Saturday, February 28, 2015

Togo Week 3: Pushing farther

This week, Brett, Felisha, and I met with a number of challenges, but today offers a chance to reflect on how we are overcoming them. Firstly, Brett got malaria (we think) on Thursday, and had about 48 hours of flu-like symptoms. But after taking a 6-drug cocktail last night and getting some good rest and prayer, he is back in the saddle today and taking Medicine call. Apparently not even malaria can keep that guy down for long! Compared to him, I haven't had any major challenges, but had to work through another couple days of low motivation and fatigue after taking two call shifts back-to-back earlier this week. But I'm back in the saddle today, too, thinking and learning and working, and taking OB call.

The challenging, sometimes sad, but always interesting cases continued this week. I got my wish and saw my first snakebite. A young man came in on Monday after being bitten on his foot by a snake 3 days prior. His leg was swollen and painful and he was having some bleeding from his mouth as well as from numerous little cuts a traditional medicine man had made on his body. He identified the saw- scaled viper in our handy-dandy Snakebite Guide as the one that got him (and got away), and we gave the appropriate antivenin along with antibiotics, the tetanus vaccine, tetanus antiglobulin, and Benadryl for a mild reaction to the antivenin. And he got better, which is always nice!

Look closely and you can see two fang marks just anterior to the abrasion near his heel.

On my call shift on Thursday morning, an elderly lady was brought in shortly after being struck by a moto. With her decreased level of consciousness, blood coming from her mouth, blood (which turned out to be a bloody CSF leak) pouring out her ear, and her Cushing's response (hypertension and bradycardia), it was clear she had sustained a basilar skull fracture and had a major head bleed. She remains unresponsive with fixed pupils this morning, and as there is no neurosurgery here, we are planning on withdrawing care in the next day.

We also saw a couple children with cerebral malaria complicated by meningitis Those kids have not done well; if they ever wake up, they will be permanently disabled. 
The ICU-- one of the cerebral malaria patients is in the corner bed

I diagnosed several patients with metastatic breast cancer in clinic this week, along with a couple others with intranasal masses. It can be frustrating and heartbreaking having so little to offer. I did start the breast cancer patients on tamoxifen in hopes they would get some palliation. One 22-year-old patient came in with obvious TB, but because his sputum smears were negative for TB the government had refused to treat him. I prescribed him quadruple therapy from our dispensary, but it turns out the pharmacy is currently out of pyrimethamine. Ultimately, after talking to one of the long-term missionaries, we decided to wait on starting him on treatment. Not starting him on treatment and not knowing whether he will ever get treated has been the most frustrating case of the whole rotation.

No C-sections for me this week, though I did place three spinal blocks and first assisted on an inguinal herniorraphy on a 2-year old. I should be able to get some more spinals and OR time this coming week, and I'm also hoping to primary a Caesarian on a transverse-breech set of twins scheduled for Thursday, if she doesn't go into labor before then. Like many patients, she is staying in the Cuisine, which is a building on the grounds where patients who need to be followed closely can stay for free. 

The Cuisine on the left and OB ward on the right

OR 2

My "NICU rotation" continues-- after some reading and discussion with the Pfennigers, I feel good about how to evaluate and make decisions on babies at risk for sepsis. I can see this knowledge being put to use both back in Wichita and also in my future practice. I'm very appreciative.

My pleasant diversion this week was this morning's solo hike up the mountain road behind the hospital-- about a 45 minute walk each way, although the road was still ascending at a modest grade when I turned around. It was fairly peaceful at times, affording some moments for reflection, but also offered many opportunities to practice the situational awareness of Jason Bourne by staying out of the way of a steady stream of motos, trucks, and cars.

I would never trust a Togolese parachute.

Not much change in certain other areas: I continue to miss Mindy as well as other familiar comforts of home, The Book Of Daily Readings and Celebration of Discipline continue to inspire, and I'm still slowly learning French. My final session with Professor Tupo yesterday was excellent as usual. My nurse translator Maman Cherie continues to share the gospel like a boss and rock out an average of 2 conversions a day. It's amazing to watch.

