Blessings,
-Jordan
Friday, June 5, 2015
Final Reflections, Off to Swaziland!
Blessings,
-Jordan
Bonus Pictures
If you would like to view complete albums, click the link to visit my photobucket gallery and use the guest password appstate. Enjoy!
- University of the Free State, Bloemfontein, SA
- Weekend in Johannesburg
- Kruger National Park
- Bulembu Ministries, Swaziland
Week 4: Rose Park
6/03
This week at Rose Park hospital has been quite a transition back into modern health care. I had to stop myself in the pediatric ward from rubbing a baby's head and playing with him because I realized that I was no longer in a government hospital. Private practice is a lot like the county hospitals in the US; the pulse monitors on fingers, televisions in every room, computers with Internet, windows in tact, a more responsible nursing staff, electronically adjustable beds, the use of medical gloves, etc. I think the most significant difference between private and public hospitals were the rates of certain types of diseases and procedures. I saw maybe one or two patients with HIV at Rose Park, and almost no cases of severe acute malnutrition. Meanwhile, Botshabelo, Universitas, National, and Pelonomi had so many cases of HIV, TB, and SAM, it was no longer alarming for me to see patients looking like skeletons. I can't say that the quality of care in government hospitals was nearly as shocking as everyone described it, but it definitely did not meet American standards of medical care. It was assuring to see that most of the patients in the public sector experienced improvement in health status. Though I know that obesity is indeed associated with poverty, I have also witnessed obesity strongly correlate with all demographics and socioeconomic statuses, the only difference being the existence of malnutrition among the impoverished. Tristi, the head dietitian at Rose Park, sees a lot of bariatric surgery patients, specifically gastric bypass surgery patients. In case you are not familiar with the procedure, basically a large portion of the stomach is removed to hold about 80 ml and the duodenum is detached from the stomach where the jejunum is stapled. The result of the surgery is an unnaturally small stomach, malabsorption of nutrients, and an obsolete, dangling duodenum. Patients must have a BMI over 40 and no other comorbidities to qualify. Obviously no dietitian is in support of the surgery; it is incredibly unhealthy for the long-term yet is an irreversible long-term alteration. Yet, it is very important for Tristi to maintain a stable relationship with the surgeons, otherwise they will not refer patients to the dietitians before and after the procedure, despite the imperativeness for a successful operation. Many patients view the surgery as an easy solution, but if there are no permanent dietary changes post-op, weight loss may be minimized and re-hospitalization is inevitable, whether it be due to gastric tearing, sepsis, gastric obstructions, or major deficiencies. This is why Tristi and the surgeons collaborate by requiring the patient to lose at least 10% of their body weight before the surgery through dietetics counseling, usually over 6 -12 months. One would think that after losing 10% through only diet modification, the patient would decide against the surgery and rather pursue a health lifestyle, but many patients believe that the surgery is the only way they will be able to lose 100+ lbs. Tristi counsels all of the outpatients in the hospital, a model significantly more relationship-based than the public sector. When patients actually pay for a visit, they are far more likely to come and listen than if the same service were free. She is really spectacular at helping people develop healthy lifestyles in order to lose weight, rather than offering them a "diet" that will eventually be neglected after a few months. Fad diets work well in the short term, even the Banting diet that is so popular in South Africa right now, however, fad diets can have seriously harmful effects if made into a lifestyle. The only reason you don't hear the negative side effects is because participants ditch the diet after a couple of weeks. The best way to become healthy is to maintain a healthy lifestyle, it truly is as simple as that. One of Tristi's patients so observantly said, "My wife's friends are always dieting. I know that because they're always complaining and I never see them getting any skinnier."
