And then there was one

Black Mamba? The jury is out.

Mollie left this morning and it was pretty sad. We were great support systems for each other and it was nice to have someone my age around. Now it is just me and Dr. Dillon at meals (one of the surgeons), and he is leaving next weekend. They are desperate for doctors here right now, there is one family medicine doctor which is basically consulting on all the wards, as well as running the peds ward over the past week when I was away because that is the ward the residents are most afraid of. The poor internal medicine residents have to cover the peds ward a couple months per year, so there is a lot of learning on the go. I am trying to mentally prepare for plowing through the next two weeks and taking all things in stride.

I can’t believe I left New York over a month ago. I never would have thought I would see the things I’ve seen or been in the role that I am now. They said that sometimes there are as many as 3 or 4 pediatricians here, but somehow I arrived in a time when there was none. I had mixed feelings about mission trips before I came, recognizing that what we do here might not be sustainable and, in the end, we end up getting more out of the trip than anyone else. This may definitely be true, but this experience seems different in that it is integrated into a Cameroonian residency program. The concept is fairly new in Cameroon and still has a long way to go, but is miles ahead of where it used to be. The residents here read up on their patients, do almost every procedure imaginable, attend lectures, and make the big decisions on a daily basis. There are so many cultural differences between residency here and in the US, but the general concept is the same. They don’t have the luxury of smartphones, but they do have textbooks and libraries and experience. When we round in the mornings and evenings, they can teach me procedures and endemic disease presentations and I can remind them how the physiology of a child is more than just a little adult. It is a symbiotic relationship that I do feel is sustainable, as they will carry it with them into the Cameroonian realm of public health. At the very least, perhaps they will face the peds ward with a little less trepidation.

So today I will adjust to some solitude and check under the beds for snakes. Maybe I will look for a job, maybe I will go on a solo hike, maybe I will start a new book. I will enjoy the calm before the storm, again. I appreciate the massive amount of support I’ve received from back home, I am so flattered and humbled by the newspaper article. I am happy that the story can be shared as a window into a world that we are not used to, perhaps not even aware of. It is not about a single experience of someone who comes here for a short time; it is a medium for recognizing and giving a moment’s thought to our brothers and sisters overseas. It is not about guilt, it is about compassion and awareness. It is about perspective and a common humanity. It is a shared sadness for Cedrik and a cheering squad for Rudolf, a reminder that we are all in this together.

Horses, snakes, healthy kids

This morning I woke up and looked out the window and there were two beautiful large horses feeding in the yard. Then brushing my teeth, thinking how nice staying in this house is, I spot something brown near the towel cabinet. I shine my phone light on it—it looks like a coiled piece of leather, but I haven’t seen it before. Step closer, is that an eye? Mollie, I need a second opinion. I think it’s a snake, is it alive? Is that where there are no crickets around? How did it get in here? Are there more?

Maybe it is a house snake that kills the crickets and hides in corners. We contemplate poking it with a broom then decide that I’m too afraid that it will slither into my room. Let’s not make it mad.  It’s breakfast time, so we head up to the guest house for breakfast. I hope it doesn’t move while we’re gone. I decided to show our cooks (Margaret and Confidence) a picture of the snake and ask if it is poisonous.

Margaret shrieks when she sees the picture and says “that is in the house?? It is very poisonous! It will crawl into your bed and bite you at night! You need to call someone!” Uh oh, now I really hope it didn’t move.  She continues, “don’t eat breakfast, I will call some people, go back to your house now and I will send men to kill it”.

So we head back to the house, crossing our fingers that the snake hasn’t moved, and three men with uniforms and large sticks show up at the house ten minutes later. “Very poisonous” they tell us, “swallow fowl eggs whole”, be careful and “carry a torch at night so that you don’t step on one”. So they beat the poor snake with sticks, holding it down by the head as the rest of the body thrashed around. I kinda felt bad for the snake for half a second before I remember the thought of one crawling into my bed. I think I will go back to using my sleep sack.

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Last night we had dinner at our friend Emmanuel’s house. He picked us up in the evening and drove us to his house which is close by the hospital complex. He has three boys, ages 5 (Whitley), 7 (Keston), and 9 (Bradley) and a wife that is studying public health in Youande. There are neighbors/family members that help take care of the boys when he is away for work. One of the young girls helping around the house prepared us a goat from the yard in a stew that was served over rice. I clandestinely scooped only the sauce and veggies and Mollie got stuck with trying to politely chew the skin. The sauce with rice was very very tasty. We drank grenadine soda which was super sugary and had full blown diabetes by the third glass.

