Thursday, July 31, 2008

Is there a doctor on the plane?

Camilo, thanks for the encouragement. Witness is a big word.

My plan was to wrap this little blog up. Most of the sexy stuff worth writing and reading over. My final thoughts about the whole experience, the processing and reflection, will take days to weeks, a lifetime, I imagine. I'm not ready to write about that--still need to sort more of it out for myself. And as much as I would love people caring enough to read the details of my adventures heading home through 3 days in Nairobi and 16 hours in London, I dunno--seems a little presumptuous (not like the rest of the blog wasn't, but nevermind that for the time being).

But, by popular demand, the blog goes on. Yes, someone actually requested that I continue to write about these things, and include the goings on of travels and the week long international AIDS conference in Mexico City. I thought about it long and hard (ya right) and well, because you twisted by arm...

The blog continues.

Let's start with the story from the title...


A 9 hour flight really isn't that bad. You just watch a bunch of really crappy movies (like, Definitely Maybe, Jumper and another I forgot it was so bad--Drillbit), talk with randoms, and take naps. Like more than one nap. You can also drink beer.

I was 6 ounces into an Amstel can when I heard the following:

"This is your captain speaking and I would like to say bla bla bla

The call to action. I imagined myself standing up, busting my shirt off button by button like Kent to Superman, with my red cross shirt on underneath (it was), and stethoscope around my neck, ready to respond to duty's call.

This is not the first time this has happened. I'm kinda an ambulance chaser. It's always worked out just fine, before. And by fine, I mean, I feel really cool saying, "Why yes, I'm a doctor," and then not having to do anything because someone's already there taking care of everything. I've actually never really attended anyone in the field. Except for the lady that showed up with chest pain at my house, but that's another story altogether.

So, they ask for a doctor, and I was drinking beer, watching movies wondering, "What did they just say? Should I be attending someone a little buzzed at 16,000 feet?" So I ask everyone around me if they were asking for a doctor, just to let the entire right rear section of the plane know that i was, in fact, a physician. Would have been more efficient to just jump up like Leslie Neilson in Airplane and say, "Yes, I'm a doctor," throw the stethoscope over my shoulder and just march to the front of the plane with my chest all puffed out.

But I chose the more subtle route. I just sat calmly and hit the waitress button once. She didn't come. This was a medical emergency. They needed me--they said so overhead. They just asked for a doctor, I'm a doctor, I'm responding, and they're not coming. I felt like hitting the waitress button continuously until they came--"buong, buong, buong." But the Amstel hadn't drained enough of my senses to know that would have been absolutely ridiculous, so I waited patiently.

Finally, I grab one of the waitresses, and tell her I'm a doctor, asking what's going on. Never at any point, mind you, did I really think this through. A plane is about the worst place to have to see a patient. What if they were having some life threatening emergency? And I had to make the call to land immediately? Or what if they had something that might be really bad, but I wasnt sure. Ironically, the plane was limited like the third world in terms of supplies and medicines, so I should have been in familiar uncomfortable territory at least. Nonetheless, did I really want to see this guy?

"They've already got someone."

What? A combination of relief and disappointment. But I'm a doctor, and you need me. Who did they get? What kinda doctor are they? Do they need backup? A second opinion?

I mean, this was my chance. After 2 years of residency where we take care of ICU level sick patients, I was ready for a little airplane medicine--not much in comparison. I totally wanted to save the day, be needed and put my training to use. As opposed to when the woman who showed up on my doorstep the first month of intern year, I was ready.

In Mountains Beyond Mountains, Paul Farmer landed many a seat in first class because he had, on numerous occassions, responded to such calls on flights. I was totally wanting to start that kind of a relationship with Virgin Atlantic.

Not meant to be. Some other doc took care of it. Looked like appendicitis, according to the waitressing staff. They gave him some fluids and antibiotics, and hauled him off when we arrived. Interestingly, there's quite a protocol they have to go through in order to administer medicines. You have to get the captains approval, then they have to call some consult service over the phone, and they have to check out all the doctor's credentials, etc. At least they didn't call on my credentials and shoot me down because I'm still a resident. That might have been a little embarrassing, "Uhm, is there ANOTHER doctor on the plane?" They've apparently got quite a slew of medicines, in addition to the automatic defibrillator.

Rest assured, Lorenzy, you're time to save the day (or deal with the tough airline cases) will come soon enough. With an 11 hour flight from London, and 2 flights to Mexico in the next 3 days, maybe sooner than you'd like...

Wednesday, July 30, 2008

Bond, Cards and House Life

Bond, Cards and House Life
(Written Sunday, July 27, 2008)

We’ve got a weekday routine at the house, Masahi (Muhs-eye), Migire (Mih GEE ray) and me. We all return home in the early evening, by 5 or 6. For a couple hours, I read or write or review medicine or Swahili. They cook. We eat around 7, usually rice with chunks of beef. Or maybe spaghetti sprinkled with sugar. And maybe a passion fruit + avocado shake. It’s good, makes me want to start a shakes club at home, making my own experimental creations by throwing random things (like fruit) in a blender and seeing what it tastes like.

After dinner, we watch TV. Often a soccer game is on, local East African teams (Tanzania, Uganda, Kenya). Or we watch a movie. I don’t know how we settled on these or why we picked them in the first place—but we’ve been watching James Bond flicks. Like, exclusively. During dinner, Masahi would say, “After dinner, we watch zero zero seven?” I thought about correcting him to “double oh seven,” but refrained—in my Tanzanian memories, Bond will be, “Zero, zero.” I had these DVDs with 26 movies on each disc, and as I previously mentioned, one is the Pierce Brosnan collection, with like 5 Bonds on it. It works, we all seem to like them. The guys like the explosions and action, and I like Bond’s reckless international hero character. I never thought I’d be watching so much Bond in Tanzania.

The other thing we do at night, especially the last week, is play cards. I bought a deck, trying to get more people time, less TV time. First, they taught me a game they call “The Last Card,” which is like Uno, Crazy 8s, Dirty Neighbor—all of those. Good fun, complete with shit-talking and all. Then I taught them speed. Now that was comedy. I got a video of the two of them playing that: Masahi holding his hand out saying “Wait, wait” to Migi as he unloaded all his cards. Funny. Sorry, Masahi, but the game is speed, and as such, there is absolutely no waiting. But nice try.

Since they only knew one card game and wanted to learn more, I taught Masahi Gin. Apparently, I’m an excellent teacher. He beat me 7 out of the first 8 games, easily getting to 500 before me. He likes to talk trash, especially when he’s winning. If anyone knows me when I lose, I’m a whiney little bitch. I’m king of the poor losers. Who wants to teach their kid how to lose well? Anyway, my diplomacy triumphed within, as I graciously congratulated him. And then I whipped him in the next round to 500. Ha ha. We’ll see who takes the tie breaker, but don’t count on any international good will from me cutting him any slack.

More about the guys, Masahi and Mgire. Called him Migi. Good dudes, brothers living in this house alone, with occasional visitors depending on the time. They are two of nine children, with siblings scattered throughout the country, some here.

Mashai, 27, engaged. One of the younger of 9, his parents in their 70s, his oldest brother 50. A family of accountants (really, ALL of them), he followed suit. He thought about being a doctor, but the availability of accounting books at home steered him toward numbers. He hopes one of his kids will be a doc.

Having graduated university with a degree in accounting, he dreams of going back to school to get a masters in accounting and take their equivalent of the CPA (I told him about you, John Taggart—how you’re a CPA and all. He said you must be pretty cool, but don’t worry, I corrected him). He worries about being able to find work as an accountant, provide for his family in the future. A higher degree would help. The problem—he needs $4,000 US to make it happen. He’s looking for a sponsor. I told him I would put this out there, and see what happens. If anyone is looking to help a guy go to graduate school, we’re gladly accepting donations. I hope to have some cash for him by fall, 2009.

Masahi is about my height, thin but athletic. His English is excellent, like many here. I would say fluent, as they are taught early in school. Some of my favorite phrases of his:

007 (said “Zero zero seven”)
This man here
There is no problem. You are welcome.
Juice. (pronounced, “Jew-eece”)
Mike Iron Tyson. (Instead of Iron Mike Tyson).

He has been an exceptional host. I have a room to myself, with bed and closet space. He arranged to get a gal in town to do my laundry and cook my meals for a small fee. Whenever I need anything—internet, motorcycle—he’s on it. Several times, he has cooked for me. We’re not talking PB&J or mac and cheese (what I cook for my bachelor self), but a dinner that takes 3 hours on average to prepare. He’s made much of his life taking care of me while I’m here. At night when I shower, he warms up a bucket of water (“Are you ready to shower?” It’s kinda like a parent with a rascal anti-shower child—I took twice as many showers because he made the water, otherwise, I was fine staying on the 3x a week plan. One more thing—I cut the mane, my locks. I prefer to describe my current look as rough Tom Cruise, as opposed to long haired Tom Cruise from before. I haven’t shaved in 3 weeks either. I’m pulling a Joe Carey “the little beard that could,” except Joe had three times the jaw/sideburn coverage that my little struggling forrest has. Don’t worry, I’ll shave immediately upon arriving stateside.

