March 17, 2017

The Lure of Tropical Medicine: Ten Days in Niger

Sunday, February 5th

I arrived late at night via Turkish Airways, an airline which consistently provides excellent service, food, and entertainment. As an added bonus, their airport hub in Istanbul is a fabulous airport with a variety of wonderful shops and services. I was met by Jeremy Beebout and Chacko at the Niamey airport, which is a classic African airstrip with minimal services. There was a local official on the plane who was met on the tarmac by a private car, while the rest of us were bussed to the terminal for passport control. No problems encountered, and I was quickly shown to my apartment where I proceeded to crash. Hard.

Monday, February 6th

Awoke in the apartment in Clinique Olivia’s compound and took my first of many showers without running water, dumping a cold pitcher of water on myself in the middle of the bathroom (with a drain in the middle of the floor). I immediately went to the clinic and started to see patients, shadowing my host, Dr Susan Beebout (AKA Dr. Susan) or one of her team members. I was immediately impressed by a number of things: although I had prepared myself to see the tropical diseases that I study and lecture about, the vast majority of patients had routine, western diseases (such as DM and HTN). The biggest barrier to care for the patients is paying for the medications and tests. Most tests are available somewhere in the city, including echocardiograms and endoscopies, but few patients have the resources for pay for such services. Regardless, we set about diagnosing and treating with minimal confirmatory tests. I was forced to rely upon history and physical examination only.

Almost.

The clinic does have an ultrasound machine, although few know how to operate it. I was very happy to use it today to gather additional information and answer simple point-of-care-ultrasound (POCUS) questions. I examined two patients for gall bladder disease, looked for hydronephrosis (kidney swelling) in a patient with possible sepsis, and, unfortunately, documented the IUFD of patient with a 13-week IUP. Increased education and availability of ultrasound provides great promise for health care in resource-poor settings such as Niamey. Based on Clinique Olivia’s needs and patient population, an ultrasound machine with appropriate training replaces most imaging needed.

Additionally, I was impressed by the diversity of languages. Although French is the “official” language of Niger, a significant number of patients do not speak it. Typically, an interpreter works with the physician translating French into the patient’s tribal language (in this region, usually Hausa or Zarma). With me in the room, with my minimal French, the histories were further translated from French into English by the provider. At one point, I asked the patient for clarification on an element of their history and the clinic provider translated it into French, the translator translated that into Hausa, then the patient answered!

In the evening, I was called in to see a late arrival who was very sick. An older woman from a village five hours away was brought in for fever and lethargy. My focused physical exam, aided by POCUS, confirmed that she had sepsis (malaria was ruled out) and treatment was started. It was difficult to get an IV, so the first 500cc of saline needed four hours to infuse. By this time, she became obtunded, with a dry, caked mouth, and severe rigors. A second line was started (likely too late) as her blood pressure had dropped to 74/40. The line was started only due to the skill of the nurse and the use of my headlamp, as the power went out twice during the attempts. She likely had meningococcal septicemia; the disease is as horrifying as I had imagined. She is not expected to survive the night.

Tuesday, February 7th

I awoke to a miracle today. The old woman with presumed meningoccemia is still alive! (Her urinalysis was normal, so meningitis is the most likely source of her sepsis and coma.) Her blood pressure has stabilized and she has started to take oral food and fluids. Even more miraculous, considering her elevated creatinine at presentation (two and half times normal), is that she started making urine! She actually woke up enough to eat some meat, then told her family to “wrap it up because she wants some more later.” I think she’s going to make it. Cipro for prophylaxis from meningococcemia was handed out to the clinic team and to the patient’s family. But I declined it, because, in my paranoia, I had raided my own supply and took it the night before!

Most of the day was spent teaching. I went with Dr. Susan to the national medical school for her two hour medical English class, teaching the four hundred French-speaking West African students medical terminology in English. In the afternoon I taught Comprehensive Advanced Life Support (CALS) to the clinic team, mostly medical students. They were fascinated by ultrasound and embraced the team approach to trauma care well, although I am pretty sure they will forget everything as soon as the next trauma case appears.

