Samba's Meningitis / Cerebral Malaria

The little boy was silent. He stared at me, and looked scared. “Wetin na you nem?” I asked him, and his mother answered.
“Samba,” and she looked at him when she said it. He was bald, with a big head, but his arms were healthy and not too thin. One of the best indicators of malnutrition for young children is the circumference of the mid-upper arm. If it is less than 8 or 9 cm, they are malnourished. Samba’s upper arms were full and well padded.
I pressed the button on the thermometer and moved it towards him. It was one of the under-arm thermometers, the same kind I’ve used in my house my whole life. His eyes widened and he fidgeted, and started to cry. “A no de choku! A no de choku,” I repeated, and his mom confirmed. He had thought it was a needle. I slipped it under his arm. Heat was radiating from him.
Yusuf proceeded with his questions. “Why you de bring dis pikin ya (here) today? Wetin make you de bring de pikin?”
“Dey body dey wam...”
As Yusuf gathered up Samba’s symptoms – fever, nausea, weakness, lack of appetite, difficulty sleeping – I watched him. When I looked closer, he wasn’t in fact bald. There were small scatterings of black curls, growing stealthily into tight rings. His lips were dry, so maybe he was dehydrated. I picked up his hand and looked at the palm. It was pale, almost as pale as my hand. The paleness is often a sign of anemia, or a reduced concentration of red blood cells in the blood. It often happens in malaria, because the malarial parasite reproduces inside and then kills the red blood cells.
The thermometer beeped; 39.82 C, or about 104 F. That’s a high fever. Without noise I showed it to Yusuf, who noted it on his chart.
I stood up from my seat, picked up the stethoscope, and walked around to the bed in the consulting room. As always, the consulting room was crowded. When I turned back towards Samba, his mother was already lifting him up onto the examination table and removing his clothes. He lay down, and gave a few weak cries, but then he let me listen to his lungs. I heard the clean and quick roar of his inhale, followed by the lower flooding noise of his exhale. He was breathing quickly, but not alarmingly fast, just noticeably. Before I handed the stethoscope to Yusuf, I checked the soles of his feet. They were also very pale, mostly white with a tint of yellow on the edges.
“De feet, dey pale,” I commented to Yusuf. He grunted and nodded.
“Dat is a sign of anemia,” he announced. After motioning for Samba’s mother to dress Samba, he continued. “So, a de order some tests. But first, you go wass (wash) de pikin, becos ‘e got fever, bad fever,”
“You go use de water na well, nado (outside). Dat water na cold,” I added. We didn’t have running water in the clinic, and even if we did, she might not have known how it worked.
“Okay, den a come back?” We nodded. They stood up and left. The whole time, I hadn’t paid much attention to the daughter, who looked about three. As they left, however, I recognized her. Her name was Kadiatu, and I had met her and her father in consulting one week prior. She was a vibrant three year old, even when sick with malaria, and she had big dark eyes beneath a thin and wispy covering of curls. While meeting her, I’d learned that her father was an imam at a mosque in Koidu Town. He had been wearing a distinguished navy blue shirt and pants. They might have looked like pajamas on me or my dad, but together with his white brimless hat and curly black beard, he had looked regal.

I was jotting down the patient number of the lab results form someone had just passed me, when suddenly Samba and his mother returned. There was a lot of commotion in Krio, and Samba’s mother dropped him onto the consulting room bed.
He was convulsing. It was very disconcerting. His eyes were rolling around like doll’s eyes, and his hands and legs were beating pathetically up and down like wings. Every breath was coarse with effort, and his jaw muscles were clenched.
But on the bed, with Yusuf in the room, was the best scenario. So I calmly finished writing down the patient number, and then stood.
