Tariro in Africa

Well it’s been 2 weeks since we have returned to Canada and between an out of town wedding, reuniting with friends and family and going back to work (or for Chris, starting work), that we haven’t really even had time to fully process and reflect on the time we had in Africa.

The last few days of our trip went by really quickly.  We were still busy working, Chris worked through the weekend and we both made some trips to the new hospital to bring back donated canes and crutches for the rehab facility and other equipment for the new physio department (which is now fully completed and in use.  From the 7-9 of September, 25 mothers who have children with developmental delays from Cerebral Palsy, Down’s Syndrome and other disabilities came for the CP Village.  Everyone was very thankful for the extra space to meet, learn and receive therapy).  We hiked with Howard and Dan, two of the other volunteers.  We also spent time with Forbes, Gladys and the kids,

a family photo of the Chingonos - Forbes, Gladys, Tino, Danai and baby Kuziva (due in December)

trying to delay our goodbyes as long as possible.  It’s always hard to say goodbye to friends and even more so when you know it will likely be a few years before you’re reunited.  We had our last traditional African meal and we had Gladys and the kids over (Forbes was out of town) on Sunday for one last dinner of chicken and veggies.  On Monday we went back down to the school, one last 4 km roundtrip walk that we had done more than a dozen times over the past 5 weeks, to say bye to our friends who by now felt like our Zimbabwean family.

It’s funny how that happens.  That you arrive in one place a visitor, a tourist, and you leave feeling like you’re leaving home.  You can’t truly say that you’re a “local” because it wouldn’t be fair.  Even in our 250 sq foot bachelor apartment on the Howard compound where the power goes out several times a day, where you have to boil the water before you drink it, where you have to walk 2 km to get water when the taps run dry,  where you have to boil water (or bring it from a working tap) to draw a bath to get clean, without a tv or a radio or a reliable internet connection, we were still living a cushy life.

a view of our tiny apartment, dining/living/bedroom combo with a kitchen around one corner and a bathroom just beside (i'm standing on the bed)

We had the luxury of a indoor plumbing, a sink with running water and a flush toilet, something even middle class Zimbabweans don’t have.  We didn’t have to walk 5-7 km to school, staying overnight to study because we didn’t have electricity at home.  We don’t have to struggle when the rains don’t come or grow our own vegetables because the 20 dollars a month we are paid isn’t enough to feed our family.  We definitely weren’t there in 2008 when  people had to leave their homes because of violence around the hospital, people being shot, wives being raped in front of their husbands, children tortured in front of their parents.  Some of the things we heard about the events surrounding the last election made us feel like we didn’t know Zimbabwe at all.  No, it wouldn’t be fair to say that it’s truly our home, only to say that we truly felt at home there.

Part of the reason we felt so at home was because from the very first day we were

Dr. Thistle, Chris the surgical nurses in the theatre

welcomed with open arms by some of the kindest people we’ve ever met. Each of the staff members took time to learn about us, introduced us to others, patiently translated for us and taught us bits of shona.  The hospital sees so many volunteers it would be understandable if they felt a bit patronized.  Like “the white people were here again, swooping in to do things their way for a bit and then leave”.  But if that was the way they felt they never showed it.  

They were genuinely eager to learn about how things are done in Canada and wanted to learn new skills or ways of treating.  They thanked us for coming, and most of all for telling others about Howard.  We also saw elders treated with so much respect by the children and young adults.  Every man was sekuru (older man or grandfather) and every woman was ambuya or gogo (older woman or grandmother) and each was greeted bringing the hands together in a clapping gesture and for the women with a small curtsy.  We learned of so many different ways to say how are you and thank you. The number of times you answered “how are you” and said “hello” on a quick walk to the shops was enough to make your head spin. 

In the Therapeutic Feeding Ward I met a half dozen mothers who would eventually lose their children, all under the age of 2, to malnutrition and complications from HIV/AIDS.  Yet in that same ward I heard so much laughter and felt so much love. It was the same thing everywhere you went.  SO much laughter, SO much kindness, SO much love. Yes we have a lot to learn.

 We also felt at home for reasons that had nothing to do with feelings and everything to do with acclimitization.  We started recognizing, and being recognized by patients who came to the hospital for follow ups.  We felt comfortable with the area surrounding the hospital, recognizing the names of towns and communities and their distance from the hospital.  We started to understand the process of care at the hospital as well.  The community surrounding Howard is so small that we rarely left the compound without running into someone we knew (it was easy to pick us out from a distance though, besides Paul and the other volunteers there are no white people in the area. 

casting a baby's clubfoot on our last workday at Howard

In fact, 98.5% of the population of Zimbabwe is black).  We also had a local number, which made us feel more grounded and the snippets of language and culture that we were picking up made it easier to connect with the people we were working with and serving.

 
But eventually we had to leave home to come home.  And we are really glad to be home.  We missed our family and friends.  I missed my job, my co workers and my patients. It’s really hard to put into words the things we have learned.  I think both of us are better clinicians, more resourceful  for sure.  We also appreciate how easy life is in Canada and feel like this experience has allowed us to re-prioritize what’s important in life. We are lucky to have jobs that we can use to help others and the means and time and opportunity to do it now, and hopefully again in the future.