Right before the afternoon class started, I was called to the clinic for a patient who collapsed, fell to the floor of the clinic, and couldn't walk. She was dragged into our observation room (adjacent the old lady with meningococcal meningitis) and seemed to have lower abdominal pain and lower extremity weakness (but with proximal muscle tenderness). She smelled of ketones so I checked a blood glucose: the monitor read “H” for off-the-scale. A line was started and I began to treat diabetic ketoacidosis (DKA) with urine dipsticks, finger-stick glucose checks, normal saline, and injected insulin only (regular and NPH). That’s it. No ICU. No blood gas. No insulin drip. Dr. Susan mentioned to me today that the clinic closes at 6 and was closed all afternoon for our teaching session. And that we “never have patients overnight.” Yet in the two nights I have been here I have had two ICU-level admissions. And I am essentially on call for these two patients tonight.

In other cultural news, I made it to a market today and was able to buy cooking supplies and produce. I am psyched to cook up an impromptu West African dinner. I hope I can get close to the lunch today, which was an amazing tandoori-style chicken, rice, and a spicy okra-pea gravy that simultaneously sublime and sinful. Sadly, I underestimated the butane stove and wok I was using which rapidly burned the onions and undercooked the carrots and eggplant. I will need some practice. . .

Wednesday, February 8th

For breakfast today I ventured outside the compound to try some millet beignets fried in palm oil from a woman with an open fire on a nearby street corner. With a coating of sugar they were a delicious blend of sweet and savory, and I’m already planning some recipes featuring these treats. Maybe something with bananas . . .

I consulted in the clinic in the morning after following up on the woman with DKA. She is eating and drinking, but has severe urinary retention; a frightening development considering she originally presented with lower extremity weakness and inability to walk. We are still not sure if she has a progressing Guillain-Barre syndrome or a spinal lesion such as an epidural abscess.

The remainder of clinic was mostly managing hypertension with a few interesting tropical diseases mixed in. I saw a young man with a clavicle lesion and drainage for eight months that must be tuberculosis osteomyelitis of the clavicle and a likely case of cutaneous leishmaniasis (non-healing skin lesion with lymph node progression for one year). And a presumptive case of Schistosomiasis haematobium: a five-year-old boy who regularly bathes in local streams presenting with gross hematuria. With the expense and availability of confirmatory testing being extremely limited, I am continually impressed with the need for clinical diagnoses and empiric therapy. In fact, I find it rather refreshing. Also, the wide variety of languages continues to be a fascinating challenge. A good (and easy) research project would be to document the languages spoken by each patient (primary and others). How many speak French? How many are bilingual? Does this correlate with religion? With literacy? (Christian bibles are printed in native languages, but Korans are only available in Arabic.)

In the afternoon, Dr. Susan and I went to the University to teach a CALS class to the internal medicine residents. It went very well, and I included some cardiac resuscitation review which they greatly appreciated. Furthermore, they have a tremendous need for help with placing chest tubes and I have been invited to the National Hospital tomorrow to teach them how to place a tube. (I guess I better review that tonight. . . .)

Around the corner from my compound, near the lady with the beignets, there is a bakery with fresh baguettes throughout the day. They are totally delicious and only cost about 25 cents! I hit the magic hour tonight and got a batch right out the oven. They are heaven in a loaf, as good as anything you can find in Paris. Really.

But before I could enjoy dinner (an improved potato/carrot stew over millet) I learned the patient with DKA had spiked a new fever, despite ceftriaxone therapy. We are going to add vancomycin tonight (if the family can afford it), but we will need to get her to a hospital in the morning. She must have a spinal epidural abscess, something we can not possibly treat.

Thursday, February 9th

I went straight to the beignet lady this morning and ate them with an improvised spicy banana sauce. Not bad, but the sauce should have been cooked with milk or yogurt. I will keep trying.

The work day started with a well-received lecture on sepsis, done as a chalk-talk. Then we headed to clinic for a few hours. I applied a cast to a patient with a diabetic foot ulcer, which, although this was my first cast in about 20 years (I usually apply splints), turned out gorgeous. Through a translator, I carefully explained to the patient not to walk on the cast. She thanked my profusely, took up her brand-new crutches, then promptly walked out of the clinic into the dusty streets, fully bearing weight on her brand new cast (D’oh!).

