Saturday, October 27, 2018

Bahati Nzuri ( Good Luck)

WHAT HAPPENS WHEN YOU GET REALLY SICK IN RURAL TANZANIA AND NEED HOSPITALIZATION? 
THIS IS A STORY ABOUT HOW ITS DONE, WHAT IT TAKES AND HOW A LITTLE LUCK CAN GO A LONG WAY.


Bahati Nzuri (Good Luck)
What if you name was Luck? It is a common name in Africa.
Would it affect your life? And if so, for how long. Where does a little luck end and random chance begin?  How about the intensity of luck?  Does getting a flat tire mean that if you didn’t have some mild luck that flat tire could have been an accident…that killed you? Or maybe you have never had a flat tire or an accident. Does that mean you’re very lucky? 
And what about when your luck runs out?  Do you know that you’re running on empty, about to crash and burn? And what would you do about it anyway? Would it change the way you live your life? Maybe you would take out insurance. Where does good luck end and bad luck begin?  And finally, what is life like without luck?  Having no luck, good or bad is invisible time, the time you just don’t remember because we only remember the good and the bad times. The lucky and the unlucky times.  Luck the thread that is woven through your life. Sometimes golden, sometimes barbed wire. Sometimes creating a beautiful video of your life and sometimes creating a dark, underexposed, sweaty nightmare.
   Bahati is the Swahili word for luck. This is the story of a little boy named Bahati. It’s a story of chance and luck and the reality of being really sick in rural Africa. Bahati was a 12-year-old boy who was admitted to hospital one night with fever and abdominal pain. He was brought in by his grandfather, (Babu in Swahili.)  
   A little more about that name.  It is common in parts of east Africa to name a child after a US president. Just like you would name them after a saint, assuming your Christian. There are little kids named Washington and Jefferson. Clinton and Carter.  And, while George Bush, believe it or not, is very popular here because of PEPFAR, I have not seen any little African kids named Bush. And for that matter I have never seen a Regan. Of course, here there are plenty of Obamas and Barracks. Besides using historical or religious names its good form to name your child after a characteristic or a nice descriptive adjective. And so, the name Bahati is a beautiful gift to give a new baby. Here, more then almost any place on the planet, what more could a parent wish for their child? God knows, everyone knows, it will be needed.  We often say “bahati nzuri”, (good luck).  No one says” bahati mbaya”, (bad luck.)   Here, that happens enough; you don’t have to worry about not having enough bad luck in Africa.
   When I first went to see Bahati he was hot and his abdomen was tender all over.  He had not eaten for several days. No vomiting, no diarrhea. Everyone here with a fever gets checked for Malaria. But this was not Malaria. This could be Typhoid Fever, which is very common. That was my guess. But really, anything from appendicitis (rare here) to viral gastroenteritis (self limiting) to worms (common here) was possible. We sent off labs, ordered an x ray, started empiric antibiotics and IV fluids. Except for the fever his vital signs were OK. I closely examined his abdomen many times and felt that he hadn’t perforated his intestines, which can happen with Typhoid.  Knowing he might have peritonitis and was at risk to perforate I told his grandfather he might need surgery if he didn’t get better by morning. 
   Preparing for surgery is different here. There are no surgical consent forms here. I’m not sure Bahati’s grandfather had a signature to sign a consent even if we had one. There is no pre-operative surgical check list…. (Despite my best effort to make that a standard.) Change is hard here. 
    But there is a pre - operative discussion that takes place here that is unique. It often takes place outside the hospital. It involves the family, friends, neighbors, really the whole village in active care and that does not just mean, flowers, books and candy. A surgical hospitalization is a major economic and resource draining experience for family, friends, neighbors and fellow church goers…no matter what your religion. When I told Bihati’s Babu (grandfather) that surgery was likely the only way his grandson would get better Babu needed no coaching. He knew exactly what he had to do. Nothing happens here until some form of payment is received upfront. Everything is ala carte medicine. There is no credit card, there is very little insurance, there is no installment plan, and there is no bill mailed home after the hospitalizations. There are a million reasons for this system, starting very simply with this:  there are no mailboxes, there are no addresses. There is no insurance company negotiating payments with providers. A family member has to pay up front before therapy can start. There are exceptions, emergencies to save a life etc. But usually the family member has to go to the pharmacy, pay for the medicines, IV tubing and the IV and then bring them back to the bedside. Then the very busy nurse will give the correct meds, in the correct dose at the correct time to the correct patient…….hopefully.
