No More "TIA"

The most rewarding part of this year’s trip was definitely teaching the medical students.  They are the next generation of doctors, being trained to rebuild the Liberian health care system.  They are so crucial to this rebuilding that I really feel like I am a part of history-in-the-making.  During my time here, I have taught them not only through didactic lectures, but also by rounding with them and leading by example.  I think that is the best that we can do here.  One day on rounds when I pointed out a medication error (that led to a Burkitt’s lymphoma patient getting 3 days of cyclophosphamide instead of one… OMG!), one of the medical students thanked me later.  I used this error as an example of an error that we could all learn from.  Instead of pointing fingers at who made the mistake, I carefully spoke about our “incident reports” and M&Ms at home… and about how important it is to look at errors in order to figure out ways to prevent them from occurring in the future.  The medical student pulled me aside and told me how happy he was that I spoke about the error on rounds because just 4 weeks prior a cancer patient had DIED due to a medication error.  An error that was never discussed.  An error that this medical student discovered and didn’t know what to DO with it. 

Many of my discussions with the medical students were in regard to delivering proper care for their patients despite this resource-limited setting.  So much of the staff at JFK Hospital still have this air of learned helplessness.  NGO groups call it “TIA” syndrome, which stands for, “This Is Africa”.  When a test doesn’t get done or a nurse doesn’t fulfill your orders, someone will say, “TIA”, with a sigh and a shrug.  Healthcare providers SHOULD NOT have that attitude.  In order to move forward to providing better patient care, they CANNOT have that attitude.  Unfortunately, dealing with daily “TIA” struggles wears one down after a while.  It requires an army of people to stand up and speak out against what is not acceptable for patient care.  I hope that my words and actions will at least have taught this group of medical students that they must hold themselves up to a higher standard than the current health care providers around them.  They are the future and the hope for Liberian health care.  It has been a lot of fun and a privilege to work with them.

Monkey Jam, Eat Pepper

One of the biggest challenges here at JFK Hospital is malnutrition.  Upon first reading, one might say, “Of course malnutrition is a problem.  It’s Africa!”  But, the patients and the disease processes that come with malnutrition are only the tip of the iceberg here.  You see, the problem that I am speaking of is the difficulty that we have with TREATING malnutrition here.  Without getting myself into too much trouble and ruffling too many feathers, I will just say that the kitchen at JFK does not supply enough “high protein milk” for the kids with malnutrition here.  And, this “high protein milk” is actually not up to WHO standards.  So, these patients often LOSE weight while admitted and, not infrequently, die.  It is SO frustrating.  There are a few very capable feeding centers in Monrovia (with F-75, F-100, and Plumpy Nut donated by UNICEF …. Formulas and foods made for re-feeding malnourished children in developing countries).  However, JFK Hospital has not wanted to accept such donations.  (It is a long and frustrating explanation.  We have been trying to get this situation taken care of… but, the politics involved are overwhelming and, honestly, unbelievable.)   Therefore, when I am here at JFK, I make it a priority to discharge the malnourished patients as soon as possible to follow up at one of the feeding centers.  While the kids are admitted, I go out of my way to INSIST that the children get enough milk from the kitchen.  I haven’t made many friends in the kitchen doing this.  Lol.  But, I explain that this food is their medicine.  They have had every excuse in the book for why there isn’t enough milk… which keeps me on my toes.  My favorite was when I saw a giant tub of milk sitting on the counter and they told me I couldn’t have the milk b/c I didn’t have any water bottles to put it in.  Since that day, Katherine and I have made it our daily mission to gather empty water bottles in order to supply our patients with milk.  (I will upload a pic when possible : )

There is a saying here in Liberia: “Monkey Jam, Eat Pepper”.  It’s a different way of saying that when you are in a rough situation, you just make due with what you have.  (Obvious explanation: When a monkey is hungry and there is no food to eat, he will eat pepper.)  So, until we can get JFK to provide WHO level care for malnutrition, I will make my daily trips to the hospital kitchen to get them “high protein milk”.  It may not be perfect, but it’s something!

“I just know that they will tell me the good news!”

The people of Liberia never cease to amaze me.  They are such a resilient people.  It is fascinating to listen to the stories of those Liberians who remained here during the war.  Their tales are horrifying, seemingly out of an action movie:  fleeing their homes in the country to seek refuge in Monrovia, living for years in a one-room tent with 10 other people, watching loved ones die from hunger, disease, or gun fire, and praying for an end to the madness.  The crimes committed during these years are unspeakable.  What amazes me the most though is how each Liberian that I speak with about this ends their story with a statement of faith and hope.  They are SO happy to see their country getting back on her feet again.  While it is easy to get frustrated with how slowly this rebirth is happening, these folks remind me just how far they have come.

