Traveling and home again

It has been about three weeks since I got back to the United States and I wanted to write a final entry to tie everything up in a neat bow. If only it were that simple. First there were three weeks of pure joy as my husband and I traveled around the country. We did a complete circuit of Gabon, starting in the NW corner at the capitol, riding the train all the way east to near the border with Congo and then working our way back west and south. We saw national parks, elephants, train life, distinct ecosystems, all in one relatively wealthy African country. The story that sticks out in my mind of traveling with Owen happened near the end of our journey. I think it vividly illustrates what kind of country Gabon is, as well as the haphazard way in which we tend to travel.

We were in Port Gentil, an oil man's center of commerce on the Atlantic coast, about in the middle of the Gabonese coastline. Did I mention that we took a decomissioned Russian freighter ship stuffed with goats for a Muslim festival overnight to get there? Because we did. Our goal for one day was to walk to a local beach area, lie in the sand, and maybe eat some fresh-caught fish. According to our faulty guidebook map, it was only 4km to the beach so being the intrepid, and somewhat homeless, travelers that we are, we decided to walk. After about an hour and a half, the beach did not seem any closer and there was only one main road in the countryside so it was not as though we could be lost. Finally I approached two middle age men and asked for directions. They laughed uproariously when I told them we were trying to walk to the beach, as it was actually 18km from the center of town, not 4km. After talking a bit, they offered to have us jump in the back of their pick-up truck because they were on their way to the beach town as well. We drove all the way with them, stopping for a roadside beer and talking about all aspects of Gabonese culture and landscape. It turned out that they were friends with the village chief of the beach town, so we had to meet with him, give him some wine (you always have to give the chief some alcohol), and take pictures. Then they directed us to a restaurant with just caught grilled fish. SO good. Then we had to drink some local spirits with them and the chief, go for a walk on the beach where the village was bringing in the tuna catch for the day, and try to find vin de palme.

When we got back to Port Gentil, one of the men insisted on drinking more beers with us and eating brochettes of grilled meat for several more hours. He was extremely affronted when we tried to pay for the meal and instead urged us to buy more beers on his tab. It was a totally beautiful, funny, local, delicious, warm day and illustrative of how kind and protective and proud the Gabonese people tend to be.

Unfortunately, we had to leave our equitorial paradise for full-on Chicago winter. It has been a difficult transition back in many ways. I liked my work a great deal at Hopital Albert Schweitzer and felt useful and appreciated. Now, I am back to the lowest position on the totem pole of medical student where I get to do fairly little. And it is so cold! I am trying to be positive about the last six months of medical school and make the most of my time here in Chicago, but it is hard. Lambarene and Gabon in general, have taken a piece of my heart and I am already plotting my return for the earliest possible moment.

Leaving something lasting

As I leave for Libreville today to pick up my husband (finally!) and go traveling, I have been thinking about the traces that we leave behind. I went to talk with the directrice of care at the hospital to prepare for my departure and she asked me to sign in a book of students that have passed through Schweitzer over the past years. In the comments section, everyone always writes super cheery things “thank you for the best experience I can imagine,” or “the spirit of Schweitzer is embodied by everyone works at this hospital,” things that I consider might be true only the best of conditions here. Everyone likes to remember experiences and themselves as better than they really were. But when I look back honestly at my time at Schweitzer, I view it as a microcosm for my professional career as a whole: I hope that a few people were very positively impacted by my care and that the rest were well cared for to neutral. As if you gave all of my patients and contacts here a “sophie satisfaction scale of 1-10” and everyone rated me 5 and above. Maybe my motto can be: touch a few, and leave the rest neutral. Not wildly inspiring, but realistic?

Leaving emotional traces behind, let us think about the physical aspects of myself that I want to leave and will leave. Already I have worked on the guide to Pediatrie that another doctor started and I will continue to add to that. I will be sure to distribute that to future stagieres and to the American Schweitzer Foundation. I aim to make a little handout on diarrhea. I gave a kick bootie presentation on Pediatric asthma management, replete with posters. And I will create a mini one-page guide to Maternite for future students here as well. Will anything of these things last? How do any of us leave enduring traces of ourselves? If even, I would contend, the spirit of Schweitzer corrodes, what can a mere mortal leave?

