Last day

Today was a bittersweet last day. We found out one patient we'd admitted earlier this week had died, another was HIV positive, and a third (the subject of yesterday's post) still hadn't gone to surgery.

But I was also greeted this morning by three kids who ran over and hugged me enthusiastically, as they have every morning this week; they held my hands through most of rounds, taking turns tickling me and playing other games. Two kids politely asked me if they could use my camera. They used to demand "Give me your camera!" Now it's "Give me your camera, please!" (We taught them that they're nice kids, and should aim to sound that way.) The interns and medical officers wished us safe travels, and the Sisters in clinic said they'd miss us. We'll miss them too.

This has been an amazing month. We've learned so much, not just about the diseases that are prevalent here, but about the practice of medicine as a whole and the role we play in it. Even the saddest and most frustrating parts of the month have led to discussions about the ideal way to practice medicine vs. how it's done here. Dr. Brown has been doing this for longer than we have, and was able to share his thoughts about how things are, how things should be, and maybe how we can play a role in getting them from the former to the latter.

Namibians have a different perspective on healthcare, and it has been an honor and a privilege to be let in on their experience for the short time we've had here. The parents and patients have been very open, very welcoming, and very patient with their American visitors, and I know I'll really miss some of them. How lucky we are to have learned a bit about their world.

Anger

I've experienced a large variety of emotions here in Namibia. Sadness, discouragement, happiness, gratefulness, and sorrow. But today, I experienced anger. In fact, I was furious. I entered rounds today, to find the team discussing a 1 month-old infant who was lying crying in his crib. The first thing that caught my eye was the WBC of 49k with a left shift. The child had been admitted the night before by the on-call intern. The same intern rotating on the ward with me these past two weeks. The infant had been admitted for pneumonia, a diagnosis often used by the interns when they are unsure of the diagnosis but think the child may be sick.

The medical officer was busy saying that we should get a urine culture and lumbar puncture to be complete. I decided to examine the infant at that time, who had continued crying throughout this conversation. Fontanelle soft and flat, lungs clear, heart mildy tachycardic but no murmur, abdomen rigid. No bowel sounds. Distended. Hard. Had anyone examined this child?? I mentioned my exam findings to the medical officer who said, "Yes, we're going to obtain an abdominal series". I pointed out that I think we had our source of infection.

We finally agreed on a plan. Abdominal films as soon as possible. Addition of metronidazole. Follow up. I mentioned that the baby seemed to be in quite a bit of pain. Could we add morphine? I was told morphine is a strong drug. I said this baby needs a strong drug. A one-time dose was written at the lowest starting dose recommended. I asked for Q 1-2 hour dosing. I got QID. Luckily, the decided-on dose was too small to measure, so we gave the higher dose I requested. Unfortunately, we all know the half-life of morphine is a tad bit less than 6 hours.

We continued to round in the room the baby was in. During that entire time, roughly an hour, the baby continued to whimper with periods of intense crying out. No one seemed concerned. No one seemed to be in a hurry to get the morphine. It took 3 reminders and almost 2 hours to get the infant his medicine. I suspect the baby cried out like this the entire night without anyone showing a hint of worry.

The ridiculousness of the situation continued when after about 3 hours the films finally came back and clearly showed stacks of small bowel loops and air-fluid levels as well as questionable free-air. When the medical officer called the surgeon, he said, "we suspect obstruction". Suspect?? It looked pretty clear to me! He continued on, "the baby has bowel sounds and the belly is somewhat firm but soft". Bowel sounds? Soft?? Fortunately, the bile-stained NG outs were enough to convince the surgeon to come by. A pleasant surprise. Unfortunately, he wouldn't be by until after his next surgery.

I'm not sure what will happen to this baby. I'm just so incredibly angry about the entire situation. Starting with, and especially with, the intern who very clearly missed the diagnosis. With the nightly nursing staff who allowed that infant to cry out in pain all night long without questioning or calling a physician. With the medical officer who didn't seem to identify the diagnosis either and who did not grasp the severity of the situation. With the day-shift nursing staff who did not seem to notice or care that the infant was crying out in pain and took hours to get the baby pain medication. With the medical officer, again, for not conveying to the surgeon the critical nature of the infant or even the correct physical exam findings. This infant may die because of everyone's negligence and apparent lack of caring. So much of the death I've seen here is preventible, and that's enough to make anyone angry.

