DRC, Day 9: Back in Kinshasa

Today was a ridiculously long day.

                

Like every day, I went for my run in the morning, and then we had breakfast, etc before heading back up to Kitona. The only thing on the schedule was doing an outbrief of MAJ Lang’s public health findings before we headed back to Muanda to change and get ready for our flight. We ended up getting to BG Moustafa’s office before he did, so MAJ Lang and I decided to swing by the hospital and thank BG Amisi for his time as well. Unfortunately, we also got there before he did. He showed up a few minutes later, did an “inspection of the troops” (which I had never seen before, but involved a lot of medical officers standing around looking bored before he arrived). We had just enough time to thank him and whatnot, and then it was back to BG Moustafa’s office.

The doctors lined up for inspection

                

MAJ Lang did the outbrief, which included some good things he saw (not much) and then then top three “easy fixes” of his findings, which was to add faucets to the water pipes to keep them from running constantly and drain the pool to decrease the standing water (and thus, mosquito breeding sites); add water treatment to the water distribution (not really an easy fix, but still important); and fix spacing of latrines, trash, and kitchens in the recruit areas. I’m pretty sure none of these will actually happen, because BG Moustafa nodded and said that none of this was a surprise to him, and he had submitted it up to Kinshasa in the past, and nothing was ever changed.

MAJ Lang briefing BG Moustafa

                

In other words, he didn’t want to take responsibility for the problems.

                

After that, we headed back, changed, finished packing, and then headed to the airport to wait for our flight back to Kinshasa. LTC McCullough gave me a coin, which is kinda about time, since it was my third trip in working for him. Whatever. It was nice anyway.

                

The flight was uneventful, and then we were back in the O’Costelo for another two nights. The next large group of travelers (nine of them) was also there, in preparation for flying out to Muanda tomorrow, and the whole bunch of us went out for dinner. I probably should have stayed at the hotel and ordered a croquet monsieur (grilled cheese sandwich), because after a week in Muanda, I had forgotten how loud people can be, especially a group that large of people who were jetlagged (and therefore a little punch-drunk) and excited to be in the Congo. It was so ridiculously loud, and I just wanted to get out of there. My introvert alarms were all going off, and there was nothing I could do about it.

Shrimp

              

The shrimp was good, though.

                

The worst part was probably the civil affairs guys from USARAF, because they were acting like incredibly pretentious jerks all night, and sadly, that reminded me a lot of having to go back to work and deal with the pretentious jerks who make my life miserable there. I don’t know what it is about these civil affairs guys sometimes, but it just drove me crazy, and I wasn’t the only one. MAJ Lang was pretty frustrated by it, too, and when I told him that that was a little bit like what my life was like at Ft. Stewart, he said he understood why I’m so eager to be in the office as little as possible.

                

Ugh. Makes me really hope the job at USAMRIID at Ft. Detrick can be mine next year.

DRC, Day 8: Beach and Dinner Time

Ah, Sunday. Day of rest. Or something.

                

The day started early (0600, so not that early) with an attempt at a 10 mile run. The plan was to run on the road along the ocean, toward Banana, until I hit 5 miles, and then turn around and come back. Well, at around mile 2.6, we realized that the road was too washed out to continue, so we headed back and did a little bit along the airport, for a total run of 6 miles. The problem was, the 6 miles felt awful, much worse than I expected, which really goes to show how important it is to eat right and stay hydrated if you want to stay active, neither of which I’d been doing. Not enough water, not enough vegetables… I’m in for a world of hurt when I get back to the States.

                

After the poor attempt at a long run, we did some work on writing reports and whatnot before it was time to head to the New Cliffs, because Phillipe wanted to take us to his private beach and to eat some fish that he had caught. I thought this would be a quick trip, but I was wrong. The beach was almost an hour drive away, when you factor in the stops he made us make so he could point something out. Then we made it to his beach, hung out there for about 20 minutes, and then headed to the restaurant, where it was a two hour wait while they grilled up the fish and whatnot. The fish was delicious, as were the beers we consumed while waiting for it, but in all, we didn’t get back to the hotel until 7 pm (after leaving at 1).

Dinner being cooked

Playing after the dinner

                

Tomorrow’s going to be another short day. All we have on the agenda is out-briefing General Moustafa, and then we’re getting on the plane to take us back to Kinshasa. I can hardly wait to eat dinner in a real restaurant again, without having to deal with Phillipe and his cigarette smoke.

DRC, Day 7: The Weekend

Today was a day off of normal activities, so there’s really no much of anything to report. We woke up an hour later than usual and went on a 5+ mile walk around the “neighborhood” (instead of the usual run, because I’m planning on doing a long run tomorrow morning). Even though it was a walk, the walkers in the group are used to power walking, so it was a bit fast-paced for me. There was more than one instance when I was jogging a few steps to catch up.

                

After the walk, we worked on various reports and whatnot that we all had to do. I updated the paper I’m working on with the other members of the MEDRETE team back in June, including the information from my re-evaluation of the hospital this time around.

                

At 12, we were all supposed to go down to the New Cliffs restaurant for lunch (and an opportunity for faster internet), but the three guys from the embassy were still working on reports, so they sent MAJ Lang and I up ahead. Unfortunately, we ran into Phillipe, a really obnoxious Belgian-Congolese (white man born in the Congo) man who I don’t think does anyting but sit at the New Cliffs and drink. He took it upon himself to change our lunch order to clams, and while those were the smallest clams I had ever consumed, he also paid for lunch, so I guess I can’t fault him too much. At least, for that. For the other ridiculously stupid things that come out of his mouth, yes, I’ll fault him.

