Malaria Season

It’s malaria season right now. Everyone seems to know this around here. And at the end of May beginning of June, when wet season ends and dry season begins, when the weather shifts from raining once or twice daily, to no rain at all, p.falciparum wields its mighty sword to end more lives than the season prior once again. It is a cyclical process. And it likes malnourished children in particular – sick, weak, easy to kill. What this means for me is that the majority of children in the pediatric ward right now seem to be admitted for malaria. Out of the first 15 patients I saw last week on rounds, the first 13 were malaria. This is not a run of the mill mild malaria, these children, anywhere from 0-14 years old, come in with a severity of presentation that I doubt many nurses and doctors in the U.S. have ever seen, not at least to this degree, and not at least in the U.S. The parents here carry their children to our ward themselves in their arms. The children arrive comatose, seemingly lifeless, and then the mom or dad lays the child down on one of our beds with the child looking like a Salvador Dali painting of limp clocks over table tops: mild to no response to an aggressive sternal rub, no response to pressing strongly across their thumbnail with a solid object like my pen. Often I see children come in with high grade fevers above 39-40 degrees (102-104 degrees F) and rates of respirations in 2-5 year olds around 75 breaths per minute (more than double the normal). I see anemia, hypoglycemia, prominent Kussmauls breathing, decorticate and decerebrate posturing, circulatory collapse (algid malaria) and I have dealt with the heart going into cardiac failure – all because of malaria.

Mind you, these children that come into the hospital are so sick; it is sometimes difficult for me to fathom how parents have to walk so many hours before reaching our hospital, the child in their arms and that the child ends up presenting to us so late in the disease process. Then I wonder how these nurses and doctors do it without getting hardened to the reality of this poverty and its consequent illnesses, but then I look again and many of the doctors and nurses are more hardened to it than me. And I don’t necessarily blame them. You are a rare individual if you can deal with such high numbers of death, poor prognosis and hands tied from more advanced treatment because of a lack of medication, equipment or procedural know-how and not get a bit hardened to children dying. If you were 100% committed to all of these patients and stuck with them through hell and high water, stayed up nights and days to watch them, added additional care like you would for a family member, you would crack from the number of losses. Or you would be a saint.

Yesterday I came in determined to get my rounds done by 11am. I’d touch base with people for an hour, check my email within that first hour and then round from 9-11am in the malnutrition ward. I have been trying to round on my own in the malnutrition ward, with other nurses or nursing assistants translating for me, and then reporting the most severe cases to the doctors for consultation. I’m trying to do this because we round here with one doctor and one nurse on ~60 patients. I figure if I can lessen the load for them by ~25 patients, it helps. But then the nurses were all ready to meet regarding a new schedule I wrote up for the next 6 weeks trying to a) distribute the shifts more equally and fairly and b) make sure nights and weekends were covered by 2 nurses and 2 nursing assistants, rather than 1 of each on nights and weekends (with ~60 pediatric patients here at any given time only 1 nurse for all 60 patients overnight is not enough to decrease mortality rates here – kids are going to die at that nurse to patient ratio – it’s not possible to take care of everyone – at MGH we complain when we have 7 patients in a night – imagine…1 nurse taking care of all of MGH's Ellison 17 and 18 plus PICU. What it means is either, one very ill patient gets all the attention to the neglect of all others, or all the others are watched more closely to the neglect of the one dying.)


