I follow the shadows in front of me. With just stars to light the way, I follow Samedi and Abre to Abre's house winding amongst the shadows in the shapes of pointed roofed huts, trees, tall millet stalks and brick fences.
We round a corner and the shadows dance on the walls of the compound in the flickering light of a kerosene lamp as the shadow of Abre's wife brings in some wooden stools for us to sit on. Then she returns for the formal greeting of curtsying at the waist and bending the knees to present her hand bent at a 45 degree angle down to be shaken by each visitor.
Abre presents his problem for Samedi and I to give advice on. Once the advice has been adequately discussed and accepted, Abre's wife brings out a small metal pot filled with pasta shells and a goat meat sauce. The repas is set on the rickety wooden "coffee table" and we lean forward and dig in with our large, flimsy spoons.
As we sit up, belly's full, I ask Abre what I think will be a simple question. It turns out to be a long, twisted story that I don't really understand until later.
"Abre, how did you meet your wife?"
Abre clears his throat and starts spinning his tale in his rich, deep baritone voice.
"I was back in the village. I'd come to Béré for high school. I went home on weekends. When classes were over I went home to work my field. I saw this girl from a long way off. She pleased me.
"A few days later, she came to draw water at our well. I had a mango in my hand. I offered it to her. She didn't want it. I insisted. I asked her why I would give her a bad mango? She took it.
"When she came back to draw water a few days later, I had a bunch of mangoes to give her. We started to talk.
"I told my father that was the girl I wanted to marry. She was from a village 6 km away but had come to go to the school in my village, Kalme, and was the servant of my neighbor.
"My dad said it wasn't wise to get a girl from that village, but it was up to me. He would pay the dowry, but then it was up to me. So he did.
"Half-way through the next school year, I decided it was time to find her. I heard she was in a certain village. I went there with my friends, but she had just left. I heard she was at the market, I went there with my friends, but she wasn't there. Finally, I heard she was back in Kalme. I went there to the house where she'd been a servant. She wasn''t there.
"I knew then she was back at her parents house. I called together three of my strongest friends. I told them that tonight was the night. They nodded and we left at 10pm to walk to the girl's village. When we got to the outskirts, I told my friends to wait. I left my bike a little farther on under a certain tree.
"I snuck into the village and stole into the girl's family compound. Stealthily, I made my way to her hut. I knocked on the door. No answer. I knocked again. Still nothing. I knocked again and whispered loudly 'it's me.' She opened the door and told me to leave. I refused. I told her to come out and go get my bike under such and such a tree. She said no so I grabbed her hand and made her come with me. She fought, but not loudly enough to wake her family.
"I brought her to my bike and then to my friends. We Took her by force home to my village that very night. We got in at 5am. That's how I got my wife."
I'm sitting there stunned. Not exactly the romantic love story I'd hoped for. Fortunately, before I could say anything stupid, Samedi pipes up with an explanation.
"That's our tradition. The woman should be stolen from her family by the man who's paid the dowry. He should get his strongest friends to go with him because the family will resist and if he's not strong enough to take his wife be force they'll beat him up. Then, a week later, the girl will get her girlfriend's together and they'll go to the boy for the marriage. But everyone will make fun of him and say he wasn't strong enough to fight for his woman. So, you need to strategize, come at night and bring some tough guys with you if you want to be respected."
The next night, I'm sitting around a similar table, only this time well lighted, with our Pastor Dieudonne Atchouma. I tell him what Abre had said last night.
"That's nothing," he said. "You should check out the tribe around Bongor. Their woman are tough. They all know how to use the bowstaff like the Chinese. From an early age, the girls practice out in the fields. When you want to get married, after you pay the dowry, you are sent off into the bush with the woman and you have to fight her. If you can't beat her, she'll beat you to a pulp and send you home with your tail between your legs and you'll have to find another woman. If you beat her however, and are able to disarm her and capture her and bring her home, then you've earned her and the village's respect and you can marry her.
