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.
Week 2: Universitas
5/19
Universitas was a bit more demanding than I anticipated, but the atmosphere has forced me to move rapidly and think rapidly. The hospital is very large, and holds a lot of patients that were referred from various other hospitals to receive specialist care. It has ten floors and a couple elevators that are always ridiculously full, so most of the doctors, surgeons, dietitians, etc. take the stairs (the nurses and patients opt for the elevator). I thought Sunday was leg day, but apparently every day is leg day. There are 5 dietitians, each in charge of a different ward. There are so many wards and units on each of the ten floors that I struggle to remember where anything is at all. Yesterday began with Marli making her rounds in the cardiovascular ward with a group of other doctors huddling into each room to review each patient's status. It was excruciatingly long and was likely very awkward for the patients. I also saw a lot of diabetic patients with calcified toes, black and stone-like. In fact, there were very few diabetic patients at the hospital who did not have calcified or amputated toes. I then followed Monica around the ear, nose, and throat ward as well as the pancreatic and gallbladder diseases section. She informed me about Whipple's procedure, a surgery designed for those with cancer to remove the head of the pancreas, the duodenum, the gallbadder, and the end of the common bile duct (because they are all so tightly integrated) and then reconnect the intestine, bile duct, and remaining pancreas. We sat through a brief presentation from a Fresenius Kabi (supplement company) rep speaking about the importance of including glutamine in the feedings for critically ill trauma patients in order to consistently maintain blood glucose levels. I then followed Will around what I guess was either a geriatric unit or a surgical unit, but he sat down with me and introduced me to the application of estimated energy and protein calculations to nasogastric tube feeds and which feeds he typically prescribes for diabetics, cardiovascular patients, those with decreased renal function, malnourished patients, patients recovering from surgery, etc. He also noted that it is important to note the amount of fluid a patient is getting through the drip in order to prevent oedema. Mariechen briefly showed me some dermatology patients, some with Stephen-Johnson syndrome, a severe skin rash caused by an adverse reaction to medication. In this hospital, it is usually found in patients with HIV or TB due to a bad reaction to an ARV or antibiotic. It is a really nasty disease that causes a lot of painful, bleeding, blistered rashes that can even spread to a person's GI tract, making eating incredibly painful. Mariechen said she treats these patients much like burn victims due to the increased protein needs to repair the skin, not forgetting to include glutamine supplementation (an essential amino acid). She also checked in on a few babies who were suffering from malignant brain tumors and were severely malnourished. When I first saw the babies, I thought that maybe I was looking at conjoined twins, because the tumor was about the size of the infant's head, and the skull had formed to accommodate such. She said that she struggles with charting the infants' growth due to the weight of the tumors, and that she hopes to collaborate with a hospital near Cape Town soon. One of the infants was 2 years old, yet only weighed 17 lbs, much of which accounted for the tumor weight.
A couple of years ago I could not have handled this kind of constant exposure to gruesome deformities, but I think that I have reached a point where I am no longer appalled by the abnormal, but compelled to improve the patient's condition in any way I can, even it it just means smiling and talking sweetly to the babies that don't receive enough social stimulation.
We also visited some patients on nutropenic diets, immuno-compromised patients who must reduce bacterial exposure, so bacterial culture in foods such as yogurt and unprocessed fruits and vegetables must be avoided. We also noted that patients treated with steroids have greater appetites, so they are often fed according to diabetic guidelines (low fat, low added sugar). Tuberculosis patients are typically placed in the sunniest rooms of the hospital in rooms that also have blue lights, as light kills a lot of harmful bacteria and somehow contributes to recovery. Heidi showed me around the dialysis center, which is definitely one of the most interesting but most depressing units in the hospital. If I was ever diagnosed with end stage renal failure, I think I would just eat whatever I wanted and die quickly. In the end stage, there is no hope for ever regaining renal function or qualifying for a transplant. Even the patients with higher renal functionality who qualify for a transplant may have to wait a while remaining on the chronic program. End stage renal failure patients do not qualify for the chronic program, so if a patient wants to continue dialysis, he or she must pay out of pocket. I know the wait list for a kidney transplant in the US is at least 7 years. In the public sector of SA, there are so few donors that Heidi couldn't give me an estimate. Certainly longer than 10 years. On hearing that, I was introduced to an end stage renal failure patient that also suffered from diabetes.