In the afternoon, I was taken to the National Hospital, a chaotic, sprawling complex. I had a large audience of internal medicine residents who wanted to watch me place a chest tube in a patient with a large pleural effusion, likely an empyema. The process was a total mess, as we waited a couple of hours for the material, then the procedure took much longer than expected as I couldn't get the tube into the right layer of tissue. It was made worse by a dozen people crammed into a tiny alcove with a patient on a cot a foot off the ground. I was hunched over the entire time, and I could barely walk when it was over. But the procedure was ultimately successful, and my new fan club cheered as the pink-yellow pus flowed into the drainage bag. The patient presented weeks ago with a pleural effusion, was treated with augmentin, then returned due to more fluid. A thoracentesis showed no organisms and 95% lymphocytes. Considering the patient showed no sign of sepsis, despite a massive empyema, the effusion must have been caused by TB. I wore a mask. I was the only one in the room who did.

Once again, my head lamp was a key piece of equipment tonight. That, along with hand sanitizer and my own supply of gloves, are the three best items to bring on a trip of this kind.

Friday, February 10th

Started the day off with another effective teaching session, this time on DKA. Then I joined Dr. Susan and Dr. Gladys (another expatriate doctor, from the UK, and with the same British tropical medicine training as myself) in the clinic to work through patients with them. This experience continues to push my clinical skills. As we have limited testing options and the patients have few resources to pay for tests that can be obtained, physical examination (enhanced by ultrasound) has gained a renewed priority. Also, I am repeatedly called upon to do minor procedures despite my limited skill or experience. My remote familiarity with a chest tube, for example, far exceeds the ability of 99% of the physicians here. So, during clinic, when a patient with neurological disease needed a foley placed, I was the one putting it in. My first foley on a female since residency. And again the head lamp was critical.

The most interesting case today was a referral from a local clinic of a 37-year-old female with osteonecrosis of her hip. The patient was sent to us with a diagnosis of “bilateral osteonecrosis” so we immediately assumed it was a manifestation of a avascular necrosis of the femoral head, likely caused by sickle cell disease. Except that they had done the electrophoresis and found her to be negative for sickle cell. Further investigation found that she had a history of a prolonged fever before the onset of severe left hip pain, and the damage and pain was far greater on the left. I recorded a photo of her pelvis X-ray for later analysis, but my best guess at this point is that she has tuberculosis osteomyelitis of the left hip.

Another interesting cultural point raised in clinic today was the widely accepted practice of polygamy. Here in Muslim-dominated Niger, men are permitted to take up to four wives. It was repeatedly a subtext in addressing our patients’ psychosocial issues. One man wanted a second glucometer for his “other home.” One woman was concerned about her continued fertility as she is “competing” with her husband’s other wife. And an older man with a very younger wife is terrified that she will divorce him if we can’t treat his erectile dysfunction.

After clinic, I got a tour of the Grand Marche (or Great Market) in the center of the city. This ancient marketplace teems with tailors, merchants, and every business imaginable crammed into a couple of blocks of sprawling stalls and alleys. It was not for the faint of heart or senses, but a worthy adventure. Although I successfully haggled a nice wallet down to 1000 francs (less than $2), I was disappointed by the lack of souvenirs for my family. I will have to keep looking.

Sadly tonight, Dr. Susan learned of a tragedy in her life. Her brother in Pennsylvania has died. She will likely return to the United States this weekend, which significantly changes my schedule for the remaining days of the trip. My priority at this point is to avoid being any burden on my hosts.

Saturday, February 11th

I was expecting a nice break for today with a trip to the National Museum. As I was working quietly in the apartment over my morning tea, a clinic nurse knocked excitedly at my door, asking me to come see “an emergency.” I rushed to the clinic to find a six-year-old girl in agonal respirations and three overwhelmed Nigerien1 doctors trying to resuscitate her. They were using a bag valve mask like I had taught them a few days ago, but had no oxygen to hook it up to. They recognized, as I did, that the patient was in septic shock and needed volume replacement immediately, but they could not get an intravenous line (IV). I tried as well, but her veins were very flat. She must have been vomiting all night. Normally, I would solve this problem in an instant with an intraosseous line, but that tool is only available from “the MSF doctors” here. So, in a desperate attempt to get a line, I started working on putting a peripheral IV in the femoral vein. During the attempt, she suddenly urinated. This was an ominous sign that I knew meant she had died; at the moment of death, the muscles relax, including the urinary and anal sphincters. Sure enough, another pulse check confirmed her heart had stopped. A few minutes of futile CPR was followed by accepting the inevitable. She was dead.