"Those woman are fierce. Back in the days of the German colonists, they tried to conquer this people. They had guns and everything but they were beaten back by the women with their bowstaffs. They're hard-core."
James
Sunday, August 19, 2007
Marie
I'm poised over the body, scalpel in hand. It's hard to believe that this will be the third major surgery on this poor woman in a month. I've been torn inside as to whether this is the right thing to do, but now as I stand ready to cut, I feel peace.
"Let's pray."
As Samedi prays in Nangjere I find images rapidly running through my mind:
Huge mass. Cut ureter. Tied femoral vessels. Sinking feeling realising what I've done. Meticulous suturing. 4 hour surgery. Feeling of failure. Swollen leg, but alive. Slow but sure recovery. Discharge. Return a week later with swollen belly. Ultrasound showing loculated fluid. Is it tumor or leaking urine. Abdominal surgery again. Belly full of yellow liquid. Every surface inflammed and stuck together. Jelly like substance on everything. Retention sutures. Two drains. Three weeks in the hospital with liters of fluid still coming out. Uncertainty. If it's the leaking ureter I should take out her kidney. If it's the tumor, why put her through another major operation. Today, there's pus coming out the drain. I can't wait longer.
I open my eyes and slice from the bottom of her last rib, across her side to in front of her pelvic bone. I use the electric cautery to slowy go through fat, fascia and the different muscle layers. I open the cavity over the kidney. I dissect out the fat. I slowly release the fine fibers attaching the kidney surface to the surronding tissues. I work my way deep in and around the top part taking off the adrenal gland. Then aroudn the bottom part and the back. Finally I find the huge renal artery and vein. I delicately strip off the fat till I can see it well. It's so deep. I'm trying to not shake in my nervousness. If I don't tie it off well, she could bleed out quick. I don't really have the right instruments. I finally get three clamps on the artery. I cut the artery and tie the part I'm leaving in two places and the part I'm taking out in one. The vein is huge and branches right under where I've cut the artery. I have to go deeper. Finally I clamp it and cut it. Then the ureter is clamped and cut. I pull out the kidney and then tie off the ureteral stump. Then I tie off the vein twice and release the clamp. Blood surges into the field. I clamp the stump quickly, put it under a little tension while Samedi suctions till I can see where it's bleeding and clamp that. I tie it off. I release it. No bleeding.
I close up and finally, Marie Guelia, goes home a week later completely healed. I know that what I have done I am incapable of having done. But that's the cool thing about working here, God puts me in situations where I know I can't do it, and then when I do, I can't help but give him the credit.
James
"Let's pray."
As Samedi prays in Nangjere I find images rapidly running through my mind:
Huge mass. Cut ureter. Tied femoral vessels. Sinking feeling realising what I've done. Meticulous suturing. 4 hour surgery. Feeling of failure. Swollen leg, but alive. Slow but sure recovery. Discharge. Return a week later with swollen belly. Ultrasound showing loculated fluid. Is it tumor or leaking urine. Abdominal surgery again. Belly full of yellow liquid. Every surface inflammed and stuck together. Jelly like substance on everything. Retention sutures. Two drains. Three weeks in the hospital with liters of fluid still coming out. Uncertainty. If it's the leaking ureter I should take out her kidney. If it's the tumor, why put her through another major operation. Today, there's pus coming out the drain. I can't wait longer.
