Puzzles

Tuesday, September 24

Today was a day all about solving puzzles.  We started the day with a sweet morning report with singing “It is Well” in Chichewa.  The devotional was nice and then we had good discussion about several of our patients. I continue to be encouraged in the nurses asking questions of me and looking to me to lead the discussion as opposed to me being an outsider.  It also allows for a lot of teaching about basic conditions without it being a lecture format.  

Morning rounds again went very slowly, which sounds not good but it really is.  It gives us the time to talk through all the issues, make a plan, and document.

Stella, with heart failure, continues to slowly deteriorate.  Her edema was worse this morning but her response to our medication is not as good.  Dad verbalized his understanding of her condition yesterday evening, but the palliative care team is not really pushing for her to go home.  When she does pass away her bill will be huge. I just want for her to be comfortable and her family to enjoy the little time they have left together.  

Our patient, that we had concerns about rabies or meningitis, had improved enough that rabies was removed from the differential but still has not been doing well despite heavy antibiotics.  So I ordered a chest x-ray to rule out TB. Sure enough, radiology summoned me and he has classic findings of military TB. Not ever any lung symptoms or findings on exam. One puzzle solved.  I went and spoke to the TB director and he came and started treatment right away.  

The one in the coma was not responsive this morning and the older aunt said the she never had spontaneous movement yesterday that she was just stretching her arms for her.  All of our investigations have not led to a diagnosis and she is currently on maximum care but after 3 days in the state we do not anticipate a good outcome. It is just so hard to have unsolved cases.  

We also have a new admission.  He is 4 months old but only 2.3 kg (5 pounds).  He is much under is birth weight and is jaundice and has multiple abnormalities.  In the pictures you get a better feeling of size if you note my thumb next to his head.  My best guess after a lot of research is a syndrome called ARCS1 (Arthogryposis, renal dysfunction, and cholestasis 1).  Maybe the puzzle is solved but there is no treatment and a very poor outcome. Nutrition is really the main aspect of our care at this point. 

We also had a new admission with swelling of his lower leg and concerns about abscesses.  On X-ray he appears to have an osteomyelitis and will require long term antibiotics. On his exam he has multiple small scars where traditional healers have cut him as therapy.  Needless to say, this 4 year old is not happy with anyone approaching and screams most of the day. The traditional medicine is so rampant here, but the people know that the medical staff don’t approve so they typically deny any use.  It is just hard to wrap your mind around the customs and culture.

Our other patients continue to do well, improve, and get to go home.  The numbers of malaria cases are down this week and no one really understands.  The mosquitos certainly seem to have increased in number. I find myself tucking my skirt into my shoes at night to protect my ankles.

Lunch time was awesome because it is Taco Tuesday!!! I had pre-ordered with Victor so I didn’t have to wait as long.  He also made me 20 tortillas. We are planning to make nachos on Thursday and you can’t buy tortilla chips here so we are planning to make some. 

Melissa was babysitting little Teresa (Telesa in Chichewa).  So I got to snuggle and feed her over the lunch break as well.  

As I returned from lunch, I found that they had just pronounced the coma patient dead.  She had stopped breathing and they made resuscitation attempts but without any response.  The Malawian staff all seem to believe that the patient had received traditional medications.  I don’t know if that is a prevalent as they believe but the presentation is hard for me to explain otherwise.  Sepsis was the diagnosis given but again not the typical presentation and hospital course.  

The aunt and other family were with this patient.  There was not crying and just quick discussion about how they were going to get the body home.  It just wrecks me! One of the nurses added some additional information. He explained that especially with babies and infants, there is a belief that if you cry you may cause death of your oldest child at home.  He felt like the absence of tears with this one was that the mom was not present and that she had been unconscious for several days.  

We spent the rest of the afternoon doing some research and discussing some hospital projects.  Catherine had emailed Sam and me about a research project a student had done last year at Nkhoma and ideas for follow up.  We had a long and frank discussion in which I told him how I would interpret this type of email if I was in his place. Basically, foreigners with limited views of the work here offering up ideas that lead to more work for him.  He laughed heartily at my observation and agreed. He spoke very kind and generous words about my time here and the impact that I have had. He suggested that I remain for another year or longer. I was very complimented.  

He then really did invite me to give my opinion as he felt that I had a good understanding of the wards and I went through my observations, concerns, and recommendations.  He asked if I would repeat that back in my email to the administration and I did that immediately. I think that having mock resuscitations every two weeks to ensure coordination, review protocols, and practice moving equipment and delivering resuscitation efforts would have a positive effect and be sustainable.  Though we had many puzzles to solve I love that we are working together to solve them.

As I left, I did have one of the male nurses ask to speak with me.  At first I was worried that I had done something that had created a problem.  He was just asking for financial help. He flipped a rental car over a week ago and now has to pay for the car.  He has paid for the repair but the owner would not take it back so he is looking to sell it and then use the money to pay it off.  He has a good job but is just worried he will not be able to get the full amount together. I told him Wayne and I would need to talk but if we did help,  I would expect that when he sold the car and got back his money he would use it for patients in need. He agreed and then offered me the contact info for his supervisor to validate his story.  I told him I had watched his work ethic and his care of patients and had total trust in him. He has been one of the most respectful and helpful nurses I have worked with.

Things back at the inn are very different these days.  A group of 6 Swedish nursing students have arrived and have kind of taken over.  They are loud, stay up later than the rest of us, and leave a lot of messes. They are also taking up spots on some highly desirable rotations at the hospital.  The hospital has “Outreach” most days of the week. These consist of trucks that go out to the local villages and offer services like prenatal care, mental health (mainly seizure meds) and immunizations.  The medical students love these trips because it gives them a break from the hospital but only two can fit in the truck. Now these nursing students are claiming all the spots and have the others a little irritated.  It also has become very crowded in the kitchen and has made groups as opposed to one family feel. My cooking has definitely decreased to quick things. They are all here until after I leave so I need to just find a new groove.  I feel like my ability to be flexible is certainly increased so it should be just fine.