Other patients surged into the room, wanting to help. Katie came in. Yusuf stood up and left, inexplicably. Later I figured that he must have been looking for diazepam, a muscle relaxant for use in seizures and convulsions. The mother started to hold him down, and I stood up to try and prevent her from doing that. Then she picked him up, and I tried harder to tell her to leave him on the bed. It’s not a good idea to pick up a convulsing baby; the convulsions alone will not kill the child, but dropping him headfirst onto the corner of the desk just might. But my Krio was powerless. The room was packed with colorful dresses and loud voices.
Then, just as fast as she’d entered, the woman left.
“Ousai she de go?” No one paid me attention. “Where’s she going?” I asked Katie. I don’t recall if it was Katie or Yusuf that told me, but one of them told me they were leaving because we had no diazepam.
“Wait, Yusuf, what does that do?”
“It is a muscle relaxant. You know,” he sounded a bit regretful, “we have training for this situation in nursing school, but we need the diazepam to do what we were trained to do. If we no have diazepam, we cannot sedate the child,”
“But we’re just letting them leave? We could wait for the convulsions to subside, couldn’t we?”
“They are going to the government hospital. They can do transfusions as well, there.”
I sat down again. It was frustrating; the government hospital was going to be expensive and of questionable quality. However, if they could indeed do transfusions while we could not, perhaps that was the best place for a very anemic and sick boy to be.
“Why don’t we have diazepam?”
“Oh, we don’t have. No pharmacy, we looked, we should have [it here in the clinic], but no pharmacy, nowhere in Koidu, they don’t have.” That gave me pause.
Yusuf had been singularly unassertive during the whole situation, and I was frustrated. But he was right – diazepam or the ability to give transfusions were essential to the treatment Samba needed.
Nonetheless, the general conclusion of the staff was that Samba was going to die.

“That little boy, the one with the convulsions, he has returned.”
What? “What?” Yusuf and I were already walking out of the consulting room, and Katie appeared as well.
“The parents, they have returned, and they say they put full faith in our care,”
Hm. My initial reaction was disbelief. All the reasons why he had initially left were still valid, except now Samba was three hours of convulsions and fever sicker.
A few minutes later, I walked to the back of the clinic and saw Jalloh leaning over Samba and his mother. Samba was rigid and unbending, his eyes still randomly adrift. He was breathing fast, there was thick fluid in his lungs that crackled and wheezed with every breath, and he was still noticeably radiating heat.
“Jalloh, let me see your watch for a moment,” Jalloh tilted his wrist so I could see his fancy silver watch. It had a second hand; that was all I wanted. I counted off Samba’s breaths and calculated 60 breaths per minute. Dr. Lenny Smith had made it clear that the life of any sick child breathing over 60 breaths per minute was in danger. I also took his pulse, but it was difficult to find beneath the swollen and tight muscles in his arm. Then I noted the time and recorded all three.
3pm – 60 breaths per minute, 120 beats per minute.
The stuff in the lungs and the respiratory distress were both new, and both worrisome. I thought that Samba might die. He was too tiny, and he was breathing so hard. With every breath I could see his ribs flaring out against his skin. When someone is having trouble breathing, it’s usually because the flow of air is impeded on the exhalation, and it was no different for Samba. Humans use their diaphragm to create space, which lowers the pressure inside the lungs and causes air to rush inside. The diaphragm is a big strong muscle. But there is no equivalent strong muscle to help with exhalation. So every breath was causing Samba to get further behind on the amount of oxygen he needed, and his breathing rate was climbing. I went back into the consulting room and told Katie. She went out to look, then came back.
“He’s not just breathing fast. His eyes won’t follow a finger, he doesn’t recognize when you move towards him, he doesn’t respond when you touch him, and his muscles are still convulsing,” Her voice was urgent.
I breathed in. “But he’s not shaking, it’s just that his muscles are clenched. Is that still the same thing?”
We didn’t know.
“I don’t think you can convulse for that long,” Katie said.
There was some commotion in Krio and then Bori and a group of colorfully dressed spectators moved Samba into the observation room. They placed him on the first bed, and then stood, watching. Bori was standing beside a plastic bowl filled with Samba’s medications.
