Pictures From The Front

I will be leaving the clinic relatively soon. Before I do, I wanted to show you some pictures that demonstrate the joy and the magic that is this clinic. I know that a few of my previous blog posts have shown some of the sadness that is also part of this clinic. Now to the joy.

This is a five year old boy whose picture you have already seen: it is a picture of him when he was first admitted to the malnutrition ward:

This is the same boy, towards the end of his successful hospital stay. Amazing what a little food can do for a child. Yes, I too am in the picture, for the picture was taken as we made morning rounds.

And the same boy, happily eating Plumpy-Nut, the peanut paste that he will go home on. 

A young girl, doing what I call multi-tasking: carrying her baby sibling on her back, while she is carrying what could be the family's laundry or perhaps even the family's lunch on her head.

I have talked much about the hospital wards. I think it is instructive now to show you what they look like at night. The first one is the men's ward. However, it is not exclusively for men. There are some children and women on this ward too.

The next is the women's ward at night. This ward generally does not have men, but may have sick children. The mattresses on the floor are for the families that spend the night on the ward.

This is a woman in clinic. I am seeing her older child, who is next to her on the examining table. The woman is carrying her baby on her back, as you can see by the two, little shoes sticking out from each side of the woman's waist.

This is a picture of an adorable child I saw in clinic the other day. The T-shirt speaks for itself, but what makes the T-shirt and the picture even better is that this is a 7 year old girl wearing the T-shirt.

The following pictures are taken from one of my favorite places on earth: the top of the hill above the clinic, as the sun sets over Lake Tanganyika. 

And, finally, yes, that's me, in my normal after-work garb, standing on top of my beloved hill, as Dr. Cyriaque takes my picture.

Another Monday in Clinic

            A three year old boy was carried into the clinic this morning at 7:30 A.M. by his father. The child was in severe respiratory distress. His respiratory rate was in the 60-70 per minute range. Every breath was accompanied by an audible grunt. His nose flared in and out as he breathed. His eyes were unfocused, but he was still conscious. He was hot to the touch. The father reported that the child had been breathing like that for the last twenty-hours, but he had no access to medical care until today. This morning, the father made the forty minute walk up the mountain from Mugara with the child on his back.

     A quick exam revealed that the child was profoundly anemic, with an enlarged liver and spleen. It was immediately clear that we were dealing with a severe case of malaria. We did not need to wait for confirmation that it was malaria, nor did we need a blood count to confirm that he was profoundly anemic. We typed his blood, in anticipation of a transfusion.

     The child was so anemic and dehydrated that it was virtually impossible to find a vein for an I.V. Two expert nurses tried every possible site for at least an hour. Finally, nurse Achel found the tiniest vein in his wrist for an I.V., and a working I.V. was inserted.

     We immediately gave him the appropriate does of Quinine for the treatment of severe malaria. We also gave him a dose of Ceftriaxone, because his breathing suggested secondary pneumonia. We put him on oxygen. His blood type was A+. Miraculously, our limited supply of blood included a bag of A+ blood. Normally, we store only 3-5 bags of blood in our small refrigerator. Several patients have required blood transfusions in the time that I have been here. This was only the second patient for whom we had the correct blood type on hand.

     The child was placed on the ward. The transfusion had been started, and an oxygen mask had been placed over his face. He appeared very ill, but stable.

     I started my clinic day. I was in my office, seeing patients, when I was interrupted at 10:30 by a knock on my office door. It was a nurse informing me that the child had died. It took me a minute to process the information. The moment I did, I ran out of my office, the nurse tailing behind me.

     I quickly reached the child’s bed. The transfusion had not yet been stopped. I could still see the blood running into the I.V. on his wrist. The oxygen mask was still attached. His mother huddled by the bedside, weeping uncontrollably. The father stood in front of the bed with an uncomprehending look on his face.  

I looked down at the child. There was no sign of life. I listened to his heart in the vain hope that I would hear even the faintest of heartbeats. Nothing. It was over. I had nothing to say to the parents, except that I was sorry. But words seemed inappropriate at the time, and I do not speak Kurundi. Even if I did, the parents would not have heard me, for they were too overcome by their grief.

I walked away from the ward, down the corridor to my office. I tried to come to terms with what had just happened. I had not expected this child to die, nor did any of the other doctors. Even children this sick with malaria generally got better. This was different than the other child with malaria who had died; that child had never regained consciousness after his prolonged seizure.