Masahi has refused payment for housing me. I’m at least allowed to contribute to the grocery bill, as is minimally appropriate. But last week, he bought me lunch and dinner out at a local hotel diner. That was heart breaking. A guy on a Tanzanian salary taking his richer visitor to dinner. Wow. And he dropped his own dime going with me to town yesterday. I picked his up on the way home, and finally did buy him lunch. Repeatedly, he's treated me like a king. Makes me think about how I treat my friends and family, let alone guests.

Migire. 18 year old dude, he will probably break from the accounting pathway. Politics. I'm not sure what that means. Like a senator or president? He goes to secondary school, and is the equivalent of a sophomore in high school. He's also the only non-Catholic in the family. Some evangelical protestant denomination that I forgot, sorry. But he went to Catholic mass with me the second Sunday.

The dining table is situated such that if you are sitting in either of 2 seats, you can lean back and see the TV. Migi has the bad habit of doing this. It's quite funny, because like parents, me and Masahi will force him to sit in the other seats, with no possible view of the TV. (I've actually called myself Daddy a couple times, actually.) He then immediately hits the tube after eating.

Anyway, it was sad as shit when I said goodbye to these 2. Definitely got misty, and I'm not so much into the whole crying thing. I'll talk more about my departure later. I hope to return and see them again someday.

Kitabu and Shirati

Kitabu and Shirati
(Written Sunday, July 27, 2008)

A little late, I should describe the town, although pictures should do more justice.

On the left of the main dirt road through town, there is the hospital. Surrounded by white painted cinderblocks topped with barbwire, and a guarded gate—it looks frighteningly military at first glance. Access was restricted for most. White skin, white coat and stethoscope gained me daily passage with ease.

On the right side of the road across the street from Shirati hospital are lined a dozen places of business—mostly little corner stores or places to eat. A Tanzanian strip mall. Kinda. Not really. Made of wood or again cinder block, with tin roofs they would best be called shacks. Not very impressive, but I loved the feel. Although they stared at me everyday, the people were quite friendly—always saying hi with a smile, willing to teach Swahili. The third world pattern of having several stores that sell the exact same thing was in effect as well. A little diversity, and you guys could dominate the local market, but whatever. Don’t fix it.

Past the hospital, to the left off the main road, was the house I stayed in. About a 5 minute walk on dirt pathways, the house was in a residential area. Farmland, baby—the Tanzanian countryside. Each plot is only a fraction of a football field, with decent sized yards that often had crops—corn, tomatoes, whatever. Add your wandering chickens, goats, sheep, cows, cats, dogs—and the lake in the distant horizon. Spotted with trees, covered with yellow grass in between, the setting is a fresh contrast from polluted city life (the environment tends to be lowest priority in the developing world. Although they don’t have trash—because they burn all of it!)

A word about chickens and goats. These creatures are ridiculous. Let’s begin with the chicken. When I look at chickens, I laugh. I’m not sure why. I’ve thought about it for 2 weeks, and it’s still funny to me. “You…are a chicken.” They seem so serious all the time. Constantly pecking for food, defending their territory. And then when they run—a guaranteed good time. Something about little armless creatures in fast-waddling movement just cracks me up. I had the opportunity to see the rear view of a rooster sprinting to defend his territory—double hilarious.

Goats are equally stupid things. When we visited the neighboring city, Tarime, there was a goat continuously bleating, for no reason. “Blaaaa. Blaaahh.” I couldn’t stop laughing, he was a spaz. And he was looking at me laugh at him. Trying to make 2 eye contact, which he couldn’t quite do because as an animal of prey, his eyes are on the side of his head. Bozo. So he’d have to turn his head just a hair to the side to get one good eye on me. The locals were laughing at me I was laughing so hard. “Blaaah.” Plain goofy animals, man.

I enjoyed my walks to and from the hospital, definitely part of the “get away” from our car-based lives in the states. Joining the livestock lining the paths were various people doing I still do not know what. Hanging out, I guess. Many children, too, and one in particular stands out.

The first time we met, I saw this stubby little munchkin churning his legs a million miles an hour as he motored 100 feet from his house to meet me in the road. Standing in at all of 2 feet, 6 inches, he looked straight up at me, held out his hand and said,


“Kitabu? What’s that mean, little buddy? Cash, do you want cash? Afraid I’m out.”


“Hmmm. Maybe this is that derogatory white man term jack told me about. No. Maybe it means—sweet ass doctor. Or Tom Cruise stunt double. Probably not that either.”

“Kitabu,” he persisted. He was a dangerous little one. Put his face on TV and you’d fill your foundation’s endowment fast, he was very cute. Dimples, continuous smile, but enough mischief behind those eyes that he deserved due process.

“Kitabu? Allright, lemme check this dictionary here…kitabu. Ah, here we go. ‘Book.’ You want my book?” Practically a mobile library, I had books stuffed in every pocket of my coat, pants and shirt. “Ok, here you are.”

He bolted. Took off running back to his house, the little squirt vanished within seconds, and my book with him. It was gametime—cat and mouse, the chase, and I was in. “I’ll get you, my turkey, and your little book, too.”

I didn’t think it appropriate to enter the home, and he had disappeared somewhere inside. So I called from the front door. A woman (his mother perhaps?) saw that he’d swiped my book—she walloped him on the buns and secured the Swahili-English dictionary of mine, which would prove a crucial piece of literature during my stay. I felt bad that he got busted, gave him a hi-five and a pat on the head, and waved goodbye.

Everyday, he would greet me the same way—jump up once he saw me from his house, and come flying around the bend between his home and the pathway. I’d give him hi-fives, pick him up, throw him in the air, turn him upside down. He loved it. His favorite was to put his hands together above his head, and then with one arm, I would curl him up and down. Good exercise for my shrinking muscles, a fun ride for him. This little nugget, I would definitely take home with me, smuggle him back into the states. I got some great pics of him, including a video of his daily approach. Good memories.

Other natives of Shirati. Mem, a 20 something girl who tended her dad’s little corner store. Very nice, she taught me numbers 1-10, which I promptly forgot. I later found out she was flirting with me with she asked me to “sit on the bench” with her. Glad that one flew below my radar. Famous last words—“But I thought it was just a bench.”

A 30 something man, Edward, a high school teacher from distant town. Here because his sister had died in a kerosene explosion. Horrible. He kindly helped me find a place to lunch, and then asked me to send him a copy of the Oxford English Grammar rules. What? I figured what the hell, people haven’t asked much of me yet. More beggars in Berkeley than I’d found in this country so far. We’ll see how what the UPS rate on that one comes to.

Located about 2 hours from the Kenyan border in northwest Tanzania, Shirati is nestled within several mountains. A half hour hike west from town lands you at Lake Victoria, the second largest lake in the world, behind Lake Superior in the US/Canada. It’s quite impressive. Approaching from the east bank gives an amazing sunset view. Quite nice. My first visit was when I was feeling a little down. The bank is coated with shells. Charming, they harbored the snails that carry the parasite Shistosoma hematobium. The little buggers penetrate the skin within a second, storming the bloodstream in less than a minute. I was petrified of touching the water, let alone getting in. Judy Bliss got in when she came—she got shistosomiasis. Of course, this is the same water that I shower and brush my teeth with daily, but nevermind that.

Existence in Shirati is quaint, chill, quiet. It’s easy to feel a little trapped without transportation. But it’s not like there’s anywhere to go if you had one—back to simple, rural life. Makes me wish I had a guitar or piano. Not that I really play both, but one of my little escape dreams is to set up camp at a place like this, work during the day, then just retire for the evening learning guitar on the porch, sipping a beer. There are a few bars in town. I found the beer tasty, but often warm.

To find a Tanzanian hut, made of straw and mud, you just have to go a little outside of town. Once beyond the perimeter of the town, they are plentiful. These folks often speak local tribal languages, not Swahili. Loa is one, for example. And these languages vary depending on the part of the country you're in.

The Return of Lorenz; AIDS

The Return of Lorenz; AIDS

As you can see, I’m feeling better. Several things helped. Wednedsay, I spoke with Dr Ester, an expatriot American doctor (the only MD within miles) who was the medical director for several years at the hospital before starting a local clinic of her own. She echoed my experience of Tanzanian medicine: treating for several things at once without a clear diagnosis, sending malnourished kids home (likely to die) after “health education” because the hospital didn’t have money for inpatient feeding, and frequent death you can do little about.

Shortly thereafter, Dr Kitono gave me a book I wish I had upon arrival:

Guidelines for the Management of Common Illnesses with Limited Resources.