So yesterday, before I knew it would be another malaria death day, I am meeting with the nurses about schedules. It was like a British Parliament session, discussion, bantering, passionate debate all in Kinyrwanda. I had no idea the topic would elicit such a thorough discussion. Through a translator I am told that they need time to examine their old schedule and study the new schedule and that they will come back to me with a consensus. I was actually looking forward to this. Because it seems the schedule system could be improved and although no one seems to have worked on this topic exclusively, now that it was re-presented in a different fashion, I think it allowed for an open discussion about times and work hours and such. At least I hope so. About this time, Alice, the nutritionist, gets me out of the meeting and tells me there is a child she is worried about. The past few times I have learned that Alice is getting better at assessing when a patient is doing poorly, or needs more assistance than the child is getting, and so now I have more confidence in her. I hope also she is learning that when she sees a kid doing poorly that there is actually something we can do for him or her. So I leave the meeting, go to the malnutrition ward, stethoscope and Harriet Lane in hand. And just like the 10 month old with malaria I ended up doing chest compressions on last week, this toddler looked in the same shape. ( The 10 month old was a child who came in the week prior, during a Saturday night while I was there, and when I went to examine the child when she started all of sudden gaspingfor breath, fast and loud, there was no heart rate, no pulse, I listened again and again, incredulous that there was no heart beating, had the nurse confirm and once he said, “Oui, il n’y a rien,” I immediately started giving chest compressions, then carried the infant to another bed where our one oxygen tank was and took our one oxygen source off a 7 day old baby in respiratory distress and put it on the 10 month old baby with no heart rate and started giving more chest compressions, cranked up the oxygen tank, gave more chest compressions, had the nurse pull up 50% glucose and adrenalin, gave both, gave more IV fluids, got blood transfused into the child…and low and behold, the heart started beating again…the infant survived – I couldn’t believe it – the moment when the heart started again I just kept listening to the heart rate again and again with my stethoscope – checking the pulses – is that possible? Did the heart really start beating again? It was unbelievable to me – I am still in somewhat disbelief that what I and another nurse did together started the child’s heart again. Not only did the infant survive, but she went home healthy and happy, continued quinine medicine in tow just a few days later. Was also the second time in my life I’ve ever done chest compressions. The first time was with the child who died a few weeks prior.)

Anyway, this child yesterday looked in the same shape. Close to comatose. A loud rapid gasping for breath with deep sternocostal retractions on the toddler’s marasmic ribcage, eyes rolled back and lethargic. When I held her fragile skinny arm in the air it flopped down like a rag doll (like I have said before in previous writings) and I cursed to myself, angry that this child looks now like two children I have seen before in pediatrics who have been in critically bad shape. One who lived, the other who died.

So Tuesday’s child, had a heart beating; it was a regular rhythm but faint, I counted the respiratory rate. It was ~75/minute on this 7.8kg 2 ½ year old. I could not feel a pulse in one of her wrists, but the other one I could feel – a rapid feeble thing but nevertheless, a vital sign. I notice I depend a lot more on vital signs here. It is a reassurance for me at this point – got a pulse, your breathing, OK, good sign, good sign. Unfortunately we only have one machine to tell oxygen saturation and it is often finicky and doesn’t work and of course with this child, it wasn’t working. So you focus on what you have – respiratory rate and heart rate. Limp, unresponsive to verbal questions and commands, eyes rolled back, pupils dilated. Now problem is, I was told by one of the docs here that kids who are malnourished are very sensitive to fluid overloads and electrolyte imbalances so adding IV fluid to their regimen is something that needs to be done with great caution. So I was hesitant to start an IV on this malnourished mixed kwashiorkor/marasmic toddler. I stalled a bit in the decision making process and listened to lung sounds. Cursed to myself again because there were crackles in the left lung. Fine quiet crackles but crackles. This makes me even more hesitant to add fluid because the child already has fluid in the lungs and it was the reason we stopped fluid on the child who died about three weeks ago, he developed crackles in his lungs not long after administering the IV fluid. So instead yesterday, I figure, OK, fluid in the lungs, I’ll stall a bit more, lets get as many labs and as much info as possible. I take the baby myself, wrap it up in a urine soaked blanket because there is nothing else and take her to radiology, jump in front of the line, take her straight into the room and the lab tech sees the urgency in this tiny little 7.8kg child gasping for breath loudly and rapidly, and we take off her clothes and the lab tech puts a protective gown on me and I hold the baby so she can have a chest x-ray. Then I take the baby back to the ward and try to draw blood. Again, she is a Kwashiorkor/marasmus toddler so her feet, cheeks and belly are swollen, but her chest and arms are concentration camp thin. A vein is incredibly hard to find on her. Plus she had diarrhea for the past two days despite a solution we give for that, vomited much of her fluid intake despite her NG tube and is dehydrated, skin tents on her chest. Then on top of that her skin is black and I am still not very good at finding a vein in tiny black marasmic arms of 2 year olds, especially when complicated by all these other factors. Nope. I can’t get anything. I have another nurse try and she can’t get anything. We have a person from the blood lab try and he can’t get anything. I know she probably needs blood. At least by my new bush medicine standards...which is you look at the conjunctivae, pulling down the lower lid of the eye and if it’s pale white, they probably need blood – that’s a hemoglobin of 4-6 and we transfuse below 6-7gm/dL. So the lab guy said, “Can’t we just transfuse her anyway?” And I said that would be great except I thought if we can’t get enough blood to do a hemoglobin, how can we get enough blood to do a cross and match. And he brings out some dies and chemicals and his glass slides right by the bedside and says he can figure it out right there. She’s 0+. I thought we were low of 0+ at the hospital so I said if we have it, then let’s give it, but I thought we didn’t have any here.

