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Monday, 01 May 2006

Volunteering in Lesotho

Written by Devon Rossetto
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a village school for disabled children
The early morning sun shines brightly; I hang my wet clothes to dry on the clothesline, hoping it will not rain before I come back for lunch. Ever since the water pump has broken and there has been no running water, simple chores like washing clothes takes infinitely more time. As Tarra, a visiting PhD student said to me, “you haven’t been to Africa until you’ve experienced the joy of bucket showers”. I wonder if my experience is even more enriched since our bucket showers come from our rainwater tank, which was also the home for a colony of small red worms that found their way into the buckets and thus, in our showers.

As I head toward the hospital, my eyes find the windows to the pediatric ward. A baby is crying. I can see one of the painted giraffes on the wall through the window. On the other side of the building, a small gathering of women has lined up around the rainwater tank with large buckets. The hospital, like the entire district, has been out of water for over a week now. I decide that while taking a bucket shower in the company of worms is an inconvenience and a little bit gross, having to run an entire hospital without running water is a much larger problem.

I have to walk through the male ward to reach the pediatric ward. The stench of vomit, urine and death flood my nose and I begin to walk faster. There are eight to ten men to a room, mostly with tuberculosis and complications from AIDS. If they were to be anywhere other than in sub-Saharan Africa, many would be in an intensive care unit. But here they are, lying in their beds. Some have begun to move about the ward, carrying the urine filled bag attached to their Foley catheter. A woman sets up a cart with hot sorghum porridge, looking like watery clay that some men wait in line for hungrily. I am taking care of one of the male patients. I peak by his room, see him sitting on the bed, staring.

I admitted this patient when I walked into the clinic one Friday afternoon to the nurses exclaiming: “Doctor, will you see this patient? He is having trouble breathing”. I winced at the sound of the word ‘Doctor,’ because although I am still a fourth year medical student, the nurses’ call me ‘Doctor’ and expect me to make decisions with the calm confidence of a physician. I have been in Lesotho, Africa for about a month doing a two-month rotation at one the referral hospitals during my last year of medical school. I wince again when I see the patient is a fifty year old man. As a budding pediatrician, I have spent almost all of my fourth year doing pediatric rotations. Since I am the first one back after lunch, I have to see the patient. His breathing is becoming increasingly labored.

The vague history I receive from a family member is that over the past two weeks he has become increasingly short of breath; now he is unable to speak and is complaining of left sided chest pain. I am already forming a differential diagnosis in my head, but continue to ask the review of systems (where the physician asks a series of systematic questions about every body system). His review of systems is negative, except for abdominal pain that is worse than the chest pain. The abdominal pain broadens the differential from primarily respiratory and cardiac disease to include the gastrointestinal system. An acute abdomen, a surgical emergency where bacteria has spread within the abdominal cavity, must be ruled out. Meanwhile, the nurses have given him oxygen by a nasal cannula, which he keeps trying to remove. Another nurse is preparing an albuterol nebulizer, which helps to open the airways in the lungs. An IV is started.

 


 

The patient is in severe respiratory distress; he is breathing at about 60 (normal for an adult is 14-20) and is unable to speak. He is afebrile. I wish for an oxygen saturation monitor that can tell me if his blood is being oxygenated; a useful sign in ruling in certain pulmonary processes like pneumonia or asthma. They are standard of care in every emergency room in the United States. On my third day in Lesotho when I was still adjusting to the limitations here, Dr. Rodriguez, an Argentine supervising doctor at the hospital, told me frankly: “We are in Africa now. Forget what you might do at home with technology and fancy imaging. You can only help your patients by using your head and your hands”.

His lungs sound clear beneath my stethoscope, moving entities like pneumonia or asthma farther down on the list. I stop and listen to his heart. I linger here for several moments longer than I normally would in this emergent situation. That’s odd, I think. I can’t hear his heart beating clearly. The sounds are muffled. I have never heard this before, but muffled heart sounds is a buzz word which every first year medical student learns is associated with pericardial effusion: fluid around the heart. If the fluid collects too quickly, the heart is trapped beneath the pericardium and cardiac tamponade ensues, which can lead to death because the heart is unable to pump against the weight of the fluid. Could this be the cause?

When I reach his abdomen, I have difficulty examining him because he is so short of breath that he can’t lie down. Sitting up, I can feel that his abdomen is soft (a good sign), but his liver is several times the normal size. There are many causes of hepatomegaly, most of which require lab tests to elucidate the cause. If I had been working in Africa for longer than a month, I might be able to put two and two together sooner and come up with the most likely diagnosis. However, the important thing at this point is to stabilize his breathing. At this time, we have drawn blood for labs and a young doctor from Malawi has joined me. We bring out an old portable ultrasound machine from the prenatal clinic to look for fluid around his heart. His heart, a fuzzy beating blob on the small screen, is completely encased in pure blackness, representing the fluid within the pericardium (the sac around the heart). This patient is in cardiac tamponade and the treatment is emergent pericardiocentesis. The fluid has to be removed.

I think about what might have happened at Boston Medical Center, where I trained. Cardiology would be there to perform the procedure. Or maybe interventional radiology would get involved. The state of the art imaging technology would be available. Most likely, he would be in the ICU. He is complaining of getting tired of breathing, a sign of respiratory failure. I hand Dr. Dullie a thirty cc syringe attached to a long needle. Using the ultrasound probe for guidance, he finds the largest fluid collection in the left side of the chest and sticks the needle in. He withdraws pinkish fluid. We wait. Almost instantaneously, the man begins breathing comfortably and starts to talk. I also breathe comfortably at this point and begin to get his paperwork together for admission. We will admit him for observation. I will learn through my reading that the most likely cause of a pericardial effusion and tamponade in Africa is tuberculosis. This is consistent with his large liver; extra pulmonary TB is also very common.

