Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (31 page)

This man had tetanus.

I was rounding one afternoon, out in the fly-infested “intensive care verandah,” when I stopped at a patient who had been puzzling me for days. He was a young man who, someone told me, was a policeman in a small village some distance from Kano. His three brothers were caring for him. He had been here on the verandah for three or four days. “Meningitis, fairly classic case,” I had told myself initially. (Of course, my workup consisted of lifting the man's head up to see whether his neck was stiff—it was.) I had treated him with oily chloramphenicol and when that didn't work, ampicillin. He was one of the few patients who didn't either die or get better; he just slowly, slowly kept looking worse and worse. Was this a weird case of meningitis, I asked myself, or was it something else? Occasionally we would find, after a day or two of symptoms that suggested meningitis, that in fact we had a cholera case in our midst. We would have to drag the patient off to the cholera camp and dowse the ground where he or she had lain with chlorine bleach. But this wasn't cholera. Sometimes I would wonder—malaria? Cerebral malaria? I had no way to tell other than empiric therapy, so I went ahead and gave IV chloroquine. Sometimes when I did this, the patient would make a stunning recovery—but not very often. I tried chloroquine on this patient, but he only seemed to look a little worse, just as before.

That day I just squatted there, looking at him. The man was conscious but extremely weak, a strange type of weakness. He could gesture a little with his hands, but he had trouble speaking, or even swallowing. His brothers would try to feed him a little soup, but it was clear that for this man even opening his mouth was extremely difficult, almost painful. That morning the patient lay back stiffly, his head in the lap of one of his brothers. As I watched him, his hands made the pill-rolling gesture common to Parkinson's patients, while across his naked belly there were ripples of abdominal muscle contractions, a wave of fasciculations—tiny, chaotic muscle spasms. Whatever this was, it didn't look like any meningitis—meningococcal, malarial or otherwise—that I had ever seen.

I picked up his hand. It immediately assumed a claw shape. I tried stroking it gently, but this only seemed to make the hand spasm worse. I checked his temperature, using the only thermometer I had, my hand on his bare chest. Maybe a low-grade fever. As I hunched over, looking at him, the medical director of the mission, Jean-Paul, a Zairian political refugee with a lifetime of experience in tropical disease, walked by and paused. He must have been puzzled by the sight of one of his doctors kneeling by a patient as if in prayer. He looked down at me, an eyebrow raised in question.

“What is this?”
I asked him.

At this he looked even more puzzled. Thinking back, I realized that the expression on his face was incredulity. He couldn't believe I didn't know what this patient had.

“This man has tetanus,” he said, nodding his head at me, and then walked on.

I sat back on my heels and looked down at the man. “Tetanus,” I said in wonder. “Lockjaw!” To an American doctor this was a disease as mythical as the plague. There are, maybe, a handful of cases a year in America.

I jumped up and ran after the director, catching up to him out on the barren brown yard in front of the hospital. “Tetanus,” I said. “But what do I do?”

He looked at me as if I were daft. “Why, you send him to a tetanus hospital.” He moved on, shaking his head again.

I walked back to where the man was and gazed down at him lying there on the dirty floor. A tetanus hospital, I thought. For a moment I imagined a real hospital with real beds and real sheets and floors not covered with contaminated needles. Screens on the windows. No flies. I thought of my hospital back in the States. I saw before me, like a mirage of precious water, our supply room. The room was crammed with everything you could ever want to take care of a sick patient, shelves and bins filled with endotracheal tubes and Foley catheters, syringes, sterile needles, bottles of Pedialyte, triple-lumen central lines, Betadine, hydrogen peroxide, We Care hand lotion, suture kits: everything disposable, use once and throw away.

I found Simon, my nursing assistant. “Jean-Paul says we must send this man to a tetanus hospital,” I told him, “wherever that is.”

Simon gestured vaguely to the east. “By the old city,” he said.

“Do they have a way to get there?”

Simon shrugged. “I will find out.”