So, did we find tariro in Africa? In short, yes, we found tariro everywhere, in every country we visited, even amidst some sadness and suffering.  And we found tariro within ourselves.  That we have the power to make a difference, if only in the life of one patient or one staff member or one stranger that we will never even meet.

So thank you, tatenda, mazviita, maita basa, for reading our blog and sharing our journey with us.  If you are interested in seeing more pictures from our time at Howard there is a link to a photo album is below.

Chris and I and rural Zimbabwe in the background

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Coming to an End

Our last full week at Howard is already halfway through! Just like the rest of the trip, this week is flying by.  It would be redundant to tell you how busy the hospital is.  The wards are full, so full that to make more room there are patients on mattresses on the floor.  Paul’s office has a perpetual line in front of it and yesterday Chris did 5 surgeries by himself, in addition to the ones he assisted Paul with.  Rehab has been non-stop as well, finally slowing down for a bit this afternoon allowing us to catch our breath. 

Over the weekend there was a combi accident near the hospital that injured three people.  Combi’s are public transport here, vans that can carry up to 15-20 people at a time and travel from rural areas into Harare and around Harare itself.  Two, from the same family (at first I thought it was a mother and daughter but later we found out that those two, as well as four others, shared one husband), had leg fractures and one, who was 8 months pregnant, was referred to physio by the doctors because she had no fractures but was complaining of knee pain and an inability to weight bear.  On examination I found that her MCL was torn.  It was a great learning opportunity for the Laurentian girls and Chris and Michelle to feel the difference between the good and injured knee, and a great refresher for myself! It’s not often I see an MCL tear working in brain injury rehab! We made a backslab for one of the women and casted the other one.  It was my first time doing a cast with windows to expose the sutures from her surgery!  All three needed crutches.  Because of a lack of resources and finances most people pay opt to pay 10 dollars for homemade crutches that are essentially broomsticks with a rectangular end.  We cut them to their size and wrap the rectangular pieces of wood with padding and tape.  The patients then have to hold around the broomstick, which is rather uncomfortable.  They seem to manage really well though! 

Another patient that came over the weekend was a 32 year old woman named Belinda.  Belinda was working in Zambia and became ill.  She came home to her parents house, who live about 60 km from Howard where she tested positive for HIV and began antiretroviral treatment.  Her mother said she was doing really well and feel great when she had a stroke last Thursday (her parents finally brought her to the hospital on Saturday).  I asked Marjury, one of the rehab technicians, whether it was common to see someone with a stroke so young.  She said that it’s becoming much more common and that a few months ago she treated a 20 year old with a stroke.  In any case I have been seeing her every day, sometimes twice a day, to try and maximize her recovery before she is discharged tomorrow.  At first she had a completely flaccid right side with only flickers of muscle activity but today she presented with lots of tone and had active movement in her hip and shoulder muscles.  Yesterday when I told her that maybe tomorrow we would try and walk she laughed at me but today we walked almost 30 meters with a high wheeled walker!  At one point I was advancing her foot and she turned and told me to stop moving it for her.  Then she proceeded to bring the foot partway forward herself, a movement that she didn’t have at all yesterday.  Her parents keep asking me for my prognosis and I’ve assured them that it seems like it will be really good, though it’s hard to ever say for sure. She is young and motivated and is already showing a lot of motor recovery. I encouraged them to try and have her go for physio in Bindura, the town closest to her home, twice a week once she is discharged.  Even still it will be a 25 km trip each way plus the fees (at Howard it is 5 dollars per visit) to see the physio.  She desperately needs speech and occupational therapy treatment but therapists are few and far between in rural areas. 

With Bindura being the closest town to her, a town that has a hospital, it begs the question: What made her family bring her all the way to Howard? Numerous people have told us that people trust mission hospitals more than government run hospitals so will often go out of their way to go to one.  Some people come from Harare all the way to Howard or one of the other rural mission hospitals just to see the doctors there.  There are rumours of corruption at the government hospitals, where doctors take under the table money to speed up your surgery to give you better treatment.  The fees at mission hospitals also tend to be much cheaper which means that you can more easily afford the treatments you might require.  At Howard consultation fees in the outpatient department are 10 dollars, x-rays and physio are 5 dollars each and if you are admitted you will pay 20 dollars per night that you are in the hospital.  They also pay for medication and equipment.  Those may seem like nominal fees but many people in the rural areas are unemployed and those who are employed (like government workers: nurses, teachers etc) make just 250 dollars per month.  

Today one of the inpatients that I wrote about a few weeks ago, a little girl who they suspected had a brain tumor, came back today for follow up.  She immediately showed me how strong she was, walking independently, raising her arms above her head and marching on the spot.  I walked by her on my way to the market later and she broke out into this huge smile, pointing and waving.  It was really cute.

-Sarah

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As Sarah alluded to, things have been pretty busy around the hospital.  As I’m learning more, and gaining further experience and training, I am being given the opportunity to independently perform a variety of procedures on my own.  On any given day I could be doing a few ward procedures, up to 20 ultrasounds, several inductions of labour, most of the minor surgical procedures and assisting in the major ones after that.  To close out the day, I’ll end up spending a few hours in the out-patient department.  It sounds busy, but I’m loving my time at Howard.

