Malaria by Moonlight Part I

I sat down on the edge of the bed and took hold of the little boy’s arm, firmly but gently. He was radiating heat, even in the hot African afternoon. He was sweating, and he was scared.
According to the medical form, Abu was three years old. (Out here in Kono, using only first names to identify people provides an unprecedented level of anonymity; there are more repeated names here than in A Hundred Years of Solitude.) His father had brought him to the clinic about 2pm that day, just as Katie and I slipped out for lunch. The chief complaint was his distended abdomen. As I quickly noticed, he also had an intense fever.
Almost every patient who comes to Yusuf, the nurse, gets a malaria test. It is common, dangerous, and the test is cheap. It’s especially dangerous for children who have nutritional problems. Abu’s malaria test came back ‘++’, which meant that he had between 10 and 20 malarial parasites per viewing field on the microscope. His hemoglobin concentration, however, was 7.0g/dL. That’s about half of the median recommended value.
Yusuf had prescribed him a course of quinine during an overnight stay, and now we were all gathered round the middle bed in the observation room, trying to put in the IV line. Yusuf, Bori, Confort, were all buzzing around the bed with jars, vials, and syringes. Abu’s father was quietly holding Abu’s legs with both hands. I was holding Abu’s arms.
At this point all I knew was that Abu had severe malaria. This confused me a bit, because while the malarial test result, fever, and hemoglobin concentration all matched, the distended abdomen didn’t fit. The next morning I learned that Abu had been given a large quantity of traditional herbs by someone, but Bori couldn’t tell me whom. I’m not sure if Bori knew but couldn’t say, or if Bori didn’t know but the father knew.
I’m no doctor, but usually the liver filters and otherwise deals with chemicals entering the blood, and when large quantities of strange chemicals come through, it can get temporarily damaged. When it’s damaged, it filters at a slower rate, which increases the blood pressure and causes water to be forced out of the blood into the spaces between cells, especially where the pressure is highest – right by the liver. Bori told me that it could take Abu weeks to recover from the damage from the herbs.
I could feel a slick layer of sweat forming between my hand and Abu’s forearm, which I was controlling. Confort handed me an alcohol pad to open and then hand to Yusuf. Yusuf carefully wiped the area above Abu’s wrist. Then he pulled a syringe device out of a package. It was a syringe with a rubber tube on the inside. All the adults braced, but Abu just kept crying at the same intensity. He didn’t know what was next. Yusuf had already tied off Abu’s arm with rubber just below the elbow, so I guess Yusuf could see where the vein lay. I couldn’t.
Yusuf stuck in the needle. Abu screamed more, and tried a bit harder to get free. When the needle was in, Yusuf slid the rubber tube through the needle into Abu’s vein. Then Yusuf removed the metal needle and attached a small plastic apparatus, kind of like a tap, to the end of the tube. A bit of blood came out of the apparatus before he could close it. “Gloves...” Yusuf shook his head. No one was wearing any. I actually hadn’t seen a pair since I arrived.
Confort and Bori, I think, were setting up the small jar of medicine. Confort was busily uncapping syringes, inserting them through rubber seals into small glass jars with long scientific names on them, withdrawing some small quantities, removing the syringes and capping the needles. Sometimes she diluted with water after drawing some chemical into the syringe. This involved holding the plastic water container at an angle, inserting the syringe through a small hole in the top, and pulling in water to the right amount. The largest glass jar was already hanging from the IV stand, and every now and then Confort would inject something right into this jar, through its rubber seal. The Krio all around was loud and argumentative, but it was mostly gibberish to my ears.
“Hold on. A de go for de get towel, a de soak towel an putam na de pikin.” I parroted a section of our malaria health module to Yusuf and the dad, and then motioned for the dad to hold Abu’s arm as well. Yusuf was in control of the arm with the IV.
I ducked outside and soaked my bandana in well water. I shook it off a bit, then came back in and wiped Abu’s brow a few times. It may have been coincidence, but he calmed down quite a bit. Amhidu was reclining on the third bed in the observation room, and he laughed. “You de soak towel, an’ putam na de pikinbody.” He quoted part of Katie and my health module on malaria.
After a while, the line was hooked up and the yellow medicine was dripping slowly down into Abu. Yusuf went back to the consulting room for one last patient, but Bori and Abu’s dad stayed. Abu’s dad and I kept him from flipping and twisting to prevent him from hurting the IV connection.
Abu actually wasn’t the only patient in the observation room. The first bed was occupied by Fanta, also three. I’d found all my computer class students while they were putting the IV into Fanta’s wrist. She also had ++ malaria, and she was very dehydrated. Later on that evening, her mother explained to me that Fanta had been in another hospital for two days, but she wasn’t getting better, so the mother pulled her out and brought her to our clinic. Putting in her IV had been much less eventful; she was very dehydrated and weak. I think there was something in the medicine that was making her sleep. Her treatment was a four-hour alternation between quinine for malaria and glucose solution for her dehydration. Every now and then I watched carefully to see if she was breathing, and took her pulse. It’s all I really know how to do, but it’s a good warning sign. If it’s too slow and weak, something is wrong. If it’s too fast, something is wrong. Otherwise, at least the heart is working alright. as Abu went to sleep, Fanta began to stir, so I moved over and made sure she didn’t damage her IV while flailing in her sleep. Her mother had gone home to get some things for staying the night.
