But they were not there, so I visited their compound and spent the day with Dr. Princia, Abdoul’s daughter. I saw her clinic practice and home practice. Both were lovely and so was she.
Monthly Archives: February 2013
Critical Condition Thursday
When I pulled up to the clinic i immediately noticed a patient affected by leprosy waiting in the pavilion. For every leprosy patient who comes to the clinic I do a careful examination, make a problem list, sometimes dispute the diagnosis and suggest steroid doses based off of the training course I took in India, and I gather the necessary information to follow the case. He was an old man– in his 80s with grotesque arthritis and tremors. He had lepromatous nodules over his legs and arms. I asked him to hold out his hands for a sensory/motor test, however when he did, the hands began jerking uncontrolled in different directions. His head dipped and I could see he was no longer conscious. He began seizing so I guided him to the floor. A puddle of urine pooled beneath him as he lay twitching. His son tried to wake him, shaking his shoulders and lifting his head up. The old man faded in and out of coherence. We tried to obtain blood pressure but it was so low it was inaudible. His pulse was thready and slow (50 BPM). His skin was leathery and when pinched it remained raised, indicating dehydration. He needs to be admitted, I said, wondering if this could be epilepsy, ketoacidosis, or some other sever condition. The old man’s son lifted his father easily. He hoisted the semi-conscious man on his back and carried him up the hill to the hospital. I followed, wanting to learn what his condition is and wanting to follow up on the leprosy assessment. The doctor at the hospital told me she would send him to the dispensary where I work after his perfusion so that I could finish the leprosy assessment. I never saw him again. I wonder if he is alive still. I will go to the hospital and find out what happened to him.
The problem with diagnostics here is that everything is purely clinical, no laboratory investigation. I would want to do a complete blood count, blood sugar, urine analysis, skin smear for leprosy and if i knew more tests and more about what he possibly could have been experiencing, I would send for those tests too. Here you just work with the knowledge that he lost consciousness, seized, has bradycardia (slow heart rate), BP too low to determine, fatigue, weakness, swollen joints, pain, lepromatous nodules… I have no idea what happened to the elderly man.
I left the hospital and accompanied Dr. Abdoul to his home practice. There he taught me a good technique for placing an IV line and getting the vein on the first try. It has to do with the way you hold the butterfly needle. That afternoon I convinced Marius to come to do the ulcer dressing despite the hurricane wind. We actually couldn’t bike there so we got a ride in the ecology car. I watched as Marius did the dressings. From now on I will be watching as he works, rather than being the one to do it, because he is the one that will be here in the long term. He is very good at the procedures but sterile technique is lacking so I focused on setting up a system for sterilizing instruments in-between patients. I missed having contact with the patients, but observing was a good experience for me. Marius is very thorough and works quickly. These patients are very lucky to have him. I rode my bicycle back to Antalaha in the rain but with a beautiful tail wind.
Contraception Wednesday
I rode to the clinic early, hoping to go with Dr. Abdoul to Sambava to meet the leprosy patients who are cared for by catholic priests. Dr. Abdoul had already left when I arrived so I spent the morning with the nurses in the dispensary. Then I went back to the house to give Eric Lan’s mother her perfusion. This time everything went well. In the afternoon I arranged for a car that would take 6 girls from Belfort village to the dispensary for contraceptive implants. It wasn’t easy. Victorie the teacher had been trying to convince the young female students who are particularly promiscuous to consider the implant. Valerie from France had talked several girls into it. These girls are as young as 13 and Victoire told me they have not been sleeping in their houses in the village, meaning they are spending the night with men. She is very concerned for these young girls because she wants them to continue their education, not drop out of school with a pregnancy like so many girls here. This is a very sensitive issue because in the end it really is up to the girl. She is very young and maybe doesn’t make the best decisions for herself, but it is her choice. If she does not want somebody to surgically insert a progesterone pump into her arm, she should have to have it. The youngest girl, 13, was so scared when we arrived in the village with the bus that she refused to move her feet. Two men carried the screaming child into the bus and slid the door closed. “She is frightened,” Victoire said. I felt really unsure about this. She is refusing the treatment and we can’t just force her into a car to go have the procedure. “No no,” Victoire told me, “we won’t force her; I will have a consultation with her at the clinic and she will have a choice.” At the clinic she, along with four other girls, chose not to have the implant but consented to the medroxyprogesterone shot instead. This prevents them from becoming pregnant for 3 months as compared to the implant’s 3 years but neither provides any protection from SDIs. I see a lot of men with STIs in the clinic…
Sexual education is very important here. It must be supplemented with free condoms and promotion of condom use. It won’t work here to tell the girls to abstain. That is simply unrealistic. So they should be educated. They should know the risks. They should have access to the best protection, and in the end they should make their own choice. This is what I believe.
