A week in the wards

June 22, 2007

After spending last week at Baylor's pediatric AIDS clinic, I spent all of this one in the pediatric ward of neighboring Kamuzu Central Hospital. KCH is where any of Baylor's 1800+ patients go when they become acutely ill and require inpatient treatment- so at any given time, at least one or two of Baylor's doctors are assigned to work the wards rather than the clinic. This week, I shadowed Anjalee.

The first day in the KCH pediatric wards was pretty shocking. (The picture above is really not representative of the week as a whole, but rather is from of the happiest moments with an almost-recovered patient who wouldn't leave my side.) From the outdoor courtyards in which dozens of mothers were washing clothes and preparing meals, to the three huge rooms of about 40 crying pediatric patients each, the sheer crowdedness of the whole scene overwhelmed me. Add to it all of the various hospital smells that wafted in from room to room, and you'd wonder whether anyone could ever recover from anything there. To the contrary, the end of my first day marked my first direct encounter with a patient's death. We had a 13 year old patient, Calvin, in the "high depenency unit" (HDU) with an acute febrile illness which we were not able to figure out. After assisting with a lumbar puncture on what seemed to be a much more serious patient, I returned to the HDU to find that Calvin had convulsed about 10 minutes earlier and was now dead, probably of a brain bleed- it turned out that he was a known hemophiliac. Now, I understand that throughout my career, I'll need to be prepared to deal with death- but this one really caught me by surprise and hit pretty hard.

In the wards here was the first time that the phrase "resource poor," which is thrown around all the time in public health and development literature, really began to hit home for me. Its not just that they don't have money here (they don't), but some truly necessary medical equipment does not exist in the entire country of Malawi. Case in point: we had another girl in acute renal failure from glomerulonephritis (an attack of the kidney's filtering ability), who hadn't passed urine for days and was thereby retained all of her water, making her one of the puffiest children I'd ever seen. According to the doctors, she probably could have gotten over her acute renal failure with just a few rounds of dialysis, allowing us to treat the cause of her illness. However, unlike in the US where dialysis is readily available in every city and small town, we were not able to put the proper equipment together for her after calling in favors from across the country. We had a hemodialysis machine but lacked a pediatric catheter- necessary for the patients 6 year old arms- and we knew of a peritoneal dialysis machine but had no fluid to use in it. By Thursday things were getting desperate and I contacted my uncle - a South African nephrologist - to see if he might be able to find one or the other and express ship it to Malawi. By the next day, he'd drummed up 24L of PD fluid and we contacted Air Malawi to help with shipping it here. Unfortunately, this effort was futile: right before the fluid was to be shipped, the girl suddenly took a turn for the worse and died. It was in all regards a death that never should have occurred. All in all, this was definitely a tough week for me to take in- but far worse for a few of our patients.

As bad as some of those anecdotes seem, I have to say that among our hospital's limitations, there were some really positive things happening there. For example, Anjalee and one of the other Baylor doctors started a study documenting the progress of a switch to "Plumpynut" calorie-filled peanut butter as a staple food for all children in moderate malnutrition status or worse. By procuring large quantities of this food and allocating it based on medical criteria, they methodologically showed that malnutrition can be combatted in a big way even in as poor a place as Lilongwe. The Nutritional Resource Unit, currently the emptiest ward with less than half of its ~60 beds full at any given time, used to have up to 3 children per bed just about one year ago, with high mortality rates to boot. Though the people here probably haven't gotten that much wealthier in a year's time, science and dedication has made quite an improvement. I am optimistic that there will be more success stories in the coming years as knowledge of and funding for international health picks up.