My observations were certainly not limited to beriatric surgery patients; I saw countless diabetics and renal failure patients. Carika (another dietitian) said that she thinks the high rates of renal failure are due to a combination of high uncontrolled diabetes rates and frequent consumption of meat in Afrikaans culture, particularly red meat. Protein has its advantages, but an abundance of it can definitely have detrimental effects on the kidneys. I also saw quite a few cholecystostomy and hepatotomy patients. Those patients are started off with NPO post-op, then they transition to clear fluids, fortijuice, and finally a regular low-fat diet. Sometimes you get a patient with only one medical condition, which allows for less complex nutritional formulation. The patients who suffer from multiple diseases require more careful consideration. The most complicated case I saw was in the multi ICU. This poor man suffered from hepatitis B, cardiac failure, renal failure, hypertension, and diabetes. I honestly would have no idea how to feed a patient like that. Low protein, low carbohydrate, low fat - what is there left to eat? Carika just put him on a NG tube of the 2kcal at 70 ml/hr over 18 hrs. We also saw a 96 year-old with renal failure, bronchitis, oedema, and hypotension. Carika put him on a renal soft diet supplemented with supportan. We saw a man who was experiencing organophosphate poisoning, likely from pesticides, and a young guy with a laparoscopic nissen fundoplication (a gastric hernia). I've noticed that dietitians in South Africa supplement with glutamine quite frequently to support wound healing, a practice that is a bit less common in the US. I didn't get to sit in on many of Tristi's counseling sessions, which was unfortunate as I have heard that she is a really motivational dietitian and all of her outpatients love her. From what I did gather, it seems that her secret is just encouraging patients to make minor dietary alterations until the new habits become a lifestyle. I very intentionally used the word 'encouraging.' I did learn a bit more about low-residue diets from one counseling session, and I learned loads more about renal diets from taking on case studies of patients that the dietitians assigned me to work out. I was already pretty familiar with the numerous foods that renal patients are not allowed to consume, high potassium, high sodium, high phosphorus foods, but I was always curious as to what renal patients actually can eat. One thing I need to inquire about during Advanced Nutrition II next semester is the biochemical pathway and function of glucophage (metformin) in preventing glycogen release from the liver and reducing insulin resistance. I looked it up on the web, but it seems like the biochemical pathways are only generally understood (it activates AMPK, but how?). A lot of pre-diabetic patients are prescribed glucophage to promote insulin reception. One theory I was totally astounded to discover today (Thursday) was that the application of ketogenic diets for some epileptic patients may reduce the prevalence of seizures. I did some research to make certain that what I was being taught was evidence-based, and I found that Tristi was right on. It actually was a bit frustrating to know that I had never been taught this information before now, and I was an epileptic from age 9 to 15. I didn't dwell on it though; I've been so abundantly blessed in healing, there is very little I can reasonably complain about.
-Jordan
This week at Rose Park hospital has been quite a transition back into modern health care. I had to stop myself in the pediatric ward from rubbing a baby's head and playing with him because I realized that I was no longer in a government hospital. Private practice is a lot like the county hospitals in the US; the pulse monitors on fingers, televisions in every room, computers with Internet, windows in tact, a more responsible nursing staff, electronically adjustable beds, the use of medical gloves, etc. I think the most significant difference between private and public hospitals were the rates of certain types of diseases and procedures. I saw maybe one or two patients with HIV at Rose Park, and almost no cases of severe acute malnutrition. Meanwhile, Botshabelo, Universitas, National, and Pelonomi had so many cases of HIV, TB, and SAM, it was no longer alarming for me to see patients looking like skeletons. I can't say that the quality of care in government hospitals was nearly as shocking as everyone described it, but it definitely did not meet American standards of medical care. It was assuring to see that most of the patients in the public sector experienced improvement in health status. Though I know that obesity is indeed associated with poverty, I have also witnessed obesity strongly correlate with all demographics and socioeconomic statuses, the only difference being the existence of malnutrition among the impoverished. Tristi, the head dietitian at Rose Park, sees a lot of bariatric surgery patients, specifically gastric bypass surgery patients. In case you are not familiar with the procedure, basically a large portion of the stomach is removed to hold about 80 ml and the duodenum is detached from the stomach where the jejunum is stapled. The result of the surgery is an unnaturally small stomach, malabsorption of nutrients, and an obsolete, dangling duodenum. Patients must have a BMI over 40 and no other comorbidities to qualify. Obviously no dietitian is in support of the surgery; it is incredibly unhealthy for the long-term yet is an irreversible long-term alteration. Yet, it is very important for Tristi to maintain a stable relationship with the surgeons, otherwise they will not refer patients to the dietitians before and after the procedure, despite the imperativeness for a successful operation. Many patients view the surgery as an easy solution, but if there are no permanent dietary changes post-op, weight loss may be minimized and re-hospitalization is inevitable, whether it be due to gastric tearing, sepsis, gastric obstructions, or major deficiencies. This is why Tristi and the surgeons collaborate by requiring the patient to lose at least 10% of their body weight before the surgery through dietetics counseling, usually over 6 -12 months. One would think that after losing 10% through only diet modification, the patient would decide against the surgery and rather pursue a health lifestyle, but many patients believe that the surgery is the only way they will be able to lose 100+ lbs. Tristi counsels all of the outpatients in the hospital, a model significantly more relationship-based than the public sector. When patients actually pay for a visit, they are far more likely to come and listen than if the same service were free. She is really spectacular at helping people develop healthy lifestyles in order to lose weight, rather than offering them a "diet" that will eventually be neglected after a few months. Fad diets work well in the short term, even the Banting diet that is so popular in South Africa right now, however, fad diets can have seriously harmful effects if made into a lifestyle. The only reason you don't hear the negative side effects is because participants ditch the diet after a couple of weeks. The best way to become healthy is to maintain a healthy lifestyle, it truly is as simple as that. One of Tristi's patients so observantly said, "My wife's friends are always dieting. I know that because they're always complaining and I never see them getting any skinnier."
