Some descriptions to help you picture where I am. I'm trying to get photos as I'm able- somehow the best moments are times when I don't have my camera, or the light is wrong, or it just feels too intrusive to take a picture of someone.
The country- Togo is in West Africa, with a strange mixture
of tribal traditions and colonial legacy both of France and England. Ghana is very nearby and a patient I saw
today came across the border to see us at the hospital. Because she is from
Ghana, she and her husband both speak some English, which was a refreshing
change. When I flew into Lome, it felt
like a small provincial kind of city, but the grocery stores had real cheeses,
and there was an amazing French bakery we stopped at on our way out of
town. The drive up to the hospital was a
bit of a blur because I had flown all night the night before and was dozing on
and off. The southern part of the country, where the hospital is located, is
lush and green. Rainy season has started and it rains almost every night. There
are hills surrounding the hospital, and we are right next to a plateau that is
known for its hiking and beautiful views. This area is also known for
butterflies.
The hospital is located in the village of Tsiko (pronounced
“CHEE-co”), near the town of Adeta. The nearest big town that shows up on most
maps is Kpalime (pronounced PAH-lee-may) which is about 45 minutes away. Patients literally come from all over the
country and from surrounding countries as well- Ghana, Benin, Ivory Coast, etc.
etc. There is paved road all the way to
the hospital gate and the drive from Lome takes about 2.5-3 hours, depending on
how many stops you make to buy fresh fruit at the best vendors.
The climate is similar to Honduras: hot and muggy
during the day, cooling down at night.
Now in rainy season, there is a thunderstorm and rain every few
afternoons which brings the temperature down and cleans the air. At night you
can hear mangos falling from the trees, thudding onto the ground below. There
are geckos here as in Honduras, but the ones here don’t make noise. I've seen
plenty of ants and spiders, though no scorpions and no monkeys yet.
The hospital compound is large, with a path running
around the inside that is about ¼ mile long.
There is an airstrip just outside the compound and several of the
families who live here are pilots who will be using planes to access more
remote parts of the country when they have a working airplane. The hospital
buildings sprawl across about half the compound. There is an outpatient clinic
building, a separate building for the obstetrics clinic, a nurses’ dorm, a set
of overnight call rooms for the mid-level providers, an administration
building, and the main hospital building which includes pediatrics, men’s, and
women’s wards, as well as maternity, labor, OR, ICU, lab, pharmacy, and ER.
There is also an ‘infection’ ward where people who need minimal care but still
close supervision (i.e. daily dressing changes, traction on a fracture for
several weeks, once daily IV antibiotics, etc.) can stay. A final building on the hospital side is
called the ‘cuisine’ which is a covered but open air building where families of
patient or discharged patients who live far away, can stay if they need to be
close to the hospital but not admitted (for example, OB patients who are in
very early labor but live far away).
The country is part Christian, part Muslim, and mostly
animistic. You can see some of the differences with Muslim women wearing
scarves over their heads, and certain tribes having different dress. The Fulani
tribe has facial tattoos, and a 4 day old Fulani baby I saw in clinic already
had tribal markings in the form of 3 lines on each of his cheeks, hands, and
feet. The Fulani wear bead necklaces and
have interesting earrings which make them distinct as well.
This evening I was checking on a patient when singing began
at the nurses’ station. One of the chaplains was leading the nurses in a song
(perhaps a Togolese hymn?) and they were singing in perfect 3 part harmony. As
I walked outside to head home, I saw a woman putting out a section of blue tarp
and bowing toward what I presume is Mecca for evening prayers as her toddler
crawled around exploring. I assumed that
if I spoke French I would be able to function easily here, but I am discovering
that the nurses and patients often speak in tribal languages to one another so
I literally have no idea what is going on about 80% of the time. I have learned
how to say some basic phrases that help me exchange pleasantries with patients. One
of the other volunteers here is a former French teacher! I have been pestering
her relentlessly with French questions and working on putting the words into
practice right away. The most common
tribal language in this region is Ewe (pronounced ‘EH-veh’). Today I saw a
patient using a 3 way translation: I spoke in English to the medical assistant
who translated into tribal language #1 to a man who spoke tribal language #2 to
the patient, and back up the line to me. It made me realize why clinic seems to
go so slowly here, and to be very selective about the questions I ask!
