These last few days have been simply amazing. I finally got to do some traveling.

I headed off on Friday to the town of liwonde-where I went on a safari and had an amazing time. The weather was great and it gave me a chance to see a lot of animals out in the wild. Getting to liwonde was such a fun trip. I opted to travel via mini-bus which basically is a van crammed with passengers. I find that buses like these while sketch at times are the best way to get the total malawian experience. after all the vast majority of people cannot afford luxury buses, or have their own personal cars. The trip went through some amazing parts as we worked our way more south. passed through rolling foothills with amazing views through miles and miles of farmlands. One could see the farmlands dotted with mudhuts and little children standing by the roads watching out of curiosity and waving their tiny little hands yelling hello hello as the buses passed by. we passed small towns... farmers standing on the side of the road selling their produce to passengers from the van window. potatoes, corn, tomatoes, garlic, sugar cane, carrots.

The trip took about 5 hours but didn't feel long at all. From liwonde originally i thought i was going to head down to a mountain so i could do some mountain climbing however i heard rumors from other travlers that the mountain was very slippery from recent rain. Being somewhat random and whimsical at times i randomly decided on sunday morning that it would be my last day in liwonde and headed to zomba. The trip to zomba was once again amazing. great views passing by tea plantations. zomba was the former capital of malawi. located high up at the base of a plateau. the only problem was when i arrived in zomba it was pouring down rain. My goal was to reach the plateau and the two options i was debating between was 1. climbiing up the 8km to the hotel or 2.taking a taxi up. i'm not a fan of taxi's. they are so boring, but huddled at a gas station to escape the rain i encountered my 3rd option. right in front of me was a car rental place. only problem was i didn't bring my license or photo id, but figured i would give it a shot. within 10 minutes i was offered a 2007 toyota corolla as my car rental from the day.. no ID needed, no cash up front nothing. i was shocked. it only costed me 5000 kwacha or 50 dollars.

headed up the plateau which was quite and experience. the steering wheel was on the right side and i was driving on the left side. plus it was raining and utterly foggy-- what a great day to learn driving european style. unfortunately the views going up sucked b/c of the fog however i finally made it to the hotel sunbird which is a ritzy hotel located high up in the plateau. there met some really cool british girls who were doing their medical rotations in blantyre at the queen elizabeth hospital center.. had a nice chat with cups of hot chocolate. and decided to call it a night.

next morning was greeted to the sounds of baboons jumping on the room. had breakfast under the watchful eyes of 4 baboons who kept inching their way closer to see if they could get a bite to eat from me. alas i decided not to finish my scone and i held it up and get this.. the huge baboon walked up to me and grabbed it from my hand and then climbed up a tree. I swear monkeys are just like human beings. all the other baboons were watching but then i realized i made a mistake to give the first baboon my scone b/c on my way back to my room i was followed by 5 baboons walking close behind me and another 2 swinging up on top of the trees. i close the door to my room and i heard a knock--looking through the peep hole the baboons were knocking on my door. oh great. what is this. all of a sudden i thought of the movie "the birds" you know the alfred hitchcok movie and wondered if they would make a movie out of

my death... "the baboons". finally the coast was clear and i ran back to the lobby. The sun was finally out and it was a beautiful day. I opted to go for a hike hiring a guide. It was a great 5 hour hike through the plateau, through rivers, waterfalls, finally making our way to the "queens view" and the "emperor's view" which overlooked the town of zomba underneath. simply breathless. very surreal. went through miles and miles of pine trees, cedar trees which surpisingly were all imported plants donated from various parts of the world. On my way back it got really foggy again and we simply could not see in front of us. every now and then random ppl would pop out of the mist to sell us various indigenous berries like rasberries. it was real spooky and for 5 miles this kept happening. random ppl popping out of the blinding mist and fog to sell us fruits.

finally felt it was time to leave the ritzy hotel of the sunbird. I had passed by a trout farm on my hike and saw that they were renting out small cabins. on a random whim, i felt what a wonderful experience it would be to live in a trout farm for a night. It was quite the experience-good and bad. although i did catch my dinner for the night which was surpringly (not quite) trout and over open campfire which i did not start --- one of the forest rangers did--- i cooked--basicaly burnt my trout.