My observations were certainly not limited to beriatric surgery patients; I saw countless diabetics and renal failure patients. Carika (another dietitian) said that she thinks the high rates of renal failure are due to a combination of high uncontrolled diabetes rates and frequent consumption of meat in Afrikaans culture, particularly red meat. Protein has its advantages, but an abundance of it can definitely have detrimental effects on the kidneys. I also saw quite a few cholecystostomy and hepatotomy patients. Those patients are started off with NPO post-op, then they transition to clear fluids, fortijuice, and finally a regular low-fat diet. Sometimes you get a patient with only one medical condition, which allows for less complex nutritional formulation. The patients who suffer from multiple diseases require more careful consideration. The most complicated case I saw was in the multi ICU. This poor man suffered from hepatitis B, cardiac failure, renal failure, hypertension, and diabetes. I honestly would have no idea how to feed a patient like that. Low protein, low carbohydrate, low fat - what is there left to eat? Carika just put him on a NG tube of the 2kcal at 70 ml/hr over 18 hrs. We also saw a 96 year-old with renal failure, bronchitis, oedema, and hypotension. Carika put him on a renal soft diet supplemented with supportan. We saw a man who was experiencing organophosphate poisoning, likely from pesticides, and a young guy with a laparoscopic nissen fundoplication (a gastric hernia). I've noticed that dietitians in South Africa supplement with glutamine quite frequently to support wound healing, a practice that is a bit less common in the US. I didn't get to sit in on many of Tristi's counseling sessions, which was unfortunate as I have heard that she is a really motivational dietitian and all of her outpatients love her. From what I did gather, it seems that her secret is just encouraging patients to make minor dietary alterations until the new habits become a lifestyle. I very intentionally used the word 'encouraging.' I did learn a bit more about low-residue diets from one counseling session, and I learned loads more about renal diets from taking on case studies of patients that the dietitians assigned me to work out. I was already pretty familiar with the numerous foods that renal patients are not allowed to consume, high potassium, high sodium, high phosphorus foods, but I was always curious as to what renal patients actually can eat. One thing I need to inquire about during Advanced Nutrition II next semester is the biochemical pathway and function of glucophage (metformin) in preventing glycogen release from the liver and reducing insulin resistance. I looked it up on the web, but it seems like the biochemical pathways are only generally understood (it activates AMPK, but how?). A lot of pre-diabetic patients are prescribed glucophage to promote insulin reception. One theory I was totally astounded to discover today (Thursday) was that the application of ketogenic diets for some epileptic patients may reduce the prevalence of seizures. I did some research to make certain that what I was being taught was evidence-based, and I found that Tristi was right on. It actually was a bit frustrating to know that I had never been taught this information before now, and I was an epileptic from age 9 to 15. I didn't dwell on it though; I've been so abundantly blessed in healing, there is very little I can reasonably complain about.
-Jordan
Wednesday, June 3, 2015
Week 3: Pelonomi
5/26
So I am stationed at Pelonomi hospital this week, and though I have been told that Pelonomi has a reputation as the worst hospital in South Africa, but I haven't seen anything too bad.
Yesterday (Monday) Cariene, one of the four dietitians, took Hannelise and I through the burn unit and explained to us the steps of burn acre:
1. Cool the burn (at least 30 mins under cool water)
2. Assure the patient has an airway and adequate circulation. An emergency tracheostomy and drip may be required.
3. Determine % TBSA and severity of wounds. -Epidermal: sunburn, hot water, 1 wk. to heal if correctly managed -Superficial Dermal: 14 days to heal -Deep Dermal: 21 days to heal -Sub Dermal: exposed muscle, bones, tendons, no capacity for healing without skin graft Total Body Surface Area is calculated using the "rule of 9,"
4. Clean and dress the wound to avoid infection and heat/energy and fluid loss.
5. Address nutrient needs, feed within 4-12 hours after burn. Adequate enteral nutrition throughout the healing process protects villi and gut flora integrity and prevents additional complications such as curling ulcers or refeding syndrome. Patients are usually given the low fat house diet, 9739 kJ (2330 kcals), 352.1 g CHO (61%), 126.2 g Protein (22%), and 43.4 g Fat (17%) along with protein energy supplements if necessary. Curreri's formula is the most commonly used energy equation. Patients may benefit from supplements containing vitamin C and zinc for wound healing, or a multivitamin containing vitamin A and D. Iron deficiency is not of great concern for wound healing, because high ferretin levels may feed infection.
6. Monitor U&E and albumin at least weekly. If albumin is less than 26 administer a semi-elemental supplement for easier protein absorption. Often Peptomen Prebio is given in addition to a normal feed to allow for better absorption while also maintaining the capacity to digest larger molecules. Monitor Hb weekly if shown to be an issue. Monitor the amount eaten and patient feelings towards the feed. Also make sure the physical/occupational therapists work with the patients to prevent contracture .It is quite painful, but necessary for maximum mobility.
