Friday, 5 April 2013

A sense of urgency - or not

Zimbabweans are "chill," "relaxed," often without a set schedule. It's nice. Until it's your patient.
There is an emergency system. That you pay for. These are private ambulances that may be covered by your employer or self-purchased insurance plan. 

Nonetheless, I have been struck by the general lack of urgency when it comes to very ill patients. Maybe it's because there are limited resources, it's easy to move slowly since it probably won't affect outcome. But, that's quite a pessimistic view. 

I have watched 2 patients die, and wondered if urgent care would have changed the outcome. One was in the casualty ward (ED) in the trauma bay (right). I happened to be eyeing a TBI patient next door, when I noted a 3rd year resident quietly asking the nurse for a functional Ambu bag. I meandered over and saw a patient with very shallow breaths. Unclear if there was a pulse. There was no crash cart. When I asked if he wanted to intubate, he responded, "it's too late" and there was apnea on the monitor. He asked the nurse to confirm absent breath sounds and covered the patient with the sterile, tan blanket. I inquired as to the history, and I got "obstructive uropathy;" the urologists placed a suprapubic cath and asked "physicians to see" = admit to medicine. No help there. He was moved back to the trauma bay with the nurses noted shallow breathing, and the admitting medicine physician was eventually called. Unclear what the delay was to arrival-at least 20 min. There is no loudspeaker, pager, or code team. The casualty officer (nurse) then informed the wife and son, and they cried out loud. I watched, and cried inside.

Thursday, 4 April 2013

Challenges

Practicing neurology in Zim has been one of the hardest things I have ever done.

With no confirmatory diagnostics, limited therapeutics, and rare oversight, cases have been extremely challenging. Not to mention +HIV in >13% of the adult population. So if you see a CN 7 palsy in HIV+ patient, can you claim a self-limiting Bell's palsy and leave it at that? Actually, Yes.

My handwritten "plan"
How about acute onset myelopathy in a 75 year old female, hx of treated pulm TB, with no history of trauma. No, you can't have an MRI.
She is empirically on TB meds, prednisone, and B12.  Too bad there are no IV steroids in stock at the moment.

Empiric therapy is the rule. Every HIV+ patient with neck stiffness is on CTX -- then it's stuck for 7 d. TB meds for questionable CXR is understandable.

Most common challenge is acute strokes with no imaging and high BP (we're talking 250s/120)? ASA? I have been going with Yes.
Unless there are some major clinical signs that indicate hemorrhage
Occasionally, you can convince a family to spend $200 on a noncontrast head CT at a neighboring private hospital to please help you rule out a hemorrhage and manage appropriately. We even got one on this TBI case, a young 21 year old male hit by a vehicle in a presumed RTA (road traffic accident).











As Zim was previously colonized by UK, most of the Shona-speaking patients thankfully also speak English.

The medical training system also mirrors the UK.
Undergrad=med student: 5 yrs
JRMO=intern: 1 yr
Govt experience/house officer: 1-2 yr
MMED/registrar=resident (e.g. IM): 5 yrs 

Monday, 1 April 2013

Chitungwiza

The Zimbabwean people are so open, welcoming, accommodating and treat me like family. Literally, I spent the afternoon in Chitungwiza - the next town over - with Baba & Mai Mametsuwa (Caroline's family).

Mai (Mother) made an all vegan meal from their garden sugar peas served over sadza, of course!
They took me around town, and I saw people in their daily routine selling, buying, being.

There is a mix of both "high density" (no garden) areas and rural space (thatched huts etc).






No matter where you are, communal farming on government land is respected. It is a beautiful place.










Balancing rocks (below) are a big thing. They naturally fall this way.

Saturday, 30 March 2013

The Bride Price



An African wedding actually begins when the groom (via the bride's family members - never directly) asks her father for her hand. Eventually, the OK is passed back down the chain and groom and father sit down to negotiate a "bride price" to be paid by the groom. Additional fines charged if the she is already pregnant!  



Following the payment of the bride price, an optional church wedding & reception may occur after several months. Caroline, an MMED (3rd year IM resident -- out of 5!), and I attended this wedding reception of another classmate.

After the ceremony and pictures, the bridal party is introduced dancing into the reception tent. I fell in love with the Zambian pop song by Mampi, to which they are dancing.    





The MC coordinates speeches, jokes, dancing, and the delivery of gifts. The gifts here are striking. There is no registry. You do not request "No boxed gifts." In fact, your large (bigger the better) household appliance is lugged to the wedding site, put on display for all to see, and then carried before the bride and groom while giving a speech and congratulating them. If you get 3 microwaves, too bad!

Caroline organized her co-residents to each pitch in $40 to purchase this washing machine and gas stove.




Children were out playing with the clown or bouncing in the "jumping castle."




The bridal party, in this wedding, changed their clothes to perform another funky dance to this popular Nigerian song. They went on to perform 3 total dances in between the distribution of the gifts/speeches. Simultaneously, plates of meat, rice, salad were delivered to each guest; there were probably 300. People moved freely in and out in any degree of formal or informal clothing. The whole affair is quite relaxed, except for the part where the MC pointed me out "Ladies and gentleman, we have an Indian here!" and later danced with me in front of the whole crowd!







Friday, 29 March 2013

Mbizi


















Is it still considered a zoo if there are >1000 acres (protected) and the animals feed on their own? These are "game parks" and have nothing to do with hunting. This is where I met mbizi = zebra.




















Vegan animals! Eland (above), a large antelope. Giraffes, tall/dark male and shorter/lighter female. Impala (below) antelope in female harem, but can't spot single male leader.




Wednesday, 27 March 2013

Milton Park B&B aka Home sweet Home


The B&B where I am staying is cared for by a pleasant Shona woman, Jaldine, and gardner/cook/helping hand, Lovemore. Both greet me upon arrival with uninhibited laughter and positivity as they showed me to my room.

Tuesday, 26 March 2013

En route


I almost missed the flight as I wandered through the small city of the Dubai airport in a maze to get to the gate. The flights to sub-saharan Africa (expect Johannesburg) are stuck in the back of the airport. I had to go up 3 huge flights of stairs, and then down another 3 to get to the bus that took me around the airport to an outdoor staircase up into the plane. I was the last one on! I doubt a US or UK flight would ever require this... Subtle prejudice. We also were sprayed with ?pesticide before departure. 



No where on my ticket was Zambia mentioned, yet the flight stopped here in Lusaka. So much for a "direct" flight. Again with the pesticide before take off. 


Thankfully, I was actually on the correct flight and made it to Harare as the sun set. The air is warm and fresh, negligible humidity, and everyone around is smiling and relaxed.