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The New Routine

Posted Jan 24 2009 8:18am
Monday I attended what I sadly realized would be my last delivery for some time. It was fast and smooth, and moments after mother and baby were cuddling and feeding, staring contentedly into each other’s eyes. Last week I finally received word from the College of Nurse Midwives that I passed my nursing registration exam and was informed that I could now begin my hospital orientation. Unfortunately the orientation is for general nursing and so the 90 day period includes only a brief allocation to Obstetrics and Gynecology during which I’m not sure whether I will be permitted to attend deliveries. Orientation will finish in mid-April and then, having spent nine months without any income, it will be time for me to head to Texas in search of a well-paid short nursing contract which will keep us going here for another year. That means I will most likely not be attending deliveries again until the fall.
Nurses here still wear white dress uniforms and little white caps (as they do in all wards minus delivery in Malawi as well). I have been able to avoid this up to now by never asking about a dress code and just showing up in my American scrubs. However the letter from the Council explicitly mentioned that I must wear white and the Director of Nursing at KATH – the large teaching hospital where I will do my orientation – made sure I was aware of this. After a few hours worrying and then laughing at the idea of sending my midwifery classmates a picture of me in a white nursing dress, a little white cap, and Minnie Mouse shoes (as my aunt Joanna used to call them) I found a shop selling second hand white scrubs from Europe. I am the only nurse in the hospital wearing trousers but no one has complained so far.

Wednesday was my first day. I left the house at 6:30 and walked to the corner to catch a tro-tro. (After 7am the tro-tros are few and the hopeful passengers many and more aggressive than I can bear.) I don’t mind the 30 minute cross-town trip in a small minivan with 14 other people, I appreciate not having to drive, it is the other part of the commute which I find exhausting. The tro-tro stops on Roman Hill, named for the large Roman Catholic Cathedral perched on top, and from there I walk down the hill, across a corner of Kejetia Market, and up the opposite hill to the hospital. Someday I will have to video the walk. Even at 7am the streets are full, vendors who have already displayed their wares, shout prices to attract customers. Others quickly transform minimal wooden structures into colorful full shops. Permanent shops lining the road sell mattresses, or household items; their goods brought to the road side every morning and repacked every evening. In front of them sit the vendors, each with their little square of land. Women squat in front of large steaming pots selling foods I still can’t identify. Men stand next to tables of brightly packaged pirated copies of movies and CDs, irons and rice cookers, tables of cell phones, stacks of dvd players. At the bottom of the hill women sit beside their produce arranged in colorful heaps, tomatoes, carrots, onions, bell peppers, buckets of lettuce, yams, piles of smoked fish, dried shrip. One woman positioned just where I take my first turn straddles a large bushel of giant snails. Just about everything needed for daily life is available and everyone who has a spot returns to the same location daily.

Vendors sell soap, shampoo, beauty products, costume jewelry, used magazines and books, live chickens, cans of diet coke, vegetable seeds. Men stand at carts piled high with coconuts carving a hole for customers to drink their milk and then cutting them open with swift exact chops from their machetes. For a long stretch both sides of the road are filled with people selling used clothes, some heaped in piles, some displaying the best pieces on the walls of their stalls, some walking up and down with a pile over their shoulder. Along my walk I pass a minimum of three stations for roadside preaching. Each day at every station a different person yells into the microphone connected to enormous pair of speakers blasting his or her voice into the din. People selling CDs also amplify their music – I suppose the idea is to attract customers but it is deafening to anyone close enough to actually browse through their selection. Those who do not have their own corner of the market walk back and forth carrying their wares on their heads. Yesterday I saw a woman with purses hanging from her arms and piled stories high on her head. Men carry stacks of handkerchiefs, towels, used clothes, yogurt, chewing gum. Women carry sachets of water, trays of freshly baked bread, chocolate drinks in bags floating in plastic containers with bubbles of ice, bananas and peanuts, fried plantain chips, cheap plastic toys, women’s underwear, neat packages tied with banana leaves (the inside edible identifiable by the shape, circular, long and rectangular, or small and rectangular), pineapple, dried fish and fried yam.

Then there are people transporting packages. Carry-o girls with their white basins wait to carry items for you for a few cents. Wearing head scarves, and layers of mismatched bright prints, their eyes painted with charcoal, ethnic tattoos on their foreheads they are visible everywhere, some moving swiftly under enormous loads and others sitting or sleeping in the midst of chaos, their bodies draped over empty overturned basins. Wherever tro-tros stop men shout and frantically try to fill them with passerbys. Every day at some point along my walk a man stands in front of me or grabs my wrist pulling me towards his bus asking “where are you going?” but not waiting for a response. Every inch of space is colorful and full. The sound is overwhelming, talking, yelling, music, and endless honking. Cars move slowly, drivers keep their hands on their horns, and people weave through them, across the street and back like trails of ants.

