Treating Severe Malaria in Mweso

In the thick of our malaria epidemic, we saw up to 25 patients a day with severe malaria at the hospital. Most of those patients required blood transfusions as they had developed anemia related to the severe form of malaria. Most patients were also in a coma. For a period, we were doing up to 10 blood transfusions a day! On our worst day, we had 25 patients in 11 beds in the Intensive Care unit. All of this was in addition to the 800-1200 cases a week of “simple” malaria that we were seeing at the health centres that MSF supports.

Everyone worked hard to set up extra beds, increase blood donations, and treat malaria cases as early as possible. This included setting up specific mobile malaria clinics that ran 5 days a week in the areas with the highest concentration of cases. We also successfully lobbied the local Ministry of Health leaders to change treatment policy in the area to more effective therapies. This meant the difference between one quick injection a day versus several hours-long infusions a day for severe malaria. We were able to make this treatment available in our supported health care centres, thereby decreasing time to treatment. Despite the heavy caseload and severity of cases, this treatment change helped us to keep mortality very low throughout the epidemic.

Each year, around eight million simple malaria cases progress to severe malaria, where patients show clinical signs of organ damage, which may involve the brain, lungs, kidneys, or blood vessels. It is therefore critical for people to be able to access health care more easily. Severe malaria cases often stay in the hospital for over a week. This can be much longer, especially in children with malnutrition who are prone to other infections. If caught early, however, simple malaria can be treated with a 3-day course of pills.

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A big “Thank You”!

I used to be able to read the clouds. I could look up and tell you their names and what they foretold. I learned that at summer camp, years ago. Looking up at the sky today in Mweso, I realized I have forgotten most of it. I long for the simplicity of those days; the wind in my hair, looking up at the clouds.

But what I am living right now is not so different. I live in close quarters with many people in a wooden building, sleep in a small bed under a mosquito net, and the mosquitoes and bed bugs are just as nasty! But this is the strangest summer camp I’ve ever been to!

I am in the 8th month of my mission. Apparently month 8 can be the hardest in a mission. I am tired. The kind of tired that doesn’t go away with sleep. Emotionally tired. Months of malaria, cholera, and 120% capacity at the hospital take its toll. But this is why I want to say thank you.

Thank you to everyone who reads my blog, and a special thank you to all those who comment on it. Some of you I know, some of you I don’t, but all of you have brightened my day in some way. Sometimes I feel so tired in the morning, I think I just can’t go into the hospital. But then I read your words of encouragement and it gives be strength.

Many of you have asked me questions over the past months. I’m sorry that I can’t respond individually. But I’m hoping you will accept some general answers from me.

Some of you have asked about the patients I write about. All of them are still alive, unless I wrote otherwise. I hold on to these successes when things get tough.

You have also asked how you can help. The first way is you can donate to MSF. All MSF funds come from people like you. Without you, we couldn’t continue the work we do in so many countries. Another way to help is to share the stories you read with friends and family. You can also work for MSF. You’d be surprised by the variety of backgrounds and experiences of those I work with. Contact your local MSF office and see what you can do to help.

A special note to all those doctors and nurses, in training or long in the field, who want to work for MSF. Please do! We need so many people to run all the projects. MSF holds regular information sessions, so call your local office and attend!

And most of all, I would be honoured if you kept reading my blog. And can’t express how much it means to me.

Jen Turnbull, MD, Mweso, DRC

Posted in Democratic Republic of Congo, Doctor, Paediatrics | Tagged , , , | 23 Comments

Up in the hills

All around me there is mist settling between the mountains that seem to go on for miles. Behind me, the sky has become dark and the quiet chatter of the villagers is punctuated by sudden bursts of thunder. Directly in front of me is a terrified 5 year old boy sitting on his father’s lap with a 2cm gash in his cheek. I am back in the village of Ihula with our Mobile Clinic.

I am kneeling in the dirt, preparing everything to stitch the boys face. As I approach the father and son with a syringe of lidocaine (freezing), I explain in my best (read: terrible!) swahili that I am sorry, this will hurt and he has to hold his son VERY tight. As I inject, the boy manages to get a leg free and makes contact with my shoulder and then my shin. “Nice try kid” I think to myself, “I already got you. In a minute you’ll feel nothing and you’ll thank me”. An elderly local woman pitches in her 2 hands to hold the boy’s legs. Kneeling again, I get to work. Only 3 stitches in the end. He’ll come back next week to get them out.

