Aimee’s pain was definitely real

Posted on May 16, 2013 by

Please note: all patient names are changed to protect confidentiality.

At 2pm on May 7th, Aimee, age 25 years, arrived at a primary care medical facility here in eastern Chad. She had abdominal pain radiating to her back and she had not had her menstrual cycle since April 18th. The treating medical staff did a basic exam and ordered some lab investigations. The clinical notes for her case are contained in a small notebook cut in half. Half a football player’s face is on the front. This is Aimee’s patient health record.  Most of the writing inside is practically illegible and incomplete. As is the case for most Chadians who seek health care in a cost-recovery setting, she was charged 4000 Chadian francs for what can best be considered an inadequate medical assessment.

A later documented medical note revealed Aimee continued with abdominal pain and was very agitated. For reasons that are unclear, she was given a perfusion of intravenous normal saline. Apparently, it was learned later that Aimee’s husband told the treating medical staff that his wife is often anxious around the time of her menstrual cycle. It was later learned that the treating medical staff felt that Aimee was indeed just anxious related to her menstrual cycle. Aimee was given a medication to relax her intestines as well as intravenous diazepam, a benzodiazepine medication used for limiting anxiety and causing sedation.

One of the most critical concepts for me as an emergency physician is “trust no one and believe nothing”. This even applies to information given to me by a well intentioned family members or fellow medical staff. These caregivers and caring people can give you misleading information, clouding your objective medical assessment. “Trust no one and believe nothing” does not mean to not listen to people. It is just a warning to keep an open mind to all possibilities and not fall victim to what we call “premature diagnostic closure”. A critical error by the medical staff that first attended to Aimee was accepting the easiest diagnosis possible and not considering first the most serious or life-threatening diagnosis for abdominal pain in a young woman who was likely pregnant.

Aimee later had a gynecological examination and she was found to have pelvic bleeding. She was still in a lot of pain as well, as the clinical notes revealed. For this reason, the primary care facility referred her to the Amtiman Hospital maternity service – nine hours after her first presentation with severe abdominal pain.

In the Amtiman maternity supported by MSF, the nurses and midwives on duty made a complete medical assessment. A legible, full medical note is written into Aimee’s health notebook. It turned out that this was Aimee’s second pregnancy and her main problem was intense abdominal pain. Vitals signs were completely taken and they indicated Aimee had a fever and was breathing abnormally fast. In my experience, the most neglected and yet revealing vital sign in medicine is the respiratory rate. Pain or shock are key reasons why the respiratory rate is elevated. Normally, it should be around 8-12 breaths per minute, but Aimee’s respiratory rate was 26. Not good at all.

In the maternity, rapid testing for malaria and syphilis were negative. A crucial pregnancy test was found positive. The maternity team on duty suspected Aimee was either having an abortion or ectopic pregnancy. They started an aggressive intravenous fluid bolus, gave paracetamol (Tylenol), and an oral iron pill (the last medication for a reason unknown to me). They decided they needed a doctor and an emergency ultrasound.

At midnight, our expatriate German midwife Sigrid called me. I had been sleeping poorly due to the heat. She asked me to go to the hospital to evaluate Aimee – particularly by ultrasound.  I said “no problem” and a few minutes later our driver and I were inside an old, rickety and dusty Land Cruiser on the way to the hospital. The night air was hot. Even though we were driving slowly, the potholes in the road made our bodies slam back and forth into the car doors beside us.

When I got to the hospital at 00:15, I greeted the staff and examined Aimee. I draped her shawl over her legs to protect her modesty. The nurses warned me it was covered with blood, but it was all we had. The nurses offered me gloves, but since I prefer to examine a patient’s abdomen with my bare, human hands – I declined. First however, I listened patiently with a stethoscope to Aimee’s abdomen. It was completely quiet, a bad sign that her intestines had stopped moving. I gently put my hand on her abdomen in different places and she winced in severe pain. There was no question at this point – she needed surgery – tonight. Aimee’s pain was definitely real.

I opened the suitcase I use for carrying the portable ultrasound and asked one of the nurses to hold the machine carefully. I put the ultrasound probe over Aimee’s right kidney on the side of her chest. What immediately appeared was an ominous finding that confirmed that she had an ectopic pregnancy (a pregnancy dangerously outside of the uterus). Not only did Aimee have an ectopic pregnancy – but it had also ruptured and she was bleeding internally. I have attached a photo of Aimee’s ultrasound– you can see her kidney (shaped like a kidney bean) with an abnormal black stripe around it (this black stripe is blood –evidence of intra-abdominal bleeding). The ultrasound exam of her uterus also revealed it was empty – which was further evidence of an ectopic pregnancy.

MSF, Chad, obstetrics

Ultrasound image of Aimee's intra-abdominal bleeding. The black strip (or sliver) between her kidney and liver is evidence of abnormal intra-abdominal bleeding. © Raghu Venugopal

 

 

At 00:30 I called our midwife Sigrid and our surgeon. Sigrid mobilized the MOH head nurse, operating room staff, and laboratory staff. She came herself to the hospital to make sure everyone did their job. Aimee was in the operating theatre at 01:10 and at 02:40 the surgery was finished. The surgeon found a ruptured ectopic pregnancy and was able to remove the abnormal pregnancy and stop the bleeding. A blood transfusion was started at 03:22.

