This week I saw my second ever case of Tetanus. It really upset me, I seem to have lost any of my doctor emotional detachment.
The 10 year old boy had not received any immunisations, they are free & readily available here so I can only assume that poor community education is to blame, although my friend tells me many parents do not 'believe' in vaccinations even though they have been educated on the benefits. The last patient I saw with tetanus was an adult who had been living in the middle of a violent civil war when he was a child, which made his lack on immunisation easier to fathom. In my country the only children who aren't immunised seem to be those of middle class parents who are conspiracy theory believers, that think immunisations are poison & a multinational's money making evil scheme. I took some video footage of this boy in paroxysms of pain, which I wish my professional code would allow me to show the next middle class person I meet who thinks their child dying of preventable infectious diseases is 'natural & organic'.
The staff in the ER thought the child was fitting & as he was burning up with fever had treated him for meningitis. Every time someone talked loudly, so in Cambodia that is every time someone talked! he was triggered to go into a spasm of his whole body, impeding his breathing. But he was awake, alert & could tell me through clenched teeth he was 10 years old & it really hurt.
The doctor was concerned that he couldn't suctioning the boy's airway as his jaw was locked shut. I suggested that perhaps this child had Tetanus. The doctor nodded & had already written this as a differential diagnosis. Then the very long conversation - one hour to be precise - began where I tried to communicate these salient management points;
1) He needed Metronidazole as this is the first line antibiotic for Tetanus - I had to wait 10 minutes for my slow internet connection to allow me to show the most up to date guidelines because the hospital has the old 1999 guidelines that they were still following. My work colleague made this extra relaxing by despite watching my computer screen struggle to connect repeatedly kept asking me "whats the dose? They need to know the dose now!"
2) He needed proper maintenance fluid i.e. normal saline or Ringers lactate and NOT the 10% Dextrose he was currently being given. I even worked out the hourly rate for them & gave a 10 minute session on calculating fluids in children.
3) He needed to be nursed in a quiet & low light setting - my work colleague suggested the local guest house, mocking me & implying that this was impossible in Cambodia. He seemed to think what I was suggested was equivocal to asking them to nurse him on the moon. He then proceeded to have a loud conversation about fishing with the ER nurse causing the child to go into further painful paroxysms. Apparently gentleness, quiet & consideration were not an option for this child. Ironically the other patient I saw in Cambodia was nursed in a room with the shutters shut & everyone respectfully muted - so it would seem it was slightly unreasonable for my work colleague to reject my nursing suggestion out of hand, but hey this is Cambodia.
4) He needed an infusion of diazepam - I calculated the dose & rate for them & shared by workings, which was put up whilst I explained that "over 24 hours" is the same as "in 24 hours" - this took me 15 minutes to do because clearly I am a very poor communicator.
I think what upset me about this situation was that in all this time the only person that spoke softly & gently with words of reassurance to the frightened child was me. His parents weren't even in the room for any of that time & in an that hour made no effort to talk to him or comfort him in any way.
Imagine your jaw clamped shut, unable to swallow with no one you know near by & lots of strangers pulling at you & shouting, each time they do this it provokes your whole body to contort into a uncontrollable agonising spasm. Then this strange, fat barang is telling you not to be afraid in very bad, almost incomprehensible khmer & gently stroking your head.
Can you see why I was so upset? And then it just got worse.
The child was transferred, on my advice, to my base hospital where I asked my assistant to check on their progress the following day. Of course he was in a bright, noisy room with no sedation & no nursing care. The mother thought he was having seizures & wasn't clear about the diagnosis. My assistant was too scared to ask the doctor on duty about the management plan but a kind nurse reassured her that the boy would soon be transferred to one of the local NGO paediatric hospitals.
Now I am left, as is normal following any clinical encounter here, feeling upset, unsettled, worried & frustrated but mainly just feeling like I have once again monumentally failed to do my job properly. Could I have capacity built better? Did I do everything to ensure he got the best care? Will he survive the variable quality health care provided here?
So please could you do something for me - if you are reading this & have children would you please fully immunise them because although its sounds like a massive cliche - prevention really is much better than cure.