                

That was pretty much the day, culminating in returning to the New Cliffs at 6 for dinner and watching the sunset over the Atlantic. In all, it was a low-key, relaxing day with no obligations, which was nice in and of itself.  

DRC, Day 6: Going into the Weekend

Yay! It’s Friday! The last day before the weekend…in a town where there’s nothing to do… Oh, well.

                

We got an early start to the day to go to the women’s sensing session, which was actually pretty well attended, with about 43 female soldiers, officers, and police. It's a very civil affairs thing, and it was facilitated by a woman from Dyncorp, which is doing the civil military operations training during the exercise as well. She had the women go around the room and ask what they did in the FARDC (or police). There were quite a few nurses and nursing students, but a lot from the “regular army” as well. Then she asked the reasons for joining the military, which is pretty similar to why people join the military in the States—no money for education, hope to get training, want to serve/defend the country, etc. The last question was about what they hoped to get out of joining the military and what they still hoped to accomplish, and that opened up the floodgates. Almost universally, they said that the opportunities for the good training—English language training, computers, etc—was always given to the men, because they assume the women would mess it up. They said they aren’t treated as equals, there’s nobody to help with the childcare when they’re at work, nobody respects them, and on and one. They said it’s a problem with the leadership, that the views of women in the military come from the top down.

During the sensing session

After

                

This was confirmed when, after the sensing session when we were getting a picture, the general drove up, saw that the sensing session had already happened, and told me that I should work with the women to teach them how to be better soldiers, because they all think they’re there to “service the men.” I really didn’t know what to say, but it definitely made me believe the women who said that they get no respect from the leadership.

Talking to BG Moustafa

                

After we were done with that, we all headed to Banana Naval Base (where the Congo meets the Atlantic), to give the Navy doctors a chance to shake hands with the navy people (the navy that has no boats…), and then the Navy doctors hopped on the Kin-Avia flight back to Kinshasa, while MAJ Lang and I get to suffer through a weekend in Muanda with nothing to do. It’s really not fair, but I guess that’s life. What I’m really bummed out about is that I’ve now been to DRC three times, and I still haven’t seen the bonobos (apes that are only found in DRC; there’s a reserve about an hour outside Kinshasa). I’m sure they’ll find something for us to do in Muanda… or I’ll just take a lot of naps and do a lot of reading. One of those, I’m sure.

DRC, Day 5: Last Day at the Hospital

Today was, with any luck, my last day at Kitona Military Hospital. Hopefully forever.

                

The work day started with the pediatrics ward, where I did rounds with the doctors and nurses. Although their antibiotic selection seemed better than it was in June, they also had fewer patients, so it was hard to tell. Also, they’re still treating anything with fever as “malaria”, even if the malaria tests are negative, so that’s a little frustrating. I’m not sure what it’s going to take to change that practice. Probably getting to the doctors when they’re still in medical school. I’m sure that’s where they’re getting this information, that everything that looks like malaria clinically must be malaria.

Seeing a patient with Juvenile Rheumatoid Arthritis

                

They also had a five-year-old girl with Down Syndrome, and they kept asking me how we treat Down Syndrome in the States. They couldn’t understand when I said that there was no treatment. I think they couldn’t grasp that there was anything that we couldn’t treat or cure.

                

I was spared from having to stand in on a cesarean section by MAJ Lang, who came by to pick me to take to see the water distribution center for most of the base. It was actually off-base, and it was pretty obvious that nothing had been done to improve the area since 1954 (we joked about that; we’re talking about getting tee-shirts that say, “Kitona Military Base. Unimproved since 1954” since that’s the year that people always give when you ask when something was last fixed.) It used to be a water treatment and distribution center, but we’re guessing that when something at the “treatment” stage of that broke, they just redirected the pipes to turn it into a distribution center only. The infrastructure is still there, but a lot of the stuff is too old and corroded to be of much use. MAJ Lang said his solution would be to scrap the old treatment center and add a smaller, semi-portable set-up (like what we used in Iraq and still use in Afghanistan) to the pipe at some point.

MAJ Lang studying the settling tank with the FARDC engineer and a water employee

                

That was pretty much our day, so we headed back to the hotel and worked on our reports and whatnot. After finishing that (and taking a nap), we headed to dinner at the New Cliffs and prepared for tomorrow. There’s going to be a “sensing session” (when people can air their complaints) with the female soldiers/officers tomorrow morning, so I might go to that, to see what the complaints of the female service members in the FARDC are.

DRC, Day 4: Evaluation of the Hospital

It was back to Kitona Referral Hospital today, for the first full day of the medical engagement of Operation Lion Rouge. It was exactly as I remembered it—the good and the bad (but mostly the bad).

