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.

Lack of resources dumbfounds medical student

Today I was doing prenatal consultations in the maternite, and as I do with all patients, I closed the interview by asking if she had any questions or concerns. This patient completely dumbfounded me by saying, yes, I do have a concern, my husband's mother beats me. She pulls up her dress to show me all these bruises on her body. She goes on to explain that she moved to Lambarene to be with her husband's family and she has no support here. So she gets beaten and no one stands up for her. Goodness, that is not what I meant by any concerns. I was literally dumbfounded. I had no idea how to counsel her or what resources were available. After asking around, I found that none exist here, of course. I felt so helpless. What on earth could I offer this patient? People don't hug here, so even my human contact with her was limited and constrained by cultural differences. Agh, so frustrating to not have anything at all to tell my patient or offer to her.

Born on arrival

Today we had the third baby I have seen in three weeks nearly born in a taxi. If your amniotic fluid gushed in a taxi, plus or minus some blood and excrement, what do you think would be a fair price to pay the taxi driver for clean-up charges? Also who knew this would be such a common occurrence? The first time it felt like a movie. Now it is starting to feel a little ordinary.

The French and their shorty shorts

This weekend, my roommates and I embarked upon a Libreville expedition of epic proportions. Purportedly, our aim was to drop our French roommate off at the airport for her return trip to Dijon, but there was also big city tomfoolery to be had. I have already written about our French military friend, who is an absolute sweetheart. Well this weekend he introduced us to French military life a la etrangere. First and foremost, when the French military embarks to a hot weather climate, they have tiny shorts that they wear as their uniform. It is too super! We arrived at an after work party on Friday afternoon to find dozens of men in military shorty shorts. I was so taken by the scene and expressed my appreciation for this mass display of sexy shorts that our friend commanded one of his subordinates to strip and give me his shorts. So if back in the US, or elsewhere in the world, you see me wearing a pair of tiny cammos, you know they came directly from the thighs of a young French military man. Too great.

In other news, I bought all the train tickets that I will use for when my husband arrives at the end of the month. We are going to travel this country--I am so excited!

Be careful what you pretend to be

In middle school when everyone was reading Kurt Vonnegut because he was a relatively deep, interesting author that was nonetheless accessible to young minds, I wrote one on his quotes on my wall that stayed there well into college. It read: “Be careful what you pretend to be, because you are what you pretend to be.” Although this is a bit cliche, reflecting on this idea has served me well in the domain of medicine since so often I am just pretending to be a doctor. I have to pay attention because the habits, manerisms, and knowledge that I display now are the kind of doctor that I will be. I have been thinking about this recently in the Maternite because there is not always a lot of supervision of the work there and I get to make decisions somewhat on my own. Thus the habits that I am developing in examining patients, in doing pre-natal consultations, and in doing deliveries are the habits that will shape the kind of doctor that I am. I think about this every time I do something new, like rupture an amniotic sac yesterday afternoon, that the way I do this now may be the way that I do it for the rest of my life. Or at least for some time. It is a wonderful and frightening feeling at the same time.

In other random musings, I think that living in a foreign country for so long has been an impetus for me to reject received notions of my tastes and limitations. In short, Gabon has helped me to work through some of my fears and dislikes. For example, before I came here I would have sworn to you that cheesecake makes me vomit. But at the American house in Libreville, I ate two pieces of cheesecake, and it was delicious. I have been eating mayonaise on fish and omelettes for dinner (when there is not a good vegetarian option) the whole time I have been here. Those three foods are things I would have told you are repulsive to me before Gabon. Interestingly, it turns out that is not the case here.

My greatest triumph over my formed ideas of myself and my limitations occurred today though: I gave blood! Pre-Gabon, I would have told you that I was not someone who could donate, that I would faint, or be anemic, or just not tolerate the procedure. But I was wrong. I guess that my food and blood limitations are the corrollary to the notion that you are what you pretend to be. Even if you pretend to be something, and it starts to become a part of you, it does not mean that you can't pretend to be something else later on.

Be careful what you pretend to be

In middle school when everyone was reading Kurt Vonnegut because he was a relatively deep, interesting author that was nonetheless accessible to young minds, I wrote one on his quotes on my wall that stayed there well into college. It read: “Be careful what you pretend to be, because you are what you pretend to be.” Although this is a bit cliche, reflecting on this idea has served me well in the domain of medicine since so often I am just pretending to be a doctor. I have to pay attention because the habits, manerisms, and knowledge that I display now are the kind of doctor that I will be. I have been thinking about this recently in the Maternite because there is not always a lot of supervision of the work there and I get to make decisions somewhat on my own. Thus the habits that I am developing in examining patients, in doing pre-natal consultations, and in doing deliveries are the habits that will shape the kind of doctor that I am. I think about this every time I do something new, like rupture an amniotic sac yesterday afternoon, that the way I do this now may be the way that I do it for the rest of my life. Or at least for some time. It is a wonderful and frightening feeling at the same time.

