9/21/12

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.