The end of paediatrics (kinda)

Warning: potentially upsetting stories about children dying

Sorry it’s been ages since writing on here. The internet at the compound has been broken for almost 2 weeks so I’m using this weird internet USB stick with my sim card that’s very temperamental + slow. Sorry it really can’t cope with pictures!

I finished my 3-week block in paeds yesterday and started surgery today. I was really happy about this. Those 3 weeks have probably been the most stressful 3 weeks of my life. That’s a bit of an exaggeration, but still it has been insane. I have never had so much responsibility over life and death (clearly I need to get a grip back home if this isn't as stressful as some other much more mundane things!).

Over the last 2 weeks I have probably been present at the death of about 15 children, almost all of which I was either the most senior person there or equal most senior with the other med student Liz. Our only qualified paediatrician left a couple of weeks ago so we’ve been running the paeds ward with the physician assistants – who are brilliant + definitely senior to me, but often not there when we’re called to see dying babies. The two of us have done so many paediatric resuscitations I’ve lost count. There have been so many that I’ve even been called to 2 since yesterday morning when I officially stopped working on the paeds ward. Thankfully some of the resus’s have been successful, but sadly most are not.

Some deaths have been really upsetting, particularly when the child has been there a while. Most of them however arrive to the hospital peri-arrest (ie on the verge of stopping breathing/heart beating). There’s a huge social problem with healthcare here. I think a lot of it is parental education – so many of these kids have been ill for days before coming in, but the parents are out in the fields working all day and don’t really pay that much attention or don’t know the signs of when their child needs medical care. There are also difficulties with transport, many patients travelling all day to get to the hospital. Another big problem that I find quite concerning is that all too often these children will be referred from small community clinics where they will have been sat there receiving very little care a few days, getting sicker and sicker, until eventually the parents decide to take them to hospital, by which time it’s too late. There is also ‘local treatment’ – the witch doctors, whose treatment is recognisable by little cuts on the skin over the site of problem.

The hardest death was probably my 2^nd resuscitation – a little two year old with cerebral malaria. He had developed a severe pneumonia probably from aspirating during febrile convulsions (ie he breathed in vomit when fitting, the fits being caused by the high temperature + malaria in the brain). Within minutes of his arrival he stopped breathing, but still had a heart beat. As I’ve said before there are no ventilators here, so Liz and I bagged him for an hour and a half (gave breaths using a mask fitted to a rubber globe that you squeeze and it pushes air into their lungs) - really the only kind of resuscitation available here. All of that time his little heart kept beating and I had this vague hope that if we kept going for long enough his antibiotics might have time to kick in… but the combination of not breathing properly during the seizures and the pneumonia had left him with fixed + dilated pupils – a sign that he was severely brain damaged beyond hope of recovery. Eventually Dr Coppola, the hospital’s head doctor who had been coming to see how we were getting on, told us to stop. That was probably one of the hardest things I’ve ever done, knowing that we had been keeping him alive, and then listening as his heartbeat slowed down. Then his mother told us this was her 4^th child who had died. We were all really upset.

It really makes you question though, surely after the first 3 children dying, wouldn’t you think to come to the hospital a little bit earlier? There has got to be some kind of educational or cultural or financial issue here stopping the parents from bringing their kids in sooner. It’s not really something I have any clue how to address.

Not all of paediatrics has been sad though. The little 3 year old boy I mentioned a while ago with the chest drain made a good recovery and was discharged a few of weeks ago. I saw him for follow up in clinic the next week. It was great to see his cheeky little face again. By the time he was discharged he’d stopped being scared of me, as his parents were so friendly + I hadn’t stuck him with any needles for a really long time! Every time I went to check on him on the ward would always give me a grin and play hide + seek behind his mum. It was great to see him again and doing so well, although when it came to time for him to leave clinic he ran up to the door and opened it and was gone before his mum could stop him. He had definitely had enough of the hospital!

The two kids from last post had really good outcomes too. The boy with the status epilepticus made a full recovery and was discharged home after a couple of days of observations. The meningitis kid took a bit longer to recover and was discharged after about a week or two with some hearing loss and possibly a mild cognitive impairment but essentially back to normal. (Turns out he’d been at a little clinic for 3 days before coming to the hospital, presumably not on the appropriate antibiotics as he’d been getting progressively worse and got better with us as soon as he was started on them).

So although it is really hard working here, it’s also really rewarding. I’ve spent most of my time here feeling pretty out of my depth, but turns out that’s a brilliant way to learn – if you don’t learn quickly, patients die, so there’s no difficulty in getting motivated!

Now that I’m on surgery I think I will be shouldering a lot less responsibility – unlike my final two weeks of paeds, there’s an actual qualified surgeon in charge.

Tomorrow I’m having my first full day off since getting here, besides ones where I was puking – woopie! I’m going to Tamale with the Coppolas –the head doctor and her family. They have 2 really cute girls (aged 6 + 9) who are a great comic relief in what can sometimes be a really depressing place to live.