Bliss

After a funny night out on the town, eating grilled carp from the Ogooue, Castel beer, and Biskrem (nature's perfect food, a shortbread like cookie with a cocoa filled interior found only in Western/Central Africa apparently), I awoke to a gentle foggy morning in Lambarene. Whereupon I made myself some lentil soup for breakfast and ate it while reading the New Yorker (thank you! roommate who just arrived from the US and brought my dose of middle-brow culture so sorely lacking here). I am in seventh heaven.

Second Monthly report

Spoiler alert: This post is LONG--and even abridged from my actual report-- and intended mostly for people who are thinking about applying to the fellowship and/or my family. It serves an example of what you are expected to do in terms of reflection during the fellowship. It is also a status update on my heart.

This report encompasses the time roughly from September 10, 2010 to October 22, 2010, or about six weeks of my time here. During this time I switched from working in Pediatrie to working in Maternite (a move I will talk about more later) and will thus focus first on Peds before switching over to describe my time in Maternite.

My heartfelt impression of pediatrics, when the place floats into my head, is that I love it there. I adored most of my patients and parents, as well as valued the experience of doing so many history and physicals, exam maneuvers, and clinical decision making. I noticed that I tend towards tough love and need to work on my judgment as far as when to take a complaint seriously (ie my baby breathes funny, has diarrhea all day, has a red anus) and when to offer reassurance. Overall I had moments, even whole afternoons when I experienced what Mihal Csikszentmihalyi's concept of “Flow” as part of good work, the notion that you are so present in what you are doing you don't even notice the passage of time. I also felt impossibly lucky at times when I realized that this is going to be my life-- I really get to take care of babies, kids, families for the rest of my life. How could I have possibly gotten so fortunate as to stumble into this job?

In terms of my actual medical work in Peds, I feel good about what I was able to do in regards to seeing a good daily load of patients and in individual cases where I felt that I made a difference. Here are some of the stories of my patients whose care and lives I became more involved with:

1. EB, a 4 year old asthmatic that I saw during three separate hospitalizations for crises in August/early September. I read about what medications were available in Gabon, measured her peak flow, tried out different doses until we seem to have found the combination that is working for her right now. It is so nice to listen to her lungs now as opposed to the first time I heard them wheezing and crackling three months ago.

2.CE, a malnourished, HIV positive baby that was with us for three weeks trying to get her nutritional status corrected. I ended up getting the family food and other resources as well as getting to know the entire extended clan well.

3.KM, a sick little 8 year old boy. I did my first LP on a child in him, which turned out to be a champagne tap (!) and we treated him for meningitis. He got so much better after the tap we joked either that it was therapeutic or that he suffered from Stockholm syndrome and fell in love with me because I was his tormentor.

4.Baby B, a premie baby that Dr. Florian and I performed CPR on my very first 15 minutes in Pediatrie (literally on the very first day of my time at HAS!), who ended up surviving that arrest episode, as well as two others, gaining 700g in the hospital and being discharged right as I switched to Maternite. We, me and Florian, tried in vain to get the mother to name the baby after me, or even him, but to no avail.

5.Drepa Mom, a kid whose electrophoresis showed homozygous SS, and when I offered to do a teaching session on sickle cell with her and the child came back the next day at 8am with tons of questions, eagerly accepted all my handmade handouts, and generally seemed like a superstar involved parent.

There are two cases that linger with me as mistakes that I made that may have negatively impacted the outcome for the patient. Not that I want to dwell on these cases, but they both gnaw at me for different reasons. The first case was a child with diarrhea and vomiting that I saw in consultation who came back to the hospital over the weekend (4-5 days later) severely dehydrated and ended up dying one day after being admitted. This bothers me because I did not have a high enough index of suspicion for a severe illness, apparently, and must not have given good instructions about warning signs that necessitate coming back to the hospital. In the second case, I gave a mother positive HIV results for her and her baby and she fled the hospital in the middle of the night because she did not believe me/HAS. In this case, I should have approached the counseling scene differently, maybe waited until Monday to give the results rather than doing it on a weekend, maybe brought a nurse or HIV counselor with me to avoid/buffer the mother's denial response. As a final set of comments on the Pediatrie:

1. I love the nurses there and think that they do a great job and deserve recognition for that fact.

2. There should be continued focus and development on neo-natal care at HAS, both nursing/medical care as well as the hospital's technical capacity to care for premature infants. Neo-natal death is a huge cause of mortality in Peds and could be a shining success for the hospital, like the TB project, in the sense that it advances our goal of creating a culture of results. Maybe we could get a neo-natologist to come consult or dust off some of Dr. Cumming's stuff (Yale peds person that created neo-natal curriculum and monitoring sheets here) that sits on an abandoned shelf in the Pediatrie.

