I need to find another Anglophone in Djibouti

June 16th, 2010 by MSF Field Blog

I feel like I have PMS, but it just isn’t that time of the month. So, I think it must be SLS, Second Language Syndrome, which is characterised by constant small misunderstandings; occasional straight-up “Honestly, I have no idea what we’re talking about,” admissions at meetings when your boss surveys the room with his eyes seeking consensus and you realise you’re about to put your stamp on something when in fact you couldn’t name whether that thing is animal, vegetable or philosophical; and overwhelming fatigue when faced with the evening’s gameshow entertainment, piped in from France, indecipherable and featuring questions not covered in your Canadian Education or cultural experience.

Other common features of SLS are a tendency to abruptly switch to your maiden tongue when excited, either out of joy or frustration, and an unconscious up regulation of mime skills and tendencies towards physical comedy.  Strangely, rather than emphasising country of origin, manifestations of SLS tend towards an international median featuring a stereotypically Italianate physicality, an Eastern European morose temperament, and, luckily for my current geography, African punctuality, as it is a common occurrence to not know that something is happening until colleagues are actually on their way there. Headaches are frequent, a result of squinting at people’s practically stationary mouths and willing them to enunciate. Feelings of self-doubt and lack of efficacy are pathopneumonic.

The up-side: new sympathies abound.  For immigrants—what courage to choose a lifetime of this!  For those with impaired hearing—I feel you straining. For anyone who has ever put their foot in their mouth or simply tripped over their own lips while trying to form some unfamiliar syllables—yes…me too.

My current treatments are pulp fiction and canned radio and lectures. I’m also thinking of implanting an early-birthday gift, “Phone the Anglophone” campaign aimed at friends and family, figuring that at the 43 cents per minute Skype-Djibouti Rate everyone could phone me for half-an-hour and skip the box of chocolates or bottle of wine come November. In the meantime, thanks be to CBC radio itunes: I’m going to go listen to “Dave Cooks the Turkey” one more time.

A good day.

June 9th, 2010 by MSF Field Blog

I woke up to see that the little girl was back to breastfeeding, just three hours after needing adrenaline for a slow heart rate. Yay! It’s a good day :)

“Glucose. We need a glucose.”

June 8th, 2010 by MSF Field Blog

“Dr Courtney.  Il y a un urgent a l’admission”

I looked up.  Moussa de L’Admission, as he’d introduced himself on my first day, did not tend to mess around.  His ‘sick’ pretty much always meant ‘sick’.  I quickly gathered the chart that was spread out on my lap at the head of a bed in Phase II, where the happy, bouncy, almost-home kids stay, and followed him out under the tent flap.

In the open, covered, admission area, I saw the moms and babes sitting on benches, looking for the one Moussa had been talking about even as he moved towards them.  You can usually tell a sick kid from the doorway.  Sure enough, there was a little one held oddly, floppy and arched, in her Mom’s arms, who seemed at first to be suckling her breast, but who had a funny kind of latch.  As I got closer, I could see that the babe’s mouth wasn’t actually sucking at all, but was open, moving in a semi-automatic looking jaw motion.  Her eyes were open, but doing a sort of saccadic movement, not focusing.

I gazed at her for about three seconds. “OK.  On les amène a la salle de réanimation.”

Moussa nodded.

We bustled the child in.  A young nurse, Abdi, took the child.

I met his eyes. “Glucose.  We need a glucose.”

Quickly, he pricked her finger and put it in the little glucose-o-meter.  It was low.

While Abdi tried with the IV, I went and got some D50, a concentrated glucose solution, and dribbled a few drops into the child’s mouth.  She did seem to perk up a bit.  He eventually couldn’t get the IV so he held her while I put down my first Djiboutian naso-gastric tube.  At home I usually stand back during resuscitations and try to be hands-off, but we don’t always have the hands here so I’ve been trying to practice some of the common procedures.  Putting the tube down wasn’t a problem…tricky tape job though.  Abdi took over.  I’d had it the wrong way.  D50 went down the tube.  I felt better.  Abdi got the next IV attempt.