                

I started the day by going by the lab to talk to them about the MEDRETE back in June. The lab supervisor is the same as then, so he was able to reiterate some of the points that LTC Cannon had made during their two weeks working together. Unfortunately, they really don’t have the money to mitigate any of the big deficiencies that were pointed out, such as not getting their equipment properly calibrated in the ten years they had had it. They also have some pretty big issues with electricity (as the entire country has), which puts a damper on the things they do and the things they can do. Dr. Olivier from PEPFAR wants to increase the capacity of the lab, especially in terms of HIV diagnostics and monitoring, but in order to do that, they need to have reliable enough electricity to keep and air conditioner going (because the machines run hot) as well as a refrigerator for the reagents. Currently, the hospital only has one generator, and it goes to the high-impact areas (the operating theater) when city electricity is down. In order to do the changes Dr. Olivier wants, the lab area would have to have its own generator.

                

They have made some positive changes, though. One thing I noticed is that they have the instructions for each of the lab tests printed out and taped to the wall, above the machine that runs that test. I don’t know if they had that before, but the paper looks new enough that I’d believe that they didn’t. I’m going to choose to count that as a win.

Lab instructions

               

The second area I went to was the blood bank. Unfortunately, the blood bank has a new supervisor since June. I’ll have to ask why the old one left. Since he’s new, he wasn’t able to explain what positive changes they had made since LTC Cannon was there. One thing that he noticed, however, was that they would draw a donor’s blood before they did the questionnaire and screening, which meant that if the tests or questionnaire led them to be excluded, that they had wasted that tubing and donor bag. Little things, but in a hospital that broke, every little bit helps. Well, when I talked to them today, I’m pretty sure they said that they do the questionnaire and testing first, then do the donation. If that is indeed the case, that’s a positive impact of the MEDRETE.

                

My last stop before I saw patients one-on-one with Dr. Patrick was the adult wards. For each of the patients admitted with malaria, I asked if they had a positive blood smear, and the answer was always yes (yay!). However, Dr. Patrick explained that even when the test is negative, they still treat, which is exactly what they did before (sigh). I guess we couldn’t have expected to change the way they do things with one lecture about diseases that look like malaria but aren’t, but I was a little hopeful. Oh, well. Anyway, they had a couple of malaria patients, a couple of hypertension/diabetes patients (yes, that’s a problem in DRC as well), and a couple of TB patients. They don’t have isolation rooms or even a separate ward for the TB patients; they’re just in the ward with other patients, a hypertensive and a malaria, in this case. I guess the bright side is that they didn’t put either of the TB patients in the same room as the patient with HIV and Pneumocystis pneumonia.

                

We ended up finishing early (MAJ Lang was doing an environmental/sanitary assessment of the base while I was at the hospital), and then headed back to the hotel to write our reports. I still need to see pediatrics tomorrow, which could be interesting. MAJ Mann found a lot of mistakes with the antibiotic selections while she was there, so I guess that’s what I’ll focus on. 

DRC, Day 3: Back to Muanda

Well, I’m back in Muanda for another six nights. The joys.

                

We got up this morning to go running, as always, and this time managed to find the running path I went on before, the one along the Congo River. Since the hotel now is further from the river than the Fleuve, we only did a short loop (about a mile) before heading back, for a total run of about 4 miles. It was nice, but the problem with running with people taller than you is they also tend to be faster.

                

Because of traffic, we were running a little late for the N’Dolo airport and our flight to Muanda, but of course, nothing in Africa runs on time, so we still had to wait after making it through customs and security. The flight was uneventful (always a good thing in those little prop planes), and then we were back in Muanda.

Flying over Bas Congo. The cleared patches are oil test wells

                

Our only official duty today was to go around the installation and do introductions. We met with BG Mustafa, the base commander; the head of the nursing school; and BG Amisi, the hospital commander (COL Amisi last time I was here). I think we came up with a plan for activities for everyone. MAJ Lang, the environmental science officer, will go around with the base engineer and do sanitation and hygiene surveys. BG Mustafa said he should find quite a lot of things wrong. The two Navy doctors will stay at the nursing school, mostly giving an overview of trauma care for the two days that they’re here. And then I’ll be at the hospital, doing a follow-up from the MEDRETE in June.

Outside BG Mustafa's office. He's the one in the striped polo shirt.

              

I still have open sores on my heels from my blisters that I got while hiking in Lesotho, so that makes being in boots pretty painful. I’ve been putting Neosporin on them, so hopefully they don’t get infected. I’d rather not have tropical ulcer as a souvenir of my time in Africa.

DRC, Day 2: Dealing With Kinshasa

Today felt like a pretty long day, and unnecessarily so. It started when MAJ Lang and I went for a run, trying to find the running route we took from the Fleuve last time (this hotel is fairly close to the Fleuve). However, we were on the right track, and then got stopped by a roadblock and had to turn around. Sigh. We still managed to get three miles and change in, and then it was time to begin our day.

                

We went to the Embassy for the RSO brief, and I was “uninvited”, because I’ve been here within the last 90 days and the room was too small. So I hung out with in the Office of Security Cooperation, waiting for the others to finish. When they were done, we went down to the PEPFAR section and saw Dr. Olivier (the military PEPFAR coordinator, who went out to Kitona on both of the previous trips). Then we had the fun task of pulling money out of the cash cage. Because this trip has two separate missions, and thus two separate lines of accounting, they had funding memos for much of this part of trip, including the hotel in Muanda ($700), the rental car ($1050), the interpreters ($1050), and the interpreters’ travel expenses ($600). That was a lot of cash to be pulling out in my name, and I hope to get rid of as much of it as possible, as soon as possible. I think I’ll pay for the hotel room and rental cars as soon as I get there, instead of saving it for the end.

