Beyond Mvuma

Hospice Beginnings

Today was much more tolerable than yesterday but still I was struck during rounds at the most ill patients and their suffering and impending death. It is very odd to go from one bed to the next, from a man that is being discharged to one who will die in the next few hours if not days. In one ward room, there is a line of beds, 8 to 10 on each side, and there is no order or categorization of disease. So there might be a young boy in traction for a femur fracture 2 beds down from a dying, wasted 30 year old man with intractable diarrhea. Most patients have at least one or two relatives there with them, attending to their needs or just sitting beside them on a stool. But there is the occasional patient that has been dropped off at the hospital door without any attendant or relative to give a history of what has happened or what the complaint is. Usually, these are the patients that are not coherent and cannot speak for themselves, but given the environment, you assume they are an end stage AIDS patient and do what you can to treat whatever symptoms you find and are able to treat. Dr. Clara is trying to get the nurses to start a hospice or comfort care room or ward within each of the wards for the terminal patients.

Baby in Scale

This photo was taken at Holy Cross, one of the nearby outpatient clinics that is visited every 2 weeks by a physician. The rest of the time it is staffed by a nurse. Holy Cross, actually has a ‘hospital’, with the capacity for 12 female beds, 12 male beds and 6 peds. beds. When we were there last week, there were 4 in-patients and some outpatients to see. Check-in and weights are done outside in the open air.

A Difficult Day

Today was one of my most difficult days emotionally. In the morning, we (Dr. Clara) and I rounded on the women’s ward, the ped’s ward, and did problem rounds on the men’s ward. There was an 8 year old child that weighed 18 kgs and at least 25% of the weight was probably edema. She had extensive kwashikor—protein malnutrition—with sores, bruises and blisters on her legs, gross extremity edema and abdominal swelling. She had come in on Friday but was not seen by a doctor until today. I am not sure why, and feel some responsibility for not seeing her either Saturday or Sunday. She was alert in the morning when we first saw her, but collapsed sometime later. An IV was started, she received dextrose IM, some fluid, and oxygen but died an hour or so later. We do not know her HIV status but suspect this is why she was so malnourished. I was also told she was an orphan which may be why it was so long before she was brought to the hospital. In some way, I am relieved that her suffering is over, but the injustice of an eight year old child dying of malnutrition is extremely difficult to accept.

My patient with the suprapubic catheter was doing well this moring. Dr. Clara attempted another uretheral catheterization but was unable to get past the prostate. It looks as though he is going to have to live with his suprapubic catheter for a couple of weeks until the uretheral trauma subsides and he can be assessed for a prostatectomy at Dreifontein, the nearest hospital with a surgeon.

Ambuya

Ambuya is the shona word for grandmother and is a respectful term with which to address any Shona woman of mature age. I have been reading Dr. S’s journal from when he was here working in the 1970’s. Back then, Ambuyas did not have a good repoire with the medical officers as they were often apt to advise younger family embers to go to the Nganga (Witch Doctor) to get powerful and sometimes deadly ‘muti’ (medicine) instead going to the doctor for treatment. He also struggled with Ambuyas who oversaw and botched home deliveries, then when it was too late, brought a dying mother with a dead baby to the hospital to be fixed. These days, Ambuyas are often the only ones available to care for children, especially in families where the adults are dying or have died of AIDS. We have seen several malnourished HIV orphans who rely solely on an Ambuya who is often too old and sick herself to care for a young child.

Doro + BPH = Suprapubic Catheter

This morning I went to the early mass (mainly by and for the secondary school students who sing beautifully). I was hoping to record the singing but my jukebox recorder malfunctioned. After mass, just as I was sitting down to a breakfast of omelette, toast and bacon, there was a knock at the door. A summons for ‘Dr. Angie’ to come to the hospital. The patient was an older man with acute urinary retention and 2 failed attempts at a catherization. The nursing staff had seen the patient and wanted me to come do a suprapubic catheterization. Huh? What’s that? I have never seen one done, much less done one myself. I went to see the patient. He indeed had a full bladder. . . up almost to his umbilicus, and was extremely uncomfortable. He had an enlarged prostate by exam but denied any chronic BPH symptoms (Benign Prostatic Hypertrophy). As I probed further, he said ‘yes, maybe so Doctor’ which I think was really an attempt on his part to be the agreeable, doctor-pleasing patient. The more recent history was that he was out drinking ‘doro’ (homebrew) on Friday night, lost track of just how full his bladder was, and then couldn’t pass any urine all day Saturday. He was extremely uncomfortable and begged me to do something. I attempted uretheral cath but couldn’t get it to pass either (2 of the nurses had also tried). Then, I got out the book and started reading about how to do a suprapubic catheterization. I also told the patient I had never done this and we could wait 8 or so hours for Dr. Clara to get back from Mashingo. He said, ‘please doctor, I can’t wait any longer.” The theatre (operating room) suprapubic catheter kit has a trocar system so I decided to attempt the method for which we had tools. It is a pretty straight forward but barbaric procedure in that you give local anesthesia and then jab the trocar into the abdomen midline between the pubis symphysis and the top of where the bladder can be felt. I twisted and pushed pretty hard, and eventually, it pushed through and urine gushed out, all over my sandaled feet. I threaded the catheter through the trocar canal and then put a couple of stiches to hold it in place. Then I admitted him, put him on an antibiotic, and waited eagerly for Dr. Clara to arrive and to find out if anything else could be or needed to be done.

