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.