Mild, Moderate, Severe

Another interesting day - we were eating lunch in the conference room when a Sister (nurse) came by and asked whether Dr. Brown was still in the hospital. We replied that he wasn't, and asked why. She replied "I just wanted him to have a look at a baby in the Gastro unit." and walked away. We both thought for a second, then got up and decided to go see what was going on.

As it turns out, there was a very dehydrated baby there who had acutely decompensated. As we worked on helping the intern with assessment, resuscitation, and reassessment, it was hard not to notice that he was the picture of severe dehydration - it was as though he'd read the textbook. He was obtunded - lying with eyes half-open and not responding even to multiple IV attempts, with skin that stayed in an unnatural ridge long after you pinched it. His hands and feet were cold, and his nailbeds took 4-5 seconds to return to their usual pink color after we'd pressed on them. He was grunting, and had thready pulses which were initially only palpable very centrally. His heart rate had gotten as low as 60 when we first arrived.

The amazing and somewhat scary part was that this child had been doing reasonably well just a few hours prior, when he was seen by the team on morning rounds. Then his diarrhea had increased in frequency and volume, he began vomiting, and the volume loss exceeded his capacity for compensation. As we've heard time and time again - kids are resilient. They'll keep on compensating until they absolutely can't. He had reached that point.

I can't tell you for certain if the diarrhea and vomiting had given him electrolyte imbalances or an acidosis; there was no blood gas or istat to help us assess his situation acutely. We sent off labs once he had stabilized a bit, but we'll be lucky to see the results even tomorrow; when I called for his admission labs, which had been drawn two days prior, I was informed that there were never any labs drawn on that patient. Were they drawn but not sent? Lost at the lab? Mislabeled? We'll never know. I had the lab lady search for his results 4 different ways, none of which proved fruitful.

The baby got transferred to the High-Care unit, where he will get closer monitoring. We'll see how he does. He might pull through, or he might be one of the kids who "just dies" overnight. Yesterday we'd seen a child nearly as sick who looked quite a bit better today - it's amazing what proper hydration can do. Maybe today's baby will be as lucky.

Code Captain

Today, I was the official code captain for a real code for the first time in my life. I wasn't the person standing at the door trying to learn how to manage a critical patient yet stay out of everyone's way. I wasn't the person placing orders for the medications that were administered and the portable films that were performed. I wasn't even the person at the bedside bagging the patient while following the orders of an attending. I was the person who entered the scene to find inappropriate bagging and lack of coordinated resuscitation who subtly took charge, took over performing chest compressions, and began directing my very limited team on how to manage this patient. I even decided when to stop after 20 minutes of CPR with no resultant pulse. There was no attending, no back-up to call, no one more knowledgeable than I on whom I could rely.

It's difficult to explain how I feel following such an experience. It was exciting to take charge, because despite my quiet personality, I am a leader at heart and was able to make sure things got done as well as they were able to be. But I'm also incredibly sad. She didn't make it. I was the one who decided when to stop. That's an enormous responsibility... to say we've done what we can but this is the end. It's a very painful decision to make, especially on a child who had seemed relatively well just two hours ago on rounds.

The experience has given me a lot to think about and is one that I'll not soon forget...

Novelty

Today, I saw a healthy patient. A little eczema, some lacrimal duct stenosis, and a classic case of colic, but an otherwise happy, healthy, six-week-old infant. In addition, she was accompanied by two loving, doting parents. Why write about something so ordinary? Well, in a country filled with poverty, malnutrition, extreme sickness, and a general feeling of apathy, it was both delightful and refreshing to see a chubby, healthy, thriving infant with two parents who clearly loved her...

Erindi

Sara and I went to the Erindi Game Reserve this weekend and had an absolutely fabulous time! We saw all sorts of animals including lions, elephants, a leopard, giraffes, various antelope, zebra, ostriches, and crocodiles. Take a look at just a few of the pictures we took (I managed 449 and Sara a whopping 700). It was a much-needed break that we thoroughly enjoyed. :)

Doctor, look!

