22 June 

Jambo! Leaving today. A bit apprehensive considering how busy I have been and how unprepared I feel.

 

13 July: Day 1

I’d be lying if I told you I imagined my first day to be anything like this. Everything leading up to today made me think that this externship was an opportunity to see some very interesting cases, while conducting my hypertension research in a modern, Swiss training facility in rural Tanzania. All of that may be true, but what was left out of that prediction was the extremity of nearly every ailment imaginable, the lack of resources at the Ifakara hospital (not Swiss-owned), or the instant doubt cast on my ability to practice medicine, one day into my surgery rotation.

I chose surgery first, hoping to get some hands-on experience. I was disappointed to find out that operating days are Wednesday and Friday, so we had a full day of rounding ahead of us. We walked through the wards and saw patients of all ailments. The doctor picked one boy up, and explained that he had been there for 30 days with this burn, one he had received when he fell into a large pan of boiling water used to mix with cold water for baths. When asked if the child MUST stay for all 30 days in the hospital, the doctor replied, “of course, for this is a sterile place, not like their home.” As if there was a director somewhere who shouted “cue the irony!” a large chicken walked past the physicians’ legs and then fluttered out of the window to an area with more chickens.

We went on rounds for the next 45 minutes and saw a number of interesting cases, most of which were young children who would not receive operations because their bones were still malleable and their injuries not severe. The real reason might have been that the entire hospital had run out of general anesthesia, and was quickly running out of local anesthesia as well. Priority for the anesthesia was given to OB/GYN for C-sections, but even they were becoming very selective on recipients.

In the corner of the room, watching peripherally through half-shut eyes, was an 18-year-old boy. He had had a seizure while home alone, and had knocked over the fire that was boiling water, as well as a candle in their small straw and mud hut. He does not remember anything, but was found on his knees nearly an hour later in the fire. His entire back, arms, head and parts of his legs had been burnt down to the layer of bone and muscle you see in anatomy drawings. Now, all that was visible was his eyes and mouth, and I happened to glance over to catch him in the moment he realized he was next up in the batting order.

As they wheeled him over, the boy who had not said a word all day because it hurt to move his third-degree-burnt lips began mumbling what sounded like prayer. I was to hold one of his legs down, as the surgeon removed his bandages. I do not know how to describe the pain one must feel when removing bandages from third-degree degree burns that have now become septic, but it was not nearly as bad as what was to come. As he was held down, each of us took turns removing his burnt skin from his body. This boy screamed out in howls and “oooooweeees” I had never heard before, but never an outright scream. We cut his yellow layer of subcutaneous skin off of his burnt black veins, all the while hearing cries to God and pleas to stop as we crossed over areas where his nerves were not entirely fried. There was blood everywhere, which quickly reminded me we did not know his HIV status. Dr. Simon came to the foot on my side and quickly cut open a fist-sized heat blister, which allowed clear fluid to splash all over the floor. He then handed me what looked like a tiny ice cream scooper and told me to get started. “Where?” I asked. “On his face and head,” Dr. Joseph replied, pointing to his own head. I nearly passed out, for I quickly realized that the utensil exchange and discussion had all been caught by the now watery eyes of our 18 year-old epileptic.

As I walked around his bed, his eyes followed me, all the while pleading with me in Swahili not to do what I was going to do. As I put the tool to his forehead, I closed my eyes and peeled back, only to open them to a stream of fresh blood where I had removed burnt skin, and a stream of tears from his eyes.  Watching him look up at me while I caused him such pain pulled at every heart string in my body. This went on for nearly half an hour more, until his head was free of burnt or infected skin, and I was devoid of any emotion or attachment I had to the field of surgery prior to this.

The procedure ended abruptly, as one of the nurses (a nun) called it over on account of the amount of human suffering outweighing the good we were doing in one day. The surgeon argued that this all will be pointless if we do not remove all the infected skin, but to no avail. We all removed our gloves, washed our hands and silently walked back to our campus. Those surgeons took a quick break, and continued treating patients without anesthesia for the rest of the day. And have done so for the past month. And they have been out of epidurals for three months. And there have been weeks without sutures, or gauze. There are no IV antibiotics, either.

Somewhere inside of me, I know I helped that kid. Some day he might even think that too. But I am already trying to forget it, and will make a point to visit the chapel tomorrow.

