Another Mitchell Adventure...This time its Cole.

Erin told Cole the other day that he is famous.  I told him that you don’t want to be famous, and definitely not because you are sick and in one of the poorest countries in the world.  Social media is a powerful tool and we are thankful that it can spread the word to PRAY.  If fame brings prayer support…we’ll take it.  Because of your love, Cole has people on several continents praying for him and for that we are forever grateful. 

Our family has used a blog before, first when Erin tried to die in 2012, then while we were in Kenya from 2013-2015.  I’ll resurrect it as I try to summarize our ordeal in several posts. 

Day 1  Saturday March 17.

Saturday morning, Cole, Alex and I went out for a 15 minute jog so the boys could get ready for a 5K running race that was taking place soon after we returned home from Burundi.  Our family (all 7 of us) was in Burundi to help for a month at a mission hospital staffed by our dear friends.  Just before heading to Burundi, we had spent a week at Tenwek Hospital catching up with friends.  (We used to live there from 2013-2015).   So, on this Saturday, we had been in Burundi for the first week of four and I didn’t have any responsibilities at the hospital, so we went out for a jog.  I joked with Cole that he was the only sixth grader doing “elevation training,” since we were at about 6,000 feet.  He kept a good pace without any pain or issues.

That night Cole complained of a pain on the outside of his right leg, but we just thought it was from the running that day.  It was probably something typical like shin splints or a pulled muscle.  Later, he had a fever of 101.5F, which seemed odd. 

Day 2  Sunday March 18

On Sunday he continued to feel poor, and his leg really started hurting.  He was limping and hopping around the house.  I had a diagnostic dilemma.  Were the fever and leg pain from the same problem?  Or were they from two things…leg injury AND Malaria?  In retrospect, the signs and symptoms were classic for acute osteomyelitis, but that wasn’t on my radar being a general surgeon.  Plus, the kids who usually get acute osteo are malnourished African kids.  If anyone knows Cole, he is NOT malnourished.  Our children eat us out of house and home. 

Day 3 Monday March 19

Monday morning we got some labs and an XRAY of his leg, since he was not getting better.  His white blood cell count was elevated with evidence that there was a bacterial source of the fever.  The XRAY was normal.  I asked Dr. Alyssa Pfister, Kibuye Hospital’s missionary pediatrician what she thought, and we started him on some antibiotics by mouth, not knowing what we were treating. 

Day 4 Tuesday March 20

By Tuesday morning, Cole still didn’t feel well, and he had to be carried from the bed out to the living room.  I decided to do an ultrasound of his leg, seeing as how we didn’t have an MRI…the test he would have gotten if we were in the US.  I saw a fluid collection around the small bone of his lower leg, the fibula.  I told Dr. Joel Post, a visiting orthopedic surgeon from the US, and we decided to explore the area, with the concern for osteomyelitis or pyomyositis.  Dr. Post had also examined Cole over the past few days and had been just as baffled as I was.  Now our diagnosis was clear.  Either osteomyelitis or pyomyositis.  Pus in the bone, or pus in the muscle.  Unfortunately, I was familiar with the prospect of operating on one of my kids.  The last time we were in Burundi I had to fix up Alex’s foot in the operating room when a huge piece of glass went through his shoe and into his foot.  Per the missionaries at the hospital, AJ’s incident was the last time a missionary had to be operated on.  Go figure.  I was very thankful this time for Dr. Joel, as he would lead the charge and I would assist him. 

I went up to prepare the OR, and as Erin carried Cole on her back from the car to the operating room they acquired a lot of strange looks.  “Why was a Muzungu (white person) having surgery here?”

Once we were in the OR, the Burundian staff was awesome to Cole.  The Burundian nurse anesthetist did a great job with the Ketamine, as Cole was understandably nervous.  I gently bent down next to his head and asked him, “Do you trust me.”  Without hesitation, with tears in his eyes, he said, “YES.”  A moment I will never forget.  Soon we had opened Cole’s leg and found the culprit.  He did have osteomyelitis of the fibula, and it had elevated the periostium (covering of the bone) of 2/3 of the fibula.  If only we had recognized things sooner, there wouldn’t have been as much extension.  But again, why would a healthy kid like Cole get acute osteo?  We don’t have a microbiology lab at Kibuye so we couldn’t see what the specific bacteria was that caused all this problem.  Usually not an issue, as almost none of the Burundians have drug resistant bacteria.  But, Cole was just in the states two weeks ago.  Do we treat him as a Burundian boy, or an American Boy?  Burundian bacteria, or likely antibiotic resistant American bugs?  Time would tell.

 Cole during surgery in Burundi at Kibuye Hope Hospital.  If we had written up a consent form, I would have signed his it twice.

