Tuesday, November 13, 2018

Update from the Under 5s Outpatient Clinic

This clinic has been Susie's "home away from home"! There was a post about it last year so this one will be brief. Each day, many mothers bring in their small children to be seen and patiently wait until they are called. This is dramatically different then the "over 5 and adult" clinic where Dave sees patients - there, the noise and commotion are sometimes deafening!!

Susie has been the only doc in the under 5s for almost all of our time here. There are 2 excellent "screeners" who see and are able to take care of many children, only referring the sickest to Susie to evaluate. Some of these children can be treated as outpatients but many  need to be admitted, usually urgently, for antimalarial treatment, transfusion, malnutrition, or severe measles.

Below is the exam room with the lead screener, Abdou, in the foreground and Susie in back.

So far, Susie has admitted 138 children, averaging around 10 for each clinic day. Of those, 16 died. Each morning from around 8 to 10 AM, she rounds in the hospital on about 15 to 20 of her patients.

We have been blessed to have excellent translators who help us in the hospital as well as the clinics. Below are Dave's translator Dada on the left (with pink "puffy" down coat since it was "only" 75 degrees!!) and Susie's translator, Usmane.

Rubeola (Rougeole in French) - Measles!!

....Our first experience dealing with measles was in 1977,  during our first mission trip to Liberia. Complications of measles were the most common cause of death in children way back then. We did not see measles again until quite recently!

 .....2 year old Imran looks and feels sick but us actually doing a bit better. He has conjunctivitis with one eye matted shut. His lips and mouth are quite sore and have a Gentian violet coating to give some antisepsis. A nasogastric tube is in place to give him fluids. He is also receiving a broad antibiotic intravenously, tetracycline eye drops, and vitamin A.

.....The picture below shows his rash better. It has gotten scaly and crusty in a few places.

....Imran is in an 8 by 12 foot room at the back of the hospital with 4 or 5 other children with measles - that is as close to "isolation" as we can get here.

Before the measles vaccine was introduced in 1967, over 90% of children and adolescents under age 15 experienced measles. The vaccine reduced the number of cases by over 99% and the US was declared “measles free” in 2002! Since then, isolated outbreaks have occurred and there were 118 cases reported in 2017.

Humans are the only reservoir for measles. The virus, rubeola, is highly contageous and 90% exposed to it contract measles. It is spread by the respiratory and personal contact routes. Virus-containing droplets can survive for up to 2 hours after a cough or sneeze which helps explain this.

During the 1-3 week incubation period, the virus spreads from the respiratory tract to the bloodstream and then throughout the body. Patients develop what looks like a typical “viral syndrome” with fever, cough, runny nose, and conjunctivitis (eye irritation). A few days later, the typical rash occurs, starting on the face and then spreading downward. A few days after that, the rash begins to darken and fade and the child improves. The contagious period begins 5 days before the rash appears and for a few days after the rash is first seen.

Complications occur in a third of cases including pneumonia, diarrhea, and occasion brain involvement.  Diarrhea is the most common complication while pneumonia is the most common cause of measles-associated death and is reported in 6% of cases in developed countries but is higher in developing countries like Niger where excellent healthcare, good nutrition, and reliable access to clean water are sometimes not available.

Treatment for measles is supportive care – there is no cure. Children are given tylenol to control fever, antibiotic eye drops if their eyes are inflamed, antibiotics if there is any hint of pneumonia or other infection, and generous fluid intake especially if there is diarrhea. Nutrition is stressed and children are given a couple doses of Vitamin A which helps their eyes. Unless the child is critically ill, it is better for them to be cared for at home so that they do not infect others in the hospital. Here in Niger, children tend to come in later in their disease and often are malnourished and suffering from diarrhea or pneumonia from the outset.....all of which lessens the chance for a quick recovery.

In the US, children are given their first dose of measles vaccine at age 12-15 months. Not all children get an immune response to the first dose so children are given a "booster" at age 4-5 years, before they go to school.

 In Niger, the 2 doses are recommended at 9 and 16 months. The World Health Organization has estimated  that about 80% of children get their first dose here but only about 40% have received a second dose.  While the government supplies most of the vaccines, some children are not immunized due to lack of parental education about the benefits, issues with transportation to the vaccination centers, and issues with healthcare infrastructure.

