Shamwanesqueries, shamwanoddities

Shamwanesqueries

Resteront gravées, pour la postérité...

Les nuages sur les collines au petit matin, lorsque je cours sur la piste d’atterrissage, et le brouillard qui se lève.

Toutes les petites filles qui pilent du manioc. La femme congolaise de brousse travaille de l’aube au soir, et tient tout de la bête de somme aux yeux des hommes.

Les orages-moussons presque prévisibles en saison des pluies, la pluie tambourinant sur notre toit de tôle.

Les absurdités de Shamsterdam. Conséquences de nos désastres logistiques dûs à la bureaucratie de la capitale: le fait qu’on ait à racheter à la population locale la farine de maïs distribuée gratuitement par Concern (via le Programme d’Alimentation Mondiale de l’ONU) pour... nourrir les patients à l’hôpital suite à nos ruptures de stock. Le fait que la majorité de notre staff national, les urbains de Lubumbashi, ne consomment pas le manioc local et donc aussi rachètent la farine de maïs (il y en a même qui se mettaient en ligne chez Concern à la distribution, alors qu’ils constituent clairement la haute bourgeoisie de Shamwana).

Vue du nouvel hôpital, vers la salle d’op



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Shamwanoddities

This is pretty much my last mass e-mail from out here as I am now flying out of Shamwana on March 6th - it keeps on being preponed! And who knows if I’ll ever get to meet my replacement as the flights are as unpredictable as ever – and more out of incomprehensible coordination problems, not weather issues.

The last week was a busy one. I thought that I would commit it to staff evaluations and end-of-month and end-of-mission reports... but instead, it was time to go back to the operation theater!

After a few months of normal deliveries, we’ve had a string of obstetrical disasters again. Our deliveries in hospital have increased to about 30 a month from less than 10 when I first arrived in August. Last week, a woman was sent from Kisele, one of our peripheral villages, with a dead baby and a roaring infection of her uterus. Our midwife had to use the vacuum to pull it out and, I’m told, the stench was palpable. The patient now has a vesiculo-vaginal fistula, to be expected, that is, a permanent connection of scar tissue between her bladder and her vagina. It means that she is now incontinent of urine. Fortunately, the fistula surgeon will be back in Dubie sometime this summer so she might be eligible for surgical correction.

Then last Thursday, our new Congolese midwife (who used to be a mental health counsellor), called us urgently to the delivery room. A woman no taller than 1m40 was on the table, visibly diaphoretic and talking. Upon taking the vitals signs, her blood pressure was... absent. I verified by checking her radial pulse... absent as well. True shock, and yet, there she was, still talking and crying! She had been in labor at home for one or two days, and was finally transferred to Shamwana on a bicycle as usual. Her contractions had stopped; her cervix was fully dilated, but there was no fetal heart. This kind of scenario spells a disaster: a probable full uterine rupture. After crossmatch and an IV line, we went straight to surgery. The uterus was completely ruptured and attached to its lower third by a mess of organized clots and necrotic tissue circumferentially. The baby had been dead over a day – its skin was literally falling off and it was hard to grab it to take it out. Talk about stench and sight again! I assisted my Congolese colleague in performing a total hysterectomy; we couldn’t even salvage the adnexae or the ovaries. We were in there for a mere... four hours. I came out exhausted. But... she is alive, stuffed silly with antibiotics, and received almost two units of blood. Surely, she would have died of haemorrhage or overwhelming sepsis with a decomposing baby in there. Yikes.

Who said that green wasn’t a good colour for me??? :)


As well, we hadn’t used our blood bank for a while, and then we got a string of children sick with malaria causing severe anaemia. I encountered the lowest haemoglobin that I’ve ever met: 14. For comparison, my own haemoglobin probably hovers around 140. Again, the child was defying all medical knowledge: he was still breathing and crying, in spite of having 10% of one’s normal oxygen-carrying capacity. Unfortunately he did not survive in spite of the transfusion that we gave him – he could not compensate any further. Human resilience does not cease to amaze me, and few of these disastrous cases ever make it to the literature. Nobody teaches you this in medical school!