Kejetia market is alluring and repulsive. Enormous piles of trash generated daily by the 10,000 venders and their customers rise along the road. I know the areas on my route where the stench rising from gutters is overpowering and go out of my way to avoid them. As I turn out of the market I pass the same woman in the morning always grinding pepper by hand in her clay pot. Across the street a speaker projects the shouting of an unseen man yelling tro-tro destinations. Every day I see the woman and hear the main in the same monotone shout, “Accra, Accra, Accra, Circle, Circle, Circle, Lelela, Lelela, Lelela . . .” A few paces from there I often meet the same street cleaner, a lone woman sweeping who smiles and says good morning. As I walk I have the sensation that I am again beginning the same day. On one hand it is the disquieting sense that there is no progress but on the other hand there is a sense of reassurance - that the worst has been survived previously and might be survived again if necessary - and a little hope that maybe today may be better.

As I walk up the road the market descends and I am soon overlooking a bus depot filled with hundreds of small buses of every make, year, model, and color imaginable. I continue up the street and approach what appears to be an enormous noisy swarm of birds flying in circles over a few acres of strange brown deformed trees and undeveloped land. But, as I get closer I can see that the birds are actually large bats and the strange brown branches are actually clusters of hanging bats. I walk up a back street filled with men weaving baskets and book stands then through the gate leading to the dorms for medical students and flats for doctors. There always seems to be a few chickens roaming freely followed by a cluster of fuzzy chicks.

When I reach the hospital I find a closet or an exam room where I change into my white scrubs and then find the room where I am supposed to report and introduce myself to the doctor. This week I spent two days in the outpatient pediatric triage room and two days in the adult triage room. All consultations are conducted in Twi, the most widely used local language of which I only understand a handful of words. Over the past few days all the doctors have willingly translated a summary of the patient’s complaint and involved me in their thinking process while making a diagnosis. Malaria accounted for a high percentage of the hospital visits. These cases are relatively straight forward a patient typically presents with chills, fever, and occasionally nausea, vomiting, diarrhea. Many times even if malaria is consider only a possible diagnosis the physician will prescribe the treatment because delayed treatment can be devastating and there are not enough resources to test everyone who comes in with such symptoms. While in pediatrics I saw a child come in and have a febrile seizure while in his mother’s arms. I saw two sisters with imperforate hymens. I was very impressed by the fact that the triage doctor just walked the mother with her young girls down the hall to see a specialist (in Malawi there are few physicians fewer specialists) and I was very impressed by the specialist who talked to the five year old, asking her her name, telling her what he would do and asking her permission – something else I have rarely seen. Back in the consultation room I saw several children with sickle cell anemia. Sickle cell anemia is much more common here than in Malawi. Children are currently tested at birth and at least in large cities there are regular clinics for positive children to help make sure their lives are as long and healthy as possible. The pediatrician I followed one morning said that sickle cell positive people in Ghana can live into their fifties but many patients die young and suffer greatly.

In the adult consulting room I saw many cases of malaria and many more of hypertension. Hypertensive patients came to refill medication which either they were not taking correctly or they were taking correctly but failed to control their blood pressure. I did not see a single well controlled hypertensive and many who came had blood pressures which classified them as severe. A few of these people were overweight but most of them were just middle-aged women (one of the male physicians said men would rarely their medicine, much less come for a refill, because of the side effect of impotence). One relatively fit looking young man perhaps in his early forties came for his medication refill, his limp and posture evidence of a previous stroke, and his blood pressure frightening at 170/110. There were a few elderly patients with bladder infections, an elderly woman with congestive heart failure, and a confused man with an infected laceration. Then there were the two men who pushed their relative through the door in his wheel chair, saying that three days previously their relative was normal and had complained of knee pain. I eyed the patient, suspicious of his immobility. He sat upright, eyes closed and his face relaxed. While the doctor conversed with the men I first thought he might have a psychiatric condition. Then I watched his chest for movement and saw nothing. The doctor checked his pupils with her pen light, felt for a pulse and then told the men that people from the mortuary would come and collect the body. The relative asked a few more questions of the doctor and when he left the room she said that he had no idea the man was dead until she mentioned the mortuary. He was a hypertensive and was only 48.

I miss birth already but I know I will see a lot during my six day weeks here and I hope that this experience will make me a better nurse in this setting.
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