I gave the injections one at a time and when all was done the previously nervous, crying, screaming girls were relaxed and I even small one or two smiles. Done! But… in 3 months please come back.
Cyclone Tuesday
Late in the night and early in the morning the sea crept over the dunes and buffer trees and deposited a dead dog in front of Matt’s house. I saw it as I biked to the clinic that morning. It was pouring rain and the sea-bloated dog had sunk deep into the wet sand. In this moment with the dead dog before me two traumatic dog memories flooded my brain:
The first was recent. It was a little puppy I had found with a cord tied around its neck washed up on the shore. His body was pink and round and his eyes sealed shut. His little curled tail moved as waves passed over him. I stopped running when I saw him, bent down, and took him by his leash out into the sea. It was strange holding the leash of a dead floating puppy and pulling him along, but I felt compelled to bring him out to sea because the image of his corps on the sand was too haunting. I remember the water was perfectly blue as the sky and I could hear it splashing as waves moved past me and the puppy. I gave him a strong fling with the leash and watched as gentle waves carried him away. How did he drown initially? The cord around his neck, the bloated pink body…
The second dog memory came from India. It was nighttime and we were riding motorcycles. Villagers had gathered around a woman holding a bleeding dog by the container in which his head was stuck. I see the dog dangling in the air, blood streaming down his neck.
And here on my path to the clinic another dog, regurgitated by the sea. Barely any patients had braved the cyclone (which at this point was only wind and rain) to come to the clinic. I sat with Catherine for an hour talking and then I left for the market. Miraculously it was open and I bought potatoes, ginger, garlic, cucumber, oats, rice, beans, tomatoes… I have always loved food shopping (as opposed to ANY other kind of shopping) but here it is particularly fun because nothing comes in packages. Honey, oil, milk, and other products we find in neatly labeled packages decorating grocery stores in America are all sold from from the hive, the tree, the cow. When I food shop in America I don’t actually see the food. I see the package. But here there is no separation, no distance, and the experience is richer. I went to the pharmacy and collected medicines for Eric Lan’s mother: Vit B complex, calcium, Vit C, quinine, iron tablets, glucose and saline perfusion serum.
When I got back to the house I prepared her cocktail and placed the line without any supervision. Everything was fine. I said I would return in one hour to remove the line. I went to the beach, enjoying the drama of the cyclone. The waves looked crazed, smashing into each other and crashing violently into the reef. The sky looked peaked. I spent almost an hour out there when suddenly Eric Lan’s brother came running onto the beach. Come quick! He yelled. I followed him to where his mother lay. The IV bag, hooked by a hanger in the window, had blown down onto the floor below the bed. Cyclone. Gravity was pulling blood- a lot of blood- out of her arm and into the tubbing and IV back. The line was flowing in the wrong direction because the bag was below her arm. Noting her fluids were finished I ran into the room, unfastened the tape over the tubing and carefully pulled the needle from her arm. She was bleeding from the insertion. I grabbed cotton with alcohol and pressed firmly. I taped a wad of cotton over the site. Then I looked at her face, which in the emergency I had neglected to see. She was terrified. She thought something really terrible had happened. I assured her that she didn’t lose much blood and that she would be fine. “It isn’t a problem” I had her son translate from French to Malagasy. Then I thought: it could have been a problem. She could have lost a lot more blood but luckily the brother found me and I could disconnect the line quickly. I wondered walking away if it would have been possible for the whole IV bag to fill with blood: would the air chamber have stopped it?
I hope i don’t have to find out in tomorrow’s post-cyclone wind perfusion.