Today is day six after Aimee’s surgery. She is having fever still and is being treated with three antibiotics. She is also being treated with strong pain medications. But she is able to sit up, to shake hands with me, and to smile when I took a photo of her with her consent.

Obstetrics, Chad, MSF

Aimee on day 6 following her surgery. She's able to sit up and smile (photo is with patient consent and the patient's real name is not used). © Raghu Venugopal

 

 

Aimee’s pain was definitely real. Her case highlights gaps and problems in the Chadian health care system and why maternal mortality is so high in this country. Qualified medical staff are lacking. Basic and life-saving health care is unaffordable to the rural poor. On a positive note however, the MSF supported medical staff recognized the seriousness of Aimee’s pain and sought timely help. For the future as well, I am teaching the Chadian midwives and nurses how to use ultrasound to answer basic clinical questions. I hope they will use ultrasound, with support from future doctors, after I return home.

Aimee’s pain was definitely real. And she is definitely better now.

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

Raghu

 

 

 

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What will day 58 bring?

Posted on May 13, 2013 by

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.

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Malnourished children and displaced people

Posted on May 9, 2013 by

We all knew that late in the dry season, malnutrition would peak. But this week it hit us hard. Our outreach teams had difficulty coping. The hospital was temporarily over-run. Dr. Johanna, our MSF doctor from Sweden, told me the hospital “looked like a refugee camp”. The team and myself surveyed the hospital grounds. Two patients shared a bed in some circumstances; the area we use for children’s play was covered with mattresses on the ground and patients; and our tent used for epidemic infectious disease was filled with malnourished children.

I quickly emailed our nutritional epidemiological data to our medical coordinator, Cristina, from Spain – she coordinates our medical operations from the capital and has many missions of MSF experience.  She quickly produced some graphs for our team and provided medical direction. The increase in our malnutrition curve had never been so steep in the past four years. The following graph can give you a sense of the spike in cases we are seeking now and the seasonal rise in malnutrition in 2012 (TFP stands for therapeutic feeding program).

MSF malnutrition programme

 

Quickly, we started making plans to deal with the increased numbers. Stefano, our Italian MSF head of mission, and Luigi, our Italian MSF project coordinator quickly met with me in front of an erasable whiteboard.  I outlined the mobile clinic situation. We quickly agreed on an action plan based on the data and our team’s input. We would immediately add five staff to our mobile clinic outreach team. Andrea, our Swedish mobile clinic expat nurse, sat down with her Chadian team and made a plan to support the hardest hit health centers. Our Chadian hospital supervisors shifted nurses to the malnutrition wards to aid with the increased numbers. Gardy, our construction logistician from the United States, started constructing new beds and putting up a new patient tent. Oliver, our supply logistician from Germany, starting having new mattresses made.

The same day the mattresses were delivered to the hospital and the next day the bed frames were ready. Within one to two days the extra outreach team members were hired and deployed. At some point we had 50 children in the malnutrition service and 43 in the pediatrics service. The doctors, nurses and nutritional assistants worked extra hard this week. The intensive care was completely full. But at the end of the week, the situation was stabilizing. A new reality was settling in – the malnutrition season was here in force.

At the same time, violence to our east had erupted. In the Tissi region just east of Amtiman, tens of thousands of displaced civilians poured into eastern Chad from Sudan and the Central African Republic. Internal to Chad as well, the population was displaced in this area with a tri-border between Chad, the Central African Republic and Sudan. Violent clashes in neighboring Darfur had lead to about 50,000 people fleeing. Our MSF mission responded swiftly. Lead by our MSF Chad Emergency Response Unit (CERU), our team was providing vaccination against measles, primary health care, emergency medical care and clean water.

Our Amtiman project pitched in to help the emergency response in Tissi. Our site became a strategic operational base where staff and logistics could be funneled to Tissi. MSF emergency response staff came in, got ready for Tissi, and shipped out by Land Cruiser or plane. We made a decision to deploy our Congolese expat doctor, Guy, to Tissi. I knew conditions there must have been difficult. He texted me after he got there – asking me to send a towel, soap and toilet paper. He got it the next day with Claudia, an MSF nurse from Germany, here on her eighth mission. Claudia had recently been evacuated by MSF from the Central African Republic, to our south, after their own violent change in regime. She had quickly agreed to come be part of our mission in Chad.

Soon, our Amtiman physician, Dr. Johanna from Sweden, will head to Tissi. It will make our work here harder losing her temporarily – but we all have to dig a little deeper when an emergency strikes. Everyone in our team is being flexible. That is a watchword in MSF work – flexible. We need to be flexible and nimble at all times – able to shift and adapt to the ever-changing local circumstances. While we have our ethics, our founding Charter and our operational plans as a backbone of our operations, everyday here I learn that our role shifts and evolves all the time.

Otherwise, the last week for me has been tricky. I’m covering for our expatriate hospital nurse who is on vacation and also Dr. Guy’s usual responsibilities in the HIV/TB service. Our laboratory expat is also on vacation, so I cover her position as well. One has to be flexible. We’re also entering a major planning phase for the rest of the year with our medical data for the past four months. It’s very busy.