                

After that experience, which took a couple of hours, we headed out to lunch at a Lebanese restaurant (not bad, and not too expensive), and then went back to the Thieves’ Market (for a third time for me…) so the other people in the group could buy some souvenirs. I was pretty much done at that point and just wanted to go back to the hotel and take a nap. Even though I’m not fighting jet lag, I’ve forgotten how draining just being out in this heat and humidity is. It’s going to be a long week at Kitona, starting tomorrow…

DRC, Day 1: More Travels

I didn’t write anything yesterday, because as far as I’m concerned, yesterday and today are the same day. I guess that’s what happens when you travel through the night and only sleep in airplane seats.

                

I went on a long run yesterday morning (well, longish—only six miles, which is a short run back home, but with the altitude and hills, I’ll call it a long run in Lesotho) and then bummed around the hotel until the shuttle came to pick me up for the airport at 2. After that, it was a quick check-in process and short flight to Johannesburg, where I then had a seven and a half hour layover.

Three African airports... Yeah, let's go with the African luggage security system of plastic wrap

                

The Johannesburg international transfer system is interesting. In Maseru, they only gave me my ticket for that flight, and said I had to get the remaining tickets in Johannesburg. Well, I get to international transfers, and I see a line of desks and agents, none of which were for Kenya Airlines. So I go through security, thinking I’ll get my boarding passes at a Kenya Airlines desk at a gate. Wrong. The gates aren’t airline specific, and they don’t have agents sitting there. So then I went back to the unsecured area, finally found an automatic check-in terminal, and checked in, changed my seats, and got my boarding passes.

                

By this time, I had about six and a half hours left of my layover.

Zebra pelt, anyone?

                

I went and got a massage (because, why not?), exchanged my remaining South African Rands for U.S. Dollars, and then headed to the lounge. Since I was flying Kenya Airlines, which is a Sky Team partner, I couldn’t use my Gold Star Alliance card to get in that lounge. So I paid $30 to go in another lounge, which had food, drinks, outlets, and wifi, so I was okay paying. Unfortunately, they closed at 10, which left me with two hours to kill before boarding.

                

Once I finally got in the air, I was out for the entire flight, waking up once to realize that I had missed a dinner service (who serves dinner at 1 am?) and that was about it, and then arrived in Nairobi around 5:30 am local time. The flight to Kinshasa didn’t leave until 8:30, so I wandered around, bought some hot chocolate (have to take malaria pills with milk, after all), and met up with MAJ Lang, the environmental science officer for U.S. Army Africa (USARAF) and my companion for this trip, and we chatted until it was time to board. And again, I was out for most of the three hour flight to Kinshasa (I did wake up for the food this time).

                

It was the usual scene at customs at the Kinshasa airport, a process I’m now unfortunately familiar with, and then we got our bags and headed out. Unfortunately, we’re not staying at the Fleuve Congo Hotel this time, which has me really disappointed. It was pretty much the only decent thing about going to DRC, and I was really looking forward to it. The hotel we’re in isn’t bad, but it isn’t even in the same class as the Fleuve. I’m going to see if we can get moved to the Fleuve when we come back to Kinshasa after our week in Muanda.

The pool at the O'Costelo

                

After some overpriced lunch, I took a nap, and then I navigated the hotel looking for a decent place to connect to the internet (turns out, the only place that works is the bar…) before an overpriced dinner. Neither MAJ Lang nor I was ambitious enough to try to call motorpool to get a pickup to take us to a real restaurant, so instead I paid $15 for a croquet monsieur (grilled ham and cheese sandwich). Gotta love it.

                

I think all we’re doing tomorrow is going to the embassy for the Regional Security Office (RSO) brief, which is about all the security and safety threats in the area and the rules to follow to not get hurt. It only takes about half an hour, so I have no idea what we’ll be doing for the rest of the time. Oh, well. I guess time will tell.

6-13-13: Last Day in DRC

I realized earlier today that I never wrote a blog entry for yesterday. Oops. Well, nothing exciting happened. We flew from Muanda to Kinshasa and arrived in one piece, and that was just about it.

The plane that took us back to Kinshasa

Today we got back to work, with an early morning meeting at the Embassy. We had an outbrief with the ambassador, and I presented the medical piece, as the “medical mission lead”. I presented an overview of Kitona Health Zone, using the surveillance data that we heard in academics during the mission, and then touched on the kinds of patients we saw and the health assessments we did. It went pretty smoothly, but what I neglected to say was that while I noticed that the MoD had solid programs and policies in place, they were obviously having problems with implementation, based on what we saw. Oh, well.

Out-briefing the ambassador

After the out-brief with the ambassador was the press conference, and LTC McCullough asked COL Lesho to be the medical representative on the panel, as the highest ranked military officer. He did his piece well, although I would have answered some of the questions a little bit differently than he did. But that’s what LTC McCullough wanted, and it was his show.

