The Cook of My Food

Alphan died November 23rd. He was 27 years old. On December 13th his son was born.In a lot of ways this story is typical for sub-Saharan Africa. Tragic ways, distressing ways...
Alphan was my friend. Yes I paid him to cook food that he bought for me in the markets of Mwanza. In Swahili you do not have a cook but you pay someone to be the cook of your food.
I discovered that Alphan died because someone sent a text to my Tanzanian cell phone that a physician colleague is using in Dar this month. In addition to the announcement of Alphan's death was another missed message. This one was from Alphan. It said' "Please call me." I knew he had been ill but when I last saw him a week before his death he was supposed to be improving.
Alphan cared. His work reflected his commitment to excellence. He was intellectually curious, reading my books, going to school in the evenings. He was funny and his smile came easily and was luminous. He was a good man.
I am so sad to lose him.

Important and Insignificant

A person who viewed himself as insignificant would not spend time away from his family and go to work in a developing country. Significance is a major motivator of this activity but does that make one who engages important?
A large humanitarian organization visited recently. Included in the delegation were two representatives from the United States House and the president of the organization. The stated goal was to encourage the development of global health champions within Congress. I was given a heads up that they would sit down with me for an hour or two to talk with me and other physicians on site. My sense of importance swelled. The next day I was told that the delegation would not have time to meet with me.
My elevated self-importance was transformed to lowly insignificance.
Paschal or Chesterton or both observed the dialectic of human existence that man was supremely important yet wholly insignificant. It seems that we in the developed world have a healthy sense of importance that actually magnifies when we leave our comfortable environment to spend some time in a developing country. Just how insignificant do the people here feel? Is it a factor in the apparent facile acceptance of death? No human can live unaware completely of their importance nor of their insignificance. We important people of the West however could use some reminders of our insignificance. Likewise the people of the Rest could use reminders of their importance. I believe the humanitarian organization got it mostly right and I am grateful for the reminder.

Be Sensitive and Make It Interesting

Can you blog with others in mind? It seems a mostly self-conscious act. But there are bits of patronizing opinion that might hurt others.These thoughts coupled with trying to keep it interesting(again with others in mind ie you the reader)has paralyzed my hunt and peck keyboarding for a few weeks.

I find life most rewarding when change is happening. Wouldn't everyone want a system to change that suffers from high child and maternal mortality? As an outsider in this setting, I cannot lead progressive change because it risks dependency and unsustainability. I am hoping change can be catalyzed. Because that is the role that I believe is most appropriate. Ideally the process won't require the continuous presence of the catalyst to perpetuate. This I don't know...

Most exciting for me is the recent decision by the director of the hospital to move the casualty department into the department of surgery. He has created an Accident and Emergency Committee chaired by an orthopedic surgeon(mentioned in a previous post)to lead the transformation of casualty to an A& E department. So Presbyterian of me to get all excited about a committee being formed.

Tropical diseases and abject poverty provide great fodder for interesting stories. What makes it interesting? Certainly a good storyteller helps. I don't have any stories today.

Ferris Wheel

The fair ride most used in analogies is the roller coaster. But I'm choosing the ferris wheel. Ups and downs without forward progress.... then ending back where you started, at the bottom...
Have you read many descriptions about the view from the bottom of a ferris wheel? That's where my ride was last week so the view looked something like this....
She must have been about 3 or 4 and she lay whimpering on the stretcher beside a mother sitting with her infant in her arms. Blisters from second degree burns covered her buttocks and legs. She shared a lollypop with some flies. Alone, she would briefly doze then wake up crying. Her crying stopped when I rubbed her back.
Systems change, capacity building are part of the view from the top of the ferris wheel with Trauma Registry, pediatric resuscitation trolley, triage system, bedside ultrasound, emergency nurse training, Primary Trauma Care Course all in the works. Setbacks, delays and barriers frustratingly abound. Nothing has changed.
You always get off the ferris wheel at the bottom, don't you?

