Rounds...

For those who might be interested in the patients we’ve been rounding on the past couple of days, I wrote about them here. It might be kind of long, and I apologize if it doesn't all make sense. I wouldn't be hurt if you don't read it :) …

- Elderly woman (after about 50, they don’t keep track of their age anymore – they tend to relate their age to whether they were alive when certain events happened and if you know in what year the event happened, you can get a rough idea of the patient’s age – I’m not sure this patients exact age is that important however…) with aplastic anemia. Initial HCT was 14%, WBC 250. She was given a transfusion, which increased her HCT to 22%, but her WBC is now 150. We’re not sure what is causing it. Before she came to the hospital, she had been given MANY different medications from outside clinics for treatment of her fever. We’ve removed almost all the medications in hopes that one of them caused the aplastic anemia, put her in isolation (not the isolation I’m used to, but in a room by herself at least; the nurses were instructed that no one was to go into her room without a mask on, however on rounds this morning, there were no masks out, no sign to say that there should be masks worn and three people inside her room without masks on), and we also added antibiotics to hopefully protect her from acquiring an infection. I read that 65% of cases of aplastic anemia are idiopathic (no known cause) and that many of these patients don't recover. We hope that it is one of the medicines she was taking that caused it... 

- 6 month old boy with meningitis. He presented with a bulging fontanelle (I hadn’t ever seen this before, but it was unmistakable – it looked like he had a big ‘goose-egg’ on his head). He had a very stiff neck, fever, and looked SICK. We put him in ‘isolation’ as well and started him on ceftriaxone. Today on rounds, his fontanelle is looking a little less bulging and he seemed to be much more comfortable.

- 6 yo male with broken femur after motorcycle accident and is now in traction (hopefully we'll be able to post this picture). I feel so bad for this little one. He is so sweet, but will need to be in traction for 6 weeks. I’m sure that will seem like an eternity for his parents. Otherwise he’s doing well. His right eye was swollen shut and has some other injuries, but they are healing well...

- 3 yo twin boys – both were admitted for malnutrition and have been here for about 2 months. They have a little sister who is about 6 months who weighed the same as these boys did when they were first admitted. They have been getting an enriched formula. One of the boys is actually at a weight where he is considered to be done with treatment and the other is still trying to gain weight. They are very cute. I learned about different kinds of malnutrition in the first couple years of med school (marasmus vs kwashiorkor etc), but it’s interesting to see the social setting in which this occurred. While the twins were being breast-fed, their mother got a new boyfriend. I have been told that she would have felt pressure to have another baby to provide children for her new boyfriend so that he would stay with her (again, this is only what I’ve been told – I cannot verify that these details are accurate, however this is a common occurrence and what happened to the twins is all too common). So, she either stopped breastfeeding the twins to get pregnant or she stopped after getting pregnant, or for whatever reason stopped breastfeeding them. So, the twins went from getting relatively nutritious breast milk to eating Kwanga. Kwanga is the staple food that is made from a plant here that ends up looking like glue and having essentially zero nutritional value. So, in order to supply for the new baby (both breast milk and otherwise), the twins get not so wholesome Kwanga as their food and don’t grow! It’s wonderful to see them growing when they’re given the fortified formula here. Unfortunately, this is a common reason why many children die here. 

- 19 month female with pneumonia. We don’t have a chest xray (we’re hoping they will be able to go to the government hospital to get one), but she has fever and her lung exam seems consistent with pneumonia. She has been treated for several days now with no significant improvement. On rounds today, it was noted that she had oral thrush. This raises the concern that she may have HIV/AIDS and may explain why she is not responding to treatment. We ordered an HIV test to explore this possibility, but her father refused it. When this happens, they usually treat them as if the test result was positive for fear of opportunistic infections...

- We saw another little one with malnutrition. He was gobbling up his formula. Dr. Joe said that it’s hard to get them to drink it at first, but if you get them to drink it for a week, they will love it after that. He also said that if the parents feed them something else along with the formula (like Kwanga – some parents don’t think the formula is what their child needs so they keep giving them Kwanga), they will never like the formula. Last week, a boy (I think he was 7) who was being treated for malnutrition actually ran away. His parents were feeding him Kwanga along with the formula and I guess he hated the formula and so took off (his dad remained at the hospital ???? – I don’t get it either). Anyways, I guess the boy was in pretty rough shape and likely won’t make it long without proper nutrition which he likely won’t get...