I looked again at the babe.  She was making a funny movement with her mouth and eyes: her mouth miming a suck, her eyes darting side to side.  She seemed to be going in and out of consciousness: when the abnormal movements ended she’d look up at you and fix her eyes on a light, even though she was still very sleepy.

It was hard to tell, but it looked as though she was having intermittent seizures.  Her belly was supple, her breathing fine.  Meningitis?  Sepsis?  Was it the hypoglycemia?  No nasty skin rash.  It seemed to get a bit better after the glucose, so after getting a bolus and antibiotics started, I left her with Abdi and went back to try to take some history from Mom.

We took a closer look at the babe.  She was still making strange movements from time to time, and her vitals were totally out of whack.  She was needing sugar a few times an hour and seemed to be on the verge of passing out.  But she was breathing spontaneously.  And she wasn’t getting any worse – she seemed to be getting a bit better, if anything.  I stood there watching, trying to think of what to do next.  But all the nexts were from a distant land of laryngoscopes and CT scans.  So I propped the bag-valve-mask up at the bedside, drew up some adrenaline, calculated her dose, and left it in the afternoon nurse’s pocket with strict instructions to phone me if she got worse.

I went to a meeting. My brain whirled around thinking about her continuously.

Draped with children

June 6th, 2010 by MSF Field Blog

Today in the ‘phase 2’ tent, I make eye contact with one of the moms. I am glad – I miss adult medicine and taking care of the moms, as much as I can in a hospital geared to kids, is kind of nice.  This mom has smart eyes and a grace about her—we’ve been caring for her child for about a week.  In the absence of language I’ve been drawing conclusions about all these ladies by watching how they soothe their kids, how patiently they wait to funnel the milk into their little toddlers, the look in their eyes as I talk to them.  I’ve taken to speaking to them as though they can understand me, eye contact and gestures and all, then pausing while the nurse or nutritional therapist translates. I think it helps us get one another.

She approaches with one babe in her arms, a slightly smaller one slung across her back, and her pregnant belly making a loop in her flowing robe.  She shows me her medical record from the government doctor next door. She’d had belly pain and been dizzy so we’d sent her over to get checked out.  She wants us to know that we’d given her the iron he’d recommended for her anaemia, but that she still had belly pains.  I check over the record—she was at about 24 weeks of gestation, and her blood pressure and urine had been normal.  There is not a lot else you can do to at that point except drink fluids and try to stay comfortable. So we gave her some paracetamol to help keep her comfortable, and watch her walk away, draped in children, externally…and internally.

Inaugurating the TB tent

May 29th, 2010 by MSF Field Blog

The muezzin’s call is crackly over the loudspeaker.  I was jerked awake by thoughts of our little guy in the new TB isolation tent.  He’s here with his mother, a woman whose dramatically-beautiful face is emphasized by three small decorative scars under each cheekbone. Her shoulders are bony under her robes.  This, combined with a wretched cough, meant that Dr Modeste decided that day to admit them to our brand new TB tent.

It turns out that Djibouti has the second highest prevalence of TB in the world.  Last year, we found about 150 new cases of TB in the kids admitted to the CNTH. Luckily, kids with TB aren’t that contagious: they don’t end up with much of the contagious bacillus in their sputum and so don’t need to be isolated.  But the kids have to get it from someone, and that someone is usually family, and each child here stays with a family member.  This means that there are coughing adults amongst malnourished kids with limited immune systems. So the project realised it needed to set up a more formal TB arm to help isolate and diagnose the moms as well as take care of the babies.  Hence, we have the TB isolation area, which is just now getting set up.

Little Ahmed started to desaturate earlier this evening, and we realised it was time to move an oxygen concentrator into the TB tent.  Fabien, the logistician, figured the small electricity supply currently set up would support it.  Ahmed is in there now, on IV Ceftriaxone and Cloxacillin, breathing away.  His heart rate hasn’t changed much since admission, and he doesn’t have a fever.