In a country torn apart by war, it is astounding how united the Liberians are now.  Liberian women take care of each other’s children as their own.  On the pediatric wards, when one mother has to leave to go get food, another mother is quick to come to the bedside of her crying child to comfort him.  Today on the wards, I was a part of a beautiful display of hope, faith and unity.  We were discharging three patients from the ward today (a good day for sure!).  As the three families packed up their few belongings, other mothers came to wish them well.  One of the mothers whose child was leaving (a foster mother actually), requested that the entire ward gather round for a final prayer for all of the sick children.  The entire ward fell silent except for the hum of the one fan.  She asked us all to bow our heads and she began her prayer.  “We thank you father for ALL that you do for us.  We thank you for giving us health.  We thank you for giving us these doctors and nurses to make our children well.  We are so GRATEFUL to go back home now and we know that these other children will go home soon too.  When we see these people again, when we pass them on the street, I just know that they will tell me the good news!  We are safe!  We are well!  We are home!  Amen!”  Everyone raised their heads and shouted, “Amen!”.  Whether you are a believer in God or any higher power, this strength and hope is undeniably inspirational.  It seems to spring eternal from this nation.  This hope keeps them going day to day.  Liberia longs to be the phoenix rising from the ashes.  Each day they inch forward with this attitude.  It is simply beautiful. : )

My first Liberian "Transport"

The range of patients that come through the doors of our emergency room is pretty incredible.  You just never know what the next taxi is going to drop off or who will come stumbling through the door next.  Katherine and I were called the ED entrance a couple of days ago to see a 3-day-old infant that was transferred from another facility.  We were taken aback when the nurse shoved a handful of sheets in our faces and unveiled an infant with severe defects:  her brain was not covered by skull, she had a cleft lip and palate, her left arm was missing, and her right arm had only 2 stubby fingers.  She was breathing fine, kicking her feet, and had supposedly been tube feeding just fine.  The sight took our breath away for a moment, but I managed to utter, “well, bring her to the NICU” and started to make my way there. 

Today, a 6-year-old boy was brought in with respiratory distress after having “swallowed” a marble.  He was stridulous and working very hard to breathe.  John, an emergency resident from University of Chicago, saw the patient first.  Knowing that there wasn’t much we could offer the boy here (we have no endoscopy or pediatric surgery), started asking around about who could help this patient.  Within a matter of minutes, one of the JFK physician assistants was on the phone with an “ENT” doctor at Firestone Hospital, about 1.5 hours from JFK.  He agreed to see the patient.  So, John and I gathered up gear for the ride (a laryngoscope, ET tube, sedation, IV set up and materials for an emergency crico… yup, definitely almost sh*t my pants thinking about having to trach this little guy to save his life….) and got a taxi!  We don’t have an ambulance here, so a taxi would have to do!  The taxi we got was just like all of the taxi’s here: old and barely functional.  John was nice enough to let me have the front seat and he sat in the back with the boy and his parents.  My gaze quickly shifted from the boy’s chest to the speedometer as we started to dart through traffic… only to quickly realize that the speedometer, of course, did not work (nor did the windows, vents, defogger, etc).   I took to my mom’s favorite soothing activity to do while riding in a questionably safe car: praying the rosary.  About half way there, the boy coughed suddenly and swallowed deeply.  My body cringed as I swerved around expecting to see him blue and gasping for air.  Instead, he scooted back into his seat and started to breathe more comfortably!  I have no idea what happened… he could have swallowed it, or dislodged it enough to allow for air passage…. But, whatever happened, he was stable for the rest of the ride.  Which left me to focus on the road… Oy…

We made it to Firestone safely, got him admitted for observation and scheduled for a scope in the AM if his symptoms recurred.  The taxi ride back to Monrovia was, well, exciting for sure.  The rainy season here is just starting…. And this rain is far from a sprinkle.  I may have feared for my life a few times on the way back… but, all in all, I feel good about it.  Another adventurous day here on the West African coast!

Rough Day

Yesterday was a rough day on the wards.  3 deaths.  2 were infants, both with quite similar stories.  They were both 6 weeks old, admitted with respiratory distress.  They had been on the wards for a couple of weeks, both on oxygen by nasal cannula, but showed no improvement.  (We actually have 2 oxygen machines on the pedi wards now, which means that 4 patients can be on oxygen at a time.  This has doubled our capacity in a year.  Not bad!).  On admission, they had the typical “work up” for a child in respiratory distress: a chest Xray, malaria smear, and Hb level.  Both films revealed nothing focal.  Malaria smears were both negative.  Hemoglobin levels were both normal.  They then were managed in the typical way here in Liberia:  Started on Quinine (despite a negative smear b/c you never know what sort of medicines the mother had been giving at home), started on Amp and Gent (the usual antibiotics given to kids for… well… everything), and were admitted to the pediatric ward.  Over the course of their admission, neither could be weaned from oxygen and both became clinically worse.  I think that one of them actually had Tetrology of Fallot (he was having episodes of desating to 40s with crying and an impressive murmur) and the other I think likely had a huge VSD that didn’t make a murmur (or some other non-murmur mixing lesion).  In other words, both were cardiac kids in Liberia…. So, they didn’t really stand a chance here : (  There is no cardiac surgery here.  So, the infants had been on the ward on oxygen, waiting for the impossible. 