- We saw 3 women recovering from typhoid fever. They’re all doing pretty well right now. This is pretty common here.

- 17 yo female with severe anemia (HCT 15%). She has sickle cell trait we think (we're not totally sure) as well as malaria which I guess is not a good combination and is presumably responsible for her anemia (although I was taught that sickle cell trait is protective against malaria - I guess it protects the host from death or severe complications, but not from the disease itself. I'm not sure if anemia like this is a common complication of the two or not - I have to read about that some more yet). She’s very symptomatic so we’re trying to find some blood to transfuse her...

- Our patient who had the ectopic pregnancy is doing well. We were concerned about an infection post-op. She had some palpable RLQ subcutaneous emphysema (crepitus). We were concerned for an anaerobic infection, and we started antibiotics. She was febrile at first but otherwise was asymptomatic. She has continued to improve and yesterday, the crepitus was less and she was afebrile and is virtually without pain. So, I’m not sure what it is. It's not really by her incision. I know this can happen after laparoscopy. Anyone have any thoughts? 

- 39 yo female with very advanced cervical cancer (sorry I don’t remember what the different stages of cervical cancer are). They were going to resect the tumor, but on the day of surgery was having urinary retention, and saw on ultrasound that the tumor had grown into her bladder and her rectum, so did not do surgery. She is waiting as her family tries to raise money to get her to Brazzaville (the capital of Congo) for radiation/chemotherapy, but unfortunately this may not happen. Even while in the hospital, she has been caring for some of her own young children as well as grandchildren...

- Although I have not been involved with treatment (Candice is), there is a lady with about 50% body surface area burns who has been here for a couple of months already. Her skirt caught on fire and so her legs are severely burned. She really needs a skin graft done which Dr. Fuka will do, but I guess she won’t have it done because her husband doesn’t want it done. I’m not sure the exact reasoning, but we’re not sure where to go from here as her wounds are not healing well.

- I assisted Dr. Fuka with a hernia repair 2 days ago. The gentleman had a very large hernia that was making it difficult for him to walk (that is usually when they present – it’s not the abnormal mass that brings them in, but when it starts limiting their ability to do things). He is doing very well. He’s up walking around and eating, so hopefully he’ll be able to go home soon.

- There is a man here who is a hunter who somehow was shot with a birdshot (? I’m definitely not a hunter, so I don’t know exactly what kind of gun it was), but ended up having 48 little bullet holes in him. He went to a local clinic where they took out seven of the BBs, but did nothing else. He presented here 2 days after it happened with an acute abdomen. They took him to surgery and found 19 holes in his small bowel. Fortunately, his colon was not hit and Dr. Fuka was able to oversew the 19 holes. He has been doing great post-op except he has a growing pseudoaneurysm (or aneurysm? - I don't really know) in his right upper thigh at the level of his femoral artery (with a very impressive palpable thrill) where there are MANY bullet holes. He probably needs some kind of vascular repair, but Dr. Fuka does not have that specific training. He said he was reading up on it, but I don’t know if this is something he would try doing or not.

- There’s also a lady in labor right now!

- I also wanted to mention an experience I had last week taking a patient home. He is basically in a coma from renal failure and the family was taking him home to die there. We loaded him onto an army-style cot and put him in the back of the pick-up truck they have and with his 8 family members who were here, we drove him to their house. Their house was a mud house (truly mud), and we ended up putting him on the ground that was almost as hard as cement. It really is hard to describe the scene without pictures (which I don’t have) and I’ve never been the best at being descriptive, but hopefully I’ll be able to upload some pictures of houses such as this one.

So, these are some of the patients I’ve been rounding on. If anyone has any thoughts or insight to share on possible better treatment, feel free to share! I wanted to make sure I posted this so I would remember these patients if for nothing else, so sorry it's so long! If you read it all, thanks for reading! :)

Crocs at the Market!

