The Medicine

I've avoided something important in my blog posts so far.

The medicine.

Frankly, the medicine hasn't captivated me in the way that seeing the bigger picture has. Seeing far reaching connections come to life to slowly give hope to a new vision of Family Medicine here in Malawi has been amazing. Yes, I've seen diseases that I would likely never see back at home. I've seen patients brought to the health center propped on top of the arms and above the heads of loved ones. Ones who've possibly had tetanus, TB, end stage HIV, and severe malaria. I won't ever really know for sure if it is what they had since our diagnostic capabilities are sorely limited at Ndirande. Empiric treatment is the name of the game here. Some good coming from it (ability to utilize less trained health staff) and some bad (antibiotic resistance, diagnostic inaccuracy). But overall, nothing has gripped me enough to merit sitting in the mosquito inhabited living room at the Hutchinson's to pound out a blog post.

Until yesterday.

Back at home, I'm known as something of a "white cloud". For those not in medicine, a white cloud is someone who discharges a lot of patients, doesn't get killed with admits, and generally has a quiet day/night for better or worse. I've still had my share of crazy nights and stories to tell but overall I'm most assuredly a white cloud. 

Two nights ago I joked on Facebook before leaving for my first night call shift at Ndirande that maybe my white cloud would turn black since I'm half way across the world. 

Well, I was right.

Elizabeth joked that I may have been the first family medicine physician to have ever been on night call at a district health center in Malawi as they are typically staffed by clinical officers. I'm sure I'm not but I told her I will gladly accept the title. I also prefer to wear a sash that announces that dubious honor. And if it was an "honor" I received, it was surely baptism through fire.

The following is a chronological order of my night. It's the only way I know how to put all of this into writing. I've had two days to process the night and I think I can now get through discussing this without swearing in frustration but if I do, please either stop reading or accept my pre-emptive request for forgiveness. As always, this will be all in one take.

This was my night...

19:30: Bill drops me off at the steps of Ndirande. It's pitch black around with the exception of the florescent glow of the family planning clinic. I make my way up to the clinic area to be greeted by Jafundo (soon to be clinical officer who has finished training) and Phiri (clinical officer/head of Ndirande's clinical officers). As I set up shop, I'm told by Jafundo I already have a patient ready to see me. Phiri, the other clinical officer there for the night, sets up camp at his house for the night (he lives 1 minute away) and says good night to me.

19:35: 40yo, male, comes in with sore throat, fever, and a painful jaw. I'm limited in what I can do but I get his temp. I'ts 102.7. He's also tripoding slightly and bit of a muffled voice. I can't look into the back of his throat because it's so swollen. he's also hypoxic to 92% O2. I tentatively diagnose him with a peristonsillar abscess secondary to a dental infection. In addition, I suspect a PNA, he's unclear what his HIV status is (PCP?) The only antibiotics I have available to me are Ceftriaxone (thank God) and a vial of Gentamycin. I want to desperately get him to Queens but Jafundo tells me the only people that can be seen at Queens at night are "emergencies". By "emergency", he means actively bleeding out or dying. I give the man a gram of IV Ceftraixone and 2L NS. I check on him periodically in the night and his tachycardia improves and clinically looks stable. Sent him to Queens in the morning.

19:45: After seeing the first patient, Jafundo says he has another patient in the short stay/inpatient area that he wants me to see. I walk over to the area to witness what could only be described as something out of a horror movie. There is a 20 something year old woman covered in blood. I mean, covered. Jafundo tells me she came in about 30 minutes ago with acute vaginal bleeding. Luckily it has subsided and she is stable after 3L of fluid. I begin my line of questioning, a lot revolving around whether if she is pregnant. She isn't. I'm still mystified what may have caused this after my history taking so I tell her I need to do a vaginal examination. I put on my gloves. As I cautiously go to examine her she clamps her legs together. 

At that exact second I knew what happened.

My next question to the patient (via Jafundo) was if there was any sexual assault. I previously asked her about trauma and she denied it so I had to be direct this time. She declined to answer the question. 

