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.

Lesotho, Day 5: A Little Bit of Free Time

Today I had something I very rarely have on these short overseas missions: a completely free day.

                

I slept in a little bit (translation: to 7, which is two hours later when I was getting up all week) and since I had already decided that I was going to go hiking this morning, got to take my time getting ready for breakfast, without having to worry about going running or hitting the gym or anything. I had breakfast with my team members and then we said our good-byes, since they were planning on leaving for the airport at noon and I was planning on still being hiking.

                

I had my eye set on the hill overlooking the Pope John Paul II stage (where he gave a sermon at some point in the 80’s), and I thought it would take all day. However, it was actually pretty easy to find the trail created by a whole bunch of cattle herders leading their cattle up and down the hill, and I found myself on the top of the hill (elevation >6000 ft) after only about an hour or so, less than three miles of hiking. I explored the top for a bit, but it was cold and windy, so I didn’t want to make a whole day of it. I tried to go down a different path than the one I went up, but I kept losing sight of the cow trails, so I just gave up and went back up to the top and then headed back the way I had come up. In all, it was a little under seven miles. I would have gone longer, since it was noon when I got back, but I discovered that that kind of hiking in combat boots doesn’t really work. My heels are pretty torn up from the experience.

Starting out on my hike

Up at the top

From the top

Another picture from the top

The Pope John Paul II stage, from the top of the hill

                

The rest of my team didn’t get picked up until 2, so we had a couple of hours after I got back to talk shop (and things completely unrelated to work), and when they took off, I grabbed lunch and then settled in to finishing what I needed to of this mission before leaving for the next. After sending off my reports and whatnot, I returned to my book and read that until it was over.

                

All in all, a pretty relaxing day. Tomorrow I have the morning to myself, and then I begin the continent-hopping flights that will take me from Maseru to Kinshasa, landing around 10 am on Sunday. With any luck, my entertainment system(s) will actually be working. 

Lesotho, Day 4: Last Day of Work

This was the last day of meetings in Lesotho, which is good, because I’m about meeting-ed out.

                

I decided to get an extra half hour of sleep this morning, and did 30 minutes on the stationary bike in the gym instead of going for a run. It’s not a bad gym—it has a few treadmills, ellipticals, and bikes, as well as weights and whatnot—but I’ll always prefer working out in the real world to doing something in the gym. It’s been a while since I was on a bike, though, so I probably needed it.

                

We got our first surprise of the day when Mo came to pick us up at 8, telling us we had a meeting at 8:15 with Christian Health Association of Lesotho (CHAL), the largest health NGO in the country. He says he told us about this yesterday, but nobody had any recollection of this and we really weren’t dressed appropriately; I was in khakis and a shirt (with my boots on) and our exercise planner was in jeans and a sweater. He changed into a suit and tie; I didn’t realize what was going on and stuck with my attire. Anyway, we ended up late, but that was fine (African Standard Time…). We explained the exercise with the representative and invited any nurses or doctors to give or come to academic sessions. She seemed very interested and said she would get with some of her people to see if anyone wanted to talk. Seems positive.

Site of our meetings

After that, we went out to Maruja, which was where the first Huguenot missionaries came. They have a museum about the history of Lesotho, and we were scoping it out for a potential cultural day activity. During the MEDRETEs, there’s usually a day during the weekend to “experience the culture” of the host nation. This should really be changed to “tourist day”, because it’s really about being a tourist. There’s usually a market involved and everything. Anyway, we went to this museum, which explained the history of Lesotho from the big bang on (skipping large chunks of time, obviously). It was pretty interesting, but I’m not sure how much it would be enjoyed by the people on the mission. I guess we’ll find out.

Replica huts at the museum

             

We had one final meeting of the day at 1600, with PEPFAR. We told them about the mission and asked them if they would be willing to give some academics, and not only did they say that they would be, but they also gave us the names of more NGOs that they would put us in contact with. It was pretty much a win-win, and a productive meeting.

                

The rest of the team is flying back tomorrow, and I’m not leaving for Kinshasa (by way of Nairobi) until Saturday, so I have the day to myself tomorrow. I’m thinking I’m going to go hiking. One of the guys at the Embassy said that there are plenty of hiking trails to try that are right around the hotel, so I figure, why not? 

