Thursday, May 28, 2009

Out Into the Jungle

Well, my apologies. Girl in Africa has not had much time to post on her blog in the past few weeks. But that only means more stories!

I promised to talk about the PMI, and oh, do I have stories about the PMI. I have to say, however, that one thing that is kind of fascinating about my time in Africa is that the things that seemed so alien to me about this place when I first got here now seem halfway normal. I am..... ADJUSTING. Gasp.

Two days a week, I work with the Protection Maternelle Infantile (PMI.) This is a public health program here at the hospital, staffed by nurses, which aims to provide basic medical services to women and children. The ladies of the PMI and I travel to surrounding villages where we weigh children to chart their growth, update their vaccinations, examine pregnant women and any sick children, and prescribe any necessary medications.

Every Wednesday and Thursday, we "part en brousse", an expression I really appreciate because it literally translates as "go out into the jungle." It kind of makes it sound like we're hacking our way through the underbrush with machetes in order to save women and children. Not quite, but a little bit.

I did not realize initially that medical students typically wait until they have been here for a few weeks before going out on trips with the PMI. I was also unaware that the doctor who goes with them no longer works here. So please, picture little pale, blonde me, in this insanely hot climate to which I am completely unaccustomed, out in a village in the middle of the jungle, chickens clucking right beside me, fielding visits with 15 sick children in one afternoon. That pretty much sums up my first week with the PMI.

I arrive at the PMI office in the mornings around 8 or 8:30, which is when they tell me I'm supposed to arrive, and then we wait until 9 or 9:30 for the truck to come pick us up, because this is Gabon and time is fluid. The nurses in the PMI....How can I describe them? I LOVE them. Maman Sophie is the head nurse, and she is this wonderful mixture of motherly warmth and I-do-not-take-crap-from-anyone-ness. Marie-Benoitte never smiles, rarely looks at me, and is all business, but then when she says "How did the day go for you, Elizabeth?" I pretty much melt, because, well, that's the best you're gonna get from Marie-Benoitte. I have more or less made it my mission to crack her, and it seems to be going well. Hortense is 34 years-old, with 7 children, and giggles a lot. Filomene also seems young and though she smiles a good deal she is also quite reserved with her physical affection, which is why I was pleasantly surprised when she more or less chest-bumped me yesterday morning upon my arrival at the office. My favorite thing about these women is that, even though half the time I spend with them they are completely lost in their own conversations and I don't always follow what they're saying, they periodically say my name and then laugh hysterically. This happens at random, during lulls in the conversation, and when they say it, it sounds like, "AY-leez-ah-BETT"! I translate this as, "You crazy little pale, blonde American who sweats a ton and tires out really easily, we love you anyway!"

When the the driver finally decides to bring the van over to the PMI office, we get started loading things in. If I can ever get a decent enough internet connection to load photos, I will have to post a picture of the equipment we bring along with us, because it is fantastic; An amalgam of old, weathered medicine trunks with little metal handles, nearly all of which are falling off, some large tin boxes which also look like they came out of World War II (both the era, and the war) and, quite randomly, what appears to be a giant toolbox on wheels. Once all is loaded into the truck, we take off on a ride that feels very....Outdoorsy; I usually have the sense that I'm getting both sunburned and windburned in the van, and pretty much like I'm bumping up and down in a little red wagon, to quote that childhood song. I actually did come back with a sunburn from the van one day, which confirms that this is not just my imagination. I am getting to know the road into these villages pretty well now (there is really only one main road in all of Gabon, anyway.) We typically pass through miles of jungle, punctuated by wood huts with tin roofs, goats and chickens milling about in people's front yards, as well as children who mostly seem to run around in their underwear because it's so hot here that clothing is really just an accessory.

That incredibly bumpy, windy car ride always makes me feel somewhat sleepy (Mom, Dad, did you used to drive me around to get me to fall asleep or something?), but I always know when we've arrived because we drive through the entire village honking the horn to let all the women know that "we're here, and you need to bring your children over pronto."

The PMI carries out all its activities in the village "dispensaire", which seems to be a clinic of sorts. The dispensaire is virtually always one or two rooms made of concrete, with a table and a few chairs. Every now and then they have some supplies that look halfway decent, but usually not. Notably, I try not to have to go to the bathroom on these trips. More than once, I have found myself peeing behind a hut where I can only hope no one is watching, or into a hole in a concrete floor if I'm really lucky. Now, I'm not a snob, and I can assure you that I don't mind where my pee goes, but I do mind if some crazy jungle insect bites me in the butt. On the topic of jungle insects, these dispensaire buildings are home to some very large species of spiders. The other day, I spotted a large one moving so quickly across the wall that I couldn't even tell what it was. I turned to Maman Sophie and said, "What IS that?!" She just laughed and broke into a song about spiders.

Nzoghe-Bang: My first day with the PMI had me exhausted from being out in the heat, but we were in a village that is only 15 minutes from the hospital, so there wasn't much work to do. We weighed and vaccinated children, and Maman Sophie said something about there not being any consultations because most sick children in this village had easy access to our hospital. We lay out a table cloth at noon, ate the lunch we had brought with us in a giant cooler, and made it back to the hospital by 1 PM. I spent the rest of the afternoon hanging out on my balcony reading, and thought to myself, "I could really get used to this PMI thing."

