avocado pasta

dr. james lace, a pediatrician from salem, is finally here, and we’re relieved to have an english speaker around to teach us and answer our questions; someone who understands the frustrations we have with mt. meru hospital.

walked into the hospital yesterday and soon realized we were following a trail of blood. it is best to always look down when walking around the hospital, as random fluids of all colors and consistencies frequently decorate the pathways between buildings. I look up, searching for the source of the blood, and ahead of me hobbles a man clutching a cloth to his face. that explains it. he’s walking toward the “casualties” area of the hospital – comparable to the emergency room in the u.s. but really, they could have come up with a better name than casualties, am I right? a few days before, as we were walking through the reception area of the hospital, we passed a man being wheeling on a stretcher into the casualties ward. he was unconscious, covered in dirt and leaves, and foaming at the mouth. I paused, shocked at what I was seeing, then hurried to keep up with amy and thu. they hadn’t even noticed this man, though they had walked right past him. I suppose at a place like this you can go one of two ways: tunnel vision to make it easier, or eyes wide open taking in every peculiarity. I definitely pick the latter.

we shadowed dr. lace for the day. here’s an idea of the patients you see in peds icu at a government run hospital in arusah. moses is a 9 year old boy who presents with what we think is atypical pneumonia. his tb test is negative, for now, sometimes it takes weeks or even months to sero-convert, so there’s a chance he might actually have tb. we tossed around some differential diagnoses: a fungus of some sort, wegener’s granulomatosis, sarcoidosis, and the different causes of atypical pneumonia. aside from the obvious sadness that comes with seeing a sick kid, it’s pretty cool to get to HOUSE it on the wards and try to figure out what’s wrong with these kids. he was admitted the end of june, his CXR looks terrible and hasn’t improved. his HIV status is negative as far as we know. what I found remarkable was his tachypnea and tachycardia. even the next day, when he had improved some, we saw him his HR was 120 beats/min laying down, asleep. I had amy check my pulse, 68 beats/min right after walking to the hospital. poor kid. lets hope the drugs they decide to treat with are a) available (you should see the state of the pharmacy here – duka la dawa – drugs get sold for profit and aren’t available to the patients who need them), b) affordable for his family, and c) the right treatment for his ailment. dr. lace would prefer to send him to KCMC for a second opinion and better tests. it is a university-type hospital near moshi, but it’s private and about a two hour drive away and moses’ mother refuses. dr. lace says this is not uncommon and often children will die at mt meru, there in the ‘icu’, their parents unable to take them to a more capable hospital.

next patient. a 6 week old very irritable child with a temperature of 40C, not good. even worse is that the child has bulging fontonelles, and they’re pulsing. all signs are pointing to meningitis. could be encephalitis, septicemia, malaria… the idea is to rule these out, not sure how they do that here. we do a lumbar puncture on this infant. that was interesting. placed her on her side on the nurses table because there was no other stable place to set her, tried to be as sterile as possible, four of us holding her because they don’t even have lidocaine (except here they call it lignocaine) to numb the area before the huge needle is inserted into the spinal canal and you can bet she cried and squirmed. fortunately it goes well, except we get out foggy yellow csf when it should be clear. send it to the lab and the results are back the next day (surprisingly). they weren’t able to culture anything, that would be too optimistic, but we did get a low glucose and a high protein and coupled with the clinical symptoms that was enough to make the diagnosis. we had already started her on meds, even before the diagnosis was confirmed, meningitis is not something you don’t wait around to confirm… unfortunately, they messed up the dosage, so the first day she only got half the dose she should have. hopefully with proper treatment today she’ll be doing well. it scares me that simple mistakes like this, with such devastating consequences, happen at this hospital.

next we have a one year old with a massively distended abdomen. he is a maasai baby and his mother does not speak swahili. this is an interesting challenge as only one of the group of 12 following dr. lace around speaks the maasai language enough to communicate with the mothers. we get enough of the story to realize that this baby, a twin (the other twin is healthy and fine), was given some traditional maasai herbs/medicines and has since developed the distended abdomen. lamande is the herb mixed with tea, apparently very toxic. the baby also had these patterned burns scabbing on his abdomen. a very odd culture and strange traditions to an outsider such as myself who does not understand the history. it is easy to spot these people: the maasai all wear their characteristic purple and red bright plaid kangas and they have elaborate beading around their wrists, ankles, and necks and dangling from the huge holes in their ear lobes. it will be interesting to visit the maasai village we’re going with dr. lace to in about a week.