the cabins did not have hot showers... ice cold water-- and i ended up going canoeing in the waters.

finally it was time to leave zomba and wanted to see blantyre which is a city further south--just out of curiousity.. Blantyre was underwhelming however a much bigger and more city feel than lilongwe. stayed at a place called doogle's which was the backpackers hangout--- but felt like being antisocial and called it a night. Finally the next day, i caught a bus to lilongwe which was quite the experience. i chose a bus which i thought was going to be a decent one--big, reliable and would get me to lilongwe at a decent time. unfortunately i soon realized when the bus started to pull out of the terminal 1.5 hours late that this was a local bus---that ppl on an extremely tight budget use-- no wonder it was so cheap. i smelled burning rubber one hour into the trip and then a pop. i soon ralized we had a flat tire. there were at least 90 passengers on the bus. 4 people to a seat with passengers standing up. we all got out of the bus and waited while the tire was fixed which took ages. luck would have it that we happened to stop right by a rural school for children. Let me tell you.... a big white bus with a flat tire was a cause for excitement for these children. Files and files of young children ran out of their small school hut classrooms yelling and running towards the main road where we standing.... looking at amazment at the bus... and supringly STARING at me waving their hands saying hello hello hello at least a million times. it was so adorable. finally the schoolteacher came out and with a branch shooo'ed everyone back into their classrooms. the bus was finally fixed. but the craziness of teh adventure didn't stop as i witnessed all kinds of interesting ppl board the bus. This one guy boarded the bus randomly with a bible in hand and for the next 2 hours he YELLED verses from the bible. i mean yelled. finally 2 hours later he asked for money collection and left. geez the things ppl do to make a living to survive i guess. i had another bible dude board the bus but thank god he didn't yell on the top of his lungs. while this was going on the person next to me looked at me and grinned "praise allah". oh great now this guy thinks i'm muslim. i pretended i didn't hear him so i just nodded. this was not the right time to tell this dude i'm hindu--after all he could be extremely radical and i could just be lost somewhere on the road to lilongwe--->next time you would seem would be for ransom on a taped video with someone putting a knife to my neck. but i digress. for the next 4 hours i saw hillarious things. a woman with a baby goat, old ladies carrying their local produce potatoes etc in bags and then finally once we got closer to our destination ppl started boarding the bus with chickens in hand in fact one lady had a box of young chicklets.

needless to say i was relieved i arrived back around 5:30pm. in one piece safe and sound. all in all a great trip.. a lot of memories--hillarious ones.

Tomm is my last day in malawi

a quick update.
drinking beer while hearing hippos grunt in the background in liwonde. No clue if that's a normal sound.
learned to drive the european way e.g with the steering wheel on the right side and driving on the left lane.
buying rasberries from phatoms on the zomba plateau among a thick mist of fog-
and now the transition from staying at the sunbird zomba---->to a trout farm on the plateau. I love the disparities and i love to experience both ends of the spectrum.
off to blantyre via mini bus soon.