I open my eyes and slice from the bottom of her last rib, across her side to in front of her pelvic bone. I use the electric cautery to slowy go through fat, fascia and the different muscle layers. I open the cavity over the kidney. I dissect out the fat. I slowly release the fine fibers attaching the kidney surface to the surronding tissues. I work my way deep in and around the top part taking off the adrenal gland. Then aroudn the bottom part and the back. Finally I find the huge renal artery and vein. I delicately strip off the fat till I can see it well. It's so deep. I'm trying to not shake in my nervousness. If I don't tie it off well, she could bleed out quick. I don't really have the right instruments. I finally get three clamps on the artery. I cut the artery and tie the part I'm leaving in two places and the part I'm taking out in one. The vein is huge and branches right under where I've cut the artery. I have to go deeper. Finally I clamp it and cut it. Then the ureter is clamped and cut. I pull out the kidney and then tie off the ureteral stump. Then I tie off the vein twice and release the clamp. Blood surges into the field. I clamp the stump quickly, put it under a little tension while Samedi suctions till I can see where it's bleeding and clamp that. I tie it off. I release it. No bleeding.
I close up and finally, Marie Guelia, goes home a week later completely healed. I know that what I have done I am incapable of having done. But that's the cool thing about working here, God puts me in situations where I know I can't do it, and then when I do, I can't help but give him the credit.
James
Tuesday, August 14, 2007
Baby Hernia
Friday. The end of a long week. I'm set to travel Sunday to N'Djamena to pick up some volunteers. The day is almost over. It's been pretty quiet...
"Docteur, you should see this case." Jacob pokes his head in my office at around noon.
A talk, lean father with his young wife wrapped in a bright blue, and yellow patterned body wrap walks in carrying a chubby little three month old. He's sleeping quietly. The mom sits on the exam table and unwraps the baby exposing the obvious problem.
His left groin and scrotum is swollen to 10 times the normal size.
I palpate it and with gentle pressure the "mass" slithers back into the belly causing the child to wake up and cry. My finger is in a hole in the inguinal canal. When I release, the cries cause the baby's intestines to pouch right back out.
If I wait, the intestines could get trapped outside, and since I'm leaving Sunday, I should operate today even though I'm tired.
Samedi, Abel and Simeon all try tirelessly to find an IV without success. Finally, we are forced to use intramuscular Ketamine for the anesthesia.
The tiny is strapped onto a "papoose board" so he can't move and Betadine applied generously to his abdomen, groin, scrotum, penis and upper legs.
I open the hernia pack, scrub, pull on sterile gown and gloves and pick up the scalpel.
It seems so big compared to the little body now draped in sterile towels.
I carefully, gently slice a two centimenter incision over the still bulging hernia.
The sac is so thin I can see the intestines inside. It reaches all the way down to the testicule. It is a delicate thing to dissect off the spermatic cord from the thin sac and it tears in a couple places but finally is free.
I push in the intestines and clamp off the sac. I tie it closed and cut off the rest of the sac. This is where I briefly think of doing something I regret not doing later. Everything I've just read says that tying off the sac in infants is almost always enough with just a 1% chance of recurrence. So, I decide not to close the hernia defect but just close the fascia over the spermatic cord. I attach the testicle to the scrotum with a button on the outside and close up the skin.
He did well under anesthesia and I go home.
The next day is Saturday so I don't do rounds until the afternoon.
I come up to see the nurse and he says that I need to see the baby I operated on yesterday, his scrotum is swollen up.
I have a sinking feeling in my stomach as I walk down the dimly lit corrider to the bare bones hospital ward packed with visitors.
The baby looks sick. He is somewhat lethargic and has a rapid heartbeat and is a little pale. His scrotum is swollen and edematous. It's not readily obvious if it's the hernia come back or a hematoma. I ask the father and he says the swelling started on the inferior part of the scrotum and worked it's way up.
Sounds like a hematoma, but I'm not sure. I feel a sense of helplessness. If it's the hernia he'll die without an operation, but he's so sick he won't survive another operation. And I'm leaving tomorrow morning early.
I make a tough decision to not operate. I suspect he has malaria as well, so I treat his malaria and hope it's just a hematoma that will resolve itself. I don't feel good about my decision, but go home with a heavy heart. I'm sure I'll never see him again.
The next day is an early day. I get on the motorcycle and as I pull away from the hospital I can't help but wondering if the baby's not already dead.