All afternoon I slept. My system was surely saped from the adrenaline rush of the morning. Later I took a walk to the dam, my new favorite spot.

Strange day

My first trip to the morturary to look at a body brought in last night. Dr. S needed to review the case before signing the death certificate. The man, 28 years old, was thrown from the back of a truck when it swerved to avoid an oncoming vehicle. Sadly, he and his wife had just gotten aboard. They were hitching a ride. She was without injury. He sustained fatal abdominal trauma and a flail chest. Later I was seeing a patient when Dr. S comes in and says: Angie, the police are looking for you.

Angie: Huh?
Dr. S: They want a copy of your passport.
Angie: Huh? Am I in trouble?
Dr. S: All I know is that the police came to the hospital administrator’s office to ask for a copy of your passport.
And so, Dr. S is drafting a letter explaining my presence here with a copy of my visa and passport. Yikes!

Mangwanani!

Mangwanani means 'Good Morning!' in Shona. Finally, I am online again, this time because the land lines are working, though chances are for just a short time. Mom, if you must reach me, try the hospital phone 263-308-208 during my morning hours 8am-11am.
Dr. S and Loretta are going up to Harare today and will be there until Wednesday and will most definitely take their computer and cell phone with them. I am going to stay here and 'cover the hospital.' Me 'covering the hospital' is kind of a joke since the staff here is very used to running things when there is no doctor around. All the deliveries (except C section which can if needed will be shipped to another hospital an hour away) are done by nurse midwives. Other big emergencies can also be transferred elsewhere. The big kink in the S's abscence is that I wont be able to check emails for several days.
I have however been able to forward some pics and postings to Hector who will then retro-post them from the states for me. . .so stay tuned!
Yesterday was Friday and very busy. We did a skin graft and a C section in the morning (all before 10am tea), made rounds on the male ward, saw out patients, amputated a smashed finger, did 3 I & D's (opportunities for abscesses are everywhere!)
The weather: Hot since I got here and getting hotter. Yesterday we had a breeze that felt like you would be standing in front of a winter heater. We have had no rain since I got here. Everyday someone says, 'maybe it will rain' but is more of a hopeful wish than any real chance.
The food: Still eating well. Fresh corn on the cob every day, mangoes galore, and Mrs. S's cooking which is 3 square meals a day.
Fast fact: Mrs. S has to take off the grocery store price sticker from the cat food because one bag costs more than either the housekeeper or gardners salary for a month!

Rural Chilimanze Clinic Day

Started this morning at 6am with a run. It’s the coolest time of the day and it’s nice to get outside of the hospital-to-home routine. I think it is strange for the kids to see a woman running because they laughed at me when I passed.

Today was rural outpatient clinic day. Dr. S and I went to Mhende, Chengwena, and Hama clinics. (Round trip about 45 kilometers). We saw about 25 patients total. We ended up referring a lot of people to St. Teresa’s because the clinics are small and there are no labs or avenues for diagnostic studies or procedures. 2 of the clinics were without any medicine. We did bring some with us but it was a limited amount. We saw a larger proportion of elderly people than we usually see at the hospital. It is really refreshing to see someone past the age of 60, even if they are wobbling in and look to be much older. I think the trend is that the older people retire to the rural lands while the younger family members go into townships and the cities to work if they are able. There were also several cases of young malnourished children that aren’t keeping up on the growth curve. It is not uncommon to see a 3 year old that hasn’t really gained weight in a year to a year and a half. You hope that it is due to parasites or lack of access to food but you wonder if its malnourishment due to HIV.

