Sorry for the long
delay, again. There were some internet
outages which prevented me posting what I had written 10 days before, but that
is not all.
I had been happy to
be back at work, and busy. We have been
admitting like crazy, and discharging nearly as many to keep our beds with no more than 2 kids each, sometimes
3.
I said had as I took
another few days to invest my time in fluid intake and SRO. And, thankfully have recovered with only oral
hydration and although not yet up to par, am doing much better after only a day
and a half. I can say that I had been
drinking a ton of water, but it seemed like a lot more before I calculated it
out. Based on some calculations, my
insensible water losses are near 5 L per day based on the temperature here, and
my maintenance fluid requirements would also be somewhere between 5 and 6 L per
day. I'm sure maintenance fluids take
into account some sensible losses, just probably not those in Africa. Regardless, my goal today has been 5- 6 L
over the period of 8 am to 8 pm, and it is much harder and much more of a chore
than I had thought. In retrospect I can
identify several times of dehydration especially in Midwest summers, but also
in West Virginia. And...based on urine
output, I'm pretty sure I have been chronically dehydrated for most of my
medical years! (Still can't believe how
time consuming and interrupting it is to have a normal urine output!)
I read an article by
the WHO (World Health Organization) to try to come up with a more accurate and
adequate goal to set for myself. It
immediately talked about the ill effects of dehydration, and for some reason that
annoyed me. I wanted the calculation,
darn it! But, as I read through, a lot
of things made sense! These calculations
are based on % weight loss, assuming that weight is usually pretty steady and
the losses therefore can be attributed to water loss…
- Fluid loss of 1% of body weight - thirst and impaired thermoregulation
- 2% - more thirst and lack of appetite
- 3% - dry mouth
- 4% - 20-30% decrement in work capacity
- 5% - difficulty concentrating, sleepiness and headache
- 6% - numbness and tingling of the extremities
- 7% - collapse
- 10% - life threatening
I had made it up to
the 6% milestone yesterday, and was closer to 7% the time before, when I
received IV fluids. My % loss since
arriving in Africa is closer to 9%, but that is only mostly dehydration and
partly not eating for a couple of weeks (which I was relieved to see occurs at
2% dehydration!)
I just had an
interesting conversation with a lady I respect, trust and admire exceedingly,
and only in a few weeks time. I can
respect and admire people easily enough, although with time that usually gives
way to being real. Not that it is lost,
it is just transformed into something that looks less like a pedestal and more
like a hug. Trust on the other hand is
another thing. I can trust others
easily, insofar as I don't have to trust them with myself - my thoughts,
feelings, health, etc. I have, in a
sense, been forced into all of these.
And surprisingly, even thankfully.
Anyway, we were chatting and she said that relationships here are kinda
on fast forward. In the states, when you
move into a neighborhood, you may be there for 5-10 years, and you have time to
meet the neighbors and build relationships.
On the other hand, there is a grocery store so close, there is little
need for you to run over to the neighbors for any little thing. Here...we live closely, and everybody knows
what is going on with everybody! You
rely on your neighbors for so much.
And...people are here for varying lengths of time - if you were to wait
around for the small talk, you would never get to much else of some of the
short termers before their departures.
She also said that a relationship is built on mutual dependency. In other words, for there to exist a strong
relationship, both people have to need each other. It is not hard for me to identify my
needs. I suppose that is quite selfish,
but real. I have no idea what I can
offer in return, let alone what I may offer.
On one hand, this seemed like a foreign concept, but on the other, I can
easily identify why many of my relationships have suffered - because I felt as
if I was taking advantage of the relationship and getting so much out of it
without being able to offer something in return. To protect myself from being too greedy or
needy, I inserted the distance, and the relationship often crumbled as a
result. Other than being an intriguing
thought, it does motivate me to seek some guidelines for such interactions,
friendships and relationships. I would
be more than happy to oblige if I knew what I could offer.
Part of the lack of
writing has also been too much fun!
