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2007-02-09
2007-01-23
Oncology clinic
Thursday afternoons are the part of my week that I both look forward to and dread.
It takes a very special person to want to be an oncologist. I am not that special.
My friends ask me how I deal with the constant flow of sick people and misery and pain. I have a little secret to tell you: it's not always like that. My days are full of people finding something that makes them smile, of people having ordinary problems like being a little constipated or hating red jello. And I like people, generally.
Surgery is fantastic because you get to see people come in sick, get operated, and get better. They go home and maybe a month later you see them in clinic looking like a rock star.
But now I'm doing clinics and in their infinite wisdom (and the fact that I didn't know what to choose so I left it up to my school) the powers that be have decided to plunk me into medical oncology clinic.
Now I am dealing with a constant flow of sickness and misery and pain and fear and the unknown and side-effects....
A young man who has had a complicated course with Ewing sarcoma and who had eventually decided not to have any more surgery or chemotherapy came to see us for follow-up. He had been pursuing several holistic therapies, and he felt that these were helping. Though he was having some pain, he chose not to speak to the palliative care team, because he was not ready to accept 'palliative care,' end-of-life care, terminal care, whatever you want to call it. He pushed for a follow-up CT scan to see whether his tumours were actually getting smaller. The oncologist did not want to do the scan, but to just follow-up clinically. But he did the scan because the patient wanted it.
And it showed the tumours growing. A lot.
The patient was terribly disappointed. He is now having more pain. He is panicking at night when he is alone. He is asking us about the possibility of more surgery, which of course at this point would be of more harm than good. He finally realises that this cancer is going to kill him, and soon.
Finally, now, he has decided that palliative care might be a good idea. They are a good idea. These are people who have put the art back into medicine. They are a group of people who take whole-person care to heart, and will talk to a patient about his fears of dying, about what his hopes are for the remainder of his life, and for those he will leave behind. They have also taken the science of pain control to a whole new level.
For simple people like me, this is hard.
It takes a very special person to want to be an oncologist. I am not that special.
My friends ask me how I deal with the constant flow of sick people and misery and pain. I have a little secret to tell you: it's not always like that. My days are full of people finding something that makes them smile, of people having ordinary problems like being a little constipated or hating red jello. And I like people, generally.
Surgery is fantastic because you get to see people come in sick, get operated, and get better. They go home and maybe a month later you see them in clinic looking like a rock star.
But now I'm doing clinics and in their infinite wisdom (and the fact that I didn't know what to choose so I left it up to my school) the powers that be have decided to plunk me into medical oncology clinic.
Now I am dealing with a constant flow of sickness and misery and pain and fear and the unknown and side-effects....
A young man who has had a complicated course with Ewing sarcoma and who had eventually decided not to have any more surgery or chemotherapy came to see us for follow-up. He had been pursuing several holistic therapies, and he felt that these were helping. Though he was having some pain, he chose not to speak to the palliative care team, because he was not ready to accept 'palliative care,' end-of-life care, terminal care, whatever you want to call it. He pushed for a follow-up CT scan to see whether his tumours were actually getting smaller. The oncologist did not want to do the scan, but to just follow-up clinically. But he did the scan because the patient wanted it.
And it showed the tumours growing. A lot.
The patient was terribly disappointed. He is now having more pain. He is panicking at night when he is alone. He is asking us about the possibility of more surgery, which of course at this point would be of more harm than good. He finally realises that this cancer is going to kill him, and soon.
Finally, now, he has decided that palliative care might be a good idea. They are a good idea. These are people who have put the art back into medicine. They are a group of people who take whole-person care to heart, and will talk to a patient about his fears of dying, about what his hopes are for the remainder of his life, and for those he will leave behind. They have also taken the science of pain control to a whole new level.
For simple people like me, this is hard.
Everyday or Madman?
Anagram genius may just reveal something about you.
To those who know me, that the above is an anagram of my name will come as no surprise. Oh, minutes of fun.
To those who know me, that the above is an anagram of my name will come as no surprise. Oh, minutes of fun.
2007-01-20
I'm not a doctor but I play one on TV
Trust the Brits to do something like this: *scientific proof* that surgeons are hot!
