Pediatrics

Dr. I is a gentle and unassuming man with a penchant for elegant patterned ties, which he wraps around his spectacles when they are not in use. He presides over one of four pediatric wards at Mulago Hospital, each of which rotate in turn as they try their best to admit the hundreds of extremely sick children who arrive at the acute pediatrics unit every day.

The children range in age from newborns to young teenagers, and they fill up the waiting room, resting on their mothers' laps. Frequent crying punctuates the air, as a child suffering from sickle cell anemia struggles in pain. Sickle cell anemia is a genetic condition that occurs when some or all of the red blood cells produced are abnormally shaped and can easily form the shape of a sickle. These blood cells cannot move properly through the circulatory system and easily form clots in the smallest blood vessels, triggering the painful crises that the children are experiencing. Even more troubling is the anemia, or lack of red blood cells, that occurs when the spleen filters out these defective cells.

A rare moment of silence in the waiting room belies the dangerous condition that many of the children are facing. Without a sufficient number of red blood cells, the anemic body cannot bring enough oxygen to the tissues throughout the body, and severe illness and death is imminent.

The on-call responsibilities are taken by Dr. I's ward today, and he scans the waiting room area, triaging the patients to find the sickest ones. It's a simple test: he pulls down the eyelids to see the color of the conjuctiva lining the inside of the eyelid. If you look at your own in the mirror, it is probably a shade of pink or red, depending on how long you have been staring at the computer screen. In the sickest children, the color is a blank white. The same test is done for the tongue and palms of the hands. Similar results are found.

The mothers are instructed to bring their children inside, and Dr. I begins writing the patient's charts. A cursory diagnosis is given, for the first priority is for the patient to receive blood. More detailed treatment options can be discussed later. So Dr. I begins to jot down the patient's history. Other than the genetic sickle-cell anemia, the other common cause of anemia is infectious-pediatric malaria.

Malaria is a disease caused by tiny protozoal parasites. After a nighttime bite from an infected Anopheles mosquito, the parasites enter the blood stream, invade the liver, and spread to red blood cells. The parasites multiply within the blood cells and rupture their hosts when their numbers are sufficiently high.

The patients in the acute care ward arrive only after prolonged waiting and even transfers from other hospitals, so their conditions are often very severe. High fever, anemia, and a marked increase in size of both the liver and spleen can be seen. To confirm a diagnosis, however, a blood smear must be done. Without a lancet, the laboratory technician finger-pricks hundreds of children a day, and smears the blood on a glass slide. A blue field stain and red malarial parasite stain is added, and the slide is viewed under an oil-microscope.

The P. falciparum species of parasites are endemic to Sub-Saharan Africa, and are easily seen. Infected red blood cells present with an ominous red dot, and malaria parasites swimming freely in the blood can be easily spotted. Based on the number of parasites seen in each microscope field, a diagnosis is given: no malaria parasites seen, +, ++, +++, or ++++. Many of the children present with +++ or ++++ malaria.

After the diagnosis is confirmed, the children are moved to the emergency treatment room, where there are cannulated. A plastic cannula tube is inserted into the veins on the back of the hand, but not without much screaming and crying. The plastic screw top is removed and a small sample of blood is drawn to determine the blood type. Four drops of blood are placed on a white tile, and four different antibodies are dropped on each blood spot: anti-A, anti-B, anti-AB, and anti-Rh factor. Swirling the tile around reveals clotting in the anti-A, anti-AB, and anti-Rh spots. The child has A+ blood.

Blood shortages at Mulago are a constant worry. Some of my colleagues witnessed a child who did not receive a transfusion in time and passed away on the table. Each bag of blood is precious and contains life. Gingerly, Dr. I removes a bag of blood from the refrigerator and brings it to the child's mother, asking her to warm it under her arms. The child is transfused, a dose of quinine is given to kill the malaria parasites, and one life is saved for today.