The group before the press conference

After a quick lunch (of pizza) we headed to Camp Kokolo, which is the main military base in Kinshasa, to visit the hospital. This was the site of MEDFLAG 10, a joint-service medical mission in 2010, and also a site that LTC McCullough neglected to take us to during the pre-deployment site survey back in March. The hospital is bigger and has a larger patient volume than Kitona, as well as better equipment (as a result of MEDFLAG 10), and today LTC McCullough’s rationale for not taking us there was that they get a lot of attention from NGO’s, etc, and we would have been lost in the shuffle, whereas nobody really goes out to Kitona. While this is undoubtedly true, it would have been nice to see Kokolo in March, when we were trying to find a site, instead of being herded to Kitona. It would have completely changed the dynamics of the mission, with how many days we would have been able to work (not having to take days out for travel), where we would have been staying, and even who we would have brought on the mission. It’s kinda frustrating to get actual confirmation of being used to further someone else’s agenda.

The cardiac ward at Kokolo

Anyway, after that we swung by the Thief’s Market, where I bought some more touristy things, and then we had a bit of downtime before the reception at the deputy ambassador’s house. It’s a very nice house, and he invited quite a few medical people that we got to mingle with. I talked to the head of the PEPFAR (Presidential Emergency Program For AIDS Relief, a program started under George W. Bush) program in DRC, the USAID chief in DRC, the CDC chief in DRC, and several other equally important people. It was quite an evening, and I’m sad that I didn’t remember to bring my business cards.

               

 Tomorrow we have a long(ish) day of doing not much, and then we hop on the plane in the evening to begin the epic journey back home. I can’t wait (sarcasm). 

6-11-13: Last Day at the Hospital

Today was the last day in the hospital, which was good. I think I’ve seen just about as much of that place as I can handle. For now, anyway.

                

There was some initial confusion about which doctors the three physicians were going to work with, with Dr. Patrick being in surgery and nobody really that trilled about working with the triage physician. Finally, Dr. Lesho bit the bullet and went with the triage doctor, and both Dr. Mann and I worked with the pediatrician. Since there weren’t any patients waiting to be seen, we went upstairs for rounds and saw the kids on the inpatient wards.

                

After rounds, I worked with my translator on my presentation about HIV in the US Military, and then it was time for a tour of the nursing school. It’s a military nursing school, with most of the students in the military, and a few civilians who pay tuition. We actually interrupted their finals, which I felt a little bad about.

The group outside the nursing school

The school itself wasn’t too bad, although outdated. They actually still have an iron lung in the clinical simulation center, which has got to be the oldest one still around. I don’t know if it’s still operational or not; somehow, I wouldn’t be surprised.

Iron Lung

After the tour of the nursing school was lunch, and then we had the last day of academics. We had two lectures on blood security and blood transfusions, one about the program and stats at Kitona, and one from LTC Cannon about WHO standards. I was actually surprised at how robust the program is here—they don’t pay anyone for donations, which is good, and test every unit of blood for HIV, syphilis, hepatitis B, and hepatitis C. It’s not nearly as many as we test in the States, but it meets WHO recommendations, which is always good. They do have a strange policy where they only transfuse matched blood—an A patient will only get A blood, etc. I feel sorry for their AB patients. There aren’t many of us out there.

                

The third lecture was about sexually transmitted diseases at Kitona, and then I wrapped up academics with my presentation about HIV in our military. It actually started an argument between the hospital commander and the deputy commander of Kitona Base, who was there to present the completion ceremonies. The hospital commander asked why all the recruits at Kitona didn’t get tested when they joined, the way our recruits do (and according to DRC policy, as we learned yesterday during academics), and the general said that it’s the hospital commander’s responsibility to do it. There were angry words flying around in French all over the place, but hopefully they’ll figure something out to get the testing done.

My presentation on HIV in the US Military

After the awards ceremony (read: speeches and certificates), we headed back to the hotel, and then down to New Cliffs restaurant (our usual dinner place) for a final Muanda dinner. We invited our translators and the hospital commander, and hired a music/dance group. It was a lot of fun to hear and see traditional music and dances from Bas Congo, and everyone got up on the dance floor at least once. Yes, even me, but I really hope there are no pictures of this out there.

Dancing

I gave Lt. Olivier, my translator, a gift at the end of the night: my Army Medical Department regimental crest. I brought it with the intention of giving it to the doctor I worked with, but I didn’t end up forming any sort of bond with any of the doctors, and Olivier and I got to know each other fairly well. I told him that it was what American Army doctors wore on their uniforms, and after translating for me all week, he was practically a doctor and should have it. I think he appreciated it.

Tomorrow we fly back to Kinshasa, and then there’s a couple of days of stuff that we have to do for the embassy before we head home on Friday night.

Final group picture in front of the hospital

6-10-13: Back to the Hospital

We were back at the hospital today for our second to last day of clinical and academics at Kitona. Like Saturday, we physicians rotated physicians to work with. I took the pediatrician, Dr. Lesho worked with the triage doctor who doesn’t like anyone, and Dr. Mann (the pediatrician) went to internal medicine.

                

Pediatrics clinic was slow today, so we ended up going up to the pediatrics ward for rounds. Most of the cases were simple malaria (well, simple for them), but there was one boy who’s pretty sick. He’s had swollen lymph nodes, a cough, lack of appetite, and swollen legs for about a month. I’m thinking it might be TB, but with three primary sites (lymph nodes, lungs, and possibly kidneys), which would be unusual, unless he has HIV, and the mother won’t consent to an HIV test. Dr. Mann thinks it might be Burkitt’s lymphoma, a cancer caused by EBV, the same virus that causes mono.