Gotta love it.
**OK, it's a joke, but told well.
Gotta love it.
**OK, it's a joke, but told well.
2007-01-16
A Madonna
Just reading one of my favourite blogs, by Fat Doctor, which is a thoughtful and often very personal look at life from the point of view of a beautiful and sensitive soul who happens to be a doctor.
She was talking about her desire for another child and her despair at China's new and restrictive rules on just how perfect you have to be to become an adoptive parent.
Someone in the comments section jokingly suggested "pulling a Madonna," and I wanted to comment without taking over, because of my own recent experience.
I met two azungu (white) families who had adopted Malawian children. They can attest that the government don't make it easy, and the reception by local people is not always warm.
There are about 900 000 orphans in Malawi, a country of only 13 million people. Given that fact, you could be forgiven for thinking that the government and people of Malawi would welcome families from abroad looking to adopt a child. So why isn't this the case?
I put this question to a woman who has worked in Malawi for the past eight years. She pointed out what should have been obvious: how orphaned children are regarded in Malawian culture.
It is true that there is normally a social safety net, that children would be taken in by their extended family.
What is not generally said is that these children are often not raised "as one of our own," but are used as a form of cheap domestic labour. As in any society, these children are vulnerable to sexual and physical abuse. They are unlikely to be sent to school. They are treated as workhorses.
So what would a white family want with an African child?
It seems unlikely in a place where resources are so very scarce that this child will be a cherished one, given the best that the adoptive parents can afford in terms of education and food and clothing.... it seems unlikely that this child will be coming into a loving environment. It becomes much more believeable that these children will be exploited.
Child labour.
Trade in human organs.
Witchcraft.
The list of incredible and distasteful rumours goes on.
She was talking about her desire for another child and her despair at China's new and restrictive rules on just how perfect you have to be to become an adoptive parent.
Someone in the comments section jokingly suggested "pulling a Madonna," and I wanted to comment without taking over, because of my own recent experience.
I met two azungu (white) families who had adopted Malawian children. They can attest that the government don't make it easy, and the reception by local people is not always warm.
There are about 900 000 orphans in Malawi, a country of only 13 million people. Given that fact, you could be forgiven for thinking that the government and people of Malawi would welcome families from abroad looking to adopt a child. So why isn't this the case?
I put this question to a woman who has worked in Malawi for the past eight years. She pointed out what should have been obvious: how orphaned children are regarded in Malawian culture.
It is true that there is normally a social safety net, that children would be taken in by their extended family.
What is not generally said is that these children are often not raised "as one of our own," but are used as a form of cheap domestic labour. As in any society, these children are vulnerable to sexual and physical abuse. They are unlikely to be sent to school. They are treated as workhorses.
So what would a white family want with an African child?
It seems unlikely in a place where resources are so very scarce that this child will be a cherished one, given the best that the adoptive parents can afford in terms of education and food and clothing.... it seems unlikely that this child will be coming into a loving environment. It becomes much more believeable that these children will be exploited.
Child labour.
Trade in human organs.
Witchcraft.
The list of incredible and distasteful rumours goes on.
2007-01-15
Snow Problem
It appears that we Montrealers got used to the idea that this winter wasn't playing by the rules. Currently listening to the traffic reports, and it sounds like we have forgotten how to drive in snow!!
So ashamed.
Missing Malawi today. Walked home in the snow. Not entirely looking forward to digging my car out by Wednesday (due to the impenetrable parking laws that only living here for a decade or more gets you to the point where you can begin to not get parking tickets, I have to move my car by then or get ticketed).
Still, how beautiful is my city?
And how lucky am I ?
I have the perfect solution to this weather.....
Stay in.... blog.... write papers...... drink hot chocolate...... study....... in front of a roaring fire.....Update: The radio announcer just said the words "Gong Show" in the context of traffic reports. That's generally not good news, is it?
Distraction
Read this.
My school was worried about me going to Africa and putting myself at risk, but the truth is, it could as easily happen here. In Montreal we don't, for example, use the self-sheathing syringes he cites as a great improvement, we use the old-fashioned and appreciably cheaper sort that they also use in the UK.