Yesterday ended on a worrisome note for me. A mom brought in her baby with two days of fever and diarrhea. The baby was lying there like a dishrag and not very responsive - he was (just barely) conscious, but didn't cry even when we stuck his finger to check his glucose, and his tone was very low. I was worried that he had sepsis on top of dehydration, so I admitted him. Night time at the hospital is a scary time for patients, not that any of them know it -- by which I mean that they're in the hands of one intern who is responsible for kids in the ER, all the peds floors, and resuscitation of any babies who get in trouble perinatally at the hospital down the road. There is no sign-out process, so I had no way of letting the night intern know to look out for this baby. I left the hospital satisfied that we'd put together a solid plan, but worried that the baby would worsen unnoticed overnight.

The Browns' church has a women's group, and they went to the hospital today to hand out packages of toothbrushes/soap/washcloths/etc. and to just offer some support to the moms and the kids. The visit was a success on many levels, but I started the afternoon feeling frustrated and more than a little worried - I couldn't find "my" baby anywhere on 8B - the service where he belonged. I feared the worst but couldn't let myself think that that baby had really died, so I waited to see how the day would unfold.

Next thing I knew, a mom walked by the conference room with a perky and very much alive baby in her arms. She stopped me -- "Doctor, look!" It was my baby from last night, doing a thousand percent better than yesterday. "I was so worried yesterday -- I thought my baby was going to die! But he looks so much better today. Thank you, doctor!" I was amazed and gratified to see the child make such an amazing turn-around, and had the good sense not to spoil the moment by admitting that I'd feared he might die too.

The thing is, we have minimal supervision in the clinic - that baby got better because I made good decisions and did the right thing for that child. I didn't have lab results at my disposal, no readily available imaging. The night intern wasn't there to back me up - she probably didn't even know the patient existed. So we made a plan, used good clinical judgment, and made a difference. That's amazing, and as much as I'll gripe about the broken system here in Namibia and the many frustrating things about it, it is teaching me so much. I'm so grateful to be able to have made this trip, and I'm looking forward to another two weeks of it.

A quick Friday post to mention the cordial tone which permeates hospital life. I watched a medical officer write several consults this week - all had a similar tone to this:

Dear Colleague,

I wonder if you could help us with the management of a [insert patient description here.] On our exam we found [our findings.] We would like [reason for the consult - i.e. what we want from you.] Thank you for your help in this matter.

Yours,

[Medical Officer]

I thought it was nice, and decided to try his style when I ordered an x-ray in clinic this week. So I wrote the radiographer a note on the x-ray order form, giving a description of my findings and my reasoning for ordering an expiratory film in addition to the standard AP and lateral views. When the patient walked back into clinic an hour or so later with the film, I received the following reply, with an arrow drawn pointing to the spot on the form where I'd requested the expiratory view.

"Tried my level best, but I think the experiment was just on a wrong patient, maybe if it was an adult patient it would have worked. Thank you, Angelina (Radiographer)"

I got a laugh out of the response. It was just such a pleasant reply, even if the answer was "Sorry, just couldn't do it."

Gratitude, Part II

To expand on our post earlier this week, we would like to mention a few more things we're thankful for back in the States:

1. Pediatricians. Real, residency-trained, board-certified pediatricians.
2. Effective social workers who visit more than once a week. We have children who have been here for weeks now waiting for their social issues to be addressed.
3. WIC. If we could just feed the children who don't have food here, imagine how different it would be! No more malnutrition. Healthy bodies that can more effectively fight off infection. Enough food to nourish developing brains.
4. Readily-available medications. Some of our patients live so far from clinics and pharmacies that their parents can not or will not fill their child's prescription on a regular basis. Even if they are within a reasonable distance from a pharmacy, the medications they require are often not stocked.
5. Child Life. These kids need someone to explain in a child-friendly manner about procedures and provide them with some sort of stimulation so that they can engage in imaginitive or educational play. These kids are hanging out in hospial wards with no toys to arouse their interest.
6. Sedation. Can you imagine trying to convince a 9 year-old that he wants a spinal needle placed in his back?
7. MRN's. The identification number here is the child's birthdate, backwards. There could never be overlap, right? These numbers are rarely used and when you're sending labs or following up on labs, you're stuck trying to spell out a name that is hand-written in chicken-scratch. There are often discrepencies between the true spelling of the patient's name and what is down in the lab, making it very difficult to locate results.
8. Full work days. Yes, that's right. When you finish the hospital day at 11 am, it leaves little time to do any sort of follow up, whether it be on labs, radiologic studies, or the status of your patient. It also makes it very difficult to arrange consults or diagnostic studies or to perform procedures. "We'll do that tomorrow" is a running theme.
9. Formal rounding on every patient every day. That's right. We'll often breeze over patients without discussing them, writing a note, or formulating a plan for the day. It sometimes takes days to begin a true investigation into the source a patient's illness, and even then, we tend to address one small part of the picture rather than looking at the entire illness.
10. Antibiotic approval requirements. We send you many, many thanks, Dr. Ravin! The running theme here is to use antibiotics "just in case". We've already experienced the consequences of this form of practice. Sara has a patient with an E. coli infection that the lab has reported is resistent to everything except imipenem. This includes only intermediate sensitivity to amikacin!

