A day in pictures

Today was our first day off the wards, our first day to catch our breaths. Spent the morning working on our research project, went for a hike after lunch, drank freshly ground coffee, read for pleasure, washed our white coats, picked fresh avocados, Mollie caught up with her husband, I fell asleep on the back porch.

Both baby surgeries went well yesterday. The little boy with intussusception in fact had intussusception- the oblong mass that I felt in his abdomen was his bowel telescoping onto itself. The surgeons cut out a small portion of his bowel and performed a primary anastomosis. I think he will be okay. The little girl with the jejeunal atresia tolerated the procedure well, the trick will be giving her adequate nutrition while she heals and her bowel recovers. The family medicine doctor's wife is a nutritionist, so they are trying to concoct a poor-man's TPN. That would be pretty great if it works.

Yesterday I caught up with some people with skype/facetime until the power went out. My parents looked like they were seeing a ghost when they realized my face was on the phone. Technology is nuts. I got to show them the cattle, the banana trees, and the view from the back porch. It was nice to share the view with them.

And, some pictures...

One of the back roads through Mbingo

A little pink amongst the green and brown

Finishing off "This is Where I Leave You"

Walking beyond the school for the deaf. Many children are left deaf after childhood meningitis, TORCH infections, congenital deformities, etc. There is a school on the far end of the hospital campus, many children board there as well. 

Cattle driver leading the herd back to the corral beside our house

Another house alongside a back road in Mbingo. There were children outside chasing around the chickens. The kids here are really good at entertaining themselves. Today we passed a couple boys playing soccer with an empty coke bottle and a little girl guiding a metal hoop around with a wooden stick. Things are simple but they are happy. "Gooood afternoon whiteman" they say to us. Sometimes the teenagers take pictures. 

Small hut along the road

Working on our research project, drinking tea from the plantation we visited on Saturday (Cameroon Tea Estates).

Taking a break in the shade of the banana leaves

Down the dusty path

Fresh avocado is everywhere. They call them pears here.

Some boys playing football/soccer on Sunday afternoon near the church.

Is it March already?

"Double Bubble" sign

Our little baby with jejunal/duodenal atresia is going to the OR today. We had another baby come in with bloody stools and an oblong hard mass in the LLQ. Ultrasound showed some ascites and didn’t comment on the mass. Intussusception? I’ve read about the “sausage mass” and bloody stools but I have never seen or felt it before. Surgeons are going to take the baby to the OR and find out. With limited imaging, it’s kind of how things go here. All I know is that I’ve not felt something like that before, but if they find intussusception then I guess medical school multiple choice questions are valuable after all.

Achu's X-Ray

Unfortunately the little boy (his name was Achu) who came in with what looked like acute liver failure and sepsis/ARDS died last night. He was so so sick. I can’t believe he walked into clinic the other day, let me look into his ears, pick him up onto the exam table, palpate his belly. Just hours away from rapid decompensation. He looked so horrible. I keep wondering if there was anything else I could’ve done. With an albumin of 1, he was third spacing all of his fluids. Would dopamine have helped or just prolonged the inevitable? Would Lasix have made his death more comfortable? Mollie says she sees this type of picture on the adult side all the time—usually the patients come in with acute liver failure from toxins, etc and are dead by the morning. Even in the U.S. I guess I’m just not used to seeing kids decompensate so quickly, it’s hard to believe that there was nothing I could do.

But overall, a lot of the kids are doing better. The 1yo boy previously in a coma is starting to eat by mouth and will likely go home tomorrow. The two with cerebral malaria are acting more and more like themselves. The baby with HIV has finally broke her fevers and is looking better every day. I’m a little nervous that I won’t be on the wards this week. I’m sure everything will be fine, but sometimes it is difficult to remember that children are not just little adults. After all, this is an internal medicine residency, they just happen to have a children’s ward. It is very scary to think that at some points there are no pediatricians or family medicine doctors here. These kids are very VERY sick. Even at the peak of my pediatric residency training- chock full of inpatient and intensive care exposure- it is very difficult to manage these kids in their end-stage conditions. I certainly have learned more in a couple weeks being here than many months of residency training. My physical exam skills are the best that they’ve ever been- often it is all I have to rely one. I’ve been able to consult cardiology, general, derm, radiology, PICU, NICU, heme/onc, infectious disease via email, and it has been life-saving. It’s surprising how much you are able to do when you have no choice but to do it. And people are happy to help.

Reminds me of one of my most traumatic experiences of residency (up until now), which occurred my intern year. A 9yo child with trisomy 21 was admitted to the floor NPO and on fluids for possible SBO. She was up and talking upon admission, between vomiting episodes. Alone and tired at 3am, I did a routine (and easy) admission, and prepared for the next admission. Nurse calls and says her IV came out, so I begrudgingly head to her room with supplies. But upon entering the room, her eyes are rolling back in her head and she is not responding. I put oxygen on her face, as the intern from the other floor arrives to help with the IV. I listen to her chest and I hear complete silence. We immediately launch into full CPR. Malodorous vomit spews towards my face with every chest compression. Long and horrible story short, we coded her for close to an hour and she never regains a pulse and never has a shockable rhythm. Diagnosis was likely cardiac arrest from disseminated clostridium perfringens seeded throughout her young body. A freak diagnosis. A hypothesis, really. The date was March 26^th of my intern year and I will never forget the feeling of placing my stethoscope on a dead body. The point of the story, however, is that we have an inner instinct to do what we need to do in situations that we need to do it. I would not consider myself one of those people who gets huge adrenaline rushes in the face of acute situations. I hate mock codes, I get nervous for PALS training. But at that moment, I snapped into CPR gear before my mind could even process the situation. It was an instinct. That is what happened then, and that is what is happening now. Any one of my co-residents placed in this situation would do the same here as I am doing. They probably would be better at reading EKGs and placing IVs. This is what our training is for, this is what our 30 hour calls are for, this is what our sleepless nights are for. We have the ability to do so much more than we think we do, especially when we have no other choice. We have our training, our faith, our vulnerability, our good intentions. And sometimes, god-willing, we hear a heartbeat after an hour of chest compressions.  

Tomorrow Rudolf will likely go home, will likely WALK out of the hospital. I asked him if I could take a picture to show my friends and he acted as if I had just donned him a celebrity. His mother straightened out his shirt and scolded him to sit up straight. This is a great success story. He will play soccer, he will have a future, he will live beyond his childhood.

Sitting up and smiling, ready to go home tomorrow.

Spent the afternoon at a tea plantation yesterday, was good to escape the hospital for a while. Took a couple hours to get there and involved pushing the car uphill under the hot African sun, but was so worth it...

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.