Lesotho, Day 3: Finalizing Plans

Today was my first 9/11 out of the States, and I definitely noticed the difference. While my Facebook account was covered in cries to ‘Never Forget’ (referring to not only 9/11/01, but also the events in Libya last year), I was in meetings in a country on the other side of the globe, the date having no more meaning for them than the 4^th of July or Thanksgiving. There were no moments of silence, no news broadcasters replaying the events of twelve years ago, no American flags being waved from street corners. And that was fine. In a time when everything is always broadcast and always recorded, it was nice to have a day to when all I had to worry about was what the anniversary meant for me, not for anybody else.

                

And now back to Lesotho… As I did yesterday, I got up early to go running, trying a different route this time. Since they warned us about going around town when it’s dark out (and the sun doesn’t rise until about 6:30 around here, when I’m pretty much done from my run), I’ve been staying away from the “town” parts of the roads, which doesn’t leave a whole lot, and all of it pretty steep. Looking at my elevation chart after my run, I ascended 300 feet in less than half a mile. No wonder I had to walk up some of it.

Elevation map

The entire morning was spent at Makoanyane Military Hospital, getting the more in-depth tour (which allowed me time to ask questions to refine the mission plans) as well as the tour of the Thomas Wellness Center, the PEPFAR (President’s Emergency Program For AIDS Relief) funded clinic that focuses on HIV/AIDS prevention and treatment. After the tours, we sat down and hammered out plans. My original thought was for four doctors and two Public Health nurses, the four doctors being two infectious disease specialists (one adult, one pediatric), me (preventive medicine), and family medicine. My thinking for family medicine was because of how much obstetrics work they do, in terms of the prevention of maternal to child transmission of HIV (PMTCT) treatment of pregnant and breastfeeding women and whatnot. However, when I explained my plan, they asked, “Can we get an obstetrician?”

Thomas Wellness Center

                

Hmm. Get an obstetrician for obstetrics work. Who would have thought?

                

So we changed the family practitioner to obstetrics, hammered out the rest of the details, and then broke around 1200. Mo, our Embassy contact (he’s Basotho, and like all Basotho, no American can pronounce his name, so it got shortened to ‘Mo’) drove us out to the site where the Basotho tribe made their stand against pretty much anyone who tried to invade, a large steppe with only one path up (in other words, easily defended). We took some pictures and bought some miniature souvenir woven hats (the national symbol of Lesotho) and then headed to Kick For Life, an NGO run by FIFA (soccer people), which has a good cook. Sure enough, the lunch was pretty good, for being European-type food served in Africa.

The rock

Lesotho hat

                

We headed back to the hotel after lunch, where I quickly sent of my justifications for mission personnel to the person in charge of manning the mission, and then settled in to do nothing but read a book for the remainder of the afternoon. I had grand plans of going to the gym to get on the stationary bike, but that just didn’t happen. Oh, well. Maybe tomorrow. In the meantime, I’m going to continue sitting at the bar, sipping cheap red wine while playing on the computer and pretending to watch the rugby game on TV.

Lesotho, Day 2: Let the Work Begin

Today was the first day of the PDSS, and busy. I started the day with a run, which was pretty difficult considering the elevation and the fact that the hotel is located on a pretty substantial hill. I didn’t manage three miles, but I was happy(ish) with what I did get done, considering the factors at play.

                

Our first meeting for the day was with the Chief of Staff of Operations of the Lesotho Defense Force, a two-star general. He had with him three one-star generals, so it was quite the meeting. We explained the mission—we’re going to be pairing up one-on-one with Lesotho Defense Force doctors, seeing patients in the mornings and doing clinicals in the afternoon, the same pattern as the DRC MEDRETE. They were under the impression that this was going to be a much larger mission, so we knew from there that we were going to be fighting an uphill battle. They did eventually figure out what we were talking about and agreed that it sounded like a good mission.

View of the Barracks from the road

As if that wasn’t enough high-powered people in one room, the second meeting of the day was with the Principal Secretary of the Ministry of Defense, where we again explained the mission and he did a lot of head nodding and thanked us for our support. Then we went to the military hospital—the only military hospital in all of Lesotho—to talk to the hospital commander (lieutenant colonel) and some nurses and the only two doctors in all of the Lesotho Defense Force (it’s a small country…). We again explained the mission, they told us what the hospital needs—which is mostly stuff, which we can’t provide—and we went on a quick tour. We’re supposed to get more of a tour tomorrow.