To our surprise last night, a huge sand storm was followed by rains for a few hours. The usual searing heat fell. The team and I sat outside last night savoring the cool weather of about 26 degrees Celsius. When the rains started to fall, I was skyping with Maeve, my dear fiancé in Canada. We miss each other so much. I said good-bye and ran back to our house to move my bed inside because of the falling rain. Lately with the heat, I was sleeping outside. Last night however, the whole team slept inside our tukuls – or little huts – and slept royally because of the cool breeze. After the heat, it will soon cool with the rainy season coming. The rainy season – though welcome – will bring new perils for the people here. Inaccessible roads, malaria and cholera are on the horizon. But we will be here. And we will be flexible.

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

Raghu

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Late at night

Posted on April 30, 2013 by

On April 4th late at night, Dr. Guy called me from the hospital. A child had fallen from the roof a house. He asked me to come to the hospital and bring the portable ultrasound machine since he was concerned about a serious abdominal injury.

When I got to the hospital I met Ousmane and his father. The first thing we did was shake hands. Ousmane was 13 years old and was brave and calm. I put my hand on all parts of his abdomen as gently as I could and he winced in pain. Since I graduated from medical school 12 years ago I have come to know that look of pain on a patient’s face well. It indicated to me a grave surgical problem. A hole in the right lower quadrant of Ousmane’s abdomen indicated a place where a stick or piece of wire had puncture and maybe entered his abdomen. I turned to Guy and told him I was worried. Guy and I agreed this was what we call a “surgical abdomen”. I told him we did not need an ultrasound to convince us to take the patient to the operating room.

Nonetheless, I performed the ultrasound of Ousmane’s abdomen and it was normal. Very often, in the acute stages of a serious abdominal injury with perforated intestines, the ultrasound is unremarkable. This was a clear case where the physical examination of the patient was a 100 times more useful than technology.

MSF Chad

Ousmane's hand hand and intravenous line when he first arrived. © Raghu Venugopal

 

While I prescribed three antibiotics and intravenous fluids for Ousmane, Guy called the surgeon and the surgical team. The MSF car left the hospital in the night, collected all the surgical team and returned. When the surgeon arrived, he took what seemed five seconds to examine Ousmane and agreed on the need for surgery. Within minutes, Ousmane was in the operating theatre. Later yet in the night, Guy informed me our clinical suspicion was correct, the intestines had been perforated. The surgery had gone well.

Ousmane was moved to the intensive care unit. The first days and nights were hard for him. He needed a lot of pain medications. Late at night on April 6th the nurses called me during my overnight on-call duty. They said Ousmane was unwell. I got out of bed and changed quickly into pants and a shirt and took a Land Cruiser to the hospital. The night air coming in the window was hot. The dirt streets were empty. The dust and darkness made it seem like we were driving in fog. It was calm and peaceful. The driver and I drove in silence.

I got to the hospital and examined Ousmane. He was delirious and nauseated. His father shared the bed with him and I could see he tended to him as best he could. I talked to the nurses while I examined Ousmane. Then I prescribed medications for nausea and talked to Ousmane’s father through the help of the nursing staff. Ousmane was having a rocky post-operative course.

With other doctors on the team taking care of him, and with many things going on in my daily non-clinical work, I honestly somehow forgot about Ousmane in the subsequent days. But on April 13th, I was quickly walking through the pediatrics ward and was stunned to see a young boy with a huge smile from ear to ear. It was Ousmane. He was about to go home that very moment, and he had completely recovered. He was a lovely young man. I asked him and his family’s permission to take their photos and Ousmane did great taking his own photo with my iphone.

MSF Chad

Ousmane on the day of his discharge smiling ear to ear. © Raghu Venugopal

 

As a medical team leader, I don’t work as much in the hospital at night compared to the rest of the medical team of nurses, midwives and doctors. These men and women work long and hard. In some cases, expatriate medics are needing to work seven days a week in the hospital. It’s hard and wears you down. My own time is heavily spent on medical strategy, coordinating our efforts with the Ministry of Health and other actors, and doing the behind the scenes work that is crucial to ensure a hospital and outreach team can do their job. I’ll be honest with you, that I prefer the bedside medical care – in the day and in the night.

It is possible to think of MSF’s medical work like a scalpel, which we use during surgery. The sharp end is at the bedside with patients and families. It’s the crucial end – and nothing can replace it. But behind the blade is its attachment and then the handle from which to hold the blade. These parts are crucial too. I prefer being at the sharp end – but I know the attachment and handle is just as important. You can do much with just the blade.

Behind able to go to the hospital at night requires a proverbial blade, its attachment and a handle. Practically speaking we need drivers, cars, petrol, guards and radio operators to make it happen. We need nurses on duty, who first discover something is wrong. We need logisticians who ensure there are generators to give light to the hospital at night. We need non-medical team members to also order key medications that I or other medics might prescribe at night. We need a coordination team in the capital to reach an agreement with the Ministry of Health that we can work here in Amtiman. And we need donors and supporters who generously give to make all of this possible.

Late at night we need a doctor. But we need a lot more too.

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

Raghu

MSF Chad

Ousmane does a great job taking his own photo with my iPhone. © Raghu Venugopal

Please note: patient names are changed to protect patient identity.  All photos are posted with family consent.

