Crozet Annals of Medicine: Out of Africa

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Sick kids are different than sick adults.

But first a word about terminology. ER doctors and nurses use the word sick differently than lay people. To us the term sick means actively dying. And not just from medical causes; you can have a sick trauma case roll in as well. Having the flu, while unpleasant, is not how we use the term sick.

So sick kids are different from sick adults.

Sick adults almost always come in by ambulance. We have advance notice by radio, vital signs, and IV access. We can set up and plan a little. Nobody runs.

Sick kids are rushed back from the front desk, floppy, in the arms of a grim-faced triage nurse. No time for plans, just adrenaline. It is the only time you will see an ER nurse run.

Sick adults are most often older, near the end of their life even before the acute crisis occurring now. Their quality of life may be low.

Sick kids have their whole lives in front of them. They were perfectly fine yesterday.

Sick adults may not have any family with them in the ER. They dwell in nursing homes far from their children’s homes.

Sick kids always have parents with them worrying, quietly frantic, stunned and scared. Sick kids often have bewildered and frightened siblings with them too.

Sick adults bear the stigmata of chronic illnesses and life choices upon them; the gnarled joints of the crippled arthritic, the barrel chest of the smoker, the bulbous nose of the tippler, the obesity of the sedentary.

Sick kids are beautiful. Rosy fevered cheeks, fine hair sweat plastered onto smooth brows. Angelic. They even smell good, freshly bathed (to bring down the fever)

Sick adults do not smell good.

Sick kids roll back from triage like an avalanche gathering power and substance. As the nurse bearing the child passes, every caregiver falls in, following close on her heels, a gathering swarm, impossible to mistake, attracting ever more staff in its wake. By the time the child reaches the resuscitation bay a whole team has coalesced without any forethought. Little direction is needed, everyone knows his or her job.

The first few minutes are gut-wrenching but relatively straightforward: IV, oxygen, monitor, fluids, vital signs, blood sugar, check airway-breathing-circulation. We can do this stuff in our sleep.

In our best cases the kid perks up, pinks up, looks around. In our worst nightmares the kid responds not at all. Floppy, clammy, cold. Turn on the French fry lights, as we call the infrared warmers over the resuscitation beds. Fever is bad but hypothermia is much worse.

I had one of those kids a while ago. Around three years old, sick, probably infected somewhere, he was not responding to any of our resuscitation efforts. We were running out of options and the mood of the team was edging toward fear.

One of the senior pediatric residents was taking the history from the mom in the corner of the room while the rest of the team sweated under the French fry lights.

Routine stuff: When did he get sick? Any meds or allergies? Up to date on all his immunizations?

“Oh we don’t vaccinate our children!”

Time seemed to freeze in the room. In the silence and sudden stillness the collective gasp of every team member was obvious to me. But this team was good and this kid was sick, so without missing more than that single beat everyone went back to the harrowing work. The undercurrent of anger in the room was translated into redoubled determination to save this kid.

I was reminded of this case this month because of the recent dramatic news out of Africa that due to a vigorous vaccination campaign, for the first time in history meningitis A had been virtually eliminated from the 26 countries in sub-Saharan Africa that make up the “meningitis belt.”  In previous years there were up to 250,000 cases of meningitis A infections in these countries, with up to 25,000 deaths a year.

Meningitis A is caused by a strain of the bacteria called Neisseria meningitidis. This is the same bacteria, although a slightly different strain, that killed Renee, the very first patient I ever treated. (www.crozetgazette.com/2009/11/lightning-strikes/)

Supported by a grant of 70 million dollars from the Bill and Melinda Gates Foundation, in 2001 a vaccine was developed to fight meningitis A, a strain of the disease that occurs only in Africa. Vaccination started in 2010 and by 2013 230 million people had been immunized with the vaccine at a cost of less than fifty cents per dose.

In 2013, the last full year we have data for so far, there were only four cases of meningitis A reported in all of Africa. That’s right, from 250,000 cases to four cases in just three years.  With some diligence, meningitis A, like smallpox, will disappear from the world in the next few years.

For 50 cents a person we can eliminate a fatal disease from the world.  It cost a lot more to save the child I described above from his vaccine-preventable bloodstream infection, but in the end, after lots of antibiotics and a stormy course in the ICU he walked out of the hospital.

Happy New Year!

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