Day 29: Starting on the Malaria Research Ward

Today I started my week on the Malaria Research Ward. Patients who have seizures or a low "Blantyre Coma Score" are admitted to the ward. Kids usual present in bad shape. Most are in a coma, but are able to breathe on their own. Most are comatose due to the malaria parasite, but there are sometimes other reasons for their coma. Sometimes they have meningitis, encephalitis, congenital brain abnormalities, tumors, hydrocephalus, etc. The lady who runs the ward is the one who actually developed the Blantyre Coma Score (BCS) over 20 years ago.

The research team also found that a lot of the kids diagnosed with malaria, were found on autopsy to have died from other causes. They then found that by looking in the eyes there are signs that indicate cerebral malaria vs other causes. Recently, a MRI was installed and they are getting the first series of MRI's that show cerebral malaria. It is exciting to be in the midst of discovery.

A one-year old, little girl, Grace, was admitted for seizures and coma. Her left hand started twitching on the ward and so she was sent to us. Her EEG (brain activity) showed her seizures. Apparently she had been having seizures for ? amount of time because her EEG showed seizures even when she wasn't physically convulsing ("subclinical seizures"). In the afternoon, I did my first pediatric LP on her. We couldn't send her to MRI because she wasn't stable enough.

I also helped admit Fasileni, a 3-year old child who appeared malnourished and hydrocephalic. She was slightly alert when I saw her. She had a fever x 6 months, been convulsing for 5 months. Recently she had lost her eyesight, speech and ability to walk. Mom had tried the outpatient clinics, but finally wanted answers so brought her into Queen's Hospital. We sent her for an MRI, as an LP had already been sent to the lab.



Day 30: Only so much we can do...

To make a long story short, the patient I admitted yesterday, Fasileni, was found to have a massive inoperable brain tumor. Her MRI was unrecognizable.

For the medical ppl: It is likely that she has hydrocephalus (enlarged head) from an ependyoma or choroid plexus tumor that is blocking CSF drainage. The CSF increases and the head swells. In the States, someone may have tried to operate or put in a shunt to drain the CSF, but the patient would still not live long.

Palliative care is all we can give her. When I saw her on rounds in the morning, she had slipped into a coma. Her LP results were lost in the lab, but it was decided not to put mom and the patient through the emotional and physical pain of another LP. Since she had malaria parasites, we continued treating her with Quinine. When I left that night, the Malawian registrar hadn't yet had a chance to sit mom down and tell her that her child would not live long. I spent the day trying to avoid mom's eyes and wishing I spoke enough Chichewa to explain what was going on. I watched the mothers of the ward share food and worry, as they watched us check their children, putting their trust in us, hoping that we could provide a cure.

The other patient that was admitted yesterday, Grace, was again found to have seizures on her EEG even though she wasn't visibly fitting. Throughout the day, all the drugs available on the ward were used to try and stop them. Phenobarb, Phenytoin and Diazepam. It was a balancing act because the drugs would cause her to decrease breathing and we can't intubate here (put a tube down to breathe for them). We had to accept that we just couldn't stop the seizures. Her LP was negative, her parasites had cleared, so it is likely that she also had something wrong with her brain.

Meanwhile, another child started screaming (delirium?). We weren't sure if it was the malaria or something else causing it and had to give her Diazepam to calm her down to sleep. Overnight we were told that she started up again and the Sisters told her that mom would not come back if she kept it up. Mom "left" and the patient never screamed again.

Today's admissions included Mike and Richard. Mike was another child with malaria and fever. But he was posturing (classic opisthotonos). We were able to bring down his fever, but he was still comatos. EEG was negative, and we awaited the MRI. An LP was done (negative). His eyes had classic malaria findings.

The other admission, Richard, had been vomiting, and had diarrhea. He was pale, anemic, jaundiced and hypoglycemic. He had a massive liver and was breathing heavily. HIV status was unknown. As the registrar was telling mom that he looked very sick, he coded. Stopped breathing, turned blue and lost what pulse he had. They bagged him (breathed in oxygen with a bag-valve-mask). After a few minutes with no response, they had to call it. It took a second for mom to realize and then she started to keen. The sisters went over to comfort her and we had to walk away and continue on rounds.

Don't get the wrong impression, it isn't all doom and gloom. It's just that the tough cases are the ones that stick with me. Hamid and Manuel (two older boys, one with meningitis and one with malaria) were able to sit up and eat today. They did a complete 180 degrees from the comatose state they were in before. Soon they will be able to go home. Back to their family and friends and back to their lives. The dads were so happy. Hamid was able to laugh and Manuel was able to see again.

Medicine can do wonders. Unfortunately, sometimes there is only so much we can do. It can be a humbling, fascinating and rewarding profession. It is days like today that remind me of this.