Wednesday, September 19, 2012

Love in the Time of Cholera

Sierra Leone has been in the news recently because of the cholera epidemic spreading throughout the country.  It started in Freetown but cases have now been documented in all the districts except one.  Our hospital has not been immune. 
A couple weeks ago I was down in the OB ward, getting ready to go home at about 9:30pm.  I was literally walking out the door when one of the nursing aids came and asked me to see a patient that had just come in. I walked down to the ER (ie the bench outside the nurses station) to see what was going on. 

The guy in front of me was a young, healthy looking guy, but was in rough shape.  He said he had just arrived from Freetown that day, and had been vomiting and having diarrhea since that evening.  As soon as he said he’d come from Freetown, a little light went off. I’d just come from Freetown myself and had seen all of the signs posted and heard the radio announcements about the cholera epidemic, what people should do to prevent it, when to go to the health center, etc, so it was higher on my radar than it usually would have been.

Of course I’ve seen plenty of diarrhea and vomiting cases….but this guy seemed a little different.  During the interview he had leave a couple different times to go vomit and or use the bathroom.  When the cholera episodes first started appearing, I took to ole’ Google and researched the signs as well as how to treat it.  It’s actually a simple treatment of IV fluids and/or oral re-hydration salts.  Oftentimes people will add an antibiotic because although it isn’t curative, it has been shown to decrease the duration of the diarrhea and vomiting. 
I admitted the guy and started him on IV fluids and the antibiotic and called one of the docs to let him know what I was suspecting.  He agreed with my plan so we put the guy in a private room and started his treatment.  I went down to see him the next afternoon and was doing much better. The day after that he was discharged.

We didn’t see much else that we suspected could be cholera until about a week or two ago.  At this point we’ve had four confirmed cases and others that were probable cases but we didn’t have the testing to confirm it.  We’ve made some changes to the hospital now and have moved all the women down to the OB ward so we can have the womens medical ward for the male cholera patients and the womens surgical ward for the female cholera patients. 
While cholera is relatively simple to treat, it can be extremely deadly. The fluid loss is just so extreme that if it’s left untreated for 24 hours, it can kill.  Since patients aren’t always quick to come to the hospital (see other bazillion posts about patients coming too late) it can easily kill. It’s also very easily transmitted (oral-fecal transmission….yum!) 

It turns out that trying to contain cholera isn’t easy!  Now me, I hear cholera and I think hmm…I don’t want to go anywhere near that!  When we realized that we were seeing multiple cases, we decided to limit visitors and only allow one visitor per patient.  We went up and down the wards kicking patients out, but they kept finding their way back in.  My friend explained that if you ask a family member to leave the patient, they automatically think that the patient is dying and so will do whatever they have to to be near the patient.  He had one family member that he had repeatedly asked to leave, but kept coming back.  Later when he asked this family member if the patient was drinking the ORS (oral re-hydration salts) like he was supposed to the family member said that yes, he was drinking it, but the family member had also started having diarrhea so was drinking some of it as well.  Frustrating!!!  We’re currently working on getting some better security and educating the community on the various dangers.  The WHO came a few days ago to see how we were handling things and the government is supplying free IV fluids to the hospital for all the cholera patients.  We’re very grateful that we haven’t seen any deaths (although we were fearful for one guy in particular!) and our patients are improving. 

Ironically, last week was a red letter week for me, as I received 3 different marriage proposals.  It had been awhile!  To be fair two of them were by one person who initially wanted me for his son but when I said he was too young offered to marry me himself.  This was of course after I’d already met his wife.  It must be true what they say.  Cholera is in the diarrhea….love is in the air. 

Wednesday, September 12, 2012

Spoke too soon....

The last post I did was about the successes that we had in the OB ward.  I’m sad to say, I spoke too soon.  One of the success stories I mentioned, the woman who’s baby was breech and had a c-section, died yesterday.

She was discharged.  She’d stayed her 7 days and was ready to go home.  But the bill wasn’t paid in full yet.  Her husband came to visit her almost daily, always promising to come with the money and always drunk.  On the patient’s last admission he threatened to beat one of the nurses because he was upset about the bill.  He is a policeman.  Yup.

So she was ready to go.  She had been having vague complaints throughout her stay.  Every day it was something different.  Her head hurt. Her back hurt, etc.  She spent a lot of time in bed and we had to keep encouraging her to walk.  Those of us in health care have had these kinds of patients before.  The best thing for them is to get out of the hospital, get back into their routine and they start feeling better. They forget to be sick. 

