and elephant traps, and still the battle lasted for a decade. If you cross your legs while sitting while you’re in the Fondom it’s a sign of disrespect and you need to pay the Fon a fine of livestock. They also have their own court system.

It was a busy hot day, but pretty interesting. When we arrived back in Mbingo, one of the mountains near the complex was almost completely in flames. Apparently they do this just prior to rainy season to make way for the new crops. It’s alarming to see a wild fire so close to where we are living and working, but no one else seemed phased by it. Tomorrow we are going hiking or horseback riding, Monday I officially start wards.

Another Fulani traffic jam

taxi