My first night on call...in Africa

WARNING PARENTAL GUIDANCE SUGGESTED. THIS IS A PG 13 STORY. I had been in the hospital for 4 days now and was slowly learning the ropes. I knew where the bathrooms were, where the "operating theaters" were and I was making good progress on people's names. I still didn't know where the cafeteria was but that is another story in itself.

It was winter Fri. afternoon in July and I made sure everyone who was on call the weekend knew to call me if they had something interesting, needed help or just anything. This was all volunteered by me. I was a volunteer after all. But I did want to see how the system worked on weekends, what went on, and also I wanted everyone to know that I was "into it".....which I definitely was.

Dr Akim Tampale was on the weekend. She had struck me as a pretty serious women from the get go. This was no piece of cake 9 to 5 bank job she was into. Her schedule is heavy. The hospital doctors are on night call for a week at a time. The doesn't mean you have the days off. Your there just like everybody else during the day, then you go home if its quiet but you're responsible for everything that goes on at night....it's all yours. And just like a 4th of July fireworks display your week ends with a grand finale....the weekend. If you weren't tired by Friday you you will be dead by Monday morning when your friends rescue you. This creates great teamwork. You really do love your colleagues, especially on a Monday morning.

Technology advances in odd and erratic ways throughout the world. Communication at Biharamulo Hospital is almost exclusively by cell phone. Everyone has one..everyone including me. This is a big advancement from MMC in Portland, Me. where we are still in the" beeper age".....so primative. Having left my cell phone # everywhere and given it to Dr Tampale I went home Fri. afternoon to begin our first weekend in Biharamulo.

I woke up about 5:00AM with that inner smile you have when you know you got a full nights sleep with no interuptions. Its like you dodged a bullet, no phone calls, lucked out again, hopefully Tampale had a quiet night too. I closed my eyes and the phone rang not 5 mins. later. It was Tampale, she was in the "minor operating theater with a bad accident ...come quickly.."

I was out of bed, out of the mosquito netting , dressed and walking to the hospital in the pitch dark in a flash.

I walked into the "minor theater" which serves as a procedure room and just about anything else room and all the lights were on and every one was home. On the stretcher was an 18 yo male covered with blood and dirt. One of the anesthetist was putting in a perih IV, nurses were getting bandages and Tampale had his right foot in her hands. Well almost. The only that stopped her from walking away with his foot was the remnants of his achilles tendon. He was awake and still breathing but had lost a lot of blood and was still bleeding actively. After a quick good morning Tampale tells me in English the kid is from a clinic maybe an hour away, MVA (motor vehicle accident), blood is on the way, we need to stabilize and splint. I feel the kids skin, he's cold, trembling, and not saying anything despite her moving his degloved, almost auto amputated compound fractured leg. He's in shock and about to stop breathing. I ask the anesthetist if I can put a central line in to help and he intubate the patient. He looks at me and keeps trying to get a IV in the kids arm. Does he understand English? I ask Tampale do we have a CVP (central IV line thats big and feeds fluid right into your heart) tray or kit? She tells me we don't do that here. !!!! OK, I have to remember where I am and try not to piss off too many in my first week.

The anesthetist has scored with a 16 G IV, if we get one more 14 G or 16 G IV we might have a chance. Tampale is checking the BP. It's 80. The nurse yells the 1st unit of blood is here. I lookup, its a huge bag of blood . I ask Tampale what is that and she says "its whole blood" I keep asking myself "where am I??". In this situation whole blood is a blessing. By now this kid is at risk to have coagulation problems and the whole blood is full of clotting factors..its a gift.

I talk with Tampale on the side. We are in big trouble. We need to go to the Operating Theater(OR) now. There's at least one arterial bleeder in his calf, possibly three, and he's running on empty. We need to forget washing his wounds and try to save his life. We need to stop the hemorrhage and amputate his leg.....which he's already done...mostly.

I put a tourneget on his right thigh and Tampale tells everybody in Swahili we are going to the major theater.

Before we wheel out to the OR we have another "learning moment" The kid is covered with blood and dirt and gravel. His whole body is road rashed with little pebbles in his skin. It's as if he was run over 3 times and dragged thru a gravel pit. He can't go into the OR with his clothes on and nobody seems to know how to get his pants off around his fractures. I keep asking someone, anyone, for a big pair of scissors. Finally a heavy pair of shears appears and I cut off all his clothes. I can't fixate on this but shouldn't this be done when you first arrive at the hospital? We will talk about this on Monday.

