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.