Our first code

The pace of clinic this afternoon followed Murphy's law - hardly anybody showed up for the first few hours, only to have several sick kids show up in the last hour of the day. Tammy and I worked on admitting an asthmatic, and I was feeling pretty proud that we'd learned how to navigate the system enough to work up and admit a child in this foreign setting all on our own.

As I walked back through the clinic to find a Sister to ask about sending the child to the floor, I found the medical officer quietly resuscitating a baby. She and the Sister were bagging the child while trying to gather together materials for intubation. Once we recovered from our surprise that nobody had called a "Code 22" or at the very least a "Peds 99," Tammy and I quickly got involved in the resuscitation - it was a 3-week old baby with meningitis.

I carried in the clinic's single pulse ox machine (from the opposite end of the clinic,) and our work began. We took turns bagging while everyone searched for the right equipment for intubation. First the ET tubes were all jumbled together. Then nobody could locate a stylet to aid in intubating. Then we noticed the stomach was becoming quite full of air, to the point that it was impeding our efforts at bagging. Guess what wasn't readily available. After several minutes of searching, someone finally did find an NG tube. After that the intubation blade wasn't the right size, and the right-sized one had a burnt out light. A lightbulb switch later, the medical officer was finally ready to intubate... until she took a look and asked for suction. The suction tubing was coiled all around the wall suction unit, and the Sister s l o w l y and carefully unwound it, finally passing it to one of us before turning on the vacuum... only to find it wasn't working!! (Remember, we're still bagging through all this.) Someone did bring out a backup suction machine, and finally, on the third attempt, the baby was intubated.

If the previous paragraph was painful to read, imagine standing there sorting through all of it while watching a pale lethargic baby repeatedly try to desaturate as you bag with a mask the size of the child's whole face.

Though we were glad the child was intubated and had a more stable heart rate, our work was not done. For the next hour or so Tammy and I took turns bagging the baby while the medical officer tried to sort out where we would send the child. Without x-ray to confirm placement, we used auscultation and palpation to determine that the tube was too deep. Those same skills also confirmed that we successfully repositioned it. Previous residents weren't kidding when they say that physical exam skills are incredibly valuable here.

The medical officer declared the situation "a disaster" because the child is HIV positive, and we are not supposed to resuscitate children with HIV. The position is that those children already have a shortened lifespan, so the very limited hospital resources should be reserved for those who are "salvageable." I don't even know how to begin expressing how strongly I disagree with this idea on so many levels. Can you imagine declaring a whole group of children unresuscitatable? I was so glad that we'd intubated this one before they discovered that. I can't imagine what would've happened otherwise, by which I mean I can imagine it and am unspeakably thankful that it didn't happen that way.

The medical officer then embarked on a series of phone calls to find an accepting unit for this child. The Prem unit didn't want him because he'd come in from home. Like our NICU, they prefer not to accept those children who have gone out into the world and gotten exposed to community-acquired infectious agents. The ICU didn't feel comfortable with a child as small as he was. By the time we finally went home they planned on sending the baby to Casualty (the ER) so they could sort out the patient's placement.

The discouraging part is knowing that the child will likely die, despite our best efforts. Kids die from meningitis in the USA too, but there I would've been able to honestly say "We did our best." I guess we did our best today too, given our limited resources. It was the best we could do, and our best was enough to get that baby a secure airway, good sats, and fair perfusion. ABCs, African style.