Late Saturday morning Ginny, Suzy, and Jean-Pierre took Sean and me to the market. I have been to markets before in Jamaica, Honduras, Ukraine, Bahamas, but I saw something at this market that I would have never expected to see at a market anywhere!

Yes: Crocs were at the market... and no... for those of you who know me well and my obsession with Crocs the shoe brand.  REAL LIVE crocodiles were at the market for sale! And no, they are not for pets, they are to buy, kill, cut up, cook and EAT! The crocs were tied up and sitting on tables just waiting for "their turn" to either be bought, or be today's fresh meat right on the spot!  Poor things... I am told they can live for up to 6 months without food or water... YIKES... one of them we saw somehow got his hind legs untied and I swear I heard him say "that's it... I'm outta here!" as he crawled right off the table and onto the floor.... much to his dismay, a boy went after him, picked him up and put him right back on the table...I know I heard him say "well pinky we'll just have to make another plan..." as he was positioned next to his friends again. 

We had a hard time getting over the crocodiles... we're still talking about it... but there really were other things at the market... Salvation Army clothes, new clothes, little tiny journals (we bought 2... they were too cute to pass up), soap, toothbrushes, and my second favorite thing was the fabric!  OH my... all the patterns to make traditional Congolese clothing.... so lovely.  I wondered where the women got their beautiful matching skirts, tops and head wraps!  So, Sean and I have decided that we are going to get some cloth for matching outfits.  (that is the thing to do here)... or I guess I have decided... Sean is busy falling asleep next to me while reading up on some medical stuff. 

It was nice to have a day to be here without any obligations and to just experience and to be immersed in other individuals reality... crocodile for dinner anyone?

Candice's First Patients

I saw my first patients today...
1. Little boy (6 year old in Kindergarten) who is going home after school got struck by a motorcycle, lost conscience, received CPR (thank goodness it occurred right outside the hospital gates!), and then immediately came too.... he has a hematoma on his head... but they don't have CT scan here so there is not much we can tell from the internal damage other than look at his functional abilities... Dr. Joe said that sounds like an OT thing to me... (I was asking about he mood, and if his affect had changed much)

He was so sweet... I used an interpreter (Dr. Joe's daughter Olivia who is 17... she speaks Lingala... I am so impressed). We did some gross motor, fine motor, cognitive, and orientation stuff. I think he'll be just fine, the only major symptom I saw was being shy from the white girl...:) The plan was for him to go home today. He should be back next week... we'll see if there are any other problems that come up... hopefully not.... I pray that it was just a concussion and not a more severe TBI.

2. A woman (I don't know her age) was burned in December while lighting her lamp... the oil lamp unfortunately had some gas in it, and it exploded catching her skirt wrap on fire. Her entire right leg, groin, and buttocks are severely burned, her hands with minor burns.... I saw the wounds through her bandages. She truly needs a skin graft (auto) but the surgeon here says that her husband refuses for her to have it... I am really not sure why.  Thankfully her hands have totally healed... just with white scars... but she has full function.

The hospital staff have been encouraging her to sit up and walk around a little, but that doesn't happen to often because of the "pain." She was "dying in pain" when I first arrived because they had recently finished changing her bandages (wish I could have seen it!), but as soon as Olivia (my interpreter:) ) and I began talking to her she calmed down... just needs that little distraction.

We talked about sitting up for meals at least... so there is a distraction from the pain (I can't imagine... her entire buttocks... very painful) and the opportunity to bend those joints. She said every time she walks her wounds begin to bleed... I assured her that was normal and to expect it. The unfortunate thing is that they only change her dressings 3 times a week because the pain is so much... I don't know if they give her anything for pain control or not. I decided not to ask her to range her leg for me since it was our first time to meet... I don't want to be known as the torturous white girl! I will for sure be seeing her again. 

3. Question (in Michael Scott's voice for those office fans): Does anyone have suggestions for the following:
- 3 year old little boy with a broken femur 
- In over head traction (so he is laying on his back with his left leg straight up in the air suspended)
- There is not an orthopedic surgeon here... so they have to have his leg in traction to heal... no internal fixation
- It is going to be my job to teach his parents how to keep him happy and occupied... 
- any ideas on things to play?