 We all had expected our treatment to work. I asked myself, as any doctor would, could we and should we have done anything different? I knew in my head and even my heart that the answer was no. We had given everything that we had at our disposal: I.V. antibiotics, I.V. quinine, oxygen. Even a blood transfusion had been done promptly by our standards.

  I do not know the exact and immediate cause of this child’s death, other than to say that, in the end, he was yet another victim of the ubiquitous scourge of Africa that goes by the name of malaria.

The child was quickly disconnected from the I.V. and the oxygen. The residual bag of blood was discarded. The body was wrapped in a blanket, and carried to what passes for a morgue here. The parents gathered their meager possessions, and left the ward in tears. The child’s body will be placed in a makeshift coffin, and transported later today back to their village for burial.

The bed of the dead child was quickly cleaned with alcohol, and a new sheet was placed on the bed. It was not more than fifteen minutes later that I had to make use of that very, same bed; it was another case of malaria. Such is life in Africa. One does not stop and contemplate the tragedy that has occurred. One moves on to the next patient, and the patient after that, and keeps on moving until all the patients have been seen. One cannot dwell on what has just happened. In this case, the bed was needed; what more appropriate occupant of that bed than another child with malaria?

The new occupant of the bed was a three year old girl with a fever of 41 degrees (almost 106 degrees). She too was ill-appearing, but not nearly as ill as the three year old boy. Her breathing was normal. She too was anemic, but not as anemic as the boy. Her hemoglobin was 7.0; his had been 3.4. There were no plans to transfuse this child.

I was worried about this girl, if only because of my recent experience with the boy. However, she should do well. In fact, since I am writing this the next day, I can report that she has already improved. Her fever is down, and she looks better. She will go home in a few days on oral quinine and supplemental iron. She will be one of our many treatment successes. Thankfully, those successes far outnumber our failures; however, no success, no matter how great, can ease the pain of losing a three year old boy to malaria.

There was a wedding...

…last night in Karagora, a tiny village about a thirty minute walk from the clinic. It was, by all accounts, a successful wedding. The celebration was festive, and people ate and drank. Specifically, they ate rice and beans and I do not know what else; and they drank a non-alcoholic brew made from the juice of bananas. A neighbor of the happy couple prepared the drink for the joyous event. Nurse Maneno (one of our best nurses, I should add) is a cousin of the bride. He was invited to attend, but, unfortunately, duty prevented him from doing so: he was on call at the clinic yesterday and last night. Yet it was much of his family that was in the wedding party. The bride and groom celebrated into the night, and we can only wish them the best in their married life.

I jump ahead in my narrative to this morning at 7 A.M. I was about to make rounds on the patients that I have in the hospital, among whom is a very ill, one year old girl. I approached the hospital corridor, and I was astonished to see at least 25, maybe even 30 men and women, all of whom were doubled over with abdominal pain in between bouts of severe vomiting. Here are pictures of that scene. You do not see some of the patients, who are off in the bushes vomiting.

The story is this: approximately six hours after the conclusion of the wedding, the entire village was awakened by the sounds of men and women screaming in pain. These same men and women were also retching uncontrollably outdoors. It was quickly apparent that all of the affected people had attended last night’s wedding. A decision was made to rent a truck to bring all of these sick men and women to our clinic. Where they got the truck I do not know. Suffice it to say that they got it.

The groom, who had been unaffected by this scourge, made a call to Cyriaque, who is the official on call doctor for the clinic this weekend. Cyriaque was informed that the truck was coming. I cannot imagine the ride up the hill with all of these sick patients. Cyriaque had been called at about 6 A.M., and the truck arrived at the clinic about 7 A.M. The patients were unloaded, and quickly triaged. It seemed that they were all equally ill.

I had not seen Cyriaque yet that morning, so I was unaware of the unfolding drama. That’s why I was so surprised to come upon the scene that was both chaotic and controlled, if such a thing is possible. There are two nurses on call each weekend day. The two nurses on call Saturday were the aforementioned Maneno and Feliaze. They should have left when the nurses on call Sunday, Peter and Joseph, came on duty Sunday. Instead, they stayed to help.

The four nurses worked feverishly to get I.V.’s into the 25 or 30 patients. We then opened boxes of Ringer’s Lactate I.V. solution. The solution was attached after the I.V. was inserted, and the patients were soon being effectively rehydrated. The patients were then placed on beds in the various wards. I show you one such ward with several of the affected patients. The other wards were similar.

