Challenges in Africa

One of the hardest things about doing pediatrics in Zambia is not being able to communicate directly with the children. I can smile and wave, but must have an interpreter to ask them their favorite color. I can’t ask about their favorite superhero or cartoon character.  And the interactions usually are not “friendly”. Most of the children where I’m working rarely visit the doctor and almost none of them interact with white people. However, when they do it is usually in a medical setting, which they associate with needles and very uncomfortable feelings. So when I approach the children to listen to their heart/lungs and do other (non-invasive) components of the physical exam about 70% of children under 4 years will begin crying as if I’m some scary monster. It’s definitely understandable, but not something fun to deal with.

Something that is very difficult to deal with in Africa is the magnitude of poverty and apparent lack of resources available for those in need. Poverty here is much different than in the US. In the US, poor areas and wealthy areas are generally well separated, and the “projects” are generally hidden and you almost have to go out of your way to see them if you live in the suburbs. Learning about Apartheid (in Afrikaans it means “the status of being apart” and was government sponsored segregation which ended in the early 1990s) and seeing how poor blacks were manipulated, taken advantage of, and treated inhumanely, was devastating. In Cape Town, South Africa, the highways are lined by townships, which are areas filled with hundreds of family homes consisting of cinder block walls, dirt floors and corrugated steel roofs, about 16’x10’ in size.  In 1960s blacks were forcibly (and “legally” because of Apartheid) removed from areas “reserved” for whites and forced to move to these townships. I’d encourage you to read about District 6 in Cape Town, a zone in the city where all non-whites were forcibly removed (>60,000) in the 1970s with most ending up in townships. Poverty in Africa is also different because of the extent to which it affects children. In the US I can never remember encountering a homeless child on the street begging for food and money. At least 40% of those I encountered begging in Cape Town were children.

Here are photos of townships I took from a major highway through the middle of the city.

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Learning about hope

Ok, I’ll admit, I’m slightly afraid of the dark in Zambia, where snakes and lizards and other strange animals live. After hearing stories from friends who’ve encountered puff adders and cobras, I’ve decided to be proactive. Whenever walking, I’m ready with my cat-like reflexes. At night, I lay my ironing board down behind my bedroom door (covering the crack beneath the door) so that no unwanted visitors interrupt my sleep, and I have had no problems (or sightings) yet!

Today, I want to tell you about Jackson, a 40 year-old man who’s been at the hospital for a few weeks. About two years ago he started to develop small nodules in his skin along with weakness. The nodules continued to grow in size and develop in other places while the weakness worsened. He’s been to our hospital several times for evaluations and treatment, with his current stay began about a week ago. When sitting in a chair, he is barely able to lift his thighs off of the chair. He can feed himself but also is losing upper body strength. Because we are limited in our investigative options (no biopsies, CT, or MRI), we are unable to provide him with a firm diagnosis. Our team has concluded he likely has a disease called Neurofibromatosis which is a genetic disease. However, they aren’t 100% because it normally presents earlier in life. We’ve referred him to the large teaching hospital 12 hours away, which he likely won’t reach. Knowing Jackson has been humbling. Every day when I walk by him, he’s smiling. Yesterday when I came to his bed to see how he was doing he was reading the book of John in the Bible. I asked him if he had a favorite story, and he responded that he loves the story of Jesus raising Lazarus from the dead because it gives him hope. If there’s a person who I need to learn from and be more like, it’s Jackson. A man who seemingly has no hope (since he’ll never walk again), but has found something greater…hope in life through Christ.

While I’ve been gone we lost a great man named Randy Storms who was paralyzed yet hopeful in Christ. He and his wife died in a car accident a few weeks ago. Paralyzed by an accident in his early life, he also found hope in Christ, and because of that impacted changed the world by impacting countless lives in Wichita. When you get a few minutes read/hear how this “paralytic” changed the world. The US Senate did last week.

http://www.kansas.com/2013/02/04/2663568/randy-and-suzy-storms-inspired.html

Rooftop (highs) and pediatric (lows)

The heavy rains started a few days ago but no tornadoes. Two nights ago it was raining lightly and I heard a “thud” on my roof. I live in a house with concrete walls and a corrugated steel roof. Shortly after the “thud” I heard a scratching sound and then the sound moved across the roof. Since a tree branch hangs about a foot over the edge of my roof, I figured something fell off (i.e. branch, fruit). As I waited to see something hit the ground out of my window, nothing came. I realized then that something alive was on my roof, likely a monkey. I proceeded to close the windows and go to bed, praying I wouldn’t encounter whatever was on the roof. J I survived.

