Day 8: April 11, 2014
Due to limited internet data usage over the weekend, no pictures right now...sorry!! Come back Monday for the fully illustrated version!
I woke up early on Friday morning, hoping that I'd be able to make it to 6:45 AM Mass at the Cathedral...and hoping that daily Mass wouldn't be 2 hours long as well. However, I didn't get the chance to ask any of our hosts about a key to unlock the gate that early in the morning, so I was just hoping that my waking up and rustling around the house might wake someone up and then I could ask them to let me out.
Unfortunately, at 6:15 in Tanzania this time of year, it's still pretty dark outside, and I didn't much feel like waking anyone just to let me out like a dog. So despite my opening of doors, turning on water, etc (none of which was intentionally louder than I'd otherwise be), noone awoke. My backup plan was just to fit some morning prayer and the daily readings for the Office before the now usual routine of toast and Nutella. As I finished up and got ready to make breakfast, I could hear the Cathedral bells rining in the distance out to the southwest. Oh well, next week.
This morning I made myself THREE thick pieces of toast with Nutella, as I was planning ahead for what I anticipated would be a energy-requiring day of rounds in the Malnutrition Ward. I scarfed the food down happily (I think I could eat Nutella on toast every day...I mean, c'mon, it's chocolate toast!) and did a bit more reading before we headed out to clinic...I was READY for the day, fueled by the power of hazelnuts (this blog brought to you by (and hopefully soon sponsored fully by) Nutella...can we say free Nutella for life???)
On the walk to work, I kind of got obsessed with the Cross on the side of the mountain. It was light well by the rising sun, but the surroundig mountain was wreated in clouds as well, so it was really pretty. I must have stopped seven or eight times to take pictures from different angles, and the 20 minute walk to work easily became 30. I arrived a bit later than usual, but as Friday is a relaxed clinic day (and we were working in the Wards, which didn't really start until 9:30 or so anyway, the 8:15 arrival didn't matter much.
I used the extra time to catch up on some journaling and post them while able to use the clinic Wifi. It's SOOO much easier to do that on a full functioning computer (unlike my almost useless, spyware ridden, beyond-it's-best-days laptop that was brand-spanking new and perfect for Botswana)...I added some pictures, captions, etc, in no time and had a day's worth posted before it was time to round.
This time on rounds, we were joined by one of the local Mbeyans who is also one of the clinic doctors. We made our way over to MRH and under the covered sidewalk walkways to our now familiar Wadi. As we chatted with our new team member and waited for rounds to begin, the intern Dr. Rajeb was busily working on a patient near the window in the second cubicle of beds. It became very apparent that something was not right with this patient, as he was attempting to draw blood from her right arm and she did not move an muscle. This girl was 9 or so years old, and she lay there motionless while he worked. We walked over to see the patient and hear about what was going on.
Something was not right. I immediately thought about how if this patient had presented to an ER in the US, she would have been in the ICU without a second thought. She was unresponsive, staring blankly at the ceiling, with some fine involuntary twitching of her neck, increased upper extremity tone, and a somewhat stiff neck. Reading through her chart revealed that she was a sickle cell patient who came in after a day of leg swelling and then became decreasingly responsive, to the point at which we were seeing her today. Per mom, she had been totally fine the day prior. As we thought about all of the things that could be going wrong with her (sepsis/meningitis due to encapsulated bacteria secondary to an essentially useless spleen that develops in these kids beyond early childhood, a severe exacerbation of anemia leading to decreased oxygen delivery to the brain, stroke caused by sickled cells getting essentially caught in the smaller vessels of the brain), I noticed how Dr. Rajeb performed femoral stick to draw the blood that he couldn't obtain earlier from her arm. The patient didn't so much as moan.
Almost more shocking than her presentation was the little that we could do. We sent for a blood count, but couldn't send for a culture. We started her on one antibiotic, but not double or triple coverage seen in super sick kiddos in the states. We gave her some IV fluids (which came from a partially used bottle), but without knowing the results of the blood count couldn't know if she: needed a ton of fluid to prevent hypotension and septic shock; or whether doing so would potentially overload her heart, flood her lungs, and kill her if she had a severe anemia exacerbation instead. No full monitors, no fancy lines, no intense nursing coverage. The blood count would take 1-2 hours to come back (hopefully) per Dr. Jason, about 10-20 times longer than it might take for labs in the US, and that was because we had "ticke it 'urgent'". So we did what we could, and proceeded to start rounding, keeping as close an eye on the patient as we could...though I wasn't sure what difference that might make as our options had been pretty much exercised for the time being.
