ER

I am starting to really like the emergency room at Kudjip. At first I felt intimidated every time I went there. Now I feel a little at home.

There are 6 ER beds, each separated by about a foot of space and (If the situation demands) a curtain. There are usually one or two patients standing around or sitting on stools waiting to be seen in various corners of the room as well. The supplies in the emergency room remind me a little of our trip to Haiti ... things you need for cleaning wounds, reducing, suturing, splinting fractures, IV fluids (though we are currently experiencing a shortage - did you know you can make normal saline by injecting 30mL of 23.5% saline in 1 liter of fluid?)

The presentations to the ER are usually more acute than those in the OPD. I've mentioned that I have trouble seeing patients with chronic conditions with very little command of the language. I still have trouble in the ER, but not as much so. Abscesses, broken bones, necrotic wounds, pulmonary edema, asthma exacerbations - they are fairly easy to diagnose without a lot of dialogue. The times I struggle are the times that someone comes with something I'm very unfamiliar with (TB, Typhoid Fever, Malaria and the like). But today was filled with infection.

A young man came to the ER today with an infected wound on his foot. Last week he was running from the police (I don't know why) and a bullet grazed his foot. He got a shot of penicillin from the local health center, but got worse. I put him to sleep with my fast favorite Ketamine/Valium combination and cleaned out the infection threatening to leave him without a right foot. This story was repeated ad nauseum during the day.

One patient stood out to me this morning though. A lady roughly in her 60's has been in our hospital for a few days now because she had a tracheostomy (breathing tube placed in the neck) at Hagen Hospital last week that fell out at home. This was done because she had a tumor in her voicebox, but the family wasn't sure about whether they wanted to have the cancer removed or not. The visiting ENT specialist placed a tracheostomy and told them to come back in 2 weeks with their decision. At Kudjip, we've replaced the current tube with one a little easier for the family to manage. In reviewing this patient's records and talking to her, it appears that her feelings regarding the decision about her cancer have been largely unsought. In a way, now that her voice is gone, she has very little input into anything that happens with her. I find this a problem that exists at home but greatly magnified here.

I saw a man yesterday about 70 who had pancreatic cancer and looked like he would not live more than a few months. I mentioned treatment to keep him comfortable, but his family said that he didn't know about his illness and they didn't want to tell him. I'm amazed that someone they care about could face the end of their life and they would want to keep it a secret. I'm pretty sure, and told them, that he would be able to figure out soon enough he wasn't getting better. His options, medically, are limited. He is an elder in his pentecostal church, though, and the family is praying for a miracle. I've seen a miracle in this very situation, and told them as much. It makes me very sad, though, to think that they will pray for his healing without letting him know that it will take a miracle for him to recover.

But life in general, I feel, gets treated very differently here. There doesn't seem to be as much value to a person's life while they are with us, yet culturally there are enormous obligations on family to express grief and mourning when they pass away. This is a "house-cry" which goes on for days after someone dies and relatives do not eat, sleep or drink but mourn vigorously. (One girl in the ER fainted twice at a house cry and was severely dehydrated today). I'm told that there is some animist influence to this tradition - but having recently lost a relative, I wonder if we don't fall into that tendency at home also. We are filled with remorse and regret when we lose a loved one, but we often don't have the same degree of affection while they are with us. I'm reminded of Jesus referring to his own disciples. He says that they are to celebrate with Him while He is there in the flesh because their mourning will be difficult after He departs. I wonder if I celebrate those around me as much as I would if I knew that I may not have them to see again in this life.

Tomorrow I go back to the medical ward, but will transition to Pediatrics next week and try to be more involved in Obstetrical care after Dr. Scott (our visiting OB/Gyn from the States) heads home. I'm still scared of sick children in this environment but very much looking forward to having more exposure to obstetrical care here.