A 378 page manual put together by the World Health Organization, it’s got everything I was dying to know. I had spent hours trying to download it over the slow dial up modem internet and finally gave up. With this book, I had a cookbook manual to help me with diagnoses and treatments of exactly what I was seeing. In short, turns out what I was doing wasn’t too far off from their recommendations. I wish I would have downloaded it at home and brought it (I think Nishant told me to do that, and I blew him off, figuring I could just learn from experience what I would need. Once again, brilliant, Lorenz, brilliant).

Thursday afternoon, I got back into the grove at the hospital with some procedures. A nice big lac repair—of a young farmer who was trying to get me to find him an American wife. (Ladies, any takers???). I told him I was having enough trouble finding myself a wife, but if there were any American women looking for a Tanzanian farmer, I’d be sure to send them his way.

There were 4 C-sections I missed when I was at the clinic. Initially, I was disappointed, especially because I was going to be the primary again, and I was ready for a second chance. But then I heard that on the first one, both the baby and the mother died—the mom had been kicked (domestic violence) and had uterine rupture with uncontrolled bleeding, DIC and death. Horrible--and the place of women in Tanzania, not good. Could blog on this topic for a while, too. Anyways, probably a good thing that my recent improvement from clinical depression wasn’t tested with the death of BOTH the mother and child. I might have packed my bags for home if I were the primary on that one. Whew. Very sad situation though. I'm not sure how they go about criminal proceedings here, or for that matter, if they will pursue anything or not (horrible, I know). My nervousness about the labor and delivery practices is not improved either (she had been in L&D for several hours with fetal heart monitoring only TWICE DAILY; I should discuss this more later.)

My last clinical day was Friday, and I got conned into rounding on the peds ward again alone. But I had my trusty WHO guide, which mitigated my frequent feelings of uncertainty. After that, I hung out in the outpatient HIV/AIDS treatment center. To my surprise, I didn’t see very much HIV/AIDS in the hospital. My expectation before coming was that AIDS was ravaging this continent and country, and was the leading cause of death. In my experience, most (80 %) hospital admissions were related to malaria. There were only a few cases of AIDS during my 2 weeks. Of course, those cases were bad news, with very poor prognoses--end stage.

Internationally, AIDS is a sexy disease. Very political. The hospital receives a substantial amount of US grant money (from Bushy, believe it or not) for AIDS drug therapy. The greater killer that I saw (malaria) doesn’t make those headlines or bring in such international gifts. It fooled me too—I’m going to the International AIDS Conference in Mexico City a day after returning from Tanzania. Two years ago in Toronto, there were 20-30,000 people interested in AIDS (not just doctors and medical professionals, but politicians, social workers, affected individuals) at the conference. It will be a great conference—I’ll be immersed in learning about the disease with the newest info, will make friends and meet inspirational people, in addition to making professional connections. And I’ll run around in Mexico City, the second largest city in the world. No doubt, it will be a great time.

But I’m not planning on going to the International Malaria Conference. Or the World Diarrhea Forum, if there are such things. I bet there’d be a bunch of nerds at the malaria one. Anyways, just pointing out I’m as guilty as the media about sensationalizing certain diseases over others that are arguably, just as worthy of attention. Tuberculosis too.

Back to the outpatient treatment of HIV, which is quite different from home. In the US, we rely on lab tests (CD4 counts and HIV viral loads) to determine when to start medications. When the T cells are low and the viral load is high, you start meds. Theoretically in Tanzania, they are supposed to follow patients with labs too. But in Shirati of course, they lacked the money and lab supplies to do so. So they follow clinically. Instead of having a nice quantitative number, you ask patients about their history and what diseases they’ve had related to HIV, and you stage them accordingly. AIDS wasting syndrome, characterized by >10% weight loss where somebody looks like a skeleton, would get drugs immediately (Stage IV). As would several months of diarrhea, or Kaposi’s sarcoma, or pneumocystis pneumonia—all so called AIDS defining illness. As opposed to generalized lymphadenopathy (stage II) or oral thrush. By themselves, they don’t warrant treatment yet, so you just follow the patient every couple months.

Different and interesting to treat clinically. More difficult to initially grasp, too. Treating based on 2 lab numbers versus being able to identify and diagnose 20 AIDS related diseases.

Also surprising, many of the same problems we encounter in the US related to HIV care—poor social situations, medication noncompliance, uneducated patients—are present here. There were miscommunications about meds—one patient stopped taking them for a month because he didn’t know he was supposed to keep on them. I’ve heard people say viral resistance to medication is less of a problem over here, but I suspect resistance will emerge all too soon.

There were patients of all ages—from 5 to 60. Many sadly, had survived their spouses and even their parents, who I suspect in many cases died of AIDS. Many of the pediatric cases were orphans. Sad. Kids and AIDS, there’s a subject I’m not in the mood to rant about. Talk about injustice. Largely treatable and preventable—if the mother is tested and known positive, she can be treated during pregnancy and surrounding birth, and the transmission rate to the kid can be as low as 2%. Not bad. Without it, people say anywhere from 15 to 40 % of babies born to HIV + mothers will become positive. Many children then are infected with an incurable often life taking diease, that could have been prevented 98% of the time.

That's about all I have to say about that. For the AIDS nerds in the house, they only have like 5 antiretrovirals (compared to the 40 we have)--including AZT, 3TC, efavirenz. They use a 3 drug combo for HAART, 2 NNRTI and a NRTI. No protease inhibitors. And the patients dont have to pay for them because of the international/Tanzanian government programs. That's a good thing.



(Written Friday, July 25, 2008)

The lines continue to blur on what I should include in this little blog. It would be nice to write about 3 weeks of a perfect little heal the world trip, but sometimes, that’s just not how it is, and not how I feel about it. For the sake of telling this adventure in its entirety, I’ve decided to include the following:

Wednesday and Thursday, I got depressed.

Tuesday evening, I was all messed up. The kid’s death hit me like a big cement fist in the chest. Combined with the overwhelming stress of attending 20 something kids by myself, Tanzanian medicine had knocked out my emotions. I had nothing left—emotionally drained. In a couple days, it had felt like a month of medicine at county.

And then I found out that 2 more kids died. Not good, in so many ways, for so many reasons. Following guilt and anger, depression was inevitable.

Wednesday, I had planned to go in to the hospital early and then to an outside clinic for most of the day. I slept in, completely blowing off the hospital. After the clinic, I came home and took a nap, even though I had plenty of sleep the night before. I was irritable—tired of Tanzania and the third world. Sick of the same high carb spaghetti and rice meals, but not really hungry anyway. Tired of showering by dumping a pitcher of water over my head.

And I wasn’t very pleasant, not my normal Jambo-to-everyone-in-the-African-world self. I didn’t care to learn any more Swahili, and wished I could have a conversation in English where I didn’t have to repeat myself every third sentence.

I wanted my bed, my friends, my country, and my medicine.

Did I have malaria? Fatigue, but no fevers. I had been taking my prophylactic pills, although weeks late, and was not using a mosquito net over my bed. Now that I think about it, I did have a cough for a week—so I shouldn’t rule out tuberculosis so quickly either. Nothing like learning about disease first hand. And I have totally been drinking the water, so you can include schistosoma in the differential as well.

I was a wreck. I felt things spiraling down.

It didn’t help things that I thought I should be totally happy. This was supposed to be my dream existence, right? Doctoring in Africa, free from the first world bullshit that disconnects us from living. Instead, just as the high rolling into Tanzania was one of the highest in the last years, was the low almost equally as dark. Some of it, the responsibility for dying children, uncharted territory altogether.

Then I got news that the C.E.O. had denied me access to the motorcycle because he was afraid I would crash and kill myself.

Thankfully, I had experience with this cycle. Just about the time that the novelty of the new land wears off, the withdrawal pains of the homeland (and the friends and family therein) set in. As Tanzania was beginning to let down her guard, unashamedly revealing to me her painful realities, I began to miss my 62 inch HDTV and the people that know I love cheesy chick flicks (the worse they are, the more I like them). Add on the clinical experience of dying children and attending responsibility, and you’ve got a recipe for hard times to say the least.

I had hit rock bottom. For those of us that know this place, it’s somewhat reassuring because you know that once you’re there, you’re not going any lower, and in fact, things will soon enough get better.

This is where it gets difficult to understand: I love this stuff. This is what keeps me coming back to the poor parts of the world. Few things are harder. The challenge to survive (let alone thrive) in this place gets me high; perhaps like the challenges of climbing Kilimanjaro or running a marathon inspire. Or maybe this is more like Fight Club, where you respect yourself and others the more pain you endure.

In my times in the poor world, I’ve gotten stripped clean, down to the bone. The normal daily routines—internet, music, TV, driving wherever you want, people who know me—gone. Adios, kwa heri. It’s crazy how much these silly routines give comfort, and even define us sometimes. So you go to the African bush, and WHOOSH, it’s all gone. And then shit, what am I going to do now? And even scarier, who the fuck am I?