There were 5 of us STAs (Short Term Associates or "the short
termers" ie, the folks that are here for 1month to 1 year, but are not
full-time missionaries) here for the past 5-6 weeks, and we have dinner
together 2-4 nights a week. I made
tortillas from scratch for a Mexican type meal - using what was available. I had a can of kidney beans and canned corn
mixed with some taco seasoning and onions, homemade salsa (with the assistance
of a package of salsa seasoning, and some cabbage lightly grilled and sautéed
in onions with the juice from the corn to be the lettuce substitute. Our lone male stopped by, and seeing the menu
offered to bring his meat over to be made into hamburger, and then seasoned for
the occasion. The other part of these
get-togethers, has been to share our stories, and what brought us to
Niger. I love hearing other's
stories. It helps you really get to see
the nitty-gritty moments that have defined each, and what each person really
values. I love them up until the time it
is my turn. Then I would rather cook
dinner, change the subject or be on-call in an attempt to avert, postpone or
somehow delay the inevitable. In
reality, I was allowed the prized spot of last to go, and Lisa was, in fact, on
call. My only real incentive for a
timely disclosure was the fear that more people would be coming shortly, and it
would be better to share with people I have come to know and appreciate, than
in front of any new audience. It wasn't
that I didn't have time to fret or ponder or prepare… I did. The five talks spanned over the course of two
weekends, and a few days in between...they were all impressive and
remarkable. 5 generations of missionaries
in one family, a desire to be a missionary in all of the others, a beaming with
the telling of the story, deep hurts and life transformations. It is amazing how humans, with the right
perspective, can turn tragedy into blessings.
My procrastination
led to the night before I was sure it would be my turn. I spent hours in preparation. I wrote out an outline, then even used the
voice recorder on my phone to talk through it out loud. Despite my preparation, I opted for a notes
free approach, but didn't have the confidence for anything but momentary
glimpses of eye contact. When all was
said and done, there were polite thank yous, and I was still alive.
Anyway...enough
about me, and more about the amazing patients!!
There was one
gentleman in his 30s who came in. There
is something memorable and haunting in some of the faces, and he fit into that
category. He was very thin, and walked
as a man 3 times his age; barely able to straighten himself up to walk to the
exam chair in front of my desk. He
complained of abdominal pain and a mass in his belly. From looking at his belly, you could see that
his liver extended nearly down to his pelvis, and it was hard and
indurated. He was wasted and gaunt. I invited him back to the ultrasound exam are
to confirm it was all liver, and it was.
The surgeon's had seen him three months prior and had called it a
hepatoma, but it had doubled in size during that time. I sent him for a chest X-Ray after not being
able to hear breath sounds on the right side.
The breath sounds were absent as the air exchange capacity had been
filled with fluid, leaving his lung space on that side to about 1/8th of what
it should have been. Despite that, his
breathing was not too labored. I offered
to stick a needle in it. It would be
hard to miss! The other reason of taking
off some fluid was for diagnosis - perhaps it was from TB and he could respond
to treatment. After pulling off 1200 ml
of straw colored fluid 50-60 mls at a time, I had a deep respect for this
man. He had hope for a different answer
than he had been give before, he had a quiet strong way about him, and he was
patient as I pulled off syringe after syringe of fluid. After my endeavor, I listened to his
breathing and was thrilled with the return of sound where it had once been
absent. He was breathing and feeling
better! (And all of this without
anesthesia, and no repeat chest X-Ray could be done because of time or
cost.) I asked him to come back the next
day to discuss the results of the fluid.
He found me in the under 5 clinic, where he looked a bit out of place
with all the women and children, but he had claimed a space in my heart, and I
fit him in amongst the children. The
results were negative for TB, which should be reassuring, but it meant that
this was cancer, and that there was nothing at this hospital or in this
country, or arguably given the stage, at any hospital in any country. I listened to his breath sounds, and was
disheartened by the silence. Overnight,
likely all of the fluid I had pulled off had reaccumulated. What now could I offer this man? I desperately wanted to do something more
than I could. I offered him a chance to
come back and speak with an evangelist on a day of his choosing. My local interpreter versed more in the local
customs than that of the missionaries asked me, what will this do for him? I wished I had a better answer. One that I could say out loud, and one that
he would be willing to translate. I
admitted there was little we could offer medically. We could give him something for pain (but we
have no narcotics) and could potentially try to drain more fluid off his lung,
but it would only re-accumulate by the next day. The evangelists could talk with him about
life, and death, and provide support.