I get back to Béré after midnight Wednesday after getting stuck in the mud just right before the barge crossing...just a few kilometers from Béré.
By the time I eat and hit the sack it's 1:30am. I sleep till almost 10:00 the next morning before going up to the hospital.
To my surprise, the baby is still alive and looking a lot better. He is alert and bright eyed, but his belly is very swollen and he's still pale. He now has an IV that has given him some much needed IV fluids. I order a hemoglobin...it's barely over 6, about a third of normal. We give him a blood transfusion.
The testicle is still swollen and it's obvious now that it's the hernia that's come back. I take him to surgery as the blood transfusion runs in.
Odei assists me as I incise larger and perpindicular to the old incision. A mass of swollen, dark red intestines pop into the field. I try to push them back in but without muscle relaxation and an already swollen abdomen, it's all but impossible.
It seems like most of the intestine is still viable. I push and push but can't get it all inside. It starts to get darker. The blood supply is being cut off before my very eyes. I'm feeling desperate and am sweating and swearing under my breath.
Finally, part of the intestine tears partway through. Thankfully, the inner part doesn't tear but now I have to take out part of the intestine. I open the appropriate instrument pack, put bowel clamps over where the intestine looks nice and pink. Then I clamp off the blood vessels supplying the dying part and cut it out.
Now, I'm stuck trying to suture the tiniest of small intestines in a field only about 3cm big. I make a ton of tiny interrupted stitches through the inner lining and then run a second layer through the tougher muscle layer. I release the bowel clamps. Air and stool inflates the newly sewn intestine without leakage.
Now, I'm able to push the rest of the intestine inside. I take out the testicle and cut and tie the cord pushing the stump inside. Then I close the fascia and all the the rest in three layers.
The I close my cross shaped incision. The kid's still alive though his belly is tense and he's not breathing that well.
I put him on IV fluids and antibiotics and tell his parents to not let him breastfeed or take anything to drink.
He's still alive the next few days but his belly is still very swollen.
Three days later, I come in and his belly is flat and soft, he's been farting and pooping and looks wide-eyed and has normal vital signs. The wound is healing well and he starts breast-feeding.
We'll send him home tomorrow.
"Docteur, you should see this case." Jacob pokes his head in my office at around noon.
A talk, lean father with his young wife wrapped in a bright blue, and yellow patterned body wrap walks in carrying a chubby little three month old. He's sleeping quietly. The mom sits on the exam table and unwraps the baby exposing the obvious problem.
His left groin and scrotum is swollen to 10 times the normal size.
I palpate it and with gentle pressure the "mass" slithers back into the belly causing the child to wake up and cry. My finger is in a hole in the inguinal canal. When I release, the cries cause the baby's intestines to pouch right back out.
If I wait, the intestines could get trapped outside, and since I'm leaving Sunday, I should operate today even though I'm tired.
Samedi, Abel and Simeon all try tirelessly to find an IV without success. Finally, we are forced to use intramuscular Ketamine for the anesthesia.
The tiny is strapped onto a "papoose board" so he can't move and Betadine applied generously to his abdomen, groin, scrotum, penis and upper legs.
I open the hernia pack, scrub, pull on sterile gown and gloves and pick up the scalpel.
It seems so big compared to the little body now draped in sterile towels.
I carefully, gently slice a two centimenter incision over the still bulging hernia.
The sac is so thin I can see the intestines inside. It reaches all the way down to the testicule. It is a delicate thing to dissect off the spermatic cord from the thin sac and it tears in a couple places but finally is free.
I push in the intestines and clamp off the sac. I tie it closed and cut off the rest of the sac. This is where I briefly think of doing something I regret not doing later. Everything I've just read says that tying off the sac in infants is almost always enough with just a 1% chance of recurrence. So, I decide not to close the hernia defect but just close the fascia over the spermatic cord. I attach the testicle to the scrotum with a button on the outside and close up the skin.