Medicine here in Africa is very different and challenging. Several labs I’m used to checking are not available here. In the midst of malaria season we have several anemic patients, with hematocrit down to 15% or lower. We normally transfuse if they are <16%, but today we were made aware we had three units of blood left in the hospital until a new supply comes in a few days. This makes us seriously consider whether or not to use the blood in case of a postpartum hemorrhage or need for it during surgery.

One other challenge here is the lack of advanced medical care. In the US, basically any necessary treatment can be obtained. That is not the case here because specialists and resources are not available. We have a 5 year-old boy named Nelson on the pediatric ward. Every day I see him it is sad because he has developed untreatable congestive heart failure. We are not sure if it is congenital or acquired (rheumatic heart disease) but regardless his heart isn’t pumping correctly. Because of this, he is retaining too much fluid which is collecting in his lungs and abdominal area. He has difficulty breathing because of the fluid in his lungs and his stomach skin is tight due to the distention caused by intra-abdominal fluid. He leans backward to compensate.  We are giving him diuretics, trying to help his kidneys eliminate the fluid, but it isn’t working too well. If he were in the US, he’d be a candidate for a heart transplant and have a much better prognosis. In his current state, he will be lucky to last a few months. He can barely walk 15 feet without being short of breath. Regardless of changes to our healthcare system, it’s meeting patients like Nelson that makes me grateful for the access to healthcare we have in the US. We’d appreciate your prayers for Nelson.

On a brighter note, we discharged Mata, the girl with cerebral malaria, on Monday. She went home with her whole family! Thanks for your prayers!

Stars and Small Victories

One of my favorite philosophers Katy Perry once said, “I was in the dark. I was falling hard, with an open heart. How did I read the stars so wrong?” Apparently she wasn’t in Zambia where I am because stars shine so brightly here it’d be impossible to read them incorrectly.

Life in rural Zambia isn’t as bad as it may seem. It’s a peaceful place, the locals are nice, and the community of 20 or so westerners who work at the hospital is amazing. Friday nights we have potluck together and watch a movie. Sundays after church we have pancakes together. It is apparently “rainy season”, similar to March/April in Kansas. No tornadoes, so Toto would be just fine, and Dorothy’s bicycle with the basket would fit in perfectly with all of the other bicycles. The most challenging thing about living here are the conveniences lacking: dishwasher, clothes washer, and Chipotle. Most westerners hire locals to help with washing dishes and clothes (I’ve chosen to take care of my own), but I think it may be a reach to try and obtain something like a Chipotle burrito. The sauce I bought called “BBQ” tastes very strange so I’m afraid asking for a Chipotle burrito may provide me with an interesting concoction that I may not enjoy.

I want to tell you about Mata, a special 8 year-old girl.  I’ve never seen her smile. Never heard her laugh or hear her speak. She was brought to the hospital a few days ago in a comatose state and tested positive for malaria infection. We immediately started her on the strongest anti-malaria medicine we had, hoping for a change. For two days, she has persisted in this state. Her eyes have been glazed over, failing to follow me as I move in front of her, similar to a doll. Yesterday, when I would squeeze/pinch her fingers she will frequently fail to move her hand to withdraw to pain. These signs show us that the malaria is causing significant brain dysfunction. Today, when I walked into the peds ward I went straight to her bed. It was empty and my heart immediately dropped. I went to the nurses station and asked if she had died and they told me she had been moved to the “high care” area where she is receiving tube feedings. As I walked into her room I saw her lift her leg, which I hadn’t seen before. For two days she has laid essentially motionless, with saliva gathering around her lips. Today, I sat down on her bed, and pinched her hand. She moaned and pulled her hand back. It was a small victory for me to experience, but she at least showed signs of improvement. About all we can do is watch, wait and pray. Thanks for praying for her!

Here are a few pictures. The first is of the pediatric ward (beds with mosquito nets above). The second is of the market at the “Boma”, the city centre with a few “stores” and a market.

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Irons and Governors

When coming to Africa, you’re bound to do some things you never expected. For me, one of those was to iron a pair of boxers. Apparently, if you want/need to wear any clothes sooner than two days after they were hung dry, they need to be ironed. The reason is that there are bugs here that lay eggs in wet clothes. The eggs persist for a few days and can severely irritate skin they come in contact with. Thus, I ironed a pair of boxers. Or I’ve been fooled like the step-mother in Parent Trap when she tapped sticks together to “scare away bears”.

Today, the governor of our district (similar to a state) visited the hospital and spoke to us. Throughout his speech he made several statements that made me think he believed the hospital we work at is very important to the district. He had conversations with people sitting outside the hospital and discovered that several of them were from far away, from other districts. The fact is that people sacrificially travel from far away to receive treatment at this hospital because of the level of care available.  The longer I’m here the more I believe our staff of six doctors is amazing. Three months ago there were only two docs here to care for all 160 or so patients. I can’t imagine how busy that was!

