FEB-C-11
RUNNING THROUGH
THE RAIN
ON THE LAST DAY OF
FEBRUARY
WITH A FULL
THEATRE LIST IN THE RAINY SEASON
Feb 28, 2002
I ran this morning on the first time I had patterned out a circuit run out one road toward Zambia, and connecting with the Jenda Road coming toward the CCAP, Embangweni Station—as the sign proudly announced at the junction of the dirt roads. However, behind that sign when I paused to photograph it were large accumulations of very dark clouds about to burst. I had headed out in a sprinkle, but now it began to rain, and as hard and steadily as only the tropical thunderburst can produce. The concrete hard roadways and their rutted erosion paths were quickly flooded and I began splashing my way back on the end of the circuit I have finally figured out. By the time I came upon the hospital compound’s wall, I was on the far side of it, and saw the “guardian’s” cookhouse and place for them to stay—the family or friends that the patient must have to be admitted, since there is no diet kitchen, and nursing staff is rather slender, so the guardian is the one looking after the patient during their stay. They all stuck their heads out and had quite a hoot. Here are all the Malawians hunkered down under trees and under umbrellas, and in the middle of the muddy road is a dripping wet Wazunga splashing along in the rutted road trying to carry the Nikon camera under his dripping palm to protect it somewhat in the heavy rain.
I made it back in time to get a warm shower, during which I was only slightly less wet but warmer—after all, this is a big luxury here, we have, hold on, I always have to laugh at the sober Briticism—a Geezer! “Turning on the Geezer” (perhaps the title of a book I shall write in my retirement) is one of the functions of Peter the night watchman who otherwise just sits and watches nothing happen outside my door. Until I get out that door at dawn when he springs to his feet and wishes me well in whatever it is that I do in short pants and a spattering rain at the early hours each day. Ah, and they say these Wazungas are a superior race! The “Geezer”, here, and in wherever I have been that the Brits preceded me is the hot water heater, and I still chuckle every time I hear it, but they have no thought as to why I should think it funny.
I thought of several items I had seen and heard last night while I was simply vegging with the post-prandial crew on our last evening before a list of heavy social engagements that are crescendoing during the week of my leave-taking, which begins today. We will be hosted by the Matron, Kathy, and a portly but talented fireplug who will have us over for Nsima and Din-di, and two other local officials on successive evenings. So, we decided that now would be a good time to break a few other laws and indulge in a little of South Africa’s finer products of Stellenbosch vintners, and even try to put in a video. We discussed which video it might be, but were talking about the contrast between my medical school years and George Poehlman’s and those of the current generation, being represented by Elizabeth Yellen and John Sutter. By the time we had told multiple stories, it was too late to make a choice of video anyway, so we knocked off—it being close to our 8:30 PM bedtime. The early to bed and early to rise may be making Glenn a dull boy, but at least not a non-running pre-Marathon boy, as I was feeling guilty in my Philippine stay.
The Poehlmans made a $2,000 investment before their stay here two years back, and bought an INMARSAT satellite phone. After the purchase, there is a connect fee, and a $2.00/minute user fee. This compares well with the local phone service (none) or the public phone service out of Lilongwe, a day’s drive and 85 pounds vehicle rental away, where the unreliable service I billed a $3.79/minute whether or not the connection is made, which it usually isn’t. So, to call Lilongwe from here by satellite phone involves pointing the dish up at the satellite, and dialing up the connection in California or Connecticut (run by Comsat) and they then relay it back to Africa where the local $3.79/minute phone use is added. I will make a single call to tell you where I will be before leaving, since I will apparently stay overnight in Lilongwe where the hosting Rodehavers put up Elizabeth and John for the first few days before my arrival. I thought it would be neat to try to talk by satellite for just this brief interval half way through my stay and tell you that I would be Wed/Thu in Lilongwe before takeoff back through NBO and AMS toward IAD.