In Malawi, we had the other type. Due to the perception of the risk, no doubt. I liked them.
My school was worried about me going to Africa and putting myself at risk, but the truth is, it could as easily happen here. In Montreal we don't, for example, use the self-sheathing syringes he cites as a great improvement, we use the old-fashioned and appreciably cheaper sort that they also use in the UK.
In Malawi, we had the other type. Due to the perception of the risk, no doubt. I liked them.
2007-01-11
Coming home
Funny to think that I just came back from Africa and if I went to hospital with gastro, the docs would have thought I'd brought it home with me.
But now the hospitals are being hit hard by Norwalk. Not to mention our beloved Montreal Canadiens.
Me, I'm back in the classroom and so am missing out on this one.
But now the hospitals are being hit hard by Norwalk. Not to mention our beloved Montreal Canadiens.
Me, I'm back in the classroom and so am missing out on this one.
Too true
| You Are the Swedish Chef |
 "Bork! Bork! Bork!" You're happy and energetic - with borderline manic tendencies. No one really gets you. And frankly, you don't even get you. But you sure can whip up a great chocolate mousse! |
Check it out! Found whils giggling at Mr. Hassle's Long Underwear by Doc Shazam.
2007-01-10
Waiting to Exhale
Which could be a reference to my failed attempt at scuba diving on Christmas Eve. Probably doable but not much fun when you are the only one in the group who doesn't speak Danish and therefore you have nobody to giggle and be a moron with. Breathing underwater is not obvious. Next time.
In actual fact refers to the currently waiting and living in limbo state of getting ready for/doing interviews which will decide the trajectory of my life. Questioning the wisdom of throwing myself wholeheartedly into my hope of becoming a surgeon rather than hedging my bets like most of my class did, applying to a specialty but also a second choice 'just in case.'
I figured any second choice programme would look at my record and laugh their heads off, it's so obvious I want to do surgery.
Still, if I chewed my fingernails, I'd probably be heading for the elbows by now. Wish me luck.
In actual fact refers to the currently waiting and living in limbo state of getting ready for/doing interviews which will decide the trajectory of my life. Questioning the wisdom of throwing myself wholeheartedly into my hope of becoming a surgeon rather than hedging my bets like most of my class did, applying to a specialty but also a second choice 'just in case.'
I figured any second choice programme would look at my record and laugh their heads off, it's so obvious I want to do surgery.
Still, if I chewed my fingernails, I'd probably be heading for the elbows by now. Wish me luck.
Oh and What a Time
Well, I hope you had a Merry Generic Holiday Season and all that other politically correct stuff.
Imagine, if you will, something more out of place than an Evangelical Atheist in an African Baptist Church on Christmas Day with a load of International Faithful Folks and an African American preacher from Mississippi or Tennessee or somewhere where they really do say things like "Can I get an AMEN!!!"
I was looking for the hidden cameras.
*****
This is what a Christmas tree looks like in Embangweni, a little town in Northern Malawi where the language is different but similar (-Muli uli? -Ndili makola, kwali imwe?).
I haven't had a Christmas tree in years, something to do with being a cynical atheist who hates all the commercialism that has taken over some beautiful old pagan traditions. And a bit of a Scrooge (bah, humbug) as well.
But I found decorating this one in Malawi oddly comforting. Thanks for sharing it with me, Martha.
*******
Christmas coincides with malaria season. Love that mefloquine. No problems this time. Gotta say, it really helps to take it in the morning or at least with meals to avoid the terrible heartburn.
Love that mozzie net. Because:
If you look REALLY CLOSELY, you should just about be able to make out what the sign in the minibus' rear window says.
And to answer the question:
This was the view I woke to on Christmas Day. Lake Malawi, Nkhata Bay, rainy season.
Mayoka Village.
Imagine, if you will, something more out of place than an Evangelical Atheist in an African Baptist Church on Christmas Day with a load of International Faithful Folks and an African American preacher from Mississippi or Tennessee or somewhere where they really do say things like "Can I get an AMEN!!!"
I was looking for the hidden cameras.
