Beyond Mvuma

A busy couple of days and more surgery and procedures. This morning I was called by the Maternity nurses to a delivery but the baby had already arrived when I got there. Still, there were 2 more women in labor who possibly needed C sections. The first was a woman with a previous C section and cephalo-pelvic disproportionality. Dr. Brown and I took her to surgery and started a ‘Cesar.’ Once we got to the uterus, we found a very thin, weak wall in the lower portion which when I lightly touched while pointing it out to Dr. B, started to give and tear. For a minute we thought it the bladder since yellowish fluid started to leak from it. Then, there was more of a tear, some black hair, fluid, a baby. It was the uterus! With the baby coming out! If we had waited any longer to do the C section, it could have been total disaster. . . the uterus would have definitely ruptured as labor progressed. The baby was fine after delivery. Mom was sewn and we were done by tea time.

There was another woman who reported bleeding the last few days. There was some debate about her being a placenta previa and the need for C section. A trial of labor with pitocin worked and she delivered by lunchtime. The rest of the morning and afternoon I spent seeing outpatients with the help of the Shona nurse aid/interpreters.

A lot going on today and I am struggling to remember it all. Started the day off trying to get online to register for the match, but with no success. Then, to the small theatre for an ankle block and foreign body search of a foot, with help from Dr. Brown and Cavanagh. Another LP for meningitis eval. Also tapped a traumatic knee which yielded a ton of fluid. Then, a biopsy of the woman with possible Donovanosis. Spent some time in the lab with staining and think I may have found ‘Donovan bodies’ on a Wright’s stained slide! Now, that was exciting.

I decided to recheck the young child with swollen glands and lymphadenopathy for HIV and postponed a biopsy of her lymph nodes. If it is lymphoma by biopsy I am not sure it would change anything since there is no treatment available here. So why traumatize her if it’s not going to change what we would do for her?

Dr. S went to Mashingo and Gweru today with the Cavanaghs to run errands, get Tim officially registered with the provincial medical officer and other things. Dr. Clara and Dr. Brown were in surgery (hysterectomy on a woman with a fibroid uterus that could be palpated several centimeters above her umbilicus). So that left me with the morning admits and seeing out patients.

My first was a wasted, weak and ill woman with end stage ISD (‘Immune System Disease’), c/o diarrhea, nausea, vomiting, pain when eating (esophageal candidiasis), cough, etc. I admitted her to rule out TB and to give her some TLC plus the usual arsenal of cotrimoxazole, metronidazole, and ketoconazole.

The second patient was a 1 year, 9 month old girl with swollen parotid glands (bilateral) and generalized lymphadenopathy (cervical, axillary, and inguinal) for several months. She also had extensive ‘septic’ lesions all over. The child had been seen in November and treated with no success. She was also malnourished and had not gained weight in over a year! At that time someone thought her presentation was consistent with ISD and recommended testing. But her HIV test at 1 year 7 months was negative (up to 15 months a positive test in a child can be from maternal antigens). I was wondering if she just had a bad case of chronic septic lymphadenitis but why the intractable parotid swelling? Mumps are usually viral and last about 2 weeks. And, her differential showed 75 % lymphocytes. Could this be a lymphoma? Could this be a hereditary childhood immune deficiency? I have to do some reading on this. . . but most likely, it is an ISD case with a mistaken negative test result.

Third admit was an elderly man with chronic knee joint swelling. The history is actually pretty interesting. He was admitted several months ago with bilateral calf myositis after injecting himself with ‘muti’ that happened to be medicine for livestock. Both of his calves were just about destroyed and he went to South Africa for skin grafting and rehab that lasted 3 -4 months. During that time, he had his first septic joint of the right knee. Now, he has swelling and pain and occasional fever of the left knee joint and a new internal rotation of his L hip. Dr. Brown and I tried to tap the knee but got no fluid. I put him on chloramphenicol and got Xrays of his knee and hip to review tomorrow.

I peaked in on Dr. Clara and Dr. Brown and saw the uterus they were taking out. It was huge! A red and lobulated watermelon.

The rest of the afternoon I saw out patients, including several rashes (pityriasis versicolor) and a woman who was in to see Dr. Clara about leg pain (a DVT that was treated with aspirin). When I walked in, I noticed and commented on a goiter which after some inquiry in Shona by Dr. Clara led the patient’s daughter to reveal that her mother (in her late 60’s) had had the goiter for many years and did not want anything done to it and just in the last year or so she had developed a 5 cm in diameter, round, soft, pulsating lesion on the skull in the occipital region. Dr. Clara thought of Follicular Thyroid CA which spreads hematogenously. . . we looked it up in a couple of books and think it is indeed a Follicular, hematogenously spread tumor.