There have been a few moments so far this week that have really stuck out in my mind.  As odd as it sounds one of them was an elderly man who I completed a bilateral hydrocelectomy on.  A hydrocele is essentially water encased in a capsule around a man’s testicle.  This man had them on both sides and they where each about the size of a clementine.  They had been developing for over a year and the man was in pain whenever he walked.  The procedure involves cutting into the scrotum, dissecting out the testicles, draining the fluid, and removing the capsule to make sure they don’t reoccur.  After the procedure this elderly man stood up tall and had a huge smile on his face.  He thanked me enthusiastically and explained to me that this was the first time he could stand up tall and comfortably.  It was a moment of realization that this is going to make a huge difference for him.

There was also an elderly woman who had a stroke several years before.  The lady was pleasantly confused but it was obvious that she wasn’t taking care of herself very well.  She was sent to me because they wanted me to look at her toe as they felt it could be infected.  The minute I saw the toe and the x-ray I knew this wasn’t going to be good.  The x-ray showed a bad fracture of the baby toe.  On examination there seemed to be a small cut at the base of the toe.  When I touched it and moved it from side to side it felt like I could pull the toe right off with very little force.  I ended up freezing the whole area and amputating the toe down to the next healthy joint.

One routine that I’ve been really enjoying is the rounds I do every morning in the Maternity Ward. Every day I meet with each of the mothers to see how they’re feeling, check on their progress, decide whether they should be induced, or if they have delivered whether they can go home, and prescribe any appropriate medication (general aches and pains are common as are urinary tract infections and STIs).  Each day I induce many of them, and usually only one or two deliver.  There is one mother named Beauty, and I had induced her three times and each time it failed.  Finally, this morning while doing rounds I saw that the induction we did yesterday was successful. There’s another mother, Nervious, who is pregnant with twins.  She’s been at Howard since a few days before we arrived as she’s been at risk of delivering prematurely.  Now she’s 37 weeks pregnant and can deliver safely at any time.  Each day her and I joke tha. t today is her day.  We’re both hoping it happens before we leave next week.   I’ve been developing a sort of relationship with these women that I didn’t expect.  I see them each day waiting to deliver, and we talk and hope for the next day.  Finally, the days come where I do rounds and I see them with these little bundles as they approach me.  They are excited to see me and I am excited to see them and their new child.  It’s a great feeling. 

-Chris

Howard Update

Well here we are in Harare again, my third time and Chris’ second since we arrived in Zimbabwe on July 18th.  For the most part we have been able to fill our stomachs with the amazing local produce, eggs, bread and meat from the surrounding area.  We have bought peanut butter that is so fresh the container that it’s in is still warm from the roasted peanuts.  Most of the fruits and veggies were picked the same day that we buy them.  Fresh onions, cabbage, tomatoes, potatoes, bananas, oranges etc. mmmm!!! I only wish it were mango season too but apparently that’s not until November or December.  The chickens have met their fate at the hands of Chris and Zach and Bridget, two of the other volunteers here, or they have been slaughtered for us the same day we eat them for dinner.  It takes the “100 mile diet” to a whole new level when the majority of your food is from less than 5 km away!!  There are some things that are harder to get around the compound though so we have come in for a few items to get us through until our departure date as well as to use the internet and buy some souvenirs.

Last weekend was busy and adventurous.  On Saturday we went on a hike in the mountains around the hospital.  We had a great view of the countryside from the top.  On Sunday we purchased 3 chickens for a traditional Zimbabwean feast at Forbes and Gladys’.  They helped us slaughter them (the slaughterers were mentioned above), prepare them and then cook them with sadza over a fire.  We also helped them with their corn shelling and played with the Danai and Tino.  We had an amazing time eating until we were SO full and enjoyed good company around the campfire until late walking back to Howard by the moonlight (everyone forgot their headlamps).

Tino, Chris, and Forbes

Forbes told us about how he and Gladys met (a story that had us laughing so hard we were crying) and he also told us about the lobolla, or dowry, that men pay to the woman’s family when they get married.  Gladys’ lobolla was 9 cows.  People have been asking me (more than once) about what kind of lobolla practice we have in Canada.  I told them the men don’t have to pay anything to the woman’s family when they get married.  They always seem pretty shocked (and then follow it up with where they can find a “murungu” (white) wife).

Things around the hospital are as busy as ever especially because of the holiday weekend that just went by (Zimbabweans celebrated Hero’s Day on Monday and Defense Forces Day on Tuesday.  We didn’t do much celebrating and worked half days instead).  On Wednesday Chris worked until just before 9 pm seeing patients in Paul’s office.  Last night Paul and Pedrinah had the volunteers over for dinner which was an incredible feast.  Chris and Michelle, a medical student from Western, were only there a few minutes before the phone rang and Paul asked them to go and do some ultrasounds.  They returned with Paul for a quick dinner and some socializing before they all sped off to do an emergency C-section.  Chris stumbled into our place at midnight after a long, exhausting 16 hour day. PHEW!