Perhaps this man had dreams that he wanted to share or delve into
deeper…
It was a day of
needles!
Earlier in the
afternoon a boy came in with a swollen and tender thigh after receiving quinine
injection there to treat malaria. I
stuck a needle in and drew out a syringe full of frank puss. I delivered patient and pus to the surgeons,
and he was offered surgery the next day.
There was another
cute little boy who came to see me. He
had been bitten by a dog, and the story was suspicious for rabies. The dog had also bitten another child, who
was somehow related to the first. The
dog was acting weird, foaming at the mouth, and also bit some goats. We don't have anti-venom, but treatment with
a tetanus vaccine and the rabies vaccine are worth trying, despite the cost
(the cost of the vaccines for today, was about $100.00 USD. The annual per capita income in this country
is only $300! There is a series of
vaccinations, and I'm not sure if the fee was for all of them, or if it was for
just the one.) Part of the goal of the
shot is to get it to activate as many lymph nodes as possible for best mounting
of the immune response, and as a result, the shot is divided up into 8
intradermal injections - 2 each over the upper arm, 2 each on the lower
abdomen, 2 each on the thighs, and 2 each on the upper back. Plus the tetanus vaccines, that is a lot of
shots I had to give those kids - and that is after cleansing the bites with
soap and water for 5 minutes, and cleaning with iodine. I knew the tetanus would be the worst, and to
save the trust of the kids for as long as possible, I save it for last.
I had a 14 year old
girl who came in for malaria. She needed
a blood transfusion. Her lungs were
filled with wheezes, but she had no history of asthma. (Some have said that asthma is very rare in
the tropics, and more of a disease of industrialized countries. Others have disagreed, pointing to the
immense amount of dust, allergens and living conditions. ) Tropical diseases can present with wheeze,
but I treated her for asthma first (and the malaria and severe anemia.) I don't know if I mentioned this before, but
only folks with severe anemia get transfused.
If your hemoglobin is greater than 5, don't even think about it! (Normal for a male is 13-16, and for a female
12-14, more or less.) Anyway, the
wheezes were worse the next day, and instead of the pill for of albuterol, I
gave her regular turns at the nebulized albuterol. The following day the lungs were markedly
cleared, but there was a noise over her heart that sounded like a machine. I initially called it a murmur, but was later
convinced that it was, without a doubt, the worst pericardial effusion I have
ever heard! The sound was her heart,
rubbing against blood in the sac that was supposed to provide silent
lubrication. She also had a bit of puff
to her eyes, and she was spilling massive amounts of protein. The steroids I had started on admission to
clear her lungs, should help her kidneys, too.
When she wasn't getting better to my expectations, I rechecked, and her
blood count had dropped from a hematocrit of 14 (hemoglobin of about 4.7) to 9
(a hemoglobin of 3), I requested she get more blood. Ocham's razor is a principle in medicine, if
not other things, that suggests that most symptoms can be summed up by one
diagnosis. Africa has never heard of
Ocham. She has a parasite - malaria,
causing anemia. She also has loss of
blood into her pericardial sac, exacerbating the blood loss, and preventing the
normal function of the heart. Her
kidneys are injured enough to be spilling protein, causing the swelling in her
face and feet. On the differential to
link the kidneys and the heart, probably more susceptible due to malaria and
aneamia, are TB (which is always in the differential), post-strep throat
infection affecting the kidneys, viral infection, rhematologic infection -
lupus, etc. We don't have tests to
differentiate. We can treat, and watch,
wait and pray.
An even more
impressively swollen child came in, and it wasn't limited to her face and
feet. Her face looked like it hurt it
was so swollen, and her prepubescent seven year old chest was flat as can be
despite a belly greater than that of a pregnancy 40 weeks in gestation. I desperately wanted to stick a needle in and
drain off as much as I could. But, at
only 7, would she permit me or understand that I was trying to help, while
holding still enough that I could, without anesthesia, introduce a needle into
her belly, and take the time to draw off liter after liter of fluid so that she
could sit up and breathe better. She was
so young and was in great respiratory distress, although she was stoic through
it all. Any hole I poked in her would
continue leaking for some time to come.
