Refugee Medicine – Difficult Life and Death Choices

 

November, 1983: Each day a new truck would arrive at the Catholic Relief Service’s hospital camp in southeast Thailand; a flatbed pickup filled with sick and dying refugees from the forest floor near the Cambodian border. The patients were primarily young mothers and children struggling to survive the conflict between the Khmer Rouge and Pol Pot’s regime.  They had been pressed by the advancing North Vietnamese army into a narrow strip of land on the Thai border.  The refugees had no shelters and almost no mosquito netting.  The most deadly and resistant forms of malaria, called Faliciparum malaria, had infected the majority of those who survived the conflict. In its most severe form the parasite led to reductions in blood flow to the brain causing the patient to become comatose.  This form of malaria was almost universally fatal in adults, but we witnessed an occasional almost miraculous recovery in some of the young children.

This created a dilemma as our “intensive care unit” was limited to some basic monitoring devices but no mechanical ventilators.  This meant that all artificial ventilations had to be performed manually, by squeezing an ambulatory breathing bag.  During the day the hospital was staffed by volunteers from Georgetown University School of Medicine, including an attending physician, a resident and three fourth year medical students, supported by a few physicians and nurses from India and the Philippines.  However, at night, a single medical student or resident was left to manage a population of over 300 patients.  Intubating a child in coma meant tying up the one trained medical resource.  However, a small number of young children had actually made full recover from cerebral malaria once they had received intravenous tetracycline and support care.  Because of this, each child that was in coma when they arrived was placed on artificial respiration.  The medical staff would take 2 hour shifts “bagging” the children and looking for changes in the neurologic status.

On one occasion a 3-year-old child arrived in full coma. His blood smear revealed an extremely low blood count (hemoglobin of around 5 g/dL) and 50% of his remaining red blood cells had a “ring sign,” indicating they were infected with the malaria parasite.  Despite the extremely dim prognosis, the child was intubated and given artificial respiration and intravenous tetracycline.  The child was bagged by hand for nearly 24 hours and started to regain neurologic function.  Within a week of arriving at the hospital camp he was seen playing in the yard with other children.

Based on this we would use all available resources to try and save any child in coma despite our limited resources and the drain on our ability to provide care in other areas. Unfortunately only a few of the children, and none of the adults, who required this level of support survived.

Another challenge that arose was how long to provide artificial respirations to children who were not showing signs of improvement. Many of the children continued to have normal cardiac rhythms but deteriorating neurologic signs (e.g., pupil responses).  As new patients arrived with potentially more favorable prognoses very hard decisions had to be made as to how long certain patients would be ventilated.  The most senior medical staff member would eventually make the final determination as to which patients would not continue to receive artificial ventilation, although these decisions were extremely hard on the staff members, who also tried to engage any relatives with the decision making process.

Disclaimer: the information contained in this story is true and based on the recollections of Michael Stearns, MD, who at the time was a fourth year medical student and refugee medicine volunteer medical worker.