So I arrive in this space, this alternate universe almost. I mean, in my California USA life, how much do I really need? I’m surrounded by loving friends and family, meaningful work and I’m never hungry. Never. But here—I’m needy, I’m friendless, I’m bored—it’s extremely fertile spiritual land. It’s why, I suppose, Jesus directed his message to the poor and the losers—having nothing else, they were open, willing to listen, and really in need of what he had to give.

In this bizarro Lawrence Tanzanian reality, I can hear several things. The first—people and relationships are most important. More important that I make them on a daily basis. Too much crap cluttering my life. Too much facebooking on the internet, too much (sorry ladies), too much sleeping. Well, I’m still in residency. Maybe not too much sleep. Too much paperwork for sure. But not enough moments with people. Drinking beer on the porch in Paraguay, playing cards at the kitchen table in Tanzania or a cup of tea on the deck watching the sunset in Berkeley…these kinds of simple moments with people.

What has impressed me most about my time here is how the people of Tanzania have treated me, a stranger. From my random bus friends looking out for me, to the hospital CEO making sure I have a bus ride to catch my plane, there is a value they collectively share that I am happy to adopt as my own. The greatest two teachers of this have been the two guys I’ve had the chance to live with, Masahi and Mgiri. They will get an entry all to themselves, but they way they have treated me—in this time when I was in need of both friends and food—was more than just a couple random acts of kindness. It is deeply woven into their character, their habits. They just are that way, for no other reason than it’s just them. Damn, that's impressive and inspiring.

Fertile land, finally, in terms of life dreams and goals. There is an enormous power, both politically and financially, the United States possesses more than any other country in the history of the world. A doctor in Tanzania, for example, might make $6,000 US a year and be doing quite well relatively in Africa. He could save up all his money, start a small business, whatever—and never come close to amassing $100,000 in a lifetime. Ever.

The Shirati hospital’s operating budget is around $150,000 annually, covering all operating expenses from doctors and nurses salaries to medicines, etc. I think they’re doing pretty well on that money. $150 K to us, however, really isn’t that much. You couldn’t fund a small clinic in the US for that. In fact, it’s as much as the average family practice doctor makes in the US. The average US family practice doctor’s annual salary = the annual operating budget of a Tanzanian hospital. Kinda crazy (kichá in Swahili).

You can see where I’m going with this. We have the ability, through that imperfect monster of capitalism, to do so much good for the world. The possibility to make money—generate money at your job (as a doc, eg), invest it, start a business, and then after 20 years have enough annual income to fund a hospital in Africa—that’s a fucking dream. The possibilities are endless. These kinds of dreams really are unique to America, to our time, and are such an amazing opportunity. It's the kind of thing I'm passionate about.

Yes, I've since recovered from my depression, as you can see. In the next blog, I'll talk more about it.

Death, Guilt and Anger

Death Sorry to the faithful readers (Cath is totally my biggest fan, holler for her) for the 10 day hiatus, as the numerous posts will tell, much has happened, good and bad alike. I'm screwing around in the Kenyan big city capital of Nairobi (pop 3-5 million, give or take a couple million), classic Lorenz style--with stories coming faster than I can write them (a preview: the hardest Muzungu ever, sugar daddy and a prostitute...stay tuned.) I found a huge garage sale (market) yesterday, made some friends and watched that new badass Angelina Jolie flick. I fly home Thursday morning.

Cath, I ended up not making it to Arusha again, so I missed your friends. Just took the straight shot to Nairobi this time.

Jack. I'll send you an email with the book and details. It's a good one.

Thomas. You bought a house without me? How could you! I hope it's in Berkeley somewhere, right down the street from me and Dan. It's been too long, we need to talk.

Mikah. Thanks for the encouragement, very well put. See the following posts for ample discussion on getting to know oneself, personal growth and whether this is really for me.

Death, Guilt and Anger

(Written Thursday, July 24, 2008)

I thought twice about even writing this. There’s something…sacred about death. As if talking about it is sometimes inappropriate or uncomfortable. I hesitate to put down my thoughts on this young one for everybody to read. But it will help me to share it, and will tell a sadly common story in Tanzania.

Two of the children I have cared for have died. I think I mentioned the first—a 12 year old girl who fell 2 weeks ago, then presented to the hospital with right sided paralysis, aphasia and meningeal signs. I suspect she had a bleed in her brain, but am not sure. She died the following day. Without a CT scanner and a neurosurgeon, there is little to be done. And even then, the prognosis can be ominous. For her, there was not much we could do.

With the other girl, I’m not so sure. I worry I could have done more.

Naomi was a 2 month old little girl, who presented with headache (not sure how can you tell in a 2 month old), fever and respiratory distress. She had been diagnosed days before with uncomplicated malaria and given outpatient treatment which, obviously, had failed. When she began having seizures at home, they brought her back.

As I mentioned in my last entry, I saw her around 2:00 pm. It was the end of my horrible day rounding alone; I was tired, overwhelmed and exhausted. The last thing I wanted to see was an ICU level ill child. Just eyeballing her, she was sick. She looked dehydrated, listless, pale. She was not seizing. Her neck was supple, heart tachycardic and hyperdynamic. She had an enlarged spleen. She was febrile.

I was sure this was cerebral malaria. Or seizures from hypoglycemia (low blood sugar) from malaria. I reviewed her orders—antimalarials, blood transfusion. I added anticonvulsants to control seizures, and broadened her medicines to include antibiotics for meningitis just in case, although I had low suspicion she had meningitis. She was deathly ill to be sure; we could only hope we got the medicine in her fast enough.

Because I was worried about her and the other seizing child (with meningitis), I returned to the pediatric ward around 7:30 pm to check on them. The meningitis baby was unchanged. When I went to look for Naomi, I didn’t find her in her room from the afternoon. I asked the night nurse, who told me, “Oh that one died.”

I’m not sure how I felt at that moment. Even as I think about it now. A combination of things. Numbness for sure. Shock. I knew the kid was sick. And really sick. But I was just shocked that she died. Denial that it could happen to her, and to me, her doctor.

At the same time, I felt horrible guilt. What could I have done? Should I have given more anticonvulsants? Sat at the bedside until I was sure she was stable and improving? Could I have given more fluids? Maybe more glucose? Should I have had Machage evaluate her immediately?

I reviewed the chart with the medical officer. She had just pronounced Naomi dead at 7:00 pm. The medical officer didn’t seem to have any reaction at all. Here I was, getting all worked up about what we could have done and the fact that we lost one, and to her, it was just another kid who had died of malaria. Happens all the time.

Not to me, it doesn’t.

We reviewed the chart together. Something that could have been improved—IV instead of IM quinine (the antimalarial). This was theoretical—we didn’t have the IV fluids to run it in with; we could only do IM. That was all she had to say. The lab results came back—positive for malaria. In patients hospitalized for malaria, there will be hundreds (100-400) parasite rings reported in a blood slide. This patient had 4,000—10 times the highest I’d previously seen. Tons of parasites in the blood, it’s no wonder she was so sick, with seizures, and ultimately, died.

Nonetheless, I felt horrible the rest of the night. I’m mildly nauseous still now. On the one hand, sometimes there is nothing we can do. People die. Kids die of malaria. And there a point when it is too late and there really isn’t anything that can be done.

On the other hand, malaria is a treatable infectious disease. Treat the underlying infection, support the rest of the body in the process (give fluid and glucose, control seizures and temperature, etc). I know more could have been done. But many of the things I know how to do—continuous vitals monitoring, checking blood electrolytes, giving oxygen—they just don’t do here. There is no intensive care unit for patients like this.

There was nothing we could do vs. I didn’t do enough. Sometimes, the truth only lies in the heart of the doctor. Other times, nobody knows.

I do feel like I could have done more, even here. More aggressively lowered the temperature, controlled the seizures, given more glucose.

But I doubt it would have made a difference in the end. Perhaps the worst thing about this—I will never know for sure. Maybe if I would have done all that, things would have turned out differently. Maybe if she were in the ICU at a childrens hospital in the US, she would have survived. You never know.

It’s been a couple hours since I wrote the above, where I largely felt guilt for what had happened and not being able to do more. After a couple hours, things have changed: now I’m pissed.

I’m angry. At everything. Mad at myself for not doing more. Mad at those parents for waiting until that kid was having seizures to bring her back to the hosptial. SEIZURES--Helloooooo! Mad that the hospital staff doesn’t seem to give a damn that another little kid died of malaria. TREATABLE DISEASE, PEOPLE! Pissed at Machage for dumping his pediatric service on me, and then neglecting both me and his patients. Mad at the stupid mosquito that carries malaria, and the even stupider Plasmodium parasite itself. JERKS! Angry at Tanzanian heath care, that they don’t have more treatment options, more money. And the corrupt Tanzanian government. Mad at the rest of the world for not caring more. Pissed at the nurses for not paying closer attention to the sick kid, and doing exactly what I told them. I’m just frustrated as a doctor that knows that this kid could still be alive but—for a hundred reasons to get mad about—isn’t.

Before I got here, I was shaking with excitement. Well now, I’m shaking with rage. And I’m blasting anything that moves with it.