The clinic staff informed the family, who were appropriately distraught. I offered to help take her body to the morgue and the staff looked visibly relieved, eagerly nodding yes. I know they are reassured to have me in the compound for consultations. But having a white doctor in a lab coat will carry an extra level of authority and respect at their task of taking a body to the National Hospital. Whether this represents a repugnant attitude held over from the colonial days, or merely demonstrates respect for western medical training and experience, I am hesitant to speculate. But there is no question that “white doctors” are treated very differently than native physicians, both by patients and colleagues.

The experience at the morgue was unique. We, accompanied by the patient’s father, delivered the body in the clinic “ambulance” (a standard SUV painted all white). After describing the nature of the death on a prescription pad and receiving “permission” from the morgue director, we laid her on the floor in a (relatively) cold room alongside other bodies, clad in a colorful native shawl that stood out from the white sheet and reed mats covering the other corpses.

Despite the morning’s drama, the clinic staff had previously planned to take me to the National Museum, and now that we were only a few blocks away, they insisted on keeping the appointment. We drove there only to discover that it was set aside for “women and children only” today. Oh well. I have an acronym for experiences like this, adapted from a saying among the expatriate community: WAWA, which stands for West Africa Wins Again. This became my go-to expression for anything that was frustrating, non-functional, missing, or otherwise forced me to shift from my American paradigm into the West African state of mind that requires improvisation and invention.

The day wasn't a total loss. There were a number of local artisans selling souvenirs outside the museum’s gates so I could finally get the gifts for Sophie and Kristi I had wanted. I was so excited, I happily paid the vendor’s second price. My guide was so horrified by my awful negotiating skills he insisted that he handle setting the price from now on!

The rest of the day was mine to spend recovering. I was very happy to read books and write stories in my room. Reflecting on the tragic morning, I am convinced that Iowa students and residents need to place IVs routinely. That experience is essential in environments like here in Niger. And bring a head lamp.

Sunday, February 12th

Today I had the pleasure of attending Sunday services with the Beebout family at their church, Boukoki II of the EERN (Evangelical Church of Niger). Dr. Susan had left the night before for America with their youngest child, so Jeremy met me at the compound with their three girls and we drove to the church. The original church had been in burned in the riots sparked by the Muhammad cartoons published in the French satirical newspaper Charlie Hebdo in January 2015, and a huge replacement building was being erected in its place. The Beebout’s youngest girl, Abby, had a wonderfully optimistic take on the construction: “It’s a cycle! A church is built, then it’s burned, then a bigger one is built, then it burns, and then another is built!” The services are currently held in a modest temporary structure in the back of the walled property

The music program was in full swing when I walked in, and my jaw dropped. Despite the homely appearance from the outside, the inside of the plain square building was lovingly decorated with colorful streamers and paper lanterns reminiscent of a New Year’s party. Plain-dressed men sat on the left side, while color burst from the sharply dressed women on the right. At the front, a uniformed choir sang along to a live band with drums, electric guitar and bass. The songs were, apparently, Hausa-language hymnals that had been translated into French. The rhythm and melody that filled the room, decorated with the patrons’ sharp contrasts of color, was simply intoxicating. I had often read that the origins of American jazz and rock came from imported African folk singing. Sitting here, in West Africa, listening to a swaying choir rocking out to a jazz quartet, in a church decorated like New Orleans before Mardi Gras, the line from gospel to hymnals to jazz was never more obvious. My eyes actually welled up when I realized I was witnessing music that had evolved into Chuck Berry and Elvis Presley. It was like finding the Lucy skeleton or the Rosetta Stone. Suddenly, connections that had been implied were now glaringly obvious.

Following the mesmerizing musical program (of which I was able to record a few minutes and get a short video), collections were passed and a few short announcements were made. Then a very lively sermon was delivered about duties in marriage and building a strong bond between husband and wife. The pastor was animated, passionate, and funny, and spoke only in Hausa. He had a companion who translated everything he said into French (of which I was able to get bits and pieces), but obviously the jokes were really funniest in Hausa (and made virtually no sense when finally translated again into English!)

