Mahmood is a wonderful seven-year-old Chadian boy. He has a big smile and no fear of strangers. When he smiles his eyes light up and the prominent gap between his two front teeth stands out. He was bitten on his lower right leg by a snake about 10 days ago and came to our MSF-supported district hospital in Amtiman with a severe infection. He cannot walk and the slightest movement of his leg causes him pain. Our German MSF doctor Mariel asked me to examine him by ultrasound. She was concerned that not only the soft tissue -- but also Mahmood's bone -- might be infected. Infected bone -- or osteomyelitis -- is unfortunately common here.
Children in southeast Chad are often unaccustomed to seeing an outsider. They cry in fear and that can make the physical examination difficult. I always start examining children by not touching them at all. I ask the nurses to recount the medical history as best they can, while keeping my eyes on the child and trying to gain some trust with them that I will not hurt them. Usually it works, but sometimes children cry and cry and cry -- just from taking a peak at them six feet away!
Ultrasound is a great tool in low-income settings, but it requires the patient to be relatively cooperative. The test doesn't hurt, but a fearful, crying child is challenging to examine. After I palpate the child with my hands, I touch the ultrasound probe on myself, then the nurse, and then the child's parent to show that it's not harmful. Then I softly touch the child's hand, chest, and arm -- and further try to win their trust. Usually this works.
Although Mahmood was a good sport about being examined, when I gingerly removed his dressings he cried in pain because we had to move his leg. Infection had swollen his whole leg to almost double its normal size. When I put his leg back down gently with the help of a nurse, he became friendly and cheerful after a few moments.
I worried touching the ultrasound probe to his leg would hurt him. Using what I had on me, I pulled out my iPhone and clicked on the first music video available. Up popped "Bad" -- one of my favorite songs by U2. After Bono spoke a few words the song began. Mahmood's already big smile got a whole lot bigger. He watched the video and giggled. His mother looked on as well.
With Mahmood distracted by U2 I took my chance and started scanning his leg carefully. The bone looked regular, smooth and normal. I scanned up and down, back and forth. Compared to other cases where it is obvious the bone is infected and destroyed -- Mahmood's tibial bone looked good.
A few beds away, Dr. Johanna, another MSF doctor from Sweden was doing her rounds with the nurses. After a couple of songs had played, she approvingly complimented the choice of tunes! Dr. Mariel came over and I showed her the ultrasound images and we agreed the bone was OK. Only a minor surgical procedure was needed.
Mahmood lastly got to play with the camera function on the iPhone. He looked at his face and I showed him how to take his own photo. He and his mother got a good laugh over it.
Nothing beats having fun in medicine and helping a child get through a potentially painful procedure. Was it Bono in action on stage, a great song by an incredible band or a cool little gizmo that helped Mahmood and me get this test done? Who really knows for sure -- but it sure worked.
The best job in MSF has to be with the mammas and papas, and their children. They entrust us with their care and a beaming smile back is a priceless reward.
Farewell for now from the house-call.... to Chad.
Raghu
The patient's name has been changed.