An uneventful week so far. I can't believe i have 10 more days in malawi. I really will miss malawi, but I definately am looking forward to return to the city of Pittsburgh. I must say, it'll be weird going back... i still can't fathom how completely changed my lifestyle will be. I arrive on May 1st. which is Saturday and then on Monday I start medicine Wards and luck would have it I am on call. It'll be interesting to see how i react when i have every lab at my disposal to work with to make a diagnosis and every prescription i could ever want at my disposal, and ancillary staff, SW readily available. that being said, I definately feel I have changed in many ways from my experience thus far-and to an extent kind of have a fresh perspective on life--- how i want to lead it, what i want to do with and how i want to help people in the broader sense.
On Sunday, I went to the Maula prison which is the central prison located here in Lilongwe. It was such an eye opening experience- i can't even describe it in words. Overcrowded prisons sometimes over 100 prisoners per "cell" which basically is a small tin shack. No beds just mats on the ground. One toilet, one shower. Ppl for the most part wander outside. No wonder TB, and other communicable diseases are so prevalent in the prison population here. No wonder ppl are malnourished. When the government just feeds you Nsima and you have TB and are spreading it no wonder you are malnourished and waste away. I was lucky to get a tour in each cell. I saw a few foreigners imprisoned. One chinese gentleman who was caught with a lot of foreign exchange. Some white ppl who got busted for drugs. The prison is sectioned off into the women's side- approximatly 38 prisoners. It's not that bad on the women's side. One hut, they have goats and chickens e.g for eggs, milk and even have a small potatoe farm. Then there is the convicted side. they walk around in a white outfit and lastly the ones waiting trial.
A lot of people are held in prision for small crimes things that would just be considered a misdemeanor here in the US. stealing, pickpocketing, bribery. Unfortunately the judicial system is not the most organized and ppl just get lost in the system, files getting lose and are condemmeed for eternity. The lost souls of africa. the forgotten ones. I did a google search of the prison and found a NYT article about this very same prison.
I took a look at the clinic. One small hut. doctors come out to the clinic extremely rarely and the doctor who is staffed there is extremely overworked.
Besides the tour, felt that we should contribute someway to the health of prison population. I went with the lawyer from the UK and we purchased enough soap for the entire prison population. costed us about 30,000 kwacha almost 200 dollars. but this assured one bar of soap for each prisoner. we meticulously counted each bar and handed the exact number of bars to "group leaders" from each cell where they would distributed it. whether they get into the right hands that's another question.
It's interesting, within each cell the group leaders and the prisoners have established their mini court system- so if a prisoner breaks a law like "yelling a police officer when he enteres the room", or "walking around naked" or "fighting" the person is referred to a jury which is selected by peers and is setenced to labor to work within that cell. "clean up, do certain tasks". hence it's kind of like ppl serving a sentence within a sentence.

Other happenings this week.
not a whole lot. My malawian mentor returns tomm. On thursday-tuesday i decided to see malawi a bit. this is also an important part of the experience as i also have to learn about the country the regions. I am headed to liwonde where i will go on a safari and from there head to mount mulanje and hope to capture some breath taking views.

looking forward to it!