This week I spent the mornings in the rehab department seeing patients and the afternoons with the rehab aides teaching some refresher lessons.  They were really receptive and even requested that we have a test on Friday to make sure that they understood everything (at first I thought they had to be joking … but no).  We spent one afternoon doing transfers.  There are a lot of bad habits that the aides have gotten into using including getting the patients to wrap their arms around their necks for leverage or lifting patients from their arms. I tried to discourage those in favour of some more “body mechanic conscious” habits.   Some of the transfers that are most common for them we had to work through together.  Most individuals in the rural communities sleep on the ground on mats and often don’t have tables and chairs and so floor to stand transfers become really important.  The second afternoon we spent reviewing some clinical reasoning – how to quickly assess a patient and determine what type of treatment will be most appropriate.  We also went through some cases and tried to brainstorm how we might treat the patients.  On Friday two of the Laurentian students and myself set up a mini Practical Skills Exam with 3 questions with the aides coming in groups of 1 or 2 to assess and treat.

Practical Skills Exam

I’m looking forward to going back into the community next week (especially now that I have my own bike!! ) to see if they are applying some of the concepts.  I also want to interview some of the patients to get an idea of what they think of the rehab aide program.  Paul is really excited about this program.  He told Chris and I that there has been interest from the University of Zimbabwe and the ministry of health.  Nurse aides and pharmacy assistants etc are common here but Howard is the first hospital to have trained individuals to support rehab.

This was a short week but I still managed to see some really interesting patients.  There are two that specifically stick out in my mind.  The first was a woman in her 40s with really bad hip arthritis.  She had a pretty significant leg length discrepancy and came hobbling in to the office in obvious pain with a terrible antalgic gait.  We fitted her for a forearm crutch and I molded her a heel lift out of plaster of paris (POP) to insert into her shoe.  I thought my OT friends would be proud.  By the time she left her gait was much smoother and she appeared much more stable.  We are referring her to get a permanent orthotic but my POP will provide her with a good alternative until she is able to get there.

The second patient was an older woman (in her 70s)  I saw yesterday who was walking with a walking stick (that kept slipping on our floors).  She was complaining of feeling very weak and unstable.  I found out that anyone over 65 gets free medication and equipment so I grabbed a rollator walker and adjusted it for her.  Her daughter and I walked with her for a bit and showed her how to lock the walker so she could use the seat for a break etc.  I asked her (through her daughter who acted as our translator) how she felt and what she thought about the walker.  She said it was so beautiful she wished she could bring it home.  When I told her that it was hers to keep I thought she was going to cry! She kept shaking my hand and thanking me over and over.  From what I understand there are a lot of walkers and crutches in the new hospital warehouse so I am hoping to get over there this weekend to make an inventory.  Our rehab room is also on its way to being completed.  By this time next week we are hoping that we will be moving into the space! It could not happen soon enough.

– Sarah

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As for myself, this last week was pretty amazing.  Work was busy, as Sarah described, but there were some pretty interesting cases.

Early in the week, Paul and I did a below knee amputation of a poorly controlled diabetic women.   I actually did the sawing of the bones, thank goodness for taking shop in high school.    I had never seen it done before and was actually amazed at what a basic process it is.  I guess if you are cutting something off you don’t have to worry as much.  On Friday, we saw an older man with a huge cancer on his leg. It was shocking and ugly.  It extended from just below the knee all the way down to the ankle and was about half the width of his leg.  We were setting him up to do a biopsy when he requested an above knee amputation to help stop the pain.  We just dressed him and will get him setup next week.  I also had a case were a man had gangrenous fingers so I amputated them and sewed them up nicely.  What did I learn from each of these cases?  The people here seem to ignore their health problems for quite some time before they seek out treatment.  I’m not sure if it’s a financial situation or a cultural one.  It’s quite sad actually, because by the time you see them the options are very limited: cut it off or dying soon from the infection that is setting in.

Cyst Excision

Another interesting cultural situation I fell into this week was when I was seeing a pregnant women with a sexually transmitted disease.  The protocol for this is to treat her, treat her husband, and counsel them on protective behaviours.  After I did all of this, the wife asks me “So what do we do about the other woman in the relationship?”.  A pretty surprising question and I explained that she would have to be treated too.  They decided to just remove her from the relationship instead.  Polygamy seems to be relatively common here.  Apparently, if you have traditional weddings you can have as many wives as you want.  If you go to court for any of the weddings, you have said that you will not take any more wives than you already have.

There were a ton of ultrasounds and inductions of labour this week too, which means a ton of births (12 last Sunday)  I’ve been managing to do the ultrasounds with increased efficiency.  The night that we got called in to do the C-section was pretty intense.  The woman’s uterus had ruptured internally and the baby had to come out immediately so that we could fix her up.  We got it done and in the end mother and baby were well and happy.

Chris and Michelle

Thursday night we all went to Dr. Thistles for dinner.  they made this amazing dinner.  We were all in heaven with ice cream, apple pie, and cupcakes making up the dessert.  the next night we went to the Smiths for a similarly great dinner.  it was great to spend some time with everyone having fun before the Smith family left for the rest of their trip.

Speaking of the family leaving.  We just travelled into Harare with them and packed 15 people into the hospital truck.  It was a ridiculous ride, but good fun for sure.