After that depressing prognosis, Will brought me to the kitchen to meet the foodservice manager, Thelma, and to retrieve the nasogastric feed that he had prescribed earlier. At this hospital, there is some form of a computerized system. The dietitians input general diet orders for patients receiving something other than the house diet. Listed options were endless and included diets order such as "Diabetic 7000 kJ" or "Low fat low sodium cardiac diet 8000 kJ." If the dietitian really wanted to, they could fill out diet cards with specific menus for every meal and snack that a patient receives and submit to the cafeteria, but that would be insanely time consuming. He fills out a diet card every now and then for a patient with mild renal failure. All of the items prepared come from Cook-Freeze, a foodservice company right by the university that prepares foods six months in advance and freezes it with nitrogen before distributing. Hannelise has actually been stationed there for the past couple of weeks. Will also explained the "Kangaroo Mothers" initiative for breastfeeding. Mothers are encouraged to hold their babies skin-to-skin for at least 2 hours following the birth, along with all the other breastfeeding guidelines that I've talked about previously. All of the hospital's nurses are required to be trained in breastfeeding and bottle feeding is heavily discouraged. When a baby is given a bottle or a pacifier, the sucking reflex is encouraged, rather than the suckling reflex needed for breastfeeding. Once the baby learns to suck, the ability to use the whole mouth and tongue to suckle is reduced, and the baby may refuse the breast. If the baby cannot be breastfed, cups are used in feeding, because cups still require the infant to lap up the milk using the tongue. Apparently in many grocery stores, you must request infant formula from behind the counter, because it cannot be found directly on the shelves.
Today (Tuesday) kicked off with a visit to the plastic surgery ward with Will, a unit usually host to patients with cleft palettes and breast cancer survivors. There was however, one outstanding patient who came in for a sex change, because he had previously visited a sort of village wizard called a "sangoma" who had given him funky tea and and then advised him to cut off all of his genitals. Unsurprisingly, the home operation was unsuccessful and landed him, who is now a her, in the hospital due to infection of the wound. He was referred to the dietitian due to increased protein needs while recovering from surgery. Village sangomas have the potential to be quite problematic for the health of rural communities. In addition to infections caused by primitive surgeries, some pregnant mothers are given strange teas and herbs that may cause fetal deformities. We also visited the CVD ICU unit and the cardiothoracic ward.
Monica and I visited the prem clinic again and checked on some babies who suffered from the blinding effects of congenital rubella. Then Marli took me to the gastrointestinal ward and pop quiz roasted me about paraenteral nutrition, total gastric outlet obstruction, ulcerative colitis, Crohn's disease, refeeding syndrome, Billroth 1 and 2 procedures, and the Roux and Y procedure. I haven't yet taken medical nutrition therapy or nutrition counseling, but I did my best to infer and maintain a minimum level of dignity. One thing I learned that really stuck with me while in that ward was the importance of maintaining a positive attitude and what I like to call 'doctor etiquette.' Doctor etiquette usually means avoiding habits like standing by a patient's bedside and saying to the intern, "Very few people recover from a condition like this," or "Hopefully the nurses don't forget to flush the tube this time." It kind of frightens the patient into thinking that they are not receiving adequate care and that their illness is terminal, which doesn't quite improve the odds of recovery.
5/24
So I am trying to document all that has happened since Tuesday, and I finally just gave up on trying to describe everything in detail. Let's just sum up the week by saying that Universitas was a difficult place to work. The workload was heavy and individualized patient care was often compromised for the sake of time. Not to mention the poor students Johanrè and Shannon are always stressed, always working on blue books for the patients that the dietitians assign. Wednesday was a bit more relaxed as I visited National hospital, specifically the branch associated with Universitas' oncology patients that were referred here but still classify as Universitas patients. Rianna showed me around the oncology department and I noticed that most of the inpatients had esophageal, mouth, or lung cancer due to excessive alcohol consumption and smoking. A lot of patients smoke sketchy things rolled in newspaper and drink homemade brews, which increases the exposure to toxins and carcinogens even further. I try to be very good about greeting all of the sisters because otherwise they get very offended. But of course, the one time I forgot was on my way to the bathroom. I noticed one sister outside the bathrooms intently reading, so I thought it best to not disturb her, but afterwards when I was trying to exit the bathroom, the door was locked. I voiced to the sister my concern and she said she locked the door because I didn't introduce myself, to which I responded, "Oh sorry! Hi, my name is Jordan. Nice to meet you. Can you please unlock the door?" Her name was Gladys, and I picked on her later in the day when she couldn't remember my name, "...even after all we had been through together." We laughed about it and all was good at the end of the day.