Benguie-4: My second day with the PMI was in a village much farther from the hospital (roughly 30 miles.) After we have weighed most of the children, Maman Sophie suggests we start the consultations. I want to say, "But we have no doctor!" It turns out that the white chick with the stethoscope around her neck and the green scrubs is the doctor. Oh, shit, that's me. So, I start doing "consultations" with sick children, which involves me sitting in a chair in a corner of the dispensaire, facing a mother and child in a chair two inches away from me. I find myself praying before each patient comes that the complaint will be something I can manage. For the most part, this is the case in Benguie-4. And fortunately, Maman Sophie sits beside me that day, making sure I know what medications we have available and what doses we give. Also invaluable is her knowledge of the diseases that commonly plague children in this region. Yes, medicine is medicine wherever you go, but common things are also common, and you simply cannot just show up in some random part of the world and expect to know what maladies you need worry about the most. I can assure you, for instance, that we do not empirically treat every child in New Hampshire who presents with a fever for malaria.

I keep thinking we are going to be eating lunch soon, just like the day before, so I don't bother to eat the Clif Bar I had brought with me that day. The consultations just keep coming, one after the other, and I pretty much feel like I am withering. I drink nearly a liter of water and still feel weak and thirsty. My last consultation is a little 6 year-old boy who breaks my heart. His mother tells me he has developed a fever and cough 1 week prior. Then, out of left field, when I ask if he is peeing okay, she replies, "Oh, sure, he pees a lot. But he pees blood." A little taken aback that this wasn't the FIRST thing she wanted to mention to me, I ask how long this has been going on, and she replies, quite nonchalantly, "Oh, for about a month." So then I look at this boy, who has his head down and is staring at the floor, and I ask him if it hurts to pee. Without lifting his head, he raises his eyes and nods slowly. I am literally wanting to take him home with me, and I am also kind of wishing I could call Child Protective Services. Little do I realize, this is the kind of situation that is going to become commonplace for me here. I treat him for malaria, a UTI, AND schistosomiasis, because out here in the jungle, with virtually no diagnostic tools other than my stethoscope, I simply cannot know for sure what is plaguing him. I try to get the mother to bring him to the hospital, but she doesn't want to have to pay for the consultation fee there, so I give her a laundry list of things to look out for, followed by, "and if that happens, or this doesn't get better, you MUST. BRING. HIM. TO. THE. HOSPITAL." I then spend the next two days replaying the scene over and over in my head, wondering if I should have insisted, no demanded, that he come in, pouring over his symptom complex and asking myself if I had treated him for everything that could possibly kill or scar him.

We ate lunch at 4 PM that day, and rather than feeling satiated, as soon as I had finished I felt sick to my stomach, as if my body had worked so hard in the heat that it couldn't muster the strength required to digest my meal. I got home and went straight to bed, without dinner, at 6PM.

Ebel-Abanga: I am dreading Week 2 with the PMI. I am not only remembering how tired and nauseated I felt at the end of my last trip with them, but I am also dreading being the person making medical decisions about these children with no supervision, or at least with no follow-up. I hate not knowing if the treatment I prescribed for a child worked. I hate not knowing if a parent will really bring their child to the hospital if his condition deteriorates. I know that Ebel-Abanga is way farther from the hospital than Benguie-4, and I am worried that there will be even more consultations that there were last week; I am wondering if my body can actually handle that.

There is no actual dispensaire in Ebel Abanga. We weigh and vaccinate children in an outdoor hut. Maman Sophie sets up my consultation "office" in the sand underneath an adjacent tin roof overhang. We see pregnant women in the village chief's house next door. Maman Sophie has left me on my own today, which I feel is a measure of trust I have not yet actually earned.
Fortunately, the number of consultations that day is not unmanageable, but as the sun moves overhead in the sky, the shade above my imaginary office begins to disappear. I keep moving my chair closer to the side of the house, which means I am moving steadily up a sloping surface. My bottle of hand sanitizer keeps falling over into the sand, so that I am eventually cleaning my hands between patients with sandy alcohol. I also drop my pen repeatedly, to the point where it stops clicking open because the tip is clogged with sand. I am marveling at this entire scene as it is happening. Am I really HERE? Doing THIS?

All the while, I am doing what I have always vowed I would never ever do as a physician, prescribing antibiotics and other medications empirically because I feel that if I don't, worse things than the development of resistant bacterial strains may occur. I am still feeling the mild panic and loneliness of being in a chair in the sand making medical decisions not only all on my own, but also without any of the tests and equipment that could at least tell me whether or not I am on the right track. I have loaned my oto-opthalmoscope to the Pediatrie for the week, so I am peering into children's throats with my keychain flashlight. I have my stethscope, my eyes, my ears, and my hands, and that is pretty much it for my diagnostic tools.