 

 

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Ali’s cough

Posted on April 22, 2013 by

Ali is 36 years old and has been coughing for a long time. He has been coughing since at least 2006. When we first met each other and shook hands I was happy to learn he spoke French, so we could talk directly. We did not need a translator from French to Arabic.

The majority of our patients here in Amtiman speak Arabic. I’ve learned a number of Arabic phrases here to adapt to the local culture. They are mostly words and phrases I use when seeing patients. Being able to speak a few words of Arabic to each family makes me feel our connection as patient and doctor is somehow a little closer than if we just communicated through a translator. The following Arabic words I mostly use for seeing pediatric patients, and they include:

· Hello, how are you?

· Is your child a boy or a girl?

· What is your child’s name?

· How is your baby?

· You have a beautiful baby!

· You have a really beautiful baby!

· Can you please breast-feed your baby? (a baby not able to breastfeed is a concern)

· Please remove your child’s clothing.

· It is really hot today!

· It is really, really hot today!

· No problem.

· Slowly, slowly – things will get better.

· Congratulations – you can go home now!

I was called to see Ali on my mobile phone by Dr. Guy. Guy is our Congolese expat doctor who follows our HIV+ and tuberculosis (TB) patients. I was working at the MSF base on my computer and Guy’s call was a welcome change from sweating behind my computer on seemingly endless, important emails.

Dr. Roland, a German doctor with MSF, had just arrived from Berlin to our base to evaluate the quality of our medical operations. I passed by the MSF house, we shook hands quickly and I asked him if he wanted to immediately go to the hospital. He agreed.

When we got to the hospital we found Dr. Guy and Ali in the HIV and TB clinic office. He was joined by our Chadian HIV-TB nurse Theophile and our HIV-TB counselor Jean-Blaise. The mid-day heat was about 41 degrees. Ali was coughing and I immediately asked everyone to put on a facemask, including Ali.

TB MSF

Ali (not his real name) most likely has multidrug-resistant TB (photo with Ali's permission) © Raghu Venugopal

 

Guy presented Ali’s medical history and we all listened. Ali was diagnosed with HIV 11 years ago. He took anti-retroviral  medications, but was not adherent all the time. Ali did not know his CD4 count – a measure of the strength of his immunity. Unfortunately, as well, Ali had been treated for tuberculosis a total of four times – but had never achieved a clinical cure. He had been treated for TB in 2006 for six months, 2007 for eight months, 2010 for eight months and again started TB treatment in October 2012.

Guy called me because he suspected Ali had multidrug-resistant TB (MDR-TB). MDR-TB is a major concern of MSF’s since it is under-diagnosed and undertreated around the world. When the diagnosis of MDR-TB is made, the treatment is very difficult. It consists of painful injections everyday for the first eight months and then up to 20 pills a day for two years. The treatment also has significant side-effects including nausea, bodyache, rashes, permanent deafness and psychosis.

MSF is deeply concerned that this current approach to treating MDR-TB is too long, too toxic and too costly. Each course of treatment costs about USD $4000. These reasons are why MDR-TB is so important to MSF and why we are working with the Chadian Ministry of Health to improve the diagnosis, treatment and advocacy effort on MDR-TB. Critically, MSF is also supporting research on better treatment regimens.

To make the diagnosis of MDR-TB for Ali, we decided to contact our MSF TB and laboratory colleagues in Europe for advice and try to send Ali’s sputum to Antwep, Belgium, for confirmatory testing. We also plan to test Ali’s sputum when a new sophisticated machine, called the ‘Genexpert’ arrives in Amtiman in May. The Genexpert is a significant advancement in the diagnosis of TB and drug-resistant TB. Rather than needing sputum from deep in the lung for diagnosis we can just use saliva from the inside of a patient’s mouth.

As well, we can improve the detection of TB in children with the Genexpert. Children are highly susceptible to TB infection and are notoriously difficult to clearly diagnose. With the Genexpert we can pass a small tube from a child’s nose to their stomach and remove some fluid to test for TB with greater reliability than ever before. To prepare for the arrival of this new equipment, MSF is sending its Chadian and expatriate lab staff to regional expert trainings in Nairobi and upgrading the logistical ability in our hospital laboratory. We will also invite an MSF TB expert from London to join us for a few weeks in June to support our local efforts.

Ali’s problems were not just his cough however. In addition to being gaunt and cachectic [physical wasting with loss of weight and muscle mass], he had dark, purple-ish lesions inside of his mouth. Guy, myself and the team looked at the lesions and suspected a form of cancer, called Kaposi’s sarcoma. We were not entirely sure however. With Ali’s permission, we took a photograph and last night I uploaded it to the MSF telemedicine website for external support from an HIV expert. This morning, 12 hours later, an MSF HIV expert confirmed the photos we uploaded from Chad were indeed Kaposi’s sarcoma. The expert also included three scientific articles for Dr. Guy and myself to read to improve our knowledge on this topic. I was amazed at the speed and quality of the telemedicine support.

MSF is working with the Chadian Ministry of Health to aid patients like Ali. Our first goal is to make the right diagnosis using our clinical judgment and appropriate technology. Our next goal is then to use the right drugs to try to cure Ali. An option is not to keep using the same ineffectual drugs for Ali – which may only worsen his suspected drug-resistant TB. Médecins Sans Frontières is bringing all of these resources to bear to help patients like Ali. I hope, 2-3 years from now, Ali’s cough is gone.