Since shadowing in the hospitals, I've seen a lot of nasty things like calcified toes, gangrene, mouth cancer, colostomy bags, bloody oxygen masks, you name it, but I think I encountered the nastiest yet in the burn unit. I have no idea how this poor lady survived for several days at home before admitting to the hospital, but she suffered from sub-dermal burns from the knee down on both legs. You could see all of the tendons, muscles, and bones in her legs, and it was gruesome to say the least. But the sight was not half as nauseating as the smell. I have decided that bacterial growth on rotting flesh is definitely my least favorite smell, as it almost made me lose my breakfast. Another guy across the hall had only 9% burns on his right arm and hand but suffered from HIV and his hand was completely shriveled and dead, resembling frostbite. His room smelled even worse. Unfortunately he passed away last night.
It seems that most adult burns are products of open fire pits, alcohol, or both. There are also a substantial amount of burns due to domestic disputes. If a man is admitted with boiling water burns, one can usually assume he was either drunk and trying to cook, or received it from his wife. Women who suffer from burns due to domestic disputes are rather lit on fire or pushed into fire pits. Most child burns are due to household accidents, but it is always important to analyze the story to make sure it matches up with the burn characteristics. Every now and then there is a case of child abuse that is evident, such as a clear burn line where the child was dipped into boiling water. Thank goodness for social workers.
Today was a pretty relaxed day as well. I accompanied Anika, another dietitian, around the general medicine wards, learned of a refeeding patient, and revisited the problems with having an uncooperative nursing staff. At Universitas, Pelenomi, and most other government hospitals, the sisters may or may not follow the diet orders verbally given and written out on a specific sheet in the patient's files. This is especially a concern for malnourished patients at risk for refeeding syndrome. Usually Anika starts the patient out with a 10-15 kcal/kg bw nasogastric tube and divides that amount by 18 hrs to determine the ml/hr that ought to be given on the machine, so it is very important to follow the orders exactly.
We also stopped by the neonatal unit and found a new mom that needed help with latching, which was a surprisingly easy case as all she needed to do was rub the baby's cheek to stimulate the reflex. The rest of the day was a bit slow, as the dietitians didn't have any more work for me, so I worked on this post a bit and encouraged Wieda to become the president of South Africa.
-Jordan
5/27
I was with Nicoliene today in the pediatric wards, my favorite place to visit in the hospital. We checked in with numerous SAM patients, noted Mid Upper Arm Circumferences below 11.5 cm and oedema states, and Nicoliene updated any diet orders for the day. If the infant (6-12 mo.) shows no signs of oedema, then 130 ml/kg bw is prescribed of whatever fluid is being consumed. If oedema is present, 100 ml/kg bw is prescribed. I love the pediatric wards not only because I love babies and children, but because it is so gratifying to see the patients pick up weight and improve on their growth charts. If the mommy is on board and the nurses follow the diet orders, improvement is far more likely than with adult patients that do not want to listen or heed the diet orders. Also, with the children it is very evident when they are not feeling well or when they are feeling better, but adults are a bit harder to read. The amount of SAM cases in the government hospitals here is very high compared to the US. I very frequently see 9 and 11 month-olds weighing less than 4 kg (8.8 lbs), babies that are HIV positive, and babies that have not received any immunizations due to the extremely low level of education and care among mothers. As a health care professional, one cannot allow oneself to become depressed by the depressing; health care professionals need to be positive, uplifting, and compassionate to the patient. I used to think that I could never work in a hospital setting, but after what I have experienced so far, I wouldn't mind doing it for a while. However, I find follow-ups with outpatients far more gratifying as you can develop relationships with patients and track progress. I went for a quick run after our return and came to the realization that I only have 9 days left in Bloemfontein :(
5/28
It seems that Pelonomi is a very low-stress environment. I accompanied Wieda and Hannelise to do some nutrition screening in the general ward, visited Wieda's blue book (nutrition assessment) patient with RVD and meningitis, and visited Hannelise's blue book patient with 30% burns. Her patient experienced the burns exclusively on the front of her body and additionally suffered from RVD (HIV). The etiology of the injury was either due to a household cooking accident or a domestic dispute. The files always list HIV as RVD in order to preserve patient confidentiality, because the medical files are easily accessible to anyone in the hospital as they are laid out on the table beside each bed. She couldn't stand, so we roughly measured her length using a measuring tape and visually estimated her weight. I really love counseling, educating, and interacting with patients. The only patients I don't prefer to greet are the prisoners and the ones in the isolation ward. We go in there with masks and such, but med-resistant tuberculosis is a very frightening disease. Also, sometimes I really wish God didn't call me to love the people who are hard to love, because I have some serious resentment towards rapists, molesters, and child abusers. I believe that rape is the worst thing you can to to another human being, far worse than murder. I still have some serious work to do on my own heart if I am ever to become a beacon to the people that I despise the most. Pretty much the rest of the work day was spent voluntarily reading through Krause's Food and the Nutrition Care Process, the Bible, and Out of the Silent Planet. Also, I am finally grasping a respectable amount of Afrikaans, as that is the language that I hear in over 75% of all conversations. Give me two more years and I'm confident that I could become fluent. I am greatly enjoying this week because all of the dietitians are very sweet and I enjoy the company of Hannelise and Wieda, but I do hope that next week is a bit busier. I don't do well under low-stress situations.