*****
This is what a Christmas tree looks like in Embangweni, a little town in Northern Malawi where the language is different but similar (-Muli uli? -Ndili makola, kwali imwe?).I haven't had a Christmas tree in years, something to do with being a cynical atheist who hates all the commercialism that has taken over some beautiful old pagan traditions. And a bit of a Scrooge (bah, humbug) as well.
But I found decorating this one in Malawi oddly comforting. Thanks for sharing it with me, Martha.
*******
Christmas coincides with malaria season. Love that mefloquine. No problems this time. Gotta say, it really helps to take it in the morning or at least with meals to avoid the terrible heartburn.
Love that mozzie net. Because:
- It is BLUE.
- It keeps the little buggers from whining in your ears which is possibly the most annoying thing in the world.
- It also keeps out cockroaches, mice, snakes, and other assorted things you don't want to be thinking about whilst trying to sleep.
- It is impregnated with permethrin which kills off anything creepy-crawly which happens to creepy-crawl over it.
- Did I mention the whole BLUE thing?
- Oh yeah, three years, Elephant Marsh, Mulanje foothills, Lake Malawi, you name it and NO MALARIA.
If you look REALLY CLOSELY, you should just about be able to make out what the sign in the minibus' rear window says.And to answer the question:
- There will be 23 people at least in this Hiace
- I could tell you how fast they go but you wouldn't believe me. It doesn't seem scientifically possible for such a small engine to pull that much weight at these speeds. But as my old friend Dirk used to charmingly comment on such things: "Science stops at the equator."
- Traffic accidents are deadlier than any tropical disease.
This was the view I woke to on Christmas Day. Lake Malawi, Nkhata Bay, rainy season.Mayoka Village.
2006-12-16
Ectopic in the Tropics, with Icky Photos
Hanging out with the curios sellers, buying jewellery. Only three working days left to this rotation, in Embangweni which is in the Northern Region.
******
An eventful month for me. Twins. Triplets. Breech deliveries. Cord prolapse. Uterine rupture. Ovarian cancer. Cervical cancer. Ectopic pregnancy. Tuberculous pleural effusion, tuberculous osteomyelitis, tuberculous cystic abscess, pulmonary tuberculosis. HIV positive, HIV negative. Kaposi sarcoma. Cerebral malaria, neonatal malaria, malaria with anemia, or just ordinary malungo. Kwashiorkor. Septic abortion.....
*******
Ectopic pregancy in Canada presents in a particular way: pain, positive pregnancy test, ultrasound showing no intrauterine pregnancy but not necessarily locating the ectopic, and not necessarily showing blood in the abdomen. But this is the fear: a ruptured tube and exsanguination (bleeding to death in the abdomen).
It is managed urgently or emergently depending on the level of pregnancy hormone and the presence of fluid in the abdomen. Either methotrexate to cause the pregnancy to abort and resolve, or if it is too late for that, surgery to remove the pregnancy and the source of bleeding.
In Malawi, women put up with incredible amounts of pain before coming to medical attention. And sometimes the results are surprising.
The doctor I have spent this month with tells a story of a lady who presented to Zomba Central Hospital because she was overdue. They confirmed her dates and tried to induce her labour, but nothing happened. They gave her repeated doses of drugs but her cervix stayed as tight as Fort Knox.
Eventually she left this hospital, because she felt she was not being helped, and presented to MMH. There, they performed an ultrasound and found that the baby was outside the uterus. The placenta had implanted on the outer wall of the uterus, and the amniotic sac was intact in the abdominal cavity. They performed a laparotomy to remove a live post-term female infant with apgars of 8 and 9.
Mother and baby did fine and went home after a week.
*****
Of course, this is unusual. I saw a lady who was sent to us by the prenatal clinic, known as sikelu or scale. She was sent for failing to gain weight normally. Her last menstrual period had been in April, but her uterus was 22 weeks, and felt, well, weird. There was a hard lump that felt subcutaneous in the epigastrium.