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More Shamwana pictures around the hospital

Seriously cute kids!




J, our burn patient, the one who had seized. He’s now into his third month at the hospital but is getting so much better. We actually discharged him earlier today




Our last set of twins – Kyungu (=oldest twin) was the sick one, whereas Kabange (=younger twin) was the fat one at 2 kg.



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Sur ce, je vous souhaite une bonne continuation. Je vais rouler ma bosse sur le continent avant de rentrer pole pole à la maison quelque part en avril. Je serais sur des plages tanzaniennes, sur le Kilimanjaro, et à Amsterdam chez une certaine psychologue. Portez-vous bien et on se revoit à mon retour!

Angels and insects

La brousse fourmille de vie. Tous les matins, dans le seau qui nous sert de lavabo, on retrouve noyées quelques grandes mantes religieuses de 10 cm, copies conformes de fines tiges d’arbre sèches. Notre nouvelle sage-femme zétazunienne est fascinée par la quantité de mantes religieuses ici. Il est vrai que chez nous, elles sont rares et, me dit-elle, c’est une espèce protégée. Ici, elles pullulent. Et sont de toutes les couleurs, formes et mimétismes. Feuilles vert émeraude, brins de foin jaunes, branches marron. Toutes volent ou sautent, mais ne piquent pas, heureusement. Sylvester le chat s’amuse à les chasser au soûper tous les soirs à notre réfectoire et parfois en fait une collation.


Au soûper, on est attaqués par des espèces de fourmis volantes au derrière allongé frétillant qu’on ne voit à nulle autre heure de la journée. Dans ma chambre vit mon araignée familière de 5 cm, toute plate, qui parfois se cache derrière mon coffre, ou sous mon bureau. Heureusement, ma moustiquaire me protège et elle ne m’embête pas la nuit. Depuis le Cameroun, j’ai appris que les araignées sont serviables et mangent les moucherons et les moustiques. Celle-ci ne m’effraie pas malgré mon arachnophobie notable. Au moins ce n’est pas une grosse et poilue tarantule. Il faudrait lui trouver un prénom – auriez-vous des suggestions? “Sam the spider” me semblait bien...

Le mois dernier, la maison a été envahie de petites fourmis qui curieusement produisaient un peu partout des tas de poussière de la dimension d’une tasse en moins d’une demi-journée. J’ai finalement réalisé que c’étaient des termites, et que la poussière en question était... de la fine sciure de bois, résultant de leur digestion des planches de fondation. Horreur! La maison va nous tomber dessus et il va falloir que j’emménage dans un tukul! La solution? Simple et toute congolaise en sa débrouillardise: verser de l’huile de vidange dans les orifices du sol. Ma chambre a senti le garage pendant deux jours; mais le stratagème a fonctionné puisque les envahisseurs ont disparu.

Il y a quelques semaines, après le seul gros orage qu’on a eu, quatre scorpions ont fait leur apparition sur le terrain MSF en moins de vingt-quatre heures. Deux en plein soûper au réfectoire, et un devant l’entrée. Le quatrième a fait sursauter mon collègue congolais lors de sa visite de la tente-maternité. Les gardiens les gèrent avec un clou au bout d’une planche de bois, un tue-scorpions congolais ma foi. Je n’ai pas eu de réponse claire quant à leur venin, mais comme il n’y a pas eu de présentations critiques de piqûres de scorpion à l’hôpital, on va présumer qu’ils ne sont pas mortels...


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L’équipe médicale a changé. C’est un bol d’air. Je m’étais habituée au néo-colonialisme et à l’autorité de l’ancienne équipe en m’en isolant tranquillement et en faisant usage de silences judicieux. Les nouvelles arrivées sont plus expérimentées et bien plus humbles. De par nos origines communes du Nouveau Continent, nous avons le même esprit de collégialité, que ce soit avec les expatriés ou le staff national. La communication est plus fluide. C’est rafraîchissant de ne plus s’engoncer dans la hiérarchie. Au PPD, ils nous avaient prévenus que c’était l’équipe qui marquait le plus une mission, et c’est foncièrement vrai. J’en soupire de soulagement.


