Malaria Strikes

Now, about Suzanne's bet with James over the Milkyways ... she lost.

It started with headache and really bad muscle aches in her tricepts. The fatigue was a bit hard to figure out, since the lack of food combined with the heat makes one tired all the time anyway. But she was tired, that's for sure. Add a little nausea, and viola... you've probably got malaria. We didn't even bother to check her blood smear, we just started therapy. And since she wasn't vomiting yet, she didn't have to have me start an IV for her quinine. She could just take the pills. Those are combined here with doxycycline. You do have to keep eating though, which is no small deal since the quinine takes most of your appetite away. But if you don't, the quinine makes you hypoglycemic. It also make your ears ring a high, annoying pitch. Bad enough to make it hard to sleep at night sometimes, and difficult to hear a conversation under certain circumstances.

The first night she was miserable. She was restless, had fever alternating with chills, a bit of nausea ... just felt awful all over. Fortunately, I'd made her start medication earlier that day (over dosed her a bit with the doxy, as a means of revenge on the malaria parasites), and the next day she was feeling much better. On the up side, after a week of quinine, 3 weeks of situps and just as long eating only 2 meals a day... she's lost 2 inches around her waist and now fits loosely into her "skinny jeans."

As for me, I continue to be well... not even a case of traveler's diarrhea (though I admit that the cigarette smoke in Paris first, and then N'Djamena, gave me sinusitis). I've gotten a few mosquito bites, but I take my low dose doxycycline prophylaxis faithfully and I'm on my cumulative 14th week of life in Africa still malaria free.

We continue to be busy in the operating room... usually 2-4 cases per weekday. Today brought in an unusually good smelling Arab woman with an equally unusual problem. As best as we can tell, she'd been unable to get pregnant by her relatively older husband (recall, the average life expectancy in Tchad is 41). She'd been allegedly pregnant recently, but had lost the child, and had been unable to get pregnant again since. We prepared her for exam and probable D&C. It QUICKLY became apparent that she was NOT going to let 4 strangers, all men, uncover her to get ready for the proceedure. Of course, unless she was buck naked in a certain specific and strategic area, there was nothing we would be able to do for her. She thrashed around a bit, enough to to make us feel like we were forcing her against her will (even though she'd already agreed to the procedure), and we gave up for the moment, not sure what to do or say (in Arabic, which none of us spoke) So, I figured it was time for a little better living through chemistry. After 15 mg of Valium, not only did she not care she was dressed down as Allah originally made her, she was no longer going to remember the 4 men she was with instead of her husband.

Turned out that her cervix was about as uptight as she was, and it took James a good 20 minutes of dilation before we convinced ourselves that she was no longer impregnable. We rolled her out of the OR and were promptly met by her devout husband as he covered her from head to toe. James, in his limited Arab, explained that, "The door of the house of the child (This is literally the phrase translated as uterus) was shut. I opened it. May Allah give you many children." He looked very relieved. Later, when he passed me on the path he paused to speak with me and taught me the typical Islamic greeting "salaam aleikum," (Peace be with you) and it's customary response, "aleikum asalaam," (And peace be with you).

After settling into the guest house later that day, I was summoned by one of the student missionaries who ran to get me. I was told that a baby had been admitted with severe malaria, but that they couldn't get an IV to rehydrate and start quinine. So, I quickly went to the peds ward to see what I could do. The two of us found the child, now lifeless on the ground outside the entrance to the peds wing, her mother weeping bitterly over her form as the father covered the tiny body with a drape. I learned she had been brought in 20 minutes ago, and had to wonder, yet again, why it is that people wait until the last possible minute to take action. The more important it is to do something, the longer it is they wait to actually do it. I circled around the ward to see if there was anything else I could do before heading back home. When I walked past the doorway again, the family was gone. A little wrist bracelet, so common on the children here, remained on the dirty concrete where they had been. I stooped to pick it up, and stood, looking for the parents. I never saw them again, and have kept the bracelet as a reminder to not put off the important things in life.

Not long afterwards, I got another call for a similar problem. Same story, though this time the parents had come sooner in the course of the disease. Everybody had tried to get an IV on this kid, and had blown all the best veins (I thought that only happened in the US!) I tried a few places where I imagined veins to be, until I was convinced they were all mirages. I gave up... and went to get a 20 gauge IV to start a femoral line. No sterile prep, no drape, no lidocaine, no nothing except gloves (which the parents had to buy), and IV catheter on a syringe, and some alcohol sprayed on the skin. I knew if I hit the femoral artery instead of the vein, the 13 red blood cells left in this kid would end up flowing out on the bed (the lowest hemaglobin I've seen here is 2.3). I said a prayer, and then slipped it right in. I stitched the IV onto the leg, covered it with a tegaderm and made sure the quinine was ordered and the blood transfusion was dripping. As I turned to go, I wondered how long the parents would keep the think working (nursing care is largely provided by family members, since THE nurse has to cover the whole ward).

I didn't have to wait long. I got called back that night because the IV wasn't working. I went to take a look. The dressing I had so carefully places was partially pulled back, and a fly was crawling on the bloody joint where the IV joins the catheter. "Nice," I thought. There was dried blood and feeding flies on the tape I'd used earlier to secure the line to the leg and prevent any unnecessary tension on the catheter/tubing junction. I do this on purpose because they have no screw-on Leur lock connections here... everything is slip tip, making it exceptionally easy for IV sets to come apart. This is by design, as there are no such things as 3-way stop cocks which would otherwise allow IV injections to be made without any disconnecting of the IV drip set tubing. To uninitiated eyes, the filth and lack of care and cleanliness is simply revolting. It's just that patients, no... people survive, and rarely thrive, in this dirty world. Or, they do not live at all.

I took of the tegaderm dressing, pulled the catheter back a bit, got it running again, redressed it, and went back home to go to bed. I was glad to see that in the morning, the blood transfusion had been completed, and there was enough fluid in those little veins so that another IV could be started... since my femoral line had infiltrated (or something), and then removed.


Things you don't want to hear in the mission field: "Say... what's your blood type?"