"Mr. F died at 6:00 pm. He was treated for a pneumothorax with chest tube and was treated with ceftriaxone, metronidazole for sepsis. At time of death his chart could not be found, but the guardian of another patient stated that the patient's chart seen in the hands earlier in the afternoon of a brown colored mazungu".
I still chuckle everytime i think of this. The patient of mine who had the chest tube placed ended up passing away yesterday. The above quote is what i saw written in the patient log book of overnight happenings. I feel really bad that the patient died but then again sort of relieved as this patent was suffering for a really long time. The quote in the book just makes me bust out and laugh. It's so cute and funny. a mazungu is a foreigner. that's the malawian way of saying "the chart was seen by a brown colored non-malawian".. i'm assuming they meant me. After all i'm the only brown colored person working this week.
Today the president of malawi got married. It was billed as the grandest wedding ever known to man. I doubt it reached that high level of acclaim. But nonetheless all this hoopla was worth checking out. I headed out to the old town of the city and watched as the motorcade made it's way around kamuzu procession road. Unfortunately i could not see Bingu himself (the president) but i'm assuming he was in the huge bus that had the sign just married written on it."
I had an incredible past few days. The hospital always takes me into a world that is none like any other on ths planet earth Often times, i take a deep breath before i step foot in the hospital as you just feel the suffering all around you, and each time you think about the disparities in resource allocation that sends shivers down your spine-as if you were a part of this disparity. After all get to leave in one week-back to my western world, whether technology is rampant and i can bring back a patient who is on the brink of dying by inserting IVs in early vein possible wth a machine to help me breath, medcines to maintain my blood pressure and a tube to feed me. Contrast that with this place... only 2 maybe 3 ventlators in the entire hospital..
I've been busy as anything the last 2 days but I swear the days are just so rewarding. I was able to bring back a patient who came in with a low systolic blood pressure, had not eaten in days, stopped talking and had a very tender abdomen. After doing an ultrasound i discovered his bladder was so full that it was displacing his liver, spleen, and bowel. After inserting a foley he pee'd out 2 liters and his stomach deflated. I treated him for heart failure after he had signs of CHF. crackles in his chest, frothy sputum, and dilated hepatic vessels on a glimpse of his ultrasound. There was his hepatic vessels, and inferior vena cava expanding with each inspiration. A lot of work it took-getting the O2 tank, moving his bed so i could access an outlet to plug the machine in, personaly administering lasix. in 24 hours he woke up, startred talking, sat up on the side of the b ed and started eating./ His family was ecstatic-each of them gave me a great big hug as if i were a saint, and the brother had me pose by the patient with me offering his first cup of porridge in one week. It was so humbling. All the nurses had smiles on their faces. Moments like these make me happy I came to malawi-as with suffering there are also always success stories. But great moments don't always last as the next patient i ended up dealing with was a patient with a hemothorax.. His heart displaced all the way to the right. He was sent to casualty for chest tube insertion however after 24 hours the chest tube stoppped draining. IN addtion he started to develop diaphragmatic pain---reffered to the shoulder blade. Oh great. what is it wth me and chest tubes. Is god trying to tell me my true calling is to be a thoracic surgeon or does he/she just want to punish me for my lack of knowledge on chest tubes by sending me patient after patient. With kussumaul breathing, distended neck veins and his PMI visible in the right 5th intercostal space this much i knew. the chest tube would have to be placed again. but did he also have a perforation. The challege was to get him to the x-ray. this required finding a stretcher and then wheeling him on the stretcher down an elevator to the x-ray machine and then have him sit up to take pictures. Ended up doing an ultrasound downstairs too and after much debate b/w me and the radiologists we came to the consensus tha the small amount of fluid beside the spleen was ascites rather than a splenic laceration.
His chest tube is clottted up from the blood- no clue what to do. next step is to find a pleura-vac. that's what he needs.
I also had an interesting experience wth a patient who i was treating for acute pancreatitis. He has been getiting worse. He has some sort of disseminated infection whch i don't know exactly what it is, but he is on the kamuzu central hospital "big gun" medications. ceftriaxone, quinine and metronidazole. He stopped urinating and the family insisted on a urinary catheter. attempted an 18 french w/ no success and found a 16 french. Slid it up and then a loud yell from the patient, some seizure like activity and then shivering. In an instance the famly members ran to bedside and the evangelical tirade began. PETER IN THE NAME OF CHRIST I BECKON YOU TO WAKE UP. IN THE NAME OF THE LORD CHRIST SUMMONS YOU TO WAKE UP. beating and shakng the patient yelling with loud religious rants. THE LORD COMPELLS YOU TO WAKE UP. i just stood there, stepped aside. and just watched the loud tirade until i started to hear the loud wailing and screams. it was then i stepped in and told the family that the patient is alright. he must have some sort of vesicle in his urethra that caused irritaton and caused him to shake in pain. I am convinced now he has some sort of disseminated herpetic infection as he has vesicles in other areas of his body. today i went to see him and he was not looking so hot.
i have told the family that they should be prepared for his death and that today would be a good time if he were to have any visitors that wanted to see him while he were alive.

Yesterday after work had a great evening as arthur and I headed over to Henry's bar. a great view of the sunset with some drinks with some of the doctors who work with the baylor project. I don't know why, but for some reason i diddn't really enjoy the conversation that much. I felt a lot of it was superficial and ppl were just discussing all of the bad things about malawi. and whenever i would bring up the positive things someone would come up w/ a smart comment to make even that sound negative. I did learn last night that there are rumors to shut down lilongwe airport for about a week. something about redoing a runaway. unfortunately they are rumoring to close it down on the 20th till beginning of may, possibly rerouting ppl via small planes to blantre ( a city down south) and from there to catch a plane to johannesburgh. It's just a rumor though. In any case i don't know if i really do believe these guys. esp w/ all the negativity.
Well it's been a busy few days. saw lots of sick patients but i'm having a good time working. I really felt i have established a great relatinoship with all the ancillary staff and have gained their trust--- as they all have opened up to me and really respect when i tell them to do something.. they actually listen and it's not out of frustration but it's about putting the patient's best interests foremost. I thin when they see that even i will do things like place foleys, change bed linens, get the oxygen, personally administer medications, ask the opinions of them on what they think, they are more open in participating in the care.
They also crowned me the king of central lines. never have they seen a doctor on the medical wards place that many central lines. i guess initially i just wanted to save everyone, but in all honesty now i just let the patient go.. sometmes its better to die than just prolong suffering.