We can’t believe that our trip is starting to come to an end.  We have week and a half left at the hospital.  We will try to post again this coming week.

-Chris

TIA – This is Africa

As promised here are some of our interesting, and at times disturbing facts from our trip so far:

  1. During all 6 of our flights with South African Airways we have received a meal and drinks (including beer and wine).  Some of the flights have been as short as an hour and a half. Air Canada (and United Airways for that matter) could use some pointers.
  2. As much as we loved Cape Town, and felt safe, it turns out the advice we got to take cabs after dark should include dusk as well.  We were walking to a restaurant at about 5 pm one night when a man approached Chris and asked for change.  Chris said he didn’t have any and we kept walking but the man persisted eventually telling Chris that he “didn’t want to commit a criminal act but he had a knife in his pocket.”  Chris gave him all the Rand he had in his pocket (the equivalent of about $1.50) and the man thanked him and took off.  It’s unlikely he actually had a knife but it was nerve racking nonetheless
  3. There’s an animal that lives in our ceiling here at Howard.  Sometimes we hear it fighting with another animal up there.  It’s either a rat or a cat but neither of us is going to go up and confirm which it is.
  4. We would like to tell you that the operating theatres here are completely sterile but that would be a lie.  There are actually tons of rats that live in the OR and run around the feet of the staff and climb the shelves.  All of the equipment is sterile and cleaned before each surgery of course but the rats still manage to startle the visitors (the locals are used to it!)
  5. Their solution to the rat problem: cats introduced into the OR.
  6. As we post this we are in the process of slaughtering 3 live chickens (with the help of Forbes and Gladys) for a big feast
  7. Chris has become proficient in performing bilateral orchidectomy … men around the hospital cringe when he walks by (just joking)
  8. Mice are a shona delicacy … too bad rats aren’t … that could solve the OR problem mentioned above.
  9. There are lots of animals around the compound that appear to be wild (cattle, goats, chickens etc) and lots of fields of corn that don’t look to be on anyone’s property.  It turns out that they all belong to people (the animals are loose to find food and you are allowed to plant corn on any spare chunk of government property for free) but there is just an understanding that you don’t take another person’s food or animals.  Pretty amazing for people who are, for the most part, desperately poor and often struggle to feed their families
  10. They are keeping cows at the new hospital to keep the grass short.  They are doing a great job.
  11. The ratio of cell phones to people is about 2:1 despite the fact that most people in this area don’t have electricity. The Laurentian students’ have been running a charging station out of their house for the pregnant mothers and patient families since their house is right outside the wards.
  12. The best price for bananas yet: $1 for 16.
  13. We have been asked many times what our staple food in Canada is.  Here they eat sadza every day for almost every meal (if they have more than one meal per day).  It’s hard to explain to them that we don’t have anything like that in Canada
  14. In the children’s ward they wear their identification taped on their head instead of in bracelet form.

Nigel with his Name Tag on

Busy Busy Howard

Howard continues to be a very busy place and we continue to be very busy because of it.  We are thankful to be able to take some of the load off the overworked staff of the hospital.  Our weekend was quiet, Chris worked on Saturday morning while Sarah played ultimate Frisbee with one of the rehab aides and some of the boarding school kids from the Salvation Army run Howard High School.  The kids caught on fast and it was a fast and competitive game.  They had moves that aren’t typically used by our Frisbee team back home including faking and then throwing it through the defenders legs! Saturday night we had Forbes and Gladys over for dinner and they reciprocated on Sunday night.  We are definitely getting our fill of sadza that’s for sure!!

shelling corn with Forbes and Gladys and Tino last weekend

I (Sarah) have been spending more time around the hospital over the past few days. Thursday and Friday were relatively quiet and I split my time between the outpatient department and seeing the inpatients with the rehab aides.  A few of our inpatients were quite ill and one, a 26 year old man with suspected meningitis, we attempted to wake up only to find he had passed away.  Most of the inpatients are too frail to walk but we try to keep their muscles loose with passive range of motion and we change their laying positions.  Mondays are typically very busy in the outpatient department and it is also the day when children with clubfeet come to be assessed and casted.  My first patient was an 5 year old girl from the children’s ward who they suspect has a brain tumor.  She has some weakness in her right side and so I gave her a stuffed animal and we played “lifting the weird looking stuffed cat wearing a shirt and pants over your head”.  She liked the game and I saw her doing the same thing with her grandmother later on that morning.  We also walked hand in hand back to her bed.  It was a great progression from when I tried to see her on Friday and she cried and refused to let me touch her.  I don’t take it personally, a lot of the little kids burst into tears at the sight of a white person or clamor into their parent’s arms.  In the rural areas, especially if they’ve never been to the hospital before to see Paul, many of them have never seen a white person.  It’s understandable that my ghost like complexion would be a bit frightening.

Later on that morning I had the opportunity to cast a 1 month old little girl who had a clubfoot.  It was my first time casting a clubfoot and it was a challenge to do it on such a little foot.  I’m excited that I will get to see hera few more times before I leave, kids under 3 months get their casts changed every week.  Another repeat patient was Brendan,

Brendan - all casted up

the little boy with severely externally rotated hips (see previous blog entry).  The casting appears to have worked a bit and when standing he was in much better alignment.  We were encouraged by the results so we recasted him, including his feet, for another week.  We hope that it will be the last time.  The rest of the week should be busy and I’m excited to have the Laurentian students here (they arrived safely today) to get their hands dirty.  They will have lots of time to get adjusted since they will only work 3 days before our 4 day holiday weekend!