That's all the answer I needed. 

Since she was stable, I told Jafundo that we don't need to do any further examination right now and we can wait for the ambulance to arrive to take her to Queens.

The ambulance never came.

She laid in bed with her infant child the rest of the night. Her partner came to see her. Of course I was pretty vigilant at this point but he seemed genuinely interested in her health and my spidey sense never went off. I would let her process this and tell him in due time (or not) but I kept an eye on her the entire night.

20:00: Two year old female comes in with tachypnea and fever for one day. Based on her history and exam I feel very strongly it's malaria. I ask Jafundo to get us a MRDT test.

We're out.

The only reliable test we have at Ndirande. The test that is probably ordered at least 50 times a day at the clinic and we're out. 

I oscillate whether to treat empirically or have her come back in the morning. I decided to treat her empirically and then come back in the morning. 

20:20: One year old female comes in with a possible allergic reaction. She took Amoxicillin for a likely viral URI which then her parents noticed what looked like a blood blister on her upper gums. No other allergic signs. I thought about SJS but it really wasn't characteristic. She was otherwise well. It was also unclear if this was just coincidence when the parents noticed the finding. I told the parents to stop the Amoxicillin because she likely didn't need it anyways. Warning signs were given for SJS and to stay hydrated.

20:45: Thirty something year old male comes in covered in blood. Turns out he got a nice head laceration from an in-law hitting him with a stone during a dispute. He gives me a piece of paper that is a request for medical attention. It's from the police station. The request is officially documented on  a loose, lined piece of paper. 

Otherwise, the guy is fine. I have Jafundo stitch it up since it wasn't too bad. 

21:15: While I go to see Jafundo clean and stitch another woman comes straight to short stay with fever, generalized body pain (a favorite symptom of Malawi), and joint pain. I go to take her temperature. Oh wait, I forgot to tell you my thermometer broke after the second patient. Oh well. I'd kill for an MRDT test right now but I'm convinced enough to also empirically treat her for malaria. I thought enough of her presentation to treat with IM Quinine (instead of LA) but I also covered myself with 1g Ceftriaxone and a bunch of IV fluids. She looks quite well in the morning, enough where I thought she could follow up at the clinic as an outpatient.

22:40: 30 year old male comes in with shortness of breath and lower extremity edema. This has progressed acutely. No signs of pulmonary edema, history suggesting that this isn't likely cardiac in nature. I look back in his health passport and notice he was treated with Amoxicillin for "tonsillitis" roughly 5-6 weeks prior. Great good treatment for possible strep throat. 

The problem is that proper treatment of strep throat actually doesn't protect you from post-streptococcal glomerulonephritis, only from Rheumatic Fever. He has dark urine. I tentatively diagnose him with ARF secondary to either post-strep GN or malaria since he had a subjective fever as well. This is one patient I told Jafundo needed to go to Queens. I had so little in my diagnostic and therapeutic tool kit that I just couldn't manage him if it all turned south. So I sent him off with his father and brother into the darkness and the hope that he was able to get to Queens.

00:00: It's finally quiet. I ask Jafundo if this is the norm for Ndirande. Thankfully he says no. We go to the back room in the Peds department (our HQ for the evening) and sit down. Jafundo then hits the hay in the bed. The problem is that there is no mosquito net in this room. I knew at that point I would be getting no sleep so I decided to stay up. I proceed to kill time by playing Plants vs Zombies on my phone. I quickly finish the entire game and am left bored again. In an act of desperation I pull out my secret weapon. The one thing I would rely on for emergency entertainment during my 5 weeks here. "Jack Ryan: Shadow Recruit". This most random of movies was a last second decision by myself to put a one on my phone prior to leaving. I didn't watch it on the plane as I knew I would need it in the worst case scenario. I decided this was the time.

The movie sucked.

But it kept me up for 1.5 hours.

