A lesson in futility

Coded the baby for 2 hours this morning, No heart rate, epi epi epi epi, chest compressions, chest compressions, chest compressions. Intubated the baby and hired human mechanical ventilators. Started on digoxin, broadened antibiotics. Heart rate 80, heart rate 55, heart rate 0, heart rate 75. Walked away and the baby arrested again, did it all again. Pupils dilated, extremities ice cold. Barely any O2 is seeing the brain. Felt like everyone was looking at me like  'let him go doc'. I guarantee that as soon as I leave, they will let him die. But what can I do?

Dresses and stresses

This morning we hitched a ride back into Bamenda for work, but ended up meeting with a seamstress (Wiliet) on the compound and headed to the market to buy some authentic African fabric for some homemade dresses. The patterns are wild and beautiful. Wiliet is making me a dress and a skirt and a funky shirt for Brooksy B.

I received my compound phone today which is equivalent to an on-call pager. When the scheduler handed it to me, she smiled apologetically and said, “I’m sorry, you’re on call every day. But I gave you a Saturday off.” On Monday the entire ward is mine, I think I have some reading to do. When I walked into dinner tonight, one of the surgeons was there and he said ‘I have a present for you’. Which for him is a set of triplets to be delivered this week. The general surgeons do the c-sections here. I’m so grateful that our Sinai NICU nurses sent me with some Ambu bags. ‘Don’t worry,’ he said, ‘I’ll send you some extra staff’. Thank youuuuu.

I had just sat down for a nice cup of tea and a chat with the boy tonight when the phone rang and the on call attending was on the phone and asked if I could come take a look at a baby in respiratory distress. I headed up to the hospital with pneumonia, viral syndrome, reactive airway disease on my mind. There I found a 3mos old baby febrile to 40C, tachypneic to 90s, and O2 sats in the 50s. On exam he looked dusky, severe retractions, fatigued, crackles throughout, sunken fontanelle, harsh murmur, and dysmorphic features (wide set eyes, flat nasal bridge, webbed neck, wide-spaced nipples). And the intern was reading from a chart, “…had a fever…was getting tired with feeds…transferred from outside hospital…and what does this say?...Complete Atrioventricular Canal defect.” Nothing like congenital heart disease and rapid heart failure to get the adrenaline going. Call cardiology? Holy crap, I don’t know what to do, normally these babies get whisked away to the cath lab. Okay, IV Tylenol and antibiotics and stat CXR. Place the oxygen. Do we do ECHOs here? Can we get some Lasix? He got 20mg of Lasix at outside hospital- He weighs 6.5kg, holy crap that was way too much Lasix. Can I give a bolus in a baby with florid heart failure? Why does he not have an IV? Why don’t we have a baby-sized BP cuff? Is he septic? Why are his sats in the 60s with O2 supplementation? Why is the only thing I can use for an A-stick an angiocath? Do I start digoxin? Why are the parents so calm? Is this Noonan’s or Trisomy 21? Does it matter?

I don’t know if the baby will make it through the night. My guess is that he has decompensated heart failure that was tipped over by some viral or bacterial infection (WBC 36), but we can’t do blood cultures and he’s too unstable for a lumbar puncture. I guess I can blast him with antibiotics and prayers and oxygen. The only thing that will truly fix him is cardiac repair, but that’s a little beyond my paygrade. Thank goodness for my budding cardiology co-resident Cheryl that I can frantically text about digoxin dosing and appropriateness. Thank god for friends with brains and hearts.

This is all I can do with what I have for now. I am in charge of managing this child on a tightrope of life and death, and I know that this is only the first of many. I’m not a cardiologist, but I will have to play one. I’m not a let-goer, but I will have to be one. All you can do is everything you can do.

Tomorrow is Valentines Day. Exactly one year ago from tomorrow, I met my most favorite patient ever in hematology clinic. His name was Kelvin and he was diagnosed with T myeloid leukemia and admitted to that hospital later that day. About a month ago, I attended his wake in Chinatown, the only ceremony of a patient I’ve ever attended. Even in one of the best hospitals in New York City, all you can do is everything you can do. I just got a tiny glimpse of how Kelvin’s oncologist must feel and it isn’t pretty.

But tomorrow is a new day and we will travel and enjoy beautiful Cameroon. For now, I will finish my cold tea, scratch my mosquito bites, and try to get some sleep.

How many people can you fit in a Toyota Tercel?

The answer is 9- four in the front, five in the back, for an hour ride into Bamenda for a grand total of 2 USD. Two men in the driver’s seat, me and another woman on the passenger’s side, one man in a leg cast, a child with two wrapped burned hands, his mother, another man, and another woman. Delayed only by the herd of cows blocking the road out of Mbingo. They are led by Fulani herdsmen who are apparently a nomadic people who travel horizontally across Africa. They are easy to pick out because they wear flat hats and have long skinny faces with very fine features. The women are very slim and beautiful, would probably be millionaire models if born in the US. That’s really all I know about them.