we see a small child, 15 months old, 6 kg, who looks terribly emaciated. malnutrition at its worst. and upon seeing the CXR it becomes apparent that the baby has extreme cardiomegaly. I’ve never seen heart boarders that almost stretch chest wall to chest wall. apparently cardiomegaly with malnutrition is fairly common (we’ve discussed a future research project about this with dr. lace, we’re actually in the process of sorting out several research possibilities). we discuss rickets, vitamin D and calcium deficiency. what’s interesting is that we’re probably getting more vitamin D here than we did all spring in oregon, and yet all the people here, and especially the babies, are bundled and hardly get any sun exposure. it is winter and they dress like it’s winter, though we are comfortable running around in skirts and tank tops.

we had a baby with what we thought was a UTI. to get a urine sample dr. lace wanted to put in a foley catheter. they didn’t have one, so he tried to use a feeding tube. needless to say it didn’t work. I’ve also seen an IV tube turned into a drain post-surgery using a pair of scissors and a glove for it to drain into. they get creative here. on a side note I saw a woman with a poorly done tattoo on her shoulder that said, only god can judge me, and it had a stick figure type drawing of a wine bottle being poured into a wine glass. classy.

next patient: 4 month old febrile baby who came in because the mother complained of the baby having vomiting and sob. we listen to his heart. he has a grade 4/6 holosystolic murmur. spent a long time discussing this patient and the options, the outlook doesn’t seem good at this point. the day went on like this, patient after patient, and all the while the boy with cerebral palsy, who is pretty much on the ward indefinitely, was howling and screeching, as he always does. we pretend like we don’t hear it, raise our voices and talk over the repetitive yelling, but it eats away at you, listening to him suffer like that.

then it was to the OR to spend some time with dr. lee. casting, lots of casting today. it’s interesting because they were using this yellow liquid today to knock the patients out. the problem is that the patients would still howl with pain as dr. lee manipulated the broken bone. saw more gumby limbs, it still gets me, even when I know the ulna and radius are broken all the way through, that the hand can move like it’s detached from the arm… well it is, but still, it’s weird, like an optical illusion or something. also cleaned out this old man’s infected finger. dr. lee literally pulled dead bone out of the end and flushed the finger from the inside out, it looked very unnatural and quite frankly, was disgusting.

as we left the hospital I saw a nurse carrying the autoclaved container of surgical tools on her head – how’s that for an african cliché?

now after that gross OR talk, how do you feel about talking about food? the past two nights we’ve been experimenting with food from the local stands, attempting to cook at the hostel. we can only handle fried food for so long, we’re craving fresh veggies! yesterday night we went with a sautéed assortment of vegetables from our favorite veggie stand lady down the street. it’s amazing that a zucchini, carrot and eggplant can fill us, but the fruits and veggies are all so much bigger here! we also had a lady convince us to buy three avocadoes. a single avocado here is bigger than two combined back home, and she wanted 1000 tzs for all three – that’s about 70 cents for three massive avocados, and yes, im already trying to grow an avocado tree in our room :) avocadoes = best purchase of the day, they are to die for!! i’ve never tasted something so delicious in my entire life. night one I made an improv version of an avocado bruschetta I make back home (you know what im talking about nat!) and it turned out pretty amazing considering the circumstances. we even gave some to vene, one of the women who works here, and she loved it too. the next night we decided to make pasta, and because of the abundance of avocadoes in our life, we made avocado pasta. it was basically a spaghetti version of a spring roll because we had cucumber in there too, and I have to say, of all the meals we’ve made, this one has been my favorite. yes, we’ve been trying some strange things, so far it’s worked out well… though I am waiting for the day we sit down to eat some new concoction we’ve just made and everyone takes the first bite and spits it out. but that avocado, so good I’d eat it on my breakfast cereal :) I miss breakfast cereal…