Yusuf came in and sat down on the edge of the bed. Samba was small, so he didn’t take up very much bed. Yusuf tied a rubber elastic around Samba’s forearm, but the vein didn’t appear. The forearms looked very swollen. It’s true that babies often have chubby forearms and no wrists, but Samba’s forearms and wrists looked tight and uncomfortable.
“’E no dere...” Yusuf said to himself. He asked Bori for a razor. I tried to think of why he needed a razor, and couldn’t.
While Bori was gone, Yusuf and I told the spectators, including the parents, to leave. They shuffled out. All of their expressions were hard to read. I couldn’t tell if they were watching from concern, or from the morbid fascination with which we all watch car accidents. Samba’s eyes were half closed, and his breath was still gurgling and croaking at 60 breaths per minute.
Bori was back with the razor. Yusuf turned Samba’s head to the side and shaved off a couple square inches of hair above and behind his ear. Then he laid the elastic flat across Samba’s head, above the ear. It wasn’t an elastic like you find on broccoli at the grocery store, it was about an inch thick.
“Hold.” I nodded, glad to be helping, and then held down both sides of the elastic. Was this to keep his head in place? After a moment, a vein appeared under his scalp, in the area Yusuf shaved. Then Yusuf inserted the IV needle, pulling back the metal and leaving the plastic tubing.
Samba didn’t react at all.
In a couple of minutes Katie came into the room. She sat down beside me, and we took another set of vitals.
3:10pm – 60 breaths per minute, 120 beats per minute.
Jalloh let us hang on to his watch.
Katie updated me on the convulsions. “Anemia doesn’t cause convulsions, not according to Wikipedia. But cerebral malaria does.”
“Is that just malaria that infects the brain? I hope it’s not malaria inside the brain, behind the blood-brain barrier where we can’t get any drugs,” I know almost nothing about the blood brain barrier. That’s probably the only individual piece of information that I know about it.
“I don’t know,”
“But I’m really worried about the crap in his lungs. Is that cerebral malaria? How does malaria infect the lungs? Where did it come from?”
Katie shrugged. “I read that convulsions can cause loud breathing.”
“No, but don’t you think that loud breathing is just like panting, or like this,” I demonstrated some loud breathing, “not like gurgling mucus and crap in the lungs? I don’t believe that convulsions can magically cause a whole bunch of fluid to enter the lungs,” In my mind’s eye I imagined fluid surging out through the membranes of cells in the alveoli, some kind of inflammatory response. Something was missing. I later learned that when people convulse, they can vomit some stomach acid and then inhale both saliva and stomach acid, causing something known as ‘aspiration pneumonia.’
“I don’t know, but that’s just what it said, loud breathing.” We didn’t know, and it didn’t make sense.
So we looked at Samba. He was propped up on pillows, with his chin on his chest. His eyes were half closed and lolling from side to side like googly eyes on arts and crafts day at camp. I pinched myself a couple times to measure how much it hurt, then I pinched him. Nothing.
“He didn’t respond to the needle, Katie,”
Katie just looked deeply worried. We felt his feet. They were cold. His hands. They were cold.
Yusuf came back and strung up the first round of drugs – a cocktail of antibiotics. “Gentamycin and ampicillin,” he said. Vincent came in and pricked Samba’s finger to test his hemoglobin concentration. That sounds fancy, but all it actually involved was pricking his finger, putting a drop of blood on a piece of special litmus paper, then holding the litmus paper up to a color gradient and reading off the numbers corresponding to the color. We never found out what it was. It was probably low, given that his palms and feet were almost as white as mine.
“Why isn’t Vincent doing a malaria test?” I asked Katie.
“They did one this morning. He was positive, two plus,” two plus is a severity designation that accords with the concentration of parasite that Vincent sees under the microscope. Two plus is medium severity in an adult, but can be very dangerous for young people (Samba) or people who’ve never had malaria (Katie and I).
“Oh, man, I didn’t even know. Well, your cerebral malaria idea makes a lot of sense.”