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We are visiting the village of Kabala quite a bit lately. Monday, it was my turn to accompany the mobile clinic team there, on one of the Land Cruisers, the T-32. On the road, the “agent focal”, the local MSF community worker, signalled us from his bike. Earlier in the morning, he had tried to bring a woman from Kabala to the Monga clinic after she had spent the night in labour. However, strapping a pregnant woman with active contractions on a bike and riding on Congolese roads is no small feat. He ended up dropping her off in Beela, halfway to Monga. So we stopped there and I investigated the scene. The lady, primiparous, was alone in a hut the size of a queen-size bed, in full-blown labour. She was fully dilated but there was so much cephalhematoma that I couldn’t tell the head position. Membranes had been ruptured for a while. The birth canal felt so small, and with the history of prolonged labour, I could not take a chance. In Africa, my stethoscope’s bell morphs into an excellent fetoscope: good fetal heart. So off we strapped her in the back bench of T-32 and back we headed towards Shamwana, a good forty-five minute ride. The nice, capable national nurse and I sat next to her on the opposite bench, while the Canadian nurse went back to the front seat.

In the car, she was lying silently, asking only “are we there yet?” in Kiluba. I was deeply, deeply sorry for not carrying around my obstetrics textbook at all times. The contractions barely extracted a wince from her face. We had pulled gloves, a dressing tray of three basic surgical instruments, and a few rolls of gauze kling: the only relevant stuff available from the mobile clinic equipment. All of us sweating buckets in the car.

At thirty minutes, I examined her and tried to convince myself that she hadn’t progressed – but she had. Still all caput though: the head felt so tight in that canal, I could not feel the skull. Sweat started pouring down my back. The last delivery I ran was in February up North, and it was an easy one, with expeditious labour – a small baby and a large birth canal. If anything, this was the opposite. But after a few contractions, the head started moving down and the caput was slowly crowning. The nurse went “Euh Docteur, je crois que ça y est!”. He was right. I yelled to the driver to stop the car. Still incredulous, I held the scissors and was contemplating an episiotomy à froid. But then I was too terrified to go through with it. I thought sheepishly: “People who actually know what they’re doing will deal with the tear when we get back to Shamwana. I just can’t do this, I just can’t, it’s been too long. “

Resisting the head so that it would not be pushed out too quickly, I helped it out gently during the next four contractions, praying that the tear would be fixable. The nurse was assisting me by giving constant uterine pressure. The head took forever to come out, an elongated, eggplant-shaped ball of humid black hair. Occiput anterior, face downwards, thank God. No cord around the neck. The baby restituted quickly to my right and was out before I could take the next breath. Loads of baby poo in the amniotic fluid, both the pea soup and the dark green kinds. A few squeaks from a blue baby boy, but not much else. We clamped the cord with the only hemostat from the dressing tray, then tied the rest with torn gauze, then cut it. The kid still wasn’t breathing much... No oxygen, no suction, not even a rubber pear – we’re in the middle of the road in the Congolese bush after all. Sweating buckets. Too bad; it came as a reflex, the old school thing that I’d never done before but had seen on TV: I grabbed the limp baby by the feet, head down, and then administered a few solid slaps on his back. And it worked! He spat out green meconium onto the beige khakis of the Canadian nurse who had come to help from the front seat. Finally, he let out a good scream and pinked up. The newborn scream is a familiar sound to me by now; yet, every time, it still is the best sound ever! I could feel the relief evaporate from my body while I was wrapping the baby in one of the mother’s two pagnes. Off we drove, back to Shamwana. The umbilical cord was still dangling between mommy’s legs, but hey, I’m of the ‘scoop and run’ school and I thought that it was best to bring her back to the appropriate facility as soon as possible.

