On cholera

On Saturday we went to visit a cholera camp. There is currently an outbreak of cholera in Malawi (people keep suggesting it may have come from the horrendous cholera situation in Zimbabwe, but I’m not sure how true that is), and as I expressed an interest last week in learning a bit more about the disease, Dan took Kate, Becky and I out to one of the poorest areas of Lilongwe to visit a cholera camp. There is also a small camp at the hospital, and there may be others throughout Lilongwe, no one really seems to know what is going on, even a doctor at KCH who is supposed to be the cholera specialist. Patients are taken to camps when they present at the hospital with suspected cholera, or are encouraged to present directly to a camp. There have so far been around 300 cases of cholera in Malawi, and 15 deaths resulting from the disease. I don’t know but I wouldn’t be surprised if the deaths are those patients who seem to sent back and fro between the cholera camp and the hospital because of uncertainty and disagreements about their diagnosis. There seem to be quite a few stories about this, and the end result is that time is lost on the treatment front, and patient’s die.
Cholera is a bacterial infection of the gut, causing profuse watery diarrhoea (patients can loose up to 30 litres of fluid). Cholera usually doesn’t present with abdominal pain. Of course never say never in medicine, but if you have the runs and a sore tummy, you are probably OK! If cholera is left untreated, death arrives quickly due to dehydration. This is especially a problem in children, but also occurs in adults. We had a patient on the medical ward with cholera (before the outbreak was recognised and there were camps), where I learned that people shouldn’t die from this disease because all they require is early fluid rehydration. This patient spent about a week on the ward, with continuous intravenous fluids (he had a drip), and went home when his diarrhoea had ceased. Antibiotics are given in severe cases to speed up the recovery process, but the mainstay of treatment here is rehydration. The main way cholera is spread is through human contamination of food or water supply
We arrive at a medium-sized white marquee, with big UNICEF letters on the roof. There is a brick shed next to the tent where we go first. Just near the door are two women with some children. One woman is holding a 16 month old toddler who is sleeping and very floppy. We are told this child can take oral fluids but her eyes are very sunken (I’ve never really seen real dehydration before), and she is very sleepy. Her skin turgor (this is a measure of how fast the skin returns to normal when you pinch it between your fingers and is a mark of dehydration severity) is reduced but not markedly so. The staff at the camp (3 nurses, apparently some doctors came earlier in the morning) haven’t managed to get a drip into this child, and so gave up and decided to stick to oral fluids. Dan rightly decides this isn’t enough and thinks we should try and get venous access. The mother carries the floppy bundle inside while we dip our feet in chlorine and put on aprons and gloves. The whole set up reminds me of the Cumbrian foot and mouth outbreak, with a foot bath outside the door, and signs reminding you to wash your hands in the tubs of chlorinated water provided. The baby is laid on one of the plywood bed next to an older toddler who is already receiving fluid through a drip. The room has 8 beds in total, either made from bare plywood or string netting with black plastic over the top. The plywood beds are quite high off the ground, about 3 feet, whereas the string and plastic ones are just over a foot from the floor. Each bed has a hole in the centre, measuring about a foot across in diameter. Adult patients lie on the bed with their bottom over the hole. When I heard about these beds I didn’t really see why this was necessary, why can’t you just get up to go to the toilet, or have a bucket at the side of the bed? What we experience at the cholera camp shows us why you need a hole in the bed. The diarrhoea is pouring out of people into buckets under the holes. There is one lady, looking quite cheerful while chatting on her mobile phone (don’t be shocked, absolutely everyone has a mobile here, whether they are rich government officials or paupers from the villages), but when you look under the bed the bucket is being regularly filled through the hole. We get to see what ‘rice water’ diarrhoea looks like. It’s not like anything I have seen before. The room doesn’t smell at all, which is a pleasant surprise. So, back to the wee one who has been placed on the bare plywood. Dan tries the internal and external jugular veins on each side of the neck with no success (I managed to cannulate the jugular on an adult patient in the ward this week, if you remember one of the first blog posts I wrote I mentioned I might like to try this procedure). Then he tries the femoral veins in the groin, the three of us holding down the baby, she struggled and whines a little bit but is very weak and sleepy so its not difficult to keep her still. By the time we’ve tried several times she even stops whining. She’s a lovely wee thing and it feels horrible sticking needles into her tiny body, but if we don’t her chances are probably quite slim. Just as we are about to give up, Dan gets the cannula sited in the left groin, and starts pouring in a litre of fluid. I am reminded that I need to re-learn all about paediatric fluid resuscitation, how fast it should occur, how much per kg, etc. She sleeps quietly when we’re done and Mum comes to sit on the bed beside her. She has a diarrhoea-soaked bottom but no one seems to mind. We had to use an adult cannula (pink for those who know what that means) for this child. The camp has no paediatric equipment, which would have made things much easier. I didn’t ask but am sure they don’t have intraosseous transfusion (using a fat, short needle screwed into the bone [usually the lower leg] to administer fluid when a child is so dehydrated that you can’t find any veins) equipment, which might have been the next step for this child if we hadn’t managed to get venous access.
There are a few other patients in the room that need to be seen to because their drips are not flowing. A couple just need flushing and another needs re-siting. We do that, making use of the chlorine bucket in between patients to wash our hands.
Then we go into the marquee. There are 14 beds here, all woven string covered in plastic, and all occupied, by patients who have stopped having diarrhoea and are recovering. Everyone looks quite cheerful, including a couple of cheeky young boys. This is good to see people recovering. There is not much to do in here. Before heading back to KCH we check on the little one in the brick shed again. She seems a bit more active now. Hopefully she will recover. Back at KCH we go to the small cholera camp at the hospital where there are two children, one looking very unwell, unable to brush the flies from his face. It’s good to see such impressive infection control practice though, with chlorine hand washing and foot baths, a marked change from our observations on the ward this week.
So, it’s been an interesting day. Something interesting I learned from Dan at the end of the day was that there is a cholera outbreak every year in Malawi. Despite this, the outbreak always seems to come as surprise to the health service, and there is no organised system ready at the right time of year (when the rains start). There appears to be confusion over who is in charge, about where patients should go, and about who provides care in the cholera camps. In addition, doctors don’t seem to be routinely trained in cholera management. Dan wanted to create a rota for some of the interns to come and help at the camps, but said not until he had trained them on cholera. This seems a bit strange in a country where there is an annual outbreak.