Bittersweet goodbyes with MSF in Bangladesh

Yesterday was bittersweet, as I discharged my favourite patient from the MSF facility in Bangladesh where I have been working. She is 8 years old, and in many ways, she is one of the lucky ones. Having managed to escape Myanmar with her whole family, everyone made it across the border into Bangladesh and into safety. However, she is also one of the unlucky ones as she contracted diphtheria. I first met her one mid-afternoon on a day shift in the hospital. She had the typical presentation; a few days history of sore throat and fever with some difficulty swallowing.

When I shone the torch inside I found her tonsils coated with the by now familiar thick white coating of pseudomembrane, a layer formed from dead cells and debris produced by the diphtheria toxin. However, this was not the main concern. The concern was that she only had the smallest opening for an airway which could close at any moment.

We gave her the vital treatment of antibiotics and diphtheria antitoxin. Remarkably she remained stable overnight but the next day, her neck had swelled to double the size, giving her the so-called ‘bull neck’ of diphtheria, and she had developed a partial airway obstruction. At our facility we are unable to provide advanced airway management. Back home, there would be no delay. We would plan for an intubation with emergency cricothyroidotomy or tracheostomy back up, but here we have no such thing. The team gave what they could, simple adrenaline nebulisers and steroids. We all had an anxious night. Thankfully she remained stable and slowly over the coming days, as the treatment we were giving worked, we saw signs of improvement.

Her neck swelling reduced and her pseudomembrane eventually diminished. She was here for 12 days in total and I had gotten used to seeing her face every day. I watched her through the pain and tears, through the toddler like tantrums as she vented her frustrations and through her smiles as we started to talk about home. I watched her devoted mum and dad who stayed by her side through it all, desperate to keep close to their precious daughter. I held her 6-month-old baby sister to give her mum a break whilst she attended to her other daughter. Her mother was heavily pregnant as they crossed the border and delivered a healthy baby girl shortly after their arrival. Yesterday was bittersweet, for yesterday we said goodbye. I will miss her and her family, for who knows what lies in store for them.

She was not the only patient I said goodbye to yesterday. Two days ago we had a patient admitted from another MSF facility. My second patient is 10 years old and is also one of the unlucky ones. Having survived the journey across the border, she had also contracted diphtheria and had the most severe form. Her symptoms had been present for eight days before she was taken to the first hospital but she was given treatment with diphtheria antitoxin in the hope that it may still help. She had a stormy course after treatment; she lost weight and refused to eat and drink. She was also getting chest pains. On the night of her admission to our hospital (11 days in,) she developed a dangerously low pulse rate down to 35 beats per minute. We have limited investigative capability; all we have is a basic monitor which can show us only a little of what her heart rhythm was doing. It was beating slowly in a rhythm called complete heart block. The diphtheria had caused severe damage. Again, the team did what they could but if this continued she would need a pace maker, but there is nowhere that can do such procedure here.

She survived the night and in the morning, after passing through some pretty scary cardiac rhythms, became much more stable. However, the future remains uncertain. Without further investigation her prognosis is difficult to judge. I cannot say how long she has, maybe she will live for many years, maybe the rhythm will change once again and she will die within the week. I talked at length with her mother who cried and blamed herself for waiting too long before taking her to hospital and who believed me when I lied and said that it wouldn’t have made a difference. Her mother, who had lost so much already, having watched family members die; having stood powerless as the army took all of their belongings. Her mother, who took her family and ran for her life. Her mother who, as she wept, thanked me and prayed for me for everything that I did to help her daughter, even though it was very little. Her mother, who was grateful for everything they had been given in Bangladesh after they had lost everything in Myanmar.

My time in Bangladesh is now over and I am back home with my family. I find myself reflecting on the past month, on the work myself and the team have done, on the patients we treated. Inevitably there are thoughts of what more we could have done, what more I could have done. However, I look back and see that by the end of my time in Bangladesh our centre had seen and successfully treated close to 1,400 people. Indeed, through their hard work, MSF centres combined havd treated over 4,280 people by the end of January alone. So yes, it feels that there is always more that can be done, but there is also hope that our treatment has allowed many people, like these two little girls, to live with one less worry for their health and to concentrate on trying to rebuild a safe future.