 

14 July: Day 2

“The next patient is JW. 18. Burn victim. Arrived yesterday with septic burn wounds.  Patient’s wounds were treated in theater three, and bandages will need re-dressing today. The next patient is…” That was it. As Dr. Amani read through his surgery ward notes during the case presentation round-table this morning, I could not believe that the horrific two hours from the day before were merely 20 seconds of the hour and a half meeting. The reality is, it WAS a minor procedure, and things that may seem major to the naive medical students from Detroit are routine in rural Tanzania. Having worked for nearly two years at Detroit Receiving Hospital’s ED, I had mistakenly thought I had been through the ringer. Gun shot wounds, drug abusers, and the extremes of heart failure or sepsis. Ass-out-of-u-and-me.

 

16 July: Day 4

Atul Gawande’s book, “Better,” attempts to show how diligence, integrity and ingenuity can be used to do better — as physicians and as humans. Gawande presents chapters on cleanliness, specialized surgeons’ salaries, and the constant loom of malpractice insurance. I wonder what the surgeons of St. Francis Designated District Hospital would think of Gawande’s bestseller.

On cleanliness:

The idea of a compromised surgical field is surely different here as it is in any developed nation. Yesterday, those on the surgery rotation were getting ready to take our break for lunch when Erin, a nursing student from Canada, asked us if we wanted to see an abscess irrigation. Not the ideal pre-lunch activity, but a slow morning had left us eager for anything. After 30 minutes of meticulously irrigating and packing the wound up to Canadian code, the two nursing students had managed to complete the task at hand with only minimal wincing (by both the patient and myself). An impressive feat, no doubt. The only problem is that this foolish student was not sterile, and was touching everything in the room and then touching the patient’s infected area.

On physician salaries:

Dr. Elias Kweyamba let his salary slip when we discussed his reasons for wanting to practice in America: $12,000 a year. U.S. dollars. Sure the cost of living is fractional here compared to the U.S. and most of the developed world. Sure he works at a hospital that treats the uninsured and poor.  Stunning to think about, nonetheless. The chief of OB/GYN at the hospital (Elias’ boss) drives a 1998 Toyota Mark II. Elias owns a car, but drives a mangled mountain bike mostly.

When I spoke to Elias about the salaries, he told me that physicians are the highest paid profession, as far as government-paid jobs go. Engineers next. He wants to come to America, not only because of the lifestyle, but because of the frustration he feels knowing there are better treatments or medications out there for his patients. He is helpless, not because of a lack of competency or swiftness to diagnose, but because his surroundings put him on the front line without a gun. In America, the average starting OB/GYN salary after residency ranges from $198,000 to $261,000.

On malpractice:

As we rounded with Dr. Joseph (currently the equivalent of a third-year surgery resident), we were pimped only minimally. When standing around a woman with right-sided numbness, extremity weakness on her right side, pain in the right-lower quadrant of her abdomen, Dr. Joseph looked to us for possible diagnoses. “Appendicitis?” We then find out she had a mass of some kind removed one year back, but she does not know what was removed. Hmmmm. “Is it a peripheral neuropathy as a result of a surgery complication?” Dr. Joseph mulls it over. “Yes it is possible.” “Could it be syphilis?” Again, brief silence. “Yes, that is possible too. We will put down peripheral neuropathy and refer her to internal medicine. Let’s move on.” So, two medical students from America and two from Canada came up with three possible diagnoses. None was confirmed or ruled out, and the patient was set to be transferred.

Yikes.

The physicians of SFDDH would scoff at the idea of doing “better,” as Atul Gawande’s suggests. They would not be dismissing it because they cannot do better, but because everyone knows you must learn to walk before you can run.

 

21 July: Day 9

This morning during rounds, we passed from G5P2 to G3P0, while Dr. Elias explained the treatment plans for each woman and their complications (they ALL have some kind of complication). We watched as an eight-months-pregnant, eclamptic mother-to-be had a tonic-clonic seizure, as all available hands gently kept her arms and legs from causing her or her child any harm. On the other side of the privacy curtain, a woman lay supine with her legs spread, waiting for a doctor’s diagnosis. She had clearly walked a very long distance to get to SFDDH, as her feet were covered in mud and dust. Unfortunately, I knew the diagnosis before the doctor carefully explained it to the weary six-months-pregnant mother. He had the gut-wrenching job of explaining that her baby’s arm, which was visible to the elbow joint coming out of her vagina, was that of a stillborn. She had walked a few miles with the appendage dangling between her legs, unsure if this premature sign was an indication of early labor.

