Ugh.

This afternoon, for the first time in the nine weeks since we moved to Malawi, it rained.  It does not typically rain at all until November, so the sudden downpour was certainly a surprise.  It was cool and refreshing.

Today was hard.  I am in the wards again, and this time I am alone, except for the translator who assists me and a medical student who is visiting from University of Pennsylvania.  The first thing that I notice each day as I enter the hospital is the stench.  There is, truly, no other word for the smell.   It is the odor of urine and sweat, and it seems to hang in the air like a curtain that slaps you in the face as you enter the building.  The wards are overcrowded and chaotic.  There are no bed numbers or charts.  To find patients we shout their names, and if we have trouble or someone is missing, we often ask their neighbors.  Sometimes they have died, other times they have simply left; occasionally we never find out why they have disappeared.  The sinks are without soap, and are often crawling with insects, which can also be seen scurrying across the floor or climbing the walls next to the patients’ beds.  It is almost unbearably hot, and the children sweat as the mothers fan them with their chitenges (colorful clothes they use as skirts or to carry babies) to keep the ubiquitous flies from landing on their mouths and eyelids.   One nurse is often responsible for 50 to 100 patients, and there are no meals provided unless families bring them in.  The charts consist of paper records of the medicines ordered, on the back of which the clinical officers scribble their notes in no discernible order.  I do not know what is lost in the translation, but histories from patients are often very difficult to obtain, and it can feel like torture to stand in the purgatory of the ward, dripping in sweat and trying not to breathe through my nose, as I search through the masses of paper and repeatedly ask the same questions in order to figure out what has happened to the children to bring them in. 

My favorite part of pediatrics is the children.  I love to interact with them, comfort them when they are scared or sick, and play with them when they are well.  Perhaps because I do not look anything like the people familiar to them, or maybe because every time they see a Mazungu they are stuck with a needle, the children here do not like me.  When I was walking home from work the other day and passed a little toddler on the dusty street she actually screamed and hid in her mom’s skirts in terror when I smiled at her.  The kids on the ward cry each time I approach them, and are not placated by the toys or stickers I bring with me.  It is not only depressing, it makes examining them very difficult.

Once I have muddled through the history and tortured the child with a physical exam, I need to decide what on earth is going on with the patient.  There simply are no tools.  The X-ray machine is perennially out of reagents.  The only lab test that can reliably be ordered is a CBC (looking at white and red blood cells), which is not all that useful.  If I am able to come up with a diagnosis and want to give medications, it is usually the mother’s responsibility to try to get them from the pharmacy and give them to the child.  Most of these women do not have a primary school education, and none of them speak English.  Although I am always accompanied by a translator, for some reason much of what we spend time carefully explaining to the moms does not happen until we have asked and explained for several days in a row.  Especially compared to the moms I have worked with in the States, these women seem so passive to me.  I don’t know if they don’t understand how sick their children are, or if they do not have faith in the medicines that we are advocating for, but it is so frustrating to have worked so hard to come up with a plan only to find that nothing has changed when I come in the following day.  There is one girl on the ward who has a tumor in her bladder which is bleeding (it has been there for a long time, and I do not know why no surgery has been performed yet, but it is due to happen this week).  She came in with a hemoglobin of 2.2 (for non-medical people that is UNBELIEVABLY low).  She was transfused, but because she is still bleeding, it is now only 3.7, and she is pale and weak, with an elevated heart rate.  I wrote for a second transfusion, but when I came back to ask mom how she was I found out that it hadn’t happened.  In the US it would’ve been an EMERGENCY.  Here, it was ignored.  I had to plead with a passing clinical officer to help me to get it done, and I do not know if he was able to.  If she is not transfused, I do not think she will live to have her surgery in two days.   Another child came in with anemia and severe malnutrition.  He was transfused, but he was so weak that the blood put him into heart failure.  He needs nourishment.  I asked the nurse to start the refeeding program, but when I returned in the afternoon she told me she had been “too busy”, and that perhaps she would get to it tomorrow.  This child is emaciated and in obvious respiratory distress, and would be in intensive care in the US, but here he languishes without even getting nutrition.

I feel frustrated and tired and ineffective.  I do not know how to make the system better.  I do not know how to use the system that exists to help make these kids better.   I am tired, and I have only been here two months, and it is not even malaria season yet.  For the first time today, I wanted to go home.  I miss being in the ED at Moses Cone, where I had a team of excellent nurses who worked with me to provide compassionate care to children, and they usually got well. 

When I got home, the electricity was out.  Eamonn was in a tizzy because he has a "market" tomorrow at school, and he is responsible for baking 75 chocolate chip cookies to sell, which we obviously could not do without power.  So, filled with angst and frustration from the hospital, I switched to mama mode and we threw the dry ingredients together as I phoned friends to see if other parts of the city had power.  I then loaded all of the ingredients into the car and set out in our giant truck, only one windshield wiper working, the windshield opaque with fog, and tried to navigate the pitch-black streets across town.  On the way, as I narrowly avoided being hit in an intersection, Dave called to say that power had been restored and I returned home in time to bake several dozen cookies.  Tomorrow I go back to the ward to see who has survived the night.

At least it rained today.