A Tuesday trip to Nyamuti school

May 24, 2016

Good evening my friends,

I hope this message finds you all well.  I have had a few very encouraging emails this week from colleagues and family and I am feeling very grateful. Thank you.

We spend the morning visiting a local school to donate a few of the dollar store nick knacks that we had brought along.  Our family set off at 6:45am with a 9 y.o old guide, JoJo and walked along the path with other school children the 30min it took to reach the Nyamuti school.  An elementary school with 480 students grades SK-7.  The headmaster was expecting us and was glad to see us because the books that we had purchased had just arrived the day before ! (what books you ask? – well we asked the same question).  It turns out that a Norwegian donor gave money to replace the very old school books.  So what are we to do, with the entire school assembled, the Zimbabwean flag about to be raised and the table of books out – we played the part of the token “Mourungou” (white person) and smiled for the cameras as we distributed the books to the children.  We also watched as the grade 7 girls carried drinking water over 800m from the village well to the school, as they do daily.  Dr Thistle is hoping to raise funds for a water project as well.  It was a nice trip.  The kids giggled and laughed at Mathieu as he played the class clown role, carrying a load of bricks instead of gently waving goodbye and thank you (he says that he was carrying plates?). It helped put poverty into context; the level of poverty of a hospital worker’s child compared to the village children, compared to the missionaries children, the white Zimbabwean etc etc. Many more questions…  I tried to relay my thanks and appreciation to the teachers for the work that they do as we all know the important role education plays in lifting people out of poverty.  I’m sure that my smile and the books were well received but that it hasn’t changed the class size (45 students to 1 teacher), their salaries (~400 US $/mth) or their work condition (on-site accommodation next to the VERY rural school, no electricity, fire wood at cost).  

We were in back in time for tea (10am) to savor a piece of the pumpkin, chocolate bread that I had made the night before and then we were off to work.  I performed a prostatectomy, a cystoscopy and a biopsy of a metastatic lung cancer that had metastasized to bone, leading to a compression fraction causing paralysis and replacing his sacrum with a huge mass.  I felt happy with my day for a few reasons… I had a bit of down time and family time, the dressings are almost all sorted and in order, I performed the prostatectomy from start to finish (having seen only one before) and the conversation with the family of the elderly man with the lung cancer was honest and well received.  The family members will come back next Friday to get pathology results (faster than my turn around time in Canada – by the way) and will likely follow my suggestions against more travel to consider chemo or radiation and to care for him at home during his final last months.

Time is going by so fast.  Tomorrow is a STAT holiday (Africa Day?). We leave Karanda on Sunday.  I will be busy baking muffins for the kids’ classes and my colleagues in the OR.  I’m looking forward to a good nights rest after all that walking (Mathieu was in my arms for most of the trip back after using up all his mischievous energy). 

Good night, Sleep tight,

Michelle

(photos are really hard to upload given limited bandwidth - will try on Sunday when to wifi is supposed to be free - if not from Harare or Zambia - stay tuned - and thank you for your ongoing interest... )

Pieds-nus contre crampons - Football sans concession !

Michelle me met la pression elle qui est déjà prête à poster son prochain texte.  Pour moi une autre semaine typique qui s’achève avec une utre série de vélos qui repartent dans un meilleur état qu’ils sont arrivés !

La nouveauté vient du côté sportif avec la saison locale de football qui commençait cette semaine.  J’ai adopté le rythme de l’entraînement quotidien qui commence à 4 :45 pour se terminer vers 6 :15 à la nuit tombée. Ceux qui ont eu la (mal) chance de jouer avec moi savent que j’ai deux pieds gauches et qu’en plus ils sont carrés mais ces temps-ci c’est plus mon âge qui me fait mal. Deuxième plus vieux de l’équipe, je rends en moyenne 15 ans aux autres joueurs. Donc c’est dans un rôle de défenseur latéral que je joue avec le capitaine / entraîneur (l’autre vieux de l’équipe) en défenseur central. Ces gars là sont dans la forme de leur vie, courent comme des lapins, ont des jambes fines comme des allumettes et ont en majorité une technique footballistique ahurissante quand on considère les conditions dans lesquelles l’on joue ici.  Rien à voir avec nos terrains européens.

Faisant dos à mon but voici la meilleur description que je puisse en faire :

-       Une pente naturelle de la droite vers a gauche d’environ 5% à 7% sur la longueur du terrain rend les courses latérales soit épuisantes et impossibles soit emballantes à en perdre l’équilibre suivant la direction de la course ;

-       En divisant le terrain en 6 carrés avec les carrés 1 (gauche) & 2 (droite) devant mon but, 3 & 4 en milieu et finalement 5 & 6 devant le but adverse les conditions changent du tout au tout. Cantona serait fier de me voir jouer au ‘beach soccer’ vu que mon carré alterne entre le sable et la terre battue. Le carré 2 est par contre en terre solide mais très inégale car traversé par un chemin que les locaux utilisent quotidiennement pour aller à la rivière pour chercher de l’eau avec des bœufs ainsi qu’une route de terre pour aller à la station de pompage ;

-       Les carrés 3 & 4 sont les plus réguliers tant dans la forme que le fond malgré la pente naturelle ;

-       Le carré 5 souffre d’une pente accentuée et de nombreux trous assez profonds quand au carré 6 il est le très inégal et est entièrement de terre et de sable.