At the morning case presentation, Dr. Anthony Magoda, the medical director of SFDDH, held up a trophy that had been awarded to the hospital for being the best in the district. God bless the other 1o hospitals in the district.

 

22 July: Day 10

On a brighter note, I had a chance to speak with JW (burn victim from day one) yesterday. I was passing through the ICU looking for a different patient when I found him by the grass on the ward’s patio.

John: Jambo! Habari? (Hello. How are you?)

JW: Mzuri. Hisia zaidi. (Fine. Feeling better.) [As I had exhausted my Swahili greetings, I called the one nurse who speaks English well to translate.]

John: Do you remember me?

JW: Ndiyo doctor. You wenzangu siku ya kwanza. (Yes, doctor. You were with me on the first day.)

John: I’m a student. I was very scared for you.

JW: Mimi nilikuwa na uhakika siku hiyo kwamba atakufa. Mimi kuomba kwa ajili ya mwisho kuja. Sasa wanasema mimi ni kufanya vizuri, lakini ni vigumu kuwa na uhakika. (I was sure on that day that I would die. I prayed for end to come. Now they are saying I am doing better, but it is hard to feel sure.)

John: I hope you are doing better. I’m very sorry for any pain I caused you that day.

JW: Hakuna haja ya kuwa na makosa. Ni kwa mikono yako na mikono ya Mungu kwamba mimi ni mzima, hivyo nakushukuru na mimi kumshukuru. (There is no need to be forgiven. It is by your hands and the hands of God that I am alive, so I thank you and I thank Him.)

 

28 July: Day 16

Having finished our last day at SFDDH, there are plenty of frustrations I could choose from to vent about, but it would only be a waste of my time and yours. I’ve realized that the cruelties and injustices of this place, like thousands of other hospitals in developing nations, will either make you stronger or break you. The truth is, every medical student, resident and physician no doubt experiences the breaking point: that moment of helplessness or hopelessness that either pushes you over the hump that is suffering, or sends you tumbling back.

Over these past three weeks in Ifakara, I have seen amazing and unbelievable things. I was quick to judge the circumstances here. While I understand that the forward progress that these physicians hope for is written in medical annals somewhere in America, their resolve is uncanny. As Dr. Elias put it, “It is like trying to eat soup with a fork.” The compassion and strength one must have to see your critical patients die more often than survive is the stuff of legend, and here they are, titans waging a war that they will not win in their lifetime. Sure, there are bad apples. But altruism reigns supreme in these parts, and I’m grateful I got a chance to see medicine in its most intrinsic form.

JW’s prognosis is currently very poor. Aside from his septic wounds, he has now become anemic, and is not taking to the blood transfusions. He also has developed some sort of stress ulcer. He has been refusing food for two days and is beginning to waste away. Being the realist that I like to believe I am, I am certain he will not live another week. Without proper medication or money to support his stay, he will waste away while further complications develop.

I don’t like being proven wrong. This time, I’m hoping for it.

 

18 August: Feedback

I realize now that my responsibility to this program did not end with my flight back home. After having two weeks to re-submerge myself into the routine of lecture, late-nights, and cold coffee, I’ve noticed that the majority of my conversations still revolve around my experiences in Ifakara. It is hard to describe to people the things I saw with any brevity, but the vigor with which I talk about it coupled with the enthusiasm I have received has let me know that my job now is to spread the word.

We are very lucky to live the lives we live. We eat well. We enjoy the luxuries of life from time to time. We even blog. Most relevantly, we have a fighting chance against nearly any ailment when we step foot into a hospital. Our physicians are not only the brightest in the world, but they have every resource imaginable at their (sterile) fingertips to ensure the best effort is put forth. Going forward in my medical training, I will not only strive to keep the memories of the people and things I saw in Africa in the forefront of my mind, but keep a positive attitude in the midst of crisis knowing, “it could be far, far worse.”

 

21 August

I received an e-mail today. It was from Elias. It reads: Hi JD, am sorry I did not let you know about JWs status yesterday as I promised. It’s painful that he died (passed away) on 9th August; the immediate cause of death is not clear. –