******
An eventful month for me. Twins. Triplets. Breech deliveries. Cord prolapse. Uterine rupture. Ovarian cancer. Cervical cancer. Ectopic pregnancy. Tuberculous pleural effusion, tuberculous osteomyelitis, tuberculous cystic abscess, pulmonary tuberculosis. HIV positive, HIV negative. Kaposi sarcoma. Cerebral malaria, neonatal malaria, malaria with anemia, or just ordinary malungo. Kwashiorkor. Septic abortion.....
*******
Ectopic pregancy in Canada presents in a particular way: pain, positive pregnancy test, ultrasound showing no intrauterine pregnancy but not necessarily locating the ectopic, and not necessarily showing blood in the abdomen. But this is the fear: a ruptured tube and exsanguination (bleeding to death in the abdomen).
It is managed urgently or emergently depending on the level of pregnancy hormone and the presence of fluid in the abdomen. Either methotrexate to cause the pregnancy to abort and resolve, or if it is too late for that, surgery to remove the pregnancy and the source of bleeding.
In Malawi, women put up with incredible amounts of pain before coming to medical attention. And sometimes the results are surprising.
The doctor I have spent this month with tells a story of a lady who presented to Zomba Central Hospital because she was overdue. They confirmed her dates and tried to induce her labour, but nothing happened. They gave her repeated doses of drugs but her cervix stayed as tight as Fort Knox.
Eventually she left this hospital, because she felt she was not being helped, and presented to MMH. There, they performed an ultrasound and found that the baby was outside the uterus. The placenta had implanted on the outer wall of the uterus, and the amniotic sac was intact in the abdominal cavity. They performed a laparotomy to remove a live post-term female infant with apgars of 8 and 9.
Mother and baby did fine and went home after a week.
*****
Of course, this is unusual. I saw a lady who was sent to us by the prenatal clinic, known as sikelu or scale. She was sent for failing to gain weight normally. Her last menstrual period had been in April, but her uterus was 22 weeks, and felt, well, weird. There was a hard lump that felt subcutaneous in the epigastrium.
We did an ultrasound and what we saw led us to schedule a laparotomy for the next day.
The hard lump turned out to be a calcified fetus, which had died months previously, presumably when the placenta could no longer get enough blood from where it was attached to keep up with the fetal growth needs. It was largely resorbing and only some fetal parts were identifiable.
The placenta was attached to the woman's right fallopian tube, and had destroyed the tube. It had developed into a large vascular ball instead of the flat leafy shape we are used to. The lady had, on history, had a lot of pain in May and througout the pregnancy, really, but had thought it normal and never complained.Her uterus and other tube were normal, and in all likelihood, she will be able to complete her family. She recovered without incident and went home a week later.
2006-12-15
Missing Home
Well, sometimes.
I'm on the traveller's weight loss programme. More effective than Jenny Craig, faster than Weight Watchers. *sigh*
But my sister sent me this photo, and you know what? It makes me really grateful to be here.
2006-12-11
Mangoes
How much does a mango cost? You know, the fat red creamy ones?
The ladies are selling them for under 5 Kwacha each. There are 275 kwacha to the British pound. It's highway robbery to take them away for that, but they are so plentiful, none of the locals are buying for more.
I love mangoes, and to help out the ladies I am buying tons of them. I expect to be orange and sweet by the time I go home.
*****
The hospital had a busy weekend. Two uterine ruptures: one baby survived, the other came in too late.
But both mothers survived. And you know what? That's a damn miracle.
******
This morning's entertainment: Young girl from Mozambique, from Villa Milanje. Hello. Oh, you're due this week. Having abdominal pain and that's why you came in. Okay.
Who came with you? (Every patient has a guardian to cook for them, wash their clothes, advocate for them.) Your mother and your sister? Alowetsani (bring them in).
And so in comes sis. Also pregnant, with a notebook which serves as a medical chart here in Malawi. Hm. A load of help YOU'RE going to be. Also due this week. No abdominal pain.
You're sisters? Yes.
Same mother and father? Ah, no.
Same mother? No.
Oh. Same HUSBAND. Not sisters, co-wives.
Both doing fine, both around 19 years old, both due this week. I hope he's faithful to both of you, because if not he's putting a lot of people at risk.