- he will be in this position for 6 weeks (I know... I can't believe it either) 

Overall... it was good to get a feel for things... it is SO SO SO different here... it is difficult to get information and difficult to know what the best thing to do is since their culture is different, and I am still unfamiliar with it... So I smile a lot... I touch their hands... and try to remember to keep praying that God will use my facial expressions, my touch, and I will gradually find out how to touch their lives in a more specific way.

Fun Fact #3: It is hotter than HOT here... it is so hot that sometimes I don't think my body remembers what cold feels like. It is the "dry" season... but I don't know what that's about... just because there isn't any rain doesn't mean it's dry... there is plenty of moisture in the air... and plenty of sweat on my clothes!  So those of you with snow and freezing temps... send a cool breeze our way!  

Sean's First Patient

So Tuesday night... right after I finished writing the past few posts Dr. Joe came into our "blue house," saying... " I know I haven't oriented you yet... but there is a case that is too good to pass up..." So Sean and I got up and left the house with him... I'll copy Sean's comments about the patient below... although I will say what he won't tell you: he got the correct diagnosis and treatment very quickly without much information...  the experience was amazing... I couldn't be more proud of my husband!

My First Patient

I hadn't officially started yet, but Dr. Joe came by and said there was an interesting case to come evaluate. It was a 39 year old female who presented to an outside clinic complaining of "difficulty walking". It was obvious when she arrived at the hospital that her main complaint was abdominal pain (I'm sure this made it difficult for her to walk, but "difficulty walking" was not our main concern). She had been having this pain for about 26 hours when we saw her. We found out she was about a month pregnant and she was very anemic (HCT 15).

We determined she likely had a ruptured ectopic pregnancy (the fetus/tiny baby had implanted somewhere other than her uterus and had ruptured causing massive bleeding into her abdomen). Their only imaging modality at the hospital currently is ultrasound (they have x-ray, but it hasn't been working since July). The ultrasound machine was in the operating room so we took her there to confirm the diagnosis. We were unable to see the fetus in the uterus, but did see it in one of her fallopian tubes and could see that her abdomen was full of blood. 

We took her to surgery and Dr. Joe asked me if I had ever removed an ectopic pregnancy before. I said that I had assisted on a few laparoscopic cases (everything here is done open without laparoscopy). he then asked if I wanted to do the surgery saying that I will never learn how to do it by assisting. So I said sure!  With the help of Dr. Fuka (Congolese general surgeon) and with Dr. Joe as the "scrub nurse", I did the surgery from open to close. The whole surgery was done using Ketamine for anesthesia (they normally do spinal anesthesia for these cases, but her blood pressure was very low and they didn't want to risk dropping it further). We removed close to 3 liters of blood from her abdomen and removed the ectopic pregnancy. Candice was present and helped throughout the surgery as well and took some pictures (maybe we might be able to upload those at some point).

It was quite an initiating experience! I am not sure I've ever sweated so much (partly because of what I was doing and partly because it had to have been 90 degrees in the OR!). The patient is a very sweet woman and is doing well right now. I'll try to update on her condition later. I know this won't happen very often... but an interesting first experience to start things off here! 

Singing!

February 3, 2009

Thanks so much for the emails from some of you! It is so nice to get them!

We are good... still experiencing some jet-lag... they say it takes one day to every hour... so I guess that means it will take us about 6-8 days maybe to feel more "normal." The accomodations are pretty nice... it is a 3 bedroom house with 2 bathrooms, a kitchen, a dining room, and internet access. I am using Suzy's computer right now (she is the pharmacist who lives in this house regularly. She has been here for 3 months now and will be here for a total of one year).

We need to get our computer "switched over" in order for it to be hooked up to the internet. So once we get that done maybe we will be able to update more regularly. 

Today we rested... we slept until about 8:00 a.m., showered, and unpacked our bags. We went over to the Harveys for lunch (they live about a mile away from the hospital grounds on the "mission" site. It was very good!  We visited and talked more about what we can expect... how they ended up here etc. Dr. Harvey asked us if we would be ready to start up tomorrow at 7:00 a.m.  we said yes... we'll see how it goes... because he also said that we should sleep whenever we can ... so if that is  in the morning... that is when we should sleep for now.  We'll see... mainly it is Sean who is expected to be there regularly... I am along for the ride I guess!