We took more vitals.
3:20pm – 66 breaths per minute, 120 beats per minute.
Then Yusuf gave him a shot of something, perhaps adenosine? to make his heart beat faster, to help him in his oxygen distress and get some blood back into his hands and feet. It was magical. Just a minute or two later, his hands and feet were warm and his heart was racing.
At some point, I don’t remember when but it was near the beginning, we started holding his airway open. It wasn’t easy, because his muscles were so clenched. But the only thing I know about respiratory distress is that you must do everything you can to aid the person in breathing. Any extra challenge could be too much, and they’ll go unconscious or worse. In the hospital in France, they would give tracheotomies to elderly people with bad pneumonia simply to get rid of the obstacle of all the dead air in the mouth and throat. I slipped my thumbs against the sides of his jaw and pushed up, gently. His mouth refused to open. We waited, and Samba filled the room with desperate breathing.
Yusuf returned. Katie wanted to know what he was injecting.
“What is that? Yusuf, what is that?”
“Diazepam.” Yusuf uncapped a tap on the IV drip line and then injected a syringe of yellow fluid. “Dissolve half a milliliter in two milliliters.” Then he was gone again. We waited for the diazepam to slacken his muscles, so that we could possibly open his airway better, or at least get his mouth open and try and get him to cough up some of the noisy crap in his lungs and airway.
The diazepam made his eyes roll around and close in a very scary way. He looked possessed, and his muscles hardly relaxed at all.
I laid my hands on his chest. “Feel that,” I said to Katie. His entire ribcage was rumbling and vibrating with every breath he took. “You can feel the stuff, it’s all through his lungs.” Later, Yusuf told us that he thought the mucus and fluid was mainly in one of the two lungs, which makes sense because the branching from the windpipe into the lungs is not the same on both sides. When fluid – or a tube, or anything else – goes past your esophagus, it’s much more likely to go into one lung than the other. I forget which one is which, and I certainly didn’t notice that one lung was more impeded than the other.
3:32pm – 72 breaths per minute, 180 beats per minute.
His heart was racing because of the heart drug Yusuf gave him, but his breaths were also increasing. I had to change the position of my hand, because it was getting tiring leaning over him in such an awkward way. As the diazepam filtered through his system, he started moving his left leg. He would pull his knee back towards his head and then kick it out, and he’d do that two or three times then stop. A few minutes later he also started making some noises with every breath, small cries.
“Where are they? Where is everyone?” Katie wanted to know why we were so alone in the observation room.
“I don’t know,”
“Well, Yusuf’s seeing patients. But where is Bori?”
Could Bori help that much? What could we do? The staff, it seemed, were not as optimistic as Katie and I. Although, I’m not sure if I was optimistic. In my head I was running through what would happen if he stopped breathing altogether. I decided that I would begin artificial respiration, and since his mouth was clamped shut, I would do it by sealing my mouth around his nose and mouth. But beyond that, what could we do if he stopped breathing? Nothing except hope that he started again. Ambulances exist, but when I’ve asked Amhidu about emergency numbers he told me the only number was the fire department (300). I may have seen an ambulance in Freetown, but Yusuf already held such a low opinion of the pediatric department at the government hospital in Kono. If he had felt they would kill Samba an hour ago, I didn’t have faith they could revive him if he stopped breathing.
As Katie and I sat on the bed, the spectators filtered back in, and they began to have a conversation about the government hospital. They all agreed that at the government hospital they would let your ‘pikin’ die and not care in the slightest, especially if you didn’t have enough money.
The rest of the afternoon is more of a blur, and I don’t remember the vitals so clearly. I’ll put them in to give you a sense of the progression, though.
3:49 – 69 breaths per minute, 160-180 beats per minute.
Katie took more and more of the vitals. My arms and hands were slick with sweat where they were resting against Samba’s skin. Samba panted along with uneasy stability, though now his breathing was becoming more irregular. I couldn’t decide whether or not it was good if his condition remained the same for an extended period of time. I was scared that at some point he would just give up.
