"When they get to Douala they'll be very tired"

I have a moment before my flight to send out one last blog entry. I'm back at the Baptist Rest House in Douala. The idea is to get into town plenty of time before the flight just in case there are traffic problems or breakdowns on the way from Bamenda. It is a nice place here to wait, a shady place to sit, overlooking the port and river, and with access to internet. On our way down we came up upon a bus with some pigs strapped to the roof. Now, this doesn't phase me too much, being that I grew up walking past a deer carcass hanging from the rafters in the garage every November (deer hunting season). The surprising thing was that as we neared the bus I noticed one of them move it's head. As we tried to pass at one point I heard them squeal. They are strapped to the top of the bus alive! There was a funny conversation in the car between our driver (Victor) and a missionary lady.

Lady: "Are they suffering?"
Victor: Nervous laughter "when they get
to Douala they will be very tired"
Lady: "When they get to Douala
are they going to get cut up and eaten?"
Victor: More nervous laughter

Heading home

I am now taking a short break from packing. I will be heading to Douala via Bamenda starting tomorrow morning. My flight takes off at 11:35 pm and I arrive in Minneapolis via Brussels/Chicago on Friday evening. I am really looking forward to seeing Christie again. I think our reunion might go something like this one. Anyways I did my final lecture of the month today on heart failure which I think was well received. The Cameroonian residents that I worked with were great. Very talented and eager to learn. In the picture from left to right are me, Dr. Anna, Dr. Francine, and Dr. Jam. I thought you would enjoy this sign that I found on the wall next to the lab. You might not expect this terminology to be used in a Baptist hospital, but in pidgin some words that we might find vulgar are just the words you use for certain bodily functions. I may or may not add another blog entry or two after I get back. Thank you to those that have taken the time to read these entries.

Sunday

On Sunday I went to church for the last time here and managed to take a video which I have included below. It is Thanksgiving here and as part of that people bring produce in addition to money as an extra offering. After church Dr. Palmer took us to Bamenda in his pickup and we had chicken and "jama jama." It has been nice to get outside the hospital and see a few things before I leave. From the perspective of the Cameroonian "residents" a residency really means residency (everybody lives at the hospital). I have a few more videos that I will post in a day or two so stay tuned . . .

Mbingo Hills

On Saturday after rounds we went out with Dr. Palmer to visit his horses which are being kept at a Fulani compound up in the hills above Mbingo. To get there we took his green Suzuki 4x4 up some rough back roads, until the road ended. Then we crawled under a barbed wire fence and started on a hike. It is not uncommon for Fulani people to live miles away from roads, only accessible by horseback or walking. On our way up it began to rain, and then as is frequently the case here began to pour. What started as a trail became a stream with water running down it. At first bounding from rock to rock to avoid getting feet wet became resigning ourselves to sloshing through puddles. We weren't going to let a little rain stop us from reaching our destination. Upon reaching a ridge that we were to hike along, however, the lightning started. A close lightning and an instantaneous thunder convinced us that walking along that ridge wasn't such a good idea. At least we were able to pass one Fulani settlement (picture below) and gave a child there some bubble gum. On our way back the visibility was limited by the rain and clouds rolling over us so we got a little lost, of course, but eventually got our bearings back and made it back to the Suzuki. We had to wait for an hour or so for the water level in the river that we easily forded on the way here to subside. Jennifer, a medical student from Kansas City arrived last week, and she brought a Flip video camera, so I was able to catch some video of the trip and embed it below; the upload is a little more pixelated than I had hoped.

"Maybe it's a holiday tomorrow"

Yesterday at dinner, the woman who cooks for me (Margaret) informed me that "maybe it's a holiday tomorrow."  This statement struck me for two reasons. First, what holiday occurs on a Tuesday in September? Second, what's with the "maybe?"  How do we find out if it is, or isn't, a holiday? "People will be looking at the moon tonight." Turns out it was announced at morning chapel, that yes today is a holiday and most people just went home.  I would think I'd like to know about the holiday before I showed up at work.  As it turns out, Eid, the day that the Ramadan fast is broken either occurs on September 30 or October 1 in different parts of the world depending on the sighting of the moon.  As it was a holiday I finished work in the hospital by noon and went for a hike up to the waterfall.  My plans on previous days had been thwarted by rain; because when it rains here, it pours.  The afternoon was sunny but I set out with an umbrella, just in case.  As I climbed the hill behind the hospital and neared the trail to the waterfall I could hear some thunder in the distance and hesitated whether I should go on or not. I figured I would go "just a little way further."  I worked my way up along a cliff and started to climb another hill. At this point I was close enough that I decided to keep going rather than turn back and give up the progress I had made.  As I finally made it to the top of the hill the rain was clearly approaching faster, and being that the hill I climbed was slippery when dry and likely treacherous when wet, and that I would be exposed to any stray lightning bolt I had to reverse course and get down the hill as fast as I could.  As it turns out the rain we got was only a sprinkle and I could have made it the rest of the way to the waterfall. I guess that will have to wait for another day.  Tomorrow we will discuss a journal article comparing fixed dose subcutaneous unfractionated heparin to low molecular weight heparin.  I offered this up as a possible article because it would potentially solve the problem of how to anticoagulate when you can't check ptt (our lab can only do INR) and you don't have enoxaparin (we don't).  Although just venous thromboembolism was studied I think given our limitations you could apply this strategy for acute coronary syndrome as well (a bit harder to diagnose/rule out since we don't have troponin!).