Easy rule to remember in surgery...you have to get the pus out.

Dr. Alyssa Pfister wearing the hat of recovery room nurse

After a time in recovery, with Cole trying to get his eyes to line back up and stop seeing double, we returned to the house with plans for IV antibiotics (cloxacillin) until he felt better.  Thankfully, Dr. Alyssa had arranged for a Burundian nurse to come to the house to administer Cole’s antibiotics.  That way, Cole didn’t have to remain in the hospital ward…with 39 new potential Burundian friends. 

Tuesday night was pretty uneventful except for a drenching sweat that soaked his clothes. 

Day 5 Wednesday March 21

By Wednesday morning, Cole was feeling ok so I went to work and started making rounds.  Around 8:30am I returned home so the nurse could show me how to administer the IV antibiotics…since he would need a dose each evening as well.  Dr. Alyssa was there “making rounds.”  Cole looked a little off…not as good as I would have hoped.  He had a slight fever, and the burning pain he felt with the antibiotic injection magnified his discomfort.  (Ask Cole about this!  He HATED the IV abx.  No longer does he want a career in surgery.  Instead he wants to be a computer engineer.  No needles or cuts in computer engineering. )

About 30 minutes later, Dr. Alyssa checked some vital signs.  He had a fever of 102, an elevated heart rate to 130, and his pulse ox (level of oxygen in the blood) was 89% without oxygen.  He had also developed some crackles in his lungs, possibly from a developing pneumonia.  Dr. Alyssa and I met eyes, and we were both thinking the same thing…Kibuye Hope Hospital is not the place you want to get into respiratory trouble or septic shock.  There is oxygen, but no ventilators, and being in the ICU means that you are in the ward bed closest to the nurse’s station. 

Since Sunday, when Cole started having the fevers, I began to ask myself on a regular basis…what would be the trigger to evacuate the country in pursuit of higher-level care?  We could do a decent amount of surgical care at Kibuye, and we had plenty of amazing doctors.  But, at this moment on Tuesday morning, Dr. Alyssa and I both knew that this was the trigger.  We had the people at Kibuye, and the control of his care, but we didn’t have the resources to take care of someone developing ARDS, a bad pneumonia, or septic shock.  Plus, we figured that Cole had bacteria in his blood and that this was the cause of the bone infection.

Erin and the other non-medical people in the room sensed our anxiety, and immediately everyone knew that we had to start planning to get somewhere quick.  We didn’t know if this was Kenya, Europe, or the U.S.  Everyone went into crisis mode, and for the next 4 hours our house was a flurry of activity.  Alyssa started focusing on taking care of Cole as well as writing up a transfer summary we would need to get approval for an air ambulance ride out.  As she attended to Cole, one drug she had in her back pocket was some expired Vancomycin, a powerful antibiotic that most Burundians don’t need because their bacteria are susceptible to normal antibiotics.  It had expired in 2016, since no one ever needed it.  Hmmm.  Give an expired med to your kid or risk him getting worse?  They don’t teach you this in medical school.  We decided the benefits outweighed the risk, and Cole started getting the antibiotic.  He tolerated it pretty well, until the end when he told me his head was itchy.  I told Alyssa that we probably infused it too fast and he had gotten a common response called Red Man’s Syndrome.  Maybe expired vanco makes Red Man’s syndrome worse.  (I will not be submitting this case to a journal as a case report.)  He got some Benadryl and Alyssa watched him closely.   

I started making phone calls to our travel agent and emergency evacuation insurance carrier, looking to see what our options were.  Erin, and several other friends started packing as well as arranging for our transportation to Bujumbura, the capital of Burundi.  It was amazing to see how this tight knit community of missionaries dropped everything and came to our aid.  We were sad that our time with them had to be cut so short. 

Just after lunch, (which only the kids ate) we all hopped into two vehicles and started the three hour trip to Bujumbura.  Susan (a missionary at Kibuye) drove the “ambulance” staffed by Alyssa and I;  George (Susan’s husband), Rachel (an intern who volunteered to come to help with the kids) and the family were in the other vehicle.  Cole and I had been approved for a medical airlift to Kenya and the rest of the family would spend the night in Bujumbura before catching a 10:00am Kenya Airways flight to Nairobi. 

Miraculously Cole improved after the Vancomycin and had an uneventful car ride.  Our anxieties calmed.   I looked at my watch and it was around 2pm our time, 8am EST.  America (and Facebook) was waking up to Wednesday morning and our story started getting shared.  In a matter of an hour Erin’s initial post pleading for prayer had 144 comments.  I then knew it was more than the expired vanco that was helping Cole get better.   to be continued.