I don’t know what I was thinking coming down here. As if I’d be able to save these kids. I’m in over my head. I wasn’t trained to do this. Seeing 30 sick kids a day dying of diseases I’ve never seen is more than I can handle. Two days on the peds ward, and I’m gunna crack.

I want out. I want to go home. I want to get on that motorcycle and just ride to the lake or the mountain or somewhere far from this frustrating hospital and get away.

This kind of limited medicine sucks. It’s frustrating. And right now, I don’t want to be a part of it. Watching kids die when I know something could have been done? Fuck that—it takes it’s toll. Either you toughen up and disconnect from patients, or you suffer. Right now, I don’t want either.

Ya, sure, they do their best with limited resources and think about all the good we’ve done—blah blah blah. I don’t want to be positive right now. I’m pissed and irritable and am going to be that way. IT’S JUST NOT FUCKING RIGHT. It’s not fair—shitty health care, growing up with malaria. I’m not even going to start with the comparisons for a kid born here versus the US. This goddamned world.

I went to medical school to do something about this stuff. Save the world, work for justice. What a fucking joke! This is more like my own little luxury vacation to feel really good about myself, and it’s sure doing me a lot of good. Two weeks is nothing. Even if I devoted my whole life to a hospital here, it would barely be a grain of sand on the beach, or a drop of water in the ocean. 40 Million Tanzanians—millions die of malaria a year. MILLIONS! Huge, the problem is enormous. Every time you treat and discharge one, the bed is filled the next day with another dying of the same damned disease. And the system changes to really make a difference are so much deeper, long-term, structural—that it makes things seem even more…


Sorry, but I’m pissed and depressed and that’s how I feel right now. If I were at home, I’d get on the love sack by myself and watch Just Friends or Toy Story or something and eat a ridiculous amount of MacDonalds, Sprite and heavy butter popcorn.

Monday, July 21, 2008

An Ectopic, The Weekend, and Peds Rounds alone (DAYS 5-8)

Taggart--Yes, Arnie has hit Africa. Hard. One DVD, all the classics. Heaven for you and me, bigboy--Josh's 7 month birthday gift???

Keck--I've been thinking of ways to exploit Europeans for years, selling Ibooks might be the way. Actually, you've got it backwards with Miss Tanzania. I think I'm stalking her harder now, than if I would have just not lost her number in the first place.

Cath--Tanzania is 40,000,000 strong, but I think they've got room for 1 more ;)

Thanks for the spicey, Pinto.

Gabe. No contract yet on the screenplay.

Jack, I've got a book for you to read. NLP, if you haven't already. Look it up. Good chapter in there I'll tell you more about later.

Without further adieu, my African name...

I know, your kinda disappointed. It's not like Larigi or Lorenzfasa or anything sweet like that. Just good old Lawrence in Africa. I introduced myself as Lawrence after Larry failed numerous times, and they are all able to say it just fine. Common name over here, believe it or not. Lots of biblical names--Jeremiah, Maria, Daniel. Funny, it's essentially the same as my Latin name Lorenzo. When a native Spanish speaker tries to pronounce Lawrence, it comes out, Lor-ence. Or Lorenz.

Lawrence it is.

Wanted to talk about a couple more things from last week--the impressive ortho professor, the ruptured ectopic--then the weekend party and church experience--then today, where I rounded on peds all by myself (and was quite uncomfortable).

Dr Maya is an orthopedic surgeon who's a professor at the regional university hospital. He trained in Germany, is fluent in at least 5 languages, and was a pleasure as a human being. Very smart--knew his stuff. And just a nice dude. Kind in the OR (many surgeons have harsh/asshole OR personalities), excellent surgeon who loved teaching me and some American medical students, and just a happy guy--he was singing to and playing with this little baby who's clubbed foot he was about to fix. I was impressed. This guy was working miracles--helping the lame walk, truly. Long hours when he was here, they worked until midnight his last day (ol' Lawrence clocked out around 5ish...).

The Ortho cases. Kirk, made me think of you and how I'm going to get you to do a week of missions for me someday in some remote place of the world. No fancy equipment. Some basic ortho repairs.
5 clubbed feet (2 of which were too young to be operated on, so were casted)
Several genu varus/valgus repairs (Blount's disease??)
Chronic osteo resections
Hip replacement
Chronic A-C Separation--lateral clavicular head resection
Friday I was about to get my hands on the hospital motorcycle for the weekend. I was salivating. I was going to get out there and chase lions with that thing--it's only a little 125 cc engine, which is practically a scooter. But it was some wheels and freedom and I had been engineering this politically all week.

I got on with this guy and was about to go filler up when I got a note from Ogendo that there was a ruptured ectopic pregnancy, and he wanted me to do it.

Dang. Ruptured ectopic versus the motorcycle. Not sure I made the right choice, but I went back in for the ectopic, and didn't see the bike the rest of the weekend. :(

The ectopic was probably scarier than the C-section story. But by that time, my nerves were so shot and dulled that little was going to scare me like the nevous sweat fountain freaker C section from days prior. We opened (again, I was the primary) with a similar incision as a C-section, and found tons of blood. I couldn't see a thing. I had to reach in and blindly grab the uterus, which was floating in blood. Still couldn't see the tubes because they were submerged, we had to walk them along and sure enough--found a Right tubal pregnancy. Clamped it off, everything was fine. The rest was a simple closure.

Sweet. A good case. Then as I was about to leave (to go and swipe my weekend joyrider), a woman came in unstable and bleeding from a miscarriage. Of course, Ogendo wanted me to do that as well, and I did. It, too, was a good case. I'm glad I did it.

But it's Monday, and I still want that bike.
This still doesn't make sense to me. 1 week ago, they had a 25th wedding anniversary party. It went fine. Then last Saturday, they had a meeting to discuss how the party went (200 guests, the logistics, I guess) and they had a party to follow the meeting. Party to follow a meeting about last week's party.

Whatever. My roommate, Masahi, was going and invited me to join. So I'm there and haven't eaten dinner so I just start drinking their warm, Tanzanian beer. Would have been great were it cold. Half a beer into it, I get a grin on my face. You know the kind. Ear to ear, wide shit-eating smile that wouldn't go away. It just stayed there.

I was drunk. And so were the Tanzanians. It was time to party.

First, they played several 1980's love songs: the titanic theme, Whitney Houston I Will Always Love You. That kinda crap. I loved it (Jules, no comments here. It was beautiful). But what I loved more--their dancing. I had high expectations for African dancing. I assume they have the natural rhythms that things like salsa originated from.

Not this part of Africa. Not this tribe.

They looked like Grannies and Grampies doin a slow boogey. It was ridiculous. I have pictures to prove it. I couldn't stop laughing. All the attending docs were there. They dance with their hips and kinda slow, side to side, back and forth. Mostly with their hands at their sides.

I decided to introduce them to American dancing, Lorenz style. Sorry, but if you wanted someone else to represent your country, you should have come yourself. Now, all they know about American dance is what they saw these legs do last Saturday. And if anyone has seen me dance, you know it's time to send an immediate envoy of American goodwill dancers to repair the damage.

But it was great fun. After the 80s love songs stopped, it was time for traditional African music. Not so exotic or what I expected, but fun nonetheless. I had a great night with a beer and a half.

Something culturally interesting--dudes dance with dudes. And hold hands while doing so. Kinda freaked out in the inner homophobe in me, not gunna lie. But it was cool with them. I couldn't do any hand holding, but I was rockin it with Ogendo, Machage and the gang just the same.

The guidebook I have said Tanzania is mostly populated with indiginous spirituality, not much Christianity or Islam. But everyone I have met in town has said there are tons of Catholics, Protestants and Muslims--most Tanzanians are one of those. Masahi, the guy I'm staying with, and many of the doctors are Catholic, surprising to me.

Love her or hate her, the Catholic Church is everywhere. Throughout my travels, I've gone to mass on 4 different continents, now in 8 different languages. And it's the same mass--structure and words--no matter where you are. Perhaps boring, it's enabled me to feel more connected to the people and the church. It's existence in this way, even in Africa, makes me wonder if the church doesn't have something universal that resonates with more than just the conservative crowd in the states.

Anyway, I went to mass with Masahi on Sunday. Not going to lie, it was tough. Long--2 1/2 hours. The time alone would send many American Catholics back to bed, let's be honest. And it was double tough being that my Swahili is good for exactly nothing. But the music was amazing. They had a choir, mostly women--good voices, drums, some maracas, and a triangle. I would have recorded it it was so good. It reminded me more of Baptist revival than a Catholic mass. The choir was clapping and dancing, and they would dance in sequence together up to communion. Much more life and spirit than your average American service. And it was quite a presentation. 8 altar boys, they entered with incense smoking and holy water flying. More dramatic a mass than I'm used to. Again, although long, it was a good experience. It was a cool experience to go with my friend, Masahi, to connect like that--we've said blessings before meals together since. I look forward to grilling him on the controversial stuff, interested to know some African perspective on things.