   But for now, Babu had to go home, this night. Even with my bad Swahili he knew what was going to be involved. And maybe he had been thru this before with other grandchildren, children and relatives.  He had to mobilize his family. He needed money. He needed a blood donor. He needed a source of food and nutrition for Bahati after surgery when he, hopefully, would be recovering from surgery. There is no blood bank. Blood donation is best done on the day of surgery. Hopefully by someone who will match successfully. Then the blood is stored in the refrigerator and is good for a day or so. But the electricity will inevitably go out, every day, which will shorten the shelf life of the blood when the refrigerator warms. Speaking of refrigerators, food is another part of hospital care the family must supply. There is no hospital food service, no food delivered on trays that everyone gets to complain about as they recover ( a sure sign of good health!). There is no kitchen. It is the family that that supplies food, bedding, comforts……or doesn’t.
   There’s a lot that goes on here that I just don’t get, don’t see and maybe never will. Babu did not strike me as a guy who owned a car or could even drive a car. But when I went by Bahati’s bed a half hour later Babu was gone. When he left, how he left and how he was getting home are things I just never get an answer to.  Bahati was left alone in a dark ward, sick, with 7 other sick older men around him.  I worried about him; hopefully the nurse would bond with him over night. There’s something about cute 12-year-old boys who are trying to die that makes even the busiest nurse find time to fall in love with them.
    The next morning I was back early ….he was no better. He had spiked a fever during the night and he looked toxic. His blood pressure was OK, in part because I gave him almost 3 liters of IV fluid over night, but he now had a rapid heart rate. Here you have to rely on your physical exam and your subjective, intuitive sense to make the decision to go to surgery. I know toxic when I see it, it’s not something you can describe you just look and you know it.  Now his abdomen while not rigid or board like was very tender and distended. Bahati was very likely septic, had bacteria in his blood, which made him look toxic. If left alone he would die, antibiotics were very unlikely to help at this stage of sickness.  I talked with doctors and medical officers at rounds, I called the OR, we scheduled the case.  
    The decision to operate and when to operate have taken up a lot of surgical literature over history. Every surgeon fears making the wrong call and doing an inappropriate or poorly timed operation. That decision process is both more difficult and easier here. It’s easier here because there are few options. There is no CT scan or laparoscopic options to help with decision-making or alternatives to widely opening someone’s belly.  It’s simple; you’re on your own with little technology to help. The decision is more difficult because even if you do make the right choice and do it at the right time surgery here is inherently dangerous. Electricity goes on and off for no apparent reason, instruments are poor, suture is limited, blood banking is worrisome and things that are taken for granted at home are suspect here. For example, I am always suspect that the antibiotics we use are not really antibiotics…or are they really just black market knockoffs that contain sugar water instead of life saving medication.
    Babu appeared back at the bedside around 8 AM (mysteriously) how he got back, where he went, I don’t know but he looked like he had been up all night. When am I going to be let in on what really is going on around here??  He seemed happy to know we were going to the OR. 
