Mes chers amis et ma famille,

It is halfway through my third week in Guinea when I return to the pediatric ward, this time with someone who speaks English. I find the head of the department to talk and my translator patiently articulates my purpose. The pediatrician says he’ll direct the meningitis patients to me, but asks that I help him, too, with some of their neurological mystery cases. I say this seems like a fair trade. He says good because they’ve got two patients that need lumbar punctures right now. A moment later, someone who seems like the chief resident arrives, and then escorts my translator and I back down to a room on the first floor. During our short transit, we manage to add about 15 people who appear to be nursing students to our group, who follow us into the room to watch. I’m getting used to medicine being a spectator sport here. 

The chief resident leads me through door to a mother carrying a sick-looking infant in a diaper. She places her son on a bed in front of me and then exits. The chief resident turns to me, hands me a pair of gloves with a mask and tells me to get started. On the bed before me is a tiny patient barely old enough to sit unsupported, looking even more unsteady from his illness. Confused, I ask where the lumbar puncture kit is. He says they don’t have any here. My nerves spiral in apprehension: my career record in lumbar punctures is 0/2 so far, and the thought of doing one without the tools I’m used to seems destined for failure. I ask him if I can watch him do the first. Without hesitation, he procures a needle and crouches down beside him. I see they use no anesthetic here. In what feels like ten seconds, he finds his target, jamming the needle into the child’s back, and as the patient cries a trickle of clear fluid begins to flow effortlessly through the needle. Grabbing the needle’s packaging, he places the wrapper under the stream, losing precious fluid due to a lack of equipment, and then a nurse hands him a syringe which he uses to aspirate almost 3 milliliters. 

Someone scoops up the infant and then he turns to me and asks if I’d like to do the other one. Yes, I say, trying to forget about the crowd that has gathered, which seems to have grown. Another mother arrives with her baby and places her in front me. The patient looks about 3 months old and seems even floppier than the last. When I catch a glimpse of her face, my brain quickly binds the features together: “Down’s syndrome,” I say. “Oui, trisomie vingt et un.” He hands me a needle as I crouch. With one knee on the ground, I place a hand on either of my patient’s hips, sitting the child upright and bending her back gently forward. The child whimpers, too small and too sick to resist. 

With my fingers navigating the contours of her hips, I use my thumbs to palpate down the spine, feeling for the spaces between the vertebrae, then press my nail into one of them to mark the spot that feels right. I forget everyone else in the room except for the patient. Keeping her bent forward, I insert the needle and it pierces her thin skin with scarcely a whimper – but it advances only slightly before being stopped; I must be too close to the vertebrae. I exhale slowly, trying to envision the anatomy. I withdraw the needle slightly, angle it towards where I imagine her belly button should be, and feel it pass smoothly through the subcutaneous tissues and into the spinal canal as a crystal-clear fluid flows through the needle.

I collect the precious liquid in the same manner that the chief resident did, and then as quickly as she arrived, the patient is whisked away. The chief resident gives me a nod of approval and then says something before turning towards the door. The translator explains he wants me to follow. I weave my way through the mass of spectators, who trail behind us, and walk behind the chief resident into one of the patient rooms. Inside, there are more visibly sick children lying in beds surrounded by their families, who are nestled in among piles of belongings that suggest they’ve been here for a while. All their eyes are on me. He points to one of them and begins reciting the history to the translator as the room continues to fill with more and more staff; we have now added a dozen residents to our ranks. It seems I am now being shown their mystery patients. 

The translator explains to me that the working diagnosis for this previously healthy 6-year-old child is currently “coma.” I see a child with a nasogastric tube, visibly wasting away, who arrived five weeks earlier with a febrile illness. He was treated for malaria, then meningitis, and eventually developed uncontrollable seizures. Now, the boy lies motionless like this around the clock, except for the one time a day when his mouth, and then his limbs start to twitch – and soon these little twitches snowball into generalized seizures, until they give him a drug to make him stop convulsing and he goes back to being unresponsive. I eyeball his medication list to find he’s now being treated for tuberculosis; they show me an x-ray with an upper lobe opacification that could be cavitating, but the film is overexposed and it’s hard to tell. Later, I’ll speak with one of the infectious disease specialists back home about the case, who will recommend tests that don’t exist here. “This would be tricky to diagnose and treat in Boston,” he’ll tell me.

They lead me to another patient, this one a year younger, with a similar story (“malaria and meningitis”) who is also now in a frozen state, minus the frequent seizures, so this time there isn’t even something apparent to culprit for his coma. What can I do for him, this poor boy lying motionless in a hospital bed, surrounded by a family who lovingly waits every day for a piece of better news? While he too is young, and children are wonderfully resilient even in the face of severe illness, his neurological exam reflects a devastating injury. I’ll speak with another colleague back home about him, we’ll decide what tests to order; later the staff will ask me to prioritize the importance of these tests, as money is an issue here, too. Before leaving the room, his father at bedside thanks me several times for coming, and I see there is a look of hope in his eyes.

The last patient they bring me to is a 9-year-old boy who experienced the sudden loss of muscle coordination several days after a diarrheal illness about two weeks ago. His father is there and tells me they have traveled from Côte d’Ivoire (the Ivory Coast). They show me testing including a CT scan and bloodwork, which are normal, and state that after giving him a short course of steroids, he seemed to get a little better. His neurological exam, other than the poor coordination hallmark of cerebellar illness, is normal. Again, they ask me what to do. I say if he gets worse or develops new symptoms, then I’m wrong – but I tell them they don’t need to do anything: the patient seems to have an acute cerebellar ataxia following a viral gastroenteritis and is going to get better on his own. His father thanks me before the medical team files out of the room, and I want to tell him I haven’t done anything – but I know that just naming the scary thing happening to your child is something.

Those first two boys from that afternoon continued to awaken me to the size of the problem of equitable healthcare access in this country. Many of these patients and families travel from the distant corners of Guinea to Conakry so their loved the ones have a chance of being treated appropriately – but with an average monthly salary of $250 and many mouths going hungry already, despite their journey, often families simply cannot afford the testing they need to secure the right diagnosis or treatment. So when the residents estimate the price of these tests for me — $35 for an EEG, $150 for a CT, $350 for an MRI – my heart breaks. What I am still struggling with is the conflict of knowing that I could access the money pay for these tests. But it shouldn’t come down to that – right Once I start paying for their care, where would I even draw the line? The immensity of the need here is so great, I cannot expect to contribute more than a few drops in the bucket; yet when the child in front of you is dying because their family cannot pay for healthcare, the bigger picture seems less important.

On another day, I join the hospital team for their morning huddle session. After they finish running the numbers and overnight events for the patients, a collection goes around to fund one of the studies I’ve recommended, and everyone donates something. The staff’s generosity touches me; this must be how they get things done here.

I’ll return to the pediatric wards to continue to follow the two unresponsive boys, consulting with specialists back home when I feel out of my league. In the meanwhile, it feels as though the number of families coming to see me at the clinic has tripled in the last week, and I now can barely keep up with the number of patients. While many of these children are sicker than I can possibly hope to cure, I can still treat them, and I can still care for their families. And so it feels, finally, that I’m doing good, steady work here, and despite my early phase in training, it is clear to me that I still have much to offer. 

Bien à vous,

Le Gringo

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