Per chance

He was sitting outside the casualty ward office. We exchanged some polite swahili greetings. He asked in English if I was a Father, not the first time I'd been asked the same question. "Not in the way you ask, " I replied.
So we talked for a little while. He was there to get steroids injected into overactive scar tissue on his chest wall suffered in an unspecified injury. He said the injections were helping.
He is in Mwanza on scholarship to university studying sociology. This education is to help him in his work in the community with refugees from Burundi, Rwanda and the DRC.
Turns out I reminded him of an Englishman who worked an office near his home village. When I shared that I was actually from the U.S, he said he'd visited Orlando.
He said how real some of the creations in Disneyworld seemed. This after inviting me to the park near his village where work is conducted with chimpanzees.
He was in Orlando to attend some kind of global conference of young people that do refugee work. His intention is to work for Peace.
Today he gave me some hope.

Why

A small roach scampered from beneath the laryngoscope blade as I lifted it from the box to place on its handle. It was symbolic of the futility of my efforts to follow.
A 6month old baby had stopped breathing. This following a 5 day illness during which he was treated at a dispensary and brought today to our hospital weakened from his struggle.
Why did this baby die?
Was it because his Mother was poor?
Was it because he was born in one place, not another?
Was something misdiagnosed or inadequately treated early in his illness?
Was it because he had an overwhelming pneumonia with poor defenses to disease?
Was it because I couldn't get a tube in his trachea?
We talk about the burden of disease. What about the burden of sadness?

Big Splash

Growing up my brothers and I would compete to see who could make the biggest splash jumping into the pool. I never won.
As mentioned in my last posting, I succeeded in getting nothing accomplished in my first three months in Mwanza. Making a difference, making a measurable difference...is that what it is all about? A big splash makes a difference but once the ripples die away, the pool, perhaps short a small volume of water remains the same.
This visit I brought two vital sign monitors purchased with the generous donation of funds from my home church, Davidson College Presbyterian Church. We've put the monitors to immediate use at the triage station and in the wards of the casualty department.
Today another woman with white eyelids and abdominal pain was rolled in on a stretcher. The new monitor revealed her blood pressure to be 85/49 and her heart rate was 140. She was cool to the touch and her abdomen was tender. In a previous posting I shared a similar case that turned out to be an ectopic pregnancy. Today was a virtually identical experience as I squeezed in the only unit of O positive blood in the hospital and waited for her to get to theatre. After she was gone I walked around the ward with a nurse from Kenya on her first day in casualty and we used the new monitor to take the women patient's vital signs.
A woman who moaned quietly as the drama of the first patient unfolded shared with the nurse that she might be pregnant. The machine reported her blood pressure as 105/79 and her heart rate was 107.
She got up to provide a urine sample ordered by the gynecology intern and passed out.
We repeated the same interventions for this quiet woman who also had an ectopic pregnancy.
These new monitors will accomplish nothing that could not have been accomplished without them. Nurses taking vital signs and a history on the patient's arrival is a process that requires no more than mercury manometers which are present but in short supply.
The question whose answer disturbs me is: When these monitors no longer work and the big splash(ok, small splash) and ripples have subsided, will the pool short of a small amount of water remain the same?

Mission Accomplished

The first three months are about to come to a close. I head home for a few months and then return to Tanzania in January.

Angus O'Shea, the executive director of the Touch Foundation gave me the following piece of advice after my arrival in Mwanza.

"Try real hard not to get anything done in the first three months." Angus did provide a bit of explanation for that advice, not a lot, a bit.

Mission accomplished.

While meeting with me to discuss a proposal I had submitted for the casualty department, the director general of the hospital shared that an expert from the U.S had made similar suggestions in the past. "But I don't know where she went. The funding must have run out."

It is way early to draw conclusions. Observations must be qualified as "initial".
I am trying to place myself in the shoes of the Tanzanian physicians. The picture is skewed at a teaching hospital with hallways full of medical students, thanks in large part to the Touch Foundation.

But...what must it be like to be one of fifteen hundred m.d.s in a country of thirty seven million people? What must it be like to come to work every day to a place where babies die and surgery is canceled because the elevator is broken or the rains have soaked the surgery linen? What must it be like to wait for donations to equip your department or have an experienced nurse transferred from your understaffed unit to a more understaffed unit? Could I have a long term perspective and continue pushing hard to move three steps forward only to find myself two steps back soon thereafter?

As an outsider seeking to be an agent of change, my goal is to construct that mission of change in a manner that is least dependent on me.

Signs of hope abound in the people I have met such as orthopedic surgeon who approached me with his dream of creating a Trauma Center at BMC. That is where hope best resides, in this Tanzanian orthopedic surgeon, his general surgeon colleague and in the medical students, interns and residents filling the hallways and classrooms at BMC.