AND THE
COORDIANTORS’ CANTACT NUMBERS IN LILONGWE
FOR FUTURE MALAWI
REFERENCE
Embangweni
Hospital
Physician
Guesthouse
P. O. Box 7
Mzimba, Malawi
Fax: c/o F.
Dimmock 265-744-560
CCAP Coordinators
P. O. Box 1266
Lilongwe, Malawi
or,
Phone: 265-750-007
Fax: 265-750-005
THEATRE DAY IN THE
RAIN AT EMBANGWENI HOSPITAL
I have had an interesting list that I had foreshadowed for you by introducing you to the patients yesterday as I had pre-op assessed them. The first was the fifteen-month-old boy who had over half his scalp burned away when dropped into a fire by a mother who had a seizure as she was holding him. Again, I think of the flickering flames as the epileptogenic trigger for the focus of what may be neurocysticercosis as the reason for the epileptic fits that seem to occur near or over cooking fires. I made a big incision down through the margin of his hair-bearing scalp to the periosteum of the skull, and then a contralateral relaxing incision through his hair-bearing scalp just over his ear on the left side. I undermined this whole area and then pulled the scalp on this “bipedical flap” with its blood supply intact from the forehead and the occipital scalp, and pulled it toward the undermined right skin of the area just above his right ear to shrink the defect down to less than half the burn area. This would mean that he would have hair on the top of his scalp and only a smaller defect above his right ear, which will have a nude area of granulation to which a split thickness skin graft will be applied later. I would have done it today, but we had no IV line and the Ketamine was running short for his anesthesia. I then looked over at the left side relaxing incision which I figured would need a comparable size STSG to cover that area above the left ear, and put a couple of “Pulley” stitches in it—far/near/near/far—like a block and tackle. I was able to raise the skin from over his left ear and close the relaxing incisions primarily, so that he will not need any skin grafting at all on his left side, and will now need only one third as much a skin graft on his shrunken right sided defect, and he will have hair-bearing scalp over the top of his head.
When I had described this procedure to Jon Poehlman, he suggested that he had another patient to undergo a similar procedure to transfer hair-bearing are to the top of his skull—his father, George Poehlman!
The second patient was the sixty-year-old patient who had been transferred to us to be seen in the hope that someone would be able to unplug his obstructed bladder after they plugged in a very filthy catheter that had been in place for a month. I called up Alex Mac Lean who had said at report this morning that he would like to take advantage of my presence here to learn a bit more of surgical technique, since he had never done any surgery, and now was gong to have to do some cases, particularly C-sections. I had helped him do the first of the operations here at 2:30 AM, an emergency C-section. Now, I suggested he might need to know some day how to unobstruct an older man with a plugged up prostate, some of them benign and some of them malignant. He had never done, nor seen a bladder operation, and said he would rather help me do it, but I suggested that the time for him to do one is when someone can be here to help him do it right and bail him out if there is a problem. So, we did it together.
I also had Mister Tembo and Elizabeth feel each time the left and right lobes of the prostate were mobilized in situ, and just before they were delivered. The procedure went smoothly, and the patient is doing well, with urine that is already clear.
James, the patient we had done earlier this week with the very large prostate removed, and an uneventful repair in a three layer bladder closure, but had plugged a little later in the day and had his scrotum swell up. But, the small clot was irrigated free thanks to the untiring effort of his brother Gordie, who was trained to sit at his side and irrigate it through the first night. In the morning, James was fine, and the urine was clear after the further irrigation was stopped. When I wheeled in today’s patient, I turned him over to Gordie, who, with James’ encouragement, said, “I will take good care of him”—and set about irrigating the bladder of a fellow he had never seen before.