The muezzin calls again now.  I wonder if that’s a bit like the snooze alarm of prayer.  I am going to do the opposite.  Try to snooze.  I have discovered that going over the continent of Africa in my head is a pretty good way to drift off to sleep.  I started memorizing it from the bottom because that part is easiest to see from the chair of my desk.  I’m on Mozambique.

A very curly creature

May 28th, 2010 by MSF Field Blog

The humidity here is through the roof.  My hair is….a creature.  A very curly creature.  There are goats out my window, and kids playing soccer in a tin can and remains of buildings strewn next door. A group of young men sit in a circle on upended dried milk cans, chatting in the shade of a tree.  An hour ago everyone was napping.  You have to.  People keep telling me that the hot season hasn’t arrived yet.  Awesome.

I and two-thirds of the approximately 700,000 people in this country live in Djibouti City.  The rest of the population are nomads who roam the hinterlands and eke out a subsistence.

Why is MSF here? UNICEF and the Djiboutian government realized in 2008 that there was a nutritional emergency in Djibouti City and put out the call for help.  In response, MSF came and set about opening up a program to treat severe malnutrition in kids aged from 6-59 months.  Basically, because Djibouti City is such a transport hub, everyone comes here on their way to somewhere else, and usually lives in very precarious circumstances during their stay.  There are Somali and Ethiopian refugees who are on their way to Yemen and Saudi Arabia, and nomads who come to town, often because life has been too hard for them outside of it.

So.  Malnutrition.  What do we do about it? We run a paediatric malnutrition program set in the slums around Djibouti City. Our patients are about 50-50 locals and immigrants or refugees.

First, there is a group of local community workers who go door to door in the slums to find malnourished kids.  They then refer these kids to one of the six ambulatory care centres, which are scattered throughout those neighbourhoods and which are run in conjunction with the government.  There, the kids are seen once a week, weighed, screened for disease, and given a week’s ration of lentils, rice, oil, and….the famous little pouches of micronutrient-enhanced peanutty-milky-goodness. This humble paste, much like a sweet peanut butter, has basically revolutionised the treatment of malnutrition by providing an alternative to the nutritional milks that need to be prepared carefully under semi-sterile conditions.  So whereas nutritional programs used to have massive wards and require long stays in hospital, we can now manage a lot of kids in the community.

But, some of the kids do get sicker. Those are the ones who get referred to where I work, the CNTH or Centre Nutritionnel Thérapeutique Hospitalière, the centre of soins intensifs–the intensive care unit (ICU).

Wait a second, you might be saying…I thought MSF worked in the bush.  What are you doing in the city?  It turns out we’re kind of a pilot project.  Worldwide, the movement of people from rural life to urban centres is flooding cities and creating massive slums, like Balbala, the one we work in.  Living conditions are so horrible that they are approaching the life-threatening conditions previously only seen in rural regions during times of disastrous harvest, or in war-torn contexts.  MSF, with its mandate to respond to emergencies, is beginning to expand that to include urgent urban situations.  So it is trying to figure out how to do bush medicine in the middle of the city.

I’ll be trying to figure that out too.

A bad day

May 23rd, 2010 by MSF Field Blog

We had a patient who stopped breathing today.

The poor little guy was sick from the start.  He was four and he had kwashiorkor, the kind of malnutrition that causes swelling.  The swelling is mostly salt water, and as we treat the kids all that extra salt water makes its way into their blood stream and has to get pumped around by their heart and then eventually peed out.  The problem is that the poor heart hasn’t been fed either and is barely capable of dealing with its normal job, let alone all that extra salty water.  So sometimes the pump fails, the fluid backs up into the lungs, and they end up in heart failure.  Unfortunately, kids with kwashiorkor are just as susceptible to all the other illnesses as all the other malnourished kids.  This little one came in with low haemoglobin last week, got a blood transfusion, and seemed to be doing better for a while.  Then he got nauseous and started vomiting, and we noticed that his liver seemed to be enlarged.  So we sent him for an ultrasound. It basically said his liver was inflamed, but didn’t say why.  We ordered some liver tests then, but first the lab was closed, then we didn’t have a ‘tube sec’ to draw into.  This is the way of it.

