#3 Zawadi… Sadness… Heaven Would Be Better

January 20, 2013

Today is Saturday so we worked a half day with the nationals.  I’m really glad we did, because Jim was able to do good follow up with the 13 yr old who is HIV+.  Her name is Zawadi, or at least that’s what we thought and have been calling her.  Apparently it’s her last name but I’ll use it for now.  We gain more information daily, it turns out she does have a dad in the camp and he’s come 2 days now with her and was not drunk.  He’s of course, also HIV+ and on ARV’s also and has taken a new wife. Zawadi has many medicines to manage and we had been told she lives alone in the camp and others look out for her (not her dad).

 

Zawadi…  she needs a momma, OR an attentive daddy

On Thursday Zawadi came into the clinic, was tachypneic (high respiratory rate) and her belly was so big she appeared to have ascites (fluid in belly) from liver failure.  This is most likely why she was breathing hard, kind of like a full term pregnancy, and it was difficult for her to lie on the exam table.  Jim did a thorough assessment and was very tender with her. He found both her liver and spleen to be enlarged, eyes NOT jaundiced, some anemia but most likely she was having bad side effects of the HIV meds which were now damaging her liver.  Her jumper dress was filthy, heavy with soil and hard to even handle. I wanted to take it with me and launder it, something we cannot do as it could cause problems in the camp with others.  Her affect was flat.  Sad, sad, sad…  Dr. Isaac came per our request, to also assess her and fill in the gaps of what had already been done for her. Turns out she’s already had 3 weeks in the hospital but it’s not apparent to us what was done for her.  He pierced a needle into her belly to aspirate fluid and only got air.  She was stoic and tears flowed gently down her cheeks. They do not prep patients here, it is normal to just have “stuff” done to you without explanation, it is not expected. Touch, I thought, “She needs touch…”  I removed my gloves as the latex barrier puts up a wall and does not feel loving.  Then I touched the tears on her cheeks and felt a little fear myself…  but she needs touch.

We are not supposed to give gifts of any sort in the refugee camp, for it can cause fighting and demands from others in the camp.  But I couldn’t help giving her a bag of 5 protein bars to take with her.  I opened a yogurt coated protein bar and had her take a bite.  No smile but she timidly ate.  She later was up at the nationals clinic receiving medication distribution and I saw her walking behind our vehicle to go back to the camp.  I called to her and motioned her to come my way.  I gave her a ½ full water bottle and got a little smile, very little.  Then as she walked away toward the path I called out to her again and smiled and waved.  Another little half smile.  This, I feel, is our goal now… to make her smile.  Her life is so sad and hopeless, and earlier when she’d been lying on the table I turned to Jim and said “This is when heaven would be better.”  He agreed.

I love working with Jim.  He is a gentle man, 70 yrs old and very experienced and non reactive.  He is very logical and if I’m a little off base, he speaks up and gently suggests another way.  Thanks Jim.  We are learning from each other and make a great team.  Since our exam “rooms” are only a tent drape apart from each other, we hear our conversations with the translators and occasionally say across the drape “I didn’t know that”.  It takes a team for sure, and we too are learning from the nationals.  They do this care day in and day out, and see the same things over and over again.

Yesterday nearing the end of the day 4-5 men came running to the clinic with a passed out man.  I called to Jonathan, the clinical officer, saying “a man is coming that looks like he has cerebral malaria.”  He looked like the soldier we helped in Northern Uganda years ago.  Silly me, turns out he was drunk, VERY drunk.  They hustled to get an IV in, pushed high dose dextrose and fluids and apparently he came to hours into the evening when we were gone.  Jim has seen this lots in the ER, but me?  Not too much of this in peds :0)  I tried to tell his friends that he could have died and how dangerous it is for them to drink this much.  Home-made hooch it was, very strong and toxic. They said he hadn’t eaten in 2 days and this is why he was so drunk.  Sure.

