Hot Water

[Update: UAB med student, Dough Johnson was hit rather heavily by the local gut bug (? Nalerigu Wringer?) and was out of work today. He is mending and may be able to return to work tomorrow. I am mostly over this pneumonia and thank everyone for the prayers, it has made all the difference]

Hot Water: a simple concept of course, you take cold water and apply heat. Ghana is “hot” and it must be true that hot water is in consequence not a problem.

The baby was premature at birth 2 weeks ago but had grown and the midwives discharged the infant last Sunday weighing about 5lbs 6 oz with instructions to come back to the hospital (a walking distance away) if anything should happen. By the time “something had happened” on the morning on Wednesday and the parents had worked their way through the long lines and had been seen by a medical assistant and had been identified, had worked through the lab and had gotten to the ward, it was 5PM and we were at the door to leave.

He was small frail, cold, blue and gasping. His heart rate was fast and thready. I examined him and as well as I could tell, he had no pneumonia, abdominal catastrophe, trauma or “localizing sign.” He was just dying. Back home we would probably talk roundly of “late neonatal bacterial sepsis” would get labs as appropriate, would start an aggressive course of fluids, pressors, mechanical ventilators, steroids and antibiotics. He would be tubed and “lined” monitored and measured.

What we had was IV fluids, low flow oxygen and precious little faith. A spinal tap was done quickly, once the IV was “set,” antibiotics were given and I set about to see if we could reverse the inevitable. We pushed in saline to open up his collapsing blood supply but within minutes his faint breathing stopped and his heart rate fell to the sixties.

“We lost him.”

Despite all though, his gasping respirations continued and his heart rate lingered below a hundred. I was discouraged and fascinated; it is a peculiar thing that when an infant is dying, the heart continues to beat faithfully long after death is assured, long after all measures are made and failed and long after the staff are too discouraged and exhausted to notice. Even brief tortured breaths can be noted. So was it here. I gave orders to be called when he died and left at 8PM for a cold dinner of rice and beans. I circled around afterwards to talk with the staff and said how I had appreciated how they worked with the “baby who died.”

“Oh he is not dead yet.”

Humility is not a condition I cultivate but would learn something of it then.

He was still cold and pale but breathing easily with a good heart rate.

He still looked dead to me.

What more was there to do for my embarrassing patient?

“When all else fails, start at the beginning,” I was told once.

Vitals signs were ok now but this temperature? A quick check for the record; his temperature was 32.6C (about 92F); hardly above the room temperature. How were we to warm him? There is no incubator for him; no electronic gismo to make sure the temperature stays even. On the wards there is not even running water. The hospital has hot water, for washing surgical equipment, IV bottles and such, and it closes at night as does the lab.

He needed hot water bottles; a remedy of which my mother would have greatly approved. The pharmacy was at least a place to start. I called to the newly arrived volunteer, Chuck Holmes, and we started to conspire. Half-quart glass IV bottles would be water-proof with no leaking onto the bed, easily transported in cardboard boxes and insulated therein to boot. I acquired my first half-dozen bottles, filled three with hot tap water rather than the scalding distilled water from the still and carted over to paediatics the first batch. We tucked them into folds in the thin cotton “kanga” cloths which serve as bassinet, clothes and diaper for newborns; one on either side and one at the head (heat loss is largely from the head). He still looked dead and it took an exam to prove to me he was breathing and had a heart rate. I circled around, collected my next half-dozen bottles and headed back to “House 6” about a quarter mile away, with a mission.

Hot water in most African mission stations and indeed in most places I have stayed is provided by a “geyser” (pronounced “geezer” at least in central and east Africa). They generally supply scalding hot water which is diluted for washing. Five minutes and I was balancing the now heavy cardboard box on my shoulder. This became a thrice daily ritual over the next two days: a hot-water run to the house and swapping bottles of warm for hot, close enough to heat but not to burn.

Again surprisingly, our “Lazarus” gained temperature with each hour reaching normal in about 5 hours. Maintaining his temperature during our current hamartan (dust storm) was tricky, all the Ghanaians are complaining bitterly of the cold night weather, going down as it does to the hi 50’s in unheated mud wattle houses. Nevertheless, Lazarus was warm yawning and active by morning. We could even stop the bottles by this evening, as he was well enough to cuddle with mother instead.

We have just started trying to re-feed him by tube now; I have no idea whether it will be successful and what ever damage he might have sustained. I do know that anyone who says that serving is rural Africa is pointless and doomed to failure is a fool. The lessons worth learning are many, varied, and lying about like a field of diamonds. The gem I picked up I will treasure.

Cleft Lip Repair

Cleft Lip Repair

Quiet in a lime green room with piles of instruments wrapped in clean discolored and bleached out packages, stacked in a corner. A tape-player doing Bob Marley covers. A small child naked in the middle of the room on a table, an IV trailing from a small arm. He is apprehensive, wide-eyed and absolutely quiet.