                

The issue about HIV testing came up in academics this afternoon as well. In DRC, you have to “opt in” for testing, which means that a doctor can recommend that you go for counseling and testing, but can’t order the test for you. This is the system that the US used to have, before we went to “opt out”, which means that a doctor can order an HIV test for you, unless you specifically state that you don’t want it done. The problem (especially in Africa), is that if you have an opt in program, people can chose not to opt in (and usually they chose this because they’re afraid it will be positive), and then continue living life as if they’re negative, continuing to spread HIV. You’re not going to be able to fight HIV until you have the ability to get people who are HIV+ the education and treatment they need.

                

We also had a lecture on antibiotic stewardship by Dr. Lesho, who works in the wound infection division at WRAIR. The lecture was a bit too technical, especially when working through a translator who doesn’t know medical terminology, but the point was sound. Since they can’t do culture and test for which antibiotics a bacteria is susceptible to, the doctors in Kitona tend to prescribe anything and everything for any complaint, and often for longer treatment courses than necessary. For example, every patient (outpatient, inpatient, etc) gets a urinalysis, even if they don’t have any urinary symptoms (which they usually don’t). Because hygiene is an issue, and I doubt they know how to do clean-catch urine collections, there’s a lot of background bacteria. In the U.S., you don’t treat bacteria in the urine if there are no symptoms, unless it’s in a pregnant woman. Here, however, if they find evidence of bacteria, they’ll treat with 7 days of ciprofloxacin (an antibiotic). In the States, that would be a 3 day course of antibiotics. This kind of over treatment and over-lengthened treatment increases antibiotic resistant bacteria, which is a huge problem everywhere.

                

Tomorrow is going to be our last day of clinicals and academics. It’s also a surgery day, so there probably won’t be much going on clinically. I might watch a surgery or two. The academics will be long; we’ll finish up the HIV lectures, and then we have a presentation of certificates to the DRC participants, and then we have an after-action report. It should be interesting.

Random picture of the group from cultural day

6-8-13: Change of Pace

Today was much better than yesterday. We actually got to rotate physicians today, so I was working with Dr. Patrick (no idea on his last name), the deputy commander of the hospital, in the internal medicine consult room. Meanwhile, Dr. Mann, our infectious disease pediatrician, worked with the doctor I had been working with. She said that he tried the same stuff with her as with me, the “this is how we see a patient…”, “this is how you do a physical exam…” stuff, but she put an end to it by repeatedly insisting that she had been a doctor for ten years, she knew that stuff, etc, etc. So because she was being aggressive, he finally started to treat her like an equal, and at the end he said, “I guess one of the American doctors knows something.”

                

Thanks, guy.

                

Meanwhile, I was over in internal medicine consults, where Dr. Patrick was going through patients at a much quicker (and more reasonable) pace, and for each, asking me about my differential diagnosis and how we would make the diagnosis in the States. It was so nice to be treated as somebody who actually knows something about medicine. I discovered in the course of conversation that they use the word “malaria” the way we use the word “flu”. It’s not so much a medical word to describe a particular diagnosis, but a general word to describe any illness. They call real malaria Paludisme (for Plasmodium), like we would call the real flu Influenza.

Yellow Fever and Malaria signs

Now that that has been explained to me, things make a lot more sense.

                

We finished the day with academics, which was to finish the malaria lectures (there was one we didn’t get to) and then onto TB. The DRC physicians explained their programs, program objectives, and their numbers, and I’m actually really impressed with how robust the program is. Kitona was apparently the pilot health zone for the new program, and comparing numbers to historical numbers, it’s looking like it’s making a difference.

                

Their goal is make TB “not a problem” by 2050. Guess we’ll have to wait and see.

TB treatment regiments (yes, I needed a translator for this, too). 

Tomorrow is Cultural Day, since there’s nothing going on at the hospital. Should be fun. 

6-7-13: Malaria Day

Today was actually a pretty frustrating day… Well, at least the morning was.

                

The plan from yesterday was that we would try to switch off to different departments, to see different parts of the hospital and get a more rounded experience. To be honest, for as much as I hate rounding, I was hoping to do internal medicine rounds, because I feel like there’s more opportunity for teaching during rounds than while seeing clinic with the same triage doctor, who doesn’t seem to understand that he’s doing things wrong. Unfortunately, they weren’t prepared for that, so we decided to continue with the plan for today, and our logistics support would talk to the hospital commander about us seeing different things tomorrow.

                

We shall see.

                

So I went to triage with the same doctor, and the first thing we did was see a patient on the wards who came in the night before. Her eyes were very yellow (from jaundice) and her belly was very extended (from ascites). However, the doctor said that it was from a perforation in the intestines, and the air from the intestines was making her belly big. I tried to explain that we see that finding in patients with liver failure, and that the yellow eyes and extended belly are both probably from the liver. I was about to suggest that they look for different causes of liver failure—viral hepatitis, yellow fever, liver parasites—but he remained sure that the belly extension was from a perforated intestine.

                

Sigh.