I’m basing a blood transfusion on the look of conjuctivae by the way, of pulling down the lower lid and looking at the moist inner part. Crazy it is. Truly crazy to me. In the states you’d be running all sorts of labs, getting all sorts of consents and permissions for a transfusion, it’s taken very seriously and then we monitor very closely HR, RR, monitor any potential anaphylactic reactions every 15 minutes for the first hour. Yes here, like everything, it is a different situation. Here you look at the conjunctivae and the rest of the clinical presentation and often before you even find out the hemoglobin, if the child is comatose with a positive malaria smear and white conjunctivae – we transfuse. The lab tech said he would go and look and send the blood over if we had it. We had it. So by now, a nurse got an IV placed in which fluid would go in, although we still couldn’t draw blood out. I ran Hartman’s Solution and D5% at the same time. Well I didn’t run it, the nurses set it all up. And if I could explain how they piggy back here, let me just say it’s quite rudimentary. So we’re now piggy backing fluids and I’m watching vital signs, listening to lungs and again cursing silently to myself because the baby is most definitely getting increased fluid in the lungs as the fluid goes in more, but then I decided better to have some fluid in the lungs then let her lie there gasping away horribly to her death so I continued with the fluid. Listened to heart sounds, listened to the lungs. Baby is looking pretty lifeless. Gave some lasix, just out of some bush medicine tactics thinking that maybe if the baby has fluid overload, that I could help both give the needed fluid and get rid of the other fluid I didn’t want at the same time. By this time blood arrived and we hooked up the blood, stopped the IV fluid. Lung sounds are now coarse crackles throughout both lung fields. I have probably been working with this child all morning and it’s now 2pm. I am tired. I’m actually pretty hungry too. But no one is watching this blood go in, or the vital signs, so I stay and record. Monitor. Record. Monitor. One of the docs I work with regularly had come in by this point. Agreed with the management, suggested we add 50% glucose, which I was going to do, but just hadn’t done it yet…was sort of holding off for some reason, watching blood go in, and then he gave sodium bicarb via IV being that this baby was probably in a metabolic acidosis from diarrhea further complicated by fluid overload. That was my diagnosis. Although who knows. There are few labs to confirm any of these diagnoses. No way to find out any of the serum electrolytes. No way to find out bicarbonate levels. Again diagnosis here is largely via clinical observations. The way a patient presents, her history, her current status, the way the course of her illness progresses, her fever patterns. Like the majority of the world who has few doctors and nothing close to an MGH in the country, we diagnose by clinical picture ( I heard that there are 400 doctors in Rwanda for 8.5million people). Anyway, there came a point where we had done everything possible for this little toddler. Or so I thought. So did the other docs think. Gave oxygen, gave volume(d5 and hartmann’s), gave blood, gave sugar. Now all there was left to do was wait. Feels odd to just wait in circumstances like this. When a child is on death’s door. You mean, I can just go? Like go on with my day? Go check my email and finish rounding on the other patients here? Doesn’t feel right. But I did. And I kept checking up on the little girl. And low and behold, her eyes opened a couple hours later. And she started looking around, very alert. And then her mom gave her some milk. And she drank it. And didn’t vomit it. And I was sort of in disbelief. Again. Is it working? Did what we did work? And I hear her talking to her mom in her cute but weak voice and I thought, wow, all is well. She was sitting up, drinking, talking. I felt so relieved. She would get better from here. All is well.