The ladies are selling them for under 5 Kwacha each. There are 275 kwacha to the British pound. It's highway robbery to take them away for that, but they are so plentiful, none of the locals are buying for more.
I love mangoes, and to help out the ladies I am buying tons of them. I expect to be orange and sweet by the time I go home.
*****
The hospital had a busy weekend. Two uterine ruptures: one baby survived, the other came in too late.
But both mothers survived. And you know what? That's a damn miracle.
******
This morning's entertainment: Young girl from Mozambique, from Villa Milanje. Hello. Oh, you're due this week. Having abdominal pain and that's why you came in. Okay.
Who came with you? (Every patient has a guardian to cook for them, wash their clothes, advocate for them.) Your mother and your sister? Alowetsani (bring them in).
And so in comes sis. Also pregnant, with a notebook which serves as a medical chart here in Malawi. Hm. A load of help YOU'RE going to be. Also due this week. No abdominal pain.
You're sisters? Yes.
Same mother and father? Ah, no.
Same mother? No.
Oh. Same HUSBAND. Not sisters, co-wives.
Both doing fine, both around 19 years old, both due this week. I hope he's faithful to both of you, because if not he's putting a lot of people at risk.
2006-12-07
Tragedy
Woman presents in labour. Ominous past history: five pregnancies with two micarriages, one stillbirth and one live baby. But all seems well.
Baby's heart recorded at 9am as 150 beats a minute, normal for a fetus. Mother progressed slowly but steadily.
At 1340, the nursing notes say that the baby's heart rate was 122, still normal; and on vaginal exam they say the mother had reached 6cm, but they thought they felt placenta, so they sent for the clinical officer.
I showed up by chance. Nobody had called for the doc yet as the iCO was still examining the patient. He looked up with that nervous African smile that it takes people forever to understand does not mean happy, and said two of the most dreaded words in obstetrics: "Cord prolapse." I turned and ran for the doctor, who grabbed her dopplex and came.
Cord prolapse is when the baby's blood and oxygen supply, the umbilical cord, slips ahead of the baby's head into the mother's pelvis. When mum has a contraction, the force of the baby's head compresses the cord, cutting off baby's oxygen. You have very little time, minutes to get a baby out in that situation. It's hairy in the best of hospitals.
She handed me the dopplex, and ran to grab her ultrasound, ordering everyone to get ready for an emergency cesarean. I searched frantically for a heartbeat. I could hear placenta. I could hear mum's vessels.
But nothing. Nothing.
The doctor returned with the ultrasound and quickly visualised the heart. We were too late.
The intern clinical officer explained to the mother in Chichewa that her baby had died. She began to cry. The commotion around her stopped.
In Malawi, to respect the family's grief, only the immediate family are allowed to cry when someone dies. Imagine holding the hand of a woman who has just had her baby die, watching her cry and offering her words of sympathy while keeping dry eyes. Because to do otherwise would be to take something away from her.
And there was more pain to come. She still had to deliver the dead baby.
But there was no urgency now. We let her rest. The nurses didn't comfort her, and I had little to offer in her language.
A beautiful baby girl.
2006-12-06
Nguludi
Another of Malawi's pretty little secrets, Nguludi is tucked away in the hills outside Limbe. It's a verdant valley with an unexpected mission hospital and church.
At the hospital, seeing patients: primary amenorrhea in a 22-year old. Would you believe Mayer-Rokitansky-Kuster-Hauser Syndrome? (oh, yes, of course) Blind vagina, likely no uterus, to be confirmed by laparoscopy because we are not convinced by the (very expensive but notoriously unreliable) radiologist's report that he "located" her uterus on ultrasound.
Update: A visiting gynecologist brought his old-school laparoscope. One generation removed from a magnifying glass in a tube, fabulous to see how it was done. So we got to see directly that there was in fact no uterus but only rudimentary fallopian tubes attached to normal-looking ovaries. So diagnosis confirmed.
At the hospital, seeing patients: primary amenorrhea in a 22-year old. Would you believe Mayer-Rokitansky-Kuster-Hauser Syndrome? (oh, yes, of course) Blind vagina, likely no uterus, to be confirmed by laparoscopy because we are not convinced by the (very expensive but notoriously unreliable) radiologist's report that he "located" her uterus on ultrasound.