I must give credit to the four nurses who worked so calmly and efficiently this morning. Their efforts were nothing short of heroic in the midst of what could have been a medical disaster.

It was obvious what we were dealing with: food poisoning. It was equally obvious that the onset of the illness was of acute duration: 6-8 hours after the responsible item had been ingested. Food poisoning that acute, especially one that manifested with vomiting and abdominal pain, was almost certainly caused by a toxin that was self-limited. The only treatment needed was supportive, meaning I.V. hydration. We were doing that. No other medication was needed.

Cyriaque and I did what the CDC might do in this case: we took a history of the food and liquid consumption. The dishes served at the wedding consisted of rice and beans, and perhaps some vegetables. Then, at what we might call the after-party, the banana drink made by the neighbor was consumed. It appeared as if the people who ate the rice and beans, but who did not go to the so-called after-party were unaffected. The people who went to the after-party, the ones who drank the banana concoction were the ones affected.

Cyriaque and I were driven in the ambulance down the mountain to Karagora, where the events took place. We were in search of the contaminated items. Here are pictures of the villagers, as they greeted and gathered around us.

We were fortunate, because there was still a remaining portion of the banana brew and the beans. The brew had been placed in a plastic bottle for us, and the beans in a plastic bag.

I show you a picture of Cyriaque talking to the villagers before we left. What Cyriaque is saying is that we don’t know what caused the food poisoning, and that no one should be blamed. The reason he is telling them this is because, if they think the neighbor who made the banana brew is responsible, there is a good chance that they will kill him.

I now show you another picture of the ambulance before we left the village. As you can see, the back of the ambulance is crowded with equally sick villagers. The truck had been unable to accommodate all the ill people of the village. These patients were taken to the hospital in Rumonge, because our resources had been stretched to the limit.

It seems as if the banana drink was the tainted item that caused the food poisoning. Yet we cannot be sure, because it also seems that there were others who were equally ill who did not consume the drink. Among those was the bride herself. We brought the samples of the food and the drink back to the clinic. However, we do not have the means for an analysis. We are hoping that there is a laboratory in Bujumbura that can do that. Knowing what caused the poisoning won’t change anything, but it is, if nothing else, of academic interest.

All the patients at the clinic received two bags of Ringer’s Lactate solution. Their symptoms have abated by now, and we should be able to discharge all of them by this evening. A medical disaster has been averted.

I have been told that this kind of mass food poisoning at events like weddings is not unusual in Burundi, especially in the outlying areas of Burundi. However, this was a first for our clinic. 

Just another quiet Sunday at the clinic.

Four Children

I have been inundated this year by children with serious heart disease. Some of this heart disease is congenital and some acquired. The acquired cases are generally a result of rheumatic fever, a disease that we rarely see in the United States. Methode, the child with severe asthma and heart disease, was one of the children with acquired heart disease; however, I doubt that he has rheumatic heart disease.

 We discharged Methode today. We gave the family a referral to a cardiologist in Bujumbura, but I doubt that they will take him to the cardiologist. The cost of the consultation with the cardiologist plus the cardiac echo that he needs will be about $40. I don’t think his family can afford $40, but what if the family does have the means to take him to the cardiologist? What will then happen to Methode? I don’t know. I can’t conceive of it being anything good. He may have what is called a cardiomyopathy: a disease which weakens the heart muscles. If that is the case, there is no hope for him. His heart will progressively fail. But what if I am wrong? What if his heart disease is amenable to surgery? Can we not send him to Save a Child’s Heart (SACH) in Israel, like we did for the two other Burundian children, Clairia and Dainess? That is the problem I face.

I have already seen ten such children in the two weeks that I have been here. I saw another one today. Some of these children were previously diagnosed; some of them, I diagnosed because of their heart murmurs. I present below four of the children with heart disease. All four of these children had been previously evaluated by a cardiologist in Bujumbura. All four of them had cardiac echos. We know what’s wrong with their hearts. We know what must be done to fix their hearts. We know that their heart lesions are correctable with surgery. We know that all four of these children need surgery as soon as possible. Without that surgery, none of them will survive to adulthood, and one will die before she is ten.