And then he did. He stopped breathing, just for a moment. “No way, buddy,” I clapped his ribs, and he started breathing again. Katie stared down at him, eyes wide.
“I’m going to go get Yusuf,” she said.
One of us went to get Yusuf. When he returned, Samba stopped breathing again. Yusuf looked at Samba for a moment, then placed his hand firmly across Samba’s chest and pushed and massaged. Samba sputtered back to life, and Yusuf kept massaging. Samba’s eyes opened most of the way and then closed most of the way, and then stabilized. Yusuf waited a moment and then returned to consulting. Before he left, he said, “You’re doing a good job.” Maybe, but I don’t think we knew what we were doing. I certainly didn’t. I was applying standard first aid and CPR to an infant cerebral malaria case with respiratory distress in rural Sierra Leone.
Samba stopped breathing several more times, each longer than the last. Every time, I talked to him, to comfort myself, not him. “I don’t think so, Samba,” or “No way, no way,” or “Nice try,” as my hand or Katie’s hand pushed the life back into his lungs.
Afterwards, I’m not sure whether or not he would have continued to not breathe if we hadn’t palpated his chest like that. Maybe, maybe not. It wasn’t a chance we were going to take at the time, and not one I would take now. The times on the vitals are getting more approximate in my memory.
4:10 – 84 breaths per minute, 180 beats per minute.
He was starting to hiccup. Normally I wouldn’t be worried, but he was hiccupping every third or fourth breath, and so he was effectively losing 20-25% of his oxygen intake. I tried pinching him and slapping him on the chest to surprise him out of it, but he was still unresponsive. I’m sure Katie tried something too, but I don’t remember what.
The thing is, I hadn’t eaten since 8am, and at 8am I had eaten a hamburger bun and a boiled egg. So my awareness, both at the time, and in my memory, was shrinking. When I think back to the events, to sitting on the edge of Samba’s bed, feeling his swollen and rasping chest under my hands, seeing his legs kick futilely against the malaria in his blood, it’s like the edges of the image start receding inwards, and I see less and less.
4:40 – 72 breaths per minute, 120 beats per minute.
Around now I started to think that the worst had passed. His breathing was coming down, and he wasn’t trying to stop breathing every couple of minutes. Katie even managed to get his eyes to follow her finger, sort of.
“That’s better,” she said.
“He follows your finger?” I tried it.
“No, but when I move my finger, his eyes jump to it.”
She was right. Maybe Samba wouldn’t die. But I couldn’t tell if I thought that because of real reasons, or because I didn’t want to see him die. I didn’t want to see my first death today.
5:10 – 69 breaths per minute, 120 beats per minute.
The hiccupping was gone. Katie and I moved him around a bit, trying to combine an upright position with an open airway, all while not damaging his IV connection. Back around 3:30 he had taken his first dose of quinine, so now he was just on maintenance glucose drip. Hopefully that would keep his blood pressure high, according to Yusuf. That made sense, because blood pressure is related to how much fluid volume there is in your blood. If you take a pipe and you put more water through it, the pressure increases.
At some point, Katie told me this. It might have been after, as we sat eating dinner under the stars and clouds at Uncle Ben’s.
“You know, I had to force them to get the diazepam. They weren’t going to do it. They weren’t going to get it.”
“Wow. Good job making them get it,”
“It doesn’t make sense, I wish they would have tried harder for it,”
“Yusuf did tell me that it was hard to find, that it was very rare in pharmacies in Kono. But I guess not, because Bori found it pretty fast.”
“Yeah.”
His muscles weren’t as rigid anymore, and by that I mean that we could bend them without considerable effort. His mother and father were in the room now, watching. I wondered what the father, the imam, was thinking. I wondered whether he was praying for his son, or what he said to God about him.
“The dad’s an imam,” I said, at some point.