We sat in the main room and looked through photo albums and he talked to us about life in Cameroon. You could see the kids’ room across the hall with mosquito nets there because “it is hard to stay in the hospital when the kids get malaria”. The three boys played drums and hide and seek. The one would count to ten and then say “ready?” and then the other two would respond “ready!” which would completely reveal their hiding spots every time. They didn’t seem to mind. They also played a game with bottle caps where they would stack the caps and place a peanut in them and try to knock them over with another bottle cap. If you knocked the tower over you won and would get the peanut. They giggled the whole time, grenadine running through their veins and American caramels between their teeth.

Alas, healthy children.

We gave Emmanuel a solar-powered flashlight/phone charger that one of the NICU nurses had given us for our trip. He travels a lot at night so it was a perfect gift to thank him for welcoming us into his home. He loved it! And of course the kids loved the sticky caramel. He was such a great host and kept apologizing to us saying, “my wife would be much better at hosting if she was here”. He told us a lot about the way things work in Cameroon and the advances that have been made in recent years. He spoke about the traditional healers and weddings and education and children and traditions. He showed us pictures of his friends, many of which have moved to the US. When I asked him what they do in the US, he responded, “we don’t ask that question, we don’t want to know what they are doing there”. I wondered what he meant by that, but it didn’t sound good.

This Sunday is Cameroon’s National Woman’s Day. I’ll have experienced Youth Day and Woman’s Day while I’m here, so I asked if there was a Man’s Day. Emmanuel laughed and said “every day is a Man’s Day”. He beat me to the punch line.

Mollie leaves tomorrow which I’m bummed about. I will have to get better at entertaining myself, maybe set up some peanuts and bottle caps. I will be busy again on Monday when I am back on the wards and stressing about the little kids with big bellies. And then in a couple weeks I will be in Paris with the long lost boy. I can’t believe it’s already been a month since I got here, so much experience in such a short amount of time. So much to digest.

Thursday

I stopped by the pediatrics ward this morning, it seems calmer than past weeks. The 1 yo and 14yo with cerebral malaria went home. One of the girls with the massive splenomegaly is getting a splenectomy and the other one is still spiking high fevers despite every imaginable antibiotic, antimalarials, and tuberculosis treatment. I wonder what we’re doing for her other than racking up a bill at this point. What else can we do? I will be back on the wards starting on Monday and then on call for the next 7 days straight and then coverage without night call for my final week.

Rudolf and his mother and grandmother, three generations of toughness

Another one of the surgeons left this morning and Mollie leaves on Saturday. They gave me the option of moving to a small room close to the hospital if I was nervous about living in the big house by myself, but I think I will stay because it feels like a nice getaway from the hospital when things are crazy. Also, one of the surgeons lives next door, so that is nice. But it’s good to have options, in case I scare myself. There are no new residents coming until April, so I think it will be a little lonely here once Mollie leaves. There’s not much to do at night, it gets dark early and no one is out and about after the sun goes down. I guess I can catch up on my reading or continue to try to find a job. There’s a beautiful horse that hangs around the house at night—its two front legs are tied together so that it can’t go too far, but it is kinda nice to have horse as a house pet. Something other than all the spiders.

Last night we made a fire which attracted the bugs which attracted the bats and scared us back into the house. Tonight we are going to one of the hospital workers’ house for dinner “to see what a real African home is like”. I’m excited for that. Not much else to say today, as we are catching up on data entry so that most of it will be done before Mollie leaves. Hope all is well back home and overseas.

Walking home from school...

Back to Bamenda

On the home front the 11mos old little girl with schizencephaly died suddenly en route to getting her CT scan in Bamenda. I don’t know the details of what happened, but I’m not sure I want to. She looked so good the last time I saw her, sitting up in bed, eating fufu on her mom’s lap, smiling. I was shocked to hear the news last night.

I sweat out my fever last night and woke up feeling better after a magical cocktail of Cipro, Benadryl, Zofran, and Excedrin. Doctors really do make the worst patients.

We hitched a ride to Bamenda this morning with one of the “runners” who go into the city once/wk to pick up supplies, mail, etc. There’s no real mail system in rural Cameroon- the roads are too difficult and it overall it not very practical in this setting. Most people out where we are don’t have addresses, just locate themselves as living “between the church and the football field” or “around the corner from the large chicken coup.” Kinda hard to put a stamp on that. Of course if the hospital needs something, the runners make the drive to Bamenda to pick it up.

We met Fanny (study coordinator) in Bamenda this morning to pick up more material for our study. She has been busy acquiring 18 mos HIV ELISA results from the babies in our study, so we will be busy abstracting them into our database over the next couple of days.

Fanny is great, she’s young and beautiful and full of enthusiasm for public health. She says she’s really enjoyed taking part of this study, as she has had the opportunity to work with and befriend a lot of young women with HIV. She says that it is still very stigmatized and often people don’t go to the hospital because they are too ashamed. But it is getting better. She is applying for a Fulbright in various places with plans to return to her Cameroonian community to utilize the skills she has acquired for better public health education. She will do great things.