The next patient was one you know well already—Humphrey. I had tired to get Humphrey out of bed without success. He has flexion contractures at about 90—100* right and left, respectively. And I had hoped to get him straightened out with anesthesia to 140*, he might then be able to get up and waddle like a duck at least to be mobile. So, after induction of Humphrey and endotracheal anesthesia, we got both Alex and me on each side of his legs and tried to push them out straight, stretching his hamstrings and lengthening the cords by rather heroic physical therapy under anesthesia. We then took a split skin graft from his thigh—a very necessary procedure that Alex had never seen, and we meshed it 2:1 to cover his granulating wound where his pyomyositis and compartment syndrome were drained. The rest of his legs were studded with the tumors of K. S.—Kaposi’s Sarcoma. This procedure may be able to get Humphrey up, as he said he would try to be doing as he was all smiles this morning, with the chief part of this operation being to rejuvenate his hopeful consideration of a future no matter how brief and modified by his disease.
Ishmael came to me to say he had a woman who was hurting with a large ovarian cyst, as well as a big pedunculated uterine fibroid. She was eager to part with this and she is a stable operative candidate, so I booked her for tomorrow—largely because Ishmael is eager to be taught how to do the first hysterectomy of his life while the teacher is “in.”
TWO MAJOR SOCIAL
LOCAL EVENTS:
A SOCCER MATCH
WITH INTERSCHOOL RIVALRY,
AND A “BIRTHDAY
PARTY’ AT NURSE MERCY’S HOUSE
I made rounds at the hospital to see how the man whom we had done the prostatectomy on earlier was doing and also to see how Humphrey was doing post-op. It was evening and the spectacular African sunset was making a flame across the sky, over the frangey pani and flambouyant trees. Two guinea fowl walked down the steps of the guesthouse, which are flanked by two symbolic stalks of maize—the mealies being the source of most of the calories of the area in the staple food source of nsima and din-di. The single row of straw flowers around the church and the housing units came up out of the hard red concrete-like African poor soil, now with scattered puddles and mud mires. As I arrived, the only nursing personnel I found in the “Male Ward” was Gordie. Gordie is the very outgoing brother of James, the fellow on whom we had done the prostatectomy three days before, who had the brief post-op blow-up of his scrotum, but now is fine. Gordie has been faithfully irrigating the catheter on his brother until it was so clear as not to require irrigation, but he was really into it, and took on the stranger’s care in the next bed. Both were doing well, but Gordie added, “I believe you should take a look at this young boy over in the other bed. He has been scheduled for discharge, but he is not doing well, and is burning up with fever.” So much for community nursing care in Malawi. I did check on the boy and he was having a shaking rigor, no doubt now cured of his meningitis by the ceftriaxone that we had brought and having completed that course, he now comes down with malaria which may even have been acquired here at the hospital during the stay for meningitis! So, he was started on antimalarial treatment after a blood film, a luxury for his being already in the hospital, whereas, according to the MDTG “Syndromic Management” he would have been started on anti-malarial treatment as a substitute for diagnosis.
Meanwhile, Humphrey is grimacing and his white teeth are chattering. He no longer thinks I am such a great guy. I seem to have shown him too much attention and both his knees are reflecting this. He had no complaint about his primary wound, nor even his donor site (the usual thing most skin graft patients complain about most) he was hurting in both knees which had been straightened out more than they had been for months, and he was not sure he wanted them ever to be that straightened out again, even if the contracturing kept him bed-ridden. I gave him Pethidine (Demerol) for the pain, since the oral paracetimol did not seem to help.
I then looked around since all the Wazungas had disappeared. I heard a lot of noise from the open field between the primary school and the church in a wide-open area that was neatly kept like a campus. It really looks good, since the manual labor that has been employed here as they come daily to the door and ask for some means of getting cash had been put to work. You can tell at a glance the difference between a labor-intensive and a materials-intensive economy since in this instance we have half dozen men swinging a short machete as lawn mowers. It is not even a right angle scythe, but a straight short blade, so that they have to stoop and repeatedly swat the tall grass that grows in the rainy season, and the blade is sort enough that they can only cut in a day about half what a mechanical lawn mower would do in a half hour. But, this is the purpose of full employment, and efficiency would put them out of one of the few jobs to be had anywhere around here. So, there is still much grass to be “weed-whacked” around the guest house, which had been already treated on my arrival earlier, but this is a perpetual motion employment, at least as long as the rainy season.