Halfway point

I realized the other day that I am halfway done with this month in Cameroon. The past two weeks have exceeded my expectations and I am surprised to find myself halfway. As much as I am enjoying being here I am looking forward to being home, and two weeks from now actually seems to be a long way off, however probably the next two weeks will go as fast or faster than the last two have. Today I showed the Cameroonian doctor I am working with how to use ultrasound to guide a thoracentesis. Never mind the fact that I had actually only done this once before, I made sure to exude confidence. Happily for all involved to procedure went perfectly, it turns out that we weren't using a long enough needle on our previous attempts. I managed to draw out what looked like pure pus, we sent it off for cell count, and by now I'm sure a surgeon has already put in chest tube. Minor procedures here are frequently (always?) done without local anesthetic. The patients are really tolerant of this, but you can tell they are in pain and would benefit from some lidocaine. I'm not sure if the pharmacy doesn't carry lidocaine, or whether it just isn't commonly used. You could say the best we have to offer is "ashia"-caine. The other day we did a lumbar puncture with the largest spinal needle I have seen, also without any local anesthetic. Both of these patients had important findings from the procedures so at least in their case I think the pain was worth it. The patient with the lumbar puncture turned out to have (probably) bacterial meningitis and is improving well with antibiotics. She also turned out to be a new diagnosis of HIV this admission. One good thing about this hospital is that we are able to offer much more to HIV positive patients than would have been possible a few years ago. We are able to offer antiretroviral medications for those who need them. They are obtained through the government of Cameroon who obtains funding for this through the Global Fund. There is also a new program, funded by the German government (who has historical ties to Cameroon), to offer subsidized health insurance coverage for HIV patients and their families. Health insurance is not a concept that is much used here. One of the doctors here said it is a lot better to work as a doctor now than a few years ago, because now we actually have something to offer patients, and the hospital wards are not as full as they were before the antiretroviral medications were introduced in this area. The pictures embedded show the OPD (out patient department) in the top picture, the hospital wards from outside in the second picture and one of the HIV clinics in the third picture. The fourth picture shows me doing an upper endoscopy (didn't expect to be doing that here). The endoscopy equipment just arrived and we have been working on getting it to work properly. On my left is Dr. Dennis Palmer, an internist who is starting the internal medicine training program at this hospital, on my right is John, the "turn talk." A "turn talk" is basically an assistant who helps keep patient flow moving, helps with understanding pidgin (or french), and calculates the patient's bill after you have written in the medications and/or tests for them to get done. John and I also spent some time this week figuring out how to calibrate and use the spirometry attachmed for the ekg machine that was recently donated. The computer said my lung age is 44 years old, hopefully we had just calibrated it wrong!

Critters

Here are a series of pictures of creepy critters I took in my room one evening. The final picture is a critter the screen door has so far managed to sucessfully prevent from getting into my room.

I just got back from the hospital where I was called with a couple of questions by the resident about a patient that came in tonight. I saw the patient as he was going by the laboratory on the way to mens ward. He was dehydrated enough that they couldn't find a vein to draw blood from. Rather than give up, they stuck his fingers and drew up the blood finger by finger with a mouth pipet! I remember hearing about this in chemistry class in college as something you shouldn't do and thinking, who would do such a thing? The last thing I would want to do would be to do this with somebody's blood, particularly a cachectic looking man in an area with a high HIV and Tb prevalance.

This week has been going fast, and I am enjoying my time here. I am seeing plenty of interesting cases. Today I saw a case of a guy exactly my age with severe hypertension and renal failure, he is soon heading towards dialysis, unfortunately dialysis is not an option here. Not that dialysis would be the first priority for health resources here at this point, but the rate of renal failure and a young age has surprised me. On a parting note, I listened to a really funny episode of This American Life last night involving Africa, you can listen to it on-line here