Since the last blog post I (Chris) have continued to have busy 11 hour days.  As I get more comfortable in the different areas of the hospital, Paul is giving me more responsibilities and so the days are flying by.  Friday was especially busy and exciting.  Paul allowed me to complete a further debridement (where dead skin is removed from a diseased body part) and bone resection of a diabetic foot that Chris and I saw on Monday.  Diabetes in this area seems to quickly progress to this point where drastic measures are taken because of a lack of education about proper foot care and a lack of access to resources like blood sugar monitors.  I also saw a 4 year old “boy” with indeterminate gender and both male and female genitals.  The timing of this boy’s arrival at the hospital is good since on Monday a urologist will be arriving on Sunday.  We asked the mother to bring the child back on Monday to have a further examination and a possible surgery to fix his urethra which is in the wrong spot.

I worked during on Saturday but it was a quick half day seeing only patients who required immediate care.  It was an awesome opportunity for teaching though and Paul was able to show me how to do a lumbar puncture.  Since then I have done 2 other punctures on my own.

Monday was a crazy day with more patients than we’ve seen at the hospital so far (and patient they definitely were, some waiting until 8 oclock at night to be seen by a doctor).  The picture below was taken at 5 oclock at night and is the line up to see Dr. Thistle in his office.  While working in the labour and maternity ward as well as doin

The line up to see Paul at 5 pm

g lots of ultrasounds it seems as if there are a lot of twins born in this area.  I asked Paul whether this was just a coincidence but he said that in the 1970s most twin studies were done in Zimbabwe  because they had the highest proportion of twins.  While they aren’t the highest anymore they continue to have a very high incidence of twins.  Today was another day filled with ultrasounds but, in true Zimbabwe fashion, we were at the mercy of the power.  The power here seems to go out 4 or 5 times per day, usually for 10 or 15 minutes at a time.  Today was particularly bad and so some women were waiting up to 4 hours for their ultrasounds, getting all ready and then having to wait for the ultrasound machine to come back to life.  I am getting better at being able to interpret the fuzzy images I’m seeing and successfully identified the sex of a baby boy today for a very excited mother.

A 2nd year medical student from Western arrived today and so we have been seeing patients together and I have been helping to get her oriented to the hospital (Sarah has been orienting her on where to buy the best fruits and vegetables and French fries).  There are more volunteers arriving every day (3 Laurentian students today, 6 pharmacists and pharmacy students next week) and the next few weeks are going to fly by.

We are compiling our “best of Africa facts” for the next post.  Stay tuned for interesting, shocking, and “ew” facts!

Working at Howard

Rehabilitation

Our second week at Howard Hospital is almost done and both Chris and I have been busy in our separate wards, catching each other for the occasional tea or lunch break to talk about all the amazing things we’re seeing.  There is so much to talk about and unfortunately only very sporadic and unpredictable data connection.  We hope that our long, information filled updates won’t be daunting to read. Our days have been spent very differently and since I only hear about the incredible things Chris is doing with Dr. Thistle second hand it’s best if we both write a little blurb separately.

Before arriving at Howard, I (Sarah) was told about a group of local Zimbabweans who had been trained as rehabilitation aides (physiotherapy assistants as we would call them in Canada) by the rehabilitation technicians Passmore and Marjury along with a Canadian physiotherapist named Justin.  Since they were just trained in February/March, part of what my mission while I’m at Howard is to see how the program is working and what kind of gaps in either resources or knowledge still exist.  The aides work on a part time basis rotating between the community, where they follow up with patients and carry out exercise programs in the patients’ homes, and the hospital where they help with the inpatient and outpatient physiotherapy.

In talking with Marjury we decided that it would be best if I saw what the aides were doing first hand.  So I hopped on a bike and headed out into the community (70 bicycles were sent in a shipping container and 40 bicycles made it to Howard.  Somewhere between the port in Mozambique and here in Zimbabwe there are 30 more people enjoying the rest of the bikes).  The unpaved, pot hole filled roads and my bike with no brakes provided me with a challenging 5 km ride (and another 500 metre walk) to our first patient.  In an area where no car (or even bike) could get to was a 17 year old paraplegic named Innocent.  We spent time talking with him and his grandmother who takes care of him.  The aides carried out their exercise program and we educated the grandmother about checking for pressure sores.  Then we headed out.  It was unbelievable to me how Innocent even got up the steep rocky slope to his home after his injury.  He is isolated from his friends and unable to attend school but he seemed to have this great spirit about him.

Our second patient was actually the son of one of the aides, an 11 year old boy, Shelton, with cerebral palsy.  He was so sweet and was so happy.  His communication skills are poor but he was able to ask the English one-liner that every child in Zimbabwe seems to know: “How are you?”   I imagined what Shelton’s life would be like if he were born in Canada.  He would be zooming around in a power wheelchair, receiving botox injections that would decrease the tone that currently prevents him from sitting independently, attending a school where he would receive daily therapy and socialization with other children with disabilities.

