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.

Perspectives

Apparently in Northern Nigeria, polio cases are still actively occurring. One of the reasons is that the polio vaccine is suspected of causing harm. Vaccination coverage otherwise is not out of the norm. Why is this? Kebir believes local politicians have benefitted politically by frightening the local population with fears the US is purposely tainting the vaccines to harm Islamic people. I wondered how the US could successfully be suspected of this degree of nastiness. This was not a unique example. A physician from Botswanna told us of his efforts in HIV education when local people held the condoms up in the sunlight and the visible streams of lubricant flowing down were perceived as worms the Americans had placed within. Where does the fault lie for these suspicions? Interestingly, Kebir tends to place responsibility on local, Nigerian politicians. I, on the otherhand, place responsibility on my country for its international activities in recent history. With this perspective I would be cannon fodder in a presidential debate. The truth is somewhere within my and Kebir's perspectives and would be better understood with many other perspectives. It frightens me for our leadership to refrain from international dialogue. There is limited understanding and a markedly diminished understanding of the truth when multiple perspectives are not solicited.

I have made an initial visit to Mwanza, Tanzania to meet with hospital leadership and Touch Foundation folks. I plan on sharing my initial impressions in a posting to follow.

Soapbox

Today was family planning day at the DTM course. Two speakers spent the morning making the case for the need for family planning in the developing world. No argument really. Yes, there is a need. One of the difficulties in speaking about the needs in poverty stricken areas of the world is not so much making the case that the need exists but how you go about making the case. Because the intent should extend beyond educating people to inspiring them to act on the presented need. Our speakers today failed. I have shared the success' of other speakers.
There is a role that individuals play in the creation of the current world situation. It is an art to communicate this role with the appropriate degree of discomfort and personal ownership absent strident blame-mongering. There needs to be some discomfort mixed with inspiration to alter behavior and encourage positive action. Once the data of inequality is presented is the truth of inequity understood? What do we do once we are convinced of the inequity? Hopefully we find little disagreement that we should strive for equity in the world.

Inspiration

August Stitch spoke to our class on Friday February 1st.
A German physician who has worked with Medecins San Frontieres(MSF), he described some of his experiences since graduating from the Diploma Course in Tropical Medicine(DTM).
He combined scientific expertise about schistosomiasis(a common tropical, water-born, parasitic disease afflicting primarily the rural poor in Africa, Asia and parts of South America) with a captivating story of his venture into the Khmer Rouge dominated area of Cambodia to establish a hospital. This followed a time he had spent working with a Trypanosomiasis(tse tse fly carried parasitic disease in Africa) project in central Africa. His multi-media presentation was well organized and masterfully presented. He shared his frustrations with big pharma as some of the few drugs for trypanasomiasis were discontinued from production in the early 2000s for financial reasons until one of the drugs was included in some cosmetic creams for facial hair reduction and deals were struck with these companies, the World Health Organization(WHO) and MSF. He admitted his mistakes in attempting to tackle HIV with the same tactics used in the schistosomiasis effort.
Friday was a day that met my lofty expectations of the DTM.
In medicine and in life, we are inspired by mentors(or heroes, though these individuals might object to this descriptor). Friday I was inspired.