Yesterday, the little guy was retching.  His abdomen was distended but soft.  We checked his blood counts again and gave him some symptomatic treatment as we waited for his liver tests to come back.  Modeste, the other MD, who was on call yesterday, put him on some broad spectrum antibiotics last night because he was looking worse.  His urine output had decreased too.  We figured he had an infection in his bloodstream.

He didn’t pee overnight. We were called when he didn’t wake up with the AM vitals.  We walked in. he was breathing, but his level of consciousness was decreased. His sugar was low.  We did everything we could.

It is not a good feeling to watch a child stop breathing.

Kids don’t die in my medical world.  My husband is a year away from graduating from a Canadian paediatrics residency and has had to rush to every resuscitation done in the hospital, to be one of dozens of spectators, all in an effort to practice what almost never happens.  He just ran his first resuscitation two weeks ago.

I glanced over.  This child’s mother had been sitting just behind the curtain on another patient’s bed while we tried to resuscitate her child.  She had her leg up beside her. Silent.

The mother came over.  Quiet.  Neither matter-of-factly nor stiffly nor agitatedly did she draw the blanket up over her child’s face.  She simply kept breathing and did that while she was breathing.

Our tent city

May 21st, 2010 by MSF Field Blog

So…a bit more about our tent city–the Paediatric Malnutrition Intensive Care Unit, or ICU.   We work in three massive tents set up in the yard of the Red Crescent. There is a gravel path and outhouses. We can do bedside glucose and haemoglobin and provide oxygen up to 5 L/min. We’ve got lots of antibiotics and naso-gastric tubes and IVs and blood transfusions as long as we send two blood donors to the blood bank for every transfusion we request. In exceptional circumstances we can refer a child for an X-ray or ultrasound at a private hospital nearby, or ask for a consult regarding potential TB and HIV, but for the most part, those are our tools.

Of course, kids are no different in Canada than they are in Djibouti.  ICU here, ICU there – we take care of the same little ones.

The thing that saves us, and the kids, is not sexy.  This thing is…..The Protocol.  (My capitals.  Out of respect). The Protocol is clearly the labour of love of a very dedicated and extremely nerdy team of infectious disease and paediatric experts and is a comprehensive document which attempts, by working with the law of averages, to give you a way to care for most of these kids, most of the time, under field conditions.  (It is 212 pages long.  I am currently trying to memorise it.  I have suddenly discovered a very enjoyable novel set in turn-of-the 19th century England that is hampering this goal.  I am working on my self-discipline). It sets out what to do in pretty much every clinical situation, and backs up its recommendations with stats and evidence.  Having expected to end up doing pretty sloppy medicine once I understood our technical limitations, I am actually extremely impressed with the rational way we can function with The Protocol as guide.

Arrival in Djibouti

May 16th, 2010 by MSF Field Blog

We stepped out of the airplane into tropical air and it was so hot I burst out laughing.  It was 31 degrees at 2am and thick with moisture.  So hot, so humid, the air itself was alive.  I just kept giggling.  6 months, eh? My backpack appeared, top-bit partly detached, but contents held in by my Goretex hat, of all things. Nothing seemed to be gone.

I looked out into the waiting room.  There was a lanky, almost skinny guy with an MSF t-shirt.  He was tanned and sweaty and unshaven just like he was supposed to be.  He had clearly figured out who I was and looked sleepy in his flip flops. I liked him instantly.

C’est moi, Courtney.  Merci d’avoir venu!” (“Courtney, it’s me. Thank you for coming!”) I extended my hand.  I really was touched that someone from the team had actually bothered to come get me in the middle of the night.

Bonjour.  Fabien.”