Global measles vaccination is estimated to have prevented more than 20 million deaths during the past 15 years!

Sunday, October 21, 2018

PALU !!!!

"Palu" is the shortened form of the French term for malaria, "paludisme".  While the word "malaria" actually means "bad air", it is caused by a parasite transmitted by mosquitos. According to my trusty Oxford Handbook of Tropical Medicine, about 3 billion people live in at risk areas of the world including sub-Saharan Africa, parts of Southeast Asia, and parts of South America. There are 250 million cases each year and about 1 million deaths, many of those being in African infants and young children.

This time of the year is "malaria season" in sub-Saharan Africa - standing water left from the brief, recent rainy season has provided an incubation place for the Anopheles mosquitos.  Every day here, many many children and infants come in extremely sick with malaria. They all have high fever, lethargy and anemia - commonly they come in with hematocrits of 8 to 20%  (normal would be at least 35%). Most are not eating or drinking well and many are vomiting so at risk for dehydration. Some have cerebral ("brain") malaria and are nearly comatose and having seizures. Some have unmeasurably low blood sugars.

Children who come in like this have a GE test ("goutte epaisse" or "thick drop" blood smear to look for malaria parasites) and a hematocrit to see if they need a transfusion - we use a "cut-off" of 15% to order a transfusion. The blood here is matched for ABO and Rh type but the lab does not have the ability to do a formal crossmatch as is routine back home.

The good news is that most of these kids recover and go home, often in as little as 24 to 48 hours!!!! In addition to transfusion of blood, if needed, they receive daily intramuscular injections of a potent anti-malarial drug artemether. If there is any concern for a bacterial infection, the antibiotic ceftriaxone is added. Valium is given for seizures and concentrated dextrose if the blood sugar is too low. Fever is controlled with paracetamol (tylenol) and children hydrated by drinking ORS ("oral rehydration solution") which comes in packets that are mixed with water; if they can not drink, a nasogastric tube is placed to give the ORS; intravenous fluids are only given in the minority of cases.

Typically, after the initial doses of treatment +/- a transfusion, children are MUCH better - last week I admitted a young boy who was limp and critically ill but the next day, he looked bored and was playing with his mother's cellphone!! At discharge, children are given 3 days of an oral anti-malarial prescription to complete their treatment, amoxicillin if felt necessary, a few days of acetaminophen, and some vitamin/iron tablets.     .......all of the children below presented with severe malaria and went home much improved - praise God!!


 The Oxford Handbook of Tropical Medicine has been on
every trip we have made to mission hospitals. It is concise and easily fits into the "carpenter's apron" that we carry with our "tools" on our daily rounds and in the clinic.  Like the old commercial for the American Express card, "don't leave home without it!" We also carry the reference UpToDate on our kindle/tablets.

Ibrahim, age 4, with his happy grandma.
Bilyaminou, age 6, ready for home after 2 days
of treatment for malaria and severe anemia.
Many children seem afraid of docs, but
Lariya, age 5, was happy for a hug!

Tahiru, age 13, home after 1 day of treatment

8 year old Richa'ou was admitted with high fever and a hematocrit
of only 9% - home the next day!!!!


Saturday, October 20, 2018

GALMI 2018 !!! - Taking Flight !!

We were thankful that we were able to take  SIMAir flights out to the Galmi base. The journey took 1 hour and 40 minutes and we flew at an altitude of 3500 feet which is low enough that we could get a good look at the countryside. It was a bit "greener" than last year - the brief rainy season had recently ended. SIMAir now has 2 single engine planes that, except for especially dusty days when they are grounded, saves folks from the 6 hour bumpy bus ride that we had to take when we arrived last year.  They also fly to more remote places in the country of Niger.    ....We flew in a week apart and were the only passengers so sat in the co-pilot seat - it was interesting to put on the headset and hear the interaction of the pilot with the control tower at Niamey!

At the SIMAir hangar in Niamey with Dave Ceton.  Dave is an aircraft mechanic who is from our home church.
His dad, Jim Ceton, served as a surgeon at Galmi for many years before passing away 4-5 years ago. 