At this point I'm pretty tired and desperately would like to sleep. The problem is that I'm literally in the middle of a mosquito swarm. The back room is hot and protected from the wind. Perfect breeding grounds for the worst creation on earth. I put on my hoodie in the heat to protect my flesh from their relentless attacks but it only served as a large neon sign that pointed at the only piece of bare skin I had remaining.

My ankles.

I'm estimating at this point I had roughly 40 mosquito bites in total. Twenty for each ankle. The picture to the right is just a small window into the beating my ankles took. Eventually they started to just burn instead of itch. The skin was taut from the swelling. Mountains beyond Mountains of mosquito bites (Paul Farmer holla back). I was officially at 3rd trimester levels now. This continued for the next 4 hours or so. It was an experience so unpleasant that it rivaled the infamous night of Ski to Sea 2012 where I stayed up all night in a frozen car due to being an idiot (not bringing any camping equipment).

02:00: Ten day old male with fever and increased work of breathing. In short, the kid looked toxic. Was grunting and had some tongue protrusion. Was overall stable (stable=not dying this exact second) but was on the brink of turning south. This is a patient I would immediate admit and do an extensive sepsis rule out work up/treatment back at home but I ended up sending to Queens. Jafundo said that they would have to call a doctor to come in to see the baby. Don't want to make up the doctor in the middle of the night, am I right?

This was one I insisted on. 

02:30: I'm back to getting eaten by mosquitoes.

04:30: I hear a banging at the outer peds doors (the official way to get our attention) and a man comes saying that "the doc" is requested in the maternity ward. My first thought is that I'm needed for a delivery! But who am I kidding, Ben Davis being fortunate enough to have a NSVD? Even in Malawi it's far fetched.

I walk down to the labour ward and I looked to my left. The left is where there are 4 beds almost side by side. It's where the silent but laboring mothers lay as they are about to give birth. Nothing going on to the left. 

The nurse points to the right. Focusing my glance to probably the worst possible scenario. A dying newborn. I quickly make my way to the warmer and see a blue, limp, barely breathing newborn laying there. I ask the nurse how long this has been going on for.

30 minutes.

THIRTY. MINUTES.

I go to auto pilot and listen to the heart/lungs and thankfully hear a heartbeat. I hear breathing as well, albeit agonal in nature. I ask for anything to do positive pressure ventilation (PPV) and after 30 long seconds am handed a wooden box full of odd bag valve masks. None of the masks are the appropriate size but hell, it was something. I start PPV and then tell Jafundo to continue with it. I hand it off and he sits there, unsure what to do. For the first time during my stay here I almost lost my cool in the midst of my frustration. Regroup. I re-instruct Jafundo on how to do PPV. 

At this point I ask them if there is any equipment for suction. Again, the urgency in the room was low at best. This is something that would have everyone in the entire hospital up in arms back in Seattle. I can just imagine the staff losing their minds at the site of what I was witnessing.

But this isn't home (for better or worse). Unfortunately this is the norm here and eventually we all get jaded to things. I eventually get another suspect wooden box full of plastic suctioning equipment that take on various forms. None of which look familiar. I grab the one that looked like a penguin and went for it.

Nothing.

I take over PPV and have Jafundo look for deep suction equipment. Again, the sense of urgency is what feels like an all-time low as I stand there in desperation. Jafundo eventually brings over my saving grace - the deep suction equipment. I grab the cannulas and plunge them into the infants nares. Nothing comes out. I then stick them down his throat to find a substantial amount of gunk (no mec) sucked out. 

Finally, some progress.

I continue this a couple more times and eventually the infant starts breathing at a regular rate. Blue slowly turns to somewhat pink. I put on some oxygen via nasal cannula and wait. I probably waited 20 minutes in real time but it felt like a day in my mind. Just watching the baby breath. Standing there thinking what I would do next.

After about 40 minutes the baby starts to move his upper extremities. Thanks goodness. My main concern at this point was hypoxic brain injury, at least gross motor is intact. Who knows if there will be long term sequelae but for now I'll take it. We try breast feeding three separate times but the baby is just too weak to do it. I set a hard stop at 6am. If he can't breastfeed by then we're calling the ambulance.