Workers

The intern grabbed a sheet which were in short supply as the stretchers and floor space were overflowing with silently bleeding people who were in a bus that overturned on a stormy night. He gently nudged the man laying there bleeding from the nose. There was no response as he whispered "rafiki" and nudged him again. So he placed the sheet over the man and smiled when the patient clumsily tried to move the sheet off his legs.

Words come suddenly and loudly from the medical officer. "Unaumwa nini?" asked briskly as the gray haired, beleaguered woman takes a seat on the stool. More words uttered singularly, with a playful sense of authority. Eventually a smile on her tired face appears slowly like a sunrise.

Handwritten crumpled paper is unfurled as the intern moves to the front of the room and takes a seat at the table. The room is full of white jackets. The white jackets belong to the medical students with notebooks open, prepared to record the presentation. Wound toilet, debridement and wound excision are defined concisely and explained clearly. The orthopedic surgeon, after a brief period of silence, says " Good job".

Worn down. The looks on the faces of the nurses who have worked the night shift. Always, I mean always, an engaging "Habari za nyumbani?" as I walk in each morning.

Sometimes what needs to happen, happens. Sometimes not.
The moments are lived fully. That allows for interruptions that rarely seem unwelcomed. I am unsure how the future is lived in here. I don't think it is counted on. The past seems quickly forgotten as well which can be good and bad.

The conversations here can seem like flying in a small plane through a thick, white cloud. You can't see where you are going or from whence you've come. It is pleasant for the moment actually but there is a foreboding sense of a need to see if you are about to hit the side of a mountain.

Nameless

A friend of mine wrote a blog about his experiences in a developing country health care setting and chose to change the names of the people and places. I think this was a good idea.

It was my original intent to attempt to share these experiences as objectively as possible so the stories would be about this place and its people and not me. I can't seem get out of the way. I also want people to know about BMC and the work that The Touch Foundation is doing in Tanzania. I can only hope that those who see through my eyes will forgive any inaccuracies or misconceptions that may result.

The life expectancy at birth in Tanzania is 46. A perfect storm of HIV, tuberculosis, child and maternal mortality and increasing unintentional injuries from road traffic accidents combine to account for this shortened life expectancy.

There are also cases like the 23 year old who presented to casualty complaining of chest tightness. His blood pressure was 205/120 and he could not lie down on the stretcher. He had crackly noise in all his lung fields but looked comfortable as he calmly shared his symptoms with me. He also had markedly pale eyelid linings. He said his stool color had been black for 2 days. Again the ICU was full and to clear the casualty stretcher, the young man was admitted to a ward. In the meantime, I followed him to x ray after I was told a portable film was not possible. I saw the fluffy white markings in his lungs that indicated fluid was spilling into his air spaces. I walked his tubes of blood to the lab and waited for the result which was a hemoglobin of 4.4(less than 33% of what it should be).Unlucky for him, his blood type was O negative and the hospital once again had no units of the rare(for Mwanza)blood type. I rode with him up the elevator and explained to the resident and charge nurse that he should not be here and to please take him to ICU when a bed cleared. Later that day I saw him sitting on an ICU stretcher eating rice and meat. We smiled at each other and waved a greeting. I relaxed and went home. This morning I went to ICU and discovered that this young man had died at midnight.

You know if it was ethically acceptable I would choose for you to know the names of each of these patients described in my postings. I think it adds to the sadness that they are the only nameless participants in the stories I share.

The Right Thing

A surgery professor was renowned for his simple instruction to surgery residents, "Don't see what you can get away with, do the right thing."

A baby grunts when she is having trouble breathing. It is the same sound Venus and Serena make after a ground stroke, just a whole lot quieter and after every breath. It is a distinctive sound.

That sound was coming from a mother's mbeleko(the patterned scarf that holds the baby to the mother's body) A toddler was slumped to the side on her mother's back. The breathing was rapid and labored.

The nurse shared with me that the 22 month old had swallowed kerosene. This is a not infrequent problem because in the home dangerous liquids are stored within reach in soda bottles or similar containers.

The problem is that vapor and/or liquid reach the child's airways with inflammation and fluid leakage into the lungs as the result.

This baby girl was struggling with every breath. We placed her on oxygen. There are no monitors. The ICUs had no beds. There is no portable x ray.