I'm purposely trying to phase myself out of the picture these next two weeks as I don't want people to get dependent on me always being around to do things. You know, put central lines, "cover OPD clinic", cover for another team, look at patients that aren't on my team, see random consults. but everytime I get caught in another project. It's not that i'm complaining, but i'm just only one person-theres only a limit to the amount of work I can do. As you may have guessed today was one of those days I literally wanted to bang my head against the wall a million times. It all started today when the malawian physician stated to me this morning that I would be the captain of the ship for the next 6 days. Wait, what does that mean. Apparently physicians from 2 teams were leaving to cape town (second time this has happened in the two months), so there are only 2 doctors- me and someone else and he wants me to be the leader. Yikes! Not that i'm afraid of the work, but i really want to start winding things to a close.
Today i was the only person rounding on my team. The students finally arrived- and oh my god i cant believe for 2 montsh i had been working without students. One of the other doctors commented on how well i handled myself without any guidance or supervision but wow, things were soo much easier. They really took the initiative to track down labs, do things-- ordinarily i would be bogged down with such things.
One of my patients isn't doing so hot. I feel horrible. He's the guy who had the chest tube placed for the pneumothorax. It was draining out pus, so the other day we decided to remove the chest tube and have the surgeons place another one as we suspected that the first incision was infected? good lord, he is so lethargic and delirous today. not eating. I had to put a central line in today and run fluids wide open. I dno't think he is going to make it. The family firmly believes that the patient was doing fine until the chest tube was placed--- they know nothing about the pneumothoraxes or empyema but convinced that the patient's problems started with the tube. who knows. they may be right it may have been infected?
I was on call today-shortstay which was well short stay. busy as can be. One guy had a perforated cecum and i saw air under the diaphragm and i literally had the throw the x-ray in front of the surgeon's face for them to even see the patient today. I made him NPO, started antibiotics, NG. he needs surgery.
Well we'll see how things go. everyone cmes back on wednesday next week. after wednesday i'm definately going to take off for an entire week. i'm going to need a breather i feel.