It turned out that they did. The brothers had a friend with a truck, an ancient Ford pickup, which showed up just at sunset. The three men loaded the patient into the flatbed and fastened the tailgate closed with bailing wire. The whole truck seemed to be held together by rust, baling wire and the Nigerian equivalent of duct tape. I could see it rumbling down the potholed, washboarded Kano dirt roads, shaking each bump into this man's bones. At least he would make it to a tetanus hospital, I thought, where people knew what to do much better than I. I hadn't thought about tetanus, other than to give the vaccine, since medical school.

Out of curiosity, when I went home that night, I stopped at the MSF offices to search our medical library. The library consisted of four books, three medical texts and one medical novel. (Called
The City and the Covenant,
it opened inauspiciously with the sentence: “The uterus of the woman on the bed contracted according to its cellular intelligence.”) The most recent book of the four was a textbook of internal medicine—published in 1964. I had to blow the dust off the top, just like in the movies, and when I cracked the book open there was that tropical smell of something ripely rotten. Someone had visited this chapter before me. I found a bookmark there, a clipping from a newspaper that crumbled when I touched it. I glanced through the text. The first thing that caught my eye was the phrase “horse serum”—the book was that old. In the middle of the page was a drawing of a “spore forming bacillus” shaped like a squashed cigar.
Clostridium tetani.
The tetanus bacillus.

“The bacterium surrounds itself with a protective shell,” the caption read, “that makes it resistant to heat, cold, floods and desiccation. Tetanus spores are everywhere, in the soil, on animals, in humans…
blah, blah, blah
…facultative anaerobes.” That meant
Clostridia
lived without oxygen.

“The disease is more common in the tropics than in temperate zones. In third world countries tetanus is a disease of the newborn;
Tetanus neonatorum.
Typically the infection occurs because the bacillus invades the umbilical stump at the time of birth, particularly if, as is common in underdeveloped countries, the midwife uses a dirty knife or a contaminated piece of glass to cut the umbilical cord. In some countries the infant mortality rate from tetanus approaches 50 percent.”

I paused considering the sentence. “Approaches,” what a delicately euphemistic term. But what that coy sentence meant was that in underdeveloped countries one half of
all
babies born died of tetanus. I knew this fact after reading through an MSF report on health care in Nigeria. Things were no better now than they were in 1964. Worse probably.

“The tetanus syndrome,” the book continued, “is not caused by the bacillus
per se
but by an exotoxin.” I looked up from the page. I remembered this from medical school (the memory accompanied by the faint perfume of formaldehyde). An exotoxin is a poison that bacilli, under the right conditions, manufacture and export to the body of the host. In some lungless part of the body—say a necrotic wound or a cut—the conditions become just right for the
Clostridium
to flourish, multiply and manufacture exotoxin. The exotoxin makes its way to the circulation and is disseminated throughout the body. The toxin is called
tetanospasmin
—one of the strongest poisons known to man.

Tetanospasmin mimics the neurotransmitters that govern our muscle system, causing muscle cells to fire. The bacterium itself doesn't do this; only the toxin does. When the body is awash with tetanospasmin, the muscles depolarize—contract—chaotically. This produces the tonic-clonic movements and the muscle seizures that are the hallmark of the disease.

I went back to the text. “The first signs of tetanus are small muscle spasms that involve the muscles of the neck and the jaw. Patients become unable to swallow normally or even open their mouth. Hence
lockjaw,
as the common name for the disease.”

This was the stage my patient was in now.

“Treatment.”
The essential part. I lingered here because I knew tetanus was treatable, quite treatable, even in 1964 and even in Nigeria. Not much magic here. Just penicillin, Valium and “horse serum,” (now replaced with cloned tetanus antitoxin). Penicillin kills the tetanus bacillus, Valium reduces the muscle spasms, and the tetanus antiserum deactivates the toxin. One, two, three. This is the regimen they would use in the tetanus hospital.

I went back to my room and looked through my own library. Somehow I had lost my book of W. H. Auden's poems. This reduced my library from four volumes to three, one of which was a textbook of tropical disease. This book had pages and pages about traveler's diarrhea but nothing in it about tetanus. My other two books were the
Lonely Planet Guide to Africa on a Shoestring,
and
The Complete Poems of John Berryman.