I talked with the pediatric resident on call to explain the situation and she said to admit the baby to the ward. We had to take the baby off oxygen to get an x ray. There are no portable oxygen cannisters.

Today I went to the ward where the baby was admitted. She was doing fine. We got away with it. There was no right thing to do.

Context

In the telling and hearing of stories, the context is important. What constitutes a context? Why is it important? In my case the context is all new and includes geography, culture, politics and history. My anthropology friends(Can you believe I have more than one?) caution me that my understanding of illness and treatment are different from my patient's understanding and in this culture the differences are more pronounced. I am limited by language and perspective in understanding them.
Politics and history I can read about and my son Luke gave me a depressing but informative book entitled "The State of Africa" which reviews the last 50 years of post-colonial African history. We all make judgments on the basis of our experiences and context is important as it informs your judgment. I have shared with you a number of experiences but I wanted you to know that my context is limited for now.

The Touch Foundation for whom I work has as its objective to address the shortage of health care workers in Tanzania and I refer you to their website for more information. www.touchfoundation.org. Let me share with you one "statistic" that has informed my judgment. I attend 0730 morning surgical rounds and the surgery interns report on their previous day. There are 4 interns. One is on call for the wards and one for the casualty department. On average the intern on the wards reports that there are 300 patients on the surgery service in the hospital. The interns scrub in on theatre cases and attend outpatient clinics. Those of you with a medical background know the relative impossibility facing these young Tanzanian physicians as they perform their daily duties. The overwhelming responsibility of this patient load is but a microcosm of what the country as a whole faces.

Speaking of new experiences I will end with a list of firsts:

To feed a monkey my breakfast buscuit as he jumped beside the hospital walkway on my way to surgery morning report.
To observe a 13 year old girl barely flinch as she sat on a stool having her blood drawn. Her regal bearing was all the more amazing because her hemoglobin returned 2.8(should be 4 times higher)
To watch a mother carry her limp 5 year old son who 2 days earlier had been bitten by a snake on the right foot. His leg was swollen twice its size up to the thigh.
To walk home for a superbly prepared vegetarian lunch every day. Alfan is the cook of my food(that's the way it is expressed in swahili which I prefer to "my cook")
To be left on the side of the city street as my taxi driver negotiated a "fine" with police for pulling out in front of another vehicle.
To sleep inside a mosquito netting every night. Something is a bit more unsettling here about being awakened by the high pitched buzz of a mosquito around your ear.
To watch the sunset over Lake Victoria in the evening.
To discuss with a nurse in Australia about the transfer of a patient to Johannesburg or Nairobi or Sydney

Peasant

What does the word "peasant" bring to mind? Castles, kings and moats.... Just wrote the word over the occupation line of a death certificate.

Sometime this morning a 50 year old man found himself under an overturned oxcart. He was transported to the nearest hospital where note was made of decreased breath sounds in the left chest and air in the skin(it feels crackly for lack of a better descriptive term). Transport was then arranged to BMC. An official stamped referral letter accompanied the patient.

On a stretcher in casualty with two 14 gauge angiocaths in his chest wall and a blood filled endotracheal tube in his trachea, he died.

It is the 21st century and we still write peasant on a death certificate. The life and death for a peasant has probably varied little between the centuries.

In the twenty first century it means your baby dies of malaria and your dad dies in the afternoon when the oxcart falls on him in the morning. It was probably much like that inside and outside the castles in the middle ages. It is still happening outside the castles today.

Blood Warmer

One of the many functions of the human body is to warm the blood. A couple times in casualty my body has warmed someone else's blood.

The first patient was too weak to stand from the wheel chair and his friend could speak enough English to tell me that he had vomited blood. The bottoms of feet are not supposed to be the color of the sheets and when they are it is a bad sign. Not having a blood pressure is another bad sign. Yet anotherbad sign for a system is that this man had waited to be seen long enough for his old record to be on his stretcher. In that old record was evidence that this man had esophageal varices(enlarged veins lining the wall of the esophagus, prone to bleed because they are close to the surface and not designed to carry large volumes of blood). He had schistosomiasis which is a parasitic infection caught from exposure to water(fishermen on Lake Victoria and children who play in infected water) and a subset of people with this infection get scarred livers and abnormal circulation in vessels outside the liver.