A nice and lazy weekend. Love it. Spent pretty all of Saturday relaxing. I went into work for a few hours as on Friday I admitted a patient with gross body edema. She presented with a history of past pharyngitis about a month ago and now having problems with black urine. I never thought i would see post streptococcal glomerulonephritis here in africa. classic description of coca-cola smoky brown urine. After talking to one of the other doctor's in the hospital I have started her on oral prednisone, howver given that she is now anuric and is symptomatic from electrolyte disturbances I talked to the dialysis team to get her dialyzed. I ended up personally doing an ultrasound on her to take a look at her kidney's and they were so tiny... makes me believe this may be a chronic disease for her from now on. who knows. In any case my morning of saturday was spent putting a temporary dialysis catheter in her right femoral vein. I'm happy to say, that I can now put in a central line in about 5 minutes.. not bad... After that I removed some nasty empyema pus that was accumulating in a 1 liter flask from a chest tube that i had placed two weeks ago. I don't know why, but this guy keeps draining pus. He goes home and then wa-la a month later he comes back from empyema. I've had this similar type of experience with other patient's before. It seems that empyema can be a chronic pain in the butt. Especially those that have a known history of tuberculosis.
I've treated a lot of other pneumonias and I swear, i've never seen so much pneumonia that was the classic "walking pneumonia" not improved on ceftriaxone but when i started erythromycin they were back to normal. I felt great on Friday. I discharged a patient who came in very sick a weak earlier and through aggressive IVF, anitiboitics, mucking around with his antibiotics i ended up treating him for PCP pneumonia-he's going to complete a 21 day course... but he's feeling the best he's ever felt in quite some time. before he left he gave me a huge handshake and hug and said he would never forget me. That really meant a lot to me and all the frustrations, the hard days, the disappointments the feelings that you have nothing to offer to someone who is dying right in front of you are minimized.
Today, I headed out to the sanctuary lodge. I've been there once with one of the other doctors at the hospital and it's an amazing place. Quiet and quaint. I sat by the shade out on the patio and had a nice cold vanilla milkshake which was not bad at all! I did a lot of reading- leisure reading, and then i reflected a little on my african experience. There was live music- a band that was excellent playing the tunes of bob marley. The restaurant was crowded with malawians having picknics under the shades of trees, expatriates escaping the malawian heat and sunbathers working on their tan lines by the swimming pool. There were some college girls from spain i think i'm not sure? Extremely attractive, who surprisingly were trying their hardest to get my attention with loads of giggling and gestures for me to come over, but alas that only embarrassed me a little more and i continued my readings about pneumocystis carinii and kaposi's sarcoma.
I now sit here contemplating what I want to do for the next 2 weeks. I must admit that I am starting to get slightly homesick as this is my 7th week. I can't believe i've gone this long without driving, or without a television set. I'm glad actually... i think my brain has been happy.
I'm really contemplating seeing Jen Lyden out in Mozambique-- maybe going to pemba to meet up with her as supposedly there are great beaches out there. Looking at the map, it might be a big pain in the ass as it's all the way on the other side and would require multiple bus transfers.
It would be great to see her and really fun. Other options include just traveling within malawi. I haven't seen malawi yet. everyone tells me I MUST go to mt. mulanje or liwonde. That's another option. I've become really good friends with a malawian resident-- who is amazing in terms of his knowledge base. by far one of the most competent doctor's I've met. another option would be to do a mini trip with my malawian mentor. we've talked about it.. but no plans yet.
We'll see.. If it happens it'll be next week. I'm going to do a mini talk on EKGs and heart failure to the malawian doctors late this week. unfortunately this is a crazy week in terms of staffing so i won't be as big of a presentation as i would have hoped. but something is better than nothing.
Well, what else is new? nancy made the best lasagne the other day with real chedder cheese. simply amazing. I've gotten to know her really well- and she's such a great person. It gives me some light on the problems malawian ppl face in this country.
I've also met an amazing person. A girl who graduated from law school in britain and is doing some human rights law work here in malawi just for a few weeks. She really has good intentions and is really caring-- coming to the hospital to see if there are any prisoners brought in-and she works to get them legal representation. This week, i am going to spend one afternoon actually going to a prison here in malawi to get a first hand account of the conditions these prisons are in. I'm interested in doing this because a lot of the patients i admit are from the prison system and are brought in at the point of death. extremely starved, extremely infection and you can just hear the word tuberculosis and opportunistic infection coming out of their mouth as they gasp for air.
Well, about 2.5 weeks left. A little sad, a little happy, a little homesick- i guess a little bit of everything.

An amazing few days so far. I did my first pericardiocentesis yesterday. What an adrenaline rush. The pericardium is so thick and it's harder than you think. It was on a girl who was about 20 came in with shortness of breath, pulse tready, somewhat hyp0tensive. Under the guidance of the super smart and awesome malawian physician that i work with on my team he gave me instructions on how to do one using a central line kit. It was not that hard as one might expect it to be but still, there is something about sticking a needle right where the heart is that sends chills down my spine when I think about it. The scariest part was when i was threading the wire and using the dilator. how far should I go, i wish there was telemetry so i could look for ectopy but alas no problems and the patient was alert and oriented times 3. I drained about 600ml of straw colored fluid. for some reason she has ascites. sent it out for culture look for TB. why else would a 20 year old patient have a pericardial effusion and ascites.
I'm feeling really great this week as a lot of the nursing staff have opened up to me and stated that they really respected my work ethic. For the last 3-4 weeks i also had been trying really hard to really get to know the malawian physician that i am working with. a really quiet gentleman but we have gotten to know each other on a personal level and we really enjoy each other's company. A great person, extremely dedicated and a knowledgable person who i have grown to really appreciate. Yesterday i was suprised to learn his extensive knowledge in the world of sports in particular soccer. One of these days we plan to go out and watch one of the games- he's favoring the brazilians in the world cup and i'm favoring the argentinians.