“Wait. So Bori, you are going to stay with the patients tonight?”
“Yes.” Bori looked at me with his trademark wide-eyed excited look.
“Okay.” An idea was forming. Why couldn’t Katie and I stay too? We’d just need to duck back to Uncle Ben’s for a couple of things. That would only take two hours of walking, or twenty minutes of forbidden motorbiking.
“Hey Amhidu, could Katie and I stay here tonight, to stay and help Bori?” Amhidu laughed at me. I think he finds Katie and my enthusiasm a bit entertaining.
“Doctor Chris, you want to stay close to the patients?”
“Well, I’m just wondering if there will be enough places to sleep. I figure there’s the third observation bed, Allan’s room, the consulting room, and is there a mattress?”
“Hmm?”
“What do you guys do when there are more people than beds here?”
“There is a mattress that we use only when we have too many people.”
“Perfect.”
In a few minutes, I asked Bori.
“Hey Bori. Could Katie and I stay here tonight and help you take care of the patients?”
“Hmm. Ask Yusuf.” I was a bit surprised that Bori hadn’t immediately thought it was a good idea, but there was a good chance he just didn’t understand me, or that he didn’t want to overstep his authority.
When Yusuf finished his consultation, I asked him. “Yusuf, could Katie and I stay here tonight and help Bori take care of the patients?”
“You want to stay to help with the patients?” I nodded. “Till daybreak, all the way?” I nodded again. “Well, that is a great idea! Great, great. Bori!” Yusuf yelled for Bori, and told him what was happening. Bori was excited.
So Katie and I headed back. We picked up grilled meat and bread sandwiches on the way. We were back at the clinic by 7:45pm, just as the sun was vanishing. There were three tiny women bowing and praying on a rug on the porch of the clinic. Each one was wearing a different African pattern of yellow, green, and blue.
Inside, Fanta was still asleep, but now her mother was sitting beside her on the bed, cradling the arm with the IV. “How de body?” I asked.
“No’ bad.” She looked worried.
“How Fanta?”
“She sleep nomo.” She only sleeps. I nodded.
“I’ good. She de get welbody.” That’s good. She’ll get healthy. Fanta’s mother looked unconvinced.
Abu was asleep, but breathing noisily.
Abu’s father was out in the waiting room with a black plastic bag. I assumed he had some food inside. “You de sweat!” He said. I laughed.
“No, a been wass!” No, I washed! He seemed confused.
Out in the waiting room, I met the third patient, Fatmata. She was bouncing on her mother’s lap. Her mother was one of the women I had seen bowing outside, and she was slight and young. The other two girls were also her daughters, I think. Fatmata was a very chubby 10-month-old. I won’t lie, I don’t mind seeing chubby children in Kono. She seemed pretty unhappy, however. According to her chart, she had been brought to the hospital simply because of her fever. We gave her a mix of three antibiotics at 5pm, 1am, and 9am, so I inferred that she had some kind of bacterial infection. Her IV tube went in on the inside of her elbow, and she seemed much healthier than the other two.
Before we left to go back to Uncle Ben’s, Katie had been recruited to help with Fatmata’s IV placement. Unfortunately Katie was most unpopular with Fatmata, who may forever associate ‘white’ people with terrible pointy needles. In any case, Katie was trying really hard to comfort her.
Fanta never stirred, but Abu eventually woke up and walked around a bit. We disconnected his IV when he awoke. Katie and I worked a bit on OpenMRS, occasionally checking in on the patients, and Bori took advantage of the power to try the typing program Allan installed on the desktop. He loved it.
Eventually Bori pulled out a double-bed-sized mattress and tossed it on the ground at the door to the observation room. In the process he unplugged the generator power cord. I winced, because the desktop had been on. Oh well... Bori said to me, “You can sleep here.”
“Well, where will you sleep?” We had already decided Katie would sleep in Allan’s room.
“Don’t worry about me!” Bori clapped me on the shoulder.
“I can just sleep like this,” I lay down the wrong way on the mattress, so that my feet hung off the edge and there was an obvious space for another person. Bori liked that.
“Okay, good.”
We turned off the lights. I set up a small lantern in the observation room so that no one tripped over any cords, and then I lay down to sleep. I offered Katie her watch, but she let me keep it. I set the alarm for 11:57pm. There were a lot of bugs; it was the first time in Africa that I’ve been legitimately annoyed by bugs while going to sleep. I also thought about how glad I was that I took my Malarone (malaria prohpylaxis) – there were plenty of mosquitoes. The buzzing annoyed me to sleep.