Then, about 430pm, we were called to the peds ward. A child that Dr. Clara admitted with a supposed insect or snake bite and very swollen lower extremity was ‘in a declining state.’ The child was very lethargic but had also received promethazine. We hooked him up to an IV and dosed some prednisone with the fluids. He perked up after the IV.

Then, an expectant mother who was hypertensive needed to be seen. Turns out she was in labor.
An exciting day medically for sure.

A Tuesday spent in the theatre with Dr. Brown. Imagine working in an enclosed, unairconditioned room with scrubs, gown, hat and mask. It is so hot! Everyone’s clothes were soaked through with sweat. First case was a repeat inguinal hernia repair. It took over 2 hours. Besides the sauna-like climate, there were other obstacles and set backs. A lot of the equipment is old, broken, or missing parts. The surgical instruments are a hodge-podge collection of leftovers and donated dull scissors. Three of the light bulbs are burned out in the overhead lamp. At one point, the electricity went out and Dr. Cavanagh had the surgery tech reach into his pocket, get his Maglite flashlight, and shine it onto the surgical field until the generator came. The second case was an open hysterectomy on a woman with suspected ovarian mass. It was at least 2 hours 45 minutes. Though I enjoyed being in the OR and seeing the anatomy, I was also reminded why I did not choose to do a residency in surgery.

Started off with an LP (lumbar puncture) of patient with suspected meningitis. Then to the womens ward for full rounds with Dr. Clara, Cavanaugh and me. Then back to the theatre for another LP and then a couple of outpatients.
My patient with the suprapubic cath came back for re-assessment of his condition. He is to go to Dreifontein (another mission hospital) to be evaluated by a surgeon for a prostatectomy.

This afternoon we saw an elderly woman whose history is interesting. Three months ago Dr. Stoughton saw her after she had been gorged by a bull in her rectum. It tore through to her vagina which Dr. S tried to stitch up. Now she is back because of pain and pus and bleeding from the area. Dr. Clara did the initial exam and found friable, fungating vaginal mucosa. Dr. Clara thinks she has cervical CA but Dr. Brown thinks is donovanosis or Granuloma Inguinale.

Granuloma Inguinale: This is not to be confused with LGV/Lymphogranuloma venereum (a painless genital chancre caused by a Chlamydia trachomatis that causes buboes/large nodes in the inguinal and femoral chains 3-30 days or so after exposure). Granuloma inguinale is caused by Calymmatobacterium granulomatis which causes chronic ulceration of the genitalia and surrounding tissues. It is described in the Oxford Handbook of Tropical Medicine as a beefy granulomatous ulcer with characteristic rolled edges. The lesion is elevated, well defined and bleeds easily with trauma. Usual sites are the anogenital region, thighs and perineum. Healing is uncommon without treatment and secondary infection can follow. This is the ‘pseudobubo’ disease in that the inguinal nodes are not involved BUT the granulomas may be mistaken for enlarged lymph nodes. Diagnosis is by Giemsa or Gram stain. Large mononuclear cells filled with cytoplasmic gram negative rods (Donovan bodies) look like closed safety pins. Treatment is with CTX (Cotrimoxazole or Trimpethaprim Sulfamethoxazole) 960 mg PO BD for 14 days or until lesions are healed. May also treat with tetracycline or doxycycline. We are starting her on CTX and will biopsy the lesion and look for Donvan bodies.
The afternoon I spent with the Cavanaughs taking Shona lessons.

How Was the Ceasar?

Last night we were called to do a ‘Ceasar’ on a woman who had a breech baby and was either retarded or mentally ill or both. Cesarean Sections are called ‘Ceasars’ by the staff. It was a bit of a mess because she did not understand what was going on and was jumping all over the table when we attempted the spinal. It took 3 people to hold her down and she still thrashed all over the place. Finally Dr. S gave her some diazepam and she calmed down enough for him to successfully do the spinal. He considered general anesthesia but she had just eaten (in the midst of labor?).

All went well with the Ceasar until Dr. S couldn’t get the head out. In a breech C section, apparently you dislodge the baby’s bottom from the pelvis and then pull out the head. In this case, he got the bottom, legs and body out but the head was too big. He tugged for quite a while. . .45 seconds at least. It was so excruciating to watch. Finally, just before he grabbed the knife to make a bigger incision, the head came out. The baby was floppy (diazepam?) for a while and eventually perked up with the assistance of Mrs. Chasvachi, the peds nurse, did a lot of vigorous slapping, holding the baby upside down, suctioning and more suctioning. Two hours later, we got another call. . . the patient was unattended for a few minutes and pulled her own stitches out! There isn’t much hope for this baby. Both of her parents are mentally out of it and apparently they don’t have any family to help or supervise them. Here, it’s a full time job for the average person to find enough to eat, work in the fields and raise their kids. I just don’t see how this disabled, mentally ill woman is going to do it. There are no social workers to refer her to.

