This little girl was born with multiple birth defects. She had a cleft palate, and her face was malformed, making her eyes protrude. She is also very small for her age, but that is pretty common among the poor in Afghanistan. She had originally gone to the doctor to be examined for cleft palate surgery, but something else showed up.
She had a very swollen stomach, which was either going to be diagnosed as liver cancer (this would have been a death sentence for her), or tuberculosis. It turns out that she had abdominal tuberculosis. They did surgery to clean out the abdomen and to do a biopsy. She was then sent back to Mazar with her family.
That's when I came in. They had left her abdomen open so that the TB drainage could drain out of it. But, apparently during the surgery, they put a small hole in her bowel, so it wasn't just TB drainage coming out, but bowel contents as well. In Kabul, they had placed a colostomy bag over the wound to catch the drainage, but since she didn't have a protruding colostomy, the bag wouldn't catch the drainage.
I went to her house (they are very poor, so their house isn't the nicest or the cleanest on the block). She was in a great deal of pain, and the drainage was unbelievable. It was (if you have a weak stomach, please don't read this part) part white cheesy TB drainage mixed with bowel contents (diarrhea). I washed my hands, and put on gloves and took off the bag. She had a big X shaped hole in her belly, and gunk (the official medical term) was pouring out of it. I cleaned her up, and tried to put a new bag on, but so much stuff was oozing out, that I couldn't get the bag to stay. It was a different sort of bag than we have in the states. There wasn't any adhesive on it. Instead, there was a strap that wrapped around your body to hold it in place. It was also very heavy, so that no matter how tight I wrapped it, if she sat or stood up, it would slide down and the edge would sit on top of her wound giving her excruciating pain.
Speaking of pain, in the midst of all this, she was recovering from surgery, and pain medicine is not usually prescribed after surgery in Afghanistan. I examined her,and found that her stomach was very distended (swollen with air), so I called a pediatrician friend in Kabul, who had been following her case (Dr. J), and he felt that she should have an enema. He said that after her surgery, the swelling was down, the drainage was minimal, and her pain was under control. So, it was a bit disconcerting that she was doing so badly.
I didn't have access to an enema that day, so I taught her mother how to keep the wound clean, then went home. That night, my roommate gave me a great idea. She told me to get a nursing student to come help me with Roqia. She said it would be a great way to mentor a student in nursing care.
I went out the next day and bought an enema, then went to the nursing school to find a student. The head of the department thought it was a great idea as well, and went to a classroom with me to find someone. There, he gave a long speech about how whoever went with me would need to behave and they couldn't look at the drainage and faint or throw up or react in any way what-so-ever. This speech had to be made, as they needed to know this wasn't about prestige and getting in good with the foreigner. It was about taking care of a sick child.
I was hoping to get a student of the same ethnic group, as this family's ethnic group is the most persecuted ethnic group in Afghanistan. Well, the girl that volunteered was not just of the same ethnic group, she had also spent most of her life as a refugee in Iran (as had this family). So, she could relate to them very well, and would treat them with respect.
I was very impressed with this girl. She washed her hands before and after and wore gloves. She also was very patient and did a lot of teaching with the family. Later on, I was to have this girl in my clinical group, just before I got sick, and she indeed will be a good nurse.
Back to Roqia. She felt much better after the enema and the drainage slowed down considerably. I visited her several days later, though and all of her symptoms had returned. I talked with Dr. J again and he said to give her another enema then start her on some medicine that should keep things moving along better. When I gave the enema this time, (warning, again, don't read this part if you are squeamish) I looked in the pan afterwards, and a long white worm had come out. So I added some worm medication to her treatment.
Thankfully, after that she began to make steady progress to get better. She was due to have her cleft palate repaired in September, but since I got sick and had to come home, someone else is following up on her care.
An aside about the family. They love this child. They are however, a typical Afghan family and don't know much about hygiene. Roqia's mom did her best to keep the wound clean, but in the process, not much else stayed clean. She had a box where she kept the rags that she was cleaning Roqia's wound with (both clean and dirty were in the same box, along with her TB medication). One day, she served me tea. When an Afghan serves tea, they must serve some sort of candy (sweets they call it). After she served me the tea, I saw her reach into the box and dig around finding all of the candy that had spilled out into the bottom of it, then she served it to me. Though I am usually not very careful with what I eat at Afghan's houses, I had to draw the line there. As a matter of fact, it almost made me retch when I saw her do that. I had to finagle around to find an excuse to not eat the candy, but I managed to get out of it.
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