After the pediatric consultations are done (there are about 10 total), Maman Sophie tells me she wants to teach me how to do pregnancy check-ups. We head next door into the village chief's house, which is a very basic structure that is plastered with posters of Omar Bongo, Gabon's only president for the past 40 years. We lay a plastic tablecloth on the dirty concrete floor, which will serve as our "exam table" for the pregnant women. The five women file into this makeshift exam room, and Maman Sophie outlines how the exam works. First, I will measure the fundal height (size of the uterus), then I will listen to the heartbeat, followed by a determination of the orientation of the baby's head if the woman is somewhat close to delivery. Finally, I will take a blood pressure. I am pretty excited about this heartbeat thing: "We have a Doppler machine?!" I am thinking.

Maman Sophie then completely takes off to do something else, so I start my exam. Only, I can't find the Doppler; All I can see is this wooden, trumpet-shaped thing sitting on the table. So, I actually have to ask my PATIENT if this is what I am supposed to be using to listen to her baby's heartbeat. She confirms that, yes, that wooden cone-thing is, in fact, what I will be using. The open-end of the cone goes against her belly, and the close end is sealed against my ear. I kneel on the floor and I get the cone in position, pressed against this poor woman's large, pregnant belly, the other end squished against my ear. I feel like I am playing telephone with a cup and some string. Remembering how much one has to search for a fetal heart tone, even with a Doppler, I start moving this cone around. To position it on the opposite side of this woman's belly, I have to basically suspend my entire body across hers, so that finally I am hanging over this very pregnant woman with a piece of equipment which I am trying VERY hard to take seriously, wiping sweat off my face with the sleeve of my scrub top. I leave the chief's house and yell for Maman Sophie. She comes in and tells me I have to press HARD with the wooden cone, so that the baby will start moving. I do this, and I periodically hear what I THINK sounds a bit like that far-off ocean sound you get when you hold a conch shell to your ear; It seems just as likely that I am creating this sound all on my own the harder I press the wooden cone to my ear. I look up at Maman Sophie and tell her that, as much as I would love to be able to tell her that I am hearing something, I really got nothin'. When I stand up from the floor, the baby is moving so much inside this woman's belly that it looks like that scene from the movie "Alien" where the alien is trying to break out of Signourney Weaver's stomach. I feel reassured that this baby's heart is beating, and I remind myself that I wouldn't be able to get the fetal heart rate anyway with that wooden cone, so knowing the fetus is moving will suffice. From that point on, during my PMI obstetric consultations, I periodically test out the wooden cone but finish by asking the patient if she can feel the baby moving inside her.

I have no appetite when we finally get around to eating lunch that day, and I still feel exhausted when we return from Ebel-Abanga, but I don't feel nauseated, so I take this as a sign of progress. On the way home, the nurses stop in the village to buy produce, and right there on the side of the road is a meat stand featuring an entire antelope, an alligator, two monkeys hanging from a pole, and the arm of a gorilla, hand still attached.

Bifoun, Tchad, etc, etc: I have now visited a total of 8 villages with the PMI. I am getting used to the crowd of young mothers with babies strapped to their backs and toddlers wandering around on their own. I now practically tune out the cries of "Mamans, Oye!" from the nurses giving the health lectures to the mothers, as well as the chorus of "Oye!" they shout in response; I am engrossed in the consultations.

I have seen more than one case of chicken pox, and diagnosed what I am virtually certain was a lobar pneumonia, using nothing but my stethoscope and my fingers; Yes, I actually PERCUSSED, something I'm not sure I have done since first-year of med school in On Doctoring, and also a skill I never thought I had mastered well enough for it to be useful.

I now know that I have to drink a can of Orangina or D'jino at exactly 11 AM if I plan to consult for a long period of time. I am adjusting to the fact that no matter how tired I am at the end of the day, I have to expect that we will stop multiple times on the way home so the nurses can buy bananas and manioc from vendors on the side of the road. I know that sometimes we will then stop again to drop these purchases off at the nurse's homes.

At the end of my third week with the PMI, I am leaving the office at the end of the day, and Hortense says to me, "We really want to thank you for the work you're doing here. Maman Sophie is so much less stressed out now that you are here doing consultations, and you are so quick and efficient." I more or less skip out of the PMI office that day. They like me! They trust me! I am HELPFUL! Then I think about her last comment, and I start second-guessing myself again. I am quick and efficient....Am I too quick? Too efficient? Have I missed anything? Ah, the torture of practicing medicine "en brousse." It really does feel like I am hacking my way through the jungle with a machete.


  1. Liz

    Please find a way to post pictures! It all sounds so amazing....and bizarre!! We miss you terribly and hope that you stay safe. Don't eat anything from the roadside cart!!


  2. Liz,
    This made me laugh just because I can picture it: This happens at random, during lulls in the conversation, and when they say it, it sounds like, "AY-leez-ah-BETT"! I translate this as, "You crazy little pale, blonde American who sweats a ton and tires out really easily, we love you anyway!"

    I think what you're are doing is absolutely amazing and I am so proud of you. I hope to see you soon after you return to the States!