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.