i’ve got good news and i’ve got bad news. the good news is that I’ve got the swahili greeting down pretty well, the bad news is that when you greet with slang taught to you by a local, people assume you know swahili, and then, once you run out phrases you know, you get stuck trying to explain in english that you don’t actually know swahili… take today for example, amy and thu needed to get their phones registered (luckily I have molly’s phone from her recent visit and it seems to be working fine, so I sat on the sidewalk outside the busy shop for over an hour while they jumped through hoops to get their phones working). such good people watching, and it was sunny and warm this afternoon, so I was relaxing after a crazy day at the hospital (more on that later), and enjoying the local scene. people come greet me, just to say hi and to try to sell me things. I’ve found that if you smile and say no thank you in swahili, as long as you’re making eye contact, it usually only takes two “hapana asante”s before they smile back and leave you alone. chatted with a few fellow tourists as well. It’s so easy to pick out the english speakers, what is with that? you don’t even have to ask, you can just begin speaking to them in English and you’re always right. Anyway, so this guy pulls up on a motor bike right in front of me, (im sitting on the curb of the sidewalk), and he says jambo so I say jambo, and he says mambo so I say poa, as I’ve been taught (which means, cool, as in, I’m cool), and we end at that. but he’s so close to me and I keep trying to avoid looking at him but every time I do he’s just studying me. So I finally look up and say “habari”(which means how are you?) and he smiles, looks a little surprised, and says “nzuri” and so, as I’ve been trained by roger, I say “mzuka” and now he’s really amused because that is a slang type of greeting like “what up” in the U.S. and he says “sana tu” just as I’ve been taught to respond when people say “mzuka”. but at that point I have run out of casual greetings and when he speaks next I have no idea what he says. Luckily I have my fallback sentence “my name is Lindsay” that I can say in Swahili (though I don’t think I can spell it) and also, when he tells me his name, I can say “ni me furahi kuku tana nwewe” back, which means basically I’m pleased to meet you. And at that point his buddy returns and I’m thankful they’re leaving because the rest of the Swahili I know is pretty much related to the hospital and medicine. The language is cool, and I’m excited to learn more, but it’s challenging and they speak so quickly!
k team, here’s the deal, this blog is going to get intense... like, don’t read on an empty stomach, or for that matter too full of a stomach, intense. intense like, if you have any heart problems, if you are pregnant (im talking to you lily cox, with your adorable ellie belly!!) or breast feeding, or if you have a family history of high blood pressure, maybe skip to the next blog entry when it comes. intense like, please read while sitting down if you decide to proceed, intense. have I made myself clear?
here we go…
day 2 at mt meru regional hospital:
the reason I put a disclaimer on this blog is because I saw my first amputation today, and I intend to give you a pretty detailed idea of what surgery is like at this hospital. we caught dr. lee just as he was headed into the surgery and asked if we could observe, of course he obliged, he's awesome. we filed into the tiny operating theater, as they call it here, and the smell was overwhelming. I pinched my face mask tightly over my nose trying to block out the odor. the room was hot and I realized that there were heat laps on the ceiling and the far wall. dr. lee was scrubbed in… sort of… if you count scrubs, a plastic apron, and huge rain boots as scrubbing in. big pots of autoclaved supplies were sitting on a far counter and the nurse was removing the wrapped surgical tools and placing them on the “sterile field”, except that sterile here does not equal sterile in the U.S. we watched one nurse drop something from her hand onto the sterile area and just pick it up. one of the tanzanian medical students scrubbing in with dr. lee did such a poor job of gloving I will be surprised if the patient avoids infection. the patient was on the table, and dr. lee was starting to drape. the amputation was necessary because the patient had a gangrenous foot. I don’t think I’ve seen gangrene in person before, the toes of the foot were jet black and shriveled, it looked surreal. this was going to be a below the knee amputation. the patient was old, but what looks old here is probably only 50’s, (though the patient looked in her 70’s to me). it wasn’t until part way into the surgery that I realized she was awake. excuse me?! you’re amputating this patient’s leg and she is going to be awake through the procedure?! the “anesthesiologist ” was a woman who answered her ringing cell phone several times throughout the duration of the surgery, left the theater without a word for a good 30 minutes mid-procedure, and was monitoring the patient’s vitals with a blood pressure cuff that I’m fairly certain did not work. I do not know exactly how they numb the patient for the surgery but I do know there was no oxygen in the room, no one monitoring RR or HR, and no blood if a transfusion where needed. the patient was receiving fluids during the surgery, and her wrinkled, grey face did not show signs of distress, but she lay there, eyes open, listening to every word and watching each surgical instrument get passed by, including the saw they used to cut though the bone of her leg. yes, a crooked, painfully (no pun intended) dull, 12 inch long metal saw that dr. lee used to cut through the tibia and then the fibula. he made his meticulous incision in order to have enough