#World Malaria Day

Before I started working in South-East Asia, Malaria Day would have been just a matter of statistics:
“Malaria 2015:  212,000,000 new cases globally.  429,000 deaths.”
Or perhaps Malaria Day would have inspired me to review a bit of esoteric medical information, knowing I would probably never use it in the US: “Malaria is a mosquito-borne disease caused by a parasite. People with malaria often experience fever, chills, and flu-like illness. Left untreated, they may develop severe complications and die.” (CDC)
In fact, I never saw a single case of malaria in medical school. During the years I worked as an Emergency Room doctor, I never saw a patient with malaria, nor for that matter, did I even order a single malaria test. Now, however, I find my mind drifting back to a few of the many malaria cases that I’ve treated in Southeast Asia over the last decade. Most of these patients were young and most needed to be in an ICU. Instead, our shared field of struggle was often just a bamboo hut in the middle of nowhere. Light was usually terrible, a flashlight or candle. Instead of 24/7 super competent nurses with nerves of steel, we were often surrounded by desperate people doing anything they could think of. These were moments in the medical trenches that one doesn’t soon forget.

I wrote about this one rainy season in 2006: A bucket full of blood and spit sat on a dirt floor. A young teenage boy leaned on the side of a makeshift bamboo bed dripping and spitting into the bucket from a nosebleed that no one could stop. Large beads of sweat covered his face; a combination of tropical heat, an unknown jungle fever (probably malaria), and fear. You could also see the fear flickering in the candlelit faces of his family standing around him. An inexperienced medic had tried to pack some gauze in his nose. Because the boy could not keep down malaria medicine, the medic had ground up an oral medication and put it straight into the boy’s IV. They were desperate. And still he bled. Judging from the amount of spit and blood in the bucket he must have been like this for hours. The boy was exhausted. The boy, his family, the medics were out of options, and they all knew it. The medic said there were 50 more seriously ill patients who needed a bed, but he had no more space on the improvised ward.

Severe malaria is a specific diagnosis. It is not just bad malaria. These patients can be unconscious and seizing, breathing fast, jaundiced, severely anemic, having spontaneous bleeding or in be shock.

Here are parts of a raw email I sent out to my colleagues for help with another patient. Forgive the grammar mistakes, but we were desperate and it was a long night.

Made it thru the night! Still not out of the woods but at least the boy is alive. The three year old came in looking toxic. Complaints: fever for 2 weeks intermittently and headache. They had tried Artesunate, Quinine, Chloroquine, Cipro already. Not getting better. Then he started having seizures. Exam: toxic looking kid. Hydration seemed ok. Neck supple. Lungs clear. Paracheck (rapid test for malaria) negative. About 2pm spiked a fever and had a seizure that I did not see. Repeated the malaria test. On microscopy, we saw both + PF malaria and PV malaria. The history of seizures was consistent with severe malaria so I started an IV and gave IV artesunate. Added high dose ceftriaxone to our shotgun cocktail just to cover for a meningitis we couldn’t rule out although that would probably have killed him by now. Around 8pm started having seizures that we couldn’t stop. Maxed out our IV Diazepam. Still seizing. Blood Sugar 119, repeated 142. Seizures were a tonic contraction, with strange chewing movements with his mouth and a smattering of various extra ocular movements. Nothing lateralizing. As we sat there pretty helplessly watching this kid convulse away, I asked if we had any other seizure meds … only oral phenobarb. Figured this kid is going to die. So, I gave an injection (5mg/kg IM.) of ketamine (a general anesthetic)  … with all the diazepam on board, I wasn’t sure at all if he wouldn’t just stop breathing and didn’t want Raykaw or one of the students having to deal with that. 2 minutes later he was resting comfortably. Figured I had about an hour. Which was right. He started seizing again. We decided to try the amount of an IV loading dose of oral phenobarb per rectally … if that doesn’t make your head spin. Again worried that he’d stop breathing. Pulse ox was a great way to monitor as it was dark. Anyrate, repeated the 12 hour Artesunate at 3am. This morning, he looks pretty good. Raykaw was like having a skilled warrior beside you in a fight. Awesome. We are both happy to see the light of day. Thanks to Caryl for encouragement. John for some wise and experienced counsel. Thanks to God for getting us through the night.

-I could go on. I remember a little three year-old girl with severe malaria. The parasite had chewed up and destroyed most of her red blood cells. She was severely anemic, lethargic and breathing fast. She wasn’t going to last long and I couldn’t get an IV line. To the rescue, our trauma nurse from Georgia, Carolyn, talked me through my first intraosseous line … straight into the bone. We did a type and cross and transfused the girl. She recovered quickly.

-Or I remember another little boy that I saw briefly on the border. He was being treated for cerebral malaria with an old antimalarial medicine, quinine. I heard later that as he was recovering, he was given an injection of quinine and he suddenly died.

-I remember stressing over colleagues who have come down with malaria. I remember taking care of our son Josh when he had malaria.

It’s a wonderful thing to have “Malaria Day”. It means we need to make a special effort to remember a disease that continues to cause unbearable suffering in parts of the world. We don’t need a malaria day in the Karen areas of Myanmar in order to remember. It is one of the top three killers of children in these areas. Although malaria rates are down all over the world, resistance in Southeast Asia to one of our main antimalarial medicines have us all worried that the lull is not permanent. Soon malaria may be back with a vengeance unless new medicines or an effective vaccine can be found.