Update: A visiting gynecologist brought his old-school laparoscope. One generation removed from a magnifying glass in a tube, fabulous to see how it was done. So we got to see directly that there was in fact no uterus but only rudimentary fallopian tubes attached to normal-looking ovaries. So diagnosis confirmed.
Have we done the patient any good? Well, probably not. We could tell her that sadly, there is no chance of children here in Malawi. The technology for surrogates exists elsewhere, but not here.
******
Blantyre: The Celtel tower was the latest casualty of the lightning, so my planned couple of hours at the internet cafe to finish up CaRMS didn't happen. Hi-speed in Blantyre vs dial-up in MJ is the difference between 2 hours and 8 hours, and my blogging, it should be noted, has been done whilst waiting for my pages to load. Yup, still loading. Dial-up=no photos, sorry.
Anyhow, did you know the University of Toronto has an Office of International Surgery? Does this sound like it was made for me? And they are here! Believe it or not, providing access to the UofT Libraries to African surgeons! How amazing is that? Given how hard it is to get your hands on up to date print materials in this part of the world, and even if it wasn't, this is an incredible resource, which can only improve patient care.
(no applause, just throw money)
*******
Sinterklaas. No, I don't speak Dutch either, but who cares. It was a fun Christmas party for the little kids and I won an elephant!
2006-12-04
More Dispatches from Malawi
The postpartum ward is nearly empty. People are either not having complications, or they are not coming to the hospital. It is the planting season, the rains have begun, and everybody is needed in the fields. There is nobody to take a woman to hospital, nobody to stay with her once she arrives, and no money for transport besides.
So who is here?
An older lady, a Jehova's Witness. We removed a mass from her abdomen last Thursday. I will have to learn to bring a camera (but I know you would strangle me, Sari), because it was HUGE. Harder to deliver than a baby. She's currently doing well.
We don't have the path report yet, nor will we until the College of Medicine reopens after the holiday (remember THAT next time you are grumbling about how long they are taking with the frozen section), but the tumour looks very like ovarian cancer. We have de-bulked the tumour and omental cake, and done a TAH-BSO, but she had peritoneal seeding and studding over her liver. She had ascites, and this is already collecting again.
In Canada, she would get chemo, molecular analysis, maybe hormonal therapy.
Here, she will be sent home with painkillers.
This is my patient. This is killing me.
******
We had a lady come in, in labour.
Not unusual.
Ok, but she had already delivered on the way to the hospital; the baby, tragically, was born dead.
Twins, you say.
Well, that's what we were thinking. Push. Oh, there's the second baby, born alive. So small. Here comes the placenta. WTF?
Another head? Triplets!
Two babies born alive. 1.1 and 1.5 kg.
If you're religious, pray for them. If you're a scientist, courier us some BLES. Either way, they need help.
Update: The bigger of the two babies died the next day, of respiratory failure. There is no respirator, and the supplemental O2 only works when we have electricity, which we don't on Tuesdays.
So who is here?
An older lady, a Jehova's Witness. We removed a mass from her abdomen last Thursday. I will have to learn to bring a camera (but I know you would strangle me, Sari), because it was HUGE. Harder to deliver than a baby. She's currently doing well.
We don't have the path report yet, nor will we until the College of Medicine reopens after the holiday (remember THAT next time you are grumbling about how long they are taking with the frozen section), but the tumour looks very like ovarian cancer. We have de-bulked the tumour and omental cake, and done a TAH-BSO, but she had peritoneal seeding and studding over her liver. She had ascites, and this is already collecting again.
In Canada, she would get chemo, molecular analysis, maybe hormonal therapy.
Here, she will be sent home with painkillers.
This is my patient. This is killing me.
******
We had a lady come in, in labour.
Not unusual.
Ok, but she had already delivered on the way to the hospital; the baby, tragically, was born dead.
Twins, you say.
Well, that's what we were thinking. Push. Oh, there's the second baby, born alive. So small. Here comes the placenta. WTF?
Another head? Triplets!