Almost all of our patients fall in the first category.

We ate Njama njama and Fufu for lunch (our staple) in the health center canteen and walked to a nearby store to check out the goods.

Corn FuFu and Njama njama

Did I mention that you eat it with your hands?

African Guitars!

Williet (the dressmaker) met us at the Health Center and brought us the dresses/skirts that she had made with the material we bought. They look great, although I’m not sure how practical Brooks’ African-style shirt will be. At the very least, it will be a nice photo op.

Handmade dress, handpicked materials

               

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Skirt with matching bag that Wiliet threw in for free :)

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We’ve been told many times since we’ve been here that Mbingo Baptist Hospital is where people go for miracles. Unfortunately, they often go to traditional healers and small clinics before making it here. Often they believe that their ailments are due to witchcraft or revenge, so it would make sense that they see a traditional healer first. The problem is that by the time they make it here, things are often too far-gone to reverse. Many children are brought in in comas, many patients die within hours of making it here. There’s no easy answer to this problem, there are so many barriers. It is the culture of disease, the difficulty of travel, the scarceness of clinics, the cost of travel and healthcare, the fear of the medical system. But when they are at their last wit, their last breath, their last leg to stand on, they show up at our doorsteps and hope for a miracle.

Another day

The baby with jejunal atresia died last night. It was sad, but she was in her mother's arms which is worth something. Her tiny body just couldn't handle the surgery. One of the nurses told me that often mothers here wait a couple weeks after their babies are born to name them, as so many die within infancy. The constant deaths are getting to me a little bit. So many young eyes I've had to close in the last couple weeks, so many silent chests I've had to confirm. On the adult side there is so much AIDS and tuberculosis, on the children's side so much foregone organ failure. The men and women are skeletons of their former selves, the children are big bellies with tiny malnourished extremities. The sadness comes in waves. On the one hand I am beginning to expect death, beginning to expect it as a part of life here. But on the other hand, I am fighting the urge to get used to it, to accept it. It is a lot to process.

But to remember the Rudolfs, the triplets, the cerebral malarias back from the dead- that is our saving Grace.

I spent most of the day in bed with a stomach bug- maybe it was something I ate or something I caught from the kids.I tell myself to be as tough as an African child, but I can't help craving gingerale and my own bed back home. After all, who can be as tough as an African child?

The hospital I'm working in used to be called Hansen's Disease Hospital (Leprosy Colony), but has since expanded to include anything and everything. There is a small store at the entrance of the hospital affectionately known as the Leper Store which consists entirely of hand-stitched goods crafted by people with Leprosy. Bought some small items there yesterday for my sisters and mom, as well as Jonas' sisters and mom, I think it is worth as much as the story behind it. I bought my father a woven bookmark to use in his missalette, a small bag for myself.

Tonight the fever will break and tomorrow I will head back to Bamenda. The rollercoaster will continue, as there is still so much to learn and understand.

A day in pictures

Today was our first day off the wards, our first day to catch our breaths. Spent the morning working on our research project, went for a hike after lunch, drank freshly ground coffee, read for pleasure, washed our white coats, picked fresh avocados, Mollie caught up with her husband, I fell asleep on the back porch.

Both baby surgeries went well yesterday. The little boy with intussusception in fact had intussusception- the oblong mass that I felt in his abdomen was his bowel telescoping onto itself. The surgeons cut out a small portion of his bowel and performed a primary anastomosis. I think he will be okay. The little girl with the jejeunal atresia tolerated the procedure well, the trick will be giving her adequate nutrition while she heals and her bowel recovers. The family medicine doctor's wife is a nutritionist, so they are trying to concoct a poor-man's TPN. That would be pretty great if it works.

Yesterday I caught up with some people with skype/facetime until the power went out. My parents looked like they were seeing a ghost when they realized my face was on the phone. Technology is nuts. I got to show them the cattle, the banana trees, and the view from the back porch. It was nice to share the view with them.

And, some pictures...

One of the back roads through Mbingo

A little pink amongst the green and brown

Finishing off "This is Where I Leave You"

Walking beyond the school for the deaf. Many children are left deaf after childhood meningitis, TORCH infections, congenital deformities, etc. There is a school on the far end of the hospital campus, many children board there as well. 

Cattle driver leading the herd back to the corral beside our house

Another house alongside a back road in Mbingo. There were children outside chasing around the chickens. The kids here are really good at entertaining themselves. Today we passed a couple boys playing soccer with an empty coke bottle and a little girl guiding a metal hoop around with a wooden stick. Things are simple but they are happy. "Gooood afternoon whiteman" they say to us. Sometimes the teenagers take pictures. 

Small hut along the road

Working on our research project, drinking tea from the plantation we visited on Saturday (Cameroon Tea Estates).