The first of these four children is a two year old girl named Charnaute Mbabazi. She has Tetralogy of Fallot, the most common congenital, cyanotic heart disease. She is, in simplistic terms, a “blue baby.” The life expectancy of a child with uncorrected Tetralogy of Fallot is less than ten years, and many die before the age of five.

Charnaute’s oxygen level at rest is low, and even lower when she cries. She did a lot of crying when I examined her, so I saw how blue she became. The only picture I could get of her was asleep on her mother’s back. You see below the picture.

Her mother brought her into the clinic this past Sunday. I do not know why she chose to come Sunday, but she did. She gave me the information I needed. I do not need to speak Kurundi to understand what she was asking me to do: save her child’s life. I told her what I have told all the others: I will try.

The second child is a beautiful eleven year old girl, by the name of Marie-Joella Buntu. Here is her picture:

Marie-Joella, like Dainess, has rheumatic heart disease. She too has severe mitral valve damage, as well as a very dilated left ventricle and atrium. She needs surgical repair of her mitral valve. She, like Dainess, will have a normal heart if she has that surgery, but, without surgery, she will progressively develop heart failure. It is that heart failure that will prove fatal, probably before she reaches the age of twenty.

The third of these children is Ariella Kaneza, and she, like Marie-Joella, is an adorable 11 year old girl, as this picture demonstrates.

 Her story is the same as Dainess’s and Marie-Joella’s: she has rheumatic heart disease with a severely damaged mitral valve and a very dilated left ventricle. Her story is exactly the same as Marie-Joella’s. Heart failure will soon develop without surgery.

The last, and perhaps the saddest, of these four girls is a 16 year old girl named Foibe Ntitangakumwe. This is her picture.

     Foibe also has rheumatic heart disease, but, unlike the other two girls, she is already showing signs of heart failure. Her liver is enlarged, and she is short of breath after the most minimal of exercise. She is alarmingly thin. I fear for her, because time is so much against her. She needs surgery as soon as possible.

     I cannot explain the coincidence of these three children with rheumatic heart disease all being girls. Perhaps I relate more to their stories because I too have girls: two daughters and a 19 month old granddaughter. I love all of my girls to distraction; I love them beyond reason. Unbreakable are the ties that bind me to my girls. They know and I know that I would do anything for them.

I look at these three Burundian girls. I see their pictures. My heart goes out to them, perhaps because I am the father of girls. How would I feel if I was the father of any of these girls? How would I feel if my daughter or granddaughter was denied the chance to live? How would I feel if I could not save my child, when salvation was at hand in the form of an organization called SACH? How could I live with the futility of seeing my child go into heart failure because she could not have the surgery she needed?

I will never have to live with that impotence, nor will anyone who reads this. That’s because we all live in the United States, where children who need heart surgery have heart surgery. It is not a question of prioritizing for us.

There are approximately 16,000 heart surgeries performed on children in the United States every year. There have been, by contrast, two cardiac surgeries on children in the entire history of Burundi. Those two children came from this clinic.

Now I am faced with four such children; four children who are equally deserving of having this surgery; four children whose very existence depends on having the surgery. How do I decide whom I should put to the front of that surgical line? I don’t. That is not for me to say. All I will do, as I have said to the parents of all of these children, is that I will try for all of these children. I will make similar applications to SACH for all four children. It is then up to SACH to decide who will be the beneficiary of their altruistic services. I doubt that it will be all four, but I can only hope for the best. 

A Busy Monday

Monday is always a busy clinic day. That’s because we don’t have a formal clinic on the weekends, although there are always a few patients who show up on Saturdays and Sundays. Often, these are very ill patients who cannot wait for Monday. That is certainly the case with the children that I see on the weekends.

So Mondays are generally the busiest days of the week, but this past Monday was beyond anything I had ever experienced. There were over 200 patients who came to the clinic that day. Those patients were ultimately seen by one of the four doctors, myself included. While I am here, I am assigned to see all the children who come to the clinic that day. I saw 44 children that Monday. Some of my patients waited over 8 hours to be seen, yet there were no complaints. They accepted their fate with a stoicism and an equanimity that is at the core being of the people of this country.  

I show you below two pictures of the patients, as they assembled that day on the terrace of the community center. Those pictures give you some idea of the numbers of patients that day.

To give you an even better idea how many patients there were that day, I show you below two pictures of the clinic corridor outside the doctors’ offices. These pictures were taken at 4 P.M., and all of the patients that you see were still waiting to be seen.