“I saw him outside, praying,” said Katie. There was a prayer mat beside the desk. It was the only medical equipment in the clinic that we hadn’t considered using yet.
5:40pm – 60 breaths per minute, 120 beats per minute.
Eventually, we had to think about what to do that night. Samba hadn’t tried to stop breathing in well over an hour, and his breaths were slowing. He seemed to be stabilizing. My stomach was empty, and the emptiness was spreading through my whole torso and making me very spacey. I’m useless when I’m very hungry. “Katie, what do you want to do?”
“What do you mean? What do I want to do now, or what do I want to later?”
“What do you want to do for food. I’m really hungry.” And I was very spent. The combination of hunger, adrenaline, and urgency was tiring.
We showed the imam and his mother what to do, how to keep Samba upright against the pillows, how to keep his airway open, and what to do if he stopped breathing. Then we left.
Before we left, we talked to Yusuf.
“Do you think he will be okay, Yusuf?”
“I don’t know, maybe he will. I’m doubtful, doubtful. The boy is very sick, he is very sick, and we don’t have the salbutamol or the oxygen or the machine,” He was referring to a nebulizer. Salbutamol is a popular asthma drug, it was the active ingredient in inhalers for many years. It’s a steroid that dilates the bronchioles in your lungs, allowing the easier passage of air. I wasn’t sure that it would really do all that much for Samba, given that his problem seemed to be that his lungs were full of fluid and mucus. The oxygen would be good, though, and I guess would have the same effect as the salbutamol. The bottom line is, I’m not a doctor, but at that moment I wished I knew what we could do. Or that Katie knew what we could do. Or that anyone knew. Yusuf had injected some folate earlier today to deal with the ‘crepitus’ – the fluid in the lungs. It hadn’t had a noticeable effect, unless it had stopped the situation from getting worse. In France I had helped the respiratory physiotherapists aspirate the lungs of elderly people that had been prone for weeks and couldn’t clear the mucus from their lungs by coughing. If we had one of those tubes and suction apparatuses, we could have aspirated Samba’s lungs.
My head was numb, and I tuned out from Yusuf. Katie later told me that Yusuf had ended his monologue with “Maybe we can ask God.”
We left in the dark. My head, stomach, and every other part of me felt empty.

The next morning we arrived, and Samba was sleeping normally. The mucus and fluid was gone. He looked sick, felt warm, and was unhappy, but it was all very normal. He wasn’t going to die. I was happy, but I was still a little raw inside from the previous day’s effort. It was a quiet happiness, a tired one.
The dad came up to Katie and I and thanked us vigorously. “Tenki, tenki,” his eyes were large, dark, and almost watering.
“’E de get welbody,” I nodded encouragingly at the dad. He’ll get healthy.
Later I measured his breathing rate. 40 breaths per minute, much better.

Samba stayed the whole day, and the next night. He left healthy, and his parents were happy. I wonder if he’ll remember it. During the first night, after we returned to Uncle Ben’s, I looked up all the symptoms, trying to figure out if what we were doing was correct. Everything seemed to line up with cerebral malaria, and one of my previous posts is a segment of instant message conversation with my friend Veronica right after I found that cerebral malaria accorded with almost everything we saw.
But when we spoke to Bailor, he said, “That sounds like meningitis. The [clenching teeth], the convulsions. Usually when it’s cerebral malaria, the patient convulses for a little while then goes unconscious. Yusuf, he treated with antibiotics, right?”
Yes, he did...
“So if it was bacterial meningitis, then that takes care of it too. That’s why you treat like that, when you don’t know. And that’s why when you see these symptoms, first thing, you do a lumbar puncture, so that you know. But when you can’t know, you can’t do that, then you have to give antibiotics and quinine. You can do the [names of two people that I forget] signs, where you get a sharp thing, and you trace along the palm and around, and if the hand flips up, it’s positive.”
Positive for what? Bailor didn’t say. Why didn’t we phone Bailor? I don’t remember. I’m glad that Samba lived.