Rainy season here = malaria season and typhoid season.
Malaria is easily confirmed with one of two different tests, while typhoid is
often a presumptive diagnosis in the setting of fecal leukocytes, low
peripheral WBCs, abdominal pain and diarrhea.
The pediatric ward especially is full of children with malaria, and
every day or two the beds seem to turn over completely and fill up with new
cases. All this should remind me to take
my malaria prophylaxis more faithfully, though I don’t think I've missed a day
yet so we’ll consider that a win.
Patients' families are responsible for many of the tasks
that nurses and techs do in U.S. hospitals, like providing food, toileting, and
bathing them. Family members sleep on
the floor next to the beds- I will never be able to complain about a hard
bed! Bath time in the maternity ward is
usually the late afternoon when most of the moms sit on a stool next to the bed
with a bucket of water next to them. They hold the baby on their laps, or
across their laps, and use a bit of the colorful African cloth to dunk in the
water and sponge over the baby. I haven’t heard a single peep out of these
infants; they must enjoy cooling down!
Most of the time I smell worse than the patients do, with my sweat mingled
with the smell of latex gloves, ultrasound gel, and other people’s bodily
fluids.
Women here by and large do not wear pants. However, the
upper half of the body is not something they think twice about uncovering. If
you walk into maternity at any point in the day, at least a third of the women
are probably naked from the waist up. Even in the regular women’s’ ward, many
women lie in bed with cloth wrapped around them that reaches only up to their
rib cage. It is a totally different perspective on modesty and sexuality. These women are breastfeeding pros. 75% of
the post-partum women I see in Honduras are giving their babies some formula by
the time I see them at their 1 week checkup.
None of the moms I see here are using any formula outside the hospital
at all. A few in the hospital are using formula to fortify expressed breast
milk (mostly hand expressed) to their premature infants at our direction. Again, a completely different perspective and
mindset here. Formula is just too
expensive to even consider, and they don’t see it as necessary at all.
I have been really impressed with the skills and knowledge
of the long-term doctors. They printed an extensive Treatment Manual which
details the common illnesses and injuries seen here and how they work up and
treat it. It is so nice to have something to reference in a setting which is
completely new, with a different formulary than I am used to, different risk
factors in the patient population, and different capabilities than I have
worked with before. The Togolese nurses, midwives, and mid-levels (Physician’s
Assistants) are also very capable and call only when an intervention that it
outside of their skill level needs to be performed (i.e. vacuum delivery,
C-section, ultrasound, etc.) I have already learned a lot from them, and am so
thankful that they take care of so much, reliving some of the burden on the
physicians.
A glimpse of my typical day here: breakfast in my room
before rounds at 7:30; hospital rounds until all the patients have been seen
(it has typically been 12 or 1pm); lunch break until 2pm; clinic in the
afternoon- I've been in the prenatal clinic most afternoons- until all the
patients have been seen (in OB it seems like it is usually 6 or 6:30pm); then
dinner at the guesthouse. Evening rounds if I am on call are at 8pm. I've done quite a bit of OB, which I really
enjoy, but it has definitely added an element of chaos to the typical day’s
schedule. There are constantly new labs that need action, vaginal deliveries
that the nurses do but may need a doctor’s backup for resuscitating the baby,
labor that stalls out or shows signs of distress that has to go to C-section,
etc. etc. etc. The typical patient load
has been 8-10 moms in maternity with 10-12 babies as there seem to be at least
one set of twins at all times…right now we have 3 sets!), 6-10 pediatric
patients, and 10-12 adult patients. I am
continually reminded of residency with feeling pulled in multiple directions,
having too many patients on a medicine team, and being so busy that snatching
time to eat seems difficult. The learning curve is also similar to residency,
but with a bit more practical experience under my belt I find myself asking
colleagues’ questions more for moral support rather than needing someone to
tell me what to do.
Tomorrow I'm attempting to go for my first run since arrival. A hike to a waterfall on Saturday was a great first excursion off the compound and it whet my appetite for more. This is a beautiful region.