Gratitude

After only a little over a week in Namibia, I already have quite a list of things at Geisinger that I'll feel very grateful for once we're back in the US.

The lab, which I used to think took too long to bring back "stat" labs, ranks high on the list; here even stat labs take at least 24 hours. This morning I found a BMP (UTE here) in our stack of morning labs - drawn on Friday morning, the report had been printed days later, on Monday morning, with two critically low values* and an automated notation to "Please attend to this value urgently." I may give "critical lab Tiffany" a hug when I get back to Pennsylvania.

Bed lists, which are such a routine thing at Geisinger I'd never even really thought about them before, are another thing I'm thankful for. That "urgent" lab I mentioned didn't come labeled with a room number -- just a patient name. There is not any readily available list of which patient is in which bed, so I spent a good portion of the morning trying to figure out which room contained that patient with the now long-deranged electrolytes. I think someone finally decided he belonged to the gastro ward down the hall.

Official radiology reports are another thing that I'm thankful for. Wet reads too. We have a patient here who has some interesting neurological findings (stay tuned for a morning report once I'm back,) so someone had ordered a CT of the brain. We knew it had been done, but for days on end the plan was "Pursue results of CT." All of our potential treatments and further workup were on hold for that. Finally on Friday someone assigned a nursing student the job of physically tracking down the radiology report. Less than an hour later, we had our answer - a hand-written radiology report dated a week ago. There were significant findings, which the radiologist had correctly identified, but nobody had been notified, nor had the team had the organization to retrieve the report earlier.

I guess the secondary theme to this post, and another thing I never thought I'd be thankful for, is urgency. There is an utter lack of urgency in the hospital culture here, as the examples above illustrate. I'm a fairly laid-back person, but when it comes to a sick baby or child, I want things to happen quickly! It's easy to misinterpret the absence of urgency here as absence of caring about the children, but that's not the case -- everyone here clearly cares about giving these children good care, but in Namibia that caring is just not tied to anyone doing anything in a rush. As they say, this is Africa -- TIA!

*Sodium 115, Potassium 1.5

Domingo

Just one quick post tonight. This is Domingo. He hangs out on 8B where Sara is working. He's quite a social little guy, and all of the staff seem quite familiar with him, but one thing puzzled us about him - the team never rounds on him. We couldn't figure out why he is in the hospital. Today one of the sisters (nurses) finally provided the answer; when asked what is wrong with him, she looked a little sad and answered "Nothing is wrong - he's not sick. He's here for social reasons - his mother left him. She disappeared."

Child abandonment is sadly common here. He is one of many children in this position. It sounds as if he'll likely end up in an orphanage. When we asked about adoptions, Dr. Brown told us that the Namibian government does not allow their children to be adopted out of the country. In addition, it's a very difficult process to adopt children within the country. It requires a two-year fostering time during which the child may need to intermittently be sent back to the orphanage. At the end of the two years, the government can decide that you are not the appropriate family and send the child back to the orphanage.


Domingo is incredibly sweet and has very readily attached himself to Sara and me. He runs up to us and greets us with a tight hug around the legs whenever we see him. He is a very happy child and laughs easily. He's bright and loves to interact with people. He deserves a loving family, and yet, he is being raised in a hospital. We are unsure of Domingo's fate but feel that it is incredibly unfair, un-natural, and horribly sad that such a beautiful child should end up in a situation like Domingo's...

Shock

So, though I had been warned and though I thought I knew what to expect, I had no idea. Yesterday, was our first introduction to the hospital. Let me just share a few experiences with you to give you an idea of what it's like here.

One of the first patients I saw yesterday was a 6 year-old girl who presented because her "eyes were bulging". After a CT scan of her head, it became clear that she has some sort of malignancy. She has a posterior fossa lesion with eye involvement. She also has soft tissue lesions on her head where the cancer has eroded through the bone. She is completely wasted. She has left corneal scarring and cloudiness secondary to an inability to close her eyelid. The unfortunate thing is that I'm not sure her mother understands the gravity of the situation. No one updates her on rounds, and she doesn't speak English for me to explain. The patient will be transferred to the oncology unit tomorrow for palliative care.