Niger countryside from 3500 foot. The main road is paved (and bumpy!) while the other roads are unpaved. 

Nearing Galmi, banking for the final approach to the airstrip.

Almost there! The airstrip is fully enclosed by a fence and the pilot has already done a flyover to make sure there are no obstacles on the runway          (goats, chickens, children etc)

Touchdown - the airstrip is 800 meters in length.

Another safe SIMAir flight !

Susie arrives at last on October 19.
Grand Rapids to Chicago to Addis Ababa to Niamey to Galmi !!

Sunday, February 4, 2018

Friends, Food, and a Fantastic Case

This will be our last blogpost from Chogoria so we thought that a potpourri might be interestiing.......

These "hugs" from our grandchildren Stella, Dexter, Lincoln, and Edison go
with us on all of our mission travels to keep us company. We miss them!!!!

Jim Ritchie is an ER physician here - he served 25 years as a Navy doc before
transitioning to the mission field. His wife Martha is the hostess/hospitality
person for the base and has been a huge blessing for us! Their son James
is the last of their 6 children who is at home.

We enjoyed getting to know Alex Lea, a 4th year med student at the Medical University of South Carolina, Greenville
campus. He is from Nashville and looks forward to studying Family Medicine.

A mission trip would not be complete without a running picture! To the left is Dave Klee, a Family Medicine faculty from
Traverse City. Next to him is AJ Pinney, a Family Med resident. Next to me in the red shirt is Larry Smith, serving
here after practicing in Anchorage, Alaska for a number of years. By the way, Larry has done some ultra marathons -
50  to 100 mile jaunts that make my knees ache  just to think about them !!!

On the way to morning hospital duties, we look down on a courtyard filled with students decked out in their uniforms.

Susie is a kitchen magician!!! This is "BRC" - beans on rice with cheese- along with sliced carrots and mango for dessert.
Vegetables here are plentiful and we have mango or pineapple nearly every day - Yum!!

Another fantastic meal - lentils/dal to the left, Kenyan black beans (njahi), and sauteed chard with onions.
and finally, the interesting case.......

This is a CT scan view from a 43 year old man with a 3 month history of weight loss, night sweats, and abdominal swelling.
He looked chronically ill and his liver was HUGE on examination.
An ultrasound showed cysts in his liver and the CT (above) reveals 2 massive cyst/abscesses occupying much of his liver - they are the darker circular areas. The possibilities that we discussed were liver abscess due amebiasis or echinococcus and he was started on meds for both diagnoses. 

The next day, Jason Brotherton, an Internal Medicine-Pediatrics doc, inserted an indwelling drainage catheter into the liver.
He withdrew 500 cc (about a pint) of thick dark fluid which was sent to the lab for analysis. The following day, we took out another pint of fluid. There's plenty more .......................

Sunday, January 28, 2018

Wildcats and More!!!!

As proud alumni of Northwestern University, home of the Wildcats, we were delighted to see some ferocious felines on our safari drives at Samburu Park!!

The king of beasts is even more impressive in person.

We were fortunate to see a pair of leopards out for a morning stroll.

We were amazed by this cheetah - note how long and lean, built for short
bursts of speed. This one was stalking several gazelle several hundred yards
away - the gazelles (fortunately for them!) sensed the cheetah and were poised
to run if needed.  

There was a plethora of ponderous pachyderms.
This is grandson Lincoln's favorite animal!!!

Besai Oryx - so stately and magnificent. 

Gerenuk - also called a "giraffe antelope".

Reticulated giraffes.



Impala buck - note the graceful curved horns.

Some African safari parks talk about the "big five" but, at Samburu, they have the "special five" which include Grevy's Zebra, Somali ostrich, Besai oryx, gerenuk, and reticulated giraffe. We saw all five of these plus the 3 big cats. It was an excellent adventure!!!


We enjoy watching birds from our sunroom back home so were delighted to see all of the beautiful birds here!!

Our favorite bird....the lilac roller.

Somali ostriches.

The superb starling.

A guinea hen.

Weaver bird nests adorn this tree like Christmas ornaments! Male weavers build their nest to attract females.