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

Raghu

Please note: patient names are changed to protect patient identity.  Ali’s photo (not his real name) is posted with his permission.

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The kindness of strangers

Posted on April 16, 2013 by

Part of the experience of working with MSF is not just work but also taking a break. The work in the project site is seven days a week most of the time, but then after two months or so, we get a break in the capital city. We call it ‘R and R’ – meaning ‘rest and relaxation’.

I can’t quite say my R and R was what I had intended but it still was interesting. A definite change of scenery compared to my usual routine of being in one of three possible places – the MSF house, the MSF office or the MSF hospital. For the past two months I have spent everyday in just these three places. It’s meaningful but my human spirit craves a bit more variety time to time.

Oliver, our German supply logistician, and I went together on R and R. I first did the morning rounds in the hospital, had a few meetings, tried to do as much email in the office as possible, and then we went to the ‘airport’. The airport in Amtiman is a dusty patch of land where the International Committee of the Red Cross and Red Crescent (ICRC) plane can land. Our MSF cars wait on the side of the airstrip for the plane to land. Staff with flags ensure children playing soccer nearby stay well out of the way. Curious villagers line the runway at a safe distance.

When the plane landed, three of our patients with vesicovaginal fistulas (VVF) emerged. They had been treated in Abeche by the MSF-Switzerland team over the course of many weeks. VVF is a tragic medical problem where there is an abnormal connection between the bladder (or bowel) and vagina. This is often caused by an obstructed labour. Women are divorced, lose their families and are ostracized for this terrible problem. At the MSF-Switzerland “Village des femmes” this problem is surgically repaired and women can recover and gain their strength among other women with the same problem. I am not sure I have seen a more incredibly important and dignity-restoring intervention than MSF’s VVF hospital in Abeche, Chad.

MSF

Village des Femmes - MSF's hospital for vesicovaginal fistula patients in Abeche. © Raghu Venugopal

 

We currently have six women in Amtiman waiting to go to the VVF hospital. Sigird, our German midwife, gives me the referrals. I scan them into the computer and send them to the capital for approval. We then fly them to and from Abeche. Sadly, three of these women have no one – no relative and no friend – who will go with them to be their ‘guarde de malade‘ or accompaniment. A guarde de malade plays a critical role in health care in Chad; they are an advocate for the patient, help with personal hygiene, and most importantly provide the human support needed when one is ill.

It breaks my heart when someone has no guarde de malade but the kindness of strangers is always inspiring. Like I have seen in Toronto, Canada, and all around the world, patients and their families band together with other patients and families and I have seen many cared for and aided by complete strangers. It’s amazing to see the kindness of strangers around the world.

The plane flight to Abeche was very hot and bumpy. I wanted to kiss the ground when we finally landed. We got to the MSF Switzerland office then waited, and waited, for a connecting flight to the capital, N’djamena. The crisis in the Central African Republic meant planes were being diverted there to evacuate aid workers. We ended up waiting in Abeche for three days. Making lemonade out of lemons, Oliver and I took the chance to visit the ICRC hospital and I got to see three patients I had transferred the week before following our mass causality incident. All were doing well. A woman I had referred with chest trauma had six broken ribs and bleeding around her lungs. She did not seem to mind the plastic tube coming out of her chest to drain the blood. The ICRC staff and myself agreed her fortitude was amazing. We shook hands and I wished her well. This has been one of my favorite ‘housecalls’. We then visited the beautiful MSF-Switzerland VVF hospital. It made me proud to be an MSFer the way these women were housed and treated.

On our fourth trip to the airstrip, three days later, we finally got a plane to the capital. The turbulence and heat again really got to me. Oliver carried my bag and gave me his water to drink as we waited for the pink MSF car to pick us up (MSF cars here are painted pink to avoid car-theft which has been a problem). We then went shopping for our team. Essentials and a few ‘comfort’ items like chocolate and cheese were on our list. Realizing how short our break was – we had 36 hours in the capital – we were asked if we wanted to stay longer. Not wanting to strand our team in the field, Oliver and I opted to return by car, as scheduled, acknowledging that just being able to get out the project was a break enough.

msf

Sitting under a tree making the best of it while waiting for a car to help us after our own car broke down. © Raghu Venugopal

 

The next day, I spent my morning with our communications officer, Laura from Switzerland, preparing for an interview with the BBC World Service. Admittedly, we did our meeting in nice café where the coffee and bread was a welcome change. We then went to the MSF office to meet the Producer for BBC Afrique. I was afraid my French would not impress her, but the producer was supportive and friendly. I talked about our patients and our work. To my surprise four days later, the nurses in the hospital in Amtiman were telling me they heard our interview on the BBC news. I was satisfied with the chance to talk about some of the struggles our patients and team faces.

The following day we woke early. The plan to return to Amtiman was by road, criss-crossing Chad from west to east. It would take two days by car. The long drive was eye-opening. Villages, trees, savanna, forest and mountains passed us. The air coming in the window was like a hair-drying blower on your face. I closed the window and listened to some music. My mind wandered to my dear fiancé Maeve in Canada who I miss so much, the work ahead and how nice it was to see some of Chad.

