October 2014 - Week Three - Douglas Grey

Another very busy week and a pattern is emerging. There are both incredible highs and profound lows associated with a job whose mission is to attempt to help train others, improve outcomes for patients but without templates for accomplishing this. One confronts all sorts of difficult clinical problems that are desperate for many disparate reasons: late presentation of disease, lack of access to adequate screening programs, lack of resources necessary even of the diagnosis is made, lack of patient resources.
One of the typical "rock and hard place" situations is around antibiotics and chemotherapy. The patients are expected to pay for their required medication by purchasing them prior to admission. It is not uncommon for patients who walk to the operating theater (room) and hand the anesthesiologist their meds. As I mentioned previously, the hospital is surrounded with small pharmacies for this purpose. Likewise for chemotherapy, where it may be ordered for a certain disease- but the patients and families have to be able to afford these drugs, and worse, the pharmacies may run out of these intermittently. We actually had the discussion at Rounds this week of! "Should the doctors pay for meds or tests that are necessary, but the patient can't afford." Interesting to contemplate how these discussions would play in the  US.
We have had some positive stories. On Monday, we consulted on a case with a 35 year old woman with a cystic tumor in the pancreas, somewhat like Steve jobs suffered from. Dr. Craig Lubbock and I helped this surgeon with the decisions around exposure, resection, and pancreatic removal, something that the surgeon did not have much experience. The operation went smoothly, and the patient has thus far has had a smooth recovery. The surgeon was very grateful for the assistance and experience offered.
The volume of patients in dire straights remains daunting. One of the processes that becomes a routine is Thursday afternoon where the schedule for the subsequent two operative days is set. We generate a list of patients requiring scheduling, which includes many cases which one could only see in circumstances such as this. Upper extremity amputations for tumor, complicated intestinal surgery for infections, complex non-healing wounds where the diagnosis is unclear. Esophageal cancer is rampant and the treatment options become less varied as the diseases are generally more advanced.
One vexing problem is patients who receive a diagnosis and want to pursue traditional homeopathic treatment as an alternative. The patient will then disappear for 4-8 months. He/she will then reappear, with a longstanding diagnosis of a severe problem, be generally much more advanced or symptomatic, and much more high risk. It becomes much more difficult to treat and the system grinds on.
Another disease category that I was not expecting was domestic violence. Two cases that stood out were a 35 year old man stabbed by his  father (survived his diaphragm and liver injury) and a wife who was caned by her husband. This could probably happen anywhere, but seeing the victims and their injuries makes it more immediate.

On a lighter note, Tuesday was Julius Nyrere a Day, a national holiday. Our surgery resident, Jeff Crawford ran a half marathon in Dar.  I went out to cheer him on and was struck by two things. The first thrill was to see the leader group in the race. This was a group of 20 runners in the elite group- legs four feet long, four to five foot strides, and as graceful as anyone I have ever seen run. The second thrill was Jeff was the "lead white runner" of the entire race and finished there.

Last weekend Craig Lubbock and  I went to Mafia Island, an island off the coast south of Dar(like Zanzibar ). It is one of the largest marine sanctuaries in the world and relatively uninhibited. The reefs were extra worldly with hundreds of fish types and coral species. Even to a color blind snorkeler, this was impressive. There was an island across the bay, Chole Island (pronounced cha-lee) (pop 1000) with no power or consistent water supply, etc. it was a paradise with charming people, engaging children (I played "I Spy" on demand with some school girls as I had with my own children- something about, "I spy a lion" in that environment was cool). There was a hand made boatbuilding  yard, with no power tools, all wood hand hewn and unique, but it works. They make all the boats for the island. Fruit trees abound of every type. Baobob trees everywhere. Fruit bats  everywhere. Beyond fascinating.

Lastly a little Swahili. Greetings are varied and the most casual is "Jambo" (hello) or "Mambo Poe" (how's it going), to which you reply "Poe" (po-ah meaning cool)  and flash two thumbs up. Thus generally gets a big smile and they assume you know more than you do.

Over and out
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