Two babies born alive. 1.1 and 1.5 kg.
If you're religious, pray for them. If you're a scientist, courier us some BLES. Either way, they need help.
Update: The bigger of the two babies died the next day, of respiratory failure. There is no respirator, and the supplemental O2 only works when we have electricity, which we don't on Tuesdays.
2006-11-29
Ulongwe TDC
To Malamulo Hospital (apparently, it translates to Commandments) today. Have photos of the OR (see the sidebar), including the lovely scrub sinks, and the buckets full of water because there is no running water today, pepani.
I didn't take photos of the hospital itself, because lovely as it is, photos can't do it justice. Colonial redbrick, 100 years old. Low buildings with covered walkways hemed in by arched 'windows,' vines and bougainvillea and all manner of well-kempt greenery.
The clinical officers were Jane from Kenya, a matter-0f-fact woman about my own age, and Blessings, a local young man, bright and attentive. They have minimal training but manage admirably at the front lines, undoubtedly better than I could running a ward without support at this point.
The cases were routine, two ladies with ovarian cysts; one had evidence of old PID in the form of extensive adhesions. Young as she is, her fallopian tubes appear to be so damaged that she is likely never to concieve, a disaster in a place that values a woman's fertility above most anything else.
We also visited Thyolo District Hospital which was under construction with the aid of Medecins Sans Frontieres while I lived here in the past (Hi Ibrahim, I wonder where you are and what you are doing, you jerk.). It's amazing, clean and modern yet very much fitting the environment. Fantastic. And they have a CD4 cell counter.
You see, people who test HIV positive in the absence of CD4 cell counts are not eligible for antiretroviral treatment until they get sick, WHO class III or IV. In limited resource settings this makes sense, saving the resources for the people who need them most. Unfortunately, some people in these categories are too sick to tolerate the ARVs; we have two patients at least who are in that situation. With CD4 cell counts, people in classes I and II may become eligible if they have a CD4 count under 200.
But a counter costs thousands of dollars in initial outlay and then in reagents and maintenance, so it is largely out of the reach of Mulanje Mission Hospital. They await with bated breath the introduction of the rumoured machine which can do the counts on a drop of blood and costs around $5000 instead of $20 000.
And maybe then the cracks through which our two ladies have slipped will narrow, and people after them will have a better chance at getting the drugs when they need them, before it is too late.
I didn't take photos of the hospital itself, because lovely as it is, photos can't do it justice. Colonial redbrick, 100 years old. Low buildings with covered walkways hemed in by arched 'windows,' vines and bougainvillea and all manner of well-kempt greenery.
The clinical officers were Jane from Kenya, a matter-0f-fact woman about my own age, and Blessings, a local young man, bright and attentive. They have minimal training but manage admirably at the front lines, undoubtedly better than I could running a ward without support at this point.
The cases were routine, two ladies with ovarian cysts; one had evidence of old PID in the form of extensive adhesions. Young as she is, her fallopian tubes appear to be so damaged that she is likely never to concieve, a disaster in a place that values a woman's fertility above most anything else.
We also visited Thyolo District Hospital which was under construction with the aid of Medecins Sans Frontieres while I lived here in the past (Hi Ibrahim, I wonder where you are and what you are doing, you jerk.). It's amazing, clean and modern yet very much fitting the environment. Fantastic. And they have a CD4 cell counter.
You see, people who test HIV positive in the absence of CD4 cell counts are not eligible for antiretroviral treatment until they get sick, WHO class III or IV. In limited resource settings this makes sense, saving the resources for the people who need them most. Unfortunately, some people in these categories are too sick to tolerate the ARVs; we have two patients at least who are in that situation. With CD4 cell counts, people in classes I and II may become eligible if they have a CD4 count under 200.
But a counter costs thousands of dollars in initial outlay and then in reagents and maintenance, so it is largely out of the reach of Mulanje Mission Hospital. They await with bated breath the introduction of the rumoured machine which can do the counts on a drop of blood and costs around $5000 instead of $20 000.
And maybe then the cracks through which our two ladies have slipped will narrow, and people after them will have a better chance at getting the drugs when they need them, before it is too late.
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