In other random musings, I think that living in a foreign country for so long has been an impetus for me to reject received notions of my tastes and limitations. In short, Gabon has helped me to work through some of my fears and dislikes. For example, before I came here I would have sworn to you that cheesecake makes me vomit. But at the American house in Libreville, I ate two pieces of cheesecake, and it was delicious. I have been eating mayonaise on fish and omelettes for dinner (when there is not a good vegetarian option) the whole time I have been here. Those three foods are things I would have told you are repulsive to me before Gabon. Interestingly, it turns out that is not the case here.

My greatest triumph over my formed ideas of myself and my limitations occurred today though: I gave blood! Pre-Gabon, I would have told you that I was not someone who could donate, that I would faint, or be anemic, or just not tolerate the procedure. But I was wrong. I guess that my food and blood limitations are the corrollary to the notion that you are what you pretend to be. Even if you pretend to be something, and it starts to become a part of you, it does not mean that you can't pretend to be something else later on.

Maternite!

I am working in maternite now, seeing lots of babies being born. Yay future career! I am very happy.

Snakes on a Plain!

Yesterday in the pediatrie, we had a kid with a snake bite! He probably wasn't really bitten on a plain, but I wanted to use that phrase so badly because of the movie, so I hope you will permit me the liberty. He was in all likelihood bitten in more a jungle/wooded area. En tout cas, it was the first time in my life that I have seen a snake bite victim. He was walking when he came across a long, black snake that struck him on the foot. The bite was not that big, but pretty deep. We cleaned and debrided the wound a bit, and then loosely wrapped it in gauze. Then, since we only had the word of a 12 year-old describing the snake (no one had been able to capture or kill the snake to aid in identification) we gave him a polyvalent anti-venom serum. Then we observed him for 24 hours for signs of local tissue swelling, trouble breathing, or heart problems. All went well and we were able to discharge him from the hospital. I thought for sure with a snake bite, the kid was going to die, but the doctor that I was working with told me that the huge majority of snake bite victims survive, either because the snake that bit them wasn't really venomous, didn't bite them very hard, or did not inject venom when it bit. The most important thing to do, he explained to me, is to reassure the patient and their family so that they remain calm and don't have tachycardia, which only further distributes the venom. Interesting that human interaction and reassurance is actually the key to successful snake bite management.

Snakes on a Plain!

La fatigue or WWASD?

It is getting HOT here; the saison de pluie has really made its inroads. The afternoons are starting to push into the high 80s with lots of humidity. And it is only going to heat up, according to what locals tell me. Along with a lot of work and the chaud politics at the hospital, I am totally exhausted. I wonder what Albert Schweitzer would do at this point? I think he must have frequently felt at his wits end. I haven't read his autobiography yet, but I am curious what he has to say about sustaining one's commitment to service in the face of physical and emotional overload.

La fatigue

It is getting hot here. The afternoons are starting to push into the high 80s with lots of humidity.

Road Accident

Traveling in a car is one of the most dangerous things you can do in Africa. More people die in road accidents than by any other cause of preventable injury. Usually it is the case of single cars crashing into each other, but every once in awhile very gory large vehicle collisions occur. The gore is compounded by the fact that people here ride in the back of trucks, which are already piled high with baggage, by the dozen. Sunday night and Monday morning we received 66 patients who were the victims of one such mass casualty event, which occurred at 50km from the hospital. Apparently they were riding in the back of a huge trailer truck, celebrating a soccer team's victory, when the truck skidded out and flipped. Four people died at the scene and the rest were transported urgently to Schweitzer. They were triaged, bandaged, and kept in waiting rooms, consultation rooms, and even outside. We did a lot of x-rays and a lot of wound debridement. And two days later, most of them have returned home cut and bruised, with whip lash, but surprisingly lacking major injuries. There was almost no abdominal or thoracic trauma (only one splenectomy!) and relatively few broken bones. All in all, it was a success for the hospital to manage a mass casualty scene like that and lots of luck that it turned out so well.

