Textbook diagnoses apparently DO exist!

I had one of those days today for which words just can't do justice. I'm going to try, though, because it was such an incredible twenty minutes that I really need to share. It started as a pretty normal day. Rounds in the maternity ward, rounds in the peds ward, and then we started consultations. Nothing too exciting at first - lots of cough, fever, UTIs, malaria, etc. Then the arrival of a six year old girl and her father. They were from Equatorial Guinea, and had lived in Gabon for a year or so, so the father spoke a bit of French. The chief complaint was cough and fever for a week. Pretty standard. After doing a history of present illness, I asked the father about the bandage I noticed on her left hand. "It's nothing," he told me. "It's healing."

The child undressed and climbed up on the examining table, and we unwrapped the hand. Both Dr. Bonito and I gasped in horror -- the wound in the photo was what we found, but filthy - covered with dirt and some sort of traditional healing "pommade" that smelled like rot. (The photo here is after the nurses cleaned the wound.) Upon further questioning we learned that the wound has been present for over a month. It wasn't a difficult diagnosis - a Buruli ulcer, which is fairly common in this area (we're in an endemic region), but the infection is so advanced that she will probably lose the finger.

I continued the physical exam as I do for any child with a cough and fever. Nothing of note on her lung exam, no heart murmurs, no lymphadenopathy... everything seemed normal until I looked in her throat. She was sitting up on the table, and tilted her head back for me. I asked her to stick out her tongue and say "ahhh" but she only opened her mouth slightly. I asked again, and her father said "she can't!" She continued to try to open her mouth for me, and as I maneuvered the tongue depressor into her mouth and her father continued to say "she can't!" the child's jaw clenched shut. Her head arched back, every muscle in her body stiff as a board, and her upper body plummeted towards the table as Dr Bonito and I reached quickly to catch her shoulders and set her down on the examining table.

My heart skipped a beat. TRISMUS?!? The thoughts that raced through my head over the next few seconds went something like this.... "could this be a case of tetanus?!? No way. I'm doing the med student thing, jumping to the worst possible conclusion." Despite my doubts, I looked at the father and asked if the child had been vaccinated. No vaccines at all. Bonito clapped me on the back. "You're thinking what I'm thinking," he said gravely.

So much for the fever and cough. After some further, more probing questions, we learned that the poor kiddo had experienced brief "crises" of stiffening for the past four days. No vaccine, clear "porte d'entree" (entry point - the Buruli ulcer) - it was a definite case of tetanus. Textbook. Trismus and everything. I couldn't believe it.

We gave her anti-tetanos serum, a tetanus vaccine, cleaned her finger wound, hit her with some heavy antibiotics, and put her in isolation, and now it's just a waiting game. We're hoping that we've caught it early enough to avoid progression to respiratory compromise, because there are no respirators here in Lambarene. Terrifying.

Sometimes I like to juggle babies.

You would think that weighing a kiddo isn't that hard. Just take off all of its clothes and toss it on one of those little shelf scale things in the pediatrician's office. Well, theoretically. But when you're en brousse, it doesn't work quite like that - instead, we suspend a little meat scale from a gnarled rope hanging from a nail above a doorframe, undress the kiddos, and hang them from the meat scale. the problem is that babies wiggle, and the little hooks on the scale aren't exactly the most stable hooks ever, because the people who designed them aren't THAT concerned about their cuts of meat wriggling out of the scale and crashing to the floor!

Anyhow I have a newfound respect for Marie Benoit, Sophie, and Hortance, who juggle babies, meat scales, pens, anti-worm pills, and carnets (medical history booklets) at least two times a week in the middle of little villages in Gabon.

les palmiers

and the road leaving the plantation, with rows and rows of neatly planted palmiers. beautiful.

cute kiddos at zile

PMI Zile (Agro-Gabon)

PMI this Wednesday took place at a plantation town called Zile. It is a plantation owned by Agro-Gabon, an enormous Gabonese conglomerate. It is a beautiful village, and only about 20 minutes from Lambarene. This photo is taken from the hill overlooking the village, where the "chef du plantation" habite avec sa famille.

at least my feet are happy though...

... even if we were rained out of the point dennis trip!

when it rains, it pours...

The original motivation for the Libreville trip (other than to see the big city, of course) was to take a boat to Point Dennis, a peninsula accessible only by boat from Libreville. Our plan: spend Friday in Libreville, Friday night at the mission, take the boat Saturday morning, spend all of Saturday on the beach, camp on the beach saturday night (we brought tents along), and take the afternoon boat back to Libreville Sunday night, then catch a cab back to Lambarene late that night.

The beginning of the plan went well - Libreville was a blast, but I awoke at 3 am on Saturday to PUMMELING rain, which lasted until about 11 am. No boats to Point Dennis on Saturday, we were told. Not even in the afternoon! It didn't make sense to spend money on the boat tickets just for a roundtrip Sunday, so we headed back to Lambarene Saturday night and decided to try for another weekend...