We went out to the van. OK, I’m sorry, but I can’t express how exciting it was to get into the MSF van.  I was beginning to feel like I was on a real mission (how embarrassing is that, like a med student with her first stethoscope).

We arrived at the compound, with its decorative doors.

Fabien showed me to a room. Double bed with mosquito net.  Desk.  More than I’d expected.  Then he turned on the air conditioner.  Definitely more than I’d been expecting.

He left.  Too excited to sleep and thinking of my three-day-squished crinkled clothes, I set about making the room my own.

16 May 2010

Arrival in Djibouti

We stepped out of the airplane into tropical air and it was so hot I burst out laughing.  It was 31 degrees at 2am and thick with moisture.  So hot, so humid, the air itself was alive.  I just kept giggling.  6 months, eh? My backpack appeared, top-bit partly detached, but contents held in by my Goretex hat, of all things. Nothing seemed to be gone.

I looked out into the waiting room.  There was a lanky, almost skinny guy with an MSF t-shirt.  He was tanned and sweaty and unshaven just like he was supposed to be.  He had clearly figured out who I was and looked sleepy in his flip flops. I liked him instantly.

C’est moi, Courtney.  Merci d’avoir venu!” (“Courtney, it’s me. Thank you for coming!”) I ex

16 May 2010

Arrival in Djibouti

We stepped out of the airplane into tropical air and it was so hot I burst out laughing.  It was 31 degrees at 2am and thick with moisture.  So hot, so humid, the air itself was alive.  I just kept giggling.  6 months, eh? My backpack appeared, top-bit partly detached, but contents held in by my Goretex hat, of all things. Nothing seemed to be gone.

I looked out into the waiting room.  There was a lanky, almost skinny guy with an MSF t-shirt.  He was tanned and sweaty and unshaven just like he was supposed to be.  He had clearly figured out who I was and looked sleepy in his flip flops. I liked him instantly.

C’est moi, Courtney.  Merci d’avoir venu!” (“Courtney, it’s me. Thank you for coming!”) I extended my hand.  I really was touched that someone from the team had actually bothered to come get me in the middle of the night.

Bonjour.  Fabien.”

We went out to the van. OK, I’m sorry, but I can’t express how exciting it was to get into the MSF van.  I was beginning to feel like I was on a real mission (how embarrassing is that, like a med student with her first stethoscope).

We arrived at the compound, with its decorative doors.

Fabien showed me to a room. Double bed with mosquito net.  Desk.  More than I’d expected.  Then he turned on the air conditioner.  Definitely more than I’d been expecting.

He left.  Too excited to sleep and thinking of my three-day-squished crinkled clothes, I set about making the room my own.

tended my hand.  I really was touched that someone from the team had actually bothered to come get me in the middle of the night.

Bonjour.  Fabien.”

We went out to the van. OK, I’m sorry, but I can’t express how exciting it was to get into the MSF van.  I was beginning to feel like I was on a real mission (how embarrassing is that, like a med student with her first stethoscope).

We arrived at the compound, with its decorative doors.

Fabien showed me to a room. Double bed with mosquito net.  Desk.  More than I’d expected.  Then he turned on the air conditioner.  Definitely more than I’d been expecting.

He left.  Too excited to sleep and thinking of my three-day-squished crinkled clothes, I set about making the room my own.

Photos

May 1st, 2010 by CourtneyH
Me and Jerry, our Congolese Ex-Pat Nurse and Guru of Ambulatory Care in Malnutrition, on Day 1

Me and Jerry, our Congolese Ex-Pat Nurse and Guru of Ambulatory Care in Malnutrition, on Day 1

Dr Modeste at Admissions gathering stats for the monthly report

Dr Modeste at Admissions gathering stats for the monthly report

The CNTH. Note shadow-net or filet-a-l'ombre floating above. I didn't know there was such a thing before arriving here. Is now key to life.

At Admissions. And people keep telling me the hot season isn't here yet.

At Admissions. And people keep telling me the hot season isn't here yet.