Makoanyane Military Hospital

                

After lunch, we headed over to the Ministry of Health, to meet with the Principal Secretary there. When we told him what we were looking for—which is pretty much for them to participate in the academic session of the exercise—he quickly found people for us to talk to, and came back with the head of the programs for TB/HIV, Integrated Disease Surveillance and Response, and International Health Regulations. In other words, exactly who we needed to talk to. We explained our plan, they agreed to participate in academics, and committed to at least six hours of lectures, in order to make sure the LDF doctors know about the national programs for disease surveillance, TB, HIV, and STDs. Success!

                

Throughout the entire day, the civilian on the survey who’s in charge of the security survey spent the entire time complaining about how boring the medical meetings are and how they have nothing to do with him. I didn’t say anything, but I wanted to tell him that when he’s going on a pre-deployment site survey for a medical mission, there might be one or two meetings about, I don’t know… medical stuff? It was frustrating, but he was fairly easy to ignore.

                

In all, late night (it’s 9:35 and I’m exhausted), and my allergies are killing me. I forgot to take into account that it’s spring in Lesotho, and spring is when my allergies are the worst. Ugh. Fortunately, it’s easy to buy medications here, so I bought some generic Zyrtec (what I take at home), and hopefully will be feeling better tomorrow.

Local allergy meds. A lifesaver.

              

And now, time to go to bed, so I can go to more meetings tomorrow.

Lesotho, Day 1: South Africa and Traveling

Today was another day of traveling and exploring and seeing new places, which is always a good thing. I started the day early and went for a three mile run in the residential area around my hotel, and by the end, I could definitely feel the altitude, compared to the 10 feet above sea level I’m used to in Savannah. It’s going to be interesting tomorrow, when I’m even higher in Maseru.

Fountain seen on the run

Unfortunately, there wasn’t enough time to go on an organized tour of Johannesburg and still make it to the airport in time for my flight, so I opted to go to the airport, check in, and then get on the train and go to Sandton, which is a shopping-type area. If there’s one thing I’ve learned about international travel to developing countries, it’s that there’s always someone at the airport will to “help”, who expects a tip at the end. Sure enough, almost as soon as I walked through the doors, a man came up and offered to help, directing me to the counter and taking my bag before I could really even protest. After I checked my luggage, he asked what next, and I said I needed to go the ATM, so he took me directly there. Then he took me to the “Bag Port” (luggage storage) so I could drop off my backpack, and then took me to the train station and showed me how to buy a card for the train.

                

Yeah, he earned his tip.

                

Sandton wasn’t really all that exciting. I was hoping Nelson Mandela Square would be a historic-type thing, but no. It’s a mall. So I wandered around for a bit, bought some souvenirs, and then found myself at the Peacemakers’ Museum. It’s very small, maybe the size of a normal store in the mall, and all about Nobel Peace Prize recipients (obviously with more emphasis put on the three South Africans). If there was one thing I learned from reading the reasons why people were awarded the Peace Prize, it’s more about the hopes and wishes of what the Norwegians want to happen than anything that had actually resulted in peace. Some people had done legitimately good things that made the world a better place (ending apartheid was no small feat), but others—like “ending the Vietnam war” (in 1973) or “peace in Israel” (hmm…)—were more of what the military calls “Good Idea Fairies” than any real accomplishments.

Normal Borlaug's speech

Nelson Mendela inside the Peace Maker's museum

Anyway, after that, I headed back to the airport, hung out in the South African Airways lounge for a bit (ah, the life of a Star Alliance Gold member…) and then met up with the three others in my group before our flight to Maseru. The flight was short—less than an hour—and then we were at the airport, where I experienced the fasted trip through customs and immigration known to man. To give you an idea, there were so few people and the plane was so small that they brought the luggage from the plane in a cart, and set it on the carousel (which I’m pretty sure is defunct).  

Baggage claim

                

Our driver gave us the brief history of Lesotho as he drove us to the hotel, so I had to ask why it existed in the middle of South Africa. He informed us that during the Boer Wars, King Moshoeshoe I requested protection from the British Empire, and became a British protectorate (not a colony, as he corrected me). Everything else in the area became British colonies, and then became South Africa. So now South Africa is very diverse, in terms of tribes and ethnicities, and Lesotho remained almost entirely Basotho (the demonym of people who live in Lesotho) with everyone speaking Sesotho. English is the official language, though.

                

After we arrived at the hotel (which is quite nice), we were joined by Mo, from the Embassy, who went over the agenda for the week. It looks like a busy day of meetings tomorrow, and then things will taper off from there.

Sunset from the Lesotho Sun

             

We shall see… 

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.