The remainder of the wards were actually doing quite well. The kids were progressing, some of them had been discharged, and the ward wasn't quite as full. Winfrida, though still swollen incredibly, was improved as well, and we got a glimpse or two of her eyes, though they were still surrounded by those puffy cheeks and lids. Everyone seemed to be making progress and heading in pretty much the right direction. We were also moving faster thru the wards than the previous day.
About halfway through, we stopped to check on the unresponsive patient, and she seemed the same as before. Now here IV fluids were running, but instead of using a pump to give exactly how much we wanted, we counted drops of water as they fell from the bag into the IV system. This was the best approximation we could get, and after Jason metioned that 15-20 drops is roughly one milliliter, we did some crude math, adjusted the crude setup, and had our "desired rate"...so long as nobody touched the thing and the patient didn't move...unfortunately we knew that the latter was not a real concern. Further, we noted that the patient's mama was trying diligently to have the girl take some milk to get her some enteral fluid as well. Literally, she poured a small amount into the patient's open mouth ( due to her involuntarily dropped jaw), and again, no recognition or response of or to anything. Some of the milk eventually just dribbled out the sides of her mouth, and I'm certain the rested dripped down the back of her throat, perhaps into her gut but perhaps into her lungs. I was sure she was aspirating. Jason asked for an nasogastric tube to be placed, much to my relief. He also mentioned to us as we finished up with her and walked out of earshot of the mother (who spoke no English, so it mattered little) that of 10 patients who come in looking like her, perhaps 1 or 2 end up being discharged. Rather hopeless...though fortunately not completely.
The one other saddening aspect though was the discussion of "palliative care" for some of the kids with cererbal palsy and malnutrition. In the States, a patient with CP who can't eat on their own well enough or safe enough uses a tube of one sort or the other to get their food and keep them alive and growing. This plan takes supplies, pricey formula, dedicated parents and a home care team, and clean living conditions...of all those, few if any exist for the kiddos here. So, when we came to our two kiddos with CP who were improving, though needing tube feedings to eat enough, we actually had to think about discussing with the mother (or bibi/grandmother, usually) how much they actually wanted us to do for them and how much we could do for them long-term. I was glad that we only noted that that discussion would eventually need to take place, not that it actually took place today. It was enough to make one feel a bit more hopeless.
We finished up with one final patient who had been admitted the day before with some low oxygen and likely pneumonia. He was initially pretty sick, but this morning looked fantastic. He was laughing and joking, and was a perfect counterpoint to our sick kiddo one wadi down. I was glad he was our last patient, as he instilled some of the diminishing hope and reminded us why you always try, even and especially when hope seems lost. Kids are AMAZINGLY resilient...and today my back was as well actually...it barely even hurt! (3 hours of rounding instead of 5 will help with that I guess)
After rounds, we headed down the road to Deluxe and I had the usual...but this time I asked for "Pilau with NO NYAMA." It was Friday after all. We finished up rather quickly, or I did at least. Carmelle, who had food left, asked for "A BOX TO TAKE AWAY." After repeating a few times and motioning with her hands, I thought the waitress understood...but when she piled my plate onto the leftovers on her plate, we were both confused. A few minutes later the waitress returned with a take away box indeed, but also with a bill that had added one more meal. Carmelle ended up with her second serving of wali nyama (white rice with meat) in a to-go box...we clearly needed to learn some more Swahili.
Back at the clinic, all of the patients had been seen for the day. It was time for a lecture on Kaposi Sarcoma (the most common malignancy associated with HIV and amazingly prevalent in sub-Saharan Africa and especially Tanzania, where the infection rates of the virus that predispose to the cancer are INCREDIBLY high). In most kiddos, the virus causes some mafua (runny nose, flu-like symptoms), but in kids with HIV, it can cause some soft tissue tumors that can be pretty disfiguring. The lecture was timely, as Friday in the clinic was KS day, where patients came in for chemotherapy for their cancer.
A few amazing things about KS in Mbeya.
1) The clinic is the only one to do outpatient chemotherapy without an oncologist, and the BIPAI docs at the clinic, Liane in particular, are able to give chemotherapy to these kiddos even though they aren't technically oncologists. It's done out of need, and they do AMAZING work.