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The children's ward at the hospital
Moving on from the men’s ward, I make a mental note to write an order for checking the man’s liver enzymes today. He has developed hepatitis from the TB medications and I am monitoring his liver enzymes for improvement. In the pediatric ward, brightly painted animals decorate the walls, but the floors are the same crumbling tile as in the male wards. Luckily, the smell is not as strong. The windows are open, allowing bugs to fly into the rooms. Steel cribs are lined up against the walls, the bright brown faces staring at me. I pass by Neo, who smiles at me; he is one of the country’s 100,000 orphans and has begun to recognize me as I play with him every day. He is only about 13 months old but is developmentally delayed in motor, speech and interpersonal skills. His mother has died and he was neglected by his foster mother, despite the fact that she collects donations in his name from unsuspecting donors. His eyes follow me across the room and I wonder if I will see him stand up before I leave.

 


 

My heart breaks for the orphans here. Some are taken care of by their aging grandparents, others in orphanages of varying quality, others live with other orhans; the older ones taking care of the younger ones. This is an after effect of the AIDS epidemic that has swept the country. Lesotho has one of the highest rates of HIV/AIDS in the world, at 30% of the population. While I don’t keep hard statistics, I am on average diagnosing HIV/AIDS in one child each day.

I am happy today because all the children are alive. There are two babies with acute gastroenteritis and dehydration. One is HIV+, and the other one we haven’t tested yet since the mother is afraid the baby is too young. Counselors talk to the mother of the HIV+ child daily about new medications that can prolong life, but the stigma here is still high. We eventually diagnosed him clinically with AIDS because his condition has deteriorated so much. When we enter the room, the mothers and grandmothers rise from their foam mattresses (on the floor next to the cribs) to tell us how much the babies are drinking of the oral rehydration solution, a low tech life saving drink of electrolytes and sugar. We move from the gastro ward to the general medical ward.

The malnourished toddler is crying and the young mother straps him to her back and begins to walk around. The baby is edematous or puffy from lack of protein, has lost pigmentation in his hair and his skin is covered in sores from vitamin deficiency. It is a sight I only used to see in textbooks but now it is staring me in the face: irritable and miserable. We see another baby with pneumonia, another being treated for meningitis, and yet another who was admitted yesterday with seizures. It is a typical day on the wards and after rounds I head to the clinic. Outside, rain begins to pour and I sigh as I think of my clothes hanging outside on the line.

The stench reaches my nose even before I walk into the exam room. There has to be pus somewhere. The other doctors in the clinic begin poking their heads out of their exam rooms. What is that smell? That smell belongs to a twelve year old boy, his arm bandaged up in a cast that hides the offending culprit. Trying hard not to breathe through my nose, I greet the boy and his sister with the few words of Sesotho I know and then, with the nurse acting as an interpreter, the cause of the stench reveals itself.

Two weeks before, he had been bitten by a donkey and suffered multiple skin wounds in addition to a fractured distal ulna. He had a cast put on his forearm at another clinic at the time of the incident. He now has serious wound infections that are causing pain, swelling, and a foul smell, which led them here to the referral hospital. Although I know nothing about donkey bites from my medical school training, I do remember the mantra of one particular surgeon at Boston Medical Center: “all pus must be drained”. Off comes the cast, revealing about seven deep lacerations around his wrist with green pus and black tissue, presumably necrotic or dead tissue. His arm is swollen and he is unable to move it. I wonder who on earth put a cast over this mess and set about to clean it up and see what was what.

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a clinic in the mountains
I decide this is a case for the operating room. There is dead tissue that needs to be removed; pus that needs to be scraped out, and the boy will be more comfortable if the whole procedure were to be done under anesthesia. He is admitted to the pediatric wards, has his wounds debrided, his arm in a sling, and soon becomes a constant fixture on the wards, always smiling. He patiently waits through daily dressing changes and the wounds, some of which gape open at 4x7 cm, beginning to close nicely. Smooth pink tissue edges close in over the exposed tendons of his wrist. It is a success. After two weeks he is begging to go home, a several hour walk from the hospital. He wants to get back to school. Not all of the patients are so fortunate.

 


 

As a medical student in Boston, I had taken care of two patients who had died. One was a man on the oncology ward with acute leukemia. The other was a young man who died on the operating table after a motor vehicle crash. These are defining moments in my training, coming face to face, for the first time, with the limitations of my future profession. The faces of those patients and their families are etched into my brain. Here it is different. There are too many patients dying for me to remember them all.


Some images are clear; a mother wailing after her 3 month old baby died from bronchiolitis. I can still see hear the screaming of a one month old with meningitis, his anterior fontanelle (the soft spot on the baby’s head), was bulging and his pupils were asymmetric, both signs that the infection have spread too much around his brain and that the pressure caused the brain to herniate through the skull. The seven year old orphan, a 24 pound skeleton who is too weak to move, is dying of AIDS. These images run through my mind constantly. What else might I have done to help them? These faces keep me up at night; poring through books on infectious diseases, hoping I might find the magic cure to bring them back and give them a chance to live their lives in this beautiful country. It is not fair. Once again, I fight back tears as I leave the hospital.

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village children
Night comes quickly. I open the back door to collect water for cooking the night’s meal of noodles and vegetables. I squat by the tap and as the bucket is filling with water and worms, I look up: the night sky is brilliantly lit up by a million stars. The Milky Way snakes softly across the sky, a sight that reminds me of childhood camping trips. The sight is so still, so perfect. I say a silent prayer for my patients sleeping in their hospital beds. For one moment, I feel at peace here in Africa.

 

©Devon Rossetto

 

 

Last modified on Sunday, 16 December 2012

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