5/29
Last night the roommates had a party that ended at 5 am this morning. I hung around the kitchen with them for about an hour to spectate, and then retired to my room to chat with the family and Ryan. I am getting excited about Swaziland as it is 7 days away now, but at the same time I am getting kind of nervous because I will have little to no access to communication, grocery stores, or hospitals. I've looked into getting a cell phone with MTN Swazi, and it looks incredibly expensive to call internationally. The postal service reaches as far as Piggs Peak, which is an hour away by the nearest grocery store, so writing letters is not a convenient option either. I may have access to email every few days, but I am preparing myself for complete isolation from the modern world. I'm going to call it an adventure and leave it with a better connotation. I was told that I will be volunteering at the primary school in Bulembu, but I think I may also check in on the local clinic and volunteer there is I have time. Now that I am more familiar with interventions for common diseases like SAM, RVD, PTB, pneumonia, CVD, hypertension, DM, and such, I feel an obligation to apply some of my knowledge through volunteering while continuing to build up my reservoir. I love being with people, even cranky people, and it is quite affirming to find that under further investigation I am still not deterred from the medical field. I especially love the pediatric ward, which I got to visit today with Nicoliene. Being able to hold and bring a smile to the face of a baby that suffers from SAM and RVD is a privilege, as that baby is not merely a product of disease and poverty, but a spectacular and precious creation of God. Her life is just as important as mine, if not more.
No one lives without struggle, it is a necessity of life and a prerequisite for mercy and redemption. That is the only way I can understand the chaos of the human condition and the seemingly randomized birth placement across disparities between the privileged and the deprived. I cannot imagine a life without faith in a world without hope. I am affirmed that there is a God because there is a such thing as corruption, and therefore rebellion against some innate morality. I am also affirmed by the presence of beauty and hope in the midst of struggle and tragedy. Love is irrational, yet even the rational fall into it. Not everything has to make sense; some things I hope to discover, others I hope to never understand, and there is much that I may never know. I'm okay with that. I love the chase and I love who I'm following.
Back to nutritional rehabilitation in South Africa, I've experienced a bit of the wake from the Integrated Nutritional Program's objectives. One of the most prominent changes brought on by this initiative is the Kangaroo Mother Care policy, which I discussed in an earlier post. I really love how strongly health care professionals discourage bottle feeding and formula company advertising. Yes, we use formula in the hospitals quite frequently whenever the mom cannot produce enough milk or if mom is not taking her ARVs. However, most of the mothers in the hospital breastfeed, which brings warmth to my heart, especially in teaching new moms how to breastfeed. Mommas are always very happy to hear your instruction and they get very excited when training leads to success.
So I am stationed at Pelonomi hospital this week, and though I have been told that Pelonomi has a reputation as the worst hospital in South Africa, but I haven't seen anything too bad.
Yesterday (Monday) Cariene, one of the four dietitians, took Hannelise and I through the burn unit and explained to us the steps of burn acre:
1. Cool the burn (at least 30 mins under cool water)
2. Assure the patient has an airway and adequate circulation. An emergency tracheostomy and drip may be required.
3. Determine % TBSA and severity of wounds. -Epidermal: sunburn, hot water, 1 wk. to heal if correctly managed -Superficial Dermal: 14 days to heal -Deep Dermal: 21 days to heal -Sub Dermal: exposed muscle, bones, tendons, no capacity for healing without skin graft Total Body Surface Area is calculated using the "rule of 9,"
4. Clean and dress the wound to avoid infection and heat/energy and fluid loss.
5. Address nutrient needs, feed within 4-12 hours after burn. Adequate enteral nutrition throughout the healing process protects villi and gut flora integrity and prevents additional complications such as curling ulcers or refeding syndrome. Patients are usually given the low fat house diet, 9739 kJ (2330 kcals), 352.1 g CHO (61%), 126.2 g Protein (22%), and 43.4 g Fat (17%) along with protein energy supplements if necessary. Curreri's formula is the most commonly used energy equation. Patients may benefit from supplements containing vitamin C and zinc for wound healing, or a multivitamin containing vitamin A and D. Iron deficiency is not of great concern for wound healing, because high ferretin levels may feed infection.
6. Monitor U&E and albumin at least weekly. If albumin is less than 26 administer a semi-elemental supplement for easier protein absorption. Often Peptomen Prebio is given in addition to a normal feed to allow for better absorption while also maintaining the capacity to digest larger molecules. Monitor Hb weekly if shown to be an issue. Monitor the amount eaten and patient feelings towards the feed. Also make sure the physical/occupational therapists work with the patients to prevent contracture .It is quite painful, but necessary for maximum mobility.
