So a week at base camp, and the place that I would call ‘home’ out here.
With no outreach buddy anywhere to be seen I have been kept busy in the
inpatient department. A variety of staff holidays and, what in the business
is called a ‘high patient flow’ (i.e. clinic busting at the seams!) means I
haven’t exactly been idle. The basic figures are as follows. Discharge - 43,
died - 7, admitted - 58. Behind every number is a story, some tragic, some
remarkably uplifting; one of each to follow;
Yesterday we tried to resuscitate a twenty-eight year old man who had
advanced tuberculosis. He had been sick for some time. Sadly there was
‘something else going on’ which is what we term any condition that we cannot
diagnose due to a lack of facilities. Basically we went for hit and hope
treatment. Take an educated guess as to what it is and cross you fingers.
Inevitably we sometimes we get the calculation wrong.
The man was showing signs of acute liver failure and had begun bleeding
heavily internally. I managed to site an IV line and the blood that flowed
was very dark and thin, indicating he was not getting enough oxygen and the
iron level in his blood was dangerously low. A lab test confirmed as much
(Hb of 1.5, yes, I know, 1.5 for the medically minded).
Blood donors only come forward at the last moment and the only
people who donate are members of the immediate family. Sadly none of this
family matched the patients’ blood group. His condition nose-dived in the
mid morning. We struggled to rescue the situation, for every problem we
addressed another two would crop up. In the end the man became very
distressed and agitated, sensing, I think, that time was short. We gave him
a generous dose of diazepam and he gurgled, foamed and convulsed until he
was finally gone. Our national staff were magnificent, considering that the
patient was a personal friend of some of them. I can’t say it was anything
other than horrendous.
Earlier in the week we had seen a child with cerebral malaria.
He was very lethargic and didn’t flinch when we put IV lines into him, which
is never a very good sign. Round the clock observation and high doses of
antimalarials seemed to be getting us nowhere. I decided to have what is
referred to as ‘the chat’ with mum and dad. The chat can basically be
paraphrased, as ‘unless there is some sort of miracle your relative is not
going to survive this’. It is useful in preparing the family for, what is
often, the inevitable demise of a loved one, but it is not exactly easy.
Slowly, very slowly, the little boy began to show signs of
improvement. He began by moving an arm and sighing (as if he found the whole
thing a bit boring). By the next day he had opened his eyes and rolled over
onto his side. Today he was playing with his siblings, and grinning from ear
to ear, my whole year is worth it just for that.
Whilst the individual success stories are, personally, the most
rewarding many more lives are saved by prevention. This week there has been
a much-needed push to improve the care we give to pregnant women. The
newborn fatality rate here is astronomically high. Pregnancy and childbirth
are a leading cause of death in women. It is not difficult to see why. Most
babies are born at home with only a village wise woman (without any training
but lots of experience) in attendance. The babies are delivered onto a muddy
floor, they often aren’t kept warm enough, they may be two days walk from a
health centre should problems develop. The vast majority of mothers have
received no antenatal care whatsoever, and are very anaemic. A consequence
of this is that they bleed heavily and often die.
This situation is compounded by some damaging health beliefs that are
commonly held here. The babies’ umbilical corn is cut with a rusty blade and
the stump is often smeared in cow dung, leading to tetanus and infection.
For the first three days the baby is fed on goats milk, as it is believed
that colostrums is bad for the child. Establishing breast-feeding after this
is very difficult.
We only see deliveries in the clinic when all other avenues have been
attempted. The traditional healer, the old ladies and a multitude of wise
women have had a go at getting baby out and failed.
By this time the mother is often tired, the baby more often than not is dead
and there is precious little we can do about it. Destructive delivery is
often the only feasible option, and I can’t begin to describe what an
unpleasant business that is.
As an attempt to stem this lethal tide we have been constructing and
improving home delivery kits. These are kits given to pregnant mothers for
use in delivering their child. They consist of string to tie off the
umbilical cord, a razor for cutting the umbilical cord, soap for mum and
baby, cloth and blanket to wrap the baby in, gloves for whoever is helping
in the procedure and a large plastic sheet in preference to a muddy floor.
Simple but, all the research indicates, very effective
Their construction rivals Wembley stadium in terms of length and problems! A
committee of a few of us (being the only children’s nurse got me mired in
this particular adventure!) have met to discuss various aspects of the kit.
What do we include, what not to include, how to train mothers and so on. The
‘do we need a plastic bag for the placenta’ argument dragged on for weeks.
Finally resolved we began to give out the kits this week.
Obviously first on our hit list was the clinics staff. I held a large
teaching session for all the staff that wanted to come. I proceeded to open
up a kit, mime having a shave with the razor, I blew up one of gloves like a
balloon bouncing it up and down and took a bite out of the soap (which was
stupid).
My point being that if we don’t teach mothers how to use the kit we may as
well not give them out. It at least got a laugh and hopefully made the
point. I finished by telling them that as there were twenty of them there if
they each told five pregnant women to come and collect a kit that would help
to save the lives of one hundred babies and one hundred women. Back to
numbers again
So health interventions in there mega and nano versions this week, what will
happen next? Your guess is as good as mine.