I've seen TB with all its varieties of complications. We have a 3 year-old who suffers from cor pulmonale with massive ascites and hepatomegaly secondary to his chronic TB. For the past two days, every time I walk by his room, he is simply standing, leaning over a chair, and never moves as he is unable to lie down or even sit comfortably. There are two other children who have both HIV and TB. One of these patients has oral thrush and has been complaining of pain with swallowing and likely has esophageal candidiasis. The other is the most wasted child I've ever seen. You could see every rib, every bone in his face, and with pants on, sitting in bed, you couldn't even make out his legs beneath the material.

The social services system is equally abysmal. We had one child who we were treating for marasmus. He had been living on a diet of cornmeal and water. When Mom conveyed that she did not have enough money for food, one of the doctors told her, "We will place a social work consult, but you need to find work. No one is going to help you here in Windhoek." That's it. End of discussion.

The kids are absolutely adorable and are starving for attention. They follow you around everywhere. Their playroom consists of a tv. They have NO toys. Anywhere. Not even a pencil to draw with. They borrow our pens during rounds and write on their bodies.

In the afternoon, we go down to clinic. My first patient was a 23 month-old whose father was an alcoholic and mother died in childbirth. Her two aunts finally took over care for her in January. However, the child is a bit withdrawn and cries out at night, and the aunt has decided this is too much for her to handle. She kept asking me to admit the child despite her lack of any obvious illness. When I pointed this out, they said that she won't eat and she vomits when she eats. I gave her some of my trailmix, and she ate it all with no emesis. Then, they told me she will only eat sweet stuff and she doesn't want good food. I explained that picky eating was a normal part of toddler behavior. They then told me she was possessed by a demon. Now, I was stuck. What do you say to that? She is very withdrawn. She just sits there, does not make eye contact, and holds her hands tightly in front of her chest. I got the very distinct impression that if I admitted the child, the aunts would not be back to pick her up. Dr. Brown says child abandonment is not uncommon. It's incredibly sad, and I'm really worried about her...

Antelopes and Wildebeests and Leopards! Oh My!

So, we've arrived in Namibia, and what a fortiutous start we've had! First of all, our luggage arrived at the same time that we did. That was pretty exciting.
Monday was a national holiday, so we were lucky enough to go on a game drive with friends of the Browns, our hosts. We saw warthogs, ostriches, springbok, wildebeests, a herd of giraffes, and our favorite - the leopard! He is a rescued leopard that is quite friendly and as tame as any wild leopard is able to be. We both took a few (okay, very many) photos, and have attached a few at the end of this post.

Today was our first day at the hospital. We began the day with a tour of the entire hospital, from the Prem unit (i.e. NICU) to the 8th floor, which will be our home for the next 4 weeks. It's hard not to draw parallels between Katatura and Geisinger. The Prem unit had babies as small as 900g on oxy-hoods! One baby was on CPAP. If a baby needs to be intubated, they intubate and then use the NeoPuff to ventilate the baby until transport can arrive to take them to Central hospital, which is not too far away.

The 8th floor is divided into 8A and 8B. For now Tammy is on 8A, which has kids >2y to 13 years, and Sara is on 8B, which has patients less than 2 years old. Both units are full of interesting patients, though they can be a bit confusing - patients do not wear ID bands, nor do their charts stay at their bedsides. Rounds are a bit chaotic in that sense, with sisters (what they call the nurses) providing charts as the team moves from bedside to bedside. Quite a contrast with Epic, our electronic medical record system, and the ease of rounding which it provides.

We spend our mornings on the 8th floor and then afternoons in Katatura's version of Knapper Clinic, seeing walk-ins. Today was quite an introduction; between babies with reflux and kids with asthma we encountered a toddler with possible TB, a girl with developmental delay and a very frustrated family, and a child with a neck abscess. Unlike all the kids I saw on the floor with neck abscesses last month (who got CTs, IV antibiotics, and the occasional I&D), here we presumptively treated my patient with PO antibiotics and had him return to assess for tuberculosis in a week.

It's going to be a long and interesting month. We look forward to sharing more as the month continues. For now, here are those photos!

Goodbye, America!

Sara and I have succesfully navigated our way to the airport and are anxiously awaiting our flight! We're very excited to start our adventure and expand our horizons! Stay tuned...