Un sejour a Libreville

Sonja, Annette, Negar and I took a day off on Friday to spend the weekend in Libreville. We woke up early and crammed into a taxi with the four of us, a driver, and two random peeps for the three and a half hour drive. The driver was nice enough to drop us directly at our "hotel," a monastery with guest rooms, so we waited until the frere in charge of logements arrived and checked in, had a picnic lunch, and explored the town. Here's a photo of us inhaling a DELICIOUS boite of chocolate ice cream, and a view of the ocean from the city (Libreville is a coastal city)

And a last view of the shoreline from belle vue

Le chantier Izzinda

Our second stop on PMI by boat was the Chantier Izzinda, which is a former chantier forestier. I'm not sure exactly when the lumber business closed up shop, but now only a few families remain. It's a fascinating spot - the tracks on which they rolled the giant tree trunks into the river are still there, overgrown with grass and jungle greenery. It's far enough from Belle Vue that it warrants a separate stop for PMI, but there are so few residents that we frequently just have the children climb into the boat for vaccinations!

When we arrived this week, the only kiddos who still live there were already "en ville" for a recent funeral, so we climbed off the boat to say a quick hello. We chatted for a few minutes while one of the village elders (yes, grandfather-aged) clambered up into a grapefruit tree and started tossing them down to another man who put them in bags for us to buy. Yum!

Ogouue

PMI at Belle Vue

PMI today was in a little village called Belle Vue (beautiful view -- named so for obvious reasons!) It was a 45 minute motorboat ride and a couple-minute walk to the dispensaire, where we set up camp and did our usual spiel for the 30 or so mothers there. This photo shows the mothers listening to Hortance as she gives a lesson on various types of intestinal worms.

After we finished, we took a 10 second boat ride to a lovely little picnic spot where we ate lunch, then headed up the river to our second PMI stop of the day...

And here we are unloading the bags from the boat to carry up the path to the dispensaire in Belle Vue... more pics to come, with some explanation.

PMI en bateau

leg cramps

Check out the difference in lower leg circumference in this poor nine year old girl. Her mother brought her in because she "refused to walk for two weeks." The poor thing had been hobbling around on this after a "fall" and it wasn't until the leg became gigantic that her mother brought her in. On exam, the leg was warm to the touch and fluctuant. The xray showed no fracture and no osteomyelitis (which is what we had originally feared) so we started her on antibiotics and she was sent to surgery Saturday morning to have the abscess drained.

Andrea checks out PMI

Andrea Havens, the research fellow on our program, arrived last Thursday (with snickers in tow, much to our delight!) At the last minute on this week's Thursday morning, one of the PMI nurses was unable to work with us, so we had an extra space in the truck. I called Andrea and she dove right in - here's a shot of her weighing some babies. It was a great PMI day - a smallish village with only about 30 kiddos to see, and only a 30 minute drive away, which meant that we got back to Schweitzer nice and early.

Le chef de la pediatrie et son assistant

The infamous Wildo returns... this time posing with my mentor, Dr. Bonito Ninteretse, in the office where we do our outpatient consultations. Dr Bonito is an absolutely FANTASTIC mentor, doctor, and person -- he is the sole pediatrician at the hospital right now, and as a result, works an insane number of hours -- he is always on call, goes to all of the c-sections, does all of the consultations, rounds in the peds ward, and rounds for the newborns on the maternity ward. yipes. somehow he manages to stay somewhat sane! it's quite incredible.

Pericardite - la guerison!

Remember the little dude with the pericarditis and the massive heart (his xray is somewhere on my blog)? He came back the other day for a follow-up and is doing fantabulously. Here he is, all better!

Examen Prenatal chez PMI

Part of the PMI (protection maternelle et infantile) program involves doing some of the prenatal checkups for pregnant women. We refer the women to the hospital for all of the blood tests, but we measure fundal height, do a brief history, give tetanus shots, and "listen" to the fetal heart out in the brush. I wanted to share a picture of our "equipment" for this adventure -- a measuring tape (pretty standard), but instead of the fetal heart monitor, we use this nice little wooden thing. the bottom end goes on the pregnant woman's stomach, and the flatter end goes to my ear... and then i wiggle around until i think i can hear something, grab the woman's pulse to see if it's her heart or the baby's, and then try to convince myself that i'm actually HEARING something...!!!!

Jess on the road to recovery

Those of you who are familiar with the fellowship probably know Jess Moukatou, the young burn victim who was able to get treatment in Boston last summer through the assistance of the fellowship and the surgical fellow Ted Lord. Jess returned to Lambarene from vacation with his family yesterday, and stopped by pediatrics to say hello. He has recovered incredibly, and is now able to move his arm nearly freely! For more questions about this ask Ted, but I wanted to share the photo with everyone.

Dinner, anyone?

Mmmm. yes, this monkey was for sale on the side of the road. I almost got beat up for taking a picture of the guy's dinner, too!
Yucko!

PMI goes to abel abonga

PMI today was a nice 1.5 hour drive towards libreville to a village called abel abonga. we saw about 50 children for growth chart plotting, deparasitizing, and vaccines, did about 10 sick visits, and 8 or so prenatal visits, then all five of us (save the driver, thank goodness!) fell fast asleep on the drive home.