Taking a break in the shade of the banana leaves

Down the dusty path

Fresh avocado is everywhere. They call them pears here.

Some boys playing football/soccer on Sunday afternoon near the church.

Is it March already?

"Double Bubble" sign

Our little baby with jejunal/duodenal atresia is going to the OR today. We had another baby come in with bloody stools and an oblong hard mass in the LLQ. Ultrasound showed some ascites and didn’t comment on the mass. Intussusception? I’ve read about the “sausage mass” and bloody stools but I have never seen or felt it before. Surgeons are going to take the baby to the OR and find out. With limited imaging, it’s kind of how things go here. All I know is that I’ve not felt something like that before, but if they find intussusception then I guess medical school multiple choice questions are valuable after all.

Achu's X-Ray

Unfortunately the little boy (his name was Achu) who came in with what looked like acute liver failure and sepsis/ARDS died last night. He was so so sick. I can’t believe he walked into clinic the other day, let me look into his ears, pick him up onto the exam table, palpate his belly. Just hours away from rapid decompensation. He looked so horrible. I keep wondering if there was anything else I could’ve done. With an albumin of 1, he was third spacing all of his fluids. Would dopamine have helped or just prolonged the inevitable? Would Lasix have made his death more comfortable? Mollie says she sees this type of picture on the adult side all the time—usually the patients come in with acute liver failure from toxins, etc and are dead by the morning. Even in the U.S. I guess I’m just not used to seeing kids decompensate so quickly, it’s hard to believe that there was nothing I could do.

But overall, a lot of the kids are doing better. The 1yo boy previously in a coma is starting to eat by mouth and will likely go home tomorrow. The two with cerebral malaria are acting more and more like themselves. The baby with HIV has finally broke her fevers and is looking better every day. I’m a little nervous that I won’t be on the wards this week. I’m sure everything will be fine, but sometimes it is difficult to remember that children are not just little adults. After all, this is an internal medicine residency, they just happen to have a children’s ward. It is very scary to think that at some points there are no pediatricians or family medicine doctors here. These kids are very VERY sick. Even at the peak of my pediatric residency training- chock full of inpatient and intensive care exposure- it is very difficult to manage these kids in their end-stage conditions. I certainly have learned more in a couple weeks being here than many months of residency training. My physical exam skills are the best that they’ve ever been- often it is all I have to rely one. I’ve been able to consult cardiology, general, derm, radiology, PICU, NICU, heme/onc, infectious disease via email, and it has been life-saving. It’s surprising how much you are able to do when you have no choice but to do it. And people are happy to help.

Reminds me of one of my most traumatic experiences of residency (up until now), which occurred my intern year. A 9yo child with trisomy 21 was admitted to the floor NPO and on fluids for possible SBO. She was up and talking upon admission, between vomiting episodes. Alone and tired at 3am, I did a routine (and easy) admission, and prepared for the next admission. Nurse calls and says her IV came out, so I begrudgingly head to her room with supplies. But upon entering the room, her eyes are rolling back in her head and she is not responding. I put oxygen on her face, as the intern from the other floor arrives to help with the IV. I listen to her chest and I hear complete silence. We immediately launch into full CPR. Malodorous vomit spews towards my face with every chest compression. Long and horrible story short, we coded her for close to an hour and she never regains a pulse and never has a shockable rhythm. Diagnosis was likely cardiac arrest from disseminated clostridium perfringens seeded throughout her young body. A freak diagnosis. A hypothesis, really. The date was March 26^th of my intern year and I will never forget the feeling of placing my stethoscope on a dead body. The point of the story, however, is that we have an inner instinct to do what we need to do in situations that we need to do it. I would not consider myself one of those people who gets huge adrenaline rushes in the face of acute situations. I hate mock codes, I get nervous for PALS training. But at that moment, I snapped into CPR gear before my mind could even process the situation. It was an instinct. That is what happened then, and that is what is happening now. Any one of my co-residents placed in this situation would do the same here as I am doing. They probably would be better at reading EKGs and placing IVs. This is what our training is for, this is what our 30 hour calls are for, this is what our sleepless nights are for. We have the ability to do so much more than we think we do, especially when we have no other choice. We have our training, our faith, our vulnerability, our good intentions. And sometimes, god-willing, we hear a heartbeat after an hour of chest compressions.  

Tomorrow Rudolf will likely go home, will likely WALK out of the hospital. I asked him if I could take a picture to show my friends and he acted as if I had just donned him a celebrity. His mother straightened out his shirt and scolded him to sit up straight. This is a great success story. He will play soccer, he will have a future, he will live beyond his childhood.

Sitting up and smiling, ready to go home tomorrow.

Spent the afternoon at a tea plantation yesterday, was good to escape the hospital for a while. Took a couple hours to get there and involved pushing the car uphill under the hot African sun, but was so worth it...