His face is marred by a cleft lip, exposing his teeth and gums. Dr George Faile, almost equally quiet, takes a “before” photo and proceeds to consider his patient. Gentle hands move lip and tissue to imitate his thoughts. Hands cup about an anxious young face, straightening it for the trial. Measurements are made and re-made; after minutes, a pen is produced and the thoughts are committed to ink on skin; hands return to move tissue to what will become new reality. A final check and a small injection into the IV. Lids flutter and close.

A small face is draped with towels; gauze is inserted into the mouth to prevent blood finding a windpipe while the boy sleeps. Suction apparatus is rigged, short quiet sentences and all is ready.

A prayer to the creator God; a request for guidance, mercy and healing for the boy.

Bright red blood against black-skin, white teeth and yellow rubber glove. Hands dance in attendance over the small field of a boy’s face. Decisive cuts, bleeding erupts and is subdued with heat and smoke. The smell of burnt flesh is part of the ritual of healing. Flesh is again measured, approximated and for the moment left open, a wide red gash in a young face. The cycle of drawing together the flesh begins. Parts long separated are reunited, flesh deficient is augmented by design; odd pattern is revealed as a fitting together of puzzles into a new declaration of wholeness. The red gash narrows; tissue layers are arranged and straightened. Finally the now thin red wound is closed by blue sutures against the black skin of the boy. A final suture is cut. He does not awake as yet but his face is whole.

Update

Dear Friends,
I continue to improve and today received a "care-package" of medications from Cindy Shumpert "just in the nick of time." I also had the pleasure of meeting Doug Johnson, UAB School of Med. MSIV, who came with Paul Shumpert MD, arrived today at Nalerigu. Today is a day of arrivals and tomorrow of departures, a Bud Young MD, Megan ( med/peds resident) and Tomas (an Argentinian) all leave for Tamale and Accre in the afternoon.
We had a bit of an outing today, going up to the escarpment with the new arrivals, a walk and a climb through this dry land, to a cliff face overseeing the dusty river bed with a thin line of verdant at the bottom.
Tomorrow I am scheduled to see all the nutrition patients. Joanna, the nutrition nurse and I are actively plotting how we will improve things while I am here. Over the weekend, we lost another baby; probably due to gastric rupture from prolonged labor. There is much to do.

BTW, some ppeople were having problems leaving comments. This should be solved as of now.

Work Permit

George Faile left me just now with a “work permit” to return to the hospital, an admonition to not get over-worked and a few days more treatment. I am no longer coughing as badly although I still have “a few crackles” on my left chest.

Let me first thank you all for your prayers and our God for his mercies. I am not well but I am better. I work from one treatment to the next and sleep well.

I went to church with Elisabeth Faile today at “First Baptist Church of Nalerigu” a mud-brick and wood affair with a steeple and cement floors, quite the architectural accomplishment. The congregation and worship are, I think opposite what I grew up with. In my youth, I attended a beautiful gothic style church in Philadelphia, all carved wood, stone, carpet and stained glass. The people were in muted colors and the music (although I love it) sedate. Here, all is “sepia-colored” says Tomas, an Argentinean born doctor, working for a now-defunct project in rural-health care north of here. The church is sepia, a quiet painted river-scene behind the baptismal pool; all the color of the place is provided by the people: chromium-yellow head-scarves, lime-green co-coordinating prints of dress, headscarf and infant blanket, burgundy-red evening dress, t-shirt with an incongruous print of Christmas stockings front and back, primary colors, gold threads, large-men in equally large prints, many in Arabic.

Choirs perform with gusto and volume; music provided by an over worked sound-system, an indifferently tuned piano, a drum set, tambourines, and an electric organ. The wind is blowing up another “hamartan” and the fans overhead are not running. Children wander in an out, are tracked-down, captured and kept hostage or escorted out by mothers, older sisters or “aunts,” babies asleep on their mothers’ backs, oblivious to the commotion.

Offerings are provided for with a whole church “march” for want of a better name. Everyone comes to the front to deposit their gifts in a box. However, the joy expressed is nothing regimented. Grandmas shuffle along shooing children from under un-steady feet, girls dance up and back, hardly touching down; matrons demonstrate dance steps I would have coveted in a previous life. All is joy and hub-bub. The service is in English and Mampuli, the local language. The sermon was on “building good relationships” Romans 12: 9-21. It was a nine-point sermon, in English; I saw many people taking notes.

I was the only volunteer attending; there were three gun-shot wounds, 3 stat cesareans (one mother who coded on the table), an acute abdomen laparotomy over-night and a morning of ultra-sounds to do. Everyone had slept in, woken, rushed out and was already back at work when I was collected. And I have a work-permit starting tomorrow.