Such was this patient.  Needless to say, when we were doing rounds on this patient on her 3rd or 4th day after being officially discharged, I wasn’t overly impressed when she said, “I torment, I torment.”  What does that mean?  “I just don’t feel well.”  Well, we all said.  You need to get home, get back to your routine, etc.  Your blood pressure is fine, your incision looks good.  You’re on the mend. 
About an hour after this conversation, she said she was feeling cold so we took her temp.  102.6.  Huh. That’s weird.  Something really is going on.  I called the doc and we ordered some labs.  While the labs were cooking, she started becoming delirious, talking but not making any sense.  The family also said that she wasn’t moving her right hand very much. 
While we were waiting for the labs, we called another doc to come look at her and see if this was a complication from her surgery.  I’d listened to the abdomen and didn’t hear a whole lot in there, so it was possible.  The doc came, looked her over but decided that this wasn’t a surgical problem.  Darnit. Back to square one.

The labs came back and she was malaria positive.  Upon admission, she’d been negative but had been given the treatment anyway (we can only test for one strain of malaria so if they complain of symptoms we often treat even if the test is negative).  Ok, now it was starting to come into focus.  Cerebral malaria.  I’ve never really been with someone it came on so while it seemed pretty fast to me…maybe that’s what happens?

Now our dilemma.  We use quinine as our injectable anti-malarial for adults when patients aren’t conscious.  It’s not the best medicine because the malaria in this area has developed a resistance to it. It also has some pretty nasty side effects.  But it didn’t matter because we don’t have any.  We have recently discovered injectable artesunate.  This is the drug we use as first-line treatment for malaria.  Unfortunately our supply is limited so we’ve been using the artesunate in the kids, the quinine in adults.  But we don’t have any quinine. We have 30 vials of artesunate.  Kids, depending on their weight will use 1-2 vials. She would need 4 vials for every dose.  It would burn up our supply pretty quickly. 
We stood there…two doctors, three nurses, trying to figure out what to do…what decision to make.  We have plenty of oral anti-malarials.  Can we give that rectally?  Will it still work as well?  We have no idea.  No study to help us decide.  What if we gave a lower dose, didn’t use as much?  But then what’s the point if it’s not a therapeutic dosage?  Does she really need the injectable artesunate?  Her family said she seemed to be getting a little better, moving her right hand now.  Could we get away with saving it for the kids?  Finally one of the other nurses suggested putting in an NG tube (tube going through her nose into her stomach) and giving it orally.  Perfect.  The oral anti-malarial we have works really well…and this way she doesn’t have to be awake to take it.  Seemed like a good solution.  I had high hopes she’d turn around.

When I came in the next morning and asked the night nurse how the night had been, she told me it was very rough because the woman was “tormenting” all night.  She hadn’t come out of it.  When the doc came by for rounds she listened to her lungs and said she was full of fluid.  They were now suspecting that she threw a pulmonary embolus (little blood clot into the lung) and this put her into pulmonary edema.  We threw a whole slew of medicines at her…..although it was frustrating because we just don’t have the testing capabilities or monitoring capabilities to do everything we would in the states.  We continued on like this for the day.  When the doctor came by in the afternoon she was hopeful that if we just gave this lady one more day, she would probably turn around.
Over the next 2 days there was no improvement.  This woman lived nearby and was well liked so the family and friends started coming by.  The crying began.  She has three children.  Two girls, age 10 and 6, and this new little baby boy.  The older girl began to see that her mama wasn’t getting better and became hysterical.  Some other family members took her home.
Yesterday she started seizing.  The family had once again begun complaining that she wasn’t moving her right hand, so we thought she must have had a stroke. Again, no way to confirm.  We got the seizures under control but now her oxygen saturation was dropping. We put her on oxygen.  We tried to suction her lungs, but there was nothing to come out. 
The ward was full of people! The rumors had started that she’d died and the nursing assistant working with me was fielding the calls to find out if it was true.  Her family came and asked me if they could take her.  They wanted to take her to her home town about 6 hours away.  This town is the center of all things “magical” “occultic” whatever you want to call it.  They said that her sickness wasn’t a hospital sickness and that her twin brother had taken something from her that they needed to go to this town to get back. 