Mindy and snow

Maman Cherie

I'm thankful for the margin I've had during my time here to set fresh new goals for the year and consider the pros and cons of my various post-residency options. I'm sure I will return home inspired. Until next week!

Saturday, February 21, 2015

Togo Week 2- Working Hard

Today marks the halfway point of my rotation here in Togo. Appropriately, Dr. Gayle (a long-term family doc here) and his wife Cheryl took several of us on an outing to the largest town in this region of Togo, Kpalime. We toured the local school for the blind ("The Village of Light"), checked out their nifty aquaponics set-up, shopped at their artisan boutique and the larger local artisanal market, dined at a nice local restaurant, and shopped in the town's outdoor market. All of the experiences-- as well as the drives there and back-- were eye-opening and enjoyable. I continue to derive pleasure from spending time with all the folks here, and am coming to appreciate more how truly wonderful most of the Togolese people are.

Yes, that is a goat on top of the van and two pigs on the back of a motorcycle. Not all that surprising when you think about it (how else are poor people going to transport their livestock?), but entertaining nonetheless given the novelty.

The workweek was also varied and productive. Since my last post, I have performed two more Caesarian deliveries (both of which went well from a surgical perspective, although one was on a known fetal demise), gotten pretty comfortable in both inpatient and outpatient OB and Medicine, and seen a lot of neat cases. There are too many stories to tell and cases to review. In rough order of frequency, on inpatient medicine we see malaria, typhoid, new HIV, anemia, schistosomiasis, acute kidney injury, osteomyelitis, and pneumonia most commonly. Common outpatient issues include dyspepsia, parasites, other infections, back and hip pain, infertility, diabetes, hypertension, orthopedic issues, HIV, and new TB. Yesterday, I was finishing up clinic when I heard a commotion in the waiting room, and a support staff person burst in the room, grabbed a fistful of gloves, and rushed out. Shortly later, I followed him out and discovered two motorcycle accident victims being rushed in on stretchers. I also discovered I was the only doc around. I instructed a nurse to get me some help from one of the local PA's, and began to run through the ABCDE's for each patient. Turns out both had head injuries (hopefully superficial only) and one had an open tib-fib fracture. Fortunately, both were protecting their airway and didn't show any obvious signs of imminent shock. After I got them exposed, I had them moved over to the hospital triage area, where we got IV's started and I was able to promptly obtain a surgery consult. That was fairly exciting.

Kristi, me, Chantal, Amanda, bowel gas, and Chuck

Alcoholic GI bleed in hemorrhagic shock

Peds ward at night

Bronchiolitis-- would have been intubated in the US, but still survived with non- invasive positive pressure ventilation


Sundowning in same baby who really needs a VP shunt

In regards to surgery, I have not pursued getting in the OR (aside from C sections) because of my workload on Medicine and OB and the presence of five surgeons here for the past two weeks. I do still hope to get a few intubations, as well as a few spinals and some General Surgery cases if I can find time. 

Tomorrow, I'm back on OB call, then on Medicine call Monday. We have some people leaving so it will be busy, but hopefully in a good way. I also hope Brett, Felisha, and I can find some time in the afternoon to repeat our Sunday Swim! 

Though it's been a busy week, I've been encouraged by reading Celebration of Discipline by Richard J. Foster and following via group text the experiences of my house church brothers and sisters as they have sought to make meditation (the topic of this week's chapter) a meaningful part of their lives. Being a part of a group of people committed to strengthening and encouraging each other is a key to making spiritual progress, and I've come to appreciate that more this week.

I also had an African feast on Wednesday, which was the first time I had knowingly eaten cassava. It was super bland. The rest of the food was ok. Though I knew cassava wasn't paleo, after reading the Wikipedia article on it, I realized it ranks somewhere near Little Debbie Cakes in its un-paleoness, consisting of almost 100% carbohydrates and requiring extensive processing to remove toxic levels of cyanide. And it's not even native to Africa, having been transplanted here from Brazil by the Portuguese in the 16th Century. Next time, I think I'll pass.

Cassava (agbeli) balls, third bowls from the front

I also had my second French session with Professor Tupo yesterday, and have made some good progress in vocabulary and verb conjugations this week. I'm hoping to practice more each day as I become able to articulate a few things and understand more. Brett has studied with me a couple times, which has been good. I have one more lesson to finish learning the rest of the language!

