Lauralee in Lankien

In all my years of doing general practice obstetrics, no mother ever named her baby Lauralee. So when the paramedic told me that the woman who delivered yesterday named her baby after me, I was thrilled, but confused.

“They called him Lauralee?”

“No,” said the paramedic, with the tiniest of smirks. “She called him Doctor.”

My namesake, Doctor, is a very nice baby. I have a photo of myself with Doctor and Doctor’s mother, sitting on the floor of the tukul. I can’t show it to you, which is a shame, because it is a nice photo. You can’t see Doctor’s face though, because he is at his mother’s breast, but I look quite satisfied.

Every doctor has at least one in his or her closet. Call them medical errors, therapeutic misadventures, preventable adverse events, whatever. But we all have them. Any doctor who doesn’t, hasn’t practiced long enough. I added one to my closet on Malaria Day. Thankfully the patient survived, despite me.

He was just a little boy, around 4. Maybe it was because I saw him late at night and I was tired, maybe it was because the examining room was dark and my eyes are getting weak, maybe it was the more than 300 cases of pneumonia already seen in the month of April. I am grasping for excuses. The paramedic made his initial assessment; the chart said “severe pneumonia, refer to doctor”. Just another pneumonia I thought, cough, rapid breathing, nasal flaring, but I can’t really hear any crackles in his chest; not listening in the right place I rationalized. Admit, antibiotics, paracetamol, oral rehydration. Back to my tukul.

The following day the little boy is getting worse. I take a good long look at him this time, the thing I should have done the night before. I pull down his lower lid; the conjunctiva is pure white. Our nurse asks, “Was the parachek (the rapid test for malaria) negative?”

The child has malaria! Start the self-flagellation.

His hemoglobin is reported as 2, the lowest hemoglobin I have ever encountered. The malaria parasite has invaded and consumed most of his red blood cells. He gets worse before he gets better. We give him IM Artemether and a blood transfusion. I feel terrible. By Day 2 he looks a little better, by Day 3 I am starting to feel hopeful, by Day 4 he looks like a rose.

I will always remember this child and I will never, ever, (never say never) make this mistake again.

The young man has spinal TB. He is a paraplegic, treated several years ago, but unable to complete his treatment because of the war. He had to flee his home and default on his TB treatment. Now he has it again, fever and back pain. He drags himself painfully across the ground using his arms. He has several brothers; they always seem to be with him. They carry him in a blanket when he is not strong enough to propel himself. He is emaciated and does not weigh very much. I imagine him the way he used to be, straight and tall, like his brothers.
 
The young man is getting worse. He spends his days curled up on his side, facing the wall of his tukul. Nothing we do seems to reverse his decline. He is dying. His brothers understand and ask to take him home. They carry him in a blanket , each one taking a corner.

 

 

At night, the sound of the frogs is deafening. They sit in the big pools of water out by the airstrip and sing their little hearts out. (More on water and the airstrip another time.)

The day spirals out of control and I never get to do another clotting test but I stick my head into the ICU tukul several times during the day to see how he is doing. He looks fine and the staff tell me he has had no further bleeding. The next morning he is discharged from the in-patient department still complaining about the itching in his foot.

"Across sub-Saharan Africa, AIDS is the only killer more devastating than traffic for people ages 15 to 44. For children, traffic is the No. 1 killer. An African is 100 times more likely than an American to die in a car?" "Last week, the United Nations called road safety a ‘public health crises, on the scale of AIDS, malaria and TB’."

-Newsweek, April 14, 2008

Sadly, Sudan can lay claim to many of the "public health crises" of our time: malaria, TB, diarrheal disease, pneumonia, malnutrition, high maternal and child mortality. Traffic accidents however, are most definitely not on the list, at least not in Lankien. Lankien would have to be several rungs up the development ladder to claim traffic accidents as a problem. There is no traffic in Lankien! I should qualify this statement. MSF has a vehicle that we use for out-reach visits; occasionally a truck from the World Food Program, or one carrying goods and passengers, comes to town. However, this is not to say that there is no burden of injury in Lankien, it’s just that the pattern of injury is different. The main injuries are burns and fractures in children, and gunshot wounds in young adult men.

