Yesterday, Laurence and I, as the two remaining troopettes, went to the regional hospital ER to observe and help out. Observe, we certainly did. Here are a few of the cases to consider.

The first case we witnessed was a 34 year-old man who had been in a motorcycle collision (I’m unaware of whether I made it clear before: EVERYONE drives scooters and motorcycles; cars are a minority. There are no helmets). Now the collision had been with an gas truck, so you can imagine the impact. He had experienced inner ear hemorrhaging (in french otorragie) and was lapsing into a coma. Most of us imagine a comatose person as being limp, calm and unresponsive. This patient looked as though he was having a panic attack, and was in major respiratory distress, probable because his brain was shutting down. So they gave him mannitol, a substance to reduce the pressure between his scull and his brain (thus minimizing the damage should he survive) and monitoring him. Unfortunately, due to equipment issues, monitoring, in this case, means only checking his pupils and taking his blood pressure (which was at 230/170, which for those of us who aren’t in a medical field is critically HIGH). We asked if they planned to intubate, and I was brought back to the harsh reality that Malians face most days. They have access to the equipment needed to intubate, but nothing to hook him up to.

He will most likely die in the next 24 hours.

He was struggling to breathe so much you could see his jugular through his neck muscles when he inhaled. His lower ribs protruded sharply from his thorax with each seemingly agonizing breath and despite my medical rationale, I couldn’t help but fear for him, because it looked as though he was AWARE of the fact that his own brain was suffocating him and there was nothing he could do about it.

I’m officially thankful for my bike helmet, but I wonder how much more could be done in a modernized, equipped setting. Could we save him, rehabilitate him? His Glascow (coma) score was 6, what were his chances upon impact? We’ll never know, and certainly he won’t.

The second case we saw was one that reminded us of how deep cultural roots really go. Much like the taproot of the great baobabs, they seem indestructible, and just as unchanging.

This patient was a 25 year-old man who had suffered a stroke. It isn’t uncommon to see high blood pressure in people as young as 20, due to both environmental (dietary) and genetic (people of African descent are much more prone to HBP) factors. High blood pressure, in layman's terms, often occurs because of reduced blood vessel size. Blood tends to take a bit longer to get though, and the slower the flow, the more odds there are of platelets and cholesterol and all sorts of little debris to collect into a neat little blob that adheres to the vessel wall, like a ticking bomb. The formation of blood clots is also much, much more frequent (ladies, this is why most African girls our side of the ocean have to avoid high-dose contraception, as this increases the risk of blood clot formation).

When a blood clot forms, it has three destinies:

1-it remains attached to the vessel wall where it formed
2-it detaches and travels to the lungs and you suffer a pulmonary embolism
3-it detaches and travels to the brain and you have a stroke (most of us are very familiar with this)

In his case, it chose Door #3.

When we did the rounds, this man was paralyzed on his entire right side (known as hemiplegia) and had emerged from a coma only a day earlier. Now here's where our notion of medecine has to go take a coffee break:

His family wanted to have him discharged and take him home because they believed his condition was caused by a djinn, or evil spirit.

Their belief was that while coming home on his bike, he passed through the house of a sleeping djinn (these are assumed to be invisible, in case you're wondering) and the djinn cursed him for disturbing him.

Fair enough, I can understand the futility of trying to explain thrombosis to people whose spirituality permeates their health. No problem, really.

The problem is that the medical staff here refuses to do anything other than insist of the scientific interpretation of the situation and the family isn't about to give any leeway to science either.

The patient's condition, regardless of its source, ISN'T any different, so why the difficulty.

I wonder how interesting it would be, just for a moment, to develop a compromise: let them take him home as he is, and encourage them to help him rehabilitate. Show them way to stimulate his mind and the right side of his body to eventually regain maximal use of it. Don't discuss magic or science, just give them tools accessible enough to help the patient.

I'm seriously contemplating doing a master's degree in Intercultural Mental Health Nursing. Now there,s a challenge (imagine that in Mali, there's 1 psych hospital, it's expensive, and it's much more of an asylum. Therapy for burn out and depression just isn't available, and furthermore, it's possible people would not be receptive to therapies we use in the West)

Our third case of the day was a young woman of 26 years with the following symptoms (see if you can guess what she has before I tell you. Remember, this IS Africa):

-severe weight loss
-opportunistic infections
-very anemic
-very low T-cell count
-exhaustion
-no appetite

5...4....3...2...1...time's up!

She had HIV that had progressed to AIDS. she never even had a chance, because she had progressed to full AIDS ( the phase of the disease where any bug you catch can potentially kill you) by them time she was diagnosed with HIV. Traditionally, the earlier you identify the virus's presence, the better the person's chances are of slowing his or her progression to AIDS.

She will be evaluated by Dr. Touré, the regional HIV case worker (for whom everyone here has great respect, because he is highly dedicated to his patients and the cause itself), then probably put on anti-retrovirals (the same ones as us, luckily Mali doesn't have a supply problem) and transfused to give her strength the fight the infection.

She was blood type A+. So am I.

So, in highly sterile conditions, I went to the lab to offer up a pint of blood, much like all the other girls in the group had done, inspired by Maude's initial gift to a critically ill mother. That patient had hemorrhaged behind her placenta, the baby was dead and she needed surgery, but because of blood loss was going into shock. Maude offered, was crossmatched and within one hour, a pouch of fresh, healthy blood was given and the woman pulled through. I've never felt more honored to know my colleagues.

At the lab, they tested me for syphilis, HIV and Hepatitis B, all clear. Yay! Then A+ blood type was confirmed and my baggie of blood was popped in the fridge. I'll never know whether she got the blood or not, but I do know that as opposed to North America, where 44% of people are Type A, the proportions are reversed here, making Type A both rare to find in a patient and just as rare to get for a patient in need. Because they also have no blood bank facilities, blood (when there is any) is stored in a standard fridge with the vaccines, giving it a lifespan of 10-15 days only before too many clots form and it is rendered useless. The older the blood, the more clots in it and the less helpful it is to the patient.

In Mali, most people are extremely hesitant to give blood, and finding a donor often implies dealing in a sort of informal black market. The families of patients hospitalized all come to the hospital and camp out during their stay, so most of the time when blood is needed, a family member will do the rounds, looking for a match. If the donor consents, and fee for the donation is set. On average, a person may earn around 4 000 CFAs per day on a good day. A single pouch of blood may sell for anywhere between 10 000 and 60 000 CFAs.

Sometimes a family must choose between giving life-saving blood and the medication that will treat the actual disease.

I really hope she got the blood.