Just a little bit lost and a little bit sad

Dear friend,

Today marks the halfway point of my trip. Apologies for the delay in update but I think I may have been subconsciously avoiding writing a post. A piece of wisdom my mum gave me as a young’un, “If you don’t have anything nice to say, don’t say anything at all.” And that’s definitely where I’ve been as of late.

I’m not sure why I’m struggling so much, but I am. Maybe I shouldn’t be writing straight after a(nother) bad day when the Sunglasses Gloomy are tinting everything a different shade of grey.

Where do I start? It all feels very messy and illogical. I like things to make sense: A + B = C, therefore C – B = A. Yet despite reflection and prayer it continues to elude me.

I’m not sure what my role is here. De facto, it’s whatever I want it to be. I thought I wanted it to be that of a surgical registrar, but it's hard when the expectations of you remain inexplicit. Without a clear role you have no idea if you’re doing what you should be or performing as you should be; whether you are doing well or not-so-well. There are no successes to celebrate nor any certainty over failures. A metaphor for this country, I seem to have no landmarks to guide my way.

I guess all this reflection stems from the fact that I made my first “surgical registrar” mistake on Wednesday.

Each day here is chaotic. On top of the wards and the clinics patients just seem to appear all around you, constantly. To make matters worse, so many of them are perfectly well, complaining of non-specific aches and pains (a pandemic!). It’s frustrating when you have an afternoon at clinic with patient after patient whose presenting complaints are, “Chest pain, ribache, neckache and backache.” How long has this been going on, you ask. Oh, years. Years! Then when you exam them they exaggerate their response, crying out in pain and grimacing at the lightest touch of their tummy (this is after jumping up onto the examination bed without any pain whatsoever and with no response whatsoever if I ask my translator-nurse to distract them by making small talk). One after another they make for long afternoons at clinic. Although, can you really blame them when the simplest of pain relief (paracetamol) is like gold here. Even Kalene is struggling with a lack of supply of paracetamol and ibuprofen, reserving them for post-operative patients because that’s all we have for them! The occasional oral codeine or tramadol. But imagine having major abdominal surgery and all you have post-op is brufen! Life, here. But I digress.

So in the context of another chaotic day I reviewed an older woman who, as soon as she saw me (the doctor) walk into the room, started crying out in pain and writhing around. Her history was of two days not opening her bowels and severe (Severe! She says) abdominal pain. Maybe one episode of vomiting. How often do you normally open your bowels? Oh, once every one to two days. Do you have a history of constipation? Oh, sometimes. When I tried touching her tummy ever so softly she started crying out in pain. Where is it sore? EVERYWHERE!

Sigh. A quick rectal exam later, which confirmed she had some constipation, I was happy to watch her over the day and if she settled, discharge home on pain relief. (No laxatives because we have none! Can you imagine a hospital back home without laxatives?)

The next morning, a theatre day, debriefing with my charge nurse about concerns on the ward before heading to get changed, she mentioned that the same woman I had reviewed yesterday might be going to theatre. For what? I asked. Bowel obstruction (=completely blocked system; very serious!).

Sigh. No way.

Nowaynowaynowaynowaynowaynowaynoway.

NO WAY.

No.

While scrubbed up for our first case in theatre one of the nurse brought that patient’s Xray, which showed classic signs of obstruction (=air-fluid levels). We proceeded to take her for a laparotomy (=opening up the tummy to see what’s going on), which showed a caecal volvulus (=twisting of some bowel).

No way.

Yes, I was (am) embarrassed. Yes, I let “constipation” lead me astray. Despite every Emergency Department Consultant telling us over and over again never to diagnose a patient with constipation. But I think the worst part of this whole experience is… Dr J reviewed the patient half a day after I did at the request of the charge nurse. He must have read my note. Yet he (as a consultant surgeon with a wealth of experience, I know, I know, I can't really compare) picked up on the possibility of an obstruction straight away. And he was right. No harm was done in the end with the safety nets in place, but I just know that if I were a surgical registrar back home I would have gotten a good talking to in the very least. But here, am I house officer? Am I a surgical registrar? Did I make a mistake? Or did Dr J not expect anything “more” of me in the first place? The worst part of this whole experience is that I remain unsure of whether I failed in my role or not.

I have berated myself enough to (clinically) learn from this mistake and take from it what I should… but I haven’t been able to debrief. Maybe there really is just absolutely no expectations of me here. But if that's the case then how do I do a “good job”? Does it even matter? Do I really need that affirmation? I thought I was more “independent” than that? Or is it just a basic human need, this desire for, "Well done, Anna"?