He did well under anesthesia and I go home.
The next day is Saturday so I don't do rounds until the afternoon.
I come up to see the nurse and he says that I need to see the baby I operated on yesterday, his scrotum is swollen up.
I have a sinking feeling in my stomach as I walk down the dimly lit corrider to the bare bones hospital ward packed with visitors.
The baby looks sick. He is somewhat lethargic and has a rapid heartbeat and is a little pale. His scrotum is swollen and edematous. It's not readily obvious if it's the hernia come back or a hematoma. I ask the father and he says the swelling started on the inferior part of the scrotum and worked it's way up.
Sounds like a hematoma, but I'm not sure. I feel a sense of helplessness. If it's the hernia he'll die without an operation, but he's so sick he won't survive another operation. And I'm leaving tomorrow morning early.
I make a tough decision to not operate. I suspect he has malaria as well, so I treat his malaria and hope it's just a hematoma that will resolve itself. I don't feel good about my decision, but go home with a heavy heart. I'm sure I'll never see him again.
The next day is an early day. I get on the motorcycle and as I pull away from the hospital I can't help but wondering if the baby's not already dead.
I get back to Béré after midnight Wednesday after getting stuck in the mud just right before the barge crossing...just a few kilometers from Béré.
By the time I eat and hit the sack it's 1:30am. I sleep till almost 10:00 the next morning before going up to the hospital.
To my surprise, the baby is still alive and looking a lot better. He is alert and bright eyed, but his belly is very swollen and he's still pale. He now has an IV that has given him some much needed IV fluids. I order a hemoglobin...it's barely over 6, about a third of normal. We give him a blood transfusion.
The testicle is still swollen and it's obvious now that it's the hernia that's come back. I take him to surgery as the blood transfusion runs in.
Odei assists me as I incise larger and perpindicular to the old incision. A mass of swollen, dark red intestines pop into the field. I try to push them back in but without muscle relaxation and an already swollen abdomen, it's all but impossible.
It seems like most of the intestine is still viable. I push and push but can't get it all inside. It starts to get darker. The blood supply is being cut off before my very eyes. I'm feeling desperate and am sweating and swearing under my breath.
Finally, part of the intestine tears partway through. Thankfully, the inner part doesn't tear but now I have to take out part of the intestine. I open the appropriate instrument pack, put bowel clamps over where the intestine looks nice and pink. Then I clamp off the blood vessels supplying the dying part and cut it out.
Now, I'm stuck trying to suture the tiniest of small intestines in a field only about 3cm big. I make a ton of tiny interrupted stitches through the inner lining and then run a second layer through the tougher muscle layer. I release the bowel clamps. Air and stool inflates the newly sewn intestine without leakage.
Now, I'm able to push the rest of the intestine inside. I take out the testicle and cut and tie the cord pushing the stump inside. Then I close the fascia and all the the rest in three layers.
The I close my cross shaped incision. The kid's still alive though his belly is tense and he's not breathing that well.
I put him on IV fluids and antibiotics and tell his parents to not let him breastfeed or take anything to drink.
He's still alive the next few days but his belly is still very swollen.
Three days later, I come in and his belly is flat and soft, he's been farting and pooping and looks wide-eyed and has normal vital signs. The wound is healing well and he starts breast-feeding.
We'll send him home tomorrow.
Monday, August 6, 2007
Chantal
I only get to know, really know, two classes of patients: ones hospitalized with chronic wounds or osteomyelitis and AIDS patients. There are really no other chronic diseases here...people don't live long enough (life expectancy = 49 years for men and 47 years for women).
For example, our little friend, Clement, has been back with us for a couple months now. He came to us three years ago with osteomyelitis of the tibia (bone infection in the lower leg) and has now had four surgeries to try and get his bone to heal so he can walk again. Two Romanian orthopedists were the last to operate on him in May and he's slowly but surely healing...we hope.