I move back to check on the 19 month old boy with severe burns. He had been scalded with hot water 4 days before. His right side, about 15% of his body, had been burned. As I have sometimes seen in Canada, his mother had applied toothpaste to his burns. They had become infected and he now had fever and pneumonia. We set up IV fluids and gave him antibiotics and painkillers. I then spent the next half hour sitting on a dirt floor, slowly cleaning and removing the thick layer of tootpaste. He lay there listlessly, a combination of the painkiller and his serious infection. We will have to bring this patient and his mother to the hospital.

Other than the mobile clinic once a week, the closest health care to Ihula is a minimum 4-5 hour walk away. This is why Médecins Sans Frontières is building a health post here, so that this population can have permanent access to free health care 24/7.

We walked through the village to visit the health post that is almost completed. On the way there, one of our Congolese staff nurses explained that Ihula had once been a very large village. Conflict had driven much of the population further into the hills. As we stood looking at the large wooden structure that would soon see women delivering babies, children treated for malnutrition and people treated for various ailments, our nurse explained that we were looking at history. Health care had never been this accessible in this region.

I will be back in Ihula in a few weeks. The child with the burn is doing well in our hospital, and I will very likely bring him back home to Ihula on my next visit. We may even see our first few patients in the health post by then.

Posted in Democratic Republic of Congo, Doctor, Healthcare Provision | Tagged , , , | 11 Comments

Hitting the ground running

I recently came back from holiday. It was great coming “home” to Mweso. Work started immediately. On my ride from Goma to Mweso, I met up with Raghu (our other expat doc) heading to Goma for his break. On a high mountain pass, in the rain, we hovered over the handover document he had prepared. This patient had gone home, this patient had passed away, please check these emails, this staff got accepted for a training course and needs a Visa asap. Lots happens in 2 weeks!

I headed to the hospital on Saturday morning for “difficult case rounds”. Then came an urgent call from our midwife Natalie. A pregnant woman had been found collapsed on the ground outside the pediatric building. No one knew who she was or if she was a patient or a visitor. I ran over, calling the hospital guards to bring the stretcher. She was lying there unconscious. Airway: check, Breathing: check, Circulation: check.

We rushed her to ICU where she started to wake up and where people recognized her as the epileptic woman from the Maternity ward. Fetal heart beat: check. She woke up, I increased her medications. All was good.

Then back to the office for administrative work. Running a 160-bed hospital that runs at 110% capacity, plus 2 health centres and a mobile clinic/health post, is difficult! A huge part of what MSF does here is logistical. Our logistics teams work tirelessly, often 12-14 hours a day to ensure that the project runs smoothly. We place orders only 3 times a year, massive international orders where we have to predict what the hospital and project will need over the coming months. This is very difficult to do, and the unexpected often happens. This can lead to increased or decreased use of medications for example. This can, of course, cause items to run out (‘rupture’) or expire.

So the rest of that first weekend back was spent in front of the computer with Ria, our expat hospital nurse supervisor, going item by item through our entire stock. What had run out? What was going to run out before our next supply delivery? What was going to expire and how do we use it/donate it? My head is spinning with excel spreadsheets!

Things have continued along the same lines since then. Emergency here, spreadsheet there. 10-12 hour days, working Sundays.

Now I’m off to organize a mass vaccination campaign. More on that later…

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Hakuna Matata

Saturday morning was difficult. We lost another child from the malnutrition ward. She took a turn for the worse on Wednesday and was sent to Intensive Care, but seemed to be doing better over the next few days. I checked on her late Friday evening, she didn’t look well at all but she was on maximal treatment. I told her to hold on, and she did, but unfortunately only until the morning.

I had to fight the heavy feeling in my heart and put on a smile for the Newborn Resuscitation training I was giving that morning for the Midwives. We actually had a great session and we shared lots of laughs as I pretended to be a woman giving birth.