After a night at the Oxfam compound in Mongo, we kept going. About 80 kilometers from Amtiman however, our MSF car broke down. I called Eve and Luigi at the base and they organized a car to come get us. A car with the Ministry of Health pulled over to check on us. Their driver got out and together with our driver they worked under the hood of our Landcruiser. They did not have to stop like so many others that past us and left us in their dust. The kindness of strangers yet again.

msf

The logistics team looking under our car hood on the road when we first started having engine problems. © Rahu Venugopal

 

It was really hot. I went to sit under a tree only to put my hand into a thorn bush and start bleeding everywhere. After a while, I got bored and Oliver and I went to go look at some camels, keeping close to our cars and team. Eventually our MSF ‘rescue’ car arrived and we made it back to the base.

I must have looked horrible and I definitely felt harried. Our R and R had not at all been restful, but we got to criss-cross the country and break the routine of life in Amtiman. The best moment was seeing MSF’s VVF project in Abeche – something I wish the world could see and somewhere I wish every patient affected by VVF could be cured.

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

Raghu

 

Posted in Chad, Doctor, Healthcare provision | Tagged , , , | 2 Comments

Hissen, a brave boy

Posted on April 9, 2013 by

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

Posted in Chad, Doctor, Healthcare provision | Tagged , , , , | 5 Comments

Doctor, what about my brother?

Posted on April 4, 2013 by

The desperate man asked me in French, “Doctor, what about my brother?” In rooms full of bloodied bodies on the ground, somewhere was this man’s brother.

A mass casualty incident hit Amtiman hospital. This man was looking for his brother amongst the 50 or so victims. An open-ended truck, full of people, had turned over. That is all we knew. Trucks and cars were then loaded with injured patients and brought to the hospital.

It was Friday night and I was on-call after a grueling week. My energy level was low and I needed to sit down to think as I did my evening rounds in the intensive care unit. The nurses and I were preparing a blood transfusion for a severely anemic child when the hospital head nurse burst into the room. He told me to come to the triage, now. I said, “Now?” He said, “Yes, now, there has been a large accident.”

I ran to the triage. There, I found complete mayhem. Police, military, crowds, screaming. Headlights illuminated the dust in the hot night air. I followed the crush of people into the triage department. It was like a war-zone. There were injured and bloodied people everywhere. All I could see were injured victims on the floor. Families tried to find their loved ones.

Triage was needed. But first, I needed help. I ran out to the MSF Land Cruiser and used the VHF radio to call the base. I yelled to the radio operator, “Get our hospital nurse Eve and get my ultrasound.” I knew the portable ultrasound I brought from Canada would be key to diagnose intra-abdominal injuries needing to immediately go to the operating room.

The portable ultrasound kept safe and secure with a few MSF t-shirts as padding © Raghu Venugopal

The portable ultrasound kept safe and secure with a few MSF t-shirts as padding © Raghu Venugopal

 

I ran back to the triage department. Then, systematically, I got on my knees and examined every patient. First, were they breathing? Second, could they talk to me? Third, how was their abdomen when I palpated it? My pants were red and I kept changing examining gloves.

Quickly, I knew there were four severely injured patients. Two adults had massive head injuries and would not talk. Next, a young boy also had a serious head injury but would talk. Also, another young boy had a very badly broken leg.

My phone rang. Sigrid, our German midwife had caught wind something was wrong and called me to see if everything was OK. I yelled into my phone, “Come now. Bring everyone. I’m not kidding. Get the surgeon. Now. Now.”

Minutes later, Eve our nurse from Canada, Andrea our nurse from Germany, Cristina our medical coordinator from Spain, and Sigrid our midwife from Germany arrived.

I sent Cristina with the two children to the intensive care unit. Sigrid moved patients to the operating room. The two serious head injuries and other orthopedic injuries went to the operating room. These patients included a woman with both arms broken. Another was a woman with an open arm fracture. One by one, they were moved through the thick crowds on stretchers. We ran out of stretchers and so just carried people in our arms. I ran to the operating room to see if things were going OK. Our Nigerian surgeon and I shook hands as he headed in for the first cases. Things were working out. The team was getting the job done.

I went back to the triage. Nurses had come in voluntarily to the hospital to help out. The Ministry of Health and MSF worked side by side to aid the injured. A man with severe facial injuries was bleeding heavily from his nose. I used some tongue depressors and tape and we stopped the bleeding. Nurses and I examined patients, turned them over and wound closure was happening everywhere.

I went to the intensive care unit. We anesthetized the boy with the femur fracture and when he was asleep we straightened out his leg. We moved stable patients to the wards and crammed extra beds into the ICU.

Back to the triage. A desperate man asked me in French, “Doctor, what about my brother?” I told him I did not know anything about his brother, but we could find him together. We went from room to room and found his bloodied brother on the floor, alone. I found a large injury on the back of the brother’s head. We gathered six men and we picked up the brother and put him on a bed. We examined the man and I got Isidro, a Spanish MSF nurse, to close the head wounds in the maternity ward. The patient was agitated and unable to cooperate. With the permission of the brother, we anesthetized the patient and completed the procedure. We then carried the man to the surgical ward for observation.

