February 4, 2014
After a long weekend completely disconnected from any electronics, medicine or really any signs of normal life while in Kruger Park, we finally started our medicine rotation at Maputo General Hospital. And as most days in residency, it started with coffee, albeit instant and lukewarm, and morning report. Only this time, it was in Portuguese and presented by medical students, critiqued by an attending and visiting American residents. I guess I expected cool infectious disease cases but the medical students presented on Wernicke’s encephalopathy then on Cryptococcal meningitis in an HIV patient. While it was difficult to understand as my Portuguese isn’t quite up to speed, I got the gist of it. And like most programs, people don’t like to participate in morning report, especially after a long holiday.
From there, we donned our N95s and made our way to the medicine wards. The heat and smells upon entering are overwhelming. With my whole body overheating under my heavy white coat in a 95 degree room with stagnant air, I feel as if every sense is heightened. The sights of patients everywhere is a bit jarring. They are all over the place, naked, coughing, cachetic, some moaning, some barely moving. The stench of sweat from hardwork out in the sun mixed with piss, feces, rubbing alcohol and freshly mopped floors seems to stick on my own sweat-dampened N95. I’m reluctant to change it since I’m trying to save as many as possible for residents who don’t have any.
A few months ago, the residents went on strike against the Ministry of Health for lack of pay, and poor resources, namely not providing masks or prevent against tuberculosis. Two residents this year succumbed to TB because of this. The result was the dismissal of all residents and forced retirement of the most experienced, near tenured faculty who were in support. Currently, some residents and essentially sub-interns were still coming to work without pay or credit so as to continue running the hospital, but most disappeared to earn money working in private hospitals in clinics in afternoon. It’s a shocking situation that we were not aware of coming to this country.
I am able to sneak into rounds and see patients with some helpful translation. 44 yo male with PMhx of HIV (unclear when diagnosed, not on meds), TB and malaria here with altered mental status…29 yo male with HIV (unclear when diagnosed, not on meds), TB admitted with shortness of breath and found to have karposi’s pneumonitis…. 32 yo male with HIV (unclear when diagnosed, not on meds), TB, malaria admitted with acute kidney failure likely from malaria nephritis. Malaria, TB and HIV, a trifecta that is plaguing an entire hospital, let alone an entire country and continent. There are limited antivirals available. There are no heroic measures in the future. HIV patients are not allowed in ICU except for a few rare exceptions. Dialysis is restricted to conditions that are acute and possibly curable. There are no chronic dialysis patients here. There is no chronic vent unit here, few even make it to be intubated. There is a crash cart that for the most part doesn’t really get used and contains digoxin, Hydralazine, epinephrine and BP cuffs. CPR isn’t something people come running rapidly for.
My first moments on the wards are beyond eye-opening. It feels more like a slap in the face or as if someone is violently shaking you from a deep sleep. Wake up from your American doldrums, people are really suffering here.
At 5 am, our trusty driver, Nelson, picked us up for a grand tour of Kruger Park in South Africa. Going outside Maputo for the first time by road was refreshing up until the border. The roads just outside the city were much cleaner and in far better condition. We arrived at the Mozambican border in the middle of what can best be described as a huge clusterfu-k. Thankfully, Nelson, having been touring this area between countries for the past 15 years expedited the confusing queues and we were out in good time. Of course, only to join the next border traffic into South Africa.
We passed through Komati where we would eventually sleep the night at a nearby by self-catering B& B. Mozambicans were all over stockpiling fruits and vegetables only to take over the border to sell at higher prices on the street. South Africa is much cheaper than Mozambique’s oddly expensive produce and food.
After another border wait, we finally arrived in Kruger Park at 9 am. 3.5 mil hectares of pure, unadulterated nature. Excitedly, we drove at snail’s pace around the park for hours oohing and awwing and attempting to photograph all the animals. How surreal it is to see these “zoo” animals in their natural habitat. It’s odd that they are just walking around going about their business, monkeys are monkeying around, impalas are playing and racing, and elephants just stuffing their faces all day with grass and amorula (a green fruit in season this time of the year that elephants gorge themselves on til they’re drunk). In the first day, we saw hundreds of impala (which oddly became less exciting), giraffes, zebras, elephants, ostrich, buffalo, mischievious monkeys and baboons. We had a grand assortment of strange and beautiful birds, and of course scarier ones like vultures feasting on carcasses. Scanning the bush all day becomes exhausting, so we ended up taking car naps throughout the way. I already have enough of a hard time on my regular habitat staying awake in moving cars so this was also difficult even with all the animals.
After two lion-less days, we went on a night safari a last ditch effort to hit the reaming bug 5. There we saw the night animals come alive with night seafowlers, lions, rabbits, porcupines,amd jackals. Two brotherly lions rested in the middle of the road protecting there territory. They hung out and posed for pics for night safarians to photograph. At night we slept at Satara rest camp on the north end of the park, known for its awesome nearby game. For me I didn’t look out the window of our little hut at night, since I was exhausted and the loud, indiscernible but frightening animal sounds were enough. Kruger park is such a wonderful, amazing place. I don’t think I can ever lock at zoo animal every day .
Driving through after 3 days of disconnection from worldly ties for 3 days, I felt very much at peace. Admittedly I’m addicted to checking email, internet, social media, etc and it was nice to just turn everything off and just watch the world around me. I had always dreamed of being here someday and feel very lucky and blessed in this trip. And damn what a beautiful view of the world. .
Jan 31, 2014 day 1 Maputo
We woke up after restless sleep to the sounds of tropical rain. Still there’s no water but we decided to wait for the housekeeper to help us. I wrote up a quick note in broken present tense only Portuguese, “Por favor nos ajude. Não temos água em pias ou banheiro! Temos sede!” Essentially, this meant, “Please help us. We don’t have water in sinks or bathroom! We are thirsty!”