Then again, the ambulance never came from my sexual assault patient.

Eventually, the child musters up enough strength to breast feed decently. He also starts crying for the first time which was music to my ears. At this point, I feel somewhat reassured at our trajectory and tell the mom congratulations in English which probably meant nothing to her. But in saying that to her, I think I was subconsciously saying that to myself.

I slowly waddled my way to the exit doors of the maternity ward and opened them to the blinding light of the morning. I went in to the maternity ward while it was pitch black and came out to the sun of the new day. It sounds quite poetic but it probably looked more like a scene from The Hangover to the women that were watching me.

06:00-06:30: I sit on the curb at Ndirande and bask in the sun and tranquility of the morning. Eventually, I start to process everything and what felt like devouring a layered cake of badness started to feel pretty rewarding.

06:30: I'm back in the Peds room eating a snack bar. My reward for surviving the night and maybe doing some good in the process.

06:35: As my feet are propped up on the desk and the crumbles from the snack bar are being wiped from my face, Jafundo comes in to say "we have one more patient". At this point I'm thinking I really don't want to see any more patients. Can't they just wait a bit longer until morning clinic starts? Before I can even stand up from my reclined position Jafundo places the patient on the bed in front of me.

A dead 4 year old boy. 

The exact moment the boy hit the bed, I didn't know he was dead. I knew it was bad but not the end. I grabbed my stethoscope and went to listen to the heart as his parents and grandmother entered the room. 

Nothing.

For the first time in my life I went to listen to a heart beat and heard nothing. I've experienced death in the professional setting many times before but never had I have to place my stethoscope to a chest only to hear silence. I stood up and just looked at the child. 

No chest rise.

I grabbed his tiny hand.

Ice cold.

I listened for a heart beat and felt for a pulse three more times until I said to Jafundo that this child is dead. His scrotum (often a marker of pediatric hydration) was as flat and dry as the skin around it. 

After I relayed this to Jafundo, I felt an overwhelming sense of anger. Instantly, I demanded to know the story of this child. He was seen yesterday at Ndirande and prescribed Amoxicillin for a fever. The parents didn't have his health passport so I wasn't able to see any history for myself. In my mind, I was about to demand to know which clinician saw this patient. I was hell bent on having my wrath felt by the unfortunate soul who "obviously" missed some warning signs yesterday.

I caught myself.

This child is dead. Who the hell cares at this exact moment why? I never asked the question and I stepped back and sat on the edge of the desk. I gave the parents a look that I hoped would convey my sentiments without the need for interpretation. 

After further discussion, Jafundo then began to prepare the body. I watched it from beginning to end. This was an unsettling event as Jafundo was incredibly proficient at this entire process. This wasn't his first rodeo. Everyone stepped outside of the room but the mother. She never said a single word but sat there staring at the ground. I wanted to put my arm around her to try and comfort her but who was I kidding? Her four year old son just died. 

I packed up my belongings into the bag and we eventually all left the room to await the arrival of whatever services they contacted to take the child.

As I stepped past the double doors to the peds department, I found the same scene I see every morning. Mothers and their children lined up along the pathway waiting for the doctor to arrive. The only difference today is that it was dead silent.

Everyone knew. Everyone looked at me. I had no answers.

I slowly made my way down to the front of Ndirande. Right before I made it to the front, Jafundo told me that he hopes we're on call together again some day in future. I never asked him why but I assume it was because we just saw the worst Ndirande had to offer. 

07:00-07:30: I sit on the curb once again at the Health Center. This time I'm waiting for Bill to arrive to pick me up. As I'm sitting there, the labor nurse walks by me on her way home for the morning. She says that the newborn baby is doing very well and thanks me. Only a very few have ever seen tears run down my face but at that moment many Malawians were added to that very few. 

-Ben Davis, SFH R3