She has measles. The fever began a week ago. She lost her appetite and began to cough. Five days ago the small red dots appeared in the skin of the head. They spread down over the arms, torso, back and legs, as the last migratory birds in Europe are now moving south towards the plains of Africa. The cough got worse and worse. Then came the diarrhoea.
She is a year and three months old. She is malnourished but not it is not acute. The girl has probably not had it easy her first 15 months of life. When the girl deteriorates, her last strength disappears and the parents understand that the situation is serious. Measles has raged in the area for some time. They know it is a dangerous disease.
They do what many others would do. They ask their closest people for advice. There are several options: They can go to the health centre/dispensary, but they have no money for medicines so choose not to do that. They can also go to a practitioner of traditional medicine, but the recommended plants will also cost money.
The treatment can be given as a drink, but usually applied in the patient's rectum. In this case, parents choose to follow the advice of the family. A woman in the family had had a genital inflammation and received treatment with potassium permanganate.
They know they can buy potassium permanganate in the market and that they can afford it. Now they might be thinking that the girl has fever and infection, and this treatment seems to help against fever and infection. They buy potassium permanganate and apply the liquid in the girl's rectum. Some of the liquid runs out and drops on the skin around the anus.
It is difficult to understand the whole story. Perhaps the rational is that the treatment is supposed to clean the girl. To drive out evil spirits, and that requires potent chemicals or poisons. When the availability of modern medical care is inadequate and the habit of the villagers or the family is to go to the practitioner of traditional medicine if someone gets sick, or buy something in the market that you believe will work, then those options sometimes seems most applicable. That is not that strange.
During my weeks in Mulongo I have seen several cases of "poisonings" with herbal mixtures, saline solutions and such strange things as agents used for killing fish applied rectally to the children. They have been recommended by different people, elderly relatives and practitioners of traditional medicine. As a doctor it is obvious that these "treatments" have a high potential to complicate the course of disease for those children who received such treatment.
They are often anxious, irritable or with impaired level of consciousness. The liver is often enlarged and becomes inflamed, because it is the one to take care of the poisonous substances. When the liver becomes ill it increases the risk of drops in blood sugar (because the liver contains the fastest sugar reserves in the body) and condition of impaired coagulation (when the blood does not clot as it should).
The potassium salt of potassium permanganate is a really powerful substance. When the liquid is applied on the skin or in the genital area it acts as a drying agent, but when it is introduced into the rectum, with its mucous membranes, there is a great risk that it is absorbed into the blood stream. High levels of potassium in the blood increases the risk of arrhythmias and sudden death.
The family lives far from Mulongo. The mother takes her daughter on her back and starts walking. They pass 48 km of sandy, bumpy, really bad roads, over a mountain pass and cross the Congo River before arriving in Mulongo. They step timidly through the door to the ward.
The girl she is carrying is really irritable, screaming and could not lie still. She coughs and her breaths require a lot of effort. Oxygenation rate in the blood is severely low. She suffers from respiratory distress. She is pale. She has low blood sugar and severe anaemia. The rattling when you listen to her right lung is a sign of pneumonia. The heart beats fast. She is tender over the abdomen, especially over the liver which is enlarged.
When we examine the girl more we see that she has spotted burns on the skin around the anus and thighs in places that have come in contact with potassium permanganate. She receives oxygen, sugar water intravenously, blood transfusion, antibiotics. The gastric lavage is blood-streaked.
The mother understands that the girl is very sick. The parents have done all they could for her sick daughter. It is not easy to leave the other children at home. Just going far from home costs money, not much, but more than they can actually afford.
The blood sugar levels drops relentlessly. Oxygenation rate gets better, and the pulse drops to more normal levels. The girl becomes less irritated, but she still has an impaired level of consciousness. Her condition is critical but stable.
The difficulty with poisonings is that the danger is not over after the first acute phase. If the liver gets affected the patient may develop an acute liver failure, which usually takes a few days to develop. In this case an emergency liver transplant is needed. The toxins are often powerful and can affect the enzymes in the body that regulates all of our body functions.
The risk of arrhythmias can continue for a long time. In this case, the girl suffers from measles, malnutrition, pneumonia, diarrhoea and anaemia. All those conditions at the same time puts the girl in a critical situation. And on top of that she also needs to tackle the poisoning.
In the morning, at six o'clock, when the sun has begun to shine in through the windows in the east, and the insects have left the bright bulbs in the ceiling where they have watched over the girl during her first night in the hospital, she deteriorates. She gets irritable again. Oxygenation rate decreases, blood appears from her nose, the pulse slows down to dangerously low levels and soon one can no longer feel the pulses in her wrist.
A few minutes later, her heart stops beating. The cardiac arrest is a fact. The resuscitation does not help her. We stop the efforts. Everything stops, as it always does when resuscitation attempts are given up.
The morning air is suddenly heavy, it almost must be swallowed in gulps. Then I turn towards the mother, to meet her gaze and say in French (which she does not understand) "it's over. I'm sorry. We did what we could." Then wait for my words to be translated, the ward is filled with the cries of the mother, she screams out her pain. She has lost her child.
What is it that really kills a child?
Without the poisoning we might have been able to save the girl. But at the same time I understand that the parents have acted to the best of their ability. There is logic in their thinking, although in this case it turns out very wrong. When modern medicine is only one of the options available when your child becomes ill, I believe the solution is modern health care of high quality.
We should be a good example. We need to show that this is the best option.