Coming to an End

I made it! Both sadly and happily, my time in Manguzi has come to an end.  When I landed in Durban 4 weeks ago, it felt like this day would never come.  Now, I can’t believe I am actually leaving. I’m sorry I haven’t written many posts this week. It was a busy one filled with lots of medicine, friends, and goodbyes. 

My last week at the hospital definitely had its ups and downs.  We had some great evening braiis (barbeques) with all the doctors, but some rough times in the hospital. I’ll try to sum up a few of the more memorable moments. Perhaps a good one and a bad one.

The limited resources available at Manguzi were a frustration every day, but I felt that, the majority of the time, we were able to work around them.  In fact, I was consistently impressed by how many diseases you could treat with just basic knowledge and sometimes a little innovation.  It’s certainly very different from how we practice medicine at home. Wednesday was the first time that I saw the direct impact of these limitations on a patient’s life, and it was a very difficult lesson.

I was taking care of a 2 month old baby who came in with what looked like a severe pneumonia.  During rounds in the morning, he was ill, but definitely stable. Around 4 in the afternoon, I happened to be walking by the peds ward and one of the nurses came running out to ask me to help with the baby.  He was having a very difficult time breathing and was wearing himself out trying to get enough air.  I put him on oxygen and started fluids and ran off to get help.  We gave him some medications, but what he really needed was to be intubated.  In the states, we see plenty of babies who get such a severe respiratory infection that they require assisted ventilation for several days, but once the infection is cleared they are able to come off the machines and be healthy babies again.  Unfortunately, we didn’t have a ventilator at Manguzi, so the only way we could intubate the baby was if we knew that transport from another hospital was on the way to transfer him to an ICU.  The attending on call, Eva, said that she couldn’t call any regional hospitals about transport until we got some stat labs.

While she ordered the blood tests and made some phone calls, I stayed with the baby.  His breathing got progressively more difficult and it was horrible to watch.  Standing by in a situation like that, you know the baby can only breathe that way for so long before he tires out and can’t breathe at all.  I wouldn’t have thought that a 2 month old could look scared, but his eyes were terrified.  And he looked straight at me, holding onto my finger, for 3 hours.  It was heartbreaking.  When the on call doc came back, she told me he would not be transferred.  I was shocked. And devastated.  But mostly confused.  Eva explained to me that the baby’s rapid HIV test had come back positive.  Because there are only three ventilators available for the entire region, they have an endless list of exclusion criteria for who can be placed on one.  Their rationale against our baby was that, because he was HIV positive, he was more likely to have an infection with an unusual bug and therefore less likely to come off the ventilator quickly.  They needed to save it for someone who would be more certain to benefit from it in the long run.

Although I understood the reasoning in the setting I was in, that didn’t make it any easier.  And to be honest, until I was able to step away from it later and think things through, I was furious.  I couldn’t believe a 2 month old was not even going to get a chance to live.  When his little lungs took their last breath, there was no resuscitation.  A resuscitation is supposed to be a bridge to intensified medical care, and that was something we couldn’t offer.  Sadly, the physicians at Manguzi see cases like this all the time, so Eva was not too upset by the situation.  It was pretty traumatic for me though.  It reminded me that, no matter how willing you are to help and how hard you try, you are still subject to the constraints of the culture and setting you practice in.  I think that would be the hardest thing for me about a career in international medicine.

So Wednesday was not my best day.  But Thursday was a great one.  Tom, the doctor I’ve been doing pediatrics with all this time, had only two hours in the morning to see patients.  He asked me to see the rest of the patients on my own, and told me that he trusted me to make the correct decisions on their care. I rounded on patients, gave nursing orders, called consultants, and discharged the kids who I thought were ready.  I ran it all by him, but he didn’t make a single change to what I had decided.  I felt like a real doctor! Having all that responsibility made me both excited and terrified to start intern year.

Thursday night they had a big goodbye party for us.  We bought lots of steaks and grilled out by the pool with all the doctors and physical therapists we have been working with for the last month.  It was so much fun! We were surrounded by good music, fresh pineapple, and lots of new friends.  Doesn’t get too much better! We were having so much fun that we stayed up til 1 a.m. Not that impressive at home, but here we call 9:00 Manguzi Midnight.  Needless to say, none of us were looking too perky at morning conference on Friday.

Friday afternoon, Bryan and I rode with two of the doctors to a small beach town just north of Durban.  When we were making reservations, all the cheaper bed and breakfasts were full, so we ended up booking one that was a bit more expensive.  It is super nice!! We went and got some “take-away” and then came back to the room to soak up the glory of being back in civilization.  Air conditioning for the first time in a month when temperatures have been upwards of 90. A bed that does not have mattress springs poking me through the top.  No mosquito nets.  A shower I can use without flip flops.  Water I can drink.  The list goes on and on. 

This morning, after a delicious homemade breakfast at the inn, we set off to Durban Centre.  Had I not spent a month wandering the markets of Manguzi it might have made me nervous, but the number of things that make me nervous these days is much smaller than it used to be.  We ended up at a large street market in the heart of a busy, gritty, very urban downtown.  Bryan and I spent the next two hours loading up on souvenirs.  The street market was awesome! There were tons of vendors selling all sorts of handmade African crafts…everything from baskets to jewelry to paintings.  We met up with our friend Jonas from the first two weeks at the hospital.  He and Bryan had a grand old time haggling with the vendors.  It was pretty funny to watch, and since I hate confrontation, I let them negotiate my prices for me.  Good thing I left so many sheets and clothing in Manguzi to make room in my suitcase for everything I bought.

We then met up with Sanushka, a doctor from Durban we met, and she took us to lunch at one of her favorite Indian restaurants.  Durban has the largest Indian population outside of India so they are very well known for their curry.  After lunch, Bryan took off for the airport and I am now alone for the first time in a month.  I have to say, it is kind of wonderful.  I took a nice long walk on the beach, had a good long Skype conversation with the parents, and treated myself to a nice dinner.  The glass of wine they brought me was big enough to knock me out for the night! I was pretty excited to find out that the restaurant I chose had ice cream sundaes. I haven’t had ice cream since I left home and have been craving it like crazy with this heat.  They brought it in a giant bowl and I ate every last bite!

Tomorrow, it’s off to Spain! I’m so excited to tour a country I’ve always wanted to go to with one of my best friends.  Should be an amazing 10 days! I will try to post at least once or twice while I’m there.  Thanks to everyone for being so incredible and supportive this month! Your emails, Skype conversations, and comments on my blog allowed me to smile and have a positive attitude every day.  Without all of your encouragement, I would not have even thought about tackling such a big adventure, and now I can’t imagine what my life would be like as a doctor without all the things I’ve seen and learned this month.  So thank you, because every one of you helped me get here. 

Here are some random photos to enjoy!

Another Jayhawk makes an appearance :)

Our last night braii

Me with the physios (aka PT, OT, and speech)

Boat Racing...the South African version of Flip Cup

Our last day :(

Entrance to the hospital (probably should have posted this one a while back)

Cool close up from Jonas' ultra-zoom camera