Sandy Christman Foundation Update

Just to keep those interested in the know.
ACTIVE SCF PROJECTS:
1) Project Tanznaia 2016. Brought a portable ultrasound ( U/S) machine to Biharamulo Hospital this year.
    Ultrasound technology continues to expand and improve rapidly. Using a portable hi definition
U/S machine in a rural setting with limited electricity allows for rapid diagnosis and treatment of emergency and chronic conditions. It is especially applicable in Biharamulo where X-ray machines need hi amounts of electricity to work and develop pictures.  There is a new approach to trauma using FAST ( focused assessment with Sonography in Trauma) which can be very beneficial here for the stated reasons plus its CHEAP!  And it doesn't have to be limited to trauma.
I predict stethoscopes will be a thing of the past in 10 years.

Tanzanian doctors learning FAST

when to go home

My plans to stay at the hospital ended after one month when I woke up one morning and had LOTS of blood in my urine. That would be disconcerting anywhere but it will really rock your world when you are in Biharamulo. As much as I  love my co workers in the hospital I really do not ever want to be sick or worse, wake up finding my self a patient in this hospital. After doing doing my own lab work ( urinalysis,  gram stain, malaria testing) I was pretty sure I did not have an infection, malaria
some weird tropical disease or kidney stones. If your in your 60's and you have painless hematuria the list of possibilities goes downhill rapidly from there. I kept working because I felt fine. The next day I did a an ultrasound ( on myself) of my kidneys and bladder, with the really neat portable ultrasound machine I brought here this year courtesy of The Sonosite Company ( part of Fujifilm). I am not a radiologist or a ultrasound tech but this machine is pretty awesome....you can see everything. The good news was what I didn't see. No bladder tumor and as best as I could tell I had 2 normal sized kidneys. When you examine yourself you have to be 1) gutsy and 2) be
aware of the power of denial...I had to deny denial...and be as objective as I could. Fact is bladder cancer was 1st on my list. So I felt better after that but that did not stop the bleeding and just raised further doubts about how good I am with an ultrasound machine. Your not suppose to do this stuff on yourself !! I deducted, guessed that I must be bleeding from one of my kidneys. That was not a fun realization and just raised the bar that this was now over my head. As much as I hated it I had to get a CT scan and see a urologist. I was now bleeding for 4 days with no slowing down. There are urologists in Mwanza, the big city six hours away but was freaking out....I had to go home.
 Just to cut to the quick. I have now had a million dollar workup at my home hospital, Maine Medical Center and I am not going to die. No one knows why I am bleeding but there is nothing bad in there....as best as we know. Good news I think its over. I don't see any more blood. Bottom line, I bleed for 3 weeks from my left kidney and while there is no obvious reason, we are pretty sure it is a benign process.

Letting Go

     LETTING GO

Patricia is 30 y.o. women I was asked to see. She had a thick chart from previous admissions and when I visited she was extremely weak, getting worse and looked like she was going to die. She carried a diagnosis of chronic Congestive Heart Failure (CHF) on her chart felt to be from Mitral Valve Regurgitation. If that were true then some of the blood entering her left ventricle would go backwards into the left atrium when her left ventricle contracted or squeezed.  As things got worse and the valve got more leaky or more regurgitant some of the blood going back to her left atrium would go farther backwards into her lungs. In time, Patricia’s lungs would get overloaded with blood, the blood pressure in her lungs would increase and fluid would be pushed into her lung tissues and the air sacks in her lungs. When severe, her lungs would fill up full of fluid, as if she was drowning and she would be very short of breath. If you listened with a stethoscope you would hear all that fluid in her lungs.  This is called left heart failure because the defect, in this case, mitral valve regurgitation, was on the left side of her heart.

  But when I examined Patricia, her lungs sounded fine, not wet or full of fluid. She was a little short of breath but I think that was from her being anemic and just her general deconditioning after being sick for so long. Looking at Patricia and examining her it was obvious that she was full of fluid but the fluid was not in her lungs, it was in her abdomen and her whole lower body. Her legs were like elephant legs. Her belly was gigantic and when I palpated her liver it was huge, probably full of fluid. Blood was trying to get into her heart but couldn’t. It’s like trying to get onto the interstate in Los Angeles; traffic was all backed up at the entrance.  In contrast to left heart failure where fluid backs up in your lungs Patricia had right heart failure because of some defect on the right side of the heart. When I listened to her heart she had a big murmur. It sounded like her Tricuspid valve was where the leak was, not her mitral valve. When I examined her neck the neck veins were distended, full of blood, even when she was sitting straight up. The traffic (blood) was backing up all over Los Angeles, like at rush hour. There’s a reason they call Congestive heart failure.