As I mentioned before, this week I’m working on the male ward in the morning and pediatrics in the afternoon. About 40% of the kids we admit are for malaria infections. Some are fortunate enough to receive treatment before the infection causes organ dysfunction and others aren’t. If the infection persists it can cause cerebral malaria, causing the child to be comatose and have seizures. About 50% of the time they recover from cerebral malaria. What makes treating cerebral malaria more difficult is that the medicine they are on (Quinine) can cause low blood sugar, which in turn can also cause brain injury and seizures. However, there are only two glucometers in the hospital so we scramble to get them and keep checking blood sugars. Medicine here feels like a battle. I feel like every parent and patient I’ve interacted with has truly been grateful for the care we provide. Because of that, and the “victories”, the fight is worth it.

Here’s a photo of Matilda (one of the victories I shared a few days ago) and her first child.

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Matilda’s Story

Every weekday morning we meet at 7:30 in the chapel where we sing a few Zambian church songs and hear a message from one of the Zambians who work at the hospital (nurse, lab tech, etc). Then from 8 till noon we round. I’ve been working with a doc rounding on the male ward, female ward, and pediatric malnutrition ward. In the afternoon/evenings I help with admitting patients. We have an outpatient clinic and urgent care/ER that will send us patients to be admitted.

I wanted to share with you the story of Matilda, a 20 year-old pregnant mother of one child, because it is a story of hope and victory. The hospital I’m at is quite an amazing place, and I hope you can gather that from her story.
Matilda showed up to the hospital last Tuesday evening, pregnant at 33 weeks with her water already broken (this is dangerous because it can cause infections for the baby and the mother). She quickly began to deteriorate (septic/hypotensive) because she developed a blood infection and was taken to the operating room for a C-section. They baby was delivered successfully through the C-section but following the surgery Matilda’s blood pressure and heart rate were very low. Our hospital here has just created an “ICU”, and Matilda was the first patient. She was started on epinephrine, a medication which helps to increase blood pressure and heart rate. The only problem is that it must be delivered at a rate of 10 drops/minute. In the US we have machines to do this. In Africa, it must be done by hand. So that night a nurse sat with Matilda in the ICU, delivering 10 drops/minute of epinephrine through a syringe. The following morning when we rounded her blood pressure was around 70/50 and she looked pretty bad. Through the day she began to perk up and by the next day she was talking to us. She’s still in the hospital but is doing very well, and her baby has been taken home.

Matilda’s survival is important because the women here are very important. Frequently the men are lost to drinking and the women farm, cook, and take care of the children. Seeing Matilda every day reminds me of how this hospital is accomplishing great things!

Here is a picture of the front of the hospital. The building on the right is the admin building and on the left is the out-patient clinic/ER.

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Hope

I’m going to have to relinquish the nickname “White Lightning”. These mosquitoes are too quick for my speedy hands!

The hospital I’m at is a very amazing place, filled with resources you probably wouldn’t expect in rural Africa. There are separate buildings for each ward: male, female, peds 1&2, and maternity. The wards consist of long rooms (40ft x 20ft) filled with beds side by side. Each ward has around 30-40 beds and also has a few rooms for patients who need to be isolated. There is also a general out-patient clinic, HIV clinic, optometry clinic, pharmacy, laboratory, two operating rooms, labor and delivery room, and newborn nursery. Power outages are frequent in Africa (today it will be out from 8am-6pm) but the hospital has generators and is able to persist in providing care. There is also an adjacent nursing school which instructs over 200 students. We have four family medicine docs, a pediatrician, and two surgeons, all from the US, Australia, and New Zealand. Most of the staff nurses were trained at the adjacent nursing school and stay after graduation for full-time work.

Malnutrition is a common condition among our pediatric patients. We have around 15-20 in the Peds 2 ward. Seeing the toll malnutrition takes on these kids breaks my heart. Around 20% of the children in Zambia are HIV positive, but the percentage of HIV positive pediatric patients at the hospital is significantly higher. One of the first patients I saw was a child admitted for malnutrition who was also HIV positive. Both of these diseases are difficult enough to manage on their own but their combination can be almost impossible to overcome. This proved to be the case in this 18 month-old girl. Yesterday she developed pneumonia and today she passed away. It seems unfair that she would be put in this situation, contracting HIV from her mother and being born in a place where obtaining adequate nutrition is difficult. When we realized her outcome was not going to be favorable, I could only think of two things. One, a Chris Rice song called Untitled Hymn (Come to Jesus) and two, the verse where Jesus says, “Let the little children come unto me.” Thank goodness life in Christ provides hope.

Link to Untitled Hymn: http://www.youtube.com/watch?v=0_hV8L65Rqo