Pour les règles du hors-jeu et les limites du terrain on repassera car il n’y a pas de marquage et l’avantage est laissé en fonction du bord que prend l’arbitre.

L’entrainement commence par un échauffement assez traditionnel et continue par un match sur un terrain réduit afin de travailler le jeu de passes courtes et longues. La notion de ponctualité étant ce qu’elle est  les joueurs arrivent à la sauvette et rejoignent l’équipe qui manque de joueur. On joue torse-nu ou avec maillot suivant l’équipe que l’on intègre et vu que – vous l’aurez compris de nos blogs précédents – tout manque, certains joueurs jouent également pied-nus.  Nous finissions généralement par une confrontation entre jeunes et moins jeunes. Les uns prêchant la fougue quand nous – les moins jeunes – tablons sur la vision du jeu, la technique, la précision.... en gros nous prenons une raclée à chaque fois.

Le défi physique, l’intensité dans le jeu, les contacts virils sont omniprésents donc je termine chaque soirée sur les rotules et par 10h du soir j’ai des crampes dans les jambes, le bas du dos et me sens généralement vieux ! Je suis le seul ‘Molongo’ (homme blanc) qui joue avec les locaux et je m’amuse comme un fou. Presque tous les jours Julien et Mathieu me suivent au terrain et jouent pendant tout l’entraînement avec tout un tas de gamins et reviennent tellement sales que si nous avions la possibilité de les laver dehors nous le ferions.

En parlant d’eau une équipe de spécialiste arrive cette semaine des USA pour revoir le système pompage et d’assainissement qui semble atteindre ses limites en espérant que cela résoudra la pénurie d’eau. Ces problèmes d’eau semblent donc en passe de se régler et nous avons pour la première fois fait face aux coupures d’électricité cette semaine. Pas si grave ! Juste quelques heures de coupures par jour puis nous savions que l’hôpital avait un gros générateur au diesel qui l’on reconnaît à l’oreille… à moins qu’un airbus soit en rodage dans la cours ! Détail important que nous avons compris par la suite est que le générateur ne supporte que l’hôpital… Ou pour ceux comme moi qui n’écoutent pas vraiment : les bâtiments de l’hôpital… et nous qui ne nous affolions pas de voir notre bouteille de gaz vide à la maison ! bien sur nous avions un four électrique donc même si on a plus de gaz pour cuisiner y a pas de problème ! donc voilà une question que j’aurai du poser : Pourquoi chaque cuisine à un four à gaz et un four électrique ?  pour qu’en cas de panne d’électricité l’on puisse cuisiner au gaz. Morale : cuisiner à l’électrique tant que possible pour préserver le gaz.  Ahhh… l’apprentissage continu.

Donc la leçon de l’eau filtrée n’a pas été suffisante pour nous mais finalement l’électricité est revenue assez rapidement à chaque fois donc rien de perdu dans le frigo ou le congélateur et nous avons du café !

Sinon le travail continue sur les vélos et je viens de passer une seconde commande de pièces car mon stock est presque épuisé. Je suis toujours surpris de voir à quel point les vélos qui arrivent sont en mauvais état mais certaines histoires m’aident à comprendre pourquoi ces vélos ne sont pas entretenus. Cette semaine j’ai du parler longuement à un vieux monsieur qui avait besoin d’un nouveau pédalier et qui avait marché plusieurs kms en poussant son vélo pour que le faire réparer. La note est salée puisque j’en ai pour $18 de matériel. Somme que bien sur la personne n’est pas disponible. Ledit monsieur est revenu me voir en me demandant de bien vouloir garder son vélo en attendant qu’il vende une chêvre pour payer les réparations du vélo.  Hier c’est le gardien de sécurité de l’hôpital qui est venu me voir pour que le répare le vélo de son fils qui marche actuellement 14 kms pour aller à l’école. J’ai blêmi quand j’ai vu le vélo arriver : pas de frein, une pédale manquante, un axe arrière partiellement manquant, deux roues complètement voilées, une chaine trop courte et j’en passe. Impossible pour moi de le réparer et je me sens désemparé devant ce père de 5 enfants qui n’a définitivement pas les moyens d’acheter un nouveau vélo et qui pensait que je pourrais faire un miracle.

