Sleepless in Moshi

The strangeness of the last 10 months is difficult at times to fully process or appreciate. Sometimes the writer's block is profound. Sometimes the drivel that comes out on the paper is so bad or comes from a place so bleak that it must be summarily squashed and hence one of the many reasons for the long delay in writing on this blog. After working in low resource settings on many short stints over the last 12 years, I thought there would be minimal difference between the way I internalized these short term experiences and those that one accrues over a longer stretch. I was wrong. The summation of many and varied exposures and the continuous exposure is fundamentally different and should be considered carefully ahead of time by those contemplating it; for there is no taking it back. And our situation is tame by most global health standards. We work in a place where there are only dozens of maternal deaths a year. There are many places that are worse. Losing track of time as we develop this or that program and submit this or that grant. The strain on family and relationships. The vagaries of new professional relationships. Concern over the loss of skills and future potential as a physician in the States. Thoughts of reintegration in to that system and moving on.

Few thoughts and recent patients:

1. Humility: I can remember my first exposure to a large number patients with obstetric fistula in Niger . Leaking of urine from a fistula causes fistula dermatitis. This can look exactly like secondary syphillis (condyloma lata) . After I had cancelled a few patients for surgery because of what appeared to be a rampant outbreak of syphillis amongst our fistula patients, I was promptly educated by an older and wiser colleague who told me what this really was. I sheepishly rescheduled the patients and learned a good lesson. We recently took a young woman to the operating room who was dying of something. We knew not what. She was thin and wasting away. Gaunt, tired. She began speaking of her own death. She had an abdomen full of ascites (fluid) and a large pelvic mass. We chose to operate to make a diagnosis in case this was a treatable type of cancer. We made an incision and on opening the abdomen found what looked like cancer everywhere. Her blood count was too low to try to remove all of this and there was only 1 unit of blood available in the blood bank. She likely would have died on the operating table if we tried to remove the tumor. We took a few biopsies and closed her up thinking there would be no hope for her. I was convinced like never before this was some terrible malignancy and hoped at least it would be one that could be treated, because every day she was closer to death. We pleaded for the pathologist (who already has a backlog of 6 months of cases to read) to give us an answer quickly. In 4 days (a miracle) we had our answer. It was Tuberculosis. We were all elated and once again I was humbled by the variety of ways a patient can manifest a disease and my limited exposures in the past. We began treatment and just three weeks later she was on her way home looking 100% better.
2. One of our patients we brought from Berega (see prior blog) is still here at KCMC. She has a rectovaginal fistula and underwent a loop colostomy to divert the flow of feces. She also has such a small bladder after her prior bladder fistula repair that she leaks constantly anyway. She needs surgery that cannot be done here for lack of a few instruments and expertise. She leaks stool now on to her abdomen through the colostomy instead of between her legs. Perhaps the lesser of two evils for her. There is no supply of ostomy bags, so she wraps a kanga around her to compress the stool and hide its odor for a while and then changes it a few times/day. Noone will take her at this point and we've been asking friends and colleagues to come with the appropriate expertise to help. She may be like that forever.
3. We have at least 4 women on the service dying of cervical cancer. A terrible way to go with bleeding and foul smelling necrotic tissue coming from the vagina. Intractable pain from metastases to the bone. No morphine to ease the pain.
4. 3 recent patients with choriocarcinoma which is nearly 100% curable, but we don't have access to the chemotherapy drugs they need. sent a few to Dar Es Salaam recently to the cancer hospital. Have to decide at some point how much is it worth spending to try to save the life of an individual woman in her prime. Is it $200, $300, $500, $10,000? If we spend $2000 in Blue Jean Ball funds on one woman do we deprive 10 women in the future of some local life saving therapy that we can't afford at that time.
5. 16 year old came in two nights ago at 32 weeks pregnancy with a intrauterine demise (stillbirth) and seizures. She had been treated for days at an outside facility and presented too late to do anything. She passes away yesterday morning. She was an orphan herself and no relative or friend was with her at any point in her labor or death.

Many more interesting and devastating stories, but time for bed.
Our team is going to a sugar plantation tomorrow (employs 10,000 people) to teach the ALSO emergency obstetrics course at their hospital.
A recent article by
Denise Grady at the New York Times
http://www.nytimes.com/2009/05/24/health/24birth.html?_r=1&em