As usual, there were some good moments in the hospital and some moments that made me stop and think.
A girl in her 20s laying in bed, completely naked. I had seen her few weeks ago and wondered about her. the way she was shaking and shivering. where was her family, her guardian? As i round I see her from the corner of my eye laying flat with blood covering her mouth and lips. With eyes sunken and so shallow, you could see the loss of hope and the suffering she was enduring. What's life if you are forced to spend weeks in the hospital in a place where we have very little to offer... no family no one to rub your forehead and tell you everything will be okay.
Here she was vomiting blood, coughing, shivering, making grunting sounds. In the corner of my eye i saw one of the interns approaching me. "Dr. Anil can you help me with this patient, she is not doing so good". No kidding. I went to her bedside and picked up her chart. Platelets of 8. she is being treated for every infection that is known in a patient that has a CD4 count less than 50. The latest medicine that was added was empiric treatment for toxo. She also had esophageal candidiasis. The intern asked me what i thought and where the bleeding was coming from.
Bright red blood.... vomiting, very sick. In my head i thought it could be anywhere proximal to the ligament of tritz, are they doing an endoscopy. The plan apparently was to do it today but the endoscope is broken so has been put on hold. IV lines in place on the right arm with fluids running wide open, i debated whether to put a central line. She will die anyway and I really do hope she passes away. She is really suffering. When life appears more of a burden than death. I brought the central line kit and justp laced it by her bedside but i shunned the thought of even trying one. with platelets of 8 and an hgb of 5 with active bleeding she needed blood products, platelets. 1 unit of blood is all the blood bank could spare. No platelets available.
She looked at me with the look of please end this all. I'm tired, please let me go. I looked at her sheets all blood stained, her face stained in red with a foul smell of dried up blood. I grabbed one of the nurses and decided that if this patient was going to die she would die clean with some grace. Took a wet cloth and moistened it with cold water and just wiped her face, her mouth her cheeks her neck. She appeared to be momentarily comforted by the touch of cold water--closing her eyes and letting out a sigh. i rubbed her head and then her temples and decided that we would change her bed sheets, her blanket. We then propped her head up to an angle of 45 degrees, and i borrowed some juice. She opened up her tiny little mouth and took one sip, then two and mumbled something that i took as "that's it thanks". she then closed her eyes and slept.
I placed 3 bags of ringers lactate fluids by her bedside with instructions to family members close by that once the bag runs out they are to tell the nurse to replace it. one IV line in place, she will not make it. I also started omeprazole 20mg bid.
I hope she passes away tonight gracefully. Another day would just be another day of suffering.

It's easter today. Things really have a festive atmosphere over here. Last night I was up really late. Really late as in 10:30 pm. Usually I'm in bed by 8:30 or 9:00. I know... that's super super early buty I've pretty much adjusted my internal clock cycle to the sun. It gets really bright by around 5:30 am and pitch black by 6pm. Hence I now follow the motto: early to bed early to rise makes a man healthy wealthy and wise. I'm always running on time here in malawi. It's funny. In a country where everything runs super super slow, i am actualy punctual and running on time. Ppl who know me-my close friends, my family know that I run on Anil time. I'm always running late. 5-10 minutes usually. You can never count on me to be somewhere at the time stated. I'm really good at timing myself to be slightly late. I guess it's the genes. Indian ppl are always running late. There is something called the real time and then the indian standard time. It's all in good humor though and i find myself somewhat puzzled by my punctuallity over here.
Last night the darkness was filled by the sounds of techno music blasting away in the night. Usually the darkness is filled with howls of dogs and hyenas and other wild animals but not last night. God forbid if i hear the black eyed peas one more time. I might just go crazy. I think the music was coming frm the house next door but who knows. whereever the music was coming from they certainly were having a good time and are addicted to that soung "i've got a feeling".
I"m usually awoken by the sounds of roosters crowing. Seriously. that's my alarm clock. The start crowing around 5:30 am. Don't laugh.. if they don't crow, i won't wake up.
chickens.... there are tons walking aimlessly around. I see them everywhere especially on my morning commutes. I always wondered, how do ppl keep track of their chickens. after all they are often unattended to. Maybe it's the honor system. You learn to recognize your chickens and you NEVER steal a chicken that doesn't belong to you. That's taboo. after all ppl are always watching.