We finally got the internet back today which makes data input a whole lot easier. Yesterday I was called for a consult while I was eating breakfast, I’m not sure how they found me by phone. Someone was calling from the maternity ward about a 32-week twin that was just born (the other twin had died shortly after delivery), and they wanted me to come by and “just take a look at her”. There is currently no pediatrician here and they are desperate for help and for someone to lead rounds with the residents. They want me to jump into this role on Monday which is both exciting and terrifying. Sink or swim I guess. I will have to widen my differential.

The people here speak Pidgin English which is kind of English and kind of not, but definitely hard to understand. I thought I would learn French while I was here but this is not a francophone section of Cameroon. There is a lot of talk about Boko Haram here, but they are 3 days worth of travel away from us. Everything that I’ve seen on the news back home names them as a Nigerian Terrorist group that is against Westernization. If you talk to people here, however, they say that they’re not sure if they’re Nigerian because they live among the people in northern Cameroon/Nigeria. They recently kidnapped the Cameroonian president’s wife and attacked a border village. The Cameroonian’s fought them to the border, but apparently Chad’s army pushed all the way into Nigeria. According to the cab driver, there are 3000 Haram, but over twice as many in the Chadian army.

The president’s wife was returned and the 32-week baby is doing great.

The food here is interesting, I don’t know what I’m eating half the time. Last night we ate fish with the face staring at us. A lot of bones, but pretty tasty. Yesterday for lunch we ate beans and something that tasted like a donut hole. For dinner tonight we ate ndole (end-o-lay) which is a spicy stew made of bitterleaf greens which we ate on top of a piece of Cassava which is a root plant. I could’ve done without the cassava, but the ndole is excellent and we eat it with almost every meal. You have to chew the meat for a long time. I haven’t seen any milk here for some reason, we always use powdered milk called Nido.

Friday we’re going back to Bamenda to do some more work. I’m going to go into town to try to find some material for a dress and maybe a soccer jersey for Jónas. The days are long with chapel in the morning and are pretty non-stop until the evenings. I think we will go hiking this weekend, maybe take a trip to an old castle that people have been talking about. I’ll be happy to sleep in a little. 

Blog from 3 days ago-- no internet, unreliable electricity

Slept like a rock last night. We really lucked out because we are staying in a house recently built by some long term missionaries, so it’s really comfy. Still with creepy crawlers and fickle electricity, but pretty nice overall. The hospital here is huge. There are tons of surgeries, as well as specific wards for ulcers, TB, Leprosy, orthopedics, maternity, ophthalmology, HIV, and pretty much anything else you can think of. There is also a large outpatient area where patients travel for days to be seen for sick visits. The patients’ families sleep outside on the grass and they are in charge of making their own meals for their sick loved ones. There are two major teams of residents- CIMS (internal medicine) and PAACS (surgeons). There a couple semi-permanent attendings, but most come and go as needed. They are desperate for pediatricians, so they tell me that they are going to keep me very busy. They have asked me to precept the residents here and run morning rounds, which is a little intimidating since the residents are much better versed in the likes of malaria and parasites and exotic tropical diseases. We will see how this goes—I’m sure I will learn a lot in a very short amount of time. It is really varied about what the hospital does and doesn’t do. There are no ventilators, so they do all major surgeries with ketamine. No blood cultures. Lots of LPs- looking at cell counts only. Will probably have to get pretty good at physical exam skills. The day starts with chapel at 6:40am and then a quick breakfast, morning report, and rounds ~8am. The day ends early, around 4pm. I won’t be starting to work on the wards until next week due to all the work that needs to be done for our research study out in Bamenda. There are a couple other residents here from the US right now- an internal medicine resident from Alabama, general surgery resident from somewhere else in the south, two general surgeons- one from Oregon and the other from Nashville, an ICU PA, and a family medicine doc from Chicago. They’re all really nice and cool- we take all of our meals together (when not in Bamenda), so I think I’ll be getting to know them all well. This morning they called us to the front of the whole congregation (it’s huge) and introduced us to everyone. The leader said, this is “Dr. Brittany, also from New York” and then I had to say something on the spot, so I ust said “Nice to meet you all…I feel blessed to be here…I’m looking forward to meeting your children.” I wasn’t quite ready to talk in front of the masses, it was 6:45am and I hadn’t had coffee yet.

This morning for breakfast we had a boiled egg, watermelon, and a piece of bread. For lunch, we went into town in Bamenda and were treated to a ton of traditional Cameroonian food. I’m not sure exactly what everything was that I was eating. I tried chicken gizzards which are apparently a delicacy, but I think it must be an acquired taste. I ate all three on my plate because I thought it would be rude to waste them, but it wasn’t easy. They also eat a ton of starch here, very little meat. Their staple food is something called Fufu which is ground cornmeal into mush that you break with your hands and use it to pick up other foods like Okra or other mystery dishes. We had Fufu wrapped in a banana leaf for dinner with another dish that reminds me off collard greens and some beef cubes. The fufu sits in your stomach like a ton of bricks. One of the missionaries was saying that his 7yo son ate two large servings of fufu and then drank a bunch of water and his abdomen became so distended that they had to take him to the emergency room. After getting the history, the doctor said, “oh he just has fufu belly”.