OK, we are in the OR and the changes just keeps on coming! This is going to be a real experience. The anesthetist has 2 good periph. IV's to pump blood and fluid into the patient. He has anesthetized the patient with Ketamine. and still has not intubated him. When I tell him he needs to be intubated Tampale starts a running dialogue in Swahili that turns into an argument. Both of the patients lower extremities have been scrubbed up to his umbilcus.

Its a good thing the OR faces east and has BIG windows because the lighting is not great. Not to worry, the sun is coming up just in time!

Tampale has disappeared. Phone call? Probably change her scrubs. Even with the tourniguet

the bleeding continues. I finish drapping the patient and wrapping his dangling leg in a sterile towel, and am looking at the back table where the all the instruments are. Speaking to the nurse, the tech, the anesthetist or anyone who cares to listen to my English. " Do we have a bovie?...you know electical cautery? I'll need a sucker (suction) and the saw and a rongeur ( bone cutting instrument) I'm getting a lot of blank looks from masked faces. The anesthetist says "lets go". I realize the back table is looking pretty bare and lacking everything I just asked for. OK, so I didn't really need an electric saw to amputate this leg but a bovie, a bovie!! thats pretty mandatory. The tech. hand me the knife. First I want to stop the bleeding by finding that artery or arteries that are out of control. But before that I ask for a big pair of scissors. Two snipes and we are through the achilles tendon and skin remnant and we can hand off his distal leg wrapped in the sterile towel. Somehow that just seems to make things neater. The leg stump is a real mess of exposed and twisted tibia and muscle and tendon. There's no real obvious pulsating squirting bleeder, every thing is just oozing everywhere. There is no cautery so I place hemostats on the biggest bleeders but this is wasting time. The best way to deal with this is start the incision and find the popliteal artery ( the main artery to the lower leg), control that, and take care of the hemorrhage. I start a long tangential incision that starts just below that bump thats 2 fingers below the lower part of your knee cap. The cut goes posteriorly and distally down the leg so you create a long flap that will later be rolled up to create a nice meaty stump, all below his knee. The purpose being to create a solid foundation for a prosthesis. I think, will this kid ever REALLY get a prosthesis so he can walk?? Well, first he's got to get through today.

Tamplale is backand scrubbed in. She is across from me and looks OK but flat. I tell what I was thinking. She's OK with that. In surgery there is a lot of protocol, culture, ownership and just simple "surgical manners" One cardinal rule is you don't ever steal a case from anyone else. I think this is universal...even in Tanzania. I ask her what side of the table she wants to be on (ownership is almost always a right side of the table thing). I tell her its her case and she can take over now. She wants me to continue. We cut through a lot of muscle with the knife which creates more bleeding. We place hemostats on bleeders as we go. I cut into a good sized artery. The field fills with blood.That may sound bad but its actually god. Now we know where we are. We control the arterial bleeding with a hemostat and follow the artery back up the leg and whamo! There it is ! The popliteal artery. If we can control this we will stop the hemorrhage. The rest is simple....well sort of.
After a few more minutes we have controlled bleeding, exposed the tibia( the big bone in the lower leg) and the fibula (the little bone) and we are ready to cut thru them both and create a stump below his knee. This part of the operation takes about a minute, if you have an electric saw...which we don't. It could take 5 minutes if we had a gigley saw...which we don't. It took more then 10 minutes with the amputation knife they handed me. I 'm starting to get the impression now that the real reason I'm here is to grunt through this part. The amputation knife is sharper then a butter knife but duller then the history channel at midnight. After 10 minutes of sawing and 2 pounds of sweat I'm drenched and the rest of the patients leg is off the table. We fold up the flap we have made and it looks like it might be an OK closure. Best of all the patient will live.
I'm relieved and have stopped sweating, Tampale is happy, her night call is over. The patient is stable and not bleeding. Even the anesthetist is happy. We get back to our regular broken English conversation with mixed in Swahili and I promise myself a big breakfast....if I can just find that cafeteria.

Every Picture Tells a Story....

Don't it.......

13/8/08 or 8/13/08:  Trip to the  Kisuma Outreach Clinic

  Biharamulo Hospital runs outreach clinics each week to rural ( relatively speaking) villages. On Wed 8/13 we traveled to Kisuma for a well baby and  pregnancy clinic.  It was time I got  out of the Hospital and I was pretty excited  to get take a trip in one of the hospitals  2 white Toyota Land Cruiser ambulances. These are definietly THE vehicle to have in Tazania.  This one is probably as old as Bob Kramers Land Criuser back home ( cerca 1990) with HUDAMA YA WAGONJWA written on all sides and an antenna on it that looks like you could talk to Mars. I had  asked one of the drivers a few weeks ago what hudama ya wagonjwa means.  Being mister smarty pants and a budding Swahili linguist I said " does that mean wagon for humanity?"  In his best English he turns to me  and says "no no, it means ambulance".