De Miracle il n’y aura pas mais j’ai trouvé un vieux cadre qui traînait dans le coin et avec des pièces de rechange je vais essayer de bâtir un nouveau vélo à moindre coût pour ce gamin.

Affaire à suivre.

TGIF

May 20, 2016

Good evening friends,

I am in a very pensive mood right now… I just got off the computer “facetime audio” with my dearest friend Marianne.  It brought me back to the Canada I love, the friends that I miss – the healthcare system that I know.

It is Friday night.  I have finished my second cup of tea.  JF and I are relishing in a few quiet moments before going to bed.  The children seem to be high on life.  Spending entire afternoons chasing each other, playing with sticks and friends – they come home wild and can be slow to calm down.  Eventually, after wiping off the dirt and filling their stomachs they crash in there mosquito netted cabin – re-energizing for the next day.  It is really nice to see.

The work week is essentially done.  I round on surgical patients on the weekend, but am done in a few hours and there has not been much emergency surgery off hours.  I’m glad to have a bit of non-medical time.  I have had a few challenging cases again this week…

-       major extensive penile condylomas in a 30y.o. male (HIV+ recently diagnosed – CD4 count 316) – he had been treating them with podophylline for 2 years (? Hoping that they would go away).  There is nothing left of his glands and foreskin – just a 10cm rough, bleeding cawliflower

-       A 59 y.o.female who was diagnosed with multifocal breast cancer in July 2015 – she didn’t have the funds for chemotherapy and presents for advice +/- mastectomy today from Harare with a huge breast mass that extends to her clavicle and to her flank and lower abdomen.  She’s in pain, can’t walk, has liver metastasis and has been jaundice for 2 weeks.

-       We operated on the very frail bowel obstruction patient 30ish y.o. female on Tuesday (HIV + CD4 57) and found perforated small bowel loops stuck onto a large uterine mass.  So we excised the bowel and the uterus – leaving her with a temporary stoma.  I got a smile for the first time today.

-       Finally a 29 y.o  female (healthy, HIV negative) with an 8cm mass between rectum and vagina (biopsy showed a poorly differentiated cancer ? sarcoma).  Should Dr Thistle and I resect it next week? We have no imaging (other than US).  We are not surgical oncologists.  Is going ahead trying our best or potentially doing harm?  All exhausting existential questions…

And on top of that, I got roped into presenting grand rounds on wounds and dressing – so last night I dreamt of wound care nurses in Canada, dressing changes, Vacc dressings.  Sometimes, I think I am loosing my mind.

Writing things down is helpful.  Things somehow seem to make more sense when they have been said or are typed.  For this, I am grateful.  I long to put all of these experiences into a broader context.  What is in the cards for me as a surgeon who has a soft spot for international surgery?  But at the same time, I would really like the ability to live strictly in the now moment, to keep things simple, to cherish my short time here without over-analyzing.

So I will try to practice what I preach, and tell you about a funny moment before I say goodnight.  On Wednesday night, JF was invited to Dr Mumvura’s home (Zimbwean trained general physician – early 30s – lovely guy – huge smile) to watch the Europa league soccer final (Liverpool vs Sevilla).  I chose to go straight to sleep at 8:30pm.  JF came home at 11pm and made tons of noise.  Turns out that he had let a bat into our guesthouse and was frantically trying to get it out.  Ah ! the Zim reality we live in.

On that funny note (just picturing JF makes me chuckle), I wish you a restful weekend.  I am off to read my Murder Mystery novel. I will write soon,

xoxo

Michelle

Weekly update from Michelle

May 15^th, 2016

Hello again,

Maybe this is becoming a Sunday afternoon ritual.  I have just come back from a 1.5hr walk with JF while a lovely 14y.o watched the kids while they nap.  His name is Innocent and he has been adopted by the headmistress of the nursing school.  We were told that he was dropped off at birth, on the steps of the hospital.  He is tall, wears round glasses and has perfect English.  He is in grade six at the same school Julien is going to and he has spent his last week watching JF repair bikes in the afternoons.  The kids love him and call him “chicken” for some reason.

Another week has gone by.  I can’t believe how fast the days past.  Let me tell you a little bit about my daily routine.  I am up and out the door by 7am.  The nursing students and senior medical people (at least those who choose to get up or who are guests) begin their day with 15 minutes of song and a daily devotion that anyone can lead.  I then finish my coffee and head to male ward to round on all surgical patients (except ortho – I had to draw the line).  Male ward has about 45 beds.  A nurse who helps translate to/from Shona accompanies me.  My gentleman who has had the penectomy was discharged on Friday.  He was so grateful, cheerful – he kept clapping his hands with a smile ear to ear, chanting our praise.  When I feel grounded – I am grateful for this type of response.  When I am tired – I question his response, his understanding – I feel like we did nothing at all – at least nothing curative. Another gentleman has had a laparotomy for a perforated peptic ulcer.  I brought him back to the OR for washout of a pelvic abscess on Friday.  Finally, a smile on his face.  Finally, feeling better.  I can just imaging this man’s life… very tall (~ 6’2), strong, a farmer – not used to being sick – never mind spending 2 weeks in hospital.  How is his family coping? What is the economic impact of his illness?  I hope he stops spiking temperatures.