                

We went back down to triage and continued seeing patients. One had a very swollen neck, which started about five days ago as an earache. If it had been slower than that, I would have thought it was TB in the lymph nodes (more common in the Pacific Islands than Africa, but still happens in Africa), but with such a quick onset, I narrowed my differential to mumps, an ear infection that infected the bones, or a dental abscess. I had my otoscope (to look in the ears), and there was no sign of an ear infection, but when I looked in his mouth, the back teeth looked a bit suspect. This led me toward dental abscess, which apparently the doctor agreed with, because we walked the patient to dental. The dentist decided that he should be put on antibiotics until the swelling went down, and then he would remove the tooth. That made sense, because I don’t think the dental clinic has general anesthesia, and it would have been too painful for him to open his mouth all the way for the surgery under local anesthesia. However, what I don’t agree with was that the doctor discharged him home with oral antibiotics. With his mouth so swollen, I don’t know that he can swallow pills, and his throat was swollen that he was struggling to breath. When you have to work so hard to breath, you can’t always keep it up forever, and eventually you’ll stop. I hope that doesn’t happen.

                

There was another patient with fever and a negative malaria blood smear, so I tried using that as a teaching point about infections that aren’t malaria, but also cause fever. I might as well have been talking to a brick wall. Both the military doctor and the junior doctor in the room insisted that fever is always malaria. When I tried pointing out that mild dengue looks like malaria, they said that dengue looks like ebola. I agreed that severe dengue looks like ebola, but mild dengue looks like malaria, and they said that dengue is not nearby. I informed them that Cabinda (the piece of Angola north of the Congo River) has dengue, and that that’s very close to Bas-Congo (the region of DRC we’re in), but they said no, that dengue was in Sudan and malaria was in DRC.

                

Clearly I wasn’t going to get through to them.

                

Lunch break was at noon, and then we had academics in the afternoon. The topic today was malaria, so I wanted the DRC physicians from Kinshasa to give their presentations on malaria, followed by COL Lesho, one of our teammembers, to present infections other than malaria (dengue, chikungunya, typhoid) last. However, they’re so eager to have us talk that they had him go first, and he was a bit awkward with the translator, taking almost an hour. That only left an hour for the DRC physicians to talk about their malaria programs, which wasn’t enough time. We’ll have to finish that tomorrow.

COL Lesho's lecture

What we did learn about malaria in DRC was interesting, though. There are no parts in DRC that are not endemic for malaria, and everywhere accepts it as a fact of life. DRC accounts for 11% of all malaria infections in the world, and is one of five countries that makes up more than 50% of all world-wide infections. Forty percent of childhood (<5 50="" all="" and="" are="" big="" doctor="" during="" for="" malaria.="" malaria="" numbers.="" of="" old="" p="" pregnancy="" so="" those="" visits="" years="">

                

Nationally, the country has programs for treatment and prevention; sadly, I can tell you from working in clinic that the treatment programs are not followed. All clinical malaria (fever + any other symptom) is supposed to be confirmed by blood smear before treatment, but all “clinical malaria” (any fever) is treated as malaria, regardless of what the blood smear says. So everyone is getting medication that they probably don’t need, and everyone is ignoring other causes of fever. I also asked what percentage of the population is using bed nets (one of their interventions), and was told “everyone”. Everyone in DRC gets free bed nets—insecticide-treated bed nets are distributed free of charge—but as far as usage? Nobody knows, because nobody asks.

                

Mosquito net sign

It’s very frustrating for me, a physician who was trained in evidence-based medicine and in tropical medicine, to go to a place where evidence is disregarded, where national and WHO guidelines are ignored, and where the physicians on the ground aren’t interested in learning from outside physicians. It makes me wonder why we’re here at all, working side-by-side with physicians who ignore our “helpful hints” and are only giving lectures to the upper-level policy makers, all of whom already know what we’re teaching.

                

I’m probably not going to give this experience a high rating.

6-6-13: Day 2 of Clinicals, Day 1 of Academics

Today was day two in the hospital, and things went pretty similar to day one. I talked to the DRC physician I’m working with before the first patient this morning, and said that I’m okay doing physical exams, but what I wanted to do was discuss what he thought the diagnosis would be and differences between symptoms in DRC and the US. However, what ended up happening was pretty much the same as yesterday. He would pretty much do a full history, full lab work, and physical exam on every patient, which is not standard operating procedures in my clinic. If I do a physical exam (which our veterinarian will tell you is hit or miss), I only examine the areas in question—if you’re complaining of shoulder pain, I’ll look at your shoulder, but don’t expect me to press on your abdomen. If you’re complaining of shoulder pain, I’ll ask you about your shoulder, what the pain is like, and how long it has been hurting. And I’ll only order labs if you look like you have an infection or if you need your cholesterol checked.

                

I did have some opportunity for teaching, or training, or whatever you want to call it: there was a man around 70 years old who came in for difficulty rising from a chair and inability to see out of one eye, and I pulled out my ophthalmoscope (to look in the eyes) and showed the DRC physician and the doctor-in-training (graduated medical school and here for additional training before he goes out into independent practice) how to use an ophthalmoscope to look into the eye. Anyway, he was completely blind out of that eye, and the pupil didn’t even change with light, which is a bad sign. I’m pretty sure he had a stroke, and possibly has Parkinson’s, but neither of which is treatable in DRC, so there really wasn’t much to do.

The second case where I got to be an expert was the last case of the morning, an obese women (yes, they do exist in Africa) with abdominal pain. I’m pretty sure she has gallbladder problems, and talked the doctor into sending her for an abdominal ultrasound to look at her liver and gallbladder. I also identified that her skin was darker in her skin folds (neck, armpits, stomach rolls) and pointed out that that is usually a sign of diabetes in the States, and maybe we should check her blood sugar. So they did. I don’t know the results yet.