John Berryman did seem more relevant to Nigeria than Auden—in his claustrophobic, paranoiac, boozy sort of way. His mood matched more the political situation here. Throughout the week, there had been riots in Lagos and in some of the upriver towns. There was no gasoline; this despite Nigeria's position as one of the top oil exporters in the world. In Kano people stood for hours in line waiting for a liter or two. The cholera epidemic in Bauchi was even worse than the one we had here; we had no resources to do anything about it, and nobody else seemed to care. Meanwhile, the newspapers featured headlines such as “Abacha Honored by the Federation of Trolley Conductors.”

And so I turned to my Berryman. I sat up that night, reading him by flashlight:

I am, outside. Incredible panic rules.

People are blowing and beating each other without mercy.

Drinks are boiling. Iced

drinks are boiling. The worse anyone feels, the worse treated he is.

Fools elect fools.

Nigeria pinned down on paper.

The morning after I sent the patient to the tetanus hospital, I started rounds and found him in his usual spot, still surrounded by his three brothers. They looked as if they had never left.

“What happened?” I asked the brothers.

“The hospital had no beds.”

“No beds? Did they give him anything?”

The brothers shook their heads.

“Did they say when they would have beds?”

The brothers shook their heads.

“He's much worse,” the brothers told me. One of them showed me how badly the patient's muscles spasmed by attempting to flex and extend his right arm. The arm was stiff as a board.

I squatted down next to the patient and momentarily put my face in my hands.
“Iced drinks are boiling.”
When I looked, up I saw Simon, the brothers, even the patient, gazing back at me expectantly. I was the doctor; I must do something. I reached out and patted the man's shoulders. This set off a ripple of spasms that spread across his chest onto his neck and belly. His arms rocked stiffly, his legs extended, quivering, tensed. His whole body shook, and you could see under the skin his twitching muscles: fasciculations. His arms twitched as well. His belly was as tense as a drum. This could have marched right out of the textbook I had read last night.

I sat there, momentarily a scientist, watching the fasciculations with interest. The millions of tiny muscle cells, contracting chaotically, produced muscle spasms. The effect was such that the entire muscle leaped to tense life. I could see on the patient, as if he were a weight lifter, the well-demarcated rectus and oblique muscles of the belly; the sternocleidomastoid on either side of his jaw was tensed, straining to bring his head down. Then I looked up at the man's face. It was in full spasm now as well. His eyes were open wide; they seemed to stare, like some cartoon character, right out of his head. His lips drew back in a hideous grin so that all his teeth showed.
Risus sardonicus.
The broad grimace of tetanus—also seen in strychnine poisoning. Contracture of the masseter and other muscles of the jaw and mouth caused the lips to draw back in a “sarcastic smile”—really more like the hideous grin of a naked skull. How could they have refused him at the tetanus hospital?

Oh, God, what to do. I thought back to the book last night. Treatment: Valium, penicillin, “horse serum.” Well, I knew we had the Valium—we used it to treat the seizures commonly seen in the meningitis patients. We also had a small supply of penicillin (differing slightly in chemical makeup from the ampicillin we used to treat the critical meningitis patients). The last drug I was not so sure of—rather I was sure we didn't have it in our supplies. The question was: could I get it elsewhere?

There was a pharmacy nearby. I had never visited it, but patients would sometimes show me packages of medicine they had bought there: Cephazolin, neomycin cream, ibuprofen.

I peeled the label from a liter of normal saline and wrote on it, “tetanus immune globulin.” Underlined.

“Here,” I told one of the brothers, handing him the label. “Pharmacy.”

The man stared down at the label in his hand, looked up at me, then got to his feet and fled.

I started an IV in the patient's arm and taped over it with my usual sign:

TOUCH THIS IV AND YOU DIE—DR. GRIM

Simon went to chase the Valium down while I rummaged around in my portable supply box. There was a little bit of everything in there: angiocaths, IV tubing we used as tourniquets, vials of ampicillin and oily chloramphenicol. I found a syringe and plucked it out, cradling it in my hand. There was something comfortable in the feel of this plastic; handling it has been my life's work. The smooth cylindrical 10 cc syringe, as simple as water, the plunger working like a piston in my hands. I returned to my box, groping around, and fished out several 20-gauge needles in their little shrouds, half plastic, half paper. Comforting to touch.