I really enjoyed the drives to and between clinics. The area around these clinics is all communal tribal land, with the traditional round, one-room thatch-roofed huts sprinkling the country side. There are usually 4 to 6 huts in a grouping. The whole group usually belongs to one immediate family. Each hut can be considered a separate ‘room’ and the grouping a ‘home.’ One hut may be the sleeping quarters for the kids, one may be for the parents, one may be a kitchen, one may be a store room, etc.The cornfields on the drive home looked better than the ones on the way to Mhende. The chief lives in Hama and they happen to have a dam with a good irrigation system, so the corn is thick and healthy looking. There were piles of shucked ears of corn in the center of one circle of huts. I think that they must be drying them to store for the rest of the year.

African Braids, a Schizophrenic and a Multitude of Bugs

Dr. S had to go to Mashingo this morning to work out some banking issues. That left Doctor/Sister Clara and I to do ‘trouble and new admit’ rounds on the wards. Then I saw a few outpatients with much assistance from Dr. Clara. I actually admitted 3 patients—an older female with CHF exascerbation, a younger female with ISD (Immune System Disease, the not-so-discrete ‘code word’ for AIDS) and possible meningitis, and a child who needs I and D of an abscess.

There was much discussion today by Dr. Clara and Sr. Agnes about starting a hospice ward within the female ward. The near death ISD (Immune System Disease) patients are too sick and too labor intensive to be cared for at home, but really there is not much we are doing for them medically. With a hospice room, the focus could perhaps be shifted to spiritual care and helping terminal patients and their families come to terms with what is imminent. This afternoon, we didn’t have many patients and Dr. S was back. So, I mostly finished a letter, excerpts which are below.

Yesterday afternoon I went to town to get my hair braided at the saloon. No, that is not a mis-spelling. It is ‘saloon’ not ‘salon’ here in Zimbabwe. There is a ‘saloon’ attached to the ‘salon’ but it is called a nightclub and the subject of joint-venture combo shops (Musafe’s Grocery, Nightclub, and Coffin Sales) is another story all its own. It took about an hour and a half, $4,900 Zim dollars (less than $1US), and a lot of head-jerking- pulls to braid my hair flat to my head in tiny rows. There were a couple of people in the saloon which was the size of a large closet. I tried to make small talk but it was obvious that I wasn’t going to get far since I don’t speak Shona. A couple of onlookers came in to see what was going on, and one girl of eleven stuck around. I could tell she was really trying to figure out how to touch my hair without being rude. All was going well until the woman doing the braiding was nearly finished and discovered the ‘slippery’ quality of my hair. The completed braids had begun to unravel. She tried all kinds of things—yarn, fake hair extensions, rubber bands, and re-braiding but nothing seemed to work. An hour more and about 4 or 5 ‘consultations’ with other women who were standing around watching she finally sent me on my way. The front and sides meticulously parted and braided, the back in a big fat rubber banded ponytail, and me with a headache from it being so tight. You get what you pay for.

This morning I was accosted by Alex, the local unmedicated schizophrenic who unfortunately does not have a paranoid component to his mental illness. Instead, he is very social, very much a drooler and spitter, unkempt, and a personal space invader. He speaks the clearest and most proper British English and is easier to understand than any Zimbabwean I have met thus far. ‘Hello, you are my wife!’ he spits as he greets me today. ‘She is my wife!’ he says to everyone as I walk into the hospital.

The day was relatively slow and left plenty of time for an open-doored office and unwanted intrusions. Alex came in and dumped a bunch of rotten peanuts on my desk despite my objections. He continued to query about the date of our nuptials.

When I went home for lunch, first thing out of Mrs. S’s mouth, “Have you met Alex yet?” Well, yes, I met him the first day and have seen him nearly everyday since. But today was the day he started his fixation about me being his wife. “Funny thing,” she says, “he was here today to ask if I would permit my son to marry him.”

As I type all of this tonight, the bugs are coming out in full force, attracted by the light. It is really grossing me out. Especially now that I have spotted 2 flying roaches. There is a clicking noise of bugs as they fly into and try to get out of the lampshade that is over my bed. I know when I turn the lights out, they make their way out too.

Morning Walk to the Hospital

The unusual sights are now starting to look familiar on my morning walk to the hospital which is not more than 300 yards. The women bringing the chicken cages outside the staff houses (they stay inside with the families at night). The pregnant ladies from antenatal care walking to and fro doing their morning chores, washing, and cooking. People from the nearby villages walking towards town with wheelbarrows, push cards or baskets on their heads. There is a rhythm it seems to everything. The crows are skwalking, the crickets are chirping and I am trying to remember some Shona so that I may say good morning as I pass. This morning, the children are starting back to school after a month-long vacation, so there is something new in the mix—groups of young kids laughing and talking in a sing-song language, walking or skipping to school in their uniforms. Then, there are the leftovers, the kids that are too young for school just yet, sitting on porches or playing in the dirt, lonely for their big brothers and sisters.