Throughout my three months here I have worked with the PMI every Thursday, which has provided a nice thread of continuity to my fellowship time. An interesting case has emerged from one of our sites, Bellevue, which is accessible only by pirogue. The first time I went to that village, there was a 4 month old baby with recently developed hydrocephaly, I referred the kid to peds, where Dr. Florian saw him and suggested the mom try going to Owendo, the children's hospital in LBV. When we went back as the PMI six weeks later, the kid's head was bigger and I got in touch with Bongolo Hospital, in the south of Gabon, because I had seen a patient with a VP shunt in peds who received the operation at Bongolo. This case, to me, begs the question of medical evacuation from PMI sites/Schweitzer as well as the possibility and desirability of a collaboration with Bongolo Hospital. I am currently trying to get the patient down there for the VP shunt surgery, have already been in touch with the surgery team there, and they have okay-ed him for surgery even if his mother cannot find the 120,000 CFA that they charge. We should also make this resource more widely known to/for our patients, especially in peds as they have a neurosurgeon there doing the hydrocephaly operation. This seems like it would be a great link up, win-win type of deal. I am so glad to have consistently voyaged with the PMI, gotten to know those nurses well, done my first true solo consultations as a physician and gotten a better sense of the geographical and emotional lay of the land in the Moyen-Oogue. It also piqued my interest and ever-running internal debate over free versus low-cost health provision, as people in the villages are much poorer, on average, than the people who can make it to Schweitzer as patients. It puts disparity and questions of value and fairness into my mind. Also every time we got out, I think of the old Quaker proverb that my Busia, Polish grandmother, used to write to me at the end of some of her letters. “I expect to pass through this world but once. Any good, therefore, that I can do or any kindness I can show to any fellow creature, let me do it now. Let me not defer or neglect it for I shall not pass this way again.”

How I learned to love childbirth and stop fearing the human body

Helping out in labor and delivery here in Gabon gives me hope and faith for my own eventual personal childbirth as well as in the capabilities and resilience of the human body. The mothers here arrive at the hospital with their cervices well dilated, often anemic, and give birth with nary a sound. It happens so much more quickly and without trouble than the deliveries that I helped out with back in Chicago. There women were usually some combination of obese, (pre)eclamptic, diabetic, and under epidural anesthesia. Their deliveries went on and on and nearly half of the time ended in C-section. Here, maybe 5 or 10% of the deliveries are C-sections. And that is at a hospital where it is possible; the majority of women still give birth at home. If a woman starts yelling, when the head is crowning, for example, a nurse will slap her abdomen or her cheek and say “tu cri pourquoi” which translates to why are you yelling. The woman will usually quickly get herself under control, stop making noise, and finish delivering the baby in seconds. Amazing. And they are up and walking minutes within delivering the placenta !?! And within a few hours you would never know that they had just recently passed a human being through their vagina. American women are horribly out-of-shape weenies by comparison. I hope to take a page from the African woman playbook and endure my pregnancy and delivery with stoicism and resilience. The one aspect of delivery in America that I would like to keep is that there delivery is a momentous event, whereas here it is viewed as common and no cause for celebration or congratulations. I would like to guard that sense of wonder and grand importance during my children's birth, while keeping it quick and stoic like African women. Are those two extremes unreconcilable?


What do in a polygamous society about HIV tests?
As I have written about dilemmas that I see at the hospital in terms of payment, choices of when to seek care, how to respond when your child dies, and physical abuse, I wanted to add another wrenching thought to our burbling cauldron: as a woman in a polygamous relationship and/or household, how do you stay HIV negative? When I give the results of the mandatory HIV tests to pregnant women (the result of a recent and I think, very beneficial, Gabonese law), I often comment that they should try to get their partners tested too. Often a woman will reply that he refuses, as in his eyes, her negative test means that his must be negative as well, or they sigh that it won't matter if he gets tested as he also sleeps with numerous other women. Can you imagine if you were trying to protect yourself, which is hard in a society that views condoms with suspicion and HIV testing as a sign that you think you might be positive, and your partner were holding you back so significantly? People here have problems that I would have a wretched time dealing with, as I have a hard enough time counseling them about their dilemmas.