This morning, I showed up and Machage, the medical director, had an all day meeting, so he asked me to round on the pediatric ward alone and then just ask him if I had any questions. I still haven't seen him; it was a rough day.

The first kid I saw: 14 month male, came in last night with fevers, weakness and decreased PO intake. Admitting diagnosis was anemia from malaria, and antimalarials were started.

When I came to see him, he was having a seizure, and had been seizing all night. They had tried valium, which didn't work. When I examined him, his eyes were fixed, his arms and legs were tight, and his neck was stiff. This was not cerebral malaria, it was meningitis. Like normal, I freaked out. I ordered to give him more valium (this time, per rectum), add meningitic doses of 2 antibiotics, and get a lumbar puncture.

Nice for my first case. Meningitis, only a severely life-threatening disease. Of course, I guess when you are daily dealing with kids who could be dying of malaria, a pediatric patient possibly dying of meningitis is part for the course.

That was the first seizing kid of the day. The second, near the end of rounds 4 hours later, when I was overwhelmed and exhausted, was a "oh by the way" would you look at this kid admitted with malaria who appears to be seizing. This one I think was due to cerebral malaria, not meningitis. So I ordered IV dextrose, valium and antimalarials.

Where's my simple diarrhea or colds? At home, not in the hospital.

I've mentioned before that if a kid presents sick and needs to come in, they practically admit all of them with a diagnosis of malaria. This makes me crazy, although I now know that while some/most but not all of them actually have the diagnosis, you have to treat them for it first. Well, that logic extends to cough.

Fever or vomiting/diarrhea or weakness = malaria and admit.
Cough or respiratory distress or chest pain = pneumonia, and add penicillin.
Diarrhea/Vomiting = intestinal parasite, add flagyl.

It's all clinical, based on history. Maybe half of the time, we get labs for malaria. It's nice to have a lab that confirms plasmodium seen on the blood smear, eases my neurotic mind to know I can narrow the differential. Even nicer to have a PCV to help assess anemia. I had 0 (ie none) PCVs this morning to assess anemia. So I was transfusing blood based on clinical exam (mucous membranes/palms pale, pt tachy with hyperdynamic precordium).

Needless to say, that was a first. I ordered several blood transfusions this morning.

So anyways, half of the kids have a cough and are therefore given the diagnosis of "pneumonia" and treated with IV antibiotics, for what I'm sure is a viral upper respiratory infection. What kills me is that they dont do chest xrays for pneumonia. It's purely a clinical diagnosis. I wanted chest xrays (and even a CBC if greedy) to help me prove this little wave of pneumonia was crap and just a virus. Repeatedly, I said to myself, "This is not good medicine."

And from a resource-rich standpoint, it's not. There are overdiagnoses and overtreatments. But that's the reality where you don't have the money to do xrays on all kids with pneumonia. Or where you can't do a PCV because THE LAB RAN OUT OF THE TUBES (this happened this weekend, we still don't have them).

And I'm uncomfortable with the whole thing. I'm worried we're going to miss something and lose a kid. That scares me. I'm used to having a tighter more established diagnosis to treat. Now, I just have to follow the kids day to day to ensure they're getting better, and if not, add some other meds, I guess.

Other situations I was not comfortable with. There were several malnourished kids. We're not talking decreasing on the growth curve. These guys fell way off the growth curve. Typical starving African child stuff that you see with Sally Struthers. One kid weighed 4.5 kg, and was supposedly 16 months old. Many babies are born at that weight. She had a big belly, skin ulcers, thin hair, had swollen face and legs because of the fluid we gave her. Yikes.

What were we doing for her? Education and then send her out. The hospital does buy food for these guys, so they just send them home and if things don't get better, the mom comes back.

I'm not comfortable with this whole situation. All I can think of is kids dying at home after going to the hospital. I'm sure with time and further discussion with the docs here, I will broaden my perspective about this whole thing. But as for now, you can see why today--seizures, meningitis, cerebral malaria, pneumo/malaria and several malnourished kwoshiorkor kids--makes me a little tired, overwhelmed and uncomfortable doing it on my own.

Friday, July 18, 2008

My FIRST C-Section (Day 3)

My first C-Section

I’m still shaking…my first C-section really as the primary surgeon.

And here’s how it went.

(WARNING: The author has chosen the use of strong language to convey the intense emotions of the story. Consider yerself warned, pilgrim. ;)

It was a packed Wednesday. The orthopedic surgeon from the regional hospital was in town and he had crammed 12 surgeries for our 1 OR. My day began before all the ortho cases, however, with an early morning C-section. They called me from home. Everything went fine, I assisted, no big deal. I told the surgeon I wanted to do the next one, and he said ok.

After the day of ortho surgeries, the day was ending around 5pm, and I went with the on call doctor to evaluate another pregnant woman in labor for possible C-section. We decided to give her a trial of labor and then if it didn’t work, we would go to surgery. We gave her 2 hours. And let’s not forget—if she needed the section, I was the surgeon…

I was kinda excited at the possibility. Finally, MY turn to be in charge and do the section, making all the incisions, pulling out the kid and sewing the mom up. We do this to some extent in residency, but we’re very well guided and told what to do, where to cut—it’s hardly all me. At this point, I thought that’s what I wanted. I was ready.

I seem to do this to myself a lot—intentionally get in over my head so that I have no other choice but to really see what I’ve got, survive and learn. Throwing myself in countries where I don’t speak the language, running a half marathon without training—for better or worse, these kind of things.

With the possibility of me doing my first section, I went home and took a nap. I was riding some weird high of being in my international dreamland here plus jet-lagged with a bus overdose. I passed out.

I de-hazed about a hour and half later, and had little desire to go in. But I had told the doc I’d go back, and I wanted my word to be good, so a little drudgingly, I returned to the hospital.

When I got there, it was on. The patient had not progressed at all in 2 hours despite adequate contractions, and she was already in the OR. IT WAS ON! He told me to change and get in there.

As I went to the men’s changing room, a little smirk snuck out on my face. It was time, here we go, I’m a surgeon. I could have been humming “I’m a little surgeon” to the tune of “I’m a little teapot” really. I was excited.

After I changed, I got a little nervous. Was the on call attending going to be there scrubbed in with me, or did he think I would do it alone? They really don’t know what a third year resident is, and what I should and shouldn’t be able to do. Some thought I was a veteran OBGYN coming to give a lecture on obstetrical emergencies, while others thought I was a medical student. I hoped this guy wasn’t erring on the side of giving me too much credit. My desire to do it all by myself was…uhm…reconsidering its relationship with reality.

I scrubbed in and one of my numerous prayers of the hour was answered—he was going to be across the operating table with me. Dr Ogendo—the same one I challenged initially with the pneumothorax diagnosis, and the one I had bonded with about international affairs and Barak O’Bama—would be in the OR with me. Thank you Lord.

Since I really haven’t been the boss, my OR personality is weak. WEAK SAUCE. I should have rolled in and been like, “Shall we begin everyone?” and just gotten started. Instead, I kinda stood there by the table, and they had to prompt me with exactly how to sterilize the skin, put on the drapes, etc. The whole language barrier didn’t help. Their doubts in me, along with my doubts in myself, were growing.

A little bit about the patient, which I neglected to mention before because I TOO DIDN’T THINK ABOUT IT BEFORE GETTING IN THE OR!!! She was a tough case. A thin 25 year old female G2P1 with prior C-Section for dystocia/failure to progress, it was thought she had an inadequate pelvis and had little chance of having a vaginal delivery in the first place. A couple other kickers: she had severe scoliosis—a curved or crooked back—so much so that they couldn’t do spinal anesthesia and had to do general. Also, she had some chest wall deformity from previous trauma complicated by lung abscess.

Wonderful first case. Straightforeward and all. Remember, I asked for this.

Dr Ogendo asked me if I wanted to assist him instead of doing it myself. Not thinking enough about the patients medical history, I insisted I could handle it, and he said ok.

We prepped and draped—which I kind of faked my was through—and were ready to begin.

With the knife, I opened with a lower transverse incision both above and below her previous section scar, excising it. As I later found out, they were impressed with my speed and skill initially. That’s nice. I hope they were impressed with the pool of sweat collecting at my feet cuz SHIT WAS I NERVOUS. But things were going ok. Hey, I’m doing this.

Then we got down to the rectus, her abdominal muscles. They were a mess. Her prior C section had left her severely scarred, and she was so skinny that I wasn’t sure I hadn’t already transected it just going down through the subcutaneous tissue.

This is where things started to go bad. I was lost. I couldn’t see the difference between the fascia above the rectus, which you are supposed to cut, and the rectus itself. It looked like a bunch of yarn all mixed together. If I cut through this woman’s abdominal muscles, she’ll never be able to do a sit up again. I still had the knife, and after dabbing off what seemed to be more than usual bleeding (although probably was my nerves), I was making little small incisions around looking for the rectus fascia.

