[This post was submitted by UNC professor Ian B. K. Martin, MD. Martin is director of Global Emergency Medicine at UNC and recently returned from Malawi, where he was visiting UNC Project-Malawi and other organizations in Lilongwe.]
Saturday, November 28, 2009 — Picture it: It’s 95°F and muggy in a small pavilion constructed of cement. This is the Under 5 (U5) clinic at Kamuzu Central Hospital in Lilongwe, Malawi.. This enclosure is packed with children escorted by various adults. Some are on queue to see the “P” clinical officer; s/he is ready to see the kids triaged as priority patients. Others are in line to see the “Q” clinical officer who evaluates these patients prioritized at this lowest level. But at one end of the structure is a walled-off area. The door to this small room reads “Emergency.” Inside are four beds for the sickest kids who require immediate attention. This is where my journey with 7-year-old “Joyce” begins.
Joyce was brought in by two women—I’m still not sure how exactly they are related to her, if at all. There she lay, listless, barely conscious, and struggling to breath. On prying her eyelids open, I could see the yellow tint of her sclerae. The accompanying adults added little more insight. When asked about Joyce’s status, the guardian responded that she is HIV negative.
I was in the U5 clinic to visit with Dr. Jeff Robison. He is an American pediatrician working with the Baylor HIV Initiative here in Lilongwe, Malawi. Jeff plans a career in pediatric emergency medicine and as such has a tremendous interest in the acute care of children. I was spending the day with him to see how he has affected the delivery of acute care to children. But as the need arose, I jumped into action to lend a helping hand caring for patients.
The team, including a clinical officer, a nurse and another pediatrician from the UK, struggled to get IV access. The British pediatrician and I finally secured two IV lines—one in the arm and the other in the neck. Joyce’s pulses were fast and thready at times and she was clearly in shock. What is from malaria or bacteria? The blood smear didn’t reveal any parasites, but it could still certainly be malaria. Fortunately, at this U5 clinic at Kamuzu Central Hospital, we could get a malaria smear, glucose and hemoglobin measurements, as well as a pulse oximetry reading right away. Joyce’s glucose was so low that the machine read only “low.” Her hemoglobin concentration was amazingly only about 2 grams (far below the normal range). And her pulse oximetry read only 77% on room air with a heart rate of about 150 beats/minutes—both signs of a girl in great distress. We needed to take action, or Joyce was going to die right in front of us!
Thankfully, Dr. Robison and his team have truly changed how acute care is delivered in this U5 clinic. Those of us from the developed world may take this for granted, but any who have spent time in the developing world, particularly sub-Saharan Africa, know that quality emergent care is not commonplace. At least at this hospital, a kid would usually wait in a long queue to be seen by a clinical officer (who is neither a nurse nor a physician). In Joyce’s case, the clinical officer likely would have identified her as very ill and just directed her to the wards to be admitted—no further evaluation and no life-saving interventions! But luckily for this little girl (and seemingly many others), things have changed at Kamuzu Central Hospital.
Clearly Joyce needed blood, and it was ordered from the laboratory. In the meantime, we rapidly infuse lots of saline—bolus after bolus. She doesn’t improve. We infuse dextrose, but still, Joyce’s condition worsens. She is given oxygen and broad spectrum antibiotics, yet her pulse weakens. “Where’s the blood?” Dr. Robison asks and asks again. Inside, I was thinking that if this girl didn’t get blood yesterday she’s as good as dead. To make matters worse, Joyce has another seizure (two or three in total). Just as hope seem to fade away completely, along comes Dr. Robison with the blood. He had taken it upon himself to go fetch it from the laboratory while the team and I continued to care for our critical patient.
The nurse hung the blood—two units in all. The clinical officer now infused quinine for the suspected malarial infection. Joyce’s pulse improved with the blood. She was responding, ever so slightly, to our critical interventions. But her breathing became more labored, and she remained barely responsive.
In richer parts of the world, Joyce surely would have been intubated at this point, but that’s because there would have been a bounty of ventilators and good intensive care unit (ICU) support. But here in Lilongwe, where could this critically ill child go?
I followed Dr. Robison to Kamuzu’s very small and modest ICU, where he pled the case for admitting Joyce to the unit. You have to understand that this ICU only has four, maybe five beds—and more importantly—only four ventilators. Resources in this environment have to be rationed very carefully. Fortunately, one ventilator (the one used for kids) had just become available. The ICU team was fearful, however, that the man who had just been extubated would not “fly” and would need the ventilator again. One of the ICU team said, “Bring her by on a trolley on your way to the ward.” We said OK.
We ran back to the U5 clinic where Joyce was still fighting. We packaged her up for transport to the ward—and hopefully ICU. Dr. Robison, a volunteer nurse from Spain and I pushed the trolley as fast as we could to the ICU. I was literally holding the infusing blood above my head while helping to push the patient. On arrival to the ICU, the intensivists came to evaluate Joyce. They were clearly concerned about her condition and quickly assumed care. First order of business: intubation!
I visited Joyce in the ICU later that same day and again a day later. She looks better and is breathing much easier. I found out that contrary to what her guardians told us, she is HIV positive, which I suspected given the very fine texture of her hair. I used to see this a lot in AIDS patients during my training in Baltimore some years ago. The intensivists agreed with our assessment (septic shock of some sort) and were continuing to support her. All we can do now is hope.
Update 12/18/09: Unfortunately, Dr. Martin has just learned that Joyce died.