I ordered O negative blood immediately for emergent transfusion along with two large bore intravenous lines with saline running wide open. The casualty nursing director worked on this patient along side me and ran to the blood bank for the blood. We transferred him to intensive care where his low blood pressure was causing confusion and he had to be restrained with sheets tieing his limbs to the bed. I stood beside him squeezing the cold blood bag with my warm hands. He is still alive.

The second patient came in today and was too weak to sit or stand. She was on a stretcher between the 4 beds in the women's ward of casualty. Her feet were pointed in the other direction but her eyelid linings were white, her pulse was thready and the nurse had written "unrecordable" where blood pressure numbers are placed on the chart. Her abdomen was tender in the lower half and up the left side. She told us her last period was August 20th. But there are not too many things that present like this in young women. I told the gynecology intern in the department that I thought this patient had an ectopic pregnancy and ordered O negative blood and 2 lines of saline wide open. For the second shift in a row I found myself at a patient bedside squeezing a cool bag of blood. This time the lab had no O negative blood so I had walked to the lab to explain that I needed a rushed blood typing and 2 units of type specific blood along with 4 units of cross matched blood. In the meantime there was some discussion about sending the husband to the pharmacy to purchase a pregnancy test. The second on-call gynecologic surgeon wanted to see the results of this test. I posed the hypothetical question that in a woman who had no bloody vomitus or bloody stool, had a tender abdomen and no blood pressure, what would they do if the pregancy test was negative. I didn't get an answer to my question. A few minutes later the pregancy test came back positive and two and a half hours later this woman was taken to the operating theatre. The intern told me afterwards that there was about three and a half liters of blood in the woman's abdominal cavity.

Both of these patients survived their time in casualty. Each is an example of the lifeboat approach to care to which I have alluded in a previous post. A whole host of questions arise about systems, culture, training and case management as a result of these two cases. Some of these questions I am ill fitted to ask, much less answer. I share these experiences and have not entirely succeeded in withholding judgment in their telling but withhold judgment I must. A greater understanding is required. For now I am a blood warmer.

Responsibility

Captain of the Ship....that pretense is gone. Captain of the Lifeboat is almost gone. The concept that requires rethinking is this whole captain thing. Living in a wealthy country, born of supportive middle class parents, I have had an intellectual appreciation of God's providence. Mostly there has been the illusion that I was in control. Granted there have been profound failures as when my nephew Charlie died after liver transplant surgery. That wasn't supposed to happen. I have seen more death here in three weeks than I saw in a year working back home. What exactly is supposed to happen?

A 3 year old the second day with large, sad eyes strapped on his Mother's back in colorful cloth had swollen lymph nodes all over, a facial mass and diffuse facial and leg swelling. I thought he had Kaposi's sarcoma, an HIV related malignancy. Sure enough, his rapid HIV test was positive but his biopsy was an inadequate specimen. He died before it could be repeated. Yesterday an older woman with abdominal pain transferred to Weill Bugando after being in a referral hospital for 3 days. She was cold, clammy in obvious pain with a firm, tender abdomen. She was tachycardic with a blood pressure of 120 over 90. I ordered IV fluids and x rays and consulted surgery. Today the intern tells me that she" collapsed" on return from x ray and died. The thin man with a swollen neck described in my first post died in the hospital within a day. A tiny 1 month old grunting in his Mother's wrap, another transfer from the same referral hospital died after a few days in the ICU. A 53 year old woman who collapsed complaining of abdominal pain. I could palpate a pulsating mass in her abdomen that was slightly tender. An ultrasound confirmed a large aortic aneurysm. Her family could not afford the cost to transfer her to Nairobi. As far as I know she awaits her fate on a medical ward in the hospital as I write. I could go on....

I have a selection bias in that I am intentionally gravitating toward the patients who appear to me to be the sickest. Amongst these, there have been some remarkable success'....the woman with a tension hydro-pneumo thorax (fluid and air in the chest cavity where there should not be)
presumably from a bronchial fistula secondary to tuberculosis. She got a chest tube and when food particles were noted in the drainage, she was taken to the operating theatre by 2 surgical registrars and a tear in her esophagus was repaired. She is currently alert and walking around the ICU.

It is actually a good thing to relinquish captaincy. I must admit that I knew enough before I arrived to expect a relinquishment. How to relinquish captaincy without relinquishing responsibility is one of the many unanswered questions at this moment in time.