In the next bed over is his twin brother except that his is the right leg and he has been with us now for only two months. Both of them love it when we come on rounds. Their faces light up and they each try to outdo each other in slapping my hand hardest in giving me "five". Sarah also entertains them with the occasional balloon, animals drawn on their hands with markers or empty syringes she's taught them to use as water guns.
Two days ago, after giving me "five", Clement held out a handful of fresh, unroasted peanuts insisting that I take them. Even though I know he doesn't get enough to eat, how could I refuse his generosity coming from such a pure heart?
The other patients I really get to know are our AIDS patients. I consult them for free to encourage them to come to the hospital whenever they're sick without waiting too long at home hoping it'll "just get better." We also only make them pay half price for lab tests and medications.
Once they are in full blown AIDS, we are able to treat them for free, thanks to generous donors, with anti-retrovirals (triple therapy) and all other medications for opportunistic infections.
Plus, each week, they come to get a week's supply of ARVs and we have a meeting to discuss problems and teach them how to care for their health and how to recognize sickness and how to avoid transmission.
I get to know them very well. The down side, of course, is that I have to watch many of them die.
Koumabeng Chantal is an exceptional case. When I first arrived in Béré, she was already considered a "Cas Social" that was treated free by the hospital. She was eight years old, an orphan taken care of by a mentally slow, yet very loving grandma. I thought for several years that she was a "Cas Social" due to her being an orphan. It's so rare for a child given HIV by her mother during pregnancy or delivery to live past five years that I was sure she couldn't be HIV positive.
I was wrong.
Since before I came, HIV was kept a secret from patients and staff, there was no record of an HIV test done on Chantal. She was in good health overall. I treated her for several bouts of simple Malaria and some ear infections over the years. The only thing that gave me a clue that she might be immunocompromised were the umbilicated nodules on her face and arms, like tiny, fat donuts (molluscum contagiosum). But I'd found them on other children here who tested negative so I didn't think much of it.
When I came back from furlough this year, Chantal came to see me and I noticed she was getting quite thin. She had another ear infection and malaria again. This time, I decided to test her for HIV.
She came pack positive. I was shocked. She was now 11 years old. How had she lived so long?
I started her on ARVs which she tolerated well and was faithful in taking (at least, she came back each week to get her next week's supply).
Two months ago, she came in with a severe headache. She was in such pain that she cried and moaned all night long keeping all the other patients awake. I was afraid of some opportunistic infection like Toxoplasmosis but she did have severe malaria so I decided to treat her for that first before thinking of something else.
After three days, she went home pain free to finish her malaria treatment at home.
A month later, she repeated the same thing. She was suffering horribly. This time she needed five days of IV Quinine before the malaria and headache cleared.
Now, she's in my office again. As always she is gentle and subdued with big trusting eyes. As I gaze into that unblinking stare I see the quiet suffering. She only whimpers as I lay her on the exam table. Her only complaint is headache and vomiting.
Her malaria smear comes back very positive at 0,20% (I'm dead sick with 0,05%). We hospitalize her again and try a new, once a day anti-malarial called artemether. A single shot in the thigh once a day without all the side effects of Quinine.
Every day, I go to see her. She lies there quietly, her form thin, but not emaciated and that same look in her eyes. One eye is slightly crosseyed. Her grandma says she refuses to eat and has vomited several times. I decide to put her back on IV quinine. Her vital signs are stable and with some Tylenol and Ibuprofen, she doesn't have hardly any pain.
That night, the nurse goes to place her evening perfusion. She calmly looks up at him and tells him it's not necessary, she's going to die. He reassures her, although, she's not afraid and seems completely at peace. He starts the drip and moves on as she falls into a deep sleep.
At 2 am, she quietly stops breathing. She's gone.
For example, our little friend, Clement, has been back with us for a couple months now. He came to us three years ago with osteomyelitis of the tibia (bone infection in the lower leg) and has now had four surgeries to try and get his bone to heal so he can walk again. Two Romanian orthopedists were the last to operate on him in May and he's slowly but surely healing...we hope.
