"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

The weekend

Happy Monday everybody. I'll take a moment here to talk about my weekend. One of the things I did was to walk down the hospital drive to the road. There has been a little market set up there. I think the market only exists because of all the people coming and going to the hospital and caregivers buying food for their patients. An interesting thing about this hospital is that every person that gets admitted has to be admitted with a caregiver (usually a family member). This caregiver is the person that makes sure things gets done and their patient gets fed as the hospital doesn't really have a meal service. Another example of something a caregiver might do is today we ordered a medication (praziquantel) which after the nurse checked with pharmacy it turned out we only had two pills left. We wrote the information on a small sheet of paper and the caregiver had to go to Bamenda to pick up a 3 days worth of medication. My main purpose of going to the market was to get a SIM card for my phone. I was on "back-up" call for the weekend in case the "residents" had any questions, but I had no phone in my house and there was no way for them to get a hold of me. I was able to purchase a SIM card (I think it was bootleg since it had already been punched out of the carton and there was no manual) and some minutes for 2000 CFA, or about $5. I apprecate that T-mobile was willing to unlock my phone a few years ago when I was in India, I have heard of other people not having had such luck with their cell phone providers. What the residents apparently do is "beep" you by calling, but expecting you not to pick up. You then call them back. The reason for this is that receiving calls is free, and we have more money for minutes than they do. Apparently this is a common enough practice in Africa that there is even a function through the phone carrier just to send a free "call me back" text message.

I spent some time the OPD (out patient department) on Saturday morning and I'm pretty sure my skin test will be positive when I return. A patient came in for "cough," although it turns out not only just cough but also weight loss, an infiltrate on chest x-ray and a positive PPD. He was already put on 4 drug Tb treatment (comes as a single combination pill rifampin, isoniazid, pyrazinamide, ethambutol) in Yaounde and came in because his cough was getting worse. Great, not only will I get Tb, but drug resistant Tb at that.

On Sunday I went to church. I The service was surprisingly understandable given my previous difficulties understanding Cameroonian "English." The service was two hours long beating out Park Avenue Methodist's service by a few minutes. I took a Sunday afternoon nap (haven't been able to do that for a while) and afterward went to the Spark's house for dinner. Dr. Sparks is a surgeon formerly at UCSD who is running the PAACS surgery residency here at Mbingo. We had homemade pizza and watched the movie "Amazing Grace;" it turned out to be the second time I've seen that movie and I realized it is a very good movie.

Rain, rain and more rain

This afternoon after dinner I ventured a little farther than I normally do away from the hospital, up a dirt track and stopped at a school yard where some kids were playing soccer. There was a view of a waterfall in the distance coming from the hills. In fact, on my way back from the school yard a young child walking along, who apparently knew I was "Doctor Dave" and informed me that we had "already met" offered to bring me there tomorrow. Well, I'm not sure if I will be finding him back (or more likely whether he will be tracking me down) but I will probably make it there sooner or later. Since this is up in the mountains the clouds were low and everything was very misty. A couple times today I wondered if I were currently dreaming. Whether the mefloquine is really affecting me or not I'm not sure. I actually had a dream last night that Joe Biden used to play for the Minnesota Twins and was crucial to their 1987 World Series victory, you can't make that stuff up. This does, however bring up an interesting question; would that influence anyone's vote? Anyways, speaking of Misty, I made a new friend last night. Mitsy the cat. Her owners have been away to the U.S. for at least the last few weeks so I guess she has gotten lonely. I was sitting out on the patio working on my computer when she decided to jump up on my lab and purr. Because I didn't want to contract rabies I immediately put her on the ground. Within seconds she was purring and up on my lap again. We repeated this sequence of events for a few minutes and eventually I tired of the game before the cat did (those darn cats can sure be persistent)she spent the rest of the evening sleeping on my lap. I guess she's lonely and I'm lonely; she misses her owners and I miss my owner so we make a good pair. My allergies did flare up today though. Thank goodness for loratadine.

It is still the rainy season here and it shows. Out of nowhere you will find yourself in a torrential downpour complete with lightning and thunder. Fortunately most of the walkways are covered so I don't get too wet. The rain can be a little depression though. It's Saturday tomorrow and apparently in Cameroon, or at least at this hospital Saturday isn't technically a weekend, so it will be up for 6:40 am chapel. Good night.

My "house"

By special request (perhaps my parents were concerned that my accommodations would be as bare as when I spent a month in Bangalore, India) I'll tell you a little bit about the place I am staying in. It is connected by patio to the house of Dr. Dennis Palmer, the head of the new internal medicine residency program here. As you can see from the exterior photo his house is on the left and the small place I am in is just behind the carport on the right. There is a covered patio with a short cement wall between the two. I have a small kitchen with a gas burner, a bathroom with a shower, including hot water (no more cold bucket showers for me!) and then separated by two large cabinets for my clothes a small "bedroom" with two single beds. I also have a desk which doubles as a place to sit and eat breakfast. I eat my lunch and dinner at the main guest house which includes a small dining room. So far the food has been good!

Mbingo

So today was my first full day at the hospital. Mbingo Bapitst Hospital started in 1952 as a Leprosy settlement. Because of its history it is located about a 45 minute drive from Bamenda, the nearest major population center. Although the hospital itself is isolated, the advantage is it is perched up in the mountains and has a beautiful view of the surrounding mountains and valley from most parts of the complex. Below is a picture taken from the front porch of the house I am staying at. The hospital has since grown and is considered a referral center with people even coming from the Doula, Cameroon's largest city, for consultations and admissions.

