I awoke the sound of a plane flying over at 1:30 am, early Saturday morning. I smiled, rolled over, and drifted back to sleep. That had to be my patient evacuating to a facility in South Africa, because normally the Lilongwe airport closes at 5 pm, but Dr. Kasmani had worked with the insurance company and the ground staff to keep the airport open some extra hours. They had expected an 11:30 takeoff time, but a two hour delay was much better than a one or two day delay in this case.
I became involved with the case on Tuesday, when I noticed a sick looking girl and a family struggling with our clinic’s check-in process. I ushered the kid and her mom to the lab for some testing – they had a positive test for Malaria on Monday, but by Tuesday she wasn’t improving on tablets. I ordered a blood film for malaria which showed that there weren’t any parasites visible, but even a small amount of parasites could cause critical damage for a Dutch girl with her first case of the disease.
It all started two weeks ago when she slept two nights without a bed net in the national park. Or maybe it started a year ago when the family decided that they didn’t need to take daily prophylaxis after six months in the country. Either way, she had malaria now. Her nausea and dehydration were easy enough to treat in a few minutes. I started a drip to ramp-up her malaria treatment and dissolved a medicine under her tongue to prevent vomiting.
What was more concerning were her platelets, those little particles which help blood clot. Her levels were severely low, which was not uncommon with the malaria we had in these parts. I was confident that her levels would increase after 24 hours of injections, and so when her family asked to go home for the night and receive their 4 am injection at a clinic close to home, I allowed them to leave, provided they would come back the next day for their final dose and a repeat full blood count to check platelets.
I gave my contact information, but I didn’t hear form them until late night the next day. They were asking what medications to take after the injections were finished, so I confirmed their choice, but asked them to tell me about the repeat full blood count. I didn’t hear from them until the next night, at which time they informed me that their daughter had a nosebleed, and that the platelets hadn’t improved the day before. Terrifyingly, they said their daughter was starting to look yellow, which is definitely not a good sign when it comes to malaria.
So Thursday night, when I heard that, was the first late night I stayed up trying to advise them. I recommended that they come into the clinic for a repeat blood test, and that they inform the night clinician about all the concerns. I expected additional injections would be ordered, I expected additional tests to evaluate liver and kidney function and make sure there were no internal bleeds. What I did not expect was for the family to be sent home with the note “follow up with Dr. Miller in the morning.” I definitely didn’t expect that the platelets would be even lower that day.
There is a very dangerous condition that happens when someone’s platelets all clot together. It can create blockages for the vital organs and then cause uncontrolled bleeding all over without platelets to help stop their blood flow. In Malaria, platelets do go down, but they should double every 24 hours. In Malawi, we had a shortage of blood products, and a plasma infusion to replace platelets was completely out of the question. So far, the patient only had bloody noses, and abdominal pain which we hoped was not internal bleeding. But she could go downhill quickly.
I communicated with the family from first thing in the morning, when I learned, horrified, that she had been sent home over the night. The family said they would plan to bring her back to the clinic at 9 am, so even though I usually work from home on Fridays I was there, in clinic, waiting. When the family didn’t show up, I started calling the numbers we had on file. I tried to communicate the importance of moving quickly. I also connected with our clinic’s pediatrician and malaria expert, and Dr. Kasmani, a critical care expert who was really good at getting people evacuated to locations where they could receive better care. I waited 2 hours at clinic, while the family was struggling to get ready and care for another sick child. Finally I instructed them to go directly across town to meet up with Dr. Kasmani. He assured me he would perform all necessary tests (she had enough inflammatory markers that her risk of dying was higher than I wanted to communicate to the family, and she was starting to show signs of liver injury. Beyond that, her platelets were lower now, critically low). I spent some time communicating with the family about the importance of bringing the child to a facility which had intensive care capacity and blood products if transfusion was needed. Dr. Kasmani called the evacuation insurance company every 20 minutes and instructed the father to do the same.
So by the time I went to bed, confident that she would get to a high level facility, I was tired and frustrated by the delays, but happy that she would be getting somewhere where she could get good help. And when I heard the flight pass overhead, I was confident that it was my patient, on her way to a better chance of recovery.