Walking down the steps of the hospital tours one through congested lines of local villagers. Amputations, blindness, open wounds and cough highlight the worry on the faces of the waiting. The angst expressions quickly dissolve into stoic intrigue as my scrub clad white skin passes by. A simple waive and utterance of "amakuru" (how are you) prompts a chorus of "ni meza" (I am well). This tends to break the ice, and smiles typically follow. The people waiting by reception may or may not be seen the same day, but they will wait until they are. They came with pots with some white rice and beans in anticipation of an extended stay. Patients must bring their own sustenance. Most did not bring extra clothes. Most don't have any. On the way to the pediatrics wards, a ramp leads past a three walled brick building. Smoke pours out of the clay shingled roof as pots of rice below sit atop wood fueled flames. This is where families can cook for loved ones as they hope to get healthy.
Up the path from the Pediatrics building is a UNICEF tent where cots were shoulder to shoulder, housing the sick children while the current building was under construction. The Pediatrics building opened within the past year. It's natural lighting and freshly painted concrete walls are a luxury compared to the adult units. The wards are divided into units. None more equipped than the other. There are the general peds wards, respiratory area, malaria unit, isolation and Intensive care unit. The beds are lined up like old smallpox wards, an endless row of mattress. There are over 80 beds, with sometimes more than 1 or 2 patients occupying each. Mothers resting with their children on stained sheets and old metal frames look up to malaria nets hanging above. There is a distinct lack of crying. I don't know if it's cultural or just my perception. Anywhere between two to five nurses and one general doctor roam the large dense building. That is not nearly enough staff.
Malnourishment is the standard. Almost every child has thin chest and looks to be at least somewhat protein deficient. You certainly don't see that much in the US. Most children have plenty of scars and chronic rashes in addition to their chief complaint. About 40-60% of the children have malaria. Almost daily there are a few new patients who arrive in a coma from the parasite. It's amazing how sick these children look, and how quickly some, and I stress the word some, get better.
Every child with abdominal pain will get a stool study. In the US, abdominal pain quickly brings to mind constipation. Our pre-packaged diets bolster our daily compaction of stool. In Rwanda, abdominal pain typically means a worm or parasite. It is not unusual to see the culprits without microscopy. There aren't many lab tests available at Kibogora, but testing for worms and malaria is a proficiency it can brag about.
There are a few things that are striking and unsettling about the medicine here. One being the lack of emergency response. A child with cerebral malaria, age 2, was in a coma. Mom is responsible for his tube feedings. The scarcity of nursing care did not make exception for this child who was clearly one of the sickest in the building. Mom pushed the porridge feeds through the syringe. As it tunneled his nasogastric tube the child started to choke and then seize. From across the room, while examining another patient, it was obvious that the one nurse who was around, did not know what to do. This was in the Pediatric ICU, a place when in the US, there would be well trained emergency response one on one nursing care. I ran to the patient and asked the nurse to bring intubation tools. There was no movement. This was not a common request apparently. I had to rummage through a disjointed and barren crash cart to find a tube that was too small and scope without a working light. The child was trying to breathe but no air movement could be heard. This child had aspirated and was going downhill fast. Surprisingly, the emergency intubation was successful and the trachea was suctioned. A true crisis was averted, but it was painful to think of how easily that child would have died. I know there are many lives that we are saving on this trip. Unfortunately, I know that inevitable death will also spread its touch.
To leave you on a high note, I'd like to take a minute to talk about a smile. We discharged a patient recently who had been in the hospital for weeks. As the child was running towards the door, as happy as always, her mother stopped and put out her hand in recognition. As the handshake developed, soft utterances of Kinyarwandan left her lips. I did not understand her words. That was alright as her eyes told the whole story. They were tired and had seen too much. They were also relieved. Her smile screamed happiness. That smile slowed down time and reminded all, that good is being done. It was a brief moment before the tugging on her dress by her daughter turned her towards the door. What a great day.
