Fieldset
Update from Maitikulu

Since my last entry we have had eventful times here in Maitikulu. Most recently, our sleeping sickness camp was visited by our Chef de Mission/Head of Mission (HoM) accompanied by our Project Coordinator. The visit of the HoM was an opportunity to reflect on the progress and future of our camp.

Since my last entry we have had eventful times here in Maitikulu. Most recently, our sleeping sickness camp was visited by our Chef de Mission/Head of Mission (HoM) accompanied by our Project Coordinator. The visit of the HoM was an opportunity to reflect on the progress and future of our camp. HoM's usually have tremendous MSF experience and there are often pearls to pick up during formal and informal discussions. During the visit of the HoM he delivered a thoughtful and motivating speech to the national and expatriate staff during our weekly team meeting. Such moments are useful in defining why MSF is in this isolated region of CAR and why MSF as a social movement exists. As a field volunteer, I appreciated his visit.

On a personal note, the process of adapting to a rural and basic living situation continues to evolve. I've started to get comfortable shaving using a computer screen as a mirror. It's tricky to not allow any water drip onto the keyboard, but totally do-able.

Here, we also tend to get up around 6 am. You can't help it, it is so bright outside and the roosters are crowing. As well, the patients and families in the hospital are up and about - babies are crying, nurses are working and people are starting their day. Given our early rise and the mid-day is the hottest time of the day, I've realized the value of a small afternoon nap. This way you can finish the rest of the day stronger, bear the heat a little better and have a bit of energy to do some work in the evening when there are less interruptions. Although it is monsoon season here, between rains it is hot and humid. Our logistician from Ireland and I find it really too hot sometimes. I've taken to rolling up my pant legs and not wearing socks anymore. The problem with that is that my legs are covered in mosquito bites and they're really itchy. Oh well - c'est la vie. It's all about adaptation and flexibility. Time also helps you get used to almost anything.

Operationally, we're currently still inviting villagers to our camp who have been previously diagnosed with sleeping sickness. Slowly, but surely, they are arriving, but not as fast as I had hoped. Soon we will be able gradually incorporate some mobile (village based) activities. These will include village based convocation of patients to our camp for treatment, verifying our current village population data, and screening (in their villages) those who have been perhaps missed by previous sleeping sickness screening efforts. I'm really excited about gradually and methodically taking our show on the road.

On another front, case management of severely ill patients remains one our key goals. Not all the time they are successful. Let me tell you about Ndodet and Doulkanoji – the story of two 2 year old boys.

Ndodet, from Bekourou presented this week in a critical state. He arrived in the out-patient department with convulsions, diarrhea, and fever. Our nursing staff quickly realized he was severely ill and notified our national staff doctor who took the child directly to the lab to be cross-matched along with his mother for an immediate blood transfusion. An intravenous line was inserted and intramuscular anti-malarial medications were immediately given. While his mother was being cross-matched I heard of the case and together we took the child to our salle de guard or emergency nursing station. As we began to give the child some intravenous glucose I noted that the child had stopped breathing. We cleared a table of its books and equipment and I put Ndodet on the table in order to resuscitate the child. On the table we could better see what we are doing since inside the salle de guard (or nursing station) its dark even in the day.

Along with our American emergency nurse-practitioner, 3 national staff nurses and our national staff doctor we "coded" or in other words, tried to resuscitate (or reanimiate) this child for 45 minutes. This involved cardiac massage, artificial respiration, intravenous fluid, intravenous glucose and intravenous epinephrine or adrenaline. Unfortunately, it did not work. We never got a pulse back. The child never resumed breathing. The team did a good job in its attempt and the process was calm, fast-moving and methodical. Everyone did what they needed to do. I wish Ndodet had arrived just 2 hours before. Even 1 hour before. I'm sure we could have saved him with just a few more minutes – as we can organize the transfusion of blood in under 30 minutes. During the code, we allowed the mother to stay at the bedside as we would do in North America. She could see what we were doing and I hope there will never be a question in her mind that her child received all the medical care possible in this rural corner of the Central African Republic. As the walk back home to her village is long, after Ndodet died, the mother gathered the body and prepared to leave immediately. A few minutes later I found her outside the hosptial on the side of the road sitting on the ground, crying. A local nurse and I comforted the mother and told her we did all we could do. She thanked us.

In contrast to the case of Ndodet, let me tell you about Doulkanoji. He is also a 2 year old boy, but he has made a dramatic recovery. This patient is from Ndahili a village 30 kilometres away in Chad. He presented in a severely emaciated state and could not sit up when he arrived here. I was very concerned that he would die. He presented weighing only 7.4 kg but after 14 days of therapeutic re-feeding he has bounced back and weighs 8.8 kg. He can now sit and unlike before, he will actually cry if he is scared or examined. Before he would only moan and lie there.

Thankfully, we have many cases like Doulkanoji and few cases like Ndodet. But this is rural central Africa, where about 1 in 5 children under the age of 5 years will die without medical assistance and functioning social services. When we can cure patients it is a wonderful experience, both personally and professionally. They balance the sense of frustration, anger and sorrow when a child like Ndodet dies. To me, is what MSF is all about – doing our best and providing necessary medical care under difficult circumstances, and ultimately measuring our success and the meaning of our work one patient and one name at a time.

Best wishes from the Central African Republic,

Raghu Venugopal