Caroline and Shelton

Here is Zimbabwe he leads a different life.  We found Shelton enjoying the sun on the veranda outside of his home, a home with no electricity or running water, on a road inaccessible by car.  Caroline, is a single mother passionate about giving Shelton the best life possible, which is one of the reasons she wanted to become a rehab aide.  She stretches his tight muscles twice a day and was eager to hear the few exercise and positioning ideas I had.  There is an amazing program at Howard that Caroline says she never misses, a 3 day CP retreat that happens four times a year. Howard Hospital hosts mothers and children from all the catchement area (with accommodation and meals provided) where mothers can get support, education and therapy for the children.  It provides mothers with a place to talk about the challenges of having a child with a disability and provides the children with an opportunity to play with others like them.

Back at the hospital that afternoon we found that what people had been saying was true: now that Dr. Thistle is back, the hospital is filled to the brim.  I spent most of the afternoon doing something that would be unheard of for a physiotherapist in Canada: casting.  Here in Zimbabwe the rehab department is responsible for applying and removing plaster of paris casts.  That day I casted 3 arms back to back, the next day 2 legs (a 6 month old with severe external rotation of his hips.  We casted him in neutral in hopes that the capsule would tighten – a treatment I wasn’t sure of but Passmore said had been done successfully in the past).

Today I was back out in the community, visiting an elderly woman recovering from a fractured femur and a man with an above the knee amputation (this time with brakes that worked, thankfully).  One of the aides I went with today, Winnet, took me to her home to meet her husband and daughter and to see their beautiful garden of cabbage and onions and sugar cane.  The 20 dollars per month salary that Winnet receives as a rehab aide is her family’s only stable income, which is true of many of the aides.   They supplement their income selling what they can at the market, vegetables, homemade peanut butter etc.

All terrain rehab!

This program has employed 13 otherwise unemployed individuals from the area surrounding Howard and has provided them with what should be a steady income.  You wouldn’t know it by their devotion –  the fact that they never miss work,  that they bike up to 20 km in the heat of the day to treat patients in the hardest to reach corners of the area, that they work up to 6 hours at the hospital to provide care for their patients – that they have not been paid in 4 months.  They are working in hopes that eventually they will be retroactively paid for their efforts.  Thankfully, funds have made their way from Canada to Howard (from what Dr. Thistle calls the “dog and pony show” that he ran while on vacation in Canada) and the aides will be paid this week.

– Sarah

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Medicine

Now that I am half way through my first week working with Dr. Thistle, I see what happens at Howard.  Paul, Aaron, and Chris (a different Chris) are three physicians dedicated to the hospital and improving the quality of life on the patients in the area.  They tirelessly complete rounds, work in the theatre (operating room) and work the outpatient department.  They deal with patients and complete surgeries through the entire range of medicine.  And here I am, getting thrown into the mix on day one.

Ward Rounds

On my first day I rounded with Dr. Thistle in the Maternity Ward, the Labour Ward, the Neonatal Unit, and the Male Ward.  We saw many patients and quite a variety of ailments, but a the most prevalent were HIV and Tuberculosis.  Of the top ten causes of death in Zimbabwe, Tuberculosis makes up about 56%, and HIV 9%.  Pretty significant numbers considering the advancements in TB detection and treatment.  I guess with 1/3rd of the world’s population infected with TB it makes it a hard one to crack.

By day three, with the help of the ward nurses I was doing rounds on my own.  Of course, translation slows the process down quite a bit, but progress was made.  Patients were sent home, treated, and held onto as required.  After some observation and instruction, I’ve completed labour inductions and performed amniocentesis (draining fluid from the uterus of a pregnant women via a large needle into the abdomen).  I also gave a short session to the nurses in the hospital on performing an ECG as the only people in the hospital who could do them previously were the physicians.  In Canada, ECG’s aren’t usually done by PA’s or MD’s, but thankfully I had a half day of training during my first year of school by EMG technicians so I felt confident

Out Patient Department

Because of the language barrier I’m spending my OPD time with Dr. Thistle.  Dr. Thistle is the only person in the hospital who can use an ultrasound machine comfortably and he is teaching me how.  So far I have completed many obstetrical, abdominal, and prostate ultrasounds (I know what you’re thinking…but you view it through the abdomen).  Unfortunately, we’ve also seen and admitted many malnourished children through this department.  Most are around 2-3 years old who look like small babies.  It’s pretty sad, but with the help of the team at the Therapeutic Feeding ward, most will recover.

Theatre

So far in 2011 the three doctors at Howard have completed close to 2000 surgeries.  They are continually expanding their skills so that they are able to complete a larger variety of surgeries.

On my first day I was doing joint reductions under anesthesia and assisting with other procedures with Chris.  Today, Aaron and I did a skin graft on a young man who had had a car accident.  We took skin from the patients left thigh, put it through a meshing device, and grafted it to the wound on his right thigh.  Afterward, we completed a c-section on an overdue mother.   During the same day, working with Dr. Thistle, I acted as anesthesiologist while he completed a bladder biopsy on one patient and then a cervical biopsy on another.  It was busy, but rewarding.