Small children, toddler age, suffer serious burns on their hands, arms, and faces. They tumble forward into the family cooking fire with outstretched hands. Children fall out of trees and fracture their elbows. These children are of course a little older, old enough to climb trees. Lastly, and most tragically, are those who suffer gunshot wounds. The victims are, with few exceptions, healthy young men in the prime of their lives. The ones who survive their injuries  are often left with a lifetime of disability.

Like all houses, tukuls require maintenance. Our kitchen tukul is in particular need of attention. Big chunks of mud are falling off the walls, particularly around the doorframe. Although the men do most of the tukul building, the task of mudding (from the verb "to mud") and re-mudding, falls to the women.

Caption: Re-mudding the kitchen tukul

Our base nurse killed a snake today. He is from Kenya, so he knows about these things. First, he got a big stick. Then he asked our ‘data collector in training’ to distract the snake. He then stunned the snake by striking it in its middle area, and finally finished it off by clobbering it over the head a few times. I took notes, in case I have to do it myself one day. The other method I have seen here in Lankien is to try to shoot the snake. This seems to take a lot of bullets and be less effective. I guess it is hard to kill an excited, angry, undulating snake.

Southern Sudan is home to some of the deadliest snakes in the world. They have names like ‘Black Mamba’ and ‘Red Cobra’. At home we have the ‘Massasauga Rattler’. I only know one person who has been bitten by a Massasauga Rattler. She waited in the Emergency Room in cottage country in southern Ontario for hours and eventually went home without treatment and without any ill effect from the snakebite. The people of southern Sudan are not so lucky. Since coming here I have seen four cases of snakebite, all of them serious. They basically come in two forms: limb threatening and life threatening. In the first kind, the snake’s venom can destroy skin, muscle and bone. Depending on the amount of venom injected, you might get only minor swelling or you could lose the entire limb. In the second form, snake toxin spreads throughout the body and can cause death from respiratory arrest or bleeding.

My first experience with a snakebite injury occurred shortly after my arrival in Lankien. The patient was a young woman in her 20’s. She had been quite innocently going about cleaning her tukul. As she was reached behind something, she felt the snake’s fangs sink into her finger. Six hours later, her arm had swelled to three times its normal size. She was in excruciating pain. We did the best we could: pain relief, elevation of the limb, antibiotics, tetanus toxoid, but the skin on the back of her hand eventually sloughed off anyway. She didn’t loose her arm though, so I guess she was lucky, in a way.

Mount Kilimanjaro, from the air, is a truly spectacular sight. You can see it on the flight from Nairobi to Zanzibar, snow capped, amidst towering thunderheads. Going to Zanzibar alone was a bit of a mistake, this occurred to me as I was having a romantic dinner for one on a "spectacular white beach". What I really needed from my R and R was someone to talk to, a sympathetic ear, the chance to ventilate. But my usual sounding boards, Erik and my sister Monica, were at home in Canada. Speaking to them on my GSM phone just wasn’t adequate. I tried to make the best of Zanzibar, but it was the incessant harassment by the street hawkers that finally did me in. At another time, in a different frame of mind, I would have loved Zanzibar, but not now. I am embarrassed to admit that I went back to Nairobi early and ensconced myself in the Hilton for two days, bothered by the persistent thought that the money I was spending would have fed X number of people in Lankien for Y number of weeks. (Pleas feel free to fill in the variables.)

I dream about Lankien when I am away from it, something I do not do when I am there.

I spent most of my R and R trying to figure out what I needed to regain my physical and emotional equilibrium before going back to the field. Tomorrow I return and it is a relief. The work is intense, fascinating and consuming. There is no time to fell lonely or homesick. .