#4 Malaria, Malaria, And More Malaria…

January 23, 2013

Sunday was a day of rest. As we enjoyed it, God’s design for it becomes more evident because we were tired. Not from overworking at all, but the fatigue of learning new routines and cultural norms, seeing this refugee / poor population, and the heat, muggy heat. It is a zapper.

It is a blessing to be working with a fellow Christian (Jim is Catholic), for we share the same dependence on and love for Jesus, and our conversations have a different depth to them. MTI is a Christian organization, but it is not a requirement to be a believer, but just a respecter of the mission statement: “To demonstrate the love of Christ to those affected by disaster, conflict and poverty.” I have been on teams that are mixed in faith foundations, and that is rich too. We tend to attract VERY GOOD VOLUNTEERS and for that I am thankful. Jim likes to go to church too, so yesterday, Sunday, we walked to the Catholic church at 8am and found one person waiting, also a visitor. So we three walked about 1/2 mile to the Anglican church and found the parishioners dwindling in from 8-8:30. Once the service got going, the preaching was passionate and the singing as always, had soul. It was lovely. I am always so blessed to see the children joining in and worshiping with their parents. Toddlers stay quietly by there parents side, because it’s just what they do. For at least 1-1/2hrs! The remainder of the day was restful (and kind of lazy) so by Monday am we were raring to go…

I was woken by a text beep at 5:15 am from clinical officer Jonathan. He had been checking on Zawadi in the ward and felt she had worsened. (by the way, we discovered her first name is actually Siffa). I feel bad we’ve been calling her Zawadi, but the staff tells us “it’s ok”. That’s like me being new at a clinic and everyone calling me “Pinneo”. Seems rude to me thankfully not here. So we are now calling her Siffa. Anyway, her spleen was now larger (it was already huge) and more tender, she’d had a bloody nose that had now stopped (this can be a caused by poor clotting due to liver enlargement), no fever now but worse “DIB” on the text. “DIB?” I thought. I called Jonathan who had been with her for 40 minutes now. She was finally urinating ok and was a bit better. They LOVE Lasix IV in Africa and use it liberally when there is poor urine output. We, on the other hand, believe in rehydration fluids to perfuse the kidneys and not further dry out the blood volume with a diuretic. When we arrived at 8:30 her pulse was now 104 (down from 160), no fever and respirations 24 (had been 40). The fluids we had ordered had worked and they had thankfully stopped giving lasix. She looked better but her pain was definitely worse, tender to palpation and we needed to work harder on getting her to a hospital. Fortunately, Jonathan had stopped the ARV’s for her HIV. This is unfortunate, BUT the side effects were so severe they needed to be stopped, Jim agreed and was planning on doing the same this am. I am clueless in this area and thankful that Jim worked with HIV/AIDS for 5 yrs. MB, your knowledge would be useful here :0)

I sat next to her on the bed, kissed her forehead and gave her some things from the little bag I’d put together. A few bars of soap (I instructed her dad to go and wash her clothes for the journey, but don’t think he ever did

), gave her a banana (she slowly ate ½ half of it and quietly handed the remainder to her dirty but cute toddler brother… so so sweet), I then gave her a protein bar and water bottle to get more calories in her. As she ate, I took one of my face wipes and gently washed her face and removed a little old blood, then washed her chest and arms. She did not resist but not a single smile. What is she thinking I wonder? Her father smiled at me and I was hoping she liked what I was doing. I do think she trusts us though, and feels loved. Touch… she needs touch…

The transfer to the hospital had to wait until afternoon due to the ambulance needing to drive someone to a meeting 30 min away first. We will follow up on this later, for we felt her transfer should have taken priority and we should have asked to discuss the prioritizing. We are learning, and don’t want to be “the ugly Americans” who insist on their way. Jim & I have the utmost respect for all the hard work being done here, they are servants to these people and without complaint. I asked my translator Joshua today if he liked his work here. He is a lab tech and rotates in as translator with volunteers. He smiled big and said “I love my work”. So wonderful to hear and also very evident in how he communicates with the patients.

MALARIA… not sure what happened over the weekend, but we saw SO MANY malaria cases today. 40? Or more? Haven’t heard the final count yet. I had one momma with a 2 & 4 yr old who came from Congo just one day ago. The kids had been sick with fever for a week and they both had very large Malaria parasite counts on their blood slides, the largest I’d ever seen. The 2 yr old had to be admitted for IV quinine since she was somewhat lethargic and couldn’t take the oral meds (remember, kids under 5 die often from Malaria). Later my translator and I were walking the 100 yd path toward the nationals clinic and came across the 4 yr old going the opposite direction to the camp. Mind you, she had only lived there 1 day but her momma sent her to go get her bag with water in it from her campsite and she obediently was on her way. A four year old! And not only that but a four year old with Malaria that we discovered hadn’t even started her meds hours later! We turned her around and had her walk with us back to the inpatient ward. Her momma couldn’t have left the 2 yr old so this was her only choice. She hadn’t started her malaria meds because they had no water. I brought out one of my bottles and gave her the first doses of her meds and the extra water… thank you Lord for having our paths cross at just the right time.