The 10 year old boy had not received any immunisations, they are free & readily available here so I can only assume that poor community education is to blame, although my friend tells me many parents do not 'believe' in vaccinations even though they have been educated on the benefits. The last patient I saw with tetanus was an adult who had been living in the middle of a violent civil war when he was a child, which made his lack on immunisation easier to fathom. In my country the only children who aren't immunised seem to be those of middle class parents who are conspiracy theory believers, that think immunisations are poison & a multinational's money making evil scheme. I took some video footage of this boy in paroxysms of pain, which I wish my professional code would allow me to show the next middle class person I meet who thinks their child dying of preventable infectious diseases is 'natural & organic'.
The staff in the ER thought the child was fitting & as he was burning up with fever had treated him for meningitis. Every time someone talked loudly, so in Cambodia that is every time someone talked! he was triggered to go into a spasm of his whole body, impeding his breathing. But he was awake, alert & could tell me through clenched teeth he was 10 years old & it really hurt.
The doctor was concerned that he couldn't suctioning the boy's airway as his jaw was locked shut. I suggested that perhaps this child had Tetanus. The doctor nodded & had already written this as a differential diagnosis. Then the very long conversation - one hour to be precise - began where I tried to communicate these salient management points;
1) He needed Metronidazole as this is the first line antibiotic for Tetanus - I had to wait 10 minutes for my slow internet connection to allow me to show the most up to date guidelines because the hospital has the old 1999 guidelines that they were still following. My work colleague made this extra relaxing by despite watching my computer screen struggle to connect repeatedly kept asking me "whats the dose? They need to know the dose now!"
2) He needed proper maintenance fluid i.e. normal saline or Ringers lactate and NOT the 10% Dextrose he was currently being given. I even worked out the hourly rate for them & gave a 10 minute session on calculating fluids in children.
3) He needed to be nursed in a quiet & low light setting - my work colleague suggested the local guest house, mocking me & implying that this was impossible in Cambodia. He seemed to think what I was suggested was equivocal to asking them to nurse him on the moon. He then proceeded to have a loud conversation about fishing with the ER nurse causing the child to go into further painful paroxysms. Apparently gentleness, quiet & consideration were not an option for this child. Ironically the other patient I saw in Cambodia was nursed in a room with the shutters shut & everyone respectfully muted - so it would seem it was slightly unreasonable for my work colleague to reject my nursing suggestion out of hand, but hey this is Cambodia.
4) He needed an infusion of diazepam - I calculated the dose & rate for them & shared by workings, which was put up whilst I explained that "over 24 hours" is the same as "in 24 hours" - this took me 15 minutes to do because clearly I am a very poor communicator.
I think what upset me about this situation was that in all this time the only person that spoke softly & gently with words of reassurance to the frightened child was me. His parents weren't even in the room for any of that time & in an that hour made no effort to talk to him or comfort him in any way.
Imagine your jaw clamped shut, unable to swallow with no one you know near by & lots of strangers pulling at you & shouting, each time they do this it provokes your whole body to contort into a uncontrollable agonising spasm. Then this strange, fat barang is telling you not to be afraid in very bad, almost incomprehensible khmer & gently stroking your head.
Can you see why I was so upset? And then it just got worse.
The child was transferred, on my advice, to my base hospital where I asked my assistant to check on their progress the following day. Of course he was in a bright, noisy room with no sedation & no nursing care. The mother thought he was having seizures & wasn't clear about the diagnosis. My assistant was too scared to ask the doctor on duty about the management plan but a kind nurse reassured her that the boy would soon be transferred to one of the local NGO paediatric hospitals.
Now I am left, as is normal following any clinical encounter here, feeling upset, unsettled, worried & frustrated but mainly just feeling like I have once again monumentally failed to do my job properly. Could I have capacity built better? Did I do everything to ensure he got the best care? Will he survive the variable quality health care provided here?
So please could you do something for me - if you are reading this & have children would you please fully immunise them because although its sounds like a massive cliche - prevention really is much better than cure.
Happy to say jabs all up to date.. And hopefully the recent measles epidemic in Swansea has prompted a few more parents... Mobile MMR clinics were swamped. Keep up the great work Esther... Your patients need you to.. It must be hard to stay motivated, such a frustrating and depressing role .. but even a flea will get someone's attention if they keep at it long enough! May the force be with you!
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