Fifteen minutes later, on our arrival to Shamwana, the pilot and the FinCo from Lubumbashi happened to be visiting the hospital grounds. Apparently they got quite the scene: the national nurse and I drenched in sweat, hair matted on our foreheads, meconium stains on the expat nurse, all of us with bloody gloves, and a woman barely covered by her pagne being ushered away to the maternity on a stretcher. A delirious smile was plastered on my face while I was holding Baby Conehead like a trophy. The bench and the floor of the Land Cruiser T-32 were stained with a mix of poo, urine, meconium, amniotic fluid and blood. Quite the scene, I must say. Unfortunately we were too rushed to take a picture. But our visitors certainly got quite the glimpse of the true MSF Congolese deep bush experience...

The new, experienced midwife examined the baby and reassured me that it had been a difficult labour, that the baby was occiput posterior (sunny side up) from the position of the cephalhematoma and somehow, he rotated along the way, either on the bike ride or during the car transport. I am incredibly thankful that the outcome was good. There were many opportunities where everything could have gone wrong – we had no equipment at all to deal with any complications. But her delivering in the car was still better than in that dark hut in Beela on a dust floor. We are joking that while we are waiting for the ventouse to arrive, we should simply attach all our ladies in difficult labour on a bike and ride around town for the babies to rotate: it might save a few caesarians... And mommy didn’t tear at all, in the end, except for the very small nick that I inflicted before deciding not to go forward with the episiotomy.

Congolese women are so accustomed to a high neonatal mortality rate that babies born at the hospital do not have a name until they leave. So for now we are referring to this little one as Bébé T-Trente-Deux, referring to the car where he decided to be born. He only weighs 2.5 kg, but then again, Mom is no taller than 4 foot 3.

Now I am afraid to see what else MSF has in store for me... what’s next, a cricoidectomy with my Leatherman on the road?


Bébé T-Trente-Deux aka Conehead, happily breastfeeding, a few moments after arriving in Shamwana. I am still tachycardic on this picture.

Of human resilience, again

This week flew by much faster than last week. The routine is settling in. I now look forward to the week-end movies that we play for the national staff. We’ve also instituted poker: I just hope that the saying ‘unlucky at poker, lucky in love’ excuses my very poor game so far!

The ‘real’ MSF experience is trickling in slowly. Most days consist on rounding on a shrinking ward: 16 patients now, down from the 29 inherited. My bipolar karma is behaving - ah, but just wait till all hell breaks loose. We had an exciting case earlier this week. The expat midwife and the outreach team went to Kisele, one of our villages, to do some health assessments. They found a woman actively seizing while in labour, kept in a hut for the last eight hours or so. So we organized a ‘kiss’, that is, one Land Cruiser leaving from Shamwana with medical supplies whilst the other car was driving back from Kisele. We met halfway through. The patient was unconscious. Her firstborn baby was lifeless and stuck in the birth canal. This is the Congo: no oxygen tank, let alone an ambu-bag so all we had was... an oral airway. We transferred her into our car and injected her with some intravenous magnesium sulphate. I was picturing the same scenario back home, on an airplane med-evac up North, and was ridiculously praying for an endotracheal tube, a laryngoscope, an IV pump, a monitor and an oxygen tank to magically appear. A long hour on the bumpy road punctuated by two stops while she was seizing: diazepam pushed in. Finally, we got back to the hospital. In the delivery room, our excellent Congolese doctor extracted the fetus with a ventouse. I treated her eclamptic hypertension, seizures and fever. The midwife thought that she wouldn’t make it. I replied: “You’d be surprised, she is young, humans are resilient.” I thought, if she survives the first day, she’ll be out of the woods. We continued aggressive fluid resuscitation, antibiotics and magnesium sulphate. The diligent nurses watched her closely, checking her vitals every hour. Two more convulsions overnight. No labs so no need to treat her likely numerous metabolic abnormalities - I am fairly sure that she has a touch of rhabdomyolysis. Four days later, this morning, she is talking and requesting food. She did make it. I can only imagine, had we had a case like that back home, what a commotion... The whole hospital would know about it, all the services would be consulted, the residents would talk about it at lunch, rounds and case presentations would be held about her.

The lady with the Bible uterus will be discharged this week-end. She is now making jokes with us at rounds and is walking around the hospital helping out the other patients. Apolline left for Lubumbashi; we hope that she comes back looking like a supermodel.

