the life you save may be your own

Always wanted to have a Flannery O'Connor title in my blog. This week
has been exhausting, but also pretty satisfying. One of the problems
with medicine at home is the sheer distance of it -- your doctor
presence has to be mediated by white coats, scrubs, ultrasound machines,
tubes, oxygen and so forth. Most people's impression of going to the
hospital is of finding yourself or loved ones 'hooked up' to various
machines, pumps, IV's, catheters, and so forth. Here, some of those
barriers still exist, but often the distance is frightening close --
frightening because it remind you of your own mortality, and frightening
because as a doctor you are working with so little reserve. At home, we
think little of transfusing 5-10 units of blood in the ER, to be
followed by another 30-50 in the OR. Here, I donated blood on Monday
afternoon and transfused that unit of blood that evening while doing
anesthesia on a sick C-section patient, since it was the only unit of
type O blood that we had. On Tuesday I was called to obstetrics because
of a baby who was born who wasn't breathing -- we put a tube down into
his lungs and I spent my lunch break acting as a ventilator until he
picked up enough to breathe on his own. What happens when you're not
there to be the blood bank, or the ventilator, or the doctor to do the
C-section?

Flannery O'Connor was trying to say that our actions have a much bigger
impact on us than they do on other people; perhaps not a complicated
idea, but a profound one nevertheless. The corollary I think also holds
true, however -- if you don't save the lives that you can, you may lose
your own way in the process as well. I think that what I struggle with
here is how exhausting that process can be, especially when you are
stretched thin between work and life and interpersonal relationships
which sometimes take a lot of effort to keep smooth. I have to think
that the lives of others are worth it; what I don't often remember is
that truth that when I seems like I'm just spending myself to the limit,
I'm also saving myself from callousness or ineptitude as well.

email slowdown

Sorry if the blogging has been sparse -- we're having some trouble with
our internet these days, which means I have to travel to the airplane
hanger to do my email, something which is rarely convenient and often
impossible when you're on call, since no one can get in touch with you
there. So sorry if the communication hasn't been so prolific.

malnutrition miracles

We've recently had some opportunities to apply to increasing assistance
and funds to help with the malnutrition problem we see here at the
hospital. For various reasons -- farming patterns, soil deprivation,
cultural stubbornness, chronic diseases like HIV and TB -- there are few
protein sources in Kasempa with resultant rampant malnutrition and
malnutrition deaths. We've recently gotten some help via surprise
deliveries of things like Plumpy'Nut and have also been offered
additional assistance via some of the HIV programs in the area.
Previously I am told that we had been declared a 'malnutrition free'
area by the World Food Programme, so our food supplementation funds had
been cut off. Most of the external donations by private individuals for
the hospital are actually designated for food of some kind.

Our visiting nurse, Kate, who's currently in charge of the malnutrition
ward, and Edgar, the doc in charge, have been working extra hard to come
up with the measurements that they need to secure the funds. These are
things like arm circumference and heights on our adults. Thanks to
their hard work, we're getting closer to maybe getting some more of the
help that we need!

the normal is the weird

People usually ask me at home 'what the normal stuff that you see out there at the hospital?' to which I usually reply things like malaria, or HIV, or pneumonia, or diarrhea.  But in actuality the cases that consume a lot of your time and brainpower are the weird, where you're struck with something you've never had to deal with before and are not even exactly sure where to begin.  Those type of cases are the usual for us, each week having to puzzle through how to take care of a huge urinary mass, or whether you should remove the breasts on a hermaphrodite, or when to do the surgery for a 4 month abdominal gestation.  Those are the things that tropical medicine diplomas can't prepare you for: you rather rely on your ability to be resourceful, puzzle through things on your own, call on remote expert guidance from doctors overseas, and tackle things without knowing all the outcomes beforehand.  Obviously that kind of working without a net doesn't always work out well, but surprisingly it does quite a bit of the time, too.

working life

working life, originally uploaded by mattcotham.

Mukinge is a very out-of-doors kind of hospital; perhaps not as much as
the mud huts that David used to work in with MSF, but I enjoy the
exposure to the wind and rain and sun on my daily rounds. Most ER's at
home have few or no windows -- they were usually added on as
afterthoughts on the ground floors of hospitals and I suppose that the
presence of a window would make sick people uncomfortable, although I
never really understood the logic of that. But here, I can sit out on
the steps outside of ultrasound while I'm waiting for the nurses to
bring a patient for a scan and enjoy the sun on my face for a few
minutes in the middle of my day. Or I can dodge the drips on the
walkways when the rainstorms suddenly hit around 2pm, dancing around the
puddles on the walk and feeling the spray from the gutters on my arms.
It's nice, it keeps me in touch with the outdoors, and it gives some
variety to my day which is sorely lacking at home.