The African ‘Beast’

Moo! This photo is for dad. The African ‘beast’ seems larger than the US cow, with very big horns. Just the other day I was walking home from lunch and under the shade tree, the butcher and hospital cook had slaughtered a ‘beast,’ carved it up and were putting it in pots to cook or store. Some one was folding up the hide while another was sawing through a big hind quarter. The hospital administrator had been in Dr. S’s office to have him approve the purchase of this ‘beast’ just a few hours earlier. The cost was $140, 000 ZIM dollars (about $28 US dollars). The slaughtering and butchering was all done outside, on the ground under the shade tree, with the flies, birds, bugs and little kids hovering. When I came back an hour later, all that was left were 2 dogs licking the dirt in the area where it had all been done.

Got Insulin?

The hospital day was busy. Dr. Clara made rounds on the Womens, Peds and Mens ward. Pretty impressive, and all before 10 am. The rest of the morning was spent at the Thursday Staff tea and seeing outpatients.

A young man with extreme jaundice (looked like his eyes were full of orange juice) came in. He had ‘flu-like’ symptoms, dark urine and general malaise for a week. I did not a liver edge, but Dr. Clara says he has hepatomegaly. And, his labs you ask? Well, we don’t have a chem 7, LFT’s or a hepatitis panel, so I checked his urine which had ‘4 +++ urobilinogen’ and assumed he had viral hepatitis. He was admitted on supportive therapy.

An insulin dependent diabetic woman came in today for her monthly insulin refill. Turns out we don’t have any insulin in the pharmacy and have been out for a month. She, too has been out for a month. Remarkably, her blood sugar was okay this a.m. I asked around the hospital about the lack of insulin. No one was really surprised or very worried about it. Some of the nurses suggested we just put her on oral meds. Dr. Clara said the woman would have to go to Mashingo and purchase the supply for herself. The patient of course did not have the money or the means to get to Mashingo. And, though she is going blind from her diabetes and has peripheral neuropathy, I am not sure she really grasped the implication of not having her insulin. I was actually surprised that she had not gone into DKA from lack of insulin. From her history, she had required it since 1992 and yet this month she had lived without any injections at all. Hum. I will ask Dr. S about this tomorrow. If any doctors are reading this, can you explain why or how an insulin dependent patient didn’t go into DKA without insulin for one month?

Walking Sticks and Beetles

Dr. Clara went on her Holy Cross clinic visit. I stayed at the hospital and saw outpatients but really floundered until she got back. I think she was a bit frustrated at all there was to do when she got back. I felt pretty useless today. When I was done at 5pm, I went for a run to the dam. It was raining and cool and just about everyone I passed stared at me with bewilderment.

Last night while reading, I heard this scratching noise at the window. I looked up to find a black, hard armored beetle the size of a small fist, with pinchers and claws trying to climb up the window. He (or she) kept sliding down (it was raining and the windows were slick) and then starting over. Finally, it was high enough when it fell that it hit the sill on its back and bounced off onto the ground.

The night before I had a similar show from an African ‘walking stick.’ I am not sure if that is really what they are called, but I vaguely remember reading or hearing something about an African insect that resembles a twig. Its body was about 7 cm long and its legs 4 cm. It was also moving up the window but would keep 3 legs attached and then move one, then the other, then the other, then the 4th. It froze and did not move after my flash went off when I tried to take a picture. Now, tonight as I recount the tale of my exotic bug visitors, some are falling from the ceiling into my bed and onto my shoulders.

Mazoe: Zimbabwean Tang

Mazoe is the staple drink here. If you are invited for tea (served in the morning at 10am) or for a drink at someone’s house, you are sure to have Mazoe as one of the options. It’s a concentrated orange drink that you add water to in various ratios depending on the strength you prefer and how many people you are trying to serve. I have been drinking it with iced tea and given it the name Charundura Tea (1/3 tea, 1/3 water, and 1/3 Mazoe). Mazoe tastes like it has orange juice in it, but its also got a Tang-like taste, especially if you drink it strong. Mrs. S likes a Mazoe Shandy which is Mazoe, water, gingerale and bitters. I hear it can be mixed with gin or vodka too.