What will day 58 bring?

13 May 2013 Comments

I only have four weeks left in Chad on this mission. The days have been long. I am exhausted. I skipped my last chance at a break to not miss one of the most critical MSF planning exercises of the year. I miss my fiancé Maeve very much. I think I have grown somewhat used to the heat, but it is still the hardest part of being here on mission. Last night it was hot and humid. I took a warm shower and collapsed in my bed. The shower is my favorite time of day – when my whole body is cool – just for a few minutes.

Today, Sunday, I tried to sleep in. It’s no use. My internal time clock is now wired to 06:30am. I don’t need an alarm clock anymore. I used the time today to sit on the floor alone in the cool pharmacy storeroom to work on Amtiman’s “4M” plan. The 4M is the time when, with four month’s worth of data, we adjust and change our annual planning. I needed to be alone to think and type on my computer to do this work. By the time the rest of the team had come back from an “explo” or exploratory-trip to a distant health center, I had re-drafted our 4M plans and was working on regular MSF matters by email. Sunday should be a time to rest, but it’s also really the only day of the week when it is calm enough to think, blog, and deal with email. It is a staple workday.

Things like planning for the 4M and email is thankfully interrupted by what I know best: hospital rounds. Let me take you on a walk on our rounds. We’ll see a few patients including David who has had 57 days of fever.

These days I am covering for Dr Guy in the hospital; we deployed him to Tissi to respond to the refugee emergency at the border of Sudan, Chad and the Central African Republic. Dr Guy is now on a well-deserved vacation and our Dr Johanna has replaced Dr Guy in Tissi. As medical team leader, I fill in the holes in the project that need to be filled – like when team members go on a needed vacation, are sick or are loaned to other sites. Positions I have covered lately include our lab supervisor, hospital nursing supervisor, midwife, project coordinator and outreach supervisor. But my favorite position is just medical doctor.

Let’s take a walk in the hospital together. We can go to the HIV-tuberculosis (TB) wards where Dr Guy usually works, but where I am covering now. It is quiet, and dust and flies are everywhere.

Mariam is 40 years old and came to hospital on April 29th. She had massive swellings on the right side of her neck. Suspecting she has TB of the lymph nodes, we are treating her with four TB antibiotics and are planning to test her for HIV. By examining Mariam and doing some basic blood tests, I do not think she has an alternative diagnosis like cancer, but it is hard to be totally sure. We’ll have to confirm Mariam’s diagnosis based on how she does day to day.

Saad is a 13-year-old boy who lives in a village far away. He was started on TB medications in December 2012 for extrapulmonary TB. Since he lives so far away, he takes MSF’s mobile clinic Land Cruiser to come to the hospital to receive his medications each month. Saad is a friendly young man. He grins ear to ear when I greet him. The nurses tell me he takes his medications perfectly.

Hasan is 38 years old and has active pulmonary tuberculosis. I always where a mask when I examine him, or any other patient possibly with active pulmonary tuberculosis. I have already contracted TB once during my first mission in Burundi with MSF, and had to take nine months of medication myself. I don’t want to be exposed to it again. Hasan is coughing a lot and when I listen to his lungs it sounds like rubbing your own hair between your fingers close to your ear. It crackles. I breathe lightly through my mask when I examine Hasan. I don’t want to get TB.

Abakar is very sick. He is critically ill with HIV and has a CD4 count of only 26. When we first met, I found him with a severe systemic infection, severe anemia and in distress. He had a strong cough, and I presumed his lungs were infected with TB. His left arm was very swollen and tender. Flies were everywhere when I examined him, on Abakar and on me. I gently moved his elbow and it cause him much pain. The bones cracked as I moved his elbow as slowly as possible. I asked twice if he had fallen. His family kept saying no, and I believed them. I pulled out my ultrasound and moved it slowly over the swollen areas – they were fluid filled and infected. I had our surgeon drain the infected fluid from the elbow area – it was serious the surgeon said. Sitting on the edge of Abakar’s bed I realized that not only did Abakar likely have TB of his lungs, but TB of his left elbow as well. The TB had infected the joint and bones, and that explained what I was seeing. We will stabilize Abakar on antibiotics, intravenous fluid, blood transfusions and TB treatment, and then start him on antiretroviral drugs for HIV. I am really worried about Abakar that he could die. We’ll do our best to cure him.

David has had fever for 57 days. His cough is strong and his lungs sound horrible when I listen to them. He is very thin and he has active pulmonary tuberculosis. Despite being on TB medications, and other antibiotics I have added to treat him for other infections, he won’t stop having fever. Dr Guy, and now me, have considered and tested him for many different pathologies – including HIV and malaria – but we can’t get his fever down. We used paracetamol (Tylenol) and ibuprofen to make him feel better, but the fever always returns. I suspect David has multidrug-resistant TB. In three days we’ll test his lung sputum again and I suspect it will still show he has active tuberculosis. Everyday when I examine David his mother is on the floor sitting next to him. We all shake hands.  David makes a soft smile each time.

Issa is our last patient for the moment. He is 25 years old and has been hospitalized for 23 days. When he arrived, we diagnosed him with a serious infection around his right lung. The right lung was floating in infected fluid. My portable ultrasound confirmed it was fluid around his lung before we inserted a needle and then tube in the space outside of his lung to drain the fluid. Despite the chest tube, I examined him a second time by ultrasound and realized the first chest tube had not drained the fluid entirely. I sent Issa back to the surgical theatre and they removed 350 milliliters more of infected fluid. Issa has had a lot of pain lately with all the drainings. I found the keys for our special locked box where we keep narcotic pain medications and filled out the forms needed to remove a small quantity for our nurses to give Issa. Issa later said the medications helped a lot with his pain and he looked more comfortable.

Thanks for taking a walk with me today on a short round of the HIV-TB ward. I wish David’s fever would not last 58 days, but I fear it will. It must be hard for him to have fever so long, especially with this heat. Even the local Chadian people find it hot. But we’re trying our best to help David. I hope day 58 tomorrow will be a better day for David.

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

Raghu

Note: all patient names are changed to protect confidentiality.