    

The way the clinic works is that the patients line up early in the morning behind the clinic gate. The gate opens at about 7:30 A.M., and they all stream in. The patients are given badges with numbers coinciding with the number that they are in the line. All the patients assemble on the terrace in front of the community center, and the nurses then do vitals on all of the patients.

     There is no formal triage system here, because they simply don’t have the personnel to do so. Therefore, I make it a point to do my own version of triage. I walk through the crowd of patients in order to see if there are any children that need to be seen before the others. That Monday, I came upon one such patient immediately.

     His name is Methode Tyihimibaze, and he is a ten year old boy. He was sitting in what passes for a wheelchair here. He looked up at me with large, dark, scared, uncomprehending eyes. I instantly knew why. He could not breathe. His chest was barely moving, as he struggled to get air into his alarmingly thin, muscular body. I listened to his chest, and there was almost no air exchange in his lungs. What I did hear was the unmistakable “whoosh” of a loud and continuous heart murmur. I also perceived a faint, high-pitched scratchy noise.  

My first thought was that this was another case of rheumatic heart disease with associated heart failure. My second thought was that the faint scratchy noise was the sound of pericarditis; that this boy had so much fluid around his heart that his heart could not pump effectively. That was why he could not get any air into his lungs. If he did indeed have pericarditis, we were dealing with a life-threatening condition. I asked Dr. Cyriaque to listen to the boy, and he confirmed my suspicions; that this boy might well have acute pericarditis.

We wheeled the boy into my office, which also serves as my examining room. There is a desk in the office, a chair for me, and two chairs in front of the desk. The patient sits with the child in one of the chairs, and my interpreter sits in the other. I use the interpreter’s chair when I examine the patient, or, if the patient is old enough, he or she sits on the examining table. Two large windows in my office look out into the fields and trees around the clinic.

The other three doctors were in my office with me. It was a given that we would all work together on this patient. The situation was too critical; a child’s life was at stake. We carried Methode to the examining table; he did not have the strength to move from the wheelchair. His eyes betrayed only fear and pain. He said nothing, nor did he even utter a sound while we worked on him.

We put a pulse oximeter on his finger, and the reading varied between the low 80’s and high 70’s. We wanted to give him oxygen, but the only two oxygen cannisters in the clinic were being used by other patients.

We needed to know if he had pericarditis. The clinic has a portable ultrasound machine. It is not the most sophisticated of ultrasound machines, but it serves its purpose. Dr. Zenon used the machine to perform an echo on Methode’s heart. There was no evidence of fluid around the heart; therefore, he did not have pericarditis. The cardiac valves looked relatively normal. However, the heart itself was markedly enlarged, and its contractility significantly diminished. Methode had a damaged heart; a heart whose function was seriously compromised. We did not know why or how it got that way.

There was more to Methode than a bad heart. I listened again to his lungs, and he was barely moving enough air to hear any sounds. Yet I perceived this time the almost imperceptible, but unmistakable sounds of wheezing. I had not heard it initially, possibly because his heart murmur had drowned out the nearly silent wheezing. The only logical conclusion now was that Methode had severe asthma in addition to his heart disease.  

 We put him on continuous inhaled Albuterol via a nebulizer over the next two hours. This was Albuterol that I had brought from home; Albuterol that had been generously provided by the WestVal pharmacy in our building; Albuterol that is unavailable in Burundi; and, finally, Albuterol that I believe saved this ten year old boy’s life that Monday morning. 

We also gave him a strong dose of steroids via an I.V. We gave him Lasix to reduce the fluid overload that had accumulated form his heart disease. Methode’s breathing gradually improved over the next two hours. His oxygen level increased to the high 80’s and even low 90’s. We were able to free up one of the oxygen dispensers to use on him. I would not say he was comfortable, but, at least, I could hear air moving in and out of his lungs.

Methode has continued to improve over the last five days. He now appears comfortable, and his lungs are almost clear. As proof of his improvement, I show you a smiling Methode from this afternoon.

We will discharge Methode from the hospital this week. His asthma has been successfully treated for now. What will happen if another asthma attack occurs, which it is certain to do? I am not optimistic. The family comes from faraway. It is unlikely that they will have access to the kind of medical care and medications that they received here. One can only hope that he recovers from future asthma attacks. But, more importantly, what can we do about the more important problem: his heart disease? I leave that discussion to the next blog post.