I've been feeling like crap for the last 3 days. Started off as a generalized malaise then progressed to a runny nose and now a vague headache. I was convinced this morning that I had cryptococcal meningitis but the logical side of my brain told me that i was just biased from all the cases of meningitis i had seen at the hospital. Regardless, the dorky side of me decided to do the kernig's maneuvar on myself. laying flat on my back, i gently flexed my left knee and then extended it. i was relieved! I didn't scream from severe neck pain and rigidity. Given that i had no neck stiffness or focal neurological signs or obvious defects I gave up on the idea that i have crypto meningitis. I am alert and oriented times 2 only- i didn't know what date it was . but then again the days go by so fast that i can't keep track.

I've been working at the hospital all weekend. I'm glad i came in this weekend. there are no doctors that work in the weekend and often patient's just lay in the wards unattended to. there are some pretty damn sick patients in the hospital right no.w. Last weekend I took both saturday and sunday off for the first time in 4 weeks and one of my patients who i had been doing a pretty good job micromanaging and taking care of died bc of neglect. while i don't take it personally i would just prefer to work all days so it doesn't happen again. The story of one patient i saw yesterday really touched me. This was a patient who is in his late 30s. He doesn't have a name nor does he have much of a history. Aparently he was brought into the hospital by one of the human rights watch groups who routinely surveys the prison systems here in malawi and was brought in b/c he was having hemoptysis. apparently he was brought in a few days before also but was discharged on an antimalarial and erythromycin. this guy was known sputum positive for TB but his treatement was never completed since he went to prison. He was cachectic, wasting way with temporal wasting, scaphoid abdomen, skin tenting and severely dehydrated. He was brought in by the guard few days ago and was just shackled to the bed and was left there.... unattended to. He had no guardian, no family members and was shackled to the bed. No bed sheets, no food and in fact had been neglected by hospital staff. a doctor had not even seen him since he arrived.

whlie making rounds yesterday i took notice of this gentleman and had a family member for another patient translate for me. Apparently this patient had been having severe chills, rigors, fevers, dry cough, abdominal pain and diarrhea. He also could not see for one week-blurry vision and had a palpable sore in his rectal area. He had no family members and said his name was steven. this guy was severely dehydrated. I asked if he had eaten and apparently he was relying on the good samaratans from other patients who would just leave food by his bedside. I quickly evaluted him. he had a dry cough, scaling skin, and a look in his eyes one could see that his iris was cloudy. he also had a rectal nodule which hurt when i palpated. I prescribed him empiric treatment for a pneumonia, recommended repeat sputum analaysis and tb treatment, VCT for HIV testing, and for his diarrhea treated him with albendzole,. metronidazole. for his eyes ciprofloxacin drops. I decided that despite what he may have done to land him in prison, my role was to be unbiased as I treat the disease and the human being irrespective of who the person is or what they've done. I ended up finding bedding for this patient, and decided that since this patient did not have a guardian i would be the guardian for the patient this weekend. I went outside and purchased a bunch of bananas, a sobo pinaapple juice box, and crackers and told him he had to eat. Almost from a movie script, I went home last night and was just flipping through a tropical medicine and parasites color atlas that's at the house and i came across something interestigah ha this could be the diagnosis. It was as if this was scripted and i was meant to see this patient. the diagnosis right in front of me. Why, This patient could have onchocerciasis, river blindness. It's a chronic disease of the skin and eye casued by an infestation witha filarial worm. the adult worm causes nodules in the skin and the larvae cause dermatitis and blindness. It's common onnly in certain parts of africa. The bite of an infected simulium (small black fly) injects infecti.ve larvae of the worm. the larvae develop into adult worms in the skin of the infected person and the adults cause painless nodules under teh kin. they can disseminate into the blood go into the eys and it's a very common cause of acute blindness.

the plan today will be to go to the hospital. to take a piece of his skin place it on a slide and watch the worms come out and migrate to a pool of saline that i will place on the slide. I will also do an Incision and drainage of that rectal mass. maybe there might be worms, maybe not. in any case my book tells me i should treat with ivermectin... maybe that's what i'll do. In fact i'll do it right now.