Since shadowing in the hospitals, I've seen a lot of nasty things like calcified toes, gangrene, mouth cancer, colostomy bags, bloody oxygen masks, you name it, but I think I encountered the nastiest yet in the burn unit. I have no idea how this poor lady survived for several days at home before admitting to the hospital, but she suffered from sub-dermal burns from the knee down on both legs. You could see all of the tendons, muscles, and bones in her legs, and it was gruesome to say the least. But the sight was not half as nauseating as the smell. I have decided that bacterial growth on rotting flesh is definitely my least favorite smell, as it almost made me lose my breakfast. Another guy across the hall had only 9% burns on his right arm and hand but suffered from HIV and his hand was completely shriveled and dead, resembling frostbite. His room smelled even worse. Unfortunately he passed away last night.
It seems that most adult burns are products of open fire pits, alcohol, or both. There are also a substantial amount of burns due to domestic disputes. If a man is admitted with boiling water burns, one can usually assume he was either drunk and trying to cook, or received it from his wife. Women who suffer from burns due to domestic disputes are rather lit on fire or pushed into fire pits. Most child burns are due to household accidents, but it is always important to analyze the story to make sure it matches up with the burn characteristics. Every now and then there is a case of child abuse that is evident, such as a clear burn line where the child was dipped into boiling water. Thank goodness for social workers.
Today was a pretty relaxed day as well. I accompanied Anika, another dietitian, around the general medicine wards, learned of a refeeding patient, and revisited the problems with having an uncooperative nursing staff. At Universitas, Pelenomi, and most other government hospitals, the sisters may or may not follow the diet orders verbally given and written out on a specific sheet in the patient's files. This is especially a concern for malnourished patients at risk for refeeding syndrome. Usually Anika starts the patient out with a 10-15 kcal/kg bw nasogastric tube and divides that amount by 18 hrs to determine the ml/hr that ought to be given on the machine, so it is very important to follow the orders exactly.
We also stopped by the neonatal unit and found a new mom that needed help with latching, which was a surprisingly easy case as all she needed to do was rub the baby's cheek to stimulate the reflex. The rest of the day was a bit slow, as the dietitians didn't have any more work for me, so I worked on this post a bit and encouraged Wieda to become the president of South Africa.
-Jordan
5/27
I was with Nicoliene today in the pediatric wards, my favorite place to visit in the hospital. We checked in with numerous SAM patients, noted Mid Upper Arm Circumferences below 11.5 cm and oedema states, and Nicoliene updated any diet orders for the day. If the infant (6-12 mo.) shows no signs of oedema, then 130 ml/kg bw is prescribed of whatever fluid is being consumed. If oedema is present, 100 ml/kg bw is prescribed. I love the pediatric wards not only because I love babies and children, but because it is so gratifying to see the patients pick up weight and improve on their growth charts. If the mommy is on board and the nurses follow the diet orders, improvement is far more likely than with adult patients that do not want to listen or heed the diet orders. Also, with the children it is very evident when they are not feeling well or when they are feeling better, but adults are a bit harder to read. The amount of SAM cases in the government hospitals here is very high compared to the US. I very frequently see 9 and 11 month-olds weighing less than 4 kg (8.8 lbs), babies that are HIV positive, and babies that have not received any immunizations due to the extremely low level of education and care among mothers. As a health care professional, one cannot allow oneself to become depressed by the depressing; health care professionals need to be positive, uplifting, and compassionate to the patient. I used to think that I could never work in a hospital setting, but after what I have experienced so far, I wouldn't mind doing it for a while. However, I find follow-ups with outpatients far more gratifying as you can develop relationships with patients and track progress. I went for a quick run after our return and came to the realization that I only have 9 days left in Bloemfontein :(
5/28
It seems that Pelonomi is a very low-stress environment. I accompanied Wieda and Hannelise to do some nutrition screening in the general ward, visited Wieda's blue book (nutrition assessment) patient with RVD and meningitis, and visited Hannelise's blue book patient with 30% burns. Her patient experienced the burns exclusively on the front of her body and additionally suffered from RVD (HIV). The etiology of the injury was either due to a household cooking accident or a domestic dispute. The files always list HIV as RVD in order to preserve patient confidentiality, because the medical files are easily accessible to anyone in the hospital as they are laid out on the table beside each bed. She couldn't stand, so we roughly measured her length using a measuring tape and visually estimated her weight. I really love counseling, educating, and interacting with patients. The only patients I don't prefer to greet are the prisoners and the ones in the isolation ward. We go in there with masks and such, but med-resistant tuberculosis is a very frightening disease. Also, sometimes I really wish God didn't call me to love the people who are hard to love, because I have some serious resentment towards rapists, molesters, and child abusers. I believe that rape is the worst thing you can to to another human being, far worse than murder. I still have some serious work to do on my own heart if I am ever to become a beacon to the people that I despise the most. Pretty much the rest of the work day was spent voluntarily reading through Krause's Food and the Nutrition Care Process, the Bible, and Out of the Silent Planet. Also, I am finally grasping a respectable amount of Afrikaans, as that is the language that I hear in over 75% of all conversations. Give me two more years and I'm confident that I could become fluent. I am greatly enjoying this week because all of the dietitians are very sweet and I enjoy the company of Hannelise and Wieda, but I do hope that next week is a bit busier. I don't do well under low-stress situations.