I didn’t see any reason to keep her.  She began doing the “guppy breathing” that people often do at the end of their life, and I knew there wasn’t anything else we could do for her.  It was heartbreaking to see her two daughters sitting by her bedside.  The older one knew that something was going on, but the little six year old had no idea that her life was about to change forever. 
I couldn’t do anything to stop this woman from dying.  For some reason, her little daughter just got to me. I wondered if she would remember her mom. I wondered if she would remember the week and a half that she spent in the hospital, only to leave with a new brother and no mother.  I wondered who she would live with.  What was her life going to be like?  I mentioned above that she and Kadiatu had become quite good little friends.  They often played with Kadi’s “baby” (a black baby doll that was sent over on the container).  People freak out over this doll because it’s pretty life-like. I’ve had tons of people stop to see if it was real, touch it, etc.   And I had another one.  The dolls came as a set of twins. I’d given the first one to Kadi on her first night with me but the other one was sitting in my closet. I’d been saving it for….something.  I ran up to the house to get it and had Kadi give it to this little girl.  She was so excited.  I felt like crap.  A baby doll?  Really? It was such a small thing to give when I knew what this girl was about to lose.  I knew, but she had no idea what was coming. 
I left that afternoon and she was still alive. I found out the next day that they had taken her that evening and she died three hours after leaving the hospital.  Leaving three beautiful children behind.

I wanted to remember the feeling I had, remember her, so I snapped she and Kadi with their babies.
 The faces are real. It is so common here to meet people who have lost their mother, their father or both parents.  While I always feel bad, I generally meet these people as adults and the wounds have had time to heal, at least a little bit.  This was the first time I watched it happen.  It sucked.  

Saturday, September 1, 2012


A lot of times it seems like the things I post on this blog are very dramatic, and oftentimes sad.  In an attempt to balance the sad with the not so sad, I thought I’d tell you about the OB ward right now.  I’m not sure what happened 10 months ago that kept people from baby making, but for the past few weeks the ward has been pretty quiet.  One contributing factor could be that it is “hungry season” right now.  This is the time of the year when planting is going on and the harvest hasn’t begun yet.  People have run out of the food/money from last year's harvest and are trying to hang on until they are able to harvest what they’ve planted this year.  For this reason, there are very few if any elective surgeries and people wait until it is very late to come to the hospital. They will also try to deliver at home to save money.  That being said, our ward for malnourished kiddos (which is free) is overflowing right now.

For the last few days we have had 4 patients in the ward.  Patient number on is a woman who had a previous c-section.  Although that baby was born alive, he/she died soon after beginning to walk.  Mom said he had been having fevers, vomiting, etc.  Stupid malaria.  Anyway, she was told after her first c-section that she would need to have another one for her next pregnancy. (No attempts at VBAC’s here (vaginal birth after c-section. Too risky).  She lives far away but came to stay in this village with relatives about a month before she was due so that she would be able to come to the hospital quickly.  Because she acted quickly after her labor started and came when we asked her too, she and her baby are both doing great and are just waiting to go home.  Success!

Patient number 2 is also a c-section.  This was her sixth pregnancy.  I walked into this delivery soon after she’d arrived. She had been laboring at home for awhile but the baby just wasn’t coming. The nurse before me had started some oxytocin to see if she could move things along.  After a while she did her second vaginal exam and said, “Um, Emily.  I’m not sure what this is, but it isn’t the head.”  We confirmed with ultrasound that indeed, this baby was coming rump first.  Although it is possible to deliver these babies vaginally (especially if they’d had many pregnancies before) this particular presentation gave us a high probability that if we tried we wouldn’t be successful.  To the OR we went and she now has a beautiful, healthy baby boy.  Success!

Patient number three is a woman who is pregnant for the first time.  She is 7 months pregnant and came to us with a complaint of fevers and dizziness.  Her hemoglobin was 4.  Very, very low!  We gave her two units of blood and are looking for a third.  But she’s doing better.  I’ve seen malaria kill multiple babies in the womb so that fact that this baby is still with us and mom’s doing better….I’ll say, Success!

Patient number 4 is a baby who came to us at 23 days old.  He was born here and they brought him back after he was crying all day and night and wasn’t breastfeeding well. His scrotum was also very swollen.  Thanks to the skill of our Super Docs he was diagnosed with a strangulated inguinal hernia.  This is where there is a weakening and hole in the wall of the abdomen and a small amount of bowel is pushed through the hole….. in this case into the scrotum.  The hole is so small and tight around the piece of bowel, that the blood supply is actually cut off and if it isn’t fixed, the patient will have some dead bowel and if left untreated will eventually die from the infection.  We see these all the time (especially in men) here, but almost never in a baby this small.  Our OR team came to the rescue and today they said he could go home.  Success!!!
Our OR team working working on the smallest belly ever.  You can barely even see the patient on the table!
There is a lot of heartbreak here in Sierra Leone and we thank God that He is with us in the midst of our pain.  But we also thank Him for the times when things go the way we want them to! J