    There was one test I wanted before we went to the OR. We loaded Bahati on his stretcher and stopped at the “X Ray Department” on the way to the OR. Besides a 1980’s Picker x - ray machine we had a 1990’s U/S machine. We took a quick look. The X ray from last night had shown no “ free air”.  Free air inside the abdominal cavity is a life - threatening sign that would suggest a hole in Bahati’s intestines was leaking gas, fluid and poop that then gets trapped inside the walls of the abdominal cavity. If the hole is not fixed the patient will die from peritonitis and sepsis. The U/S showed a large fluid collection in the abdomen with multiple small collections scattered about, a real abdominal catastrophe. These collections were probably pus. Where they came from I didn’t know but we were about to find out. After having the ultrasound, I felt re - assured we were making the right decision, doing the right thing at the right time. And I knew it was time to go when Bahati’s blood pressure started to sag during the Ultrasound. Bahati was in septic shock. We were late. It was time to go.
      The OR can be like heaven or hell. It is a miraculously wonderful place when things go well but can quickly turn to hell when things go badly.  Bad things can get compounded here when the lights go out or you just run out of supplies like suture, IV fluid or antibiotics or blood. We start every operation here with a prayer here. Sounds kinda crazy compared to the hi-tech temple I operate at in the U. S. where we have substituted advanced electronics for grace. But after you do a few operations here you are more than willing to recruit any and all the help you can muster. Personally, I was praying for a miracle, which is what we were going to need in this challenging, low tech, operating room. Two thoughts I had as we ended a prayer in Swahili and were about to begin were one: Thank you God for making this a sunny morning so even if the lights go out we can get by with all the sunlight coming in the big OR windows and two: I remember silently telling Bahati now is the time to cash in all the good luck chips he might have stashed somewhere that were associated with his name. ….he was going to need them.
   We opened Bahati’s abdomen and found liters of pus. We were worried that there must have been a hole in his intestines. But, after running, that is, carefully inspecting, all his bowel we came up with nothing. That was good news. The worrisome part was where did all this pus come from? This happens here. There is a described problem called spontaneous peritonitis. Pus in the belly not from a perforation but instead from infected peritoneal fluid often seen in patients with cirrhosis of the liver.  I also suspect Bahati had an abscess somewhere that eroded onto or seeded into his peritoneal space and then in that dark, wet, warm environment it just took off and would have killed him in another day or so with overwhelming sepsis. There is a lot of tropical pathology that happens here that doesn’t fit into my limited western surgical knowledge.
   We sucked out as much pus as the OR sucker could handle. Then washed out his abdominal cavity with 3 or 4 liters of warm saline. In the final liter we added a couple grams of antibiotic. We sloshed that around making sure we irrigated those special pockets in the abdomen where abscess like to hide, hoping for the best. I put a drain in and closed his abdominal wall. We left the skin mostly open; I put a few widely spaced sutures because of the likelihood of superficial wound infection.
  A famous surgeon once said the hardest part of surgery is getting the patient to the OR. Implying that once the patient got to the OR everything would be easy after that, that the surgery itself is the easy part.  For me the hardest part of surgery begins when the surgery is over, especially here, the hardest part is keeping the patient alive and out of trouble as they recover….assuming you did everything right.
   I was now irreversible bonded to Bihati. I was pretty much at his bedside for the next 24 hrs. I explained to Babu the uncertainties of what we found or in his case didn’t find. I told him Bihati could die and he had a 50% chance of a wound infection or going back to the OR for a second look if things didn’t get better. Bihati was sick as snot for 2 days. He was febrile and drained pus from his drain and thru his wound. His belly remained tender and very quiet. There is really no evidence that putting a drain in the abdominal cavity helps. But without good diagnostic help here like a CT scan I opted to use one in Bihati’s case. In retrospect the drain became a source of my increasing anxiety and dread as Bihati continued to smolder for two and then three days. Somewhere along day two the tube drainage just stopped. Not unusual, these things get clogged, bent, kinked. I wanted to pull it and decided, arguing with myself, to leave it for 12-24 hours and see what Bihati did with a clogged drain.  Nothing happened.  He didn’t poop, he didn’t fart, he didn’t burb, his abdomen just sat there, remained silent like a petulant angry child. Without lab work I watched his stomach and fever curve. Bihati was a tough kid. When he complained of pain the only thing he got was paracetamol  (Tylenol). He was thirsty but I refused to let him have anything but a sip of water. We waited. 