One of them passed away during rounds.  I looked over to see one of the Liberian residents pounding on the infant’s chest.  The mother was being escorted out of the room.  A nurse stood on the side of the crib on her phone.  She was calling the ONE respiratory therapist in the hospital.  I ran over and immediately realized that I was in my FIRST REAL infant code.  I checked for pulses: none.  I took over chest compressions.  It was surreal actually.  No one knew how long the baby had been not breathing… so, as I compressed and directed the bagging of this poor little guy, all I could think of was, “how do I know when to stop?”.  We tried for about 5 minutes.  It seemed like an eternity.  Then, I called it.  No one else seemed shaken.  The resident just walked away to go back to rounds.  I walked off the ward to tell the mother… never a fun job. 

Sadly, I have had many patients die here.  Many of them die overnight and I find out in the morning when their bed is empty.  My heart always sinks… but, I silently breathe a sigh of relief because I didn’t have to witness the end.  Others have been “NICU” babies that we really don’t try to resuscitate because they are very premature or need intubation.  We still have no vents, so there is really no hope for them either.  But, this one was different…my hands pumped the last bit of blood through his tiny hypoxic veins.  In the U.S., he likely would have been recovering from surgery by now and his mom would have been planning his return home.  Instead, she is planning a funeral.  What an unfair world.

Thoughts One Year Later

I didn’t quite know what to expect today.  For the past year, I have been wondering how things are coming along here… and, today, I am finally starting to find out!  To start:  the radiology department now has a computer to which images are uploaded (only Xray, still no CT).  The last time I was here, there was a pile of Xrays that I would have to shuffle through.  The computer had me super psyched!  However, I have quickly come to learn that many of the patient’s names are improperly spelled in the computer.  This makes searching for images almost as challenging as it used to be.  It’s an improvement though! 

The charts that I made on the pedi ward last year are STILL IN USE!  Not gonna lie: I had my doubts that the organization would last a whole year.  But, the nurses and other staff have incorporated this new, organized charting system into daily practice.  SCORE!  My hours of hole punching and sorting through papers last year in the 100 degree heat were not for nothing!  This is making rounding much easier.  There is a section for orders, labs, xrays, nursing notes… it’s really fantastic. 

The patient census seems to have decreased.  I am not exactly sure why though.  I would like to think that we are doing a better job at preventative medicine.  An even more optimistic thought is that our Chronic Illness Clinic is keeping our “frequent flyers” out of the hospital.  But, I do wonder if children are going to the few other hospitals in Monrovia.  JFK Hospital (where we work), is the largest in the country and considered the tertiary care center.  I am really hoping to visit at least one of the other hospitals during my trip, just to see how it compares to JFK.

Sadly, there is much that has NOT changed.  Malaria is as fierce as ever.  Most of the ward is filled with children with severe malaria, including cerebral malaria.  Malnutrition is still the second most common diagnosis for kids and has a staggering mortality rate.  Children are still suffering immensely with tremendous pain from various disease-processes…. Morphine (or any other narcotic) is still very hard to obtain here.  The nurse-to-patient ratio is still about 1 nurse to 15 patients.  (Can you imagine what one of our 5East nurses would say about that?!?!) Overall, JFK remains very understaffed…. This seems to be the key problem here.  They are in need of more educated healthcare workers. 

I was happy to see many of the same nurses on the pedi wards.  (Even happier that they remember me)  I would like to pick right up where I left off last year, and a lot of that depends on gaining the trust and respect of the JFK staff.… just need to get over this jet lag/post-NF exhaustion!

To Africa or Bust!

Since the moment I left Liberia last March, I knew that I wanted to return.  I had this sense of “unfinished business”… so many projects left undone, patients left uncared for, families left with questions, teaching left to be taught, lessons to be learned.  Therefore, I have approached this trip with much anticipation.    But, admittedly, I am starting this trip feeling a bit unprepared and rushed (thanks to my wonderful resident life: 2 weeks of night float makes getting ready for a weekend trip seem overwhelming, never mind a month in Africa!)  But…. Ready or not, here I come!  To Africa or bust!