At 715 am, Gloria arrived and magically turned on the water which lasted maybe a few drops. Neither of us showered since are bags are still lost somewhere between Senegal and here.
With one small victory of limited water coming from faucet, we ventured out to meet the UCSD residents that are wrapping up their rotation in time for us to start. We google mapped our way on a 30 min walk to the hospital and our first impressions of Maputo in the daytime. It’s filthy here. Between the diesel pollution and garbage, the city pulses with dirt. It’s in the middle of building infrastructure that perhaps hasn’t seen much growth or investment since the 60s or 70s. It’s mostly younger males walking around on the streets in the morning, less so females. But it’s 730 am.
It’s overcast here today and the coolest we probably will ever see after the rains overnight. The UCSD residents led us into the hospital and hand us N95 masks as ours were left behind in lost luggage. They told us how they had brought so many but then started only using one each every day so they could share more with the medical students who all wear regular masks that don’t protect from TB. In the US, we toss away our masks without even thinking about it.
We were to continue an ongoing project looking at HIV in Maputo. According to the residents by anecdotal evidence, it seems that the HIV rate in the hospital is somewhere around 50%. The project is looking at cd4 counts on admission. The residents warned us to not react in a shocked way when things are in fact shocking, such as the poor treatment options for HIV, or the lack of antibiotics. They told us of the many cases of infective endocarditis that occasionally get blood cultures drawn, only to keep treating with antibiotics that aren’t even susceptible since that’s really all they have. “Try not to look too shocked,” he kept telling us. “Help out where you can.”
On our first tour, the wards are open air wards with 6-8 beds per room with thin mattresses on a basic metal frame, sometimes more with just mattresses on the floor. There’s no such thing as isolation and some rooms have alcohol-water in bottles to “wash” your hands. Patients are just laying there, some motionless and awake staring off into nothing. I’m not sure what they are there for. They aren’t hooked up IVs or medications. People just seem to be on mattresses resting.
A cursory look at the paper charts show some documentation and a mix of basic labs.
After a quick tour of the area around the city, we parted ways with the residents and moved on to find somewhere to eat and shop for groceries. Tired and overwhelmed we settled on a small cafe near the hospital. I knew this would be an experience but this seems so unimaginable. Just a quick tour of the hospital and I’m already overwhelmed.
We have a three day weekend before we really start our work at Maputo General due to the Mozambican Heroes’ Day holiday. We are headed off to Kruger Park in South Africa on safari.
Of course this trip would naturally start with a rapid response on the plane. I was getting settled into my inflight movie, when I heard and felt a large thump. Something big hit the ground. It sounded like a cabinet fell down or perhaps one of the rolling carts carrying indigestible meals keeled over. Then I quickly realized it was a man who had fainted.
The movie paused and a sweet South African woman called overhead, “Is there a doctor on the plane?”
A traveling internist from South Africa, Rosa (a co-resident/travel partner on this African journey) and I (lowly second year resident) hustled over to assess this man. He was barely responsive with a thready pulse. From what we could gather, he felt dizzy and fainted as he tried to get up to use the bathroom. The airlines refused to open the medical first aid kit unless “it’s something serious” since apparently it’s a single use doctor bag and someone else more serious may need it. “Rules are rules, “they kept telling us. So no BP cuff, no finger sticks and a brief H&P. A one-liner in my head…A 60-ish year old South African male with PMHx of HTN and DM2 (not on insulin) presents with a syncopal episode while trying to rise from a seated position.
He felt lightheaded and nauseated on the plane but wasn’t sure if he lost consciousness. He didn’t have chest pain or SOB, but the airline placed oxygen on him on blast as part of their protocols. He was clammy, thready pulses but seemingly regular. Worried he was hypoglycemic, like most of us who barely ate our airplane dinners, we offered juice and gave him some fluids to help bring what we supposed was low BP. Luckily, I came well-prepared for this trip stocked with a small, adequate pharmacy and my stethoscope. He chewed up an aspirin as he mentioned he forgot to take one in the morning. And later we gave him zofran for nausea.
Eventually, he began to feel better and his pulses improved. He went back to seat and a few hours later he was pacing about the cabin like nothing ever happened, stopping by our seats to thank us over and over again. For a moment, I thought that we should be filling out an RRT sticker at the end.
First 12 hours of this trip, we haven’t even reached our destination and we already are in the thick of things. This really is a pretty awesome profession.
I will be writing from Mozambique for the next three weeks on an international elective.
Vaccinations are one of the of most incredible aspects of modern medicine. They can make previously lethal diseases disappear from society and save countless lives. There is, however, a chance that the vaccines work a little too well and our collective memory is too short to remember the devastating effects some of these diseases caused just a few short decades ago. Recently, for reasons that are not based on science or logic, many parents have outspokenly rejected vaccinating their children. Unfortunately, this has caused a reemergence of easily managed diseases. The Council on Foreign Relations has released an interactive map detailing the catastrophic outcome of these poor choices.
The interactive map gives a gut-wrenching tour of global outbreaks of measles, mumps, rubella, polio, and whooping cough from 2008-2014. These diseases — all of which are easily prevented by vaccines — can have dire consequences. The CDC estimates that 164,000 people around the world will die from measles each year, and it is experiencing quite a resurgence in the UK. The United States has recently seen a drastic increase in whooping cough, which causes around 195,000 deaths per year. The majority of these deaths occur in impoverished regions with very little access to vaccines. In the case of developed areas like the US or UK, they shouldn’t be happening at all.