Again and again I went back to the triage. The situation was stabilizing. Victims were being triaged, treated and admitted. Wounds were being closed and pain was being treated. Three doctors with the Ministry of Health worked in the operating room. The intensive care ward and other wards were filling with patients.

The triage was getting under control but we needed to get more patients off the floor, repair their injuries and admit them to the wards. The nurses and I decided to share the load of remaining patients with all the adult wards. We asked men and women standing around to help us carry the injured to the wards.

Many hands made the work light. As we arrived in the wards with patients we carried in our arms or by stretcher, I gave a one-sentence summary to the attending nurse of the injuries and the medical care needed.

The rest of the team was working hard. Eve was making sure dressings and pain medication were available. Sigrid was keeping the operating room under control and supervising deliveries at the same time in the maternity ward. Johanna, our doctor from Sweden, was helping in the intensive care unit. Oliver, our German supply logistician, made sure there were extra blankets available.

In one return to the triage, I met the head nurse from the Ministry of Health. He thanked me like never before. It was just the way he said “thank you” that I know he’ll never forget this night when we all came together to deal with this mass casualty incident.

The night went on. Eventually things started calming down. I started to have difficulty standing up I was so exhausted – emotionally, physically and mentally.

I knew the next day would be difficult, so at some point in the night, Eve, Oliver and myself left the hospital. I collapsed in a chair at the base. Amidst all the human suffering, the team had responded amazingly.

I went to bed with my three phones, still on-call for the hospital. I worried about what kind of delayed injuries might occur – ruptured spleens or slow bleeding liver injuries.

My phones did not stop ringing in the night, but surprisingly, it was not for trauma victims, but for all the other types of emergencies that happen in the night at the hospital. The most heart-warming moment in the night was at about 5am when Hasan, our pediatrics supervisor, called me. He had come to the hospital on a volunteer basis to help out. He informed me on the progress of some patients that were now stabilized and asked me “permission” to go home. I told Hasan his dedication to patient care was a model for us. I asked him to go home and rest. I assured him we would pay him over-time hours for his work – but I think he just wanted to hear he could go home.

The next day, we went back to the hospital to identify those still remaining with untreated or newly discovered injuries. The surgeon, head nurse and I did the rounds of the hospital. We identified the sickest victims that we could potentially evacuate to the trauma hospital of the International Committee of the Red Cross in Abeche – a town about two hours away by plane flight. I called the Red Cross surgeon Dr Igor – and we agreed on the transfers.

Among the transfers was the initially “lost” brother. After the dust had settled and I could examine him again, the brother had significant neck pain and what seemed like a broken arm. The team was not entirely sure if the arm was broken. When I examined his arm, there was definitely pain around the area above where a wristwatch usually is worn.

I pulled out my portable ultrasound, which I was carrying on the hospital rounds. Using a special probe I brought from Canada, I showed the assembled team the normal bone where the patient had no pain. Then, where he had pain on physical exam, the bone was obviously abnormal and broken. Everyone crowded around the machine could see the broken bone. The surgical team agreed to put a splint on the broken arm. With all the brother’s injuries, we would transfer the patient to the Red Cross in Abeche.

MSF Ultrasound

Ultrasound image of the broken arm of the initially "lost brother" © Raghu Venugopal

 

In the past day, MSF had responded to an unexpected emergency. It was amidst our usual priorities to our patients. With our partners in the Ministry of Health we dealt with each trauma victim one by one. There were no fatalities and the whole Ministry of Health and MSF team had surged in the night to deal with the emergency. The MSF team felt good about the way we had responded and the positive patient outcomes.

As a doctor, in MSF work and in Canada, family members tap me on the shoulder and ask for my attention all the time. It’s hard to know if it is an emergency or a less serious concern. The man who was looking for his brother was just one of these worried family members the night of this critical event. Everyone who has lost their brother or their sister deserves a helping hand. That is what we are here to do.

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

Raghu

Posted in Central African Republic, Doctor, Healthcare provision | Tagged , , , , | 3 Comments

Building the ICU

Posted on April 2, 2013 by

As I mentioned in my last post, MSF is building a beautiful, airy, bright and new ICU building from scratch on the hospital grounds.

The initial construction of our new ICU © Raghu Venugopal

The initial construction of our new ICU © Raghu Venugopal

The ICU construction almost finished © Raghu Venugopal

The ICU construction almost finished © Raghu Venugopal

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Oumere does not make it

Posted on March 26, 2013 by

The majority of our patients live. But sometimes they do not. Their stories, their memory and the lessons we can learn from their lives are just as important those we learn from the many lives MSF saves. As I have been rounding quite a bit in our Amtiman Hospital intensive care unit (ICU), I have cared for some of the most critically ill children lately. The patients in the ICU have problems such as extreme prematurity weighing just 900 grams, severe malaria and anemia, and severe malnutrition complicated by dehydration, pneumonia or sepsis.

I have seen many children make dramatic recoveries. I have seen a few die. A child dying is something I mostly only have experience with in Africa, back home in Canada I have rarely had this tragic experience. Here, sadly a child dying is not unexpected for most families. Chad has among the highest child mortality rates in the world.