     On day three I pulled the abdominal drain. It was clogged. I hated that thing, just a source of worry. Wound drainage had slowed down but we still had to change Bahati’s dressing 3 times a day. This was a tricky time, things were about to get really worse….or maybe better. Many wound infections take off around post op day 7. If there was more pus re-accumulating in Bihati’s abdomen we were going to hear about soon. 
            A word on hospital care. Nurses here are too busy saving lives, medicating and monitoring  patients to do personal care. Toileting, bathing, eating all the things done to make patients comfortable are done by the family, friends, etc. ( remember?). There is no indoor plumbing here. Want to go poop in the choo (bathroom)? That’s a 30 meter walk down the hall and out the back door. That’s where Babu came in, he never left the bedside. He slept on a mat under the bed, took care of getting Bahati out of bed and getting him to walk, washing his one set of soiled clothes and just like us, he waited. On day four I saw the sight that still brings chills down my spine. In the dark hall, silhouetted against the light of the open back door of the ward was the dedicated, tireless Babu walking (dragging?) the brave, trusting Bihati down the hall to the choo. Seeing Bihati leaning against his Babu as they struggled toward the background light was about as hopeful a clinical and metaphorical sign as I could dream up.  Over the next few days it turned out this was not a dream. The metaphor was prophetic!   First Bahati pooped!  That was headline news on the ward. When you are in a small 25 x 25 ft. ward with six or seven other men there is nothing that your ward mates don’t know. Privacy is gone here faster than free minutes on your cell phone. Hard for us snobby, privacy, confidentiality obsessed , gotta have a private  room Americans  to understand but in many ways that is a good thing. There is certain commune of pathology here, a sort of we are all in this together, brothers in arms on the road to wellness that has unmeasurable benefits .  Often your ward mates will not only help you physically but they will help the doctors and nurses on morning rounds in clarifying the events off the night, especially if the patient is too sick to talk. The older guys watched out for Bihati not only because he was the sickest person in the ward but who couldn’t love this sick little kid?  It doesn’t take a MD degree to know that if Bihatis bowels started to work and his temperature came down he was probably going to make it. You can learn a lot just watching what happens to people when they are really sick and as they start to get better. The longer you stay on the ward the more you learn. Maybe getting an honorary degree to practice medicine….somewhere. 
    We were on a tear now. On post op day five  Bihati keep tea down and later wanted food. Babu somehow made up some ugi or ugali, a wheat-based cereal that everyone grows up and eats here, like Cream of Wheat. I refused to let him eat anything solid but broke down and let him have a few bites. The kid was hungry! He still could hardly walk mostly because he couldn’t stand up straight but something was getting better.  It seems people, especially young people, get better quicker here then at home. They have less pain, eat sooner, walk better and just seem to bounce higher. I am suspicious that this is not a race or genetic thing. I suspect it’s because we use no narcotics here after surgery. So, it’s just a cultural thing. People know, expect and accept pain here, it’s part of life. They see family members get sick and die. They raise animals and see them do the same. Pain is OK, it’s part of life. So, with no narcotics to make you nauseous, vomit and get constipated, after even the most major operations, you might just get better quicker. 
     By post op day 7 I couldn’t stop him from eating despite my fears……everything was working!  I sent him home with Babu on oral antibiotics. I was still freaked out about how much pus was in his belly, by how septic he had been, by how freaking lucky he was and wondered what might have happened if his name wasn’t Bahati.
     
Going home with BabuMacintosh HD:Users:lawrenceadrian:Pictures:iPhoto Library.photolibrary:Previews:2014:11:01:20141101-190301:5BdXknKBRJCQPvVS4BCs1A:IMG_4302.jpgMacintosh HD:Users:lawrenceadrian:Pictures:iPhoto Library.photolibrary:Previews:2014:12:25:20141225-132619:m0kI%FbwT3CN1PapSzF7vg:IMG_4212.jpg
Hungry on day 7

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