I do not believe in miracles, but...

My daughter asked me yesterday if there was a triage system in place in the clinic, meaning do the more urgent cases go to the front of the line? Yes, absolutely. Case in point: a nineteen month old little boy by the name of Fiacre Magishsa.

Fiacre was carried into the clinic yesterday morning by his mother. The triage nurses took one look at him, did vital signs, and immediately brought him to see me in my office, which also serves as my examining room. The history, which we obtained very quickly, was that the baby had a two day history of fever and diarrhea.

The reason we took that history so quickly was that this little Fiacre may have been the most acutely ill baby I have ever seen. The only frame of comparison I can give you is Richard, whom you all know so well by now. I do not exaggerate when I tell you that Fiacre was far sicker than Richard.

Fiacre had a continuous high-pitched irritable cry, like when you step on a dog's tail. He was virtually unresponsive, reacting only occasionally to painful stimuli. His pupils reacted to light, but were completely unfocused. He had what is called nystagmus, meaning that his eyes darted back and forth, both in a horizontal and a vertical direction. Every few seconds, his legs and arms would stiffen spasmodically. This is what is known as posturing. We could not be sure, but Fiacre might also have been having seizure activity. All of these signs: the unresponsiveness, the acute onset of nystagmus, the posturing, the possible seizure activity all indicated to me that Fiacre had suffered some gross neurological insult. Or, perhaps, he was in the process of suffering some gross and irreversible neurological insult.

The other doctors, Melino and Bazile, and several nurses immediately joined me in the resuscitation process. My first thought was that Fiacre had overwhelming bacterial meningitis. Fiacre was placed on the examining table, at which point he proceeded to have profuse watery diarrhea several times. A spinal tap was attempted in order to determine if he had meningitis, but, unfortunately, the spinal tap was unsuccessful. Fiacre did not react, or perhaps reacted minimally to the painful stimulus of a needle being inserted in his back; that needle being inserted not just once, but several times in a vain attempt to get spinal fluid.

We knew that Fiacre had to have some infectious process that was affecting his brain. The two most common causes here would be meningitis and cerebral malaria. In cerebral malaria, there is acute swelling and inflammation of the brain, but the exact pathophysiology causing that swelling and inflammation is unknown. The possibility that Fiacre had meningitis dictated that, even without the benefit of having spinal fluid to analyze, he be given an intramuscular dose of Ceftriaxone, the same broad spectrum antibiotic that had been given to Richard during his resuscitation.

What we did next is not recommended, according to several tropical medicine books, because it has no proven benefit. What was more pertinent to us, though, was that it had no proven risk. At that point, we felt that we had nothing to lose. Therefore, we gave Fiacre an injection of corticosteroids to hopefully reduce the swelling and inflammation in his brain.

The nurses, who are extremely expert here in getting I.V.'s into the smallest of veins, made several unsuccessful attempts to get an I.V. into Fiacre. Fortunately, as with Richard, we did not have to go the intra-osseous route. One of the nurses shaved off what little remaining hair that he had on his head (as an aside, you probably will notice that the vast majority of the Burundian children, both boys and girls, have shaved heads. This is done for practical, not cultural reasons: to avoid lice and fungal infections of the scalp).

A tourniquet was placed around the top of Fiacre's head to access a scalp vein. One of the nurses was able to get an I.V. into one of the scalp veins. Cerebral malaria, one of the two diagnoses we were considering along with meningitis, often causes hypoglycemia. Therefore, Fiacre was immediately given fluid containing glucose through the I.V. He was then given a large dose of I.V. Quinine, the medication that is used here to treat malaria.

There was absolutely no change in Fiacre's neurological status over the almost three hours that we worked on him. If anything, he seemed to worsen. That ominous neurological activity, the posturing, the non-responsiveness, persisted. Moreover, his breathing became somewhat irregular. His heart rate remained steady, but I was, at that point, extremely pessimistic about his chances of survival. In fact, I thought the end would come very shortly. There was no way that he could recover from whatever gross neurological insult that he had suffered.

It was felt that Fiacre, despite his extremely tenuous condition, could be moved into the hospital ward, an open room with ten beds. There is virtually no separation between the beds on the ward. In the United States, Fiacre would almost certainly have been admitted directly to the ICU, where he would have been under constant surveillance with 1:1 nursing care (meaning one nurse to a patient). In Burundi, such a thing, of course, does not exist. Instead, Fiacre was on a ward with one nurse taking care of ten patients, and that nurse was generally not present on the ward. So, basically, Fiacre was for the most part unobserved by any medical professional the majority of the time.

I felt that even the most skilled and vigilant of nursing care would have made no difference for Fiacre; simply put, the child was going to die. Over the next two hours, I checked on him every five to ten minutes. There was no change in his condition, his neurological status showing no improvement.

There was nothing I could do at that point. All that could have been done had been done. Fiacre had been given all the medication that we had at our disposal. Therefore, I went back to seeing patients in the clinic. It was about an hour later that I was informed that Fiacre was sitting up in bed, wanting to eat. I rushed into see him, and it was indeed true: Fiacre had pulled the I.V. out of his head, and he was indeed sitting up, wanting to eat.

Two days after that resuscitation effort, Fiacre remains fine. He will be here for a while, because he was suffering from malnutrition, in addition to being acutely ill. Therefore, we have to treat both the malnutrition and the illness, whatever that illness may have been and is now.

Just so you know that I was not alone in my assessment of the situation, I asked Melino later that day if he thought the baby was going to die. He said, absolutely, yes, that his neurological status was so ominous that he thought there was no chance of recovery. So how and why did Fiacre get better. Was it the Ceftriaxone? Was it the steroid injection? The I.V. Quinine? The I.V. glucose? Was it a combination of all of these? Who knows? Perhaps there was some unknown factor that came into play. All I know that his cure was not a miracle. Rather, I believe that whatever we did in that resuscitation room made Fiacre better. What exactly it was we will never know, and that's fine. The salient point is that Fiacre is better, not how he got there.

I show you below a picture of Fiacre taken yesterday. I will warn you in advance that he is a much more timid child than Richard, and not as playful. Therefore, you may not be as charmed by him as you were by Richard. Also, you should remember that Fiacre is still suffering from malnutrition. But the point is that Fiacre is cured from whatever he had, and I think you can see that in the picture.