Another weekend sans arret

This week and weekend went by in an absolute blur. This is partly because I was in Libreville at the beginning of last week, which set off my internal weekday/weekend calibration and partly because the PMI trip on Thursday was brief so we had the afternoon off. My roommate and I used that time to go on a LONG walk and to pick up stuff at the tailor's. I had several things made: skinny jeans from flared jeans I got at the bins, pajama pants from elephant-print cloth, and a purse from fabric I found in the garbage. Even in Africa I like to dumpster dive! The tailor did a really nice job though, unlike the clothes I had made when I lived in India, so I am excited to get a few more things made as well.

Anyway, this weekend was completely fast and furious. Friday night we left the Schweitzer compound right after dinner to go a funeral/wake for one of the nurse's uncle who died earlier in the week. It was interesting to hear about how death is dealt with here: after an adult dies all of the women of the family who are free sit with the body for five days. People drop by all the time to pay their respects and visit with the family. You say “mes condolences”, not I am sorry for your loss, as we say in the US. After five days of sitting with the body, there is a vigil/wake the night before the burial. Everyone sits outside the house, men on one side, women on the other, and talks quietly or just sits. A lot of people spend the night with the family outside that night. Then the next day you wake up and the men start digging the hole for the burial. Burial happens, then lots of drinking and eating. Then one month to one year later there is a deuille, which is a celebration of the dead person's life and is basically just a huge party. After we sat with the family for awhile on Friday night we went to get a few beers with some of the family members.

Saturday morning we woke up early to go on a boat trip on the Oogue to the lakes that are upstream from us. This pirogue trip is kind of a classic Schweitzer experience, everyone has to do it at least once. Also you get to see hippos! I thought of my mother-in-law the whole time because she loves hippos and we were able to see several families of them swimming in quieter parts of the river. They were so funny, they would just surface with their big heads, blow off water and air, and swivel around with their ears. It made quite a racket when they would come up for air like this. Hippos can stay underwater for up to 30min, but they tend to surface every few minutes for air. We also saw monkeys, crocodiles, iguanas, and pelicans on the trip.

On Sunday morning we were again treated to the opportunity to wake up early and do something African. One of the nurses who works with us invited us to go planting in her village. Here it is often referred to as going “en brousse,” which means going into the jungle, even if you are not walking very far away from the road. Planting is traditionally considered women's work and we only saw women and children out in the jungle. The African women we were with carried everything we needed out to the field in giant paniers, which are woven baskets that have straps threaded through them that you can either wear like a backpack or around your forehead. Most women choose the forehead method which I find absolutely stunning. It would put so much pressure on your neck. Anyway, the women loaded up the paniers with machetes, taro bulbs, and small banana tree roots and me and Annie put on our backpacks. And then we headed off down a steep path into the jungle. We walked for about 20 or 30 minutes to a clearing that had been burned the week prior to prepare the soil. Here you always burn before you plant bananas. You don't have to clear the jungle, because the banana trees will grow in between the other vegetation but you do need to prepare the soil with burning. Once we got there, we got to planting. You dig a hole about 6 inches deep—with a machete, mind you-- and plop the banana or the taro into the space. Then you cover and repeat. You try and plant the taro in between the banana plants. After we had planted the first batch we went back to another, older plantation to dig up more banana roots to go back and plant at the first site. You have to do this because banana trees only give one fruiting, they are not annuals, so you have to keep replanting them every 6 months to one year. Once we finished with the third round of planting, we headed back home, in the pouring down rain (saison de pluie!), which I loved because I come from a rainy city and rain makes me happy. When we got back to Schweitzer, I fell asleep almost immediately and complained loudly the next day about how hard the work was. The life of an African woman is so physically demanding, I do not know if I could do it. Maybe if I had been raised like this and was in the habit it would be okay, but after one day of mini learning, I am exhausted and sore!

Best Weekend Ever, Part Deux

Practical life in Libreville and how the people helped us:
One of the tropes of life in Gabon is that Libreville, the big capital city, is not a friendly place. Maybe people say that about any large city or gathering of people, but the intense animosity sometimes expressed about the capital is surprising here. Thus it was with heavy, somewhat anxious hearts that Annie and I set out to accomplish practical life matters Monday morning. We had been appropriately warned about how bad things can be here. But it was nothing like that for us! Annie was welcomed and attended to heartily at the Guinean embassy. And though I was passed from one tourist agency to another, when I finally found out where to buy train tickets, an older woman actually took me in a taxi, paid the taxi for us, and walked me to the street of the train ticket office. I got a little lost on the way back home and a newspaper salesperson walked me to the taxi stand. Our experience of the big city was actually quite welcoming, a pleasant surprise.