skin to close off the amputation at the end, then cut though muscle and down to bone, tying off larger arteries as he went. sawing through the tibia was not an easy task, particularly with such a dull instrument, and he was sweating through his scrub cap by the time he got through the tibia, using his hands to break the last bit and free the foot. unfortunately, he made a bit of a miscalculation, and needed to saw off another inch of bone in order to close the skin flaps fully, and when he tried sawing through the tibia again it was an even worse struggle. the students were not much help, he had to keep asking them to concentrate please, and at one point he was almost begging them to stop talking. it took a while to find all of the bleeding arteries and tie them off individually. dr. lee had started the procedure with a huge tourniquet that was definitely limiting blood loss but also making it more difficult to find the arteries that would spurt blood once the tourniquet was removed. maybe two hours later the final suture was being tied. a foot/leg, severed mid calf, lay on the floor next to thu and I (amy was struggling with the smell and heat and opted to sit this one out about 10 minutes into the surgery). they cleaned the incision area with saline, I think, then dressed it with gauze. I should mention, that when dr. lee was scrubbing for the surgery he went to wash his hands in the small and very filthy looking sink in the corner of the room and there was no soap, so the nurse brought over a bottle of this purple liquid, which was in a reused water bottle by the way, and she dumped it over his hands. sterile? the same purple liquid was squirted on needles before they were used to start a line in the patient, and also was used to clean the leg before the start of the procedure. can you say contaminated?! it’s no wonder the infection rate is through the roof here. we’ll just have to hope the patient does well. amputation was the only option with gangrene, especially that severe, and dr. lee did a great job with the resources available to him.
Queasy yet? Here’s some more if you aren’t - about the first part of our day… this gets a little long winded so fyi, the really interesting stuff was already covered, this next part is mostly depressing… We meet for morning rounds with some of the local doctors. We start in the obstetrics ward. The doc grabs the chart at the end of each bed, talks to the patient, jots a few notes in English, and then moves onto the next bed. Doesn’t seem like he does much; he certainly doesn’t touch the patient. The charge nurse, or I’m not really sure who she is, but she seems important (and she demanded when we leave that we give her one of our stethoscopes, which we most likely will, but it was still odd when she verbally claimed amy’s), goes around pressing on the women’s pregnant bellies until they grimace with pain. She goes from bed to bed and after seeing several women in a row who had come in complaining of pain and contractions but who are actually not due for a couple weeks (and are currently having no signs of contractions), she stands up and starts announcing to the women, in Swahili, that if they come in here it should be a maximum of 12 hours until they deliver. This is not a place to come and spend 3 days, and then she proceeds to discharge most of them. She is a frighteningly intimidating woman.
We got some stories about the women, they are all a bit disturbing. For example, about prolonged labors with so many vaginal exams that infection is pretty much inevitable. there was a septic woman there from a situation like that. we saw a woman on her 7th pregnancy who wants more children because only 3 are still alive. We saw a woman pregnant for the 5th time, desperately wanting a bilateral tubal ligation after delivery. the place smells strongly of urine, and the women are two to three to a bed. At least there are blankets on the beds, even if they are stained and frayed, that’s more than I can say for the beds at the hospital in the Philippines. All the mosquito nets are knotted above the patients, I suppose they use them at night? While we were rounding I noticed a mosquito perched on one of the nets above a sleeping patient, I found it ironic.
We had heard that the pelvic exams are terrible, but today I got to witness why this is said. A woman was brought into this small space, shielded by a blue piece of cloth, with hardly enough room for the exam table, the doctor and me. He cannot even do the exam from the foot of the bed because of the way it is wedged against the wall. He does not tell the patient what he is doing as he presses roughly on her stomach, though it is obvious she is in a lot of pain. I never saw anything like this in the Philippines, it seems so unnecessary. The mother winces, in agony with every touch, and it only gets worse when he begins the pelvic exam to see how dilated and soft her cervix is. I know this sounds wild, but they seem to use the same disinfectant for everything. Whether they are cleaning the floor, sterilizing a needle before a blood draw, or cleaning this woman before the exam, they use this toxic smelling cleaning liquid that I am certain was not designed to contact skin. They use sterile gloves for the exam, a precaution we do not take in the US because it is unnecessary. Here, the rate of infection is so high they believe it reduces the risk, but their idea of sterile is so distorted that I really believe it makes no difference, especially not when you’re using that foggy, toxic, and im sure contaminated, fluid to clean the area before the exam. The doctor is rough with no regard for her comfort or well being. The idea of ‘talk before touch’ is non-existent here. Today was only a preview, from what the British students had to say, it gets a lot worse.
