Yesterday evening was the official end of my first week in pediatrics at L'Hopital d'Albert Schweitzer in Lambarene, Gabon. I spent Monday, Tuesday and Friday in the Pediatrie (the pediatric hospital) and Wednesday and Thursday working with the Protection Maternelle Infant (PMI) out in the jungle.
I arrive at the Pediatrie at 7:30 every morning dressed in scrubs, a stethoscope hanging around my neck. I greet S.P., the charge nurse, and M.R., the nurse who rounds with us. We push a large cart that holds all patient charts and any lab request slips we might need, as well as our bottle of hand sanitizer. The Pediatrie itself is one long hallway with white tiled walls, white linoleum floors and 24 inpatient rooms on either side.
The first thing that strikes me when I enter the Pediatrie in the mornings is the heat. I would definitely be embarrassed if I had sweat dripping from my face on rounds in the U.S., but here I make no apologies for the fact that I am already perspiring by the time we make it to the second patient room. It almost feels hotter inside the Pedatrie than it does outside, and yet the native Africans working in this hospital (which means everyone except me and one German pediatrician) don't even seem to notice. Furthermore, I have noted on more than one occasion that while they are all wearing more layers than I am, none of them appears to even break a sweat. The two rooms containing the three functioning incubators we have available to us are, ironically, air conditioned; Suffice it to say that I love visiting these patients. However, I still haven't quite worked out in my head how it is possible that the ambient air in the hospital is not already at the perfectly steamy 37 C necessary for those premature babies. My only consolation at the end of the day is the Dr. Scholl's Odor Destroying Spray Powder that I had the extravagance to bring with me. Believe you me, at the end of the day, my scrubs are so sweaty that they go straight into the laundry, but my feet are dry and my shoes and socks smell fantastic.
The patient rooms are fairly small and each one contains three patient beds, one against each wall. Because the hospital requires that every patient have a guardian who cooks and cares for them here, it is not unusual to walk into a room and find that, in addition to the patient, there is also a parent, grandparent, and a few siblings. I am not only sometimes confused as to who the actual patient is, but also as to who the parent is. The guardians perform much of the work that U.S. nurses would normally do, which is actually not such a bad idea, as caring for one's family members is a very natural part of the social fabric in this country. However, imagine trying to ask an illiterate mother to record how much breastmilk she has fed her premature baby, and then to aspirate and record the residuals. Needless to say, this can be frustrating.
This is not the sterilized hospital environment I am used to, but I am not so confident we are doing any better at conquering germs in American hospitals, given the prevalence of hospital-acquired infections there. The first spinal tap I witnessed here this past week involved a premature baby and nothing more than a mask, gloves, a few cotton balls, some iodine, and a sterile needle. It was, however, the quickest LP I have ever seen, and it did make me wonder about that LP I did just last month, gowned up in completely sterile surgical garb, having just draped my patient with sterile covering and at least 7 towels; Yet another reason that this place is kind of making my head spin.
Each guardian here has a thermometer, and is required to take the patient's temperature at designated intervals, but we don't have much else available in the way of vital signs. The IV poles look a bit like something I have seen in movies that are based in the 1950's, with glass bottles of fluid hanging from their hooks. As far as I can tell, we don't have any way of measuring electrolytes, and I still can't quite figure out what the strategy is for giving IV fluids, though whatever it is it seems to be working.
I say "Bonjour" to all the patient's and guardians when we walk into the room. The adults greet me as if I am someone they should respect; They seem to think I am a physician, which appears to be an instantaneous measure of important status here. The children behave differently in our presence, depending on how old they are. Most of them are frightened into silence Dr. B, the Gabonese physician I work with, who they seem to view as a stern but friendly father figure. I, however, with my pale skin, blond hair, and bright green surgical scrubs, have an entirely different effect on these children. The infants old enough to have developed stranger anxiety are often immediately driven to tears, and seem to be inconsolable until I leave the room; The same is true for the younger toddlers. The older the children are, however, the more they cannot seem to stop staring. Even if I smile, they will often continue to stare, expressionless but curious, as if watching an animal in a zoo. I won't even get into what happens when I try to examine them, but it has quickly become obvious to me that some of these children have never seen a white person in their lives. I often find myself wishing I had stickers, balloons, pens, stamps, anything that could serve as a peace offering to a child; It is becoming clear that my smile and friendly demeanor will do nothing for me here.
There are many young mothers here, and I have even met several women with 8 or 9 other children at home. Breast-feeding is so normal that the women don't cover their breasts when we enter the room, and I have noticed that the breast seems to serve as a pacifier. Even among many of the toddlers I have seen, a fussy child immediately quiets once offered his mother's breast.
The diseases here are not only clinically new to me, but the exam findings can be unfamiliar as well; Virtually any dermatologic finding looks completely different in a black child than it does in a white one. Even body habitus here can throw me off sometimes, and I cannot say that I would have instantaneously diagnosed the child I saw the other day who had, among other things, a mixture of Kwashiorkor and Marasmus (both forms of malnutrition.) During my first week here, I have already seen at least 15 cases of sickle cell, including several inpatients with acute crises. In clinic yesterday, I met a woman with 5 children, 4 of whom have sickle cell (SS.) Dr. B tells me that most of the carrier parents he encounters separate after having just one or two children with sickle cell, to avoid the risk associated with continuing to roll the genetic dice. Malaria is so prevalent here that we test every inpatient, as well as any child who presents with a fever. One our inpatients this week was sweating so profusely that he had soaked through his bedsheets, only to return a malaria parasite level that was about 6 times what is considered to be severe.
And that is the debut of my work in the Pediatrie....More to come on my jungle village visits with the PMI!