IPD-1

My role here is a little strange – they have to have someone like me as an insurance policy for (rare) emergencies, and yet there generally isn’t enough work to actually fill up my day. So I’ve started rounding with one of the general MDs in the most acute pediatrics ward, to see if there is anything I can do to help them out with their (huge) workload.

So far, I’m not sure I’ve actually been that much help – but it has been fascinating for me. First of all, just getting used to the place, and to how it works. From my description of the hospital a few days ago, you can probably already imagine that the ward is – intense. Each bed is filled, not just with the young patient but also always with a caretaking family member, usually but not always the mother. The kids are sick and hot and bored, so the ones with enough energy may very well be crying. And though there are a fair number of fans, the air is hot and steamy. And has a particular smell – sharp and sour, some combination of urine, sweat, and dust. For someone not familiar with it, the first impression is of alarming chaos, a cul-de-sac off of one of Dante’s circles of hell.

But within an hour or two, you begin to see how it works – how the patients are being looked after, what the mechanisms are for making sure the sicker ones get more attention, the pathways for moving them along toward discharge as they get better. As I’ve mentioned a few times, malaria season has arrived in earnest, and most of the patients in this ward have it. (There is still an overflow of malnutrition patients, too, but they are in a different ward.) Each patient goes through a pretty standard protocol – malaria testing; evaluation of the severity of the malaria, including whether or not the child has “cerebral malaria” (in brief, very dangerous malaria that causes brain swelling and seizures); testing of hemoglobin and blood-sugar levels (since malaria can cause severe anemia and hypoglycemia). Treatments are based on results: if it is just plain malaria, a three-day course of treatment usually cures it. If cerebral malaria is suspected, antibiotics are added “empirically” (doctor-speak for “without first waiting around to confirm that the treatment is necessary, since by then it might be too late”) to treat possible meningitis (the two are hard to tell apart). If the hemoglobin is too low, the child gets a blood transfusion. And hopefully, after a couple of days, he or she is well enough to be moved to a less acute ward and, later, back home.

The devil is in the details, however, and the details are different from anything you might see at home. Take the matter of blood transfusions: A normal hemoglobin level is somewhere between 12 and 17. For some fragile patients in the US, anything below 10 can prompt consideration of a blood transfusion, and, informally, anything below 7 is often considered a “hard” indication for the same. However, many, many people here have anemia all the time, and your body is amazingly good at adapting to it. So our cutoffs are 5 (if the patient has severe symptoms or complications) and 4 (our “hard” floor). But you can often see kids with hemoglobins under 4 – a level that would prompt US hospital staff to run, not walk, to the blood bank – sitting around looking fairly un-distressed.

Then there is the matter of where to get the blood. It appears that the idea of giving blood, as a kind of general gift to some unknown recipient down the road, just doesn’t work, culturally, in South Sudan. (I can kind of imagine why – it’s weird to give a bag of your blood to someone, isn’t it? What if they take too much – or take it all…?! And isn’t it in some way like giving away your “essence?”) So, usually, if a kid needs a transfusion, we have to get a family member to go to the blood bank right then and give some. Which, happily, most seem willing to do. Of course, being a family member does not necessarily mean you will be a match – but the blood bank does have a small stock of various blood types; if the parent doesn’t match, the bank can dip into that small reserve and save the family member’s blood for someone else. Apparently, at the height of the malaria season, about a third of the kids who are admitted end up needing transfusions – so it’s a really good thing that there is a system that more or less works, different though it may be from what we do at home.

We expats, on the other hand, have been told we cannot give blood. The explanation seems to be 1) that they don’t want us getting anemic and exhausted, and 2) that if our blood is used and something happens to the patient, we might be blamed, and it could get ugly. Apparently, though, on our last day we can give some – we can sleep on the plane home, and I guess if the patient doesn’t make it, we’ll be too far away for mob vengeance to reach us - ! So I’ll try to leave a little of my A-negative behind – actually, a relatively valuable contribution, since apparently EVERYONE here is positive. You can’t give positive blood to a negative person – so, on the off chance that a person arrives who does happen to be negative, my blood will be useful.

It’s nice to watch the ward doctor (an expat) doing his work – the principle really seems to be that this is the LOCAL PEOPLE’S hospital, and so it is the local staff who should triage, evaluate, make decisions, prescribe, update the plan as necessary, discharge. The local practitioners – called COs, or Clinical Officers – have different levels of training, from basic nursing up through MDs (albeit MDs earned in systems that are not necessarily up to what we might expect in the US). So some of them need more teaching, help, and support than others. The expat doctor provides guidance as needed, but the discussion today really was more like one between colleagues than like the outsider telling the local what to do. I’m glad it can work like that sometimes.

Hey, and check out the latest fashion - scalp IVs! EVERYBODY'S wearing' 'em! (This guy was just about to have his out - he was going home.)