I’m going to briefly explain our project, as we don’t currently have any electricity and I am typing on a word document before my battery runs out. The study that we’re working on has been going on since 2011 and it involves a cohort of ~1000 women and infant pairs with/without HIV/AIDS. Much of the work in this study has been looking at metabolic outcomes secondary to antiretrovirals and most has been done on the internal medicine side. We are now following the children at the 6 wk, 6mos, and 9-12mos visits—following parameters such as living situation, hospitalizations, breast/bottle feeding, comorbidities, mortality, HIV meds, PCP prophylaxis, HIV status, and anthropometrics. What I’m interested in is taking out all the HIV-infected children and looking at morbidity and growth parameters in the HIV-exposed children versus the unexposed. About 50% of studies done in sub-Saharan Africa have shown a statistically significant difference in mortality/morbidity among the HIV-exposed uninfected population when compared to their unexposed counterparts. There are a lot of different theories about why this exists. One such theory is that lower rates of breastfeeding may be putting these babies at higher risk for poor growth and higher morbidity/mortality rates. The WHO recommends exclusive breastfeeding by HIV positive mothers for the first 6mos in resource poor countries, due to the greater risk of death from diarrheal disease secondary to poor drinking water. In everywhere else in the world, breastfeeding is contraindicated in breastfeeding mothers. This sends mixed messages to the women in many areas of sub Saharan Africa, who often end up doing a little of both. Their babies not only lose out on the full immunological benefits of breastfeeding, but are exposed to more dietary pathogens than they would otherwise. But there’s lots of theories. What we’re doing right now is not so exciting, basically a lot of data cleaning and crunching, between electricity outages and transportation issues. But so far so good.

Okay, enough of that for now. Tomorrow is Youth Day, I hope I can make it to one of the parades that are performed by the schoolchildren—depends how much work we have, but hopefully I can sneak away. I hope everyone back home is good. Cameroon is good, things are great, I think I have fufu belly.

Rural Cameroon, View from our back door.

Traffic Jam

Ride to Mbingo, in pictures

Guest House in Douala

"I love Cameroon"

School children marching in preparation for "Youth Day", a National Holiday

Papaya

 

Town covered in clay dust

 

Looking down on Bamenda



Approaching Mbingo

Night One

Wasn't the best first night I could've asked for in Cameroon. Woke up not more than one hour after collapsing in bed, covered in a hot soaking sweat with intense itching of my face and arms. They told us we didn't need mosquito nets for Mbingo because the altitude is so high that the mosquitos are less of a problem, but I guess we didn't account for the night in low-lying Douala. Anyone who knows me knows that if there if you invite me to an evening bbq I will serve as a human citronella candle, in that I will keep the mosquitos away from everyone else. Nevermind when covered in my own sweat. And so I awoke with huge welts on my face and arms, the only places exposed out of the covers. A good twenty welts. Good thing I took my anti-malarials. And there was no telling when my shower-wet head turned into my sweat soaked hair. Needless to say, I covered myself with an industrial amount of DEET and spent the rest of the night weighing getting under the sheets in the 200 degree humidity versus an hourly blood-letting. When all was said and done, I spent most of the night peeping from above my musty sheets wondering why nature let the cockroach on the wall outsize the lizard on the window screen. Then, later, where they both disappeared to.

 

Apparently my forehead wasn't covered well enough.

 

Douala

Arrived in Douala today, flight took ~7hrs-- VERY turbulent. Stepped off the plane and was greeted with a rush of heat and humidity. Could feel the sweat dripping down my back by the time I got to the passport check. Took over an hour for our bags to come out. The airport was hectic and crowded with all kinds of smells, but I think it was less of a shock than when I stepped off the plane in Haiti. There's a ton of men trying to snatch your bags to carry, but we just looked at the ground and said "Non, merci" seven million times. One of the men from the mission met us at the baggage claim and helped with the heavy bags filled with medical supplies and everything else. We're staying on a guest compound behind locked gates, I think it's pretty nice minus the scattering of giant cockroaches when the light flipped on. Here's a couple pics from inside.

 

 

Took a nice cold shower, can't complain. We will be waking up early tomorrow and taking the 6 hour drive to Mbingo, I am looking forward to seeing more of the country. Driving in and of itself is an experience. I will try to take pictures if appropriate. So, all in all, so far so good. A little hot, a little sleepy, a little mosquito-bitten, but overall we're getting closer to where we need to be...