On the ward, there are three babies (a pair of twins and a singleton who lost his other twin) about a month of age and under 1.5 kg of weight. They play tricks on us, gaining weight one day and losing the next, playful one day and listless the next. It’s the yoyo of life. I’ve elected to treat them for their mild lethargy without any labs. I just couldn’t get myself to perform lumbar punctures on little patients the size of kittens – it would have been an academic consideration since the only result the cerebrospinal fluid would yield would be macroscopic, that is, using my eyes in plain daylight. They are back on the upgoing trend today. I hope that the antibiotics work their magic. And I can’t wait to have a functioning laboratory. And internet, and ice-cream, and sushi – might as well dream in Technicolor while I can :).

The main tent, pardon, ward.


Kitten-size singleton and his mommy


The future operation theater and bricks being laid for the next medical ward.

Of human resilience part 1

Short of pictures for now, I will recount some medical extraordinaroddities as well as some unfortunate stories. This post is meant for the clinically curious so I apologize in advance for the medical jargon.

There is a baby in our maternity ward called Kalobwa. She was born at term at a minuscule 900 grams, her mother passing away. The nurses wrapped her in aluminum foil and syringed formula in her tiny mouth; they all prayed that she be comfortable no matter the outcome. She had to be passed from caretaker to caretaker; after an initial weight gain, she started withdrawing, losing weight and waning away. Then, her father's second wife gave birth to a full size term baby and decided to breastfeed both babies, Kalobwa first in line. She was encouraged to hold Kalobwa skin to skin. With newly found motherly love, Kalobwa started thriving. She is now a whopping four months old and is doing well. We do expect that she will be stunted for life. But for a maternity ward consisting of gym mats with no electricity, let alone incubators, umbilical lines or neonatal respirators - not a bad outcome. Surely, it tells of motherly love.

Baby Kalobwa happily feeding



Because of malnutrition and precocious first pregnancies, obstetrical catastrophes are common. Women here tend to want to deliver at home. They have the habit of initiating labour voluntarily by suddenly fasting or by ingesting indigenous plants called kapilou, kakelou , or samakagna, with disastrous results: it is dangerous to start labour on a closed cervix. Last week-end, a woman presented to the hospital after 36 hours of labour. An aunt had improvised herself midwife and had kept her home for the first night of labour. Upon exam, the baby was dead, the cervix was torn away from the inside, and the uterus was ruptured. My colleague the Congolese doctor performed an emergency hysterectomy; he referred to her uterus as "being open like a Bible". We do not have a blood bank and cannot even crossmatch relatives. Well, a week later now, she is still alive. Her palpebral conjunctivae are white - correlating with an abysmal hemoglobin that would be deemed "incompatible with life" back home. She is somewhat healing in spite of eating mostly fufu. There is probably an infectious process happening, so she isn't quite out of trouble yet.

Apolline is a fifteen year-old child who fell into a fire. Three quarters of her head were burnt to the third degree, along with her right arm from the shoulder to mid-forearm. A total of close to 15% of body surface area burnt to third degree and deeper, for the clinically precise. She was brought to the hospital a week after the event, only after indigenous treatments failed. Since then, with simple Dakin's solution dressings, flesh has slowly started to grow. It has been three months now and the wounds are looking clean, although the greater part of her right triceps is gone. We are trying to send her down to Lubumbashi for grafts and contracture correction, but it may not happen at all - she may just remain scarred for life.

The law of series dictates that rare diagnoses do not present singularly. Within the same week, we received two young adult patients with polyuria, polydipsia, acute weight loss and unending hunger. Lab tests are not available in Shamwana; but the urine dipsticks were off the chart for glucose and ketones. Unfortunately, type 1 diabetics are left to their own devices here in the Congo, because insulin is unavailable - it requires a cold chain (a fridge and power for it) and is simply unaffordable. I have no idea how long a newly diagnosed type 1 diabetic can live without insulin. It seems longer than a week as they are both still alive, although one went bradycardic and asthénique last night - he is fading away. I can only offer them the services of the... psychosocial team and the local priest. Back home, type 1 diabetes is a manageable disease, not a death sentence.