In the next bed over is his twin brother except that his is the right leg and he has been with us now for only two months. Both of them love it when we come on rounds. Their faces light up and they each try to outdo each other in slapping my hand hardest in giving me "five". Sarah also entertains them with the occasional balloon, animals drawn on their hands with markers or empty syringes she's taught them to use as water guns.
Two days ago, after giving me "five", Clement held out a handful of fresh, unroasted peanuts insisting that I take them. Even though I know he doesn't get enough to eat, how could I refuse his generosity coming from such a pure heart?
The other patients I really get to know are our AIDS patients. I consult them for free to encourage them to come to the hospital whenever they're sick without waiting too long at home hoping it'll "just get better." We also only make them pay half price for lab tests and medications.
Once they are in full blown AIDS, we are able to treat them for free, thanks to generous donors, with anti-retrovirals (triple therapy) and all other medications for opportunistic infections.
Plus, each week, they come to get a week's supply of ARVs and we have a meeting to discuss problems and teach them how to care for their health and how to recognize sickness and how to avoid transmission.
I get to know them very well. The down side, of course, is that I have to watch many of them die.
Koumabeng Chantal is an exceptional case. When I first arrived in Béré, she was already considered a "Cas Social" that was treated free by the hospital. She was eight years old, an orphan taken care of by a mentally slow, yet very loving grandma. I thought for several years that she was a "Cas Social" due to her being an orphan. It's so rare for a child given HIV by her mother during pregnancy or delivery to live past five years that I was sure she couldn't be HIV positive.
I was wrong.
Since before I came, HIV was kept a secret from patients and staff, there was no record of an HIV test done on Chantal. She was in good health overall. I treated her for several bouts of simple Malaria and some ear infections over the years. The only thing that gave me a clue that she might be immunocompromised were the umbilicated nodules on her face and arms, like tiny, fat donuts (molluscum contagiosum). But I'd found them on other children here who tested negative so I didn't think much of it.
When I came back from furlough this year, Chantal came to see me and I noticed she was getting quite thin. She had another ear infection and malaria again. This time, I decided to test her for HIV.
She came pack positive. I was shocked. She was now 11 years old. How had she lived so long?
I started her on ARVs which she tolerated well and was faithful in taking (at least, she came back each week to get her next week's supply).
Two months ago, she came in with a severe headache. She was in such pain that she cried and moaned all night long keeping all the other patients awake. I was afraid of some opportunistic infection like Toxoplasmosis but she did have severe malaria so I decided to treat her for that first before thinking of something else.
After three days, she went home pain free to finish her malaria treatment at home.
A month later, she repeated the same thing. She was suffering horribly. This time she needed five days of IV Quinine before the malaria and headache cleared.
Now, she's in my office again. As always she is gentle and subdued with big trusting eyes. As I gaze into that unblinking stare I see the quiet suffering. She only whimpers as I lay her on the exam table. Her only complaint is headache and vomiting.
Her malaria smear comes back very positive at 0,20% (I'm dead sick with 0,05%). We hospitalize her again and try a new, once a day anti-malarial called artemether. A single shot in the thigh once a day without all the side effects of Quinine.
Every day, I go to see her. She lies there quietly, her form thin, but not emaciated and that same look in her eyes. One eye is slightly crosseyed. Her grandma says she refuses to eat and has vomited several times. I decide to put her back on IV quinine. Her vital signs are stable and with some Tylenol and Ibuprofen, she doesn't have hardly any pain.
That night, the nurse goes to place her evening perfusion. She calmly looks up at him and tells him it's not necessary, she's going to die. He reassures her, although, she's not afraid and seems completely at peace. He starts the drip and moves on as she falls into a deep sleep.
At 2 am, she quietly stops breathing. She's gone.
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