My day started at 6:40 am with me being introduced at chapel. I was quite surprised at how many people were there. It must be that all of the hospital staff go, and that there are more hospital staff than I realized. After chapel we have "morning report" in which the on-call resident presents one of the patients that was admitted the previous night. Today was a case of CHF exacerbated by medication non-compliance and alcohol use (did blue medicine follow me to the other side of the world?). After morning report the head social worker took me on a 2 hour tour of the hospital and I was introduced to too many people to remember. Afterwards I went on "rounds" with one of the internal medicine residents (Dr. Jam) and Kara Beth Thompson, a recently graduated FP who is spending two years here working with the residency program. It turns out the women's ward is now "my ward" and I am the "attending." With this realization that I am responsible for this ward I made a beeline for my computer and began researching a couple of the complex cases (what would I do without UpToDate?). Everything is made more difficult by the fact that #1) I don't know which medications are available and which ones are not #2) I don't know which lab tests are available #3) although I do speak English, I don't speak Pidgin English and #4) I will have to take care of pediatric patients. Fortunately the resident I am working with has been a general practitioner for several years and I'm sure with any questions I can always ask one of the family practice doctors that have been here for a while. At 3pm every day we have a lecture for the residents. I will be the one giving Friday's lecture.

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Car trouble

I'm now back to my precious internet! Apparently the hospital gets it by satellite and then has established a wireless network. I never would have expected that. Back to the story . . . yesterday was the drive from Douala to Bamenda (in the Northwest province of Cameroon). When Vincent, my driver, first picked me up at the airport I took a look at his car and wasn't sure it would make it all the way to where we were going. After a couple hours it turns out I was right. We pulled over to the side of the road and fortunately he was more resourceful than I would have been. There was a leak in the radiator hose, so after removing the "do not remove while hot" cap and letting the hot steam come out, he went for new water to refill the radiator. We were able to make it to the next town where after a short pitstop he was able to patch it back together and we were on our way! The picture below was taken when we were stuck on the side of the road (you can see Vincent coming down the road with the new water.

You will notice on the right side of the road a sign warning you about the coming speed bump. These aren't any ordinary speed bumps, the car literally scraped bottom when it would crawl over them. Maybe they could be more accurately described as speed mountains. At one point there were 5 in a row (a speed mountain range?). Comparatively the driving in Cameroon was not as crazy as India, but perilous nonetheless.

Made it to Douala!

After a long and arduous journey (just kidding) I have finally arrived in Douala, Cameroon. Tomorrow I will take the 5 and a half hour trip north to Bamenda and then 45 minutes more to the hospital in Mbingo.

On my flight from Brussels to Douala the lady who was sitting next to me, who only spoke French, had a bit of a syncopal episode. I was able to use the "I'm a doctor" line which seemed to put all the flight attendents at ease (little did they know). They were able to frantically (and usually forgetting that I didn't speak French) ask me all the questions a doctor should be able to answer when someone passes out on a plane over the Sahara desert like "is the cabin too hot?" or "should we bring her a blanket?" or "do you think she got too excited?". Fortunately she recovered quickly, and I asked a few standard questions (to try to reassure them that yes I really am a doctor). My Rx; give her some water, and stop giving her alcohol.

To cap the day off I think Doula is indeed the worst airpot I have been to. The customs process, instead of forming lanes, involves a mass of people trying to pack their way through a small doorway, and customs agents grabbing bags randomly to inspect as you pack through the narrow passageway. To top it off a guy about my age trailed me throughout the whole process offering to carry my bags for "50 euro". He also really thought I should pay the customs agent "50 euro" to let my bag through. Fortunately another customs agent told me I could go so I wrenched my bag out of the hands of the one that wanted "5o euro" and scampered my way out of the door into the waiting mass as fast as I could. Hoping to assuage any fears that I might be getting scammed the first guy, whom I literally had to slap his hands away from my bag, proclaimed to me that he was a proud supporter of Barak Obama.

Thankfully I am now in the European Baptist Rest House walled off from the rest of the city and including gardens and even a pool! Maybe I will take a dip later. If you put this in the context of a 30 hour call shift it is about 1:30 PM our time, coming up to about time for my "post call nap." I maybe would even be frantically putting in discharge orders and dealing with the CCU nurses at this point in the day. I think I prefer a flight to Africa over being on overnight call any day of the year.

Officially on my way

So I'm officially on my way, and I've officially put more entries on this blog than my previous attempt at blogging. I'm actually sitting in a food court at O'hare airport (the wonders of WiFi). My flight from Minneapolis to Chicago was, of course, delayed an hour and a half. Unfortunately we didn't learn of the delay until we are all on the aircraft, in effect turning a 1 hour flight into a 2 1/2 hour flight. I guess that's nothing compared to what's coming, an 8 hour flight to Brussels then a 6 1/2 hour flight to Douala.

Christie and I at the Minneapolis airport

At this point I'm in a state of anticipation, not knowing exactly what to expect. Of course there will be similarities to other countries in the developing world, and we have all seen Africa through the eyes of television cameras and photography, but beyond that all I can do is wait until I get there.

Pre-trip preparations

Hi all, It's a week before I leave and I'm getting everything ready. Right now I'm in a coffee shop procrastinating preparing some lectures to give the internal medicine residents while in Cameroon.  What better way to procrastinate than setting up a blog! We'll see if I keep this up.