Over lunch, our team conferred about things we had seen over the morning and what we wanted to do for academics. We have a pediatrics infectious disease physician, adult ID physician, me, a public health nurse, and a lab officer. The peds ID doc saw clinic and then rounded in the pediatrics ward, but both the adult ID doc and I just saw clinic, and would both be interested in seeing rounds. Hopefully tomorrow. Honestly, I think the public health nurse is having the best time and seeing the most things. Yesterday she went over the tuberculosis surveillance program and other surveillance programs, and today she rounded with the nurses on the internal medicine wards. The lab officer, who was requested to help them with the blood bank program and with SOPs in the lab, today tried to talk to them about quality control and calibrating equipment, but didn’t really get far. The idea of having quality control is fairly foreign to them.

                

After lunch was academics, and today was the first real day of academics. We got an overview of the hospital, which I had heard in March but the rest of the team hadn’t. The hospital commander ended up giving more of an explanation of the health zone and the six included health areas, which was good, because that was stuff that I hadn’t heard before. After that, I gave an overview of prevention of cholera, and then the academics concluded with the hospital commander with discussing the cholera epidemic that happened from January 2012-February 2013. In the 12 months of the outbreak, there were 226 cholera patients in the Kitona Health Zone area, with 4 deaths, and no cases among health care workers. Everything they had done was textbook; in the lecture I gave about preventing cholera during an outbreak, there were ten points that I had mentioned, and they did all ten of them during that outbreak. There were questions from both the DRC physicians and our team asking if we had coordinated the lectures, but we hadn’t. They had done everything that well.

Setting up for academics

COL Amisi Okito, the hospital commander, speaking about the 2012 cholera outbreak

I’m hoping to round with the internal medicine team tomorrow, which I think will be more interesting than clinic, and possibly have more opportunities for teaching. We shall see how things develop.  

6-5-13: Getting Started

Today was our first day working at Kitona Referral Hospital, which was nerve-wracking in its own right. It means that the MEDRETE has officially started, and there’s nothing we can do about it now.

For the mornings, we’re paired up with DRC military physicians, to see patients with them. My physician partner is the equivalent to a first lieutenant (one rank behind me), but he’s older. He also has a wife and five kids in Kinshasa, which came up in conversation before our first patient arrived.

                

We spent more time on the first patient than we should have, given how many patients we had to go through. I think maybe the physician I’m partnered with was unsure about my level of education or what my role is, because he explained things in much more detail than necessary, instructing me on listening to heart and lung sounds (medical student-level instruction). I didn’t say anything, but I should have, because it made things drag on much more than necessary and didn’t really accomplish anything. Tomorrow, I’m going to tell him that I’m okay on physical exam, and what I really want to do while we’re working together is talk about what he thinks the diagnosis is and why, and from there, to discuss the differences (or similarities) between those symptoms in the States and in DRC. I guess we’ll see if I have enough of a backbone to do that tomorrow.

                

The first case was interesting, though. It was a young man, maybe 23, a college student with pain with urination. My immediate thought was chlamydia or gonorrhea, both sexually transmitted diseases. However, the physician I was working with didn’t ask anything about sexual history (beyond “are you married?”), and definitely didn’t ask the “men, women, or both?” question that I was taught in medical school. He was leaning much more toward a urinary tract infection, which is fairly rare in grown men in the US, outside of some other medical problem (HIV, cancer, etc) or men who have sex with men. However, he said that UTIs are common in men in DRC, due to poor hygiene, poor sanitation, and relative dehydration.

                

The rest of the morning was fairly routine cases, and then it was time to break for lunch (me, not the DRC physician… they don’t eat as many meals as we do and don’t mind working through the day). In the afternoon, we were supposed to have didactics, but there was such an influx of patients from the community that none of the DRC military physicians were able to get away. We found out afterwards that that was because there was a message that went out on the radio saying that the Americans would be here and would be giving out free medical care.

In other words, the exact opposite message that we wanted to go out, which was that we would be training in public health and infectious disease along with the DRC military physicians.

                

Instead of doing academics, we hammered out a schedule for the week we’ll be here, with what we’re going to talk about on any given day, and then it was time to go back to the hotel. This morning, the hotel manager told our logistics people that they don’t have enough money to keep taking care of us (electricity, food, etc) for eight days, especially with the list of needed repairs that we gave them (showers not working, AC out, etc). We gave them one night pay each ($100 x 10 people) to help out before we checked out. When we got back from the hotel, we found that they had repaired all the plumbing issues we brought to their attention (for example, the switch deciding shower or bath in my shower was broken, causing there to be a slight trickle of water from both) had been repaired, and they had moved everyone who’s AC was broken into new rooms.

Landscaping at the Prosper, new since March

Apparently, when you give money to a business in the developing world, they reinvest it in their business, instead of just lining somebody’s pocket, as usually happens in the State. It was nice to see a hotel operating to provide hotel services, and not just a profit.

                

Well, it was a long day, and after waiting far too long for our food at the restaurant (as usual), I’m ready for bed. I hope tomorrow goes smoothly.

Dinner tonight: lobster :)