   I was actually kinda glad that that crazy mirror image  idea of writing ECNALUBMA on ambulances  hadn't made it to Tanzania but then I realized why should it? There are hardly any cars here and  who uses their rear view mirror anyway?

  We were suppose to leave at 8:00 and left at about 9:15.. not bad for African time. I was traveling with 5 nurses and the driver. Which in fact means one midwife, one anesthetist, two

 pediatric nurses and one who just does vaccinations.  Everything  in Africa is an adventure and

 the road trip to Kisuma proved to be  no exception.  The driver said the trip was about 40km... I  multiply .6 x 40 and say 24 miles, not to bad. We arrived about 10:15. Thats about 24 miles per hr. and it wasn't because of  bad traffic.

    Sometimes the journey really is the destination.  The journey to Kisuma  was unforgettable and the day could have ended right there and been enough of a lifetime experience but  west still had a job to do. We started out on the red  dusty road from Biharamulo. The nurses had offered me the front seat which I politely declined even knowing that to sit in the back seat on one of these trips is the kiss of death: the red dust, back injury and jeep sickness. We were doing alright when I noticed the anesthetist in the back with me  was looking a little pale. Not a good sign for an African. A few mins. later he was barfing  his breakfast in the back of the  hot dusty jeep. Soon we turned off the big dirt road onto a trail that was just 2 strips of dirt and tall grass in the middle. The road to Kisuma is not a heavily traveled thoroughfare.  For the next 40 mins we did some serious 4 wheeling, good enough for any Toyota commercial. After about 30 mins, we see some women  and children ahead. We slowed down to pick them up. I figured we were real close to the clinic. For the rest of the drive we picked as many women and children as we could,  until we reached Top-Toyota-Human-Capacity. Thats 14 adults and 4 children...18 people in a Land Cruiser bouncing ( and I do mean bouncing)down a dirt path  to a village in western Tanzania. What a ride!   

  We crossed 2 small creeks, went up and over a few hills and dropped into Kisuma.  The village sits in a flat valley floor surrounded by wooded hills. It looks like a typical Hollywood African village, grass and mud huts, no telephone or electric lines, no cars, almost too Hollywood, but it is real.  My excitement is showing and the anesthetist, who is compacted next to me, says 

 " You're going to love this. This is the real africa."   The whole village is surrounded by a sea of tall golden grass that is bone dry and looks like a huge fire hazard. I keep telling myself I have to stop thinking like an American who has seen too many "California fires" on the news. It has rained once since we've been here  and looks like it hasn't rained in Kisuma for months.  If a fire starts here, Kisuma is toast..literally.

  Our job  today is pregnancy checks, registration, nutrition, malaria and Tb prophylaxis, new baby examination, which includes wt. check and immunization. My job is to take care of any sick kid or mother and decide if he or she has to come back to Biharamulo. I've told them all  I'm not a doctor and I really don't do ob-gyn  and I'm here to learn from them.  But to them I'm the American mwazugu daktari.

  For the next  4 hrs we see an endless line of pregnant women and mothers with  newborn babies. The "clinic" is a 3 room mud  building with grass roof and dirt floors. The exam room is a mattress on a raised wooden platform that sort lists to the left ( see pictures).  There's a immunization room ( screaming room). Outside the hut is the "weighing room", a scale tied to a tree limb with a meat hook to which you attach the new born who is put into a big pair of shorts that hang from the meat hook. Its pretty comical but it works and the mothers love it. They know wt gain is best marker for health. I meet the local  medical officer, Francisco, who looks like Chris Rock. When I tell him that, he has no idea who Chris Rock is but takes it as a compliment  "...american millionaire.."  The system works, the women and children  all have paper  medical cards that documents wts., immunization status etc. They know the cards are important and I hear no complaints about "losing my card".

Chris Rock is very interested in data, number of pregnancies, number of  immunizations, number of newborns. I see a future epidemiologist in him ...for Africa, for the WHO. But somehow, I don't think he will ever get out of Kisuma. 