Then, I go to female ward, where Dr Thistle has already started – I only see the non-gyne patients and it usually goes faster.  We have been following a young lady (~ 21 y.o) with agenesis (absence of vagina).  Dr Thistle created a vagina on my first day and the passage keeps closing.  We have brought her back may times to dilate the passage in hopes that she can be discharged.  We admitted 2 ladies with probable bowel obstructions on Friday.  A ~45 y.o who is has a partial obstruction from I suspect carcinomatosis (cancer all over the lining of the abdomen), 6 months after a surgery in Harare for sigmoid colon cancer (T4N3).  Despite the fact that she is well dressed, speaks perfect English and lives in the capital – she has no funds for chemotherapy and stated that she could not return to the same hospital because of unpaid bills.  Her abdomen is tense and nodular with hard masses that I can feel.  I gave her an enema through her stoma, IV fluids and I suspect that she will be discharged on Monday.  The other lady has recently been diagnosed with HIV.  Her CD4 count is 57 (over 400, they offer Anti-retro virals).  She had not urinated for 4 days and was draining >1L of feculent stuff from her NG.  She had no peritonitis. No money for a blood count or X-rays.  We are resuscitating her and we’ll see.  I didn’t round today but I was told that she is improving.

Oh ya, so the rest of the day goes as follows – I head to the operating theatre usually by 9:30am – the team is not ready to start until after tea time (10-10:30) so I organize dressings that are all mixed up and not used or understood by the physicians here (or by me for that matter).  I have tea with the team and we start cases at 10:30.  There is a list that is not followed in order.  Most of the physicians pop in and out, being called for the cases that they are most in charge of.  Dr Thistle does the big hysterectomies, Dr Stacey Harms a new general surgeon from the states, does the VP shunts (tubes that drain excess fluid from the brain into the abdominal cavity for children with enlarged heads).  I take the dirty cases (huge sacral pressure soars), the familiar cases (hernias, scopes, hemorrhoids) or anything else (this week prostatectomy, hydrocelectomy, D&C, bilateral orchidectomy).  We work until lunch.  Take a break to go home for lunch (1-2pm) and then until 5ish.

Enough medical talk…

The highlight of the week had to be watching the Karanda truck arrive around 7pm on Wednesday from Harare.  My husband and John (the American - in charge of maintenance) had travelled to purchase IV fluids, parts for the bikes and … picked up our bags that had passed customs.  To see the suitcases on the roof – It was like Christmas. We were so happy to show the contents to Dr Thistle and his wife Padrinah (how teaches midwifery here) – 2 full duffle bags of medications, surgical supplies, soccer balls and training equipment, hand-knitted dolls for the children of hospital and an orphanage that we plan on visiting.  All intact and in time – the hospital has run out of Penicillin G, Amoxicillin, Acetaminophen and all PPIs.  We are slowly distributing things to the areas where they belong.  The lady in the pharmacy was so excited – to see the line of patients waiting outside her door was well worth the administrative headaches. We are planning a trip to the local village school next week with the boys.

As a write this, I have been interrupted.  I am surrounded by 4 crazy boys (ages 7-9; Proud, Nokutenda, Anesu and Garikai) they are making up stories about an avocado stuck in their throat making a funny sound – gueeo gueeo gueeo.  They find themselves very funny and are reading my words as I write them.  We took photos with Photo Booth and laughed out loud.

Connecting with people, from all walks of life is really my favorite part of travel adventures.  From Hannah or Prosper the OR nurses, to Camilla, our housemate – a med student from the UK who is interested in pursuing Missionary work.  Sharing pizza with Dr Thistle and his sons as well as his insights on overseas work, the present and future of this hospital.  Making popcorn with Miriam and chatting about visitors and their impact (or lack of).  We are really savoring these moments and are doing well.

The boys are now fast asleep.  They come home exhausted and filthy.  We had a great birthday party yesterday for Mathieu who turned four.  My homemade cake (he wanted a rainbow cake with super heroes) was a bit undercooked but looked great in my opinion. The kids played hockey, ate popcorn and pizza and just before going to sleep Mathieu said that if fact he would have preferred that the super hero “Flash” had been drawn on the cake and asked when could I make him another.  Oh well… I am left with his beautiful pouty face – thinking that … I can try as hard as I can, give all that I have got to give, but that just like in life – it may never be perfect. And that it’s ok.

Thinking of you all very much, I hope that you have a great week,

xo

 

Michelle