Malaria parasite counts are done on a blood drop slide and we’ve seen anything from 20 mps-3000 mps counts on the lab result sheet. The 2 yr old in the above paragraph had the 3,000 count and was getting IV quinine. Late afternoon I had a 10 kg (22lb) 1 yr. old child with a count of 8,000!!! She appeared ok so Jonathan said to have her wait, he wanted us to see more of the big crowd that had gathered, then he would start her IV and the Quinine. We were cranking through the patients as fast as we could. Nearing the end of the crowd I had Joshua look for her. She was no-where to be found

Where would this momma have gone? No one knew where she was and I felt so guilty feeling, that we had made her wait. I was praying she would show up but by the time we left she hadn’t. My hope is that she will be in the in-patient ward when we arrive in the morning…

***I should note that we have a stash of rehydration salts, antibiotics, and malarial treatment meds for us with us and in our hotel room, should either of us fall sick in the night. AND we have a pact to wake each other up if we get sick. I have yet to get a single mosquito bite :0)…. yeah! I few nights ago I had an upset stomach, both ends (sorry, TMI) threw up 3 times and felt like a charm! I called Jim just as an FYI because we had promised, in case I got sicker in the night. He didn’t mind (it was late), was very appreciative, concerned and thankful to know, a great teammate.

Wednesday… We are back at the hotel now after a shorter but HOT day in the clinic. The patients were fewer and much less malaria. Some severe cases though, 3 deliveries before we left with one more on the way. I missed the first one this am by 2 minutes!!!! Bummer. It was mom’s 6^th and she wanted to talk to someone about family planning. What a concept? They have the shots available here for much longer protection which is awesome.

We finally got news today on Zawadi (Siffa), that the hospital refused to admit her, UNBELIEVABLE, and they said her tests were normal and they put her back on her ARV’s (anti HIV drugs). She apparently in on the veranda of the hospital with her dad and brother, no mats I believe, and not sure frankly how they are making it. At some point we will have to pick her up I guess. Still figuring out the system but the staff know it and are aware. We have asked Bruce and Julie (a wonderful duo married nurse team from Oregon that worked with MTI in a few of the camps) to stop by the hospital and check on her. Hopefully they will find her

since we’d told them she was inpatient. It is so frustrating trying to help in this type of situation, and we have to back off on some of it. Her belly scan showed air and not fluid, and apparently her liver tests and kidney tests were normal… HARD to believe, especially the liver. I will keep you posted when we hear more or she returns.

Yesterday I had a toddler and 7-½ month old with severe malaria, needing an IV for quinine infusion over 4 hrs. Jonathan, the clinical officer, is the main IV guy on little ones and he tried about 6 times to get a line in on the baby. He screamed and screamed as Jonathan went from one spot to another, failing. He felt so bad and kept aplogizing to me but I told him we have a hard time with IV’s at times too, it’s “ok”. The mom was quiet and stoic, helped to hold the baby down and occasional bent down to nurse between attempts. It brought back memories of sweet Liam’s 10 days of IV’s when he was 3 weeks old. Chelsea couldn’t even be in the room at times. He had MANY IV’s but not such a hard time starting them on a chubby, well hydrated WHITE baby with BLUE veins. Loma Linda had a transducer that when held under the palm, it illuminated the vasculature. I thought as Jonathan was working so hard… “I wonder if that would work on beautiful black skin?” I need to check on this when home. They are probably so cost prohibitive, BUT these poor babies are hard to stick and it would be an amazing tool here. He finally had to give the med IM (via muscle) which is VERY painful and has bad side effects if done poorly. It was so hard to watch. This malaria parasite simply has to be stopped…

Yesterday one of the non-medical staff (27) had a question for me as we were waiting to load up and return home. Earlier in the day he’d brought one of the toddlers to me with a very concerned momma, he too was concerned and had examined the child. She showed me the boys scrotum which had one swollen side, non tender, non warm, testicles both down, and she reported it fluctuates from larger to smaller on the one side only. This is called a hydrocele, I explained, where fluid accumulates off and on and is often surgically repaired (in the states at least) but not here in this situation. The young staff member was now concerned about himself. He later reported to me that when he was in “Senior 1” (about 14-15 yrs old) he had pain in the scrotum at school and couldn’t walk so was taken to the hospital. They did surgery and he doesn’t know what they did to him. His concern? Will he be able to have children? If he marries he will need to be tested because if he can’t produce, “I’ll be of no use”. Unbelievable. I told him “What about marry for love, you can always adopt?” He said “Oh, that is very expensive”, etc. So the anatomy lesson began and I drew him his anatomy and how the testicles SHOULD be down but that they can travel up and down but should not stay up or become painful or get twisted because they can die (testicular torsion). I assured him that even with one testicle a man is very fertile. Oh my God, I was giggling inside thinking I can’t believe I’m having this conversation BUT was not wanting him embarrassed with me or to be “fearing” as they say here. He said with a concerned face “Maybe tomorrow you can check me and see if I’m ok?” I calmly said, “You know that would probably be better for Jim or Jonathan to do and they can assure you that you are fine… phew. Good answer Jeff? Too funny! (not his concern but the scenario) I also told him how he can check himself to see if he still has “two”… (smile inside again). So today when we arrived I privately asked him if he had checked himself and if so was he ok? He said with a smile, “Yes, there are two”… problem solved. YEAH!