I don’t normally attend church back home, and I felt slightly uncomfortable going to services labeled “evangelical.” But I was made to feel to welcome and the outstanding music made the experience well worthwhile. I have given much thought to a quote from David Brooks, who wrote in the New York Times in May of 2005

“The natural alliance for antipoverty measures at home and abroad is between liberals and evangelical Christians. These are the only two groups that are really hyped up about these problems and willing to devote time and money to ameliorating them.”

I think he is absolutely correct, and, as a secular liberal living in an evangelical compound in the single most impoverished country in the world, I feel like I am living Brooks’ alliance.

Following the service, I was able to get some photos of the women’s stunning dresses and accompanied Jeremy as he received dozens of messages of condolences. It is clear that the community is tightly knit and very supportive. I then took Jeremy and his daughters out to lunch at a Chinese restaurant (my first “real” restaurant in Niger). We were the only patrons, sitting in a dense garden that was rather opulent by Niger standards. There were giant tortoises and a small crocodile kept as pets. The girls introduced me to lemonelle (lemongrass) tea, argued over a bottle of coke, and shared their favorite fantasy books (remarkably similar to my own daughter’s tastes). It is refreshing to learn that young girls are essentially the same the world over.

Monday, February 13th

I consulted in the clinic today, working with a Nigerien doctor, Dr. Azouma. I got to see several of my follow-up patients who, I am relieved to say, were doing better. The first patient was a striking case of anxiety and muscle aches. She was a 43-year-old female with generalized body pain and irritability for a week. She was practically shaking in the office chair and was constantly sipping water throughout the interview (the thirst should have been a big clue that I missed at first). The patient appeared petrified, and she needed much help in getting onto the examination table from appeared to be weakness, but she said was due to pain. Her physical exam was remarkably normal, with no true tremor, no bruit over the thyroid, and mild non-pitting edema. I guessed that she had hyperthyroidism and suggested we start symptomatic treatment while we get thyroid studies. My colleague arranged this but wisely added a calcium, which can be done in a short time right in the clinic. The result was very high. She was a classic example of stones, bones, moans and groans (kidney stones, muscle aches, abdominal pain, and psychiatric changes). We called her back to the clinic and started therapy right away, followed by a biochemical workup for the cause of her hypercalcemia (it is most likely hyperparathyroidism, but may also be due to cancer).

The rest of the morning was fairly routine, with plenty of out-of-control hypertension cases. As my Nigerien colleague slammed through case after case using only the patient’s native language (he speaks four languages well: Hausa, Zarma, French, and English and a little of another local dialect), he turned to me to ask what other languages I speak. I was very proud to say that I can reasonably speak Spanish, but that was all (besides being able to read most French). He following with a playful chide, “only two languages then?” I am further embarrassed for my residents in Iowa who rarely speak anything other than English! When I explained it was unusual for an American to speak more than one language, he summed it up poetically: “When an American goes to another country he is blind to the world.”

As I continued to observe my patients’ colorful attire and occasional beautiful adornment, I recalled a comment from last week. One patient called Dr. Susan’s stethoscope her “fetish,” meaning a token. This is a wonderfully accurate observation! Physicians carry a stethoscope as a useful tool, but we generally don’t need to wear it around our necks. But we do so not just for convenience but also as a symbol of our profession. It connects us to our training and our ancestors or predecessors. It gives us comfort as a tangible embodiment of our power to heal. That’s a good definition of a fetish!

Tuesday, February 14th

I started in the clinic today by seeing a few patients alongside one of the local doctors while I generally prepared for my teaching session this afternoon. I was very happy to see the old lady who we had treated for meningitis the week before. She was finishing her 10th day of daily ceftriaxone antibiotics via her IV and was doing great. We discontinued the antibiotics and she was thrilled to be able to return to her village. I was able to get a selfie with her and me together, something I will always cherish. I really don’t think I accomplished much here in Niger, and I feel awful about losing the 6-year-old child a few days ago. But this one woman was a solid and memorable win.