Then I moved on to join our Saturday morning “difficult cases” doctor rounds. By the time I joined the group they were circled around another one of my patients from Malnutrition. This is the 4th time I have admitted her to the hospital, each time for heart failure. The last admission, the nurses and I had a very honest conversation with her family about her prognosis and what the limitations of our treatment were. Unfortunately, the family understood all too well and promptly abandoned the child after discharge. While a kind stranger had ‘adopted’ her, the sadness on her face was clear. She knew too much at 5 years old; about death, desertion, suffering. Despite medication, her breathing was too laboured to eat more than the therapeutic milk we gave her. I felt completely helpless.

Thank goodness for Raghu, the other expat doctor here in Mweso. He immediately made a positive suggestion, one that would help not only the kids, but also us. He proposed we have a movie night in the Children’s / Malnutrition ward.

He quickly got to work organizing it along with our Logistican Michi, and by 6:30PM we were ready to watch The Lion King. All the children, mothers and even nurses crowded around the beds to watch. I sat laughing with the mothers as they told me things in Swahili that I only half understood.

Just as the song “Hakuna Matata” came on, one of the nurses from Intensive Care rushed in. A child had arrived in a coma with a very low blood sugar and they couldn’t find a vein to insert an IV line. Could we help them? he asked. ‘Hakuna matata’, I thought, no problem.

I arrived to an inspiring site, at least 5 determined nurses working quickly to find a line. These guys can draw blood from stone, there was no way I would be able to find an IV. The only option was an intraosseus line, a large needle pushed through the bone of the lower leg. I sweat as I struggled to push it in. I was painfully aware of her shallow breathing, her weak pulses, her cold legs. She didn’t flinch as I pushed. Finally, “POP”, I was in. We pushed glucose and antibiotics and got a perfusion running…for about 1 minute. It stopped running; back to the drawing board. Next option: an IV in the large vein of the groin. This one is by feel, by palpating the pulse of the large femoral artery, but her pulses were weak. On the third try, in was in. “Hakuna matata”…ya right!!! I was covered in sweat despite the cold night!

She is doing only a little better today. But I refuse to lose hope. I propose another movie night when she wakes up… Little Mermaid anyone?

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Back to Mweso

I’ve been home from my first vacation for just under a week now. Already it feels like I never left Mweso.

Work continues to heat up as we are in the 4th month where the hospital is over 100% capacity. Add to this an increase in cholera and malaria and you get one busy team!

The administrative side of things is also heating up, with our medical and logistical orders and internal reporting. It is also time to complete the monthly medical report with all the project statistics. This is where I get to see the numbers that prove the high quality of work the entire team is doing. While things are busy and people are tired, our mortality rate has continued to drop. It’s amazing what a dedicated team can do in this context! And when I say team, I am referring to the national staff who are the backbone of this project, including those who work for the Ministry of Health (our partner). They work tirelessly, often separated from their families, and without them we would be a small group of expats trying to reinvent the wheel.

While I was on vacation I had a chance to reflect on what Médecins Sans Frontières is doing in North Kivu, and to share my thoughts with people I met. The theme I found myself repeating was the frustration I feel when the area is referred to as “post-conflict”. This label suggests improved security and that people are re-engaging in productive livelihoods. It also changes the type of aid offered. Population stability would mean, for example, people can afford health care. This assumption has lead to a dramatic decrease in the number of free aid programs in the area. Just a quick glance at the monthly medical report will show you that increasing malnutrition and disease disproves this assumption.

There have been massive population movements north of us due to fighting, people don’t want to use mosquito nets because they think they will be trapped if someone comes to attack in the night, and people sleep in the swamps or fields to prevent such night time surprises. This doesn’t strike me as POST-conflict.

But this is why I work for Médecins Sans Frontières. They recognize that, although chronic, this continues to be an emergency setting.

Thank you MSF for getting it!

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Mobile clinic to Ihula

I’ve been lucky recently to go out on a few outreach activities. Our project currently supports 2 health centres in the region, at the villages of Kashuga and Kalembe. This Friday, I set out again, this time for the small village of Ihula where MSF runs a mobile clinic once a week. It was a beautiful day and the road wound higher and higher into the steep hills. In the back of my truck were a mother and baby we had brought back from Kalembe about 2 weeks before. The newborn had had meningitis and hadn’t been feeding for several days. It was amazing closure to see the mother smiling with her healthy baby just 2 weeks later. As we dropped her off and I watched her slip behind the mud and thatch buildings, I thought about their future. I thought how strange it was that we had entered each other’s lives for such a short period, and that we would likely never see each other again. I suppose it is the same for many of the patients I see in the ER back home, but here the future seems so much more uncertain.