  The day is hot and dry, the pts. continue to come (from where?) I spend a lot of time at  the "wt. room". There I can see every kid in good light and get a look at them as they are hoisted up onto the hook. I'm secretly looking for congenital heart disease, underdeveloped and SOB kids. I see none,  all the kids look good. A few umbilical stump infections ( soap and water) and conjunctivitis and rashes but no seriously ill or malnutrient babies. No problem pregnancies.  No malaria!  I was all set to bring back a bunch a sick kids in the ambulance. Today is a good day.  

  At 4:00 PM it is over. The pts. stop coming. We have to leave and all those young mothers have a lot of work to do. I review the data with Chris Rock. Kisuma has 2,300 +/- people. We have just seen 70 pregnant women and weighed and immunized 105 kids. I know there are more pregnant women out there and there are kids that will be born tomorrow and that some children will die before they reach  their 5th birthday. But as a rough indicator that is a birthrate of 7.6%.  Epidemiologist Rock thinks Tanzania is growing at "about 9% and it would be 12% without AIDS".  Is he right? 

  Its a long bumpy  trip back, we are tired and dirty, my white coat is  a shade rustier. The anesthetist, who spent the whole day in the jeep, has stopped vomiting  but now is achy and has a fever. I ask him if he thinks he has the flu. He says no "its probably malaria".  He's probably right. He then asks me what I thought of the real Africa. I tell him it was just what I wanted to see, to experience, but inside I'm thinking why does the "real Africa" have to be so poor .....

  

  

market day in biharamulo

African Time

Finally! A posting! But where are the pictures?? Before we leave B-mulo we'll get some posted. They really will tell the story better than words. Obviously, we have had a LOT of trouble with e-mail and electricity. And in between outages we've been busy carting, chlorinating, filtering and boiling water. The guy who invented running water should be everybody's hero! So far we have not gotten really sick. But, of course, we don't know about worms yet. Third world living takes a lot of work. Not too much time for anything else...except maybe church. Church is really big here, and that's a good thing for these people. Gatherings of any kind are very important. Students I've met don't seem to understand the question about what they do for "fun" and have not heard of the Olympics. Biharamulo has only had electricity for two years! Imagine that! Most people still don't have it and most people still cook all their food outside over charcoal. Garbage is buried or burned, including ours! (We have 60 empty Desani bottles. I've gotten really creative at re-using them.) Contrary to what we were told before we came, the people don't speak English. The language of the people is Kaswahili. The only place where English is spoken is at the secondary school. The students take English in primary school, then go to secondary school where they are taught in English. They all take  national exams in  subject areas, and these are in English!  This is definitely a problem for the population and, I think, for the country.

The path we've been on, learning the ways of the area, the marketplace, money and language, have all been "challenging" at times, but now we are fairly comfortable with all the extra efforts required. When we finally get to a place with running water (and mvinyo) we won't know what to do with our time! And we're really looking forward to that!

Now, the people. People are poor here. Incredibly poor. Dirt poor actually. Saturday we went for an "explore" of the surrounding countryside near our house. We just followed a red dirt path as it narrowed, dropped into a small ravine and then climbed again. The ravines hold the water source for the poorest folks. They are green and lush in this dry season. The red dirt paths winding through make for a very beautiful and colorful scene. But at these water holes the children, mostly, some incredibly young, collect water for their families, bathe and wash clothes. They lay the clothes out to dry on the grass and bushes. All of this is at once beautiful and also distressing. The water is surely full of various parasites and I know they are not boiling it. Few children wear shoes. I worry about hookworm. And the people live in one room mud huts with grass roofs. They are sometimes built in the middle of the path. I can only imagine how food is prepared and eaten. Water has to run right through the huts during the rains. Never mind a mosquito net! (Most of the children in the hospital have severe malaria.) There is so much room for improvement. It is a bigger problem than I can even wrap my mind around. The poorest don't, can't, go to church or school. Clothes and school cost money.  What do they have? Do they even have a future?

Our Dedication

We make our first (successful?) blog entry with only about 10 days left of our African adventure. We have had our highs and lows since arriving, but the most serious was getting the news that our dear friend, Pat Eufemia Cavanaugh, passed away on July 7th, the day we arrived in Biharamulo. Pat's totally unexpected and grave diagnosis of lung cancer was what gave us the impetus to follow through with our dream of experiencing the world as something other than tourists NOW, rather than wait for a more perfect time. Pat was smart, optimistic and loved life and a bargain. She was an important and wonderful friend. We miss her terribly. Though we would rather be telling our story to Pat herself, we sadly are only able to dedicate our "safari" and this blog to her memory.