We did learn where on the patient’s card they identify if they are HIV + or HIV -, so that is good. But we were also warned it is best just to assume all patients are positive to be safe. So many interesting things about the way the hospital works here in contrast to in America… for one, everything is late and slow. When we met the doc this morning he said, we meet for rounds at 8, but sometimes you sleep in or are tired so really we meet more at 8:30 or 9. Riiiggghhhttt. Also, as we followed him from the ob ward to the gyn ward (they are currently on opposite sides of the hospital because of a renovation), he saunters… no, leisurely strolls… that might not even depict how slowly he moves. Even the last doc I shadowed at OHSU, though about a foot shorter than me, was near impossible to keep up with as she hurried from patient room to patient room. Here, I was doing everything I could not to give this tall doc a flat tire as we made our way to finish rounds. Side note: Pretty sure I saw a woman with chagas too, she definitely had romana’s sign.
I would say what I saw on our first set of rounds was disturbing enough, but it’s about to get worse. In the gynecology ward there are 23 beds in a long narrow building. The gray metal frames are all chipped and rusty, and the thin mattresses sink between the broken springs. Each bed has one or two women in it, and the only thing that stands out when we enter is a rolling screen curved around the foot of one of the beds, as if for privacy, except that it only extends a foot or two on either side of the bed, leaving the rest of the bed exposed. It isn’t until we follow the doctor over there that I realize there is a body in the bed, covered from head to toe in the grey wool blanket that patients at the hospital are given. The doctor tells us that this woman had a spontaneous abortion (a miscarriage) and that the fetus was not expelled, instead, it stayed inside of her, they’re not sure for how long, but by the time she came to the hospital complaining of stomach pain it was too late, she was severely septic and though they evacuated the aborted fetus, the doctor said, she expired within a few days. He told us they did all they could… it didn’t exactly look that way. Her dead body was left there, under the blanket, between two occupied patient beds, im not sure how long it had been there. They were waiting for the mortuary to come take her away. When we rounded on the patients we initially skipped her bed, until the nurse said something, brought a stethoscope to the doctor, and he abandoned his charting to listen to the woman’s heart, to be certain she’s dead, I suppose. He took maybe 3 seconds to listen with the stethoscope pressed to her chest, then decided that was enough to confirm the death. They wrote her name, Dorah, born in 1978, on a piece of paper and left it on her bed. When the men finally came to collect the body there was banter back and fourth with the nurse in the room and a lot of laughter. It was confusing and hard to deal with. No family was there, it looked like no effort had been made to help her, or at least ease her pain, I was thankful we were not here to witness the death.
So many women in the gynecology ward are there for either an ectopic pregnancy and complications associated with that, or for complications associated with abortions, spontaneous, or those they electively have induced by means outside of the hospital. the doctor says they find a way to induce an abortion, but when it gets complicated (for instance the fetus or placenta is not expelled properly) they come to the hospital seeking care. There was also a 13 year old girl who was there because she had been raped. That was a challenge to stomach. And the doctor did not do anything for her, did not even touch her chart, he told us it was someone else’s responsibility to get her tested for HIV and other STI’s and to give her the urine pregnancy test. I saw her walking around later that day, realized I was looking at her with a distraught and terribly sad face, so forced a smile. She smiled back.
I get so tired of the fluorescent lights and the bad smells. At least when the sun comes out and there’s a breeze it helps things. I’m going to stop giving the grated, screen-less windows a hard time because the gyn ward smelled worse than the obs ward and I welcomed the breezed that would, every-so-often, come in through the open windows and offer just a little bit of relief from the stench. We took vitals, listened to the doctor report on each of the patients, though we couldn’t always understand what he told us. We saw a patient with malaria who had an altered mental status and they said all they could do was observe her. Another patient, HIV+, had an opportunistic infection of some sort. From what we learned about in Biological Basis of Disease, take your pick of any of dozens of infections that HIV+ patients are prone to. This particular patient had, what they thought was an abscess behind her right eye. The orbit was bulging out substantially and she had foggy, pus like drainage coming from both her eyes and nose. It looked bad, and I swear during the time that we were there she was deteriorating. She was having trouble articulating, it was difficult to wake her, and she seemed to have AMS as well. We saw so many other disturbing cases, but that is an idea of what we’re dealing with here.
Try not to get too down, we see good things too... I'll share more in my next blog.
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