Sounds and Cold Fury

It's the end of week two. Coming as I do from North Carolina, I have slid down Bust Your Fanny Rock into a mountain stream. The shock of that cold water takes your breath away and you find yourself in beyond your depth. You the readers must forgive my first week's thrashing efforts as I attempted coming up for air. The water is still deep and cold but I have begun to tread and my head's occasionally above the surface.

The door bell is on the outside of casualty. People push the bell when they need help moving someone into the casualty area. When this bell is pushed a medley consisting of "Jingle Bells", Rudolph the Red Nosed Reindeer" and "Joy to the World" plays repeatedly.

There are birds here whose call sounds like a cross between the crow's caw and a donkey braying.

Islamic prayers over loud speakers on one side of the hill and Christian hymns on the other side.

"Karibu" "Habari dakta" "Hujambo" "Shikamoo" are some of the ways of being acknowledged or greeted. It is odd however that these greetings generally come after I am 5 yards past the oncoming person. Occasionally these greetings are in English. "Good Morning" no matter the time of day. Some "Give me money" The always popular "How are you" At other times the greeting is Swahili but the words I don't recognize. These are often followed by cackles of laughter. I'll let you know in a few months perhaps, how I've probably been serving as the butt of jokes.

Today at 4 the Jingle Bells medley signalled a 7 year old girl in a car requiring a stretcher. She arrives in the crowded women's and childrens casualty room with blood coming from her left ear and a swollen, deformed left thigh. She had been struck by a vehicle. She is sleepy but talking. Her Mom comes in and quietly takes her hand. The last sound of my work day is the Mother's whispered voice as she leans over her daughter's battered body.

Lost in Translation

My intention was to place a new post weekly but with such an intense first week, I decided to post a bit extra. I am told I will settle-in, which seems unbelievable at this point.
The patients sometimes stay on their casualty stretchers for days and I've had conflicting explanations for this. One morning I walked in to a full house with some familiar faces from the days before.
From one of the doubled-up stretchers a thin young man would periodically moan. I heard these moans on more than one occasion throughout the morning. Quiet moans.
In the afternoon when the stretcher was singly occupied by that same young man, I took a closer look at him. His chart said he was 19 but he looked 13. He was fully dressed but through his partially unbuttoned shirt I could see his ribs. His chart also reflected that he had not been evaluated by a doctor. I examined him quickly and asked someone to help me ask him a few questions. The gist of the story was 3 weeks of cough, fever and loss of appetite. What bothered him most and caused his moans was the pain in his chest when he breathed. He said his father was receiving treatment for TB. His chest x ray was suspicious for tuberculosis and I arranged for his admission.
This morning I looked at the chart of a young boy sitting quietly on a stretcher with someone I presumed to be his father. His father pointed at his left arm. On that arm he had a plaster splint from shoulder to wrist along the back side of his arm wrapped in kling(gauze). I could see the flex of his elbow seemed swollen and blistered and was covered in gentian violet. His father began to speak to me and I now know how to say "I don't understand Kiswahili" in Swahili so I shared this bit of information with him and went on my way. This afternoon I noted the surgery interns taking off the splint while the boy screamed in pain. The interns told me that he had had the splint placed a week ago for a fracture of his proximal radius and ulna(forearm close to the elbow). The skin about the elbow was markedly swollen and bleeding. I could feel what I thought was a faint radial pulse. The intern said he thought the kling had been wrapped too tight. I suggested that a hospital admission might be a good idea and went home for the weekend.
When you are a U.S. E.R. doctor it is crammed in to your head that you are the captain of the ship and responsible for everything that happens in the department. In order to accomplish this task, it is necessary to know what is going on with all the patients.
I have used the language barrier as a rationalization for failing in this task this week. But the moans and the gentian violet covered blisters required no Swahili expertise to understand.
I share this not with the intent of beating myself up.
There are indeed further rationalizations that the half-day waits that each of these suffering patients endured in the casualty bay will not contribute to adverse long term outcomes. TB will respond to treatment in the afternoon as readily as it would have in the morning and the damaged arm had sustained it's damage for many days.
But I can't help but think and feel that these cases are microcosms of the response to suffering in the world. How often do we use similar rationalizations for a failure to respond?

