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.


Anonymous said...


That was quite a post. Everything from chasing lions on a motorcycle (not a good idea, btw, they hunt in prides), to needing to send over a dance envoy to counteract your performance (don't think that's really necessary - you should see my French friend Christophe and his sister Marie Pierre dance - now that embarassed even me!), to the limitations of medicine and grim realities of life for children in Africa.

Just remember you're doing the best that you can with what you have, and although it may not always be perfect, it's more than they would have had without you. Hang in there. You're doing good works.

Aunt Cath

Tom said...

Alright, I just read four in a row and am on some sort of Tanzanian Lawrence high. Amazing stuff man, you really brought it to life. I look forward to standing across the table from you some day.
I figure I'll give you some news from the home-front, a.k.a. you talk about yourself the whole time and now it's my turn. I went from OB to medicine today and all the lovely first years were capped at four. Alright, eight is cool, 3 downstairs and two family meetings for transition to comfort care ..... you get the idea. Man, what I would give for a different set of problems. Enjoy it man, this stuff aint going nowhere (until July '09). We put an offer on a house today, should know by friday. I should have known this Africa thing was all about getting out of helping me move. We miss you a lot man and think about you every day.
Be Well,

jack said...

wassap muzungu, i'm glad to hear you are doing well there (and you are doing well, however your day-to-day feelings might be). no, i have no idea what NLP is. i googled it and got back a bunch of acronyms and didn't know which one it was. i also thought i'd give you some general news from the home front: obama is on a whirl-wind tour of europe and the middle east; the stock market still sucks; hurricane dolly hit texas; the salmonella outbreak seems to be not from tomatoes but from jalapeƱo peppers. so basically, you're not missing much (except for your friends). ok, buddy, look forward to your posts, stay safe.

Mika said...

Hey Lolo - quite an emersion exercise you're getting - this is really where it comes down to whether or not you can handle working/living/helping in resource poor settings.
The mystery liquid in the B.O.-perfumed bus without shock absorbers is small starch compared to how hard it is to accept that you do what you can with what you have.
You're doing good - enjoy the hot beer buzzes, the humbling experience of what it means to really be the primary on sections, and making rafiki left and right. You've probably learned more about yourself in the last 2 weeks then you had in the last 2 years.
Asante for sharing.

barryllium said...

Most important question ever - did you break out "the move" on the dance floor?