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.

Maternity

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

Tupo

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!