Drunk man -vs- Cerebral malaria?

Friday I was seeing refugee patients while Jim escorted Zawadi to the level 4 clinic in the Kihihi area.  This is the best referral option we have other than a 4+ hr drive to the nearest hospital. It is also where she has to go monthly to evaluate her response to the HIV meds. They were familiar with Zawadi and the charge nurse tried to tell Jim that her liver was NOT enlarged.  He is a very tactful man and not argumentative, BUT he was not going to agree with that. They conceded and the meds were changed to a different combo.  Jim feels she really needs a bigger facility and more in-depth testing.  We are not confident of her prognosis but she is uncomfortable and something more complicated is going on.  Today she arrived with a fever, higher respiratory rate & heart rate and just looked plain worse. We brought a pulse oximeter (one we will leave with them) and measured her oxygenation which was good. We are so limited on what tests can be done for her here.  Jim ordered IV fluids and antibiotics for her fever.  A plan is being set for her to be transferred to the Mbarara hospital ASAP. I was able to sit with her for a few minutes before leaving, hold her hand and pray for her.  Touch, she needs touch…

Jim and I discuss the days work – often over a cold beer – when we arrive home to our little hotel.  We are sweaty and hot having worked in a stuffy tent of about 85 degrees. I feel like a wimpy American.  Our work feels good and purposeful, but not the volume I have been used to on my other trips.  It’s hard not to grade yourself in terms of number of patients seen.  Tonight we agreed that this trip seems to be more about teaching.  Some of the staff are very young and they have them rotate through as translators, working with the MTI volunteers.  These nurses, roughly LPN training level, are seeing patients themselves and prescribing when we aren’t there.  The volume is just too great for one doctor or clinical officer to do (Uganda has one doctor per 60,000 people).

Yesterday I arrived at the camp “clinic” tent and a nurse was seeing a teenage patient and had written prescriptions.  I asked them about the patient and they said he had a cough.  They were dispensing amoxacillin for him and so I started our spiel about how you don’t give antibiotics for just a cough alone, there needs to be fever or pneumonia or something more, Jim re-enforced this.  I listened to his “clear” lungs and started to chart on the paper and saw the word “wound” also written. “Oh” I said, “I am so sorry, I thought you were giving amoxacillin for a cough.  Where is his wound?”  One nurse said “I don’t know, Provia was seeing him”, then Provia said “I didn’t see.”  I asked the young boy of about 12 where his wound was.  He pulled up his shorts and showed me what looked like a bullet wound in his left thigh, red, swollen and draining.  Turns out it had been a boil when in Congo and a “doctor” (?) had opened and drained it 2 months ago.  He has been in the camp since and this was the first time he’d come for help.  These people are stoic and live with allot of discomforts as simply a way of life.  The nurses reacted with “Ooh, that needs to be dressed”.  Another teaching opportunity…  you never prescribe a drug without first seeing what it is you are prescribing it for.  Again, I think this is common practice by the nurses (not by the docs) in order to help see lots of patients in a day.  One nurse told me they don’t listen to lungs with a stethoscope if there is a doctor around “out of respect”.  I encouraged her that it would be good to do so if she thinks someone has pneumonia and they are writing for drugs.  The doctor is 100 yds. away and he would want her to examine the patient.  Jim had an idea at dinner of having his nurse translator see the patient and he do the observing and coaching.  I thought it was a great idea and will do the same.

Teaching, that is what we are here for… and Zawadi.

~ Love ~

Nurse Janey

P.S. Simple pleasures in Uganda… watching staff enjoy trail mix with you, picking up one morsel of nut, raisin or M&M and savoring each single piece.  AND of course

… a flushing toilet  :0)

Malnourished 1yr old

 

Wonderful, hardworking nursing staff

Unexamined wound

Just a cutie pie with a hand made jute ball

Sad Zawadi…

Machete wound stitching, great job Dr. Isaac!

Community education

Peek a boo!   I love you!