Wednesday, December 21, 2011

"I think he is just tired"

You can read studies, statistics, scholarly reviews, and opinion pieces on malaria problems endemic to parts of Africa.  You can read in the new york times about the possibility of a vaccine in the next like 7 years but is being debated because of "only" of 50% success rate in clinical studies.  You can know that statistically most of the deaths from malaria world-wide are children under the age of 5 living in Sub-Saharan Africa.  You can study economics and read about solutions to poverty and join the debate about the efficacy of indoor spraying of DDT........

but nothing can prepare you for the senselessness of it all.  Nothing can prepare you for the transition from data in a chart and theories on a page to a pediatric ward overflowing children, lines of mosquito-net covered beds, and quinine perfusions dripping into hands, feet, skulls. 

or when they come in too late...

...because they know they can't pay 

...because they don't want to pay

...because they live too far away

...because they went to the traditional healer first

...because they were hoping it would just get better

Poverty, lack of education, governmental corruption, poor public transportation, lack of roads, lack of clean water, malnutrition, traditional beliefs and cultural misconceptions, inequality, poor distribution of resources, poverty... a vicious cycle, although not necessarily in that order.   

Some people think they have the answer.

Some people, like Dr. Appel, want to eradicate malaria in Tchad.

Some people, like the rebels in the north of Tchad, want to eradicate president Deby.

Some people, like the nurses here, gather in small groups and talk about how they are going to find rice, about how the rains were short this year, came late, left early.

Some people, like my family, don't put the children in bug nets at dusk because everyone works far into the evening. 

Some people, like my patients, came to the hospital only as a last resort

or like today, came 20 minutes too late.

4 years old.

10 kg.

104 F temp, hot, dry

Resp - 60 bpm, rapid, shallow, hoarse, sever pulmonary edema

HR - 180

conjunctiva - pale - anemic

eyes rolled back, sunken

convulsions.  have you ever seen a child having convulsions from cerebral malaria?  how about 10?


"how long has he been unconcious?"

3 days. 

"how long has it been since he has drank anything?"

3 days.

"how long has he been having convulsions?"

2 days. 


where is the tylenol?  the receipt says you bought it?  didn't the pharmacist give it to you?  the father...running to the pharmacy....running back.....with tylenol

tylenol won't reverse anything....but we want to try everything.

Diazepam - who mixed it?  unlabeled? we will guess. 

running to get dextrose....maybe if we correct possible hypoglycemia......

letting the quinine run in just a few drops faster.....won't reverse anything....but we want to try everything. 

the mother is already hiding her face

people don't really cry here.

the father, is holding his hand over his son's heart.

feeling it beating

feeling it slowing

is it still a statistic for you?  probably.

but how about when he asks, over and over

"he is just tired isn't he?  he is just tired."

he is just tired.

I'm pushing dextrose as fast as I can

and then he begins breathing slower



and his father can't feel the heart anymore

and i can't auscultate the heart anymore

or palpate a pulse

you can see the whites of his eyes rolled back

his mother closes them with her hand 

and still she says

"he is just tired." 

and I am tired too.

I am tired of seeing this every day.  I am tired of the fact that we don't have any oxygen.  I am tired of the fact that there is no crash cart, that even if we called a code and anyone even responded, we couldn't maintain life. 

I am tired of a president that lives in luxury in the capitol, sitting on massive oil revenues, churning out misspelled public health propaganda that his population can't actually read.

I am tired of children dying because a mosquito bit them

I am tired of the kind of poverty that dissuades people from coming even to our seemingly dirt cheep hospital

I am tired of not being able to prescribe fluids because they cost 2 days salary, of deciding which of the three necessary medications is most important.

 I am tired of leaving the same dressing on a burned baby's arm for 3 days in a row because the mother can't pay the 25 cents necessary to change it.  of the fact that the OR is refusing to do the surgery to amputate said arm because the mother can't pay.  Of the attitude that an amputation is not "urgent" so we can't fill out a "fiche de urgence"  I am tired of the reality that here, i must pick my battles, and that i must save an argument about this for something more important.  something more important than a child that has a rotting and infected with only 2 fingers left and a mother with a bad attitude its impossible to call social services on.

I am tired of saying goodbye to a 7 year old with Burkit's lymphoma swelling the side of his face because 2 cycles of treatment later, his body having rejected the cyclophasamide and dexamathasone, covered with tunnelling, pus-filled absesses we finally have thrown every medication at our disposal at him and he is sicker than when we came

i am tired of non comprehension when i insist that a kid with meningitis should not necessarily sleep next to the kid 2 weeks out from chemotherapy. 

I am tired of a country in which parents genuinely don't know that children need water.  or vegetables.  or fruit.  of a country in which malnutrition is commonplace and famine is imminent. 

I am tired of working with nurses that don't give medications or take vital signs. 

And I am tired of death.

I am tired of 4 year olds dying with their father's hand on their heart.  4 year olds that were laughing and playing 4 days earlier. 

I am tired of watching tears stream down his face as he drapes a cloth over the child, lays him across the shoulder, and walks out to face a funeral far more expensive than the hospital would have been.

"I think he is just tired"

are you?


1 million people die each year of Malaria most of them African children. - Washington Post

300 million children contract malaria each year. - WHO

 Globally an estimated 3,000 children and infants die from malaria every day and 10,000 pregnant women die from malaria every year, 86% of these deaths are in Sub Saharan Africa. - WHO

 Malaria disproportionately affects poor people with almost 60 percent of malaria cases occurring among the poorest 20 percent of the world's population. - WHO

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