5/29
Last night the roommates had a party that ended at 5 am this morning. I hung around the kitchen with them for about an hour to spectate, and then retired to my room to chat with the family and Ryan. I am getting excited about Swaziland as it is 7 days away now, but at the same time I am getting kind of nervous because I will have little to no access to communication, grocery stores, or hospitals. I've looked into getting a cell phone with MTN Swazi, and it looks incredibly expensive to call internationally. The postal service reaches as far as Piggs Peak, which is an hour away by the nearest grocery store, so writing letters is not a convenient option either. I may have access to email every few days, but I am preparing myself for complete isolation from the modern world. I'm going to call it an adventure and leave it with a better connotation. I was told that I will be volunteering at the primary school in Bulembu, but I think I may also check in on the local clinic and volunteer there is I have time. Now that I am more familiar with interventions for common diseases like SAM, RVD, PTB, pneumonia, CVD, hypertension, DM, and such, I feel an obligation to apply some of my knowledge through volunteering while continuing to build up my reservoir. I love being with people, even cranky people, and it is quite affirming to find that under further investigation I am still not deterred from the medical field. I especially love the pediatric ward, which I got to visit today with Nicoliene. Being able to hold and bring a smile to the face of a baby that suffers from SAM and RVD is a privilege, as that baby is not merely a product of disease and poverty, but a spectacular and precious creation of God. Her life is just as important as mine, if not more.
No one lives without struggle, it is a necessity of life and a prerequisite for mercy and redemption. That is the only way I can understand the chaos of the human condition and the seemingly randomized birth placement across disparities between the privileged and the deprived. I cannot imagine a life without faith in a world without hope. I am affirmed that there is a God because there is a such thing as corruption, and therefore rebellion against some innate morality. I am also affirmed by the presence of beauty and hope in the midst of struggle and tragedy. Love is irrational, yet even the rational fall into it. Not everything has to make sense; some things I hope to discover, others I hope to never understand, and there is much that I may never know. I'm okay with that. I love the chase and I love who I'm following.
Back to nutritional rehabilitation in South Africa, I've experienced a bit of the wake from the Integrated Nutritional Program's objectives. One of the most prominent changes brought on by this initiative is the Kangaroo Mother Care policy, which I discussed in an earlier post. I really love how strongly health care professionals discourage bottle feeding and formula company advertising. Yes, we use formula in the hospitals quite frequently whenever the mom cannot produce enough milk or if mom is not taking her ARVs. However, most of the mothers in the hospital breastfeed, which brings warmth to my heart, especially in teaching new moms how to breastfeed. Mommas are always very happy to hear your instruction and they get very excited when training leads to success.
Monday, June 1, 2015
Weekend 4: Fun Farewells
6/01
A recap of the weekend: Friday I went to the student presentation session as usual and afterwards Hannelise, Wieda, and I headed back to Pelonomi until 4 pm. Later in the evening, Hannelise and I went to her friend's house to play some FIFA. Saturday was a bit more eventful as Hannelise and I went to the boere mark and naval hill once last time. Shannon's family was in town, so I met up with them to have a picnic in the botanical gardens. It was still in bloom due to the very beautiful warm weather we had been having. We also went for a short hike on one of the trails there, and all was right in the world. It very much resembled Watauga hiking (only NC is a bit more scenic in my opinion), so I felt a tad of sweet nostalgia and longing for Boone's summertime mountains with wading pools and waterfalls. The view was quite nice from the trails though, it is just a much tougher climate and terrain here. I constantly have to remind myself to seize and enjoy the present. I went for a run later in the day and soaked up every drop of that deliciously sunny day. That evening, Hannelise and I watched a rugby game and on Sunday morning she took me to her Afrikaans church. I tried my best to sing the hymns, so I am certain that the older couple in front of me heard the speaking of strange tongues by a strange tongue. I quite liked the Afrikaans service, despite the fact that the only thing I interpreted from the sermon was the pastor's mention of "Honey I Shrunk the Kids." Deep point though: don't try to shrink God to fit your lifestyle, let him be magnificent and abundant, and definitely don't isolate him to your backyard. It was all in Afrikaans, but I think I was picking up what he was putting down. I joined Hannelise's family for tea and then went for another beautiful and relaxing run. Later that evening she took me to a very contemporary English church, and it reminded me so much of worship at Boone UMC crossroads. The praise team had one guy rapping some gospel during the bridge of one of the worship songs, and it was wicked sweet. I know Ryan would have been excitedly rubbing his hands together and wiggling his feet and at the sight of it (about the same response that he has when we watch "Cool Runnings"). Afterwards, Hannelise and I ate at Spur with a couple friends and that night I slept like a rock in preparation for Monday at Rose Park. In regards to Spur, I find it so peculiar that there is a Native American themed restaurant chain in South Africa that mainly serves hamburgers.