Home patients and IV lines (monday)
Eric Lan told me his mother is sick. I went to the pharmacy with Jebian to collect medicines: calcium (seriously Antalaha’s favorite supplement except they don’t use it as “supplement” but rather as treatment), Vit C, normal saline perfusion serum, quinine, cimetidine, ampicillin 1 g, IV line, 10 ml string, 5 ml syringes, cotton, alcohol. I made the IV cocktail, injecting the medicines into the IV bag with the 10 mL syringe. I set up the line, tied the tourniquet, cleaned the site and tried to find the vein. My needle was too big. I couldn’t get the cephalic vein. I called Dr. Abdoul who said he would send Robertine over with needles. She arrived and we took the needle from a smaller syringe and secured it to the IV line. I have never done this swapping needles thing and Robertine taught me a good new trick. I was so grateful to Robertine for teaching me and watching over me as I inserted the small needle into the cephalic vein. I waited until i saw the small back flow of blood that indicates the needle is in the vein before I started the IV drip. Over the next 3 days I would be setting up the lines and swapping the needles and having full responsibly for the patient by myself (she was being treated in her house which is next to my house!). When the IV was finished I unhooked it, put cotton over the site where the needle had punctured skin, and asked how she felt. Language! I think she felt better. Not sure. I said I would return tomorrow which Eric Lan translated for her.
I missed biking to Jules village that day because the IV care took so much time. That night it began to rain… and rain and rain and rain.
Saturday night
We rode our bicycles to bar Florida. It is a yellow building with a broad terrace where several crowded tables are clustered. Our table was overflowing with French, Malagasy, and American people. At the center of attention was Matthew, the American peace corpse volunteer who had just returned from a 12 day trek through Masoala national park. His stories were riveting and hilarious. Languages faded from English to French to Malagasy as the night got quieter outside the bar. Restaurants closed, other bars closed, throngs of men walked past the bar on the street below. Camille and I left with Ali and Patricia. Ali comes originally from Somalia. He lived on ships for many years in the import export business. His stories from the sea about pirates and fish and stir-craziness and ship culture are unbelievable. We drove to his beautiful house with tropical gardens stretching all the way to the beach. We sat on the steps above the fountain as the moon disappeared and the first rays of light punctured clouds over the sea. Maybe I was awake or maybe dreaming as light filled the sky and the sun appeared as an orange ball and we ran to the sea and swam.
I was too tired to sleep when I got back to the house. The sun was already high in the morning sky. I couldn’t stop thinking about this one patient in Belfort village whose ulcer is complicated (infected bone) and who is at risk of permanent damage and possible amputation. It was Saturday and I knew Modest would not be working this day but I wanted to tend to this one patient so I rode my bicycle over to Belfort. It was hard to find her. I searched the village before asking Victoire, the school teacher, to help me find the patient. She arrived and patiently soaked her foot in a diluted bleach solution for 20 minutes. Then I cleaned and dressed the ulcer. I met John, another peace corps volunteer, who lives in the Belfort leprosy village. He has started a little mango project which is quite resourceful. He noticed that there are way more mangos than can be consumed before rotting so he devised a plan to preserve them in the village and then sell the preserved mango “chips” in town. This gives the village people a means to earn money. Economic incentives are often the best in development. The villagers would build drying stations out of corrugated plastic roofing tiles with a wooden frame over which clear plastic could be secured. The intense malagasy sun shining into these mini greenhouses would cook the mangoes in 1.5 days. I watched women peel and cut mangoes into slices that they then placed in the drying device. They can produce kgs of mango chips and sell them all throughout the fall market (it’s summer here and mango season ends soon).
I rode back to the Belle Rose bungalow. Patricia, Camille, and Ali had bought rice and shrimp lunch. We ate and talked for a long time. Then it was time for me to prepare the dinner I was making for Dr. Abdoul, his wife, Jebian, and Eric Lan. We made coco-fish, tomato sauce beans, potatoes with rosemary and olive oil, rice, freshly opened coconuts, and mango dessert. The dinner was delicious. I had hoped Dr. Abdoul would discuss medicine in Madagascar with Eric Lan who wants to be a doctor, but the discussion unfortunately went in another direction. More about this perhaps another time.
Tracing Leprosy 