When we arrived in Ihula, the team started to unpack and set-up the clinic. Waiting patients were filed into a registration room in a dark wood building. I heard the grunting and laboured breathing before I could locate its source. It was coming from a small child, several months old. We hurried the mother and her child to another room where I took a quick history and did a physical exam. It was brochiolitis, an asthma-like illness caused by a virus that is very common in infants. Unfortunately, large studies have shown that the usual treatments for asthma, salbutamol puffers and steroids, don’t work for bronchiolitis. The only useful supportive treatment, that the child desperately needed, was oxygen but that was a 2.5 hour drive away. But the thing about evidence-based medicine is that it doesn’t seem to apply when you are in the middle of nowhere in a resource poor context. So we dug through our emergency medical box and found IV fluids, antibiotics and salbutamol.

It was amazing to watch the national MSF nurses work on the side of the dirt road, searching for an IV. They gave the antibiotics and started IV fluids (the child was very dehydrated, in addition to gasping for air). While they searched, I tried to figure out how to give the salbutamol. Usually it is given via mask and aerochamber but we didn’t have those. I spotted an old aluminium fetoscope, a cone-shaped instrument that you hold to your ear and press to a pregnant mothers belly to listen to the fetal heart beat. I grabbed it and cut up a latex glove and fashioned what was actually a very effective system (thank you to all those years of watching MacGiver!).

I gave the child several puffs every 15-30 minutes and reassessed his breathing. Meanwhile, the mobile clinic team was seeing about 100 patients. There was a difficult decision to be made; do we shut down early and head back to the hospital? What if there was another patient waiting who was desperately ill and we left them behind in our haste. The life of one or the life of many?

I decided to hurry things along and try to leave early. The team still managed to see all the patients who had arrived that day! Amazing!!!

We loaded up and hit the road. Our national mobile clinic nurse supervisor sat in the back with the child listening to his breathing. He told our driver, just how critical the case was, and we were off. What was a 2.5 hour drive up, became a 1 hour drive back! We flew down the pot-holed dirt roads towards Mweso. Our driver was not only fast, but surprisingly careful (mind you, fast is only 40 km/h). I felt completely safe in his hands.

The sound of the child’s grunting became reassuring in a way. As long as I could hear it, he was still breathing. A million thoughts rushed through my head. Did I leave it too late? What if the child died in the car? Should I have cancelled the clinic first thing and headed back to Mweso? The weight of those thought pressed into my shoulders and my clenched jaw.

I had radioed ahead to Intensive Care, so when we entered the hospital, the supervisor of the ICU was waiting to take the child into his arms. We put him on oxygen and continued the treatments.

The last 2 days have been rocky for this child. I still don’t know if he’ll make it. What he really needs is a ventilator, but all we can offer is the incredible care and attention given by our national staff. They are my heroes.

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Two drops of blood

Today I want to tell you a happy story. It is about a small malnourished boy, 18 months old and only 6 kg. I met him about 2 weeks ago, on my usual morning rounds. His mother had come in during the night because he was breathing fast. When I assessed him, he was working hard to breath but still let me know who was boss by firmly shoving me and my stethoscope away! Reassuring, I thought. I checked his oxygen level, started treatment and continued with my rounds.

Not more than 30 minutes later, I was called back urgently to see the child. He was barely conscious and his breathing was MUCH worse. I grabbed him in my arms and started to rush toward Intensive Care. I called out “Mama, Kariboo” which was the only thing close enough in Swahili I knew to indicate that she should follow me (it means: Welcome). I was sure he would stop breathing in my arms.

A million thoughts passed through my head. How would I feel if the child died in my arms, what would the mother think about the crazy Muzunga grabbing her child away from her and speaking in broken Swahili!