Needless to say, it’s been quite the week so far. I’m loving my time at Howard, but the 12 hour days can be long.  I’m glad to make it home for quick breaks during the day and for a late dinner to spend time with Sarah.  We are really enjoying the time here and the new experiences we are having.  It’s hard to believe that hospital is able to do so much good with so little financial support from the Zimbabwean government.  For 2011 the hospital will only receive $5000 and the rest of the finances will come from The Salvation Army, donors, and fees.

I look forward to sharing more with you as the internet permits.

– Chris

Welcome to Howard Hospital

Leaving Livingstone we split a cab to the airport with our friends, Vinny and Elaine, whom we met on the GAP trip.  We got to the airport a few hours before the flight and got through the check-in process in a matter of minutes.  To kill time until the flight we played cards and then said our goodbyes before boarding. 

When we landed in Jo-burg the place we were diverted to a different gate and delayed from getting off the plane.  This was a tense moment for me and Sarah as we only had about 1 hour to transfer for the flight to Harare.  When we finally went to the international transfer counter the agent called the boarding gate for Harare and we were told we would have to run to our gate.  We got there just on time and made out flight to Harare.

Upon arrival in Harare we were greeted by two staff from Howard.  We stopped at the grocery store before heading to Howard.  Judging but the conditions that we witnessed in town, it seems that Harare is in better shape now than when Sarah travelled in 2007.  Groceries were relatively expensive though, only slightly cheaper than we would find in Canada.  Worrisome when some of the best paid civil servants are paid between 250 and 500 dollars a month.  When we arrived to the Hospital compound it was late so we got our to the Guest House, the same one Sarah and Lilla stayed in during their last stay at Howard, and simply went to bed.

The next morning we made arrangements for an orientation to the hospital where we were met some of the staff and were introduced to some of the wards and programs that the hospital runs. The hospital has been less busy over the last few weeks while Dr. Thistle was in Toronto.  Apparently, the patients in the area trust Dr. Thistle and will wait until he returns before they seek medical attention for non-critical issues of course.  We are told they will come in droves upon his return on the 24th.  Later that afternoon, we ventured up to Nyachuru Secondary School and met with the school’s headmaster and with Forbes and Gladys, Sarah’s friends from her previous trip to Zimbabwe.

The next morning we headed to the Rehabilitation department which has one bed within the hospital’s Therapeutic Feeding ward (where malnourished children, most of whom are suffering from HIV and opportunistic infections like tuberculosis, thrush etc, come to receive supplemental nutrition and monitoring).  We met with Passmore, the Rehab Technician and made arrangements for us both to work in the department for the remainder of the week.  Over the course of the week we saw patients with fractures, strokes, complications from HIV/AIDs, musculoskeletal injuries, amputations, cerebral palsy and children who had developmental delays secondary to illness and malnutrition.  We have befriended a few of the Therapeutic Feeding Ward children since it has been so quiet.  Cosmas is a 10 pound 7 month old boy who is unable to hold his head up or sit up on his own.  His mother is understandably concerned but there is little that we can do to help until his weight increases and he is medically stable.  2 year old, Tino who has not yet learned to walk, is barely the size of an average one year old.  We reassured his grandmother that he will eventually walk and taught her to use a pediatric walker that supports his weight.  He has been happily zooming around the ward with a huge smile on his face ever since. 

One patient that has stuck out in both of our minds since we met her was a woman in her 50s with AIDs who has developed some stroke type symptoms.  While she was cognitively sound she had very little control over her body.  Her left arm was flaccid while her right had lots of tone and often crept up toward her face with effort. Both of her legs had so much extensor tone that they were rigid and completely straight.  It took all of Sarah’s effort and sometimes my help to get her right leg to bend beneath her in sitting and was took two people to transfer her safely from the wheelchair to the bed (she could not sit up on her own).  So many things were running through our mind as we thought about her discharge.  She was being sent home the next to her home in Bindura, approximately an hour and a half away from the hospital.  She lives there with her son.  There is likely no electricity where she lives, most people in this area don’t have electricity or running water.  The wheelchair was property of the hospital and she had no equipment of her own.  Most people use outhouses where they squat to go to the washroom, this woman could not even sit up on her own.  We taught the woman’s daughter what we could: education on positioning changes, checking skin for pressure sores, passive range of motion to prevent contractures, but there was so much in terms of quality of life that there was no way to provide her with.

Wednesday night we went to Forbes and Gladys’ for dinner.  They made us a traditional Zimbabwean meal, sadza with beans.  Sadza resembles mashed potatoes in appearance but is thicker and made with corn flour (mealie meal).  It is the staple food in the area and is eaten everyday for both lunch and dinner.  It has little taste, but takes on the flavor of whatever it is served with.  It was good and filling.  We enjoyed a bunch of laughs that night and invited Forbes and Gladys over for dinner at our place on Friday night for what they call a “murungu” (white person’s) meal: chicken, potatoes with pasta on the side. 

Our weekend has been quiet.  Without television or radio to distract us we have kept busy exploring the area, reading,  and now we are off to shell some corn and another meal with Forbes and Gladys.  Back to work tomorrow!