The Children's Emergency Department in Blantyre sees around 90,000 patients per year. Around half of those come through the resuscitation room. This room, the focal point of the department, is about the size of a large living room and houses 3 trolleys and a few stools. I'm told the record number of patients in this room at any one time is 17. I arrive to a conservative 3 patients. Two are being treated for respiratory conditions. The other is a nine year old who has been bitten by a snake.
From the doorway I can see how swollen her leg is, with several large blisters and peeling skin. The wounds from the snake bite on her foot are obvious and the child is barely conscious.
The team are taking the history. There are considerations I would never have thought of: how did the snake behave? Was it daylight or darkness? These factors will give clues about what sort of snake it was and the likely prognosis. There is no anti venom whatsoever in Malawi, so the truth is that this may guide the way the family are prepared for what to expect. The snake struck at night and wrapped itself around the child's leg before biting. Based on this the team thinks it's likely to be a puff adder. Not a black mamba, they say; she'd be dead already.
The story unfolds and we hear that this happened 48 hours ago. I'm shocked. How could the family have done nothing for 2 days? They didn't do nothing though: they took her to see a witch doctor who gave her local Mankwala - a black ashy looking substance rubbed in patches on her legs. The team point out the characteristic "tattoos" left by this substance. There is great belief among the local population in witch doctors, but the team report that this black Mankwala is highly toxic. Sometimes it is used as a topical application and sometimes given orally. Either way, the effect can be devastating.
Context and culture is all here. This feels uncomfortable to me. This delay in getting 'proper' medical attention may be considered neglectful at home in the UK. The local team report that work is being doing to aid understanding of the role of witch doctors. This is not an overnight change. Families trust their Witch doctors and integrating them into hospital teams, or at least understanding each other is key to ongoing relationships between healthcare workers and families if trust in healthcare workers is to be maintained.
Throughout the history taking, the child is virtually unconscious. She wakes occasionally and thrashes around, distressed and disoriented. Her oxygen level is low, the venom has attacked her ability to clot her blood normally and she is bleeding from the mouth. This indicates that there may be a severe problem with her blood clotting ability. She needs a blood transfusion urgently and this is provided with surprising speed. I'm told that blood is readily available, thanks to local school children regularly being lined up to donate blood. In honesty, I don't have time to consider the ethical ramifications of this in the moment. There is a child in front of me who desperately needs blood and blood is here.
We need to know whether the snake venom has compromised blood clotting completely, but a blood test may take days to yield results. This could be too late. A keen junior doctor suggests the 'bedside clotting test'. Simply, we will take a small blood sample, leave it in a container for 20 minutes and see if it forms a clot. This is not something we do every day. Most people in the room have never seen it. It's so simple, yet so rare. It's a tense few minutes as we watch the specimen tube. The moment of truth: the tube is inverted and the blood doesn't move. A clot! This is great news. The child has retained this protective mechanism. She is unlikely to bleed to death.
There are other considerations though: her leg is so swollen that the skin is becoming very tight. If this continues she is likely to lose the leg. A referral to the surgeons in the nearby private hospital is made. They will perform a fasciotomy to release the pressure and then only time will tell. There is a risk from overwhelming infection and the possibility of losing the limb has not gone away.
Afterwards, I think about this young lady and the likely outcome. I'm told she has a 20% chance of survival. Snake bites are not uncommon in this part of Africa but stocks of antivenom are prohibitively expensive. If money is spent on that, all the children with heart problems may not have their vital medications next month. These are everyday issues in resource limited settings. I compare it to my usual practice in the UK. These days we are constantly aware of money, but not like this. I have never been in the position where I could save one child at the expense of another. It's not easy. These are judgement calls that I am thankful not to make.
And what of this young lady? She is starting to wake up. She's making more sense. I am hopeful that she will keep her leg (apart from anything else, I know that life as an amputee here will be an eternal challenge), and I hope that the loss of a leg will be the worst that this family may have to face. Only time will tell.
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