It’s hard when you have no one you can talk to who can relate. The only other doctors are the two much older, male consultant surgeons. Lovely, sure, but attempted deep and meaningfuls wouldn’t be particularly comfortable for either party.

Apart from this not-so fun experience this week I am struggling with being in such a remote place. There is no “getting away” to clear my head. Apart from my runs there is time or space to myself. I am at work ten hours a day, six days a week, and the only Zambians I interact with are those with complaints and need something from me, and/or unsolicited visitors knocking on my door wanting something from me. As a result I fear I might be developing a conditioned response to the locals here before they even approach me – please, leave me alone for just one second…!

I recognize this as unhealthy. Most definitely. But how do I go about rectifying it? When I’m working as much as I am and there’s nowhere else to go, nothing else to do? When I’m seemingly the only one who feels this way? 


When the one baby I have "let in" has led to heartbreak?

Day 30, Case 4 continued

(Albertine, you’re breaking my heart)

An update. Last week Albertine’s mum also started to develop severe neuropathic (=nerve) pain from the waist down. On Monday ward round she was distraught – she now had weakness in both legs and was hardly able to stand. By Wednesday ward round she had no strength in her legs at all. Today she reported incontinence, a bad sign associated with a very poor prognosis.

I try not to compare things here to back home. That kind of thinking is futile and distracting. Yet something about this woman, about this case, just seems to get to me in a way I cannot describe. If this woman were back home, or any Western country, her Xray would have had the immediate attention of a handful of spinal specialist surgeons and after a series of MRIs and other imaging she would have been operated on by now and on her way home!

Her family, this week, have been adamant that they want to take her home, back to the Congo. It’s understandable. But I cannot fathom for the life of me how they will travel back. It’s a three-day journey by foot. Apparently they will take her on the back of a motorbike. The glaring question being, how do you keep a paralyzed 60kg woman on the back of a motorbike for hours over bumpy dirt road? And if they miraculously are able to make the journey back home, how will a paralyzed woman survive in an environment that necessitates walking? Walking to bathe, walking to wells, walking, walking, walking.

Today I am angry. How do we allow such injustice to exist, to prevail? The frustrating part about all this is that I am, by nature, a problem fixer, the problem being INJUSTICE. LET ME FIX THE INJUSTICE! Just tell me what I have to do, please. Just tell me the answer and I’ll do it.

...if only it were that simple.

I have been able to negotiate a few days with Albertine’s family to buy some time for me to source her a wheelchair. I am determined. I am a lady on a mission. I will not let her leave here without one. The hospital only has a few (very old) donated wheelchairs in circulation – precious commodities, like everything seems to be here. (Oh, what we take for granted back home.)

On another note, I am moving this weekend. My flatemate left this morning, back to the UK to start her final year of medical school, so I am being kicked out, reshuffled, to live with – dramatic pause – a couple of Australians…! Yes I discriminate against Australians. But unfortunately (?fortunately) these girls are just lovely. Their names are Mel and Steph and they are two paediatric nurses from Melbourne; they arrived last week and are here to volunteer for five months.

With Hayley gone and my having to pack (to shift house) I am feeling quite conflicted. I have had a lot of hands-on exposure in theatre these past couple of weeks, getting increasingly confident handling my instruments and with suturing, but at the same time I could quite easily leave right now. Not being one to quit anything before in my life I know that I won’t, but I still can’t escape the sense of not knowing what I’m doing here. I guess time will tell… I hope.

‘Till next time,

-A

P.S. On Monday I had to get my passport re-stamped by an Immigration Officer so we headed to the closest one to Kalene, at the border with Angola. ANGOLA! Yes, I had a Portuguese Fanta in Angola. The precise border is halfway across a bridge over a river, which they have split in half. After all our “official” business was conducted one of the Immigration Officers kindly walked us down to the bridge and, upon hearing how I was craving any sort of fizzy drink, took us to a small what is equivalent to a dairy shop in Angola proper. He even introduced us to a couple of the border army officers, the District Officer and the Immigration Officer! They only spoke Portuguese and the tribal dialect so our guide interpreted, but they were all very welcoming. Unfortunately no photos from Angola proper as per their national law (despite my attempted sweet-talking the Officials). 


Mel (left in photo) in Angola, myself and Steph in Zambia!