We made it to Intensive Care, but he was comatose and without a pulse in his wrists (a sign of severe shock). Here came the difficult decision: malnourished children are at high risk for fluid overload, if I aggressively gave him fluids and he wasn’t actually dehydrated, the fluid could go into his lungs and kill him. I started the fluid and called Raghu, the other doctor. I asked him to bring his bed-side ultrasound machine with him. We used it to look at the child’s IVC (the large vein that brings all blood back to the heart). If the vein was compressible, it meant to child needed fluid and we could potentially safely give him a bolus. It was compressible and we proceeded to give him repeated boluses of fluid, each time checking with the ultrasound. His pulses came back, but he was still on oxygen and in a coma.

When I looked down at my MSF T-shirt at the end of the day, I noticed 2 drops of blood that had come from the child’s IV site. I took it off, folded it and gently placed it on my shelf with a sense of superstition.

The next morning on rounds, I was told he had had a seizure. I tried to look into my crystal ball of medicine. Was it low sugar, low sodium levels? I felt blind so I treated both. Over the course of the day he started to move. Then he started to open his eyes!

I checked on him several times a day and slowly he recovered and was well enough to go back to the ward. He rapidly progressed, gained weight and 10 days after his dramatic collapse, was ready to go home!

I only now have washed that shirt…

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LOTS of work…

Well, it seems the rainy season is over as quickly as it started, leaving behind only a few threatening rolls of thunder in the distance. But that doesn’t mean cholera is over. Or the work.

The hospital has been at 120% capacity (just over 200 patients) plus the Cholera Treatment Centre (CTC) and we are feeling the crunch. There are often 2 children per bed, even in the Intensive Care Unit. Wednesday, there was myself and a national doctor to round on all these patients! Needless to say, I’m tired and Sunday couldn’t come soon enough! Another present arrived this week. A new expat doctor to replace the one that left a week before. Raghu happens to be a friend of mine, and did his ER training in Montreal. In fact, he is the one who mentored me through my MSF application process. Small world!

It was a good thing he arrived when he did because Friday hit with a vengeance! It started with an urgent call from the CTC to help put in an IV or an Intraosseus (IO, needle placed into the leg bone of a comatose patient) into a dehydrated child. Then I sat down for morning report for all of 5 minutes before being called to resuscitate an infant. Between Raghu and I, we rounded on about 100 patients, each put in an IO, both did lumbar punctures and admitted and discharged countless other patients. That was before 2PM.

Today was thankfully very peaceful, but the knowledge that cholera is traveling up the river is looming over us. We will see what this week brings us!

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Cholera?

I was going to write today about all the success stories in our inpatient nutrition centre. Everyday, I discharge healthy, plump(er) children from the ward. It’s very satisfying to see these children go from severe malnutrition complicated by pneumonia, struggling for air on an oxygen machine, to happily eating on their mother’s lap.

But plans changed last Sunday, as all things do very quickly in Congo (DRC).

The noisy clanging of one church’s “bell” woke me at 5AM (I am convinced it is actually a mother teaching her teenage son a lesson by clanging a pot for 10 minutes over his head). Usually this signals that I have 1 hour left of sleep before the church across the street gives their bell a go. Thankfully on Sundays I can sleep in! So at the oh-so-late hour of 7:30, I was up greeting the beautiful sun. It was a particularly wonderful sight because we have entered the rainy season! I lazed around for the morning and then went for a walk through town and to the Mweso river.

On returning from my walk, I was welcomed home by the news that there were 3 potential cholera cases in the hospital. MSF has not seen cholera since February, and even then it was only 2 cases the whole month. So off I went with Hosanna, our Supply Logistician, to check out the situation. By this time there were 4 patients in our CTC (Cholera Treatment Centre), 2 of them a father and child. On entering the CTC, deafening thunder started to sound. The weather is always so prophetic here! We quickly checked out the disinfection stations, then mobilized 48 litres of IV fluids from our stock warehouse, just as the sky opened up and it started to pour. Then we were off to find the on-call lab tech to perform the confirmatory testing. Within 3 hours of hearing the news we had confirmation, 3 of the 4 patients were positive for cholera.

Thankfully all of the patients are stable on IV fluids. Tomorrow will bring full scale planning to ensure protocols are followed and cases can be traced. We will send people to the affected communities to look for other cases and possible sources of spread.

Here we go! Wish us luck!

Posted in Cholera, Democratic Republic of Congo, Doctor, Paediatrics | Tagged , | 1 Comment