Though it's been a good two weeks and I'm looking forward to another couple good ones, I'll get to see my girls when I get home! And other people too, I guess. I miss you!

That's Mindy and Molive. I'll never be a cat person, but do have a special place in my heart for Molive. Mindy's ok, too.

Saturday, February 14, 2015

Togo Week 1- Growth

To those of you who don't know, I've been working at a mission hospital in Togo, Africa for the past week. I'm here with my friend and colleague Brett Hoffecker and his lovely wife Felisha. 

The first four days I was here, I was hot and exhausted all the time, didn't know how the hospital system worked, and somewhat anxious about how the month would go because I had so little energy. The last two days, I have felt like my normal self and been a lot more comfortable rounding on patients in the hospital. I'm not sure what changed, but for whatever it was I am thankful. Brett and I are alternating medicine and OB coverage every two days, which corresponds to each of us taking calls every other night (q2 call) either on medicine or OB. The other night, Brett was up literally all night delivering four babies, all of which were complicated by some combination of prematurity, pre-eclampsia, chorioamnionitis, and fetal distress. Fortunately, I haven't had a night like that yet.

My medical goals are to get lots of procedural experience and learn how to take care of some tropical diseases. This week, I did one C-section and two lumbar punctures and saw a few cases of malaria. The topic I actually learned the most about this week was taking care of newborns. My second day here, I performed a difficult neonatal resuscitation on a baby that ended up dying later that day. Although I did the resuscitation with another doctor, I felt like I could've done an equally good job on my own with the training I have received at Via Christi, which was reassuring. But I still learned a few things. The few other resuscitations I've been in on have been uneventful. But I'm also rounding on babies that would be in the neonatal intensive care unit in the United States, a setting in which I have never worked. So I am getting comfortable with treating babies who possibly have sepsis, premature babies who are not yet feeding well, and babies who aren't breathing well. It's been good. Since there are a lot of surgeons here my first two or three weeks, my only real time in the operating room was for the C-section I did and a couple neonatal resuscitations. I hope to get some more time in the OR my final couple weeks of the rotation.

Another goal of mine is to learn lots of French, which is the primary language of the staff here. Yesterday, I had my first of three hour-long French lessons with a local dude who comes here every Friday to provide lessons to the missionaries. His name escapes me, but he has a close-criopped white beard and is a pleasant guy. I'm starting to learn, which is exciting as it represents the start of a new journey.

My interactions with the short- termers, intermediate-termers, and long-term missionaries have all been positive. I'm enjoying their company and learning a lot from them. Some of them are truly inspiring. Today, a few of us short-termers went for a three-hour hike to a nearby cascade and back, which was pleasant. I'm also getting to know the national staff pretty well, and played with a bunch of kids on my run yesterday and ended up with a good story I'll perhaps share another time. I'm particularly looking forward to learning from an OB who just arrived yesterday and continuing to learn from the two Family Medicine and OB fellowship-trained missionaries here with World Medical Mission's 2- year post residency program.

Things are pretty good for me spiritually too. God is teaching me how big He is, how to live more other-directedly, and what walking by faith looks like for me, being a critical and very analytical dude. I'm going through literally the best devotional I've ever come across, a gem of a book I was given by Mindy entitled A Book of Daily Readings. It's basically a bunch of the best quotes you've never heard, some of which are religious but most of which are simply very thought-provoking and heart-pricking. Mindy found it second-hand somewhere and it blows my mind every day. I'm also starting to go through Richard J. Foster's Celebration of Discipline, which has been good so far.

Last but certainly not least, my first week of engagement with Mindy and our first Valentine's Day have been wonderful. Though we have been separated by oceans, mountains, and many miles of flatness, we have had time to process together in a way that would not have been possible if we had been in the same location, partly thanks to the power of the internet and partly thanks to journalling. I'm growing more excited and thankful for her each day as October 4th (our tentative date... not yet set in stone) approaches. 

Thanks for all your thoughts and prayers. A lot has gone into making this trip happen, and it's encouraging to look back over the past week and see some real gains in all the areas I've mentioned. If you'd like, pray that the growth continues.