    Because of gravity, most of the blood settled in her lower extremities, then her belly, then in her liver. If she stood on her head it would back up into her brain.  It was impossible to tell with out an echocardiogram, if indeed the problem was her Tricuspid Valve or some congenital defect. But what I did know was that we had the wrong diagnosis.  Patricia had right heart failure not left heart failure. She was not receiving the right medications and to be honest: none of this made any difference.  The right treatment does not exist here and even if it did Patricia and the hospital couldn’t afford it.

    But, we could make her more comfortable and maybe, if we all got lucky, she could get home.  We used 1970’s technology, I gave her big doses of diuretics, and over several days we drained 4 liters of fluid from her abdomen by placing a plastic needle through her abdominal wall. This is somewhat dangerous and of questionable value but she improved over a period of a week. I even thought about using rotating tourniquets, you’ll have to Google that one but it was desperate clinical maneuver from the 1960’s. But I’m not sure that has ever been proven to work. I calculated Patricia needed to lose at least 15 kg. (33 lbs.) to get near to her  ideal weight of about 55 kg.  We checked her weight daily (a big deal here).  Slowly over 10 days, as her weight dropped, she got moderately better.  Then she disappeared.

     She and her family (her bedside assistants) “ absconded” one night, probably to home.  This is how it is here. The family not the doctor, not the nurses, decide when to leave, and it’s often at night. The decision is economic. Maybe they had run out of money. Maybe it was time to go home and plant crops, a time when every able body person is needed to work the fields cut out of the jungle. Her family had to choose. Stay here and help Patricia or go home and plant crops so the family doesn’t starve and maybe even make money selling the crops. And it really is about the numbers. Stay and help Patricia and we all may starve in 4 months. Let her go and the family lives. Its the law of the herd, on a human scale.  

    I don’t know where they lived but it was far away in the bush. There is no follow up appointment, no letter to a local clinic or practioner.  Worst case scenario:Patricia will run out of meds, get worse and die… Best case:  she might come back here…..if the economics are right.

   So, here’s point. The practice of medicine here is acute care medicine. Get Malaria, have a baby, get bit by a snake. We can do that. But if you have a chronic condition that requires long-term medication, as in life long, you may be outta luck. In the best situation (the developed world) Patricia would need daily medications, follow up and ongoing management. Optimally, she might benefit from surgery.  Here that is impossible. In the developed world most medical care is chronic care medicine. Our medical industrial complex thrives on diseases we can’t cure but instead are treatable with long term care. Renal failure with dialysis, diabetes and its complications rheumatoid arthritis, heart disease and maybe someday cancer are all chronic care, common and often very profitable diseases in the developed world. Here, it is simply out of reach. Patricia’s family knows that, maybe not in so many words, but they know enough to make the decision they made. That is real world decision making and there is nothing more real then the developing world, where the good of the many always trumps the benefit of the few.

hot milk

9/10/16: I am drinking Radioactive milk!  I just couldn’t buy another can of Nido, the internationally famous powdered dry milk from Nestle which is found everywhere on the planet (even America). I have been drinking Nido for 6 yrs. now when I’m here and have never had a satisfying cup. However, it probably is responsible for keeping me alive with all its processed vitamins and minerals but it is not something you will ever crave. It’s just necessary.  So, this year I am trying irradiated milk from Europe.  No refrigeration needed, that’s a plus when there is no refrigerator. And it has an almost eternal shelf life even at African temps. It’s so ironic that Europe, which forbids GMO foods, allows its milk to be nuked and then sold in stores. But you know, it was good!  Just like milk back home and now my skin has a healthy glow…really. And last night I had a glass of milk before bed and I stayed warm all night. No sheet, no blanket needed; just my mosquito net. How bad could this be?  Really!

A Fractured Leg, A Broken Life

  To the reader:  Sorry to be so slow in posting. There are many stories, its the writing that is the hard part. This true story is from 2014. Attempts to follow up on the patient in 2015 failed. Now that I am back for 2 months I'll continue the search.