I came in the the next morning and the child’s bed was empty. I asked the nutritionist where she was and she informed me that the child died overnight. I am guessing heart failure from pulmonary oedema. I am also guessing, now, as well as everyone else, malaria. Which I and no other doctor checked or treated her for at the time. But most definitely that rapid decline like that was a malaria that was not diagnosed – masked by malnutrition. My giving fluids in her fragile state could have even precipitated her death. But what are you to do? These are decisions you make with your best judgment, using all your know how, and for that child I was largely on my own, with no one to ask and two doctors who came in afterwards later in the afternoon agreed with my management, so again, “Qu’est-ce qu’on doit faire?” I can honestly say I did what I thought was best given the circumstances.

So she was another malaria kid – yes, of course, it’s malaria season, just because it’s the malnutrition ward, doesn’t mean these kids aren’t catching malaria in the hospital. In fact many of them are. And now, any kid who isn’t getting better, I’m getting malaria smears on. And of course, the malnourished kids often don’t spike fevers because they are plagued with hypothermia so the fevers are masked by the hypothermia and since this child had an NG tube anyway, when she vomited, I and all others here thought it was due to the NG tube and her malnourished state and not a new onset malaria. And not only was it bad to hear this little girl died over night, the next day they move the next sickest child in the same bed, I was sensitive to it because I didn’t want that to become the death bed, the bed the kids who are dying go in, although this time we do a malaria smear right away on the malnourished child and she is GE +++, meaning very prominent malaria. And we do all the same things I did the day before except now we have quinine in the mix. But this child is younger and smaller, and breathing more desperately than the child from the day before and I just prepared myself. This one is going to die tonight. There is no way she is going to make it. She was in even worse shape than the child from the day before. I prepared the nurses, “She’s probably not going to make it tonight.” Although I think the only person I was preparing was myself. I gave one of the nurses a list of what to do overnight anyway. I decided to give Lasix this time every 4 hours 3 times throughout the night because I didn’t want to see the fluid overload I had seen from the day before. The Medecins Sans Frontieres guidelines suggested this. Because again, this child was dehydrated from vomiting and diarrhea and yet receiving fluid with crackles in both lungs. Not a good situation in which to add lots of fluid, and yet the child needs fluid. So I prepped myself. That this child probably won’t make the night. And when I came in the next morning, I didn’t go straight into the malnutrition ward, I wasn’t up for it yet, instead I went to look at my email in another office far away. Ease myself into the day. And when I saw someone from pediatrics I said, “How is that child that wasn’t doing well yesterday?” Waiting for the negative. And the nutritionist replied, “Well. She made it. She’s doing really well. Not on oxygen anymore. Eating. Drinking.” I couldn’t believe it.

Who lives and who dies? I feel like I have no sense of it here. Presentations are complicated. Management is by and large poor. Resources are limited. Malaria is, I am learning, as life-threatening as it is commonplace.

With malaria here, kids present with hypoglycemia, anemia, fevers, or no fevers if they’re malnourished, respiratory distress, some have cerebral malaria, those ones often present severely comatose, Glasgow Scale <5 meaning response to pain is often only to sternal rub, eyes do not open to verbal commands, aggressive stimulation or anything else, kids have doll’s eyes where when you move their head side to side, the eyes float the opposite direction of the way in which you move the head, or sometimes one eye floats in one direction and the other in another direction – unrelated to each other, no verbal or motor response, decorticate posturing. It is malaria at it’s worst. Some kids come out of this comatose state and miraculously, do fine. One doc called it the Lazarus effect. Supposedly 10% have neurological sequelae, so I read. And some die. I am seeing about 1-2 deaths a week here in children mostly less than 5.

Casualty of war. That’s the phrase that for some reason always runs through my head when I see a child die here: casualty of war. And then I ask myself, “Who’s war is this? Who’s who in this battle?” Unlike Iraq or Sudan, this war is something all together different. The perpetrators nebulous, the struggle misunderstood, perhaps the people, who say they are on the side of the dying children, have chosen not to fight hard enough, or they think the problem too large. It is apparent though that not many are fighting in these trenches – not many who are highly capable with large resources that is.