On the other side of the well-kempt campus was a playing field. Along the side, one donor had given two by fours and some other equipment from which were suspended old tires as swings and the only “slide” in Malawi. This slide was of heavy polished metal, and was in constant use by whole “trains” of Malawian kids coming down it, sometimes twenty or more at a time. It seemed that the girls made on group, and would wait until all the boys had slid down, and then the whole female contingent would slide down until the boys gathered at the foot of the steps again, and they did not seem to weary of the repetitive process. But, there was no concept of “playground equipment” here, apparently, so the tires from the swings were taken off for some purpose, and the chains for the suspension were needed somewhere else, and a few of the treated two by fours looked too good to be squandered in this purpose, so they were recycled (I hope not simply as firewood, as I remember the ignoble fate of the bias cut treated wooden “swimming pool deck” was at Assa.) Lacking this support, the whole wooden playground structure has tilted precariously, but that did not discourage a number of the primary school boys to clamber up to the upper deck to be using this as a set of bleachers for an observation gallery of the big event of the school day. I was watching a big match-up, the soccer match between the primary school and the School for the Deaf.
This is a big deal. It could be considered a bit of a mismatch, like a triple A high school playing a class B, since there are 2, 000 students in the primary school (with about a quorum of 1500 that show up any given school day) and there are 500 in the secondary school (giving the one in four advance in schooling I had already mentioned) and there are 70 students in the school for the deaf. But the latter are determined. Even before the school was built, there were deaf children who simply showed up from all over Malawi, having “heard” that a facility like this was forthcoming. They are the students on the soccer field in red shirts—no shoes, of course, but red shirts, against the blue of the primary school, similarly barefoot.
I saw a white woman in a long skirt and running shoes chasing the ball around with a whistle and Elizabeth’s white hat in her hand. It was Mary Bennet Poehlman, soccer referee. She could blow the whistle to stop play or give a two minute warning which the primary students should hear, but, of course, the deaf students would not—which was the purpose of the white hat, tossed in the air like a “flag on the play” borrowing from American football rather than the flashing of colored “cards” of soccer.
There was a great hollering and even a dancing cheerleader group of boys as the primary school threatened to score-a colorful sight as the boys converged down at the goal line under the flamboyant trees (as in the “Flame Trees of Thika.”) When the red shirts made a scoring attempt, there was a group of grunting waving deaf partisans on the sidelines until the ball hit the overhead of the goal and was deflected on the scoring drive.
I asked Mary Bennett (who deserves an extra helping of Nsima tonight for keeping up with the teams by running in a long skirt along the field in the referee’s position) if women or girls played soccer, and she said she heard that they did, but had not seen them. I asked if they could wear shorts to play, and she said that she thought they had to wear what the field hockey girls had worn, short skirts with leggings. We saw one brazen hussy, a very liberated girl, around the secondary school wearing a well-pressed pair of slacks—a source of a lot of talk in the town. It might be interesting to talk to such a groundbreaker, but we did not have a chance to do so, even after we saw here a few days later with a second pair of pants. Shocking! But, they may get over it, before they get over the site of a very white Wazunga, wearing a short set of shorts, running through the rain at a very wet dawn.
Mercy, a nurse at the hospital who had known the Poehlmans well during their year-long stay, had invited us over to dinner for the evening, so we are dining out as guests. The ostensible purpose for this is to celebrate a birthday of their son Robert, one of many children, with another born since Robert was born and about four older ones. So, we are going over for a birthday party for Robert, no matter that Robert’s birthday is June 14, now is when the Wazunga are here. And no matter that Robert, the guest of honor was not at home when we arrived, he would come over after a bit, perhaps after we had all had the first course of the dinner—a piece of the cake we had brought over in Robert’s honor. We all said hello to Mercy and her currently unemployed husband Gresham, who had been employed on a World Vision project, which they, rather characteristically, funded until the project got the facility built, but pulled out before it began running—a common experience I had seen especially with MSF (Medsin Sans Frontiere). After we had had his cake and opened the presents for all the other kids in Robert’s absence, Robert, about age four (coming in June 14, of course) opened the door, and stood in wide-eyed wonder at his house full of Wazungas. He froze for a moment, and then burst out in terrified tears, taking to his bed and not being seen for the rest of the evening—but, we enjoyed his party without him.