Soloing kids… both yesterday and today I had young boys come with fever, etc and get diagnosed with Malaria. So what do you do when they don’t have a momma or daddy to give the meds to? Or the bigger 10 yr old brother comes with the little 6 yr old sibling? You give it to them, to the 7 or 8 or 10 yr old. AND they will take it I am told. Momma is in the field, or taking care of other children, or, or, or… it is what we have and somehow it is working. We American’s on the other hand, can’t send a tylenol with our kid to school in their backpack, even at high school, without a doctors note… BUT they can go get an abortion without parental consent at 14, I believe 😦 Who’s really messed up?

I had a mom who delivered a baby 2 weeks ago and presented at the clinic with mastitis (breast infection). She was in so much pain, one breast was hard and warm with reddened areas, smaller and very painful, the other was larger and long and producing all the milk for the baby. They believe you don’t nurse the baby on an infected or clogged side, exact opposite of what you are supposed to do for mastitis, so it was getting worse. It was a great teaching opportunity with the clinical officer. Today I had the fear that in the moment of teaching WHAT to do with feeding, warm packs, etc. That I might have forgotten to write for her antibiotics… I hope to God I did not : /

Today I saw a 15 month old malnourished boy that Jim had seen late yesterday in the refugee camp clinic. Turns out the boy did NOT have malaria but was asked to be brought back today since he was so tiny and had other problems. The dad was about 23 or so and his wife had been killed in the ethnic cleansing attacks last November. He had just arrived 2 days ago and was alone with this tiny toddler. Unbelievable. Dad’s affect was pretty flat and the child still had a fever but sat calmly on dad’s lap and did not fuss at the Muzungo checking him out. Antibiotics were started as well as many other things, and F-75, an amazing power mixed into clean water that serves as a very hi caloric milk substitute for these babies. The World Food Organization supplies this. The boy was adorable but not really playful, AND way too tiny by the MUAC measurement of his upper arm. He was in the “red” zone, which indicates severe malnutrition. At the end of the day I walked over to the Red Cross tent to report this twosome and asked that someone check on them frequently. Our MTI nurse “jane” was concerned that dad would not do well without the momma. I, on the other hand, told her that the good thing is that he showed up with him on the first day. That’s a good start. Redcross already had their eye on him and would check frequently. Apparently he already had friends in the camp he knew in Congo. Sad but true, and could be good support. As they say… “It takes a village”, certainly true here for sure.

I am so grateful for being back “in the field”… literally and figuratively. I have felt alive taking vitals again, assessing children (and even adults), and in using play therapy with my stethoscope or pen light to win over a small child before I examine them. Nursing “stuff” is coming back to me like riding a bike… I feel alive and energized and thank God for the skills I have been blessed with and the opportunity to use them for such needy people. It is truly a privilege being here. As usual, you take away more than you left. I am a bit saddened to not feel so shocked anymore though, at the shreds of filthy clothing the woman have to dress their children in, and the suffering in the lives they lead. Now I look at them and move aside the dirty cloth and think “Wow, it’s all they have”… but I am not shocked anymore. Maybe that’s ok. Maybe not? I used to want to come home and somehow ship a peddle sewing machine to the camp for mending. Hasn’t even crossed my mind this trip. Why is that? I don’t see shame in their faces either, they are just taking care of their children as best they can, making it through each day. To clothe a child here means to put “some” cloth on them, no matter how torn, and they are dressed. Then the little herd of children runs off to who knows where and passes the time in the dirt, grass, sticks… you rarely see a child cry or complain. A 3 yr old swallows half a Bactrim pill without a wince, because it was put in their mouth and a splash of water followed. Amazing. No bargaining or whining or bribing. The staff here are either Catholic or Christian it seems, and they do not question God with what they are seeing. It is just part of life and part of fallen man that has brought most of this on. They show compassion to all and continue on working long hours without a complaint… I don’t see them eating during the day, unless we’ve shared treats or extra bananas with them. It’s what they do and I am very impressed by their hearts and hard work. They appreciate us and we appreciate them… it’s a wonderful team and this makes me smile.

Lastly, a staff member here is under medical care and I have been worried and trying to help with some intervention. It has been very helpful I believe, but today I got concerned and expressed it to the staff’s loved one (that I know from years past) and they said to me in an email,

“Janey, Don’t worry, God is in control! He is slowly stabilizing…(more context)

Please, don’t be worried because God is in control.”

Thank you:)

Faith… I want to have my faith be such that I can do what I CAN do, but give up the worry and simply trust. I have witnessed this, and this, I believe, will be one of my biggest gifts from this trip.

~Love ~

Nurse Janey