In sum, in Rwinkwavu where I am, children seem to be dying from malnutrition and infections: malaria, meningitis, HIV/AIDS, malnutrition. At MGH I never saw a child die from any of these things. In fact, I never saw a child die. In all of my almost 2 years in pediatrics I saw only one patient with meningococcal meningitis ( in 6 weeks here I've already seen 2 cases) and although he had severe neurological damage from the infection, he didn't die from it. And there are other children who died who were chronically ill and took their last breath either at home or in the PICU, but these particular children hadn't been doing well often for years. We knew usually their deaths were imminent - at some point or another. But all this aside, I never once actually witnessed a death occur on the pediatric ward on Ellison 18 during one of my shifts. Quite different than the large percentages chronic or congenital diseases I saw in the US, most of what I see here in Rwanda is treatable and curable, given the right context. It is something that like early this morning, I lose sleep over, so I am getting up right now at 4am to write.

To top all this off, as if the weekly deaths aren't enough, in this area of Rwanda, many of the moms accept the death of their toddler with a palpable stiffness and a spoonful of quiet tears. Some mothers don’t cry at all and instead stare into space blankly not a tear to be seen - an acceptance that I have yet to fully understand. I think this is because there is so much death in their environment, that a child dying is yet another child they have had that has died, or it is their child now on top of the two neighbor’s children they saw die this past month, or perhaps they are numbed a bit from their grizzly past, that one more death, doesn’t elicit the kind of outward exhibition of pain, torture, tears it would from a mother in a hospital in the U.S. with a 2 year old who has just died. Here after a death, they more often than not sit stoically, perhaps some tears, but not for long, not because they’re cold, but because I think, it happens so horrifically often. Their response to death or lack thereof reminds me often of the serenity prayer: God grant me the serenity to accept the things I cannot change. Courage to change the things I can and the wisdom to know the difference. Acceptance is the modus operandi for them; their courage has probably been widdled away slowly, one death at a time, one disappointment at a time, one bad agricultural crop at a time, one war at a time.


In the end, I think some of what I do helps. Trying to make them laugh. Tickling. Although if comatose I can’t do any of these things. And sometimes what I do is not enough or even questionably harmful, and it is easy to wonder if I should blame myself. Then I counter my inner dialogue and say, “But no doctor had any different opinion on the matter, everyone agreed with me. No one told me to check for malaria on that kid when the kid started tanking, they did tell me to do all the other stuff I was doing.” So who’s fault is this?

I am learning volumes. I am learning, terribly, the awful way – by the lives and deaths of very sick children. I wake up often now before my cell phone alarm clock rings thinking, “What could I have done differently? Is there anything I could have done differently?” And I then my brain jumps to dosage reviews in my head: Ceftriaxone 100mg/kg, Quinine loading dose 20mg/kg over 4 hours in D5, maintenance dose 10mg/kg over 4 hours, alternate with D5. In my little free time now I review malaria presentations and complications and read up on this little critter P.Falciparum and all the damage he does to these poor children. Malnutrition is the other research topic – I’m just not doing the job well enough. No deaths should be the standard. No deaths.

Prior to coming here, I did not know there was a season for malaria. Nor did I ever feel the tragedy of it. Yes I knew that many children die of it in poor countries, but it was a textbook understanding – it was an aloof “oh that is so sad” – I never felt the pain of it. I, like most people in the U.S., have never been exposed to these things, cloistered in a hospital of modern maladies, and even when traveling, with access to well trained doctors to advise me on what medicines to take, I have always been able to benefit from the luxuries of a wealthier life. Although I see children die from malaria on a weekly basis right now, it is odd to think that in some ways, this bug is something my body can fight. And that these children can’t. It doesn’t seem fair. They are much younger, smaller, and more fragile than me. Fight me bug fight me. Although then again, I have always known this world isn’t fair. And that I guess is one of the reasons I’m here. To try to make things more fair, for however little I have to add to the situation. It is a drop more than not doing anything. And P. Falciparum does a lot of damage with its little drops. So who knows maybe we can do some damage too – in the other direction – and figure out some way, to fight this bug better, drip by drip.