I had the nsima and dind-di and also saw the kitchen where the preparation had been done—three sticks and three bricks, producing heat and a choking acrid smoke. This was just beyo0nd the rabbit hutch and the duck cote—formerly holding pigeons before they were eaten, and now the elevated wicker and mud structure holds a few ducks. In the kitchen across a courtyard enclosed for the livestock is the chicken house, which holds few of the black chickens emblematic of Malawi (the “cockerels” of the “Tambala”—one hundred of which make up the “Kwacha”= “dawn.”) and two guinea fowl, each laying eggs for the larder as well.
In the ”living room” is a painting—it happened to be hanging sideways, but when I expressed interest, the painting was brought forth and held upright. There are three words along the side, with a picture of a lion standing below a half-chopped tree, in which the unlucky wood-chopper had taken refuge as the lion circled below, looking up with mouth watering interest. Also unfortunate for him is the branch on which he is standing, which has broken off, and as luck would have it, he is suspended over a river where a waiting crocodile is lurking with eyes fixed on the prize from the sky. The three words are: “Ifa Siti Thawika .” The literal meaning is “You cannot escape death,” but the American bumper sticker equivalent, Forrest Gump’s modifications notwithstanding, is “Shit Happens.”
We were inspired by this manifest truism, and continued dining, until it was time to pack up the utensils, water and other parts of the dinner that we had brought as a BYO party. We had heard during the evening that Gresham was thinking of relocating the family if he could find work in Nkata Bay on Lake Malawi, where Mercy might be able to find work as a nurse in a government hospital. She wanted to work in a government hospital since the pay scale is higher and she would get a higher salary. No matter that the government has been a little late in paying any salaries—two months late in this instance—but she would at least “in principe” (as they perpetually say in Congo) get a raise. That the salaries here are not high is true. In fact, she told us (I believe for a reason she had in mind) that her salary working as a nurse in Embangweni Hospital is 2,300 Kwacha per month. That translates to under a dollar a day-except this month since this is the shortest month with only 28 days. However, the mission pays its salaries, unlike the government, which has rather long pay period holidays, yet also there is the matter of “allowances.” We were sitting in one such allowance, a house much bigger and better than they could pay for in a family of two adults, each of whom have come through secondary school and even have marketable skills, with five (as I counted them, not counting the one coming shortly) children, all living rather well with a good deal of Wazunga donations. When food and housing, and transport and other things are all factored in, about 80% of the compensation package is allowances, and the government only matches the salary portion. The government can decree a raise for the health care personnel, and keep the salaries constant or reduced, at least through devaluation, obligating a higher allowance from the mission, which is how things came to be as proportioned as they now are.
As their “Chona” = “cat” crawled across the floor, chasing the cockroaches around the baby, we took our leave. I am sure that my friend “Chona Hamrock RN at NICU in Anne Arundel Medical Center who had gathered many of the surgical supplies I have distributed on this trip will be delighted to know that her Filipina name has a name meaning “Cat” in Malawi. I attracted quite a few lustful young men as hangers on who were coveting my special Petzel Head Lamp—too good to give away to anyone, since it was a gift to me to begin with, but also since it must light my way home, not only, but must help find ureters in tomorrow morning’s hysterectomy—which I am going to be teaching Ishmael—the first he will ever have done, but probably also the first he will ever have seen that actually excised the uterus intact, since supra-cervical hysterectomy seems to have been the only operation performed here before—leaving the most lethal part of the organ in situ to cause further trouble later on. Supra-cervical hysterectomy is an obsolete operation, and this non-gynecologic surgeon is going to bring these Malawi operators all the way forward into the …..mid-twentieth century!