Half way through my 2 weeks in Liberia

It has been a whirlwind of a week. I have seen malaria in most of its permutations and degrees of severity, from relatively mild febrile illness in a 5 year old boy seen in the clinic, to life threatening cerebral malaria in a 3 year old boy admitted to the ward. The children with malaria generally do remarkably well if they get timely treatment. Even the children with cerebral malaria who arrive looking comatose after they receive a couple of days of IV quinine wake up and are largely back to normal. The pediatric patient is incredibly resilient.

We have been able to make a small difference in the care provided at JFK Hospital through access to simple diagnostic procedures like bedside blood glucose testing that we take for granted in the United States. A clear example of this was a 3 year old boy who came into the Emergency Room with very labored breathing and an altered mental status. He looked like every other case of severe malaria with respiratory distress that had come into the Emergency Department that day, but the astute resident volunteering in the ER that day thought enough to check a blood glucose thinking that it might be low, as it often is in severe malaria, and found that it was actually high. She then asked some more questions and checked a simple bedside urine test that confirmed the diagnosis of new onset diabetes. Two simple tests that cost less than a couple of dollars saved a 3 year old boy’s life. Sometimes there are successes to report, and that is one of them.

There is still a long way to go. The case fatality rate for patients admitted to the pediatric floor with severe malnutrition is still above 20% meaning that one out of five patients admitted with that diagnosis die on the floor. The reasons are complicated and have to do with limited resources both on the part of the hospital and the parents, as they are required to pay for each test and procedure if their children are older than 5 years. However, even the alarming case fatality rate cited above is an improvement from the 30% rate of less than a year ago. This improvement is the result of better adherence to guidelines published by the World Health Organization for the management of severe malnutrition and the hard work of the Liberian staff at JFK Hospital. Bravo.

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More news from Liberia

I need to give people some background information about the country of Liberia, and how it is that I find myself here in Monrovia.

First, some background on the country.  Liberia suffered through a disastrous civil war from 1989 – 2003, which destroyed much of the country’s medical infrastructure, medical workforce and medical training programs.   The war has also taken its toll on the children of Liberia:

  • Nearly 50 % of the population is <15 years of age
  • Neonatal and under 5 mortality rate is among the top 5 highest in the world
  • 40% of children suffer from stunting due to malnutrition
  • Malaria and measles are among the leading causes of death
  • HIV prevalence rate is 5.9%  (many believe it to be higher)
  • Only about 50 physicians are presently practicing in country
  • There is only one pediatrician in Liberia

A non-governmental organization called HEARTT (Heath Education and Relief Through Teaching) was created in 2005 by Dr. James Sirleaf, son of President Ellen Johnson-Sirleaf, to address the critical shortage in medical workforce capacity in Liberia.  The goals of this organization are 1) to provide interim direct patient care   2) To aid in capacity building through education and training of medical students, interns, residents and mid level health care providers (NPs and PAs).

To give people a flavor of what type of patients we are seeing here in Liberia I have listed the diagnoses that I have seen on the floor on my service.  The pediatric floor has approximately 30 beds and we have divided the service into 2 teams.  We work closely with the Dr Emmanuel Okoh, the only pediatrician on staff here at the JFK Hospital in Monrovia to provide care for the approximately 30 inpatients as well as seeing patients in the outpatient pediatric clinic and the emergency room.

The bed census for today includes the following diagnoses…

  1. 5 yo boy with a large infectious neck mass of one week duration
  2. 6 wk old girl with malaria
  3. 1 ½ yo girl with severe malnutrition (admission weight – 5.5kg)
  4. 2 yo girl with malaria, pneumonia and malnutrition
  5. 11 mo old girl with diarrhea and severe malnutrition (admission weight – 4.2kg)
  6. 4 mo old girl with pneumonia
  7. 5 yo boy with osteomyelitis
  8. 11 mo old boy with diarrhea, severe malaria and malnutrition
  9. 6 yo girl with headaches, vomiting and tremor for 7 months and papilledema on eye exam from a presumed CNS tumor or tuberculoma
  10. 7 yo boy with miliary TB
  11. 6 mo old female with angioedema
  12. 13 yo girl with pericardial effusion caused by TB (did well after pericardiocentesis now on TB treatment protocol)
  13. 12 mo old female with AIDS and possible TB
  14. 2 ½ yo boy with Burkits Lymphoma responding well to chemotherapy
  15. 2 yo girl with severe malaria
  16. That is the patient list in a nutshell.  A rather different list of typical diagnoses from what I usually see in the office on an average day.  It has been a privilege to be involved in this work and I look forward to the opportunity to come back in the future…

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My first day at school…

Well, we saw a lot of patients today.  The ward has approx 30 patients.  The largest number of admissions are for Malaria in all of its forms followed by pneumonia, sepsis and meningitis.  The meningitis diagnoses are all presumed at present because they haven’t been able to perform spinal taps on any of the children as they have no way of doing any cultures. Even getting a cell count is difficult.  That will hopefully change in the next week or so as we will be getting a microscope and I brought a couple of counting chambers to do cell counts.  Most of the patients are treated presumptively for the main possible diagnoses.  We also see patients in the outpatient clinic and the ER who are sicker and look like they may need admission later in the day.

More from Liberia in the coming days…

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Leaving in one week!!!

I am off to Liberia in one week.  Presently, I am in the midst of spraying bed nets with insect repellent and reading up on Malaria…  I am very excited about the upcoming trip and look forward to sharing as much of the experience with all of you as I can.  More to come next week…


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