Sweethearts:
Along our travels we have managed to make some very kind friends in Gabon. One of them is a young female university student who we met at her parent's hotel at Cap Esterias. We hung out with her during our time in LBV and she was a darling showing us her city and friends. The other is a French military officer, friend of a friend, who also took us under his wing, showed us the city and offered to help with anything that was tough or going wrong here. Total darlings. When you are traveling having kind people as your friends makes a world of difference.

Best Weekend Ever, Part 1

This past weekend and surrounding days have been absolutely delightful. This explains why I haven't had time to blog--life has been too busy and fun. Allow me to tell you about the past five days in easily digestible separate blog entries:

Some interesting patients from clinic and hospital on Friday:
1.Two year old boy who presented two months ago with difficulty breathing, chest x-ray shows cardiomegaly (heart is 75% of the thorax diameter) and probable pneumonia, previous chest x-rays normal. We treated the pneumonia and the wheezing has somewhat ameliorated, but at all the follow-ups the cardiomegaly persists and he has now developed generalized lymphadenopathy including some huge lymph nodes in the armpits. Serology is negative. Next appointment in one week, let me know if you have thoughts or suggestions.
2.Kwashikor (protein deficiency that causes swelling because you don't have enough protein in your blood to keep the water in your vessels) baby!! This baby's feet and abdomen are hugely swollen for lack of protein, even as we try to refeed her protein. Did you know that Kwashikor means second baby because it is often observed in the older child when a new baby arrives because the mom starts nursing the new baby and not feeding the old one? In this patient, it actually happened this way with a new baby arriving in the family and her getting malnourished over the course of several months.

La journee d'acronymes, or I finish ERAS and FAFSA:
The world is really a small place. I can sit in the research lab at Albert Schweitzer hospital and turn in all the required documents for financial aid and residency applications! I turned in the majority of my residency documents two weeks ago, but I just put the finishing touches on programs that I applying to and uploaded a photo Sunday morning. And as I had forgotten to fill out FAFSA for this school year, my school's financial aid office kindly reminded me of this error with multiple emails and I was able to remedy that situation Sunday morning. Now all I have to do is sit back and wait for the residency decisions to roll in. It's amazing to think that I applied to residency, which is this huge process from an African country.

My other in-laws:
After I turned in my remaining official documentation to America on Sunday morning, my roommate Annie and I headed to Libreville, the capital city to take care of business there. A few weeks ago an American medical evacuation pilot/Christian missionary left a message on my blog telling us to come stay with him and his family at their guest house if I were in Libreville again. The combination of America and medical stuff made me jump at the possibility. It was a complete delight staying with them. They had American food like cheesecake (I ate it and liked it Owen!), buttered microwave popcorn, and grape jelly at their house which they generously shared with us creating us a little America in Gabon the likes of which I have never experienced. They also took us to the clinic that their church runs and helped us with a bunch of practical details. So sweet! They remind me of my in-laws who are also really good Christians, though not missionaries, which was extra nice to have that feeling of being around familiar people. And unlike all the old jokes, I love my in-laws greatly, so it was a very positive association. What a provident surprise to find each other in Gabon.

One year of marital bliss sans divorce, yay!
Speaking of in-laws, Sunday was my one year anniversary of marriage. Unfortunately Owen, my husband, is in the US working but I celebrated here in Gabon with my lovely rooommate as a stand-in. We went out to a romantic Italian dinner on the water in Libreville (Dolce Vita at Port Mole) and then watched Princess Bride when we got home. Owen and I got to gchat a little bit about our first year and agree that it has been super fantastic and we want to renew our promises that we made to each other last September 19th. We'll eat our ceremonial frozen piece of wedding cake when we are back in the US together...

Should Poor People Pay for things?

Bonjour equipe-- I have been thinking about something recently due to a spate of really poor mothers that I have met on PMI trips. Should poor people have to pay for medical care at all? It kills me when a mother says that she cannot afford the 2000 CFA (about 4 dollars) for a consultation and medicine on the PMI trips. There have been some extremely sick kids that we have not seen because of the barrier enacted by the consultation fee. It makes me feel like we should see everyone for free. But when I offered this idea to the PMI nurses, they were vehemently against it because they said it would overwhelm the system and it would cause mothers to prioritize/value health less because they would be able to get it for free. Although this idea is a bit unpleasant, there are studies (even put out by the World Health Organization) to support the idea that there should be small fees associated with health care. For the time being, I wish that I could give things for free to all my patients but I recognize that I have to respect the rules of the system that I am working in. Otherwise, if it is only me who gives things away that will only disequilibrate the hospital and community health services of the hospital even more.