Hissen, a brave boy

09 April 2013 Comments

Greetings to all the readers who take an interest in the population we serve in Chad. Your comments online are so supportive. Thank you. As usual, all patient names are changed to protect their identity.

In medicine, we are taught to examine a patient by first looking and then palpating (or touching). Next, we percuss (a gentle knocking on the patient which often is not needed) and then we auscultate (or listen with our stethoscope). The routine is unconscious after doing it enough.

Hissen, a brave boy, needed more than the routine.

Hissen is a five-year-old boy well known for sickle cell anemia. This genetic problem with his red blood cells causes them to deform. This problem not only results in low red blood cell counts (anemia) but also reduces the function of the immune system. This latter problem leaves Hissen prone to infections.

Dr Johanna from Sweden asked me to see Hissen. His left arm was swollen and painful. Was it a collection of fluid because of an infection, a fracture or a hematoma composed of blood? Infection was possible, but we had already treated him with antibiotics for a long number of days. But at the same time, we knew that no amount of antibiotics could cure a pocket of infected fluid that had to be drained surgically. As for trauma or a hematoma – they did not fit with the clinical history.

When I first met Hissen, he was very scared in comparison to the many children in our wards. Initially, he cried just because I looked at him from the other side of the room. So many nurses and doctors must have examined him in his numerous admissions to our hospital. Likely, some of those evaluations had left him aware that healthcare professionals sometimes do things to him he does not like, and cause him pain – in the hope of curing him.

When I sat on the bed across from Hissen, I just looked at him. His serious little face was angry. I fished out my mobile phone and offered it him. He took it carefully with his right hand and held onto it. I kept on giving him more things out of my pockets and he kept taking them only with his right hand. He would not use his left arm at all. After enough temporary gifts, Hissen agreed to shake my hand. Every move I made, he studied me as carefully as I was studying him.

Inspecting his left arm, we could see there was a swelling above his elbow. As gently as I could, I ran my fingers over it. Hissen did not like that. He immediately cried and I had to stop. Something was wrong.

I took out my portable ultrasound and did the usual routine I do, of trying to convince Hissen that it would not hurt him. I touched the probe to me, to his mother, to the Chadian nurse with us, and finally onto Hissen. His serious look continued.

For Hissen, it was not enough to look, to listen and to feel. We needed to look inside his arm to see what was going on. We could have done it surgically, but why put this scared child through a surgical procedure he did not necessarily need? There fits the role of portable ultrasound. This machine allows us to look inside the body without cutting the skin or causing any pain.

I gently ran the ultrasound probe over his arm. Hissen did not like it, but he did not cry. He was being brave. I recorded images and found a large pocket of fluid. It was likely a pocket of infection. Now we knew it had to be drained.

With Hissen’s mother’s permission we took him to the intensive care unit. Hasan, our pediatrics nurse supervisor, gave him a dose of ketamine, an anesthetic drug. Soon, Hissen was asleep in his mother’s arms. We then cleaned Hissen’s left arm with iodine several times, and drained infected fluid from his arm. We knew exactly where to do the procedure. Hissen felt no pain and, when he woke up, he had a dressing on his arm and his mother by his side.

After several more days in hospital, Hissen’s arm improved and his dressings were clean and dry. We discharged him home with follow-up at the hospital. I was a bit disappointed that Hissen still refused to take things from me with his left arm. But he did smile at me and he did put his little right hand in mine. Hissen was once scared of me. But as a brave little boy he overcame that fear.

Farewell for now from the house-call… to Chad.

Raghu