The Case of a Boy in a Coma

The Case of a Boy in a Coma

Discovering MSH blog series graphicOver the next couple of months, as MSH celebrates it's 40th anniversary, reporter John Donnelly and photographer Dominic Chavez will be traveling to several countries to report on MSH’s work in the field. The stories will go into a book due out in the fall on MSH’s 40 years in global health. This blog entry is a post from the road, to give a flavor of their experiences with MSH staff.

Baliyasi Samson, 19 months old with his mother, Sayankhulana Sakala, the boy entered Salima District Hospital in a coma and later was resuscitated. © Dominic Chavez

(Part 1 of this story: Introducing Triage in Hospitals, and a Baby in a Coma) SALIMA, Malawi – A child enters a hospital in a coma. Health workers resuscitate him. The child regains his health. End of story?

Not quite.

Over a couple of days in the Salima district in central Malawi, the case of the boy in a coma provided a strong insight into the intricacies of building a health system piece by piece, and just how important it is to make sure all those pieces are working.

For eight years now, MSH’s USAID-funded programs have covered a wide range of things: starting in far rural reaches of eight districts in building a network of community health care and continuing all the way to the large hospitals in training staff and adding staff in critical areas such as HIV counseling and testing.

“We work very closely with the ministry of health,” said Rudi Thetard, MSH’s country director who has overseen a staff of 120 people and an annual budget of $10 million. “We’ve always had a comprehensive approach toward strengthening the rollout of programs. It’s not only about training people, but also about setting up the systems that allow them to work in a sustainable way.”

As for the case of the child, Baliyasi Samson, 19 months old, who entered Salima District Hospital in a coma one morning in early June and later was resuscitated, I wanted to find out whether what happened to him could be linked to MSH’s efforts in building a health system.

Two days after his parents had brought him to the Salima hospital, I met the boy and his mother, Sayankhulana Sakala, 27. Baliyasi seemed content, but his mother was still deeply affected by what had happened.

On the day before he was rushed to the hospital, she said she thought the boy, one of her four children, might have malaria. He had a fever and seemed out of sorts. In the afternoon, though, the fever subsided; even though he hadn’t eaten in a day and a half, she thought he might be OK. But overnight, he grew hot and agitated. She and her husband got up at 4 a.m., and walked three kilometers to the nearest health center in the small trading center of Siyasiya.

At 5 a.m., they arrived at Khombedza Health Center, and a night watchman called one of the center’s clinicians, who came down to the center, examined the child, and recommended that they immediately take him to Salima District Hospital, 30 kilometers away. The center had an ambulance, and soon they were whisked away in the vehicle. At some point, he lapsed into a coma. The mother thought he had simply fallen asleep.

At the hospital, one part of the system failed: the driver didn’t communicate the nature of the emergency. But the system had a backup: A nurse performing triage saw the boy immediately. She called over Rodrick Kaliati, the ETAT (emergency triage assessment and treatment) district coordinator, and, after talking with the parents, he diagnosed the case as severe malaria.

Kaliati, who along with the rest of his staff had been trained for five days by MSH in emergency triage, put the boy immediately on oxygen therapy and inserted an IV of glucose to raise his sugar level in his blood. A couple of hours later, the boy regained consciousness in the ward.

“In the past, it was first come, first served,” Kaliati said of the line of mothers awaiting treatment of their children. “There were a lot of deaths in the first 24 hours of admission.”

I asked him to look up the numbers for the past five years. The statistics showed that during the month of January from 2007 to 2009 roughly two children died every day in the hospital in the first 24 hours. But during January in 2010 and 2011, an average of less than one child died daily in that time frame.

The difference? Triage training played a major role. The hospital staff was trained in September 2009, and its performance in January 2010 and 2011 showed a major decrease in deaths.

“We were really fed up with these deaths,” Kaliati said. “MSH’s training taught us so many new things. ETAT doesn’t draw a line between the nurses and clinicians; we were trained to work together as a team. So when a child in a severe way improves it is a pleasure to us all. We had just five days of training, but those five days changed us so much.”

The boy, Baliyasi, stayed just four days in the hospital. Mother, father, and son returned to his village, and there MSH district coordinator Kuzemba Mulenga and I found them.

“I thought my child would die,” said Samson Sinoya, 35, the father. “I had given up.”

MSH’s Mulenga dissected what had happened – the success of both a triage program, but also other parts of building a system.

“Many things had to work,” he said. “We had to have the drug supply and the equipment in place. The district health officer had to have put emergency vehicles in the outlying areas, to take that boy into the hospital quickly. And when they got to the hospital, the team there had to act fast, and they did.”

As he spoke, a couple of dozen children in the family’s village were dancing, singing and laughing. In one corner, several women, including Baliyasi’s mother, were shucking ears of corn for dinner.

“It’s great,” Mulenga said of the scene but also of the case of the boy who was slipped into a coma and was saved. “Three years ago, that boy would not have survived because the system was not there. Now it is.”

John Donnelly is a journalist based in Washington, D.C., specializing in global health and environmental subjects. From 1999 to early 2008, he was a reporter with The Boston Globe. He worked for five years in the Washington bureau of The Globe, covering foreign policy, with a special focus on global health issues. From 2003 to mid-2006, he opened and ran the Globe’s first-ever Africa bureau. Based in South Africa, he traveled widely around the continent, focusing on a wide range of health issues.