I started intensive care rounds with our Chadian staff by first attending to Mahamat. Mahamat is an orphan who was found in the street abandoned. The ICU is not the best place for a baby, but the nurses can keep a close eye on him there. Mahamat likes to be held and sometimes when he is crying, a kind grandmother, nurse, or our expatriate logisticians like Ben and Oliver from Germany, and Diana from Canada, will hold him. Eve, our Canadian hospital nurse, will sometimes do her medical stock counts on her computer with Mahamat on her lap. Mahamat thanked Diana yesterday for carrying him by peeing on him – to the laughter of the Chadian women watching. It turns out being peed on by Mahamat is a benediction to having many children oneself.

Oliver, our supply logistician, holding Mahamat, in the ICU © Raghu Venugopal

Oliver, our supply logistician, holding Mahamat in the ICU © Raghu Venugopal

 

As we sat on Mahamat’s bed to examine him the nurses noticed Oumere, the child in the next bed, had stopped breathing. They quickly grabbed the oxygen bag and started artificial respiration along with stimulating the child. We quickly checked the blood glucose level. Normal. We still gave a small dose of intravenous glucose anyway. His heart was beating very weakly. I slipped my hands around the small baby’s chest and began chest compressions. Although a few minutes before the electrical generator had failed, cutting off all oxygen to the ICU – including to Oumere – I’m not certain that is why he suddenly fell ill.

Oumere’s parents stayed in the ICU while we resuscitated him. They did not ask questions but watched silently – as did all the families – in the one cramped room with no curtains between the beds. This tight physical space incidentally, is being replaced in the next 5 days by a beautiful, airy, bright and new ICU building that MSF has built from scratch on the hospital grounds – which we will donate to the local authorities.

Moments before Oumere went into cardiorespiratory arrest, Dr. Guy from Congo had seen the child and suspected the reason he was not breastfeeding anymore was because he was infected by tetanus. Neonatal tetanus is a disease that is entirely preventable by vaccination of pregnant mothers. Oumere’s mother we learned had only gone to one prenatal consultation visit. She and Oumere were likely not vaccinated against tetanus. MSF provides prenatal consultation and tetanus vaccination just a few steps away from the hospital, in one of the nearby primary health care centers.

Dr. Guy prescribed the necessary antibiotics and had requested Oumere be put in a quiet, dark room in order to prevent the painful spasms that accompany tetanus. In addition, I urgently called our Canadian hospital nurse, Eve, to find the immunoglobulin needed to give Oumere quicker immunity against tetanus. Eve delivered the immunuoglobulin from our stock in a few minutes.

The tetanus immunoglobulin we used to try to save Oumere's life. © Raghu Venugopal

The tetanus immunoglobulin we used to try to save Oumere's life. © Raghu Venugopal

 

Meanwhile, artificial respirations and cardiac compressions were still ongoing. At some point, Oumere started to breathe on his own and stabilized. We kept him on oxygen and continued ward rounds on the rest of the children, but kept a close key on him.

At the end of rounds, Oumere went into cardiac arrest a second time. We gave him artificial respirations and cardiac massage again. I could see the hands of the nurses grow tired as they provided chest compressions and artificial ventilation, so we called more nurses over to help. A training nurse under my direct supervision learned how to use the oxygen bag to ventilate for Oumere. We also gave him intravenous fluid, intravenous glucose, and intravenous epinephrine [adrenaline]. I rushed to the operating room and took a car to the MSF base to get equipment to invasively ventilate Oumere with a technique called endotracheal intubation. The procedure was a success, but Oumere’s body was shutting down.

After about two hours later it was clear Oumere was not going to make it. We had hoped to stabilize him until his own body could take over and his own lungs could work again. We had followed our protocols and balanced the local reality with the best resuscitation medicine possible in a sub-Saharan context. Despite the medications, cardiopulmonary resuscitation and efforts we had made Oumere was not responding. A gentle stroke of his abdomen resulted in his body going into spasms. He had stopped breathing for a long time now and although we could stabilize his vital signs with our efforts – it was clear three hours later that he would not survive.

I spoke to Oumere’s parents several times during the critical event. His father spoke French and I explained the efforts we were making and the lack of a response. He was calm and understood. Oumere’s mother was in tears and came and went from the ICU at different times.

I asked the rest of the medical team if they had any ideas what we could further do to aid Oumere – we all felt we had exhausted our efforts. There was agreement in the team we had given our best to save Oumere’s life. We stopped our resuscitation and Oumere passed away.

I gave my condolences to Oumere’s parents. His father thanked us. I thanked our own team as well since the prolonged resuscitation had left everyone physically and psychologically worn down.

Oumere died today, but not without a fight. His parents always stayed by his side in those last moments. He received the best medical care we could provide under the circumstances.

Child survival in Chad is a day-to-day struggle. Many survive thanks to low-cost interventions like vaccination, proper nutrition, antibiotics, rehydration, blood transfusion and oxygen. Sadly, these interventions are available to too few.

On this Earth, some children have access to life-saving medications, and others do not. This unfair imbalance means lives of equal value are treated unequally. Our MSF action seeks to make a dent in this injustice. It is unfair and tragic that children like Oumere die so early in their lives.

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

Raghu

Please note all names have been changed to protect identity.

Posted in Chad, Doctor, Healthcare provision | Tagged , , , , | 9 Comments