I started to panic. The pool of sweat was flowing like a waterfall, from my head and pits down my front and back. What is this? I don’t sweat. I don’t get nervous. I’m always cool, calm and collected.

Well, not in Africa doing my first C-section as the primary surgeon.

Ogendo grabbed the knife from me and got through the fascia to the rectus, which was a scarred mess itself. We could barely make out the midline to cut and separate, but we did. Somehow, we had gotten inside.

I wanted to make a bladder flap, where we dissect off a small layer of tissue and separate the bladder from the uterus, to avoid accidentally nicking the bladder during the surgery (that would be bad). But they don’t do bladder flaps here. I didn’t like this—the scarring continued on the uterus as well, and I would have felt better having a flap. Because I was a little paranoid about the bladder and was still quivering nervous, I made a high incision in the uterus. Instead of taking a couple thin slices and then hitting the amniotic sac, when you go to high you cut into the thicker muscle layer of the uterus. It took several cuts to get in. I was afraid of going in too far because I didn’t want to cut the kid’s head inside, but I was looking like an idiot that couldn’t do a section. I was a head case. Things were not going well in that little primary surgeon brain of mine.

I finally got in, smiled up the uterus by opening the incision with my hands, and I went in to get the kid. Now the good thing is that the baby was not in distress. This was not an emergency C-section done because the baby was suffering. But the bad thing was that mom had been in labor several hours and the head was jammed down in the pelvis. These little ones are hard to remove. I dove my hand in, and as I did, the kid’s arm flailed outside the Cesarean incision. I was able to lift the head, but was worried I was going to crush or break the arm. So I backed off.

The baby was stuck. I couldn’t get her out. Just what was I going to do? The mom’s bleeding, the baby was going from fine to distressed, and the pool of sweat now left everyone in the room wading in my nervousness. I was panicking again.

Turns out, there is a god. And God sent Ogendo to me that day. He reached in and grabbed the kid out, nothing less than saving the day. Ok, ok, it wasn’t that easy, he struggled, I thought he broke the girl’s arm, but she came out, thank God.

Or so I thought. She came out blue. FUCK! I’m ruining this woman’s uterus and abdominal muscles, and now because I was a pussy futzing around with delivering the kid, the little girl’s going to die. Panic again. I was freaking out. In case you didn’t know, yes, African babies do turn blue, too. She wasn’t crying or moving either. FUCK ME!

Alright Lorenz, get a hold of yourself! Ogendo grabbed me to return to the BLEEDING UTERUS—HELLOOOOO—that I had forgotten about while I was watching the not alive yet baby in carried off by the nurses in slow motion. You’ve still got a job to do, pal. Finish. I returned my attention to the bleeding uterus, and tried to get oriented. It was still a bloody scarred mess. I tried to externalize it, but it got stuck. GREAT! So we just started suturing it back together inside the abdomen, which isn’t uncommon.

Things started to get better.

Alright, I know how to do this. I’ve done it at home a hundred times. More like 40 to be exact. Thank god for the training I’ve had. I felt quite comfortable suturing up the uterus—and did a fine job, despite dropping the pickups 20 times because I was in shock/PTSD. Really, my hands were so shakey. At any rate, bleeding was controlled. They still do a two layer closure of the uterus, using only one suture for both down and back. Impressive. Mine made it across once. Not impressive. I needed another one, and in this resource-scarce part of the world, I broke the needle, wasting the suture. Nice, Lorenz!

As we closed, things continued to go more smoothly. Then the nurses shouted out, “Apgars at 1 minute—2, at 5 minutes—10.” Thank you Jesus. The Apgar is a measure of how well the baby is doing. Out of 10 (although by convention, we give a max of 9 in the US), it’s not uncommon to have a score of 7 at 1 minute after delivery. But a 2 sucks and means the baby isn’t doing well. The 10 at 5 minutes began to put me as ease—everything was going to be allright.

I survived. More importantly, so did the baby and the mom. Because things do go wrong, sometimes it’s hard to trust that everything will be allright. A little more faith—in god, life, Ogendo, my training—wouldn’t have been a bad thing. Surviving myself, I grew a little in faith in me.

As we were closing, the anesthesiologist was complimenting me on the surgery. Said he was impressed with my speed and skill, and had demonstrated clear experience and expertise. I said thank you (asante), and told him he was kind. I’m not so sure about the expertise part. Afterwards, Ogendo and I talked about the surgery. He said it was a tough case and that’s why he suggested I assist him. I apologized. I’m still a little punk American doctor with much to learn.

I thanked him, again, saying I’d see him tomorrow. I reminded him to call me for any emergency surgeries or C-sections—not sure what I was thinking, as I type this. On my way out, I went by the newborn nursery and checked in on my little miracle. That was a new experience—feeling attending level responsibility for another life. She was sleeping peacefully. Sorry, sweetheart, but it’s time for your newborn exam so Dr B can sleep tonight. Heart and lungs, normal. Arm reflexes—equal on both sides, no apparent birth injury. See you tomorrow, little one.

The last thing Ogendo said to me on the way out was that I did a great job, and that on the next uncomplicated C-section, I could do it by myself.

I told him, “Sure,” as I have apparently learned nothing. “As long as you’re in the room nearby, rafiki.”

Shop Talk: Days 1-2 in the hospital

Shop Talk

My first two days in the hospital were good ones, eventful to say the least.

My first clinical experience turned out to be my first major foot in the mouth cultural mistake. Bonehead Lorenz in Africa.

After a short tour Monday morning, there were “special rounds,” equivalent to Grand Rounds where we talk about tough cases from the weekend. Beginning in the male ward, we reviewed the chest x-ray of a 20 something male with a knife wound to the left side. (There goes my “No violence Tanzania” idea). The Tanzanian attending said the xray looked, fine. With 2 US medical students, I decided to take another look and explain how you evaluate a chest xray for pneumothorax (air in the chest cavity), hemothorax (blood), etc. First of all, it was not easy. It’s not like we had PACS or a computer system, where I could zoom in and scrutinize for lung markings or a line. Hell, we didn’t have an xray light to put it on. It was me holding up a crappy xray against weak light from a window. My xray skills are average at best to begin with. In this situation, I was feeling like they were a smidge above dirt poor. But I did my best anyway.

As I was explaining things to them, I realized this guy had a monster pneumo—at least 50%, more like 60-70. The left lung was completely collapsed. I freaked out. The patient was stable (vitals stable, not short of breath) and there was no tracheal deviation to suggest tension pneumothorax, a life threatening emergency that would require putting a needle or chest tube in ASAP, so that was good. But the attending…seemed to have overlooked a pretty significant finding on the xray.

The problem came in the way that I handled this situation. I think it looked like I was a little punk American doctor challenging the experienced (50 year old) Tanzanian physician. I should have said, “What do you think about this, this and this. How would you manage that?” Instead, I declared, “This guy clearly has a major pneumothorax,” implying it was missed, and went on to explain my point. There was some lack of eye contact and then avoidance of the situation. We agreed to repeat the chest xray, (which was unnecessary) and moved on to the female ward.

On the one hand, I was feeling pretty good about myself. I knew what to look for on the xray, I read it correctly and applied it to the clinical situation. Solid work.

On the other hand, have I learned nothing about respecting my teachers, making first impressions and being a gracious international guest? Sheesh. I felt really bad. So I shortly thereafter genuinely tried to give him an opportunity to teach me about this situation with regard to chest tubes. Basically, they put them in for tension pnuemo, and not otherwise. In the US, if the lung is only partially collapsed (<15%) style=""> Anything more gets a needle or tube in the chest. I appreciate their perspective, and now want to review the literature to see if there really is any big difference or not.

As for my attending, he cared much less that I about my little insurgence. Things were nzuri (fine). As I’ll later discuss, he’s become an even better teacher and friend since.

After special rounds, we rounded on the pediatric ward with a different attending, Dr Machuggi, the medical director of the hospital. It’s malaria season, and the peds ward was full with 30 kids. And 90% of them had the same diagnosis: severe anemia secondary to malaria. In Tanzania, malaria is the #1 killer (according to their govt; AIDS claiming 30% of deaths was from WHO), especially of young children. Not gunna lie, it got boring rounding on them. What’s this little guy got? Well, he came it with fevers, vomiting and diarrhea; had a very low blood count (they use PCV: Plasma Cell Volume, 40 is normal, <15 style=""> They got quinine, the treatment for severe malaria, and a transfusion if necessary, and improve in a couple days.

I was initially intimidated by malaria because I’d never seen it before. Would I know how to diagnose it based on a microbiology class I’d taken 4 years ago? Sorry Professor Parmele, but doubtful. But it’s like the flu in Africa. If it’s malaria season and a kid comes in sick, check their blood. Done. I was working in the ER later that day and diagnosed my first malaria case—it was a no brainer. Little guy came in, looked sick, listeless, pale. Had a fever and vomiting for 1 day. Bam, malaria. It can hit them in a day or two, and if they get really anemic, they can die, and fast. Some blood and anti-malarials, and he started to improve.