We opted to admit her for medical management - a lot of diuretics to try
to get her to pee the fluid off her body.
After seeing how she could barely move her now bloated to 60 kg/120 lb
body, I thought it would be generous to offer a foley - a catheter to drain the
bladder so that she didn't have to get up each time. She was diffusely swollen, even down there. A day later, she seemed to breathe a little
bit better despite lying down flat, but her belly was just as big, and her
thighs were leaking fluid from the sites she had received the malaria
injections. (Oral pills wouldn't be well
absorbed because her intestines would be just as swollen as the rest of her
body; and IV quinine causes hypoglycemia at rates greater than our ability to
check blood sugars.)
Another beautiful
girl came in for evaluation of a rash. I
saw that note before I saw the child. I
would have said that someone tried to burn her face off. Starting a centimeter below the hair line,
and going down to the mid cheek. There
were a few other spots, that appeared as blisters that had lost their tops and
dried up on her arms and legs, but on her face, they had coalesced and her face
was down to raw, red tissue. There was
nothing to debride. There had been no
burn. The rash started one week before,
but she was eating well, and it didn't seem to bother her too much. After no resolution with some kind of red
pain ?medicine from a neighboring village, they came to us. I was concerned about scarring, and being
able to keep her eyes open. An
optometrist used an instrument to open her eyes, and the whites were still
white - completely unaffected by what was going on on the skin surface! I covered her with antibiotics for her face
and pneumonia, gave two different antibiotics to protect the eyes, and ordered
wound care. Her face was raw and red,
but somehow looked better the next day, and she was still happy, eating and
playful! I consulted both of my medical
mentors. I had thought perhaps it was
the ominous beetle bug that is running rampant here. If it lands on you, you get a huge
blister. Wherever that liquid touches,
also turns to blister. The mother denied
it, and one of the doctors said a mom would know if a bug fell on the face of
her 9 month old. With as many bugs as
are here, I would be surprised! The
other differential was bullous impetigo.
There were no visible bullae, but they are fragile and could pop before
we could see them. The other doctor
agreed that it could be the blister beetle.
As before, diagnosis matters less than treatment, and she was getting
better! The other suggestion to add to
her management, to prevent scarring, was aloe.
I cut off a large frawn from right outside my house, and sent it up to
her with Lisa. The mom was very
appreciative. Anything...if it can save
this beautiful girl's face from a huge scar across her forehead and cheeks!
I love storms. I love storms at the Oregon Coast. I love the storms that refresh the air like a
shower cleans and refreshes. I like
storms that leave the air cooled. Storms
in WV and in the Caribbean often times left the air hot and muggy. In Oregon, and in Africa, the storms cool. The sky seems to crack open with light, the
rains get serious an down pour. Nothing
is left to guess. You will be wet. The sounds of the storm are so loud. The thunder piercing, and then rolling, the
rain hitting the tin roofs, and hitting off the dry ground. It sounds more like
the conjoined effort of a faucet pouring than an individual drip drip. The winds blow through the screens, the bars
and the upturned glass. The curtains
dance with a refreshed energy too.
Occasionally there is a puddle in the house; that makes one dust free
clean spot on the cement floor. Walking
is tricky. The dust and dirt turn to a
thick mud, that oozes over flip-flops, and down between the toes. Sometimes the mud threatens to claim the
flip-flops and the best alternative, and with the same end result, only quicker
speed, is to take them off and walk through the mud: same amount of squishing,
same color feet when arriving at your destination. The only question in a medical mind may be
injury - glass, rocks, parasites. I love
the silhouette of trees as the lightning offers but glimpse of light. I love storms.
I was told today,
based on my troubles with dehydration, Africa may not be the place for me. It was slightly dis-settling. I am not one to cross off options only because
someone has suggested so. I
would more likely consider increased hydration, and decreased weight as better
solutions. But there was a sting to it,
and it provoked thought.