As I cleaned up in the procedure room after finishing a simple trigger point injection, I again marveled at the general lack of hygiene here in the clinic, and what I saw in the hospital last week. Universal precautions are rarely followed, respiratory protection is never worn, and sterile technique is more of guideline than a rule. This is not just due to carelessness, but more because they are used to doing so much with so little equipment. They do become lax at simple measures, including patient privacy. Several times each session a doctor will lean in on another during a patient encounter to briefly discuss a different patient. The conversation is in French, which is not often spoken by the patients, but it certainly could be! Patient privacy is simply not a priority.

In the afternoon I went to the Medical University Hospital to teach CALS to the pediatric residents. We were lost on where to hold the session, but the residents were very patient and drove to another building where we were wandering then escorted us back. When we arrived, some very eager porters carried our manikins up into the classroom (for a small tip). The session was very well received; these learners are so eager for anything you can give them. One consistent element of feedback from the students was they wanted more cardiac cases and intubation practice. We had deliberately skipped airway management as there are no ventilators in Niger, except for use in the operating theatre (really). But they would still like to learn the principles of intubations in hopes they find themselves in another country with more resources. Additionally, they specifically requested electronic copies of English-language pediatric textbooks, especially Nelsons Textbooks of Pediatrics. I will make a note of that and see what I can send them.

Wednesday, February 15th

Today is my last day in Niger. After a short day in the clinic and a quick visit to the crumbling, rather pathetic National Museum, my hosts took me out to dinner on the way to the airport. At this point, the usual literary practice is to describe how I have grown to love the people, the culture, and the land. How my programmed Western prejudices have melted away and now I embrace this country despite all its challenges and frustrations. But this is not that kind of story. I am very happy to be leaving. I miss reliable Internet, whiskey, and hot showers. But most of all I miss my family and the communication challenges have kept me separated. I assumed I would be able to use the Internet here and I had assured my daughter we would be able to stay in communication with Skype or FaceTime. Instead, I was reduced to accepting astronomical roaming charges as I utilized the local cell network to send occasional text messages to my wife. My hosts were appropriately apologetic and insisted that they had just lost Internet right before I arrived. And it came back as I packed my bags to leave. WAWA.

Regardless, this has been a tremendous educational experience for me. I appreciate the opportunity that forced me out of my comfort zone and learn, with gusto, with intricacies of a foreign culture. Shopping alongside locals for produce in open-air marketplaces and challenging my culinary skills with a limited palette was empowering. But most of all I will remember the medical enlightenments. I embraced the importance of the physical examination, a lesson that will be passed along, albeit painfully, to my students at the Carver College of Medicine. One patient here was saved and another was lost based completely on intravenous access. I will take a renewed interest in practicing, and encouraging my students to practice, placing intravenous lines. I have considered ultrasound to be a useful tool in the “high tech” emergency department but scoffed at its use in remote, technology starved regions of the world. Additionally, as a member of the emergency medicine generation that immediately preceded the advent of required POCUS training, I dismissed ultrasound skill as something for the “young bucks” in our field. Now I see that it has tremendous potential in all settings as a replacement for other forms of imaging (x-ray and computed tomography), rather than the complementary role it plays in our country. And I also have learned that head lamps kick ass, big time.

Will I return to Niger? I am not certain. I expect that, with time, the joys will be retained as the pains lessen. But for now I will encourage others to go, following my honest and evenhanded advice. I will certainly explore other medical mission opportunities in different countries, starting with Haiti. In 2001, I completed a degree in Tropical Medicine and Hygiene from the London School of Tropical Medicine. Until now, I had only used that knowledge in advising and teaching others about travel-related infections. Seeing tropical medicine cases in situ awoke a slumbering giant of intellectual curiosity within me. I went to London because I held a special fascination for bacteria, parasites, infestations, and environmental problems that, for me, existed only as exotic diseases in dusty textbooks. Now I have seen them in the flesh, literally, and I want more. Like romantic tales from a savvy explorer or images of a foreign land glimpsed through antique prints, the lure of tropical medicine calls to me. And I will answer.

1. Nigerien is the accepted term for a person from Niger, to emphasize the difference between that an a Nigerian from Nigeria.

Hans House, MD, FACEP