   After Sunday mass ( disclaimer: I go for the African mass music) I go visit a 28 yo man named Imani who was admitted during the night after a road traffic accident. He had a simple looking fractured tibia but now has a neurologic and vascular complication and cannot move or feel his leg or foot. His leg is massively swollen and I think he has Compartment Syndrome ( google that). I'm worried he will be crippled for life if I don’t do something or send him to Bugando Medical Center (BMC), 6 hours away on a bumpy road.  I discuss with surgeon on call. She has a rapid Swahili conversation with him. He has no pesa ( money), does not want and can't afford to go to BMC and  he also does not want surgery. And, just to complicate things I don’t think the surgeon wants surgery either. We will wait 18 hrs, I am afraid by then his leg will be too ischemic and he will be a one of those many dys-functional, handicapped people you see hobbling around here. This is the way it is.  I am familiar with the culture here. But I am still a visitor, still a guest. I can’t force or lobby hard here like I might be able to at home. If for no other reason then this:with my poor Swahili prolonged in depth dialogue with the pt or the family is impossible. And I am mzungu (white man).  We waited. I felt bad. Although I was not 100% sure Compartment Syndrome was the cause of his paralysis or that operating was guaranteed to make him better. I felt guilty for him loosing the function of his foot.

  The next morning with no improvement he changed his mind and agreed to surgery.  I took him immediately to the OR and with barely  sterile conditions we did a 3 compartment fasciotomy of his left leg.  By making 3 incisions down to and thru the fascia, the membranous sack that holds the muscle groups in your leg, it released the muscle which was swollen, engorged and dying because the pressure in the compartment was higher then the venous pressure. Since venous blood couldn’t get out, arterial blood couldn’t get in and the muscle was starving, dying. As soon as I cut thru the thin tight cellophane like fascia the muscle oozed out of its compartment like toothpaste out of tube. If you have ever traveled from sea level to Aspen you know what I mean. But in this case I had slit the tube wide open.  That muscle was necrotic and looked gray. Not the nice beefy pink you would expect. I reached under the wound and with a long scissor slit the fascia open inside, up and down the leg. We made 2 more incisions I opened the 3 major muscle compartments of the lower leg. Over the next few mins. the muscle started to pink up and ooze bloody fluid. It was over in 15 mins. That muscle was definitely under too much pressure. We did the right thing, the question was : were we  too late? We loosely packed the wounds and waited for the best. Besides sending him to Bugando Medical Center, there was nothing we could do but watch and wait.

   This is very hard for me to accept as a westerner. Maybe as hard for the patient to accept having a mzungu stranger tell him he wants to slice open his leg to make him be able to walk and feel his foot again. This is the part of poor country medicine we from the west have a hard time grasping. Sometimes there is no doctor, sometimes there is no nurse, sometimes there is no medicine. But sometimes its more simple then that. Sometimes there just is no money. There is no money for the hospital to offer “free” care. And there is no money for the patient, the patients family or the patients neighbors to pay. The result, Imani will be another poor crippled man. Another male who can not contribute to society, cant afford a family, cant pay taxes, cant contribute to an economy that wants to take off but is over burdened with uneducated, undertrained and thousands of crippled men. Men who despite their stupid behavior from fighting, drinking, and DWI cant get fixed and  then become the guys you see sitting around at mid day in every town and village,  crippled men. There is no Africans with Disabitities Act here.  The money spent on day 1 to take care of Imani would have been well spent compared to the lost productivity and social cost of another non productive male in this society.

    The fasciotomies helped but Imani’s lateral compartment never recovered. His leg swelling improved and the pain decreased but the muscle was irreversible damaged and the attempt to repair it was too late. I took him back to the OR 2 days later and removed lots of dead muscle from his leg. His calf muscle recovered but he never was able to move his toes or ankle.

   I found him a pair of aluminum crutches, a lucky break for him. There are no crutches here. People hobble around on a wide assortment of home made canes, single crutches made from branches or they have nothing. We don’t know this but this is how it was in the days before orthopedic and reconstructive surgery. Break a leg badly and you are a cripple for life. Break a hip and your bed bound for life or dead.

  Imani went home on day 8 with less pain and less swelling with 3 open wounds on a flexed dysfunctional leg with  his 2 aluminum crutches. He seemed happy to go home. Soon the realization will set in that he will not get better and he may still lose his leg. All because of unrecognized trauma from a” simple” fractured leg and no money to treat the resulting complications. The result: another broken life. That is the status of health care in this country today.