2) The tumors are rather disfiguring, so the work done here saves lives as well as changing quality of life and removing stigma.
3) The regimen of chemotherapy is simple, CHEAP, and BEYOND AMAZINGLY INCREDIBLE AND DRAMATIC. We were shown picture of a girl who had KS on her mouth and tongue. Her tongue, if you could call it that, was so enlarged from the grown that it filled her mouth, spilled out, and made it so that you could not see any portion of her chin. It was difficult to look at, much less live with. She could barely sip small amounts of water and could not eat. She was nutritionally wasted and likely rejected by her peers and maybe her community. After 1 round of chemo treatment, the tumor was impressively lessened...after 3 or 4, negligible...after her standard 10 rounds of chemotherapy, IT WAS GONE. You could see nothing remaining...she had gained weight and was smiling with the most priceless smile you could ever imagine. The chemo must cost thousands and thousands right? WRONG. Each cycle, dependent on severity of illness, costs between 50 and 80 dollars....so that little girl's tongue tumor melted away for $800.
Stick that on a poster and tell me who won't donate to that cause!
After that, even more uplifting events (isn't it amazing how God will allow you to see the worst of the world and then bring you right back and fill you with motivation and hope again?), as I got to call home. Ali and the boys looked happy, as did Mary-Teresa. John-Paul wasn't mad anymore thankfully, and asked "Hey dad, what's going on in Africa???" I talked with them all, showed them some of the vegetation outside the clinic, and was excited to hear that our house is going up on the market THIS WEEKEND!
Ali, if our house is sold before I get back,and you move out without telling me where you're taking the kids and yourself, I'll understand for 23 days, but then I'll be mad:-P.
After hanging up, I finished up my journaling for the day before and used the internet to post as much as I could before leaving the free wifi of the clinic for the weekend.
I insisted that on the way home I would NOT stop to take pictures like I did the day before. Well, I made it to store next door to the Cathedral and bought a bit more airtime, walked up the hill, but then broke my promise to myself. Down the hill in the valley was the beginning of a rainbow. It was WAY far off in the distance, it was incredibly WIDE, very short, and very faint. It was what I imagine a rainbow being born would look like. As we continued the walk home, the rainbow became a bit more defined, a bit more vivid, and a bit taller. It was like it was growing up before my eyes!
Time for a deep thought moment. The rainbow as beginning to form in the valley below Mbeya where part of the city lay. I couldn't help but think about how the mythical pot of gold at the end of a rainbow, and how in a sense the city was becoming that pot of gold...more and more appealing and more of a gift as the days went by. Okay, it was kinda stupid, but you're the one taking time to read it, so there.
I arrived back at the house, remarking how it was now one week in the books! It was a bit rough, with hills and valleys much like the city itself, but I felt like things were getting better each day. To demonstrate, I added my airtime to my phone, navigated thru the secret menu Josh had shown be earlier in the week in SWAHILI, and added a true bundle, inclusive of SMS and minutes! Now, granted, I had Cherise confirm that I was interpreting the Swahili correctly before making each choice and wasting my money again, but I think that just further demonstrates how much I've adapted!
I realize now that it made for 4 nights in a row, but dinner again was at Mbeya Hotel. I had a hankering for some of the delicious food I had seen my dinner mates enjoy the night before, and knew that there were many Catholic-Friday-in-Lent compatible options. Learning from my mistakes earlier in the week, I walked up and asked to order straight away, chose our food, and then got a drink to sit out on the patio to enjoy while waiting the incredibly long amount of time. I decided to pass the time while enjoying a Safari lager, watching the expats throw darts, play pool, curse in German and English, and talk about football matches coming up on Saturday. I made it an opportunity to enjoy the wait rather than be frustrated by it. It took forty-five minutes, but I didn't really mind...maybe I was adapting to the Tanzanian way of dining.
After the food was ready, we ate, and I gobbled up all of my butter paneer (Indian cheese), naan, and rice. It was SO good...I actually felt kinda like I shouldn't have enjoyed it that much, as I didn't mind the meat being absent at all...it was a wonderful Friday meal.
I walked home, stuffed beyond belief but comfotable. My stomach was happy, my mind was happy, and it was a great end to the first week. I made it a quiet night at home, checking some things online on my phone, doing a crossword or part thereof, and calling it a day earlier than in the US. I felt so content, and so tired and ready to rest, that I was a rebel, and I didn't take a shower before bed. Don't tell Ali!