Comfort Zone?! Erin's Post.

Yes indeed, despite all of our posts about sightseeing and playing with the kids, we have in fact been working…and I would like to take this post to describe what I have been up to from a medical perspective.

I think you all know that I spent some time in Ghana as a 4th year medical student, and it has been since then that I have been dying to come back to Africa, this time equipped with actual skills I could use. In planning for this trip, I tried to avoid working in large University-type hospitals or with Pediatric Cardiologists because I truly wanted to have a new experience, to be able to contribute tangibly rather than just observe. When we finally chose to come to Mozambique, we thought I would be working in a newly established rural HIV/AIDS clinic, me serving as the only actual pediatrician—perfecto! When that project was delayed, Jeff and I both had to quickly find other ways to be useful here; indeed, as you know if you’ve been following the blog, with literally one week left before departure, we were still only had a vague idea of what we would be doing, where we would be staying, etc. So, unlike Mike (one of two very dear friends of ours who are currently being pediatricians extraordinaire at a mission hospital in Kenya), I had NO assumptions going into this trip—in fact, the only thing I was sure of was that my comfort zone would likely not make the overseas flight…and boy was I right.

So what am I actually doing, you ask??? Well, as I have mentioned, I am spending Tuesdays and Thursdays working at the Maputo Instituto do Coracao (or Maputo Heart Institue) by the gracious invitation of the program’s director, Dr. Beatriz Ferriera. It is a private NGO funded primarily by donations as well as by “working relationships” with some of the areas larger companies, meaning that the institute provides medical care for employees of these companies for a significant discount. The facility is on the site of a military hospital (one of those working relationships I was talking about), and it is quite well-equipped. There are 4 Enferiemas (or wards) which are basically big rooms, each housing 3-5 inpatient beds. One of these is the Pediatric ward where I spend the mornings seeing patients and helping to write notes or orders (that is, if I can understand what the hell they said on rounds which take place solely in Portuguese—if you think learning another language is hard, try talking about complex heart disease...). There is also an intermediate care unit which can be converted to an ICU if mechanical ventilation is needed, but for the most part, they try their best to manage patients in the general wards because of nursing and cost issues. There are 3 outpatient consultation rooms, a few pretty nice ECHO machines, and even a cath lab. The diseases I have seen here are a little different than back home, but the pathology is very interesting with great physical exam findings—lots of Rheumatic Heart disease, HIV related cardiomyopathy, and interestingly, Mozambique has the world’s highest incidence of Endomyocardial Fibrosis. The physicians are very well trained, particularly in the area of physical exam, and they really challenge me to listen and explain what I am hearing. Then, we go get the ECHO machine and see if we were right. Yesterday, I even did an ECHO myself!!! The Doc who was helping me printed a picture so I could show my dad and put it in my scrapbook. Pretty cool. Next week I am going to the cath lab…☺
Unfortunately, despite my best efforts, the language barrier has admittedly limited my ability to help here, and I do feel very much like a medical student again, very far from my comfort zone of knowing what to do, who to ask, or at least how to ask it. But, boy am I learning. And perhaps one of the most important lessons I have learned at the Institute is how to deal with the problem of knowing what to do and not having the means to do it. Last week we saw a 12mo with Down Syndrome and a PDA who will never be operated on because he has Down Syndrome—he will die early. Several children go without operation because their problem is not recognized until it is too late. Others would do fine except they cannot afford their medicines. On the other hand, there is a little boy who will stay an inpatient until March when the next Cardiac Surgery Mission Team comes from New York to fix him; he is stable now but he is from the far North of the country and they fear if they let him go they will never see him again. So we do what we can.

Which brings us to the other half of my week where I am acting physician for Kutwanana Home Based Care project. This project is headed by Pastor Patrick’s wife, Grace, who has about 3 weeks of medical training, and who organizes a collection of about 20 volunteer ladies from the church who have absolutely none. On most Mondays and Wednesdays, we go deep into the village to visit the homes of the patients who are deemed most needy. As you can imagine, not all of these are children (comfort zone, where are you???) and many of them are bedridden with musculoskeletal problems, malnutrition, you name it. A significant number of them have HIV/AIDS. The first day I went out, I just kept thinking “what am I supposed do with these people…they are already dying???” And then I remembered a story my dad told me, of which the moral is that sometimes the most important thing you can do as a doctor is to prepare the family for the patient’s impending death, to be honest, to provide comfort, to allow them to ask questions and make plans. So that is what we do when we need to, something I don’t think has been done much before.
When we are not making home visits, I see patients out of Grace’s office at the church, our own little makeshift clinic. Again, I see both children and adults here, and have diagnosed things like tinea, eczema, ear infections, cellulites, acid reflux, and zoster. We do what we can at the church, and if I think a medicine is warranted, then Grace and I go later that afternoon to the pharmacy and see what they have that might work. Talk about knowing what to do and not having the means! Last week I saw a 21yo young lady with an abscess the size of a golf ball on her cheek, a LARGE golf ball. It soooo needed to be drained but all I had was my pocket knife and a pair of tweezers, so I told her to go to the hospital as quickly as possible…she said OK, but I haven’t seen her again and I am very worried that she did not go. But again, we do only what we can.
Perhaps the most lasting difference I will make is during the short teaching sessions I have with the volunteers on Fridays. The first day we talked just about HIV/AIDS. I hope to offer some tips on treating basic kid stuff before I go, because as my time here comes so quickly toward an end, I think teaching is the only way to offer any sustainability for what we have done so far.

Indeed, as Jeff and I are both finding out, there is only so much we can do in a limited about of time with limited resources, in a place where problems are so deeply embedded into the culture that they are not even recognized as problems. All we can do is provide new information, offer a new perspective, teach an alternative way of doing things…and hope they remember. As for our actual time here…the hours we have spent working, thinking, trying, playing…we are the ones forever changed.

Thank you all for your continued prayers for wisdom, patience, safety, etc.
And Paul, thanks for taking care of Joaquim. We’re glad you like him.