Last night we slept okay... we slept for about 3 hours... woke up... couldn't sleep... and then slept for another 3 hours. We had a "free concert" last night... people were SINGING  and SINGING and SINGING and someone was speaking through what sounded like a megaphone... it was kind of frightening... not knowing what they were saying... not knowing why... and at the same time thinking... when do they sleep around here!  They told us that there would be noise and maybe singing.... but I didn't expect what we heard.  

We eventually fell asleep again.... I think someone had died.... and the SINGING and loud speaker are somewhat normal of the happening of a death.  Dr. Harvey did say they lost a patient last night... so maybe all of it was for that person... and hopefully there won't be as much singing tonight!  And if there is.... we will make better use of our earplugs!

I still don't know what to expect... we are such creatures of wanting to KNOW! and so much of me doesn't know right now... I don't know how to communicate with those around me (they all speak French or Lingala)... I don't know how I can be most helpful... I don't know how I am going to learn how to sleep at night with all the noise. However.... I am reminded....

"Have I not commanded you, be strong and courageous? Do not be terrified, do not be discouraged, for  the Lord our God is WITH YOU WHEREVER YOU GO." = Joshua 1:9

From here we continue! 

Brazzaville!

February 1, 2009 (this was supposed to be posted before the Impfondo post)

We have made it to Brazzaville!  Tonight we are staying at the Mission here in the capital of the Republic of Congo.  We leave tomorrow morning around 6:30 am for the airport again to head to Impfondo, our final destination! The travels were thankfully uneventful. Our last flight from Paris to Brazzaville was late, but we can live with that! So it is around 11:00 p.m. here, 5:00 p.m. in Indiana... Yeah Superbowl!  

Fun Fact highlight of the trip #1: Before leaving Chicago... we saw Vince Vaughn and some other famous people (some girl from Sex in the City) shooting a scene for a movie at O'Hare airport!

Impfondo Arrival!

February 2, 2009

We are in Impfondo! We arrived around 2:30 p.m. local time (8:30 am your time). We are very glad we made it!  We had no trouble getting on the plane or making it on time...(Adolph - our new Congolese friend from the Mission in Brazzaville) helped us out BIG TIME!  We didn't have to check our bags - he did it. We didn't have to check ourselves in - he did it.  It was nice t have him... I am sure it would have been more expensive without him!

So the reason we are glad that we made it is the weather!  The first time we took off in the plane (it was a normal sized plane- not the puddle jumper that we anticipated) after being in the air for about 10 minutes they said that we had to return to Brazzaville because of the weather in Impfondo - from our french dictionary we learned that it was because of fog. 

After returning to the interesting "terminal" (a big HOT room FULL of people sitting everywhere) we waited for about an hour and then figured out it was time to head to the plane when everyone started walking / running back to the plane. It began to rain and we boarded, sat on the plane for at least 45 minutes and then took off, and landed in Impfondo after an hour of trying to keep our eyes open on the plane (not very successfully :) ).

Suzy (a pharmacist from Albany, New York) and Rachel (a hospital administrator from Quebec) were at the airport to pick us up. the only snafoo was one of our bags (the one with mostly items we brought for the people working at the hospital here) did not get off the plane. They figure it was still on the lane, and they would have it flown back here Friday. So pray that it comes... the people here are anxious to get the things we brought.  

So we are here... we had lunch, met Dr. Harvey (very nice), rested, had dinner with Suzy, Jean-Pierre (hospital chaplain) and his wife Ginny. After dinner of some awesome homemade bread, jam, and cheese, we played cards.  We played "classes" or Janitor. It was fun... Sean was president most of the time! :)

We are headed to bed now, and will settle in more tomorrow. Thank you so much for your thoughts and prayers. It is good to finally be at our final destination and not taking off in a plane again

We'll write more later, but wanted you to know that we are here, well, tired, but safe and happy!

Fun Fact #2: They have 2 donkey's here on the hospital grounds... Donkey and Dolly... Donkey "hee haw's" whenever Dolly is too far away from him... and some people say that Dolly then "hee haw's" when Donkey is too close to her... either way... there's lot's of "hee hawing" around here!