The Obvious

A siren blasted away outside the casualty area. Nothing unusual for me but it was unusual for a hospital in a city with no ambulance service. I watched from inside as the crowd looked out from the open air waiting space in the direction of the noise. This was going to be interesting.
Two nurses wheeled a stretcher into the department with a man lying on his back with an arrow embedded in his right chest.
The arrow was pulsating.
About that time I realized I was the only physician around. Normally not a problem. In fact I knew what obviously needed to be done and NOT done. The man needed to go immediately to the operating theatre to have the arrow removed after his chest had been opened under controlled, visualized conditions.
He came with a set of x rays from a transferring district hospital which also included a picture of his dislocated left elbow. The blood and air in his left chest were adjacent to a barbed arrowhead. Should someone had attempted to remove that arrow, the man probably would have bled to death.
As it was, he had normal vital signs and was responsive though I did not attempt to speak with him. I wouldn't have understood him anyway.
I knew what needed to be done and began with the nurses help to prepare the man for immediate surgery. We however could not locate a surgeon.
BMC is a teaching hospital and is one of 5 consultant hospitals in the country. There is a thoracic surgeon on staff who happened to be out of town. At this time the surgery intern arrived and spoke to the man. He called his senior resident. The decision was made to place a chest tube and schedule an elective thoracotomy for when the thoracic surgeon returned. They were going to leave the arrow in.
Then the intern shared with me that the arrow had already been there two days. Their plan actually made sense.
What seemed so obvious to me doesn't seem so obvious anymore.

New and Old

People everywhere. Lining the roads on the way in from the airport and along the city streets. Lining the hallways and benches of BMC. Mwanza, Tanzania is a city situated on Lake Victoria. It has hillsides lined with rock formations and homes the color of the rock and earth. It's a bit dry here now and the prevailing background is brown though scattered green trees and flowering bushes break up the earthtones. The city's construction is similarly a monotonous color of concrete broken up by some unusually colored pastel structures. The lake is a lovely, deep blue. The lake attracts as many birds as people.
The theme of the day is "I haven't seen this before."
Today was my first day on the job and introductions to some casualty staff were made. I wasn't prepared to take care of patients. Nonetheless, I saw a few of the many. And it gave me pause.
The cachectic(markedly thin) man leaning over the stretcher with the complaint of throat pain. His neck was visibly swollen symetrically and anteriorly above the suprasternal notch and I swear the swollen area felt crepitant. No history of vomiting or procedures is about all the history my language barrier allowed me to gather. This was a very sick man. Quietly he and his friend waited. The surgery staff was evaluating him amongst many others. Eventually he was gone, admitted to the ward. No diagnostic testing or treatment had been performed.
Along side him sat a young teen with draining areas on both legs and left forearm that he volunteered had been present for years. His x rays were markedly abnormal. It had begun as leg stiffness he noted playing futbol. Now both knees were fused in flexion. He seemed otherwise well. The only other patient I saw was a 3 year old girl with sickle cell disease with fever and cough one week out from a hospital stay where she had been treated with antimalarials and antibiotics. Mildly inactive, she was alert and having no respiratory difficulty.
Only 3 patients today on a day I hadn't planned on seeing any. There seemed to be hundreds waiting. All 3 presented diagnostic and treatment dilemnas. I am supposed to be an old, experienced E.D. doc. Why then does it all seem new to me?

Just the Facts Jack

On the last day of the DTMH course the course director had a feedback session. Routinely and yearly he has discovered it necessary to determine if any particular area of the world has been offended by any of the presentations. Commonly those from Africa and the U.S. experience some difficulties for different reasons.
The DTMH is African-centric with no apologies on the basis of the scale of problems and the experience of the LSHTM faculty. During some of the presentations of the problems presented by HIV, tuberculosis, malaria and neglected diseases in an environment that suffers from poverty, the situation can seem overwhelming. My colleagues from Africa shared mixed feelings of sadness, shame and frustration during these presentations. Some expressed that the picture presented left a skewed impression with those not first-hand experienced with their countries.
My take home message was that a presentation of facts is never simply a presentation of facts. There are other messages delivered with one's choice of "facts", methods of presenting the "facts" and messenger of the "facts".
It generates within me a profound sense of caution as I begin the process of sharing the "facts" of my experiences along with my subjective impressions. Nevertheless the story is worth telling, thus this blog. But I have been thinking about the message delivered with the story and I want to be as intentional with that message as I am with the story. So I need a bit more time to think about what I want to say about my first trip to Mwanza and why I want to say it.