Saturday, June 16, 2012

A Week at Kumuzu Central Hospital

We spent a morning in the Burkitt’s Lymphoma ward this week.  Burkitt’s lymphoma in Africa is quite different than in the US. In Africa, Burkitt’s mainly affects children and is thought to be a consequence of an interaction between Epstein-Barr Virus (EBV) and chronic malaria infection.  More research needs to be done into how and why this interaction develops into a B-cell tumor.  The doctor who we followed was an older British man (in his 70s?) who was the previous head of the department of pediatrics for 15 years.  He is incredibly humble and has a deep passion to help these kids.  Something that is really encouraging about Burkitt’s is that a great percentage of the kids will respond very well to chemotherapy and there is a significant cure rate.  Most of the kids present with huge tumors in the jaw, neck, abdomen, and occasionally in the brain/spinal cord.  In several months, the ex-department head will run out of money to fund this department, so I am thinking about fundraising.  I think that if people saw the desperate need for this pediatric cancer care, that we could generate some serious funding.  I think the annual budget for the department (including the two wonderful nurses, both named Mary, who have been working with these kids for over 15 years and the chemotherapeutic medicines) is about 12,000 USD.  This will be summer project #2.   I’m planning on bringing my camera with me to ward rounds on Monday.  If any of you have connections to the Leukemia Lymphoma Society or any other Pediatric Oncology Associations or big donors please let me know.  Hopefully I will be able to set something up in the next month.
Back in the OR, we have seen a large number of congenital anomalies.  It really made me appreciate the clinical correlation lectures we had during the anatomy block of first year.  The condition of imperforate anus (where the bowel does not have a proper connection to the anus and the child cannot defecate) is more common than I realized here.  I’m not sure if that is purely because we are at a tertiary care center here or if there is a certain condition like malnutrition during pregnancy that contributes to this defect.  I was able to scrub with the current head of the Surgery Department on a pediatric case and I was just in awe of the precision needed for pediatric surgeries.  I felt the same way about watching the surgeon who operates on burn patients.  Burns are a huge problem here, as many children are burned around large fires that are used for warmth and cooking.  Watching the surgeon harvest tissue from the thigh of a young girl whose entire back was burned when her clothing caught on fire as she tried to stay warm was really discouraging.  There are special knives that are specifically used for harvesting skin grafts.  Unfortunately, the blades on these knives are supposed to be disposable, yet in this resource-poor country they must be sanitized and re-used again and again.  Harvesting skin with a dull knife is nearly impossible, and it wastes valuable tissue, since the skin gets mangled instead of getting a clean graft.  Put that on the list of things for me to find.
Yesterday, Dr. Shores’ first patient was a 3 year old who had swallowed a coin.  Doesn’t that make you feel like kids are exactly the same everywhere?  Luckily, the coin (10 kwatcha piece) was in the esophagus, not the trachea, so the kid was still able to breathe, which made the removal less emergent.  After about a half an hour wiggling with scopes and foreign object grabbers, Dr. Shores pulled out the coin and the whole room clapped.  The process is a little bit like a more controlled version of that arcade game where you try and grab the stuffed animal/prize with a claw.
It seems like it is the culture here (and in the US too, to a certain degree) to avoid discussing death with the patients and their families.  One morning this week we saw an elderly woman with a malignant tumor on her chin who is not a candidate for surgery.  Dr. Shores wanted to send her to the palliative care team, who would administer pain killers and send her home to be with her family, since the hospital cannot offer her further treatment.  I cannot tell you with certainty if this happened or not.  This came up as an issue in the Surgery Department morning report too, as patients are dying in the hospital alone, instead of dying at home surrounded by family.  I think as doctors we may be afraid to say that there is nothing else that we can do for someone treatment wise- that we feel defeated.   It’s part of our type-A personalities, to continue pushing until the end.  But this may be the wrong approach.  We have the ability to empower people through their process of dying, letting them be in less pain and with their families. 
When you walk through the hospital you see so many family members, mostly women, bringing food and supplies to their hospitalized loved ones.  Women come with giant containers of food balanced on their heads, as well as clean clothes and chitenje.  The hospital is a constant flow of colors and patterns and smells moving through the hallways.  In the wards, family members stay with their loved ones, often sleeping on the floor next to their cots.  The wards are so full here, it is such a distinct contrast to the private rooms we expect in the states.  The open wards are divided into smaller waist-high walled sections with about eight beds in each sections.  There are probably ten sections in each ward.  I will try and post pictures of this on Monday. 
Even with all of the issues I wrote about, I am so happy to be here.  The people in the hospital (and everywhere) have been very kind to me.  The surgeons have been great teachers, and I love talking to the residents and the clinical officer students about their training and what they want to do when they are done with their training.  Some clinical officer students asked for my name yesterday so we could be friends on Facebook!
This weekend we are going to go exploring a little bit, maybe with a trip to the south or the lake (Lake Malawi). I also want to go to the market again and pick up some more chitenje to take home.  Tonight we are going to a Malawian casino for a celebratory outing for Brian, a medical student from Vandy who has spent the past year here and is returning home.  I will have my camera on me this weekend, so there are more pictures to come.

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