That’s what makes third world medicine so intoxicating—you can save lives and really help people. That’s the dream, I think, of all of us that went into medicine. That’s real satisfaction.

In the US, the opportunity to do that—dramatically help people or save lives—is less. There are some. But most of what I train in is chronic disease management—of problems that probably wont be cured, like diabetes or high blood pressure—and prevention. Still noble and satisfying, but COME ON. Really comparable?

I chose family medicine largely for the relationships—I wanted to be somebody’s doctor. And whatever their problem was—their weight, their back pain, their anxiety, whatever—I wanted to be the one that they could come to throughout their life to do something about it. I stick with this value in the doctor patient relationship still today. But the satisfaction that comes from saving lives is often with the specialties that are largely void of long term relationships. Surgery for example. The gallbladder gets sick, you go to the surgeon to cut it out. You are saved, you never see them again. Cure, but short relationship.

After long peds rounds, I decided to hang out in the ER with a medical officer, akin to a physicians assistant. They do much of the triage and admitting to the hospital, and function as ER docs. It was great. I’ve been writing down all of the cases I’ve had—I’ve seen over 50 patients in 2 days, including scrubbing in on 3 surgeries. In the ER, there was supposedly an “infertile” woman who hadn’t conceived in 3 ½ years of trying. They were beginning to do a whole workup on her, including ultrasound, hysterosalpingogram (I was impressed they had this), and I said, “Where’s her husband? Has he ever fathered a child? Have we tested him yet?” At this point in the workup, in the US we’d start with a sperm count before the battery of tests on the woman. In Tanzania, I think my suggestion was a little progressive and almost culturally inappropriate. The assumption being that if there’s a problem with conception, it’s her until proven otherwise. Not sure if chauvinism is the right word, but we talked about getting him tested, when to test her and how to maximize baby making during her cycle.

More to write, but I’m tired and must go to bed.


--the little rascal that stole a book from me on the street and made me chase him home.

--the genius orthopedic surgeon, a professor, visiting for 3 days doing surgery.

--cases of tumors, masses, TB (another no brainer diagnosis), and several things I still don’t know what to do with (5 year old girl with right sided hemiparesis and apahsia).

--my host and the sweet meal he made for me, with a juice shake recipe I’ll be bringing home

--the hospital outreach motorcycles I walk by everyday coming and going, and how I’ll be getting the keys tomorrow for 2 weeks!!!

Rafiki and Safari

(the "type at home, email at the office" plan is nothing short of genius. here is the first of 3 that i haven't been able to post until today, friday. it's been an amazing trip, crazy every day!)

thanks for the posts--i look forward to them every time i get an internet chance.
melanie. there should be plenty of words for you to burn coco county tax dollars with on fri/mon in the office.
cath. wish i would have read your last post--cant believe they live in arusha. will keep that in mind in case i go the wrong way heading back.
roy. because the internet is SO slow, i doubt i'll be able to get any pics, but i'll try in the next couple days.
joseph. congrats on the anniversary, exciting. dont ever read my blog in your boxers, again.
JT. happy 6 month to the young stallion, joshua lawrence! what's he eating these days?
angela. asante for the key phrases. i should memorize the "i'm lost" one.

Rafiki and Safari

Could anybody do this? Travel in the third world, I mean. When experiencing the lack of luxuries and abundance of inefficiencies and inconveniences, I think of my sister, or some girls I’ve dated, or my roommates, and I wonder if they could survive. Cold showers, bland food, long bus rides on rocky dirt roads. Sometimes I think, “Allie could do this.” And other times…well. Not so much. Sorry sister. You know I love you.

My 2 day bus ride from Nairobi to Shirati makes a convincing argument that unfortunately, third world travel is not for everyone.

To be blunt, the bus rides sucked. It took 27 hours on 3 buses and 3 taxis, and if I would have gone the way they told me to go in the email, I would have arrived Friday night. Instead, I went the opposite direction, and then took a major detour. Ouch. Salt in a wound? Try dunking your finger in hydrochloric acid. Ok, awright, it wasn’t that bad. But instead of going from San Fran to LA, I went from San Fran to Tahoe to Phoenix to Tijuana then LA.

And then there were the actual bus rides. (No, I’m not done complaining). Packed. Hot. No A/C, but plenty of B.O. On one, I sat in something wet. THE WHOLE TIME—it was my assigned seat, and I wasn’t going to wait who knows how many hours for the next bus. That was my seat in the back of the bus, which, as you know from minivan physics, when the bus hits a bump, you fly. Once, I get vertical (seat to butt distance) 2 feet, hit the seat, and bounced up for another 6 inches.

I BOUNCED, PEOPLE—IT KNOCKED THE WIND OUT OF ME! Definitely needed more junk in that trunk for that ride.

Again, if my little theme above wasn’t clear, the bus trip sucked.

But it’s the happiest I’ve been in a long time. I was on vacation—if I’m a day or two late, would anybody really care? No. Not worth getting upset about. I was on a new continent, talking with people in a new language, off to do some good in a hospital. I even thought, I might die on this bus (third world bus driving = death ride), and that would be ok. No regrets. I’m ready, right where I should be.

Tanzanians rule, and I owe much of the awesome experience of the horrible bus ride to them. The first was Jeremiah, a 35 year old guy who made the 12 hour ride to sell t-shirts. He had a wife. That info—took me about 4 hours to get out of him. Again, 3 ½ hours of audio Swahili in the Civic didn’t exactly go so far in the bush. Fate placed him in the window seat next to me, no doubt to teach me how to treat a stranger. On one of the first stops, we went to the bathroom, and he chipped in the dime for me without even asking. I almost cried. This peasant African graciously paid for a stranger. I immediately tried to pay him back, he refused. He was taking care of me. Very impressive. Later, at lunch, I gave him money to get us both food. He came back with the food, and handed me back my money. He bought me lunch, too. In Swahili, Rafiki means friend. Jeremiah was my first, but I had a feeling not my last. He got off just before I did. I was sad to see him go.

This experience of friendship with him, where he really looked out for me a foreigner, was reason to reflect. Genuine goodwill. The man had the spirit. He wasn’t religious or political. He didn’t have a mission statement. But he had some of the real thing, the deep inside stuff. That I believe in, and connect with. I’m thankful to the universe, that on a shitty bus ride, I was given this lesson from a Rafiki.

Numerous others—Gilbert the cabbie, my other bus rafiki—were quite hospitable. They all had this value of taking care of me—when I needed something, they would walk me to the hotel, find me the right bus, or leave me in the care of someone who could.

Makes me think about how busy I am at home and how stupid that is. More on this later. Slowing life down, which necessarily happens here.

Another one of my favorite things: the random conversations. My M.O. for learning languages has been to start random conversations as much as possible. Most people are happy to humor you, and even enjoy teaching. Tanzanians are no different. Here’s what my first conversations went:

ME: Jambo (“hello,” which I always say with a goofy, and I hope charming, smile).

THEM: SiJambo (“hello back”, usually laughing at me and my feeble attempt).

ME: Habari gani. (“how are you”)

THEM: Nzuri. (“fine”, with more laughter, since a monkey can ask these questions)

ME: Unasema wapi? (“where are you from,” as I press on with the basics).

THEM: Nasema…

Then I just open the English –Swahili conversation books and pick out random questions. Once I asked somebody how old he was, but it wasn’t until after he answered that I realized I hadn’t even glanced at the numbers yet, so I had no clue what he was saying. That was brilliant. Or what they do for work, if they are married, have kids, etc. By then, I usually understand nothing of what they are saying, and we both get frustrated. Sometimes, I’ll turn to writing, and ask them to write down what they are saying, and then I can look it up. That will get another couple questions out of them, and then even their well of goodwill dries up.

But I really want to know these guys. I want to know what they think about Tanzania, what’s important to them, what they think about AIDS, the UN and the US in Iraq, if they’ve heard of Just Friends or Kate Hudson, and if they think I should grow my hair long again. And the language is this bridge. With Spanish, I’ve found it’s really a key that unlocks a whole new world, an entire experience that cannot be had by the simple tourist. Making friends, understanding from their mouth—not a book or TV documentary—what it’s like to live in one of the poorest countries in the world. Communication, language is key, and I’m passionate about it.

In this process, I’ve realized some basics about human communication. A smile and a genuine desire to learn another’s language can get you quite far. That much of communication is nonverbal—I agree with. In that sense, there are some international languages. Eye contact, smiling.

Other quickies:

Transportation is a commodity in Tanzania. Buses are always full, and not cheap. And roads…developing to say the least. Half are still dirt.

Is “development” really a good thing? Would it be better to live simpler and shorter lives? Should we really be trying to develop Africa? Big discussion here, later.

There seems to be little concern of violence, theft. Very interesting. No guns. Although I’m sure they worked me on the price of some of these bus rides and cab fares. The guy that sells the bus ticket is equivalent to the car salesman in the US. Very crafty, they are.