Both Hands Tied Behind Our Backs

Professionally, I’m having a blast. I’m at the government hospital in the capital, Lilongwe, which makes Wishard look like Clarian North.

We had two kids die of rabies last week. One of the kids was bitten on Christmas Day. It was a 1/4 inch lesion on the thumb. The parents took the kid to the health center, but it was closed on Christmas day. Since Christmas was on a Friday, by Monday they thought, “It looks OK,” so didn’t take him back. He didn’t start the post bite vaccines at all and died a month later. He had hyperreflexia followed by hyporeflexia, progressive paralysis, and myoedema. The other kid, 12 y/o, had the foaming at the mouth. I’ve now seen four cases of rabies in six years: 2 in Malawi, 2 in Ecuador.

You can ask, “Why didn’t we use the Milwaukee protocol (induce a coma for 3 weeks)?” We didn’t even think about it because there are only three ventilators in the hospital, and only one can handle kids. It’s not right to use such a limited resource for a kid who has a 0.01% chance of living, even after a month long induced coma. There are also only 3 working dialysis machines in the country, all at the hospital where I'm working.

I’ve been a doc for 17 years and only encountered Burkitt’s lymphoma on board exams. In one hour I saw 15 kids with Burkitt’s lymphoma. A General Practice doctor from Nigeria has an interest in Burkitt’s & pediatric cancers, so he does the Burkitt’s kids. (Burkitt's lymphoma has mortality anywhere from 5-30%, depending on the stage when diagnosed and whether they relapse after chemotherapy.)

I took a sample of peritoneal fluid to the lab on January 3rd. Since I couldn’t find a lab tech anywhere in the lab, I put the sample down on the counter, right next to a sample of peritoneal from the SAME patient dated December 31st. It had been sitting on the counter for 4 days, untouched by human hands. All the crud growing in the test tube wasn’t so much of an issue because we can’t do cultures here. You are lucky to get a cell count, glucose and protein. My issue was that I had done all I could for the patient and if no one could do even five minutes of work over four days to help another human being, and the systems were so nonexistent that labs samples can go untouched for four days, there wasn’t anything else I could do. So, I just got in my car and drove home.

I did come back the next day. (That’s the difference between being fed up and giving up.)

Mind you, this is the free labor I’m doing in the government hospital to get my medical license. Tomorrow is my last day. Not that I’m counting, (20 hours).

Next week I start at Partners in Hope. It’s not a perfect place, and it has similar problems with motivated staff, but we can fire people who don’t do their work, pray with our patients and at least know that most everyone at the hospital cares about the patient.

This is getting long and might look depressing, but since most of the patients get better and go home, and we actually can make a huge difference. “We had both hands tied behind our back and STILL saved the patient.”

Three factoids before I quit.
1. There are three residency trained pediatricians in a country of 14 million, two here in Lilongwe and one at Queen Elizabeth Hospital in Blantyre.
2. Every day at morning report on the pediatrics ward they discuss the admissions and the deaths. There are 3 – 9 deaths per day. That’s one death every 3 to 8 hours. (In the US, if a child dies in the hospital, the whole building goes into mourning.)
3. No one can get reliable data about admissions and deaths, but the estimate is that the mortality rate is 9.1% of all pediatric admissions, down from 9.6% last year.

Each Heart Knows It's Own Bitterness

What do you do when there are three patients who need a ventilator, and your little hospital in the jungle only has two ventilators? You pray, you put the intern and resident to work ventilating by hand the patient most likely to die, and in a sad way, you hope that the sickest one passes to his final destination before the poor intern and resident stay up all night trying to keep alive a man who lost his pancreas.

What happened to his pancreas? It died. It was dead and black, except for the areas that were filled with abscesses. He survived about a month with a dying pancreas, but he passed away tonight. We went way beyond the call. He came in near death. We saw that he had air in the parts of his abdomen that should not have had air. He was taken to the operating room with the understanding might die during the surgery, but the surgery represented his only hope, as slim as his hope was. When the surgeon found that there was dead tissue and pus where his pancreas should have been, he closed the man's abdomen and took him back to his room.

As soon as the man returned to his hospital room after the "open and close" surgery, his heart stopped. After three minutes of work and medicines, his heart started again. The resident and intern did the work of a breathing machine for about 30 minutes until he started breathing again, but 2 hours later, his heart stopped and did not start again. His wife did nothing for about five minutes, then she started to cry and cry and cry without ceasing.

King Solomon wrote in the book of Proverbs:
Each heart knows its own bitterness,
and no one else can share its joy. (Proverb 14:10)

The husband and wife and their two sons had many moments of joy in their lives together, and everyone's life ends in sadness for those left behind. Tonight the couple's life together ended. She and the boys will know bitterness for a while, and loss forever, but they will have many moments of joy in the future.

After seeing a number of deaths here on the edge of the jungle, I think that we should work at making more joyful moments and work at remembering them more. Bitterness comes pretty easily; joy takes some work.