A recap of the weekend: Friday I went to the student presentation session as usual and afterwards Hannelise, Wieda, and I headed back to Pelonomi until 4 pm. Later in the evening, Hannelise and I went to her friend's house to play some FIFA. Saturday was a bit more eventful as Hannelise and I went to the boere mark and naval hill once last time. Shannon's family was in town, so I met up with them to have a picnic in the botanical gardens. It was still in bloom due to the very beautiful warm weather we had been having. We also went for a short hike on one of the trails there, and all was right in the world. It very much resembled Watauga hiking (only NC is a bit more scenic in my opinion), so I felt a tad of sweet nostalgia and longing for Boone's summertime mountains with wading pools and waterfalls. The view was quite nice from the trails though, it is just a much tougher climate and terrain here. I constantly have to remind myself to seize and enjoy the present. I went for a run later in the day and soaked up every drop of that deliciously sunny day. That evening, Hannelise and I watched a rugby game and on Sunday morning she took me to her Afrikaans church. I tried my best to sing the hymns, so I am certain that the older couple in front of me heard the speaking of strange tongues by a strange tongue. I quite liked the Afrikaans service, despite the fact that the only thing I interpreted from the sermon was the pastor's mention of "Honey I Shrunk the Kids." Deep point though: don't try to shrink God to fit your lifestyle, let him be magnificent and abundant, and definitely don't isolate him to your backyard. It was all in Afrikaans, but I think I was picking up what he was putting down. I joined Hannelise's family for tea and then went for another beautiful and relaxing run. Later that evening she took me to a very contemporary English church, and it reminded me so much of worship at Boone UMC crossroads. The praise team had one guy rapping some gospel during the bridge of one of the worship songs, and it was wicked sweet. I know Ryan would have been excitedly rubbing his hands together and wiggling his feet and at the sight of it (about the same response that he has when we watch "Cool Runnings"). Afterwards, Hannelise and I ate at Spur with a couple friends and that night I slept like a rock in preparation for Monday at Rose Park. In regards to Spur, I find it so peculiar that there is a Native American themed restaurant chain in South Africa that mainly serves hamburgers.
Sunday, May 24, 2015
Weekend 3: Wild Johannesburg!
5/24
Shannon came to pick me up Saturday
morning around 6 am because she wanted to take me to Johannesburg to
stay with her family. It was about a 4 hour drive, so we decided to
seize the day dark and early. She has a very beautiful home, and her
family was really sweet. Her mom even decorated the rooms with fresh
flowers and left chocolates on our beds. Her dad picked us up from the
house and dropped us off at the SPCA where her mom works, so I got a
behind-the-scenes tour of the Johannesburg SPCA. Shannon's mom scared me
enough for the whole weekend when she told us about her co-worker that
was hijacked a few blocks away in broad daylight. Someone just came up
to her car at a stop, pointed a gun at her window and stole her phone,
purse, car, and even the wheelchair in the back for her disabled kid.
Needless to say, from that point on I was super paranoid of every
pedestrian walking the medians, especially the ones reaching in their
pockets for what usually turned out to be a cell phone. Shannon's family
took me to the Apartheid museum around 2, where I learned quite a good
bit about Nelson Mandela. I hadn't realized that the African National
Congress was actually a communist party, and that Mandela was quite
supportive of communism, because he believed that democracy was unlikely
to be offered to the black population. I also realized that he wasn't
exactly a peaceful leader when he first began getting involved in the
apartheid movements, and that his time in prison greatly reformed his
strategy. He wound up being a really incredible leader for the nation,
however it is important to note that his influence was facilitated by
his high level of education, something that a lot of potential leaders
are denied in South Africa. In addition, many blacks are employed in
positions that they are not qualified for due to legislative requirement
of racial dispersion in the workforce and neglect for provision of
appropriate education for the black population. Even Jacob Zuma, the
president, has no more than a 5th grade education. I quite enjoyed the
museum though, I learned a lot about the South African government and
gained a better understanding of the nation's reverence for him.
Around 5:30 as the sun was setting, Shannon's dad took me up in his two-seater plane called a "Bushbaby." It. Was. Awesome. I was beaming for so long that my cheeks hurt by the time that we landed.
Weekend 3: Bloemfontein Cheetah Park
5/24
After escaping Universitas, Wieda and Marcè took me to the Cheetah
park and it was absolutely wonderful! I could tell the Cheetah
Experience was heavily focused on conservancy and saving endangered
animals. The park even hosted some wild cats that looked a lot like
house cats, but the tour guide said that people will pay R2000 just to
shoot one for sport. She didn't appreciate my humor when I suggested
that people just shoot city cats as they are free and abundant. I think
my chances for volunteering have diminished. Regardless, I can now check
petting a Cheetah off my bucketlist. Later in the evening I went to a
braai thanks to the invite of Aldinè, another dietetics student. We had a
lot of fun with many other students from the department, and it was
the most wonderful thing to see the sense of community and friendship
among those ladies. Not to mention I got to play with Aldinè's little
toy pom puppy and I got to try some new Afrikaans foods like boerewors,
sheep chops, mielie bread, and pumpkin tart.
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