Thursday was an easier half day at Universitas. After going through the ward rounds with Heidi, Monica, and Marli, we went to a guest house for a seminar on polycystic ovarian syndrome and insulin resistance, an interesting combination, though we also sat through a drug representative's presentation for Inositol and a presentation about PEN, a dietetics database of evidence-based research compilations. It was actually quite a relaxing event as there was abundant tea, milktart, salad, and quiche prepared by a catering service that Carlien was stationed at this week. I am beginning to understand why companies like interns so much. Unpaid, obedient employees that desperately seek your approval and positive evaluation are stellar for workplace efficiency. I stayed with her until the place closed up, which wound up being around 5:30 pm. Afterwards, I went to learn some field hockey moves from Hannelise and got some sushi with her and some friends after the hockey game.
Friday, I went to the department presentations just like last week, but Marli wanted me to come in afterwards. When I arrived, she handed me a thick textbook and a couple pages of questions that I was to look up and define. I did about a page before it occurred to me that I was at the hospital for clinical experience and I was not receiving grades from the distributor of said busy work, so I asked Marli if we were going to do any more clinical work such as ward rounds or counseling sessions. I had not planned on staying past 1:30 pm anyways, because our daily itinerary that I had received at the beginning of the week said that I would stay no longer than 12 pm on Friday. She didn't have any other work for me, so she let me leave, and I was thanking my lucky stars that I did not need her evaluation. She doesn't seem to favor the other two students despite their desperate efforts to appease, so I'm not exactly sure how fond she is of the American who couldn't even remember the difference between a Billroth 1 and a Billroth 2 procedure. I was just proud of myself for knowing what a Billroth procedure was, because we've not yet discussed it in any of my classes.
Universitas was a bit more demanding than I anticipated, but the atmosphere has forced me to move rapidly and think rapidly. The hospital is very large, and holds a lot of patients that were referred from various other hospitals to receive specialist care. It has ten floors and a couple elevators that are always ridiculously full, so most of the doctors, surgeons, dietitians, etc. take the stairs (the nurses and patients opt for the elevator). I thought Sunday was leg day, but apparently every day is leg day. There are 5 dietitians, each in charge of a different ward. There are so many wards and units on each of the ten floors that I struggle to remember where anything is at all. Yesterday began with Marli making her rounds in the cardiovascular ward with a group of other doctors huddling into each room to review each patient's status. It was excruciatingly long and was likely very awkward for the patients. I also saw a lot of diabetic patients with calcified toes, black and stone-like. In fact, there were very few diabetic patients at the hospital who did not have calcified or amputated toes. I then followed Monica around the ear, nose, and throat ward as well as the pancreatic and gallbladder diseases section. She informed me about Whipple's procedure, a surgery designed for those with cancer to remove the head of the pancreas, the duodenum, the gallbadder, and the end of the common bile duct (because they are all so tightly integrated) and then reconnect the intestine, bile duct, and remaining pancreas. We sat through a brief presentation from a Fresenius Kabi (supplement company) rep speaking about the importance of including glutamine in the feedings for critically ill trauma patients in order to consistently maintain blood glucose levels. I then followed Will around what I guess was either a geriatric unit or a surgical unit, but he sat down with me and introduced me to the application of estimated energy and protein calculations to nasogastric tube feeds and which feeds he typically prescribes for diabetics, cardiovascular patients, those with decreased renal function, malnourished patients, patients recovering from surgery, etc. He also noted that it is important to note the amount of fluid a patient is getting through the drip in order to prevent oedema. Mariechen briefly showed me some dermatology patients, some with Stephen-Johnson syndrome, a severe skin rash caused by an adverse reaction to medication. In this hospital, it is usually found in patients with HIV or TB due to a bad reaction to an ARV or antibiotic. It is a really nasty disease that causes a lot of painful, bleeding, blistered rashes that can even spread to a person's GI tract, making eating incredibly painful. Mariechen said she treats these patients much like burn victims due to the increased protein needs to repair the skin, not forgetting to include glutamine supplementation (an essential amino acid). She also checked in on a few babies who were suffering from malignant brain tumors and were severely malnourished. When I first saw the babies, I thought that maybe I was looking at conjoined twins, because the tumor was about the size of the infant's head, and the skull had formed to accommodate such. She said that she struggles with charting the infants' growth due to the weight of the tumors, and that she hopes to collaborate with a hospital near Cape Town soon. One of the infants was 2 years old, yet only weighed 17 lbs, much of which accounted for the tumor weight.
A couple of years ago I could not have handled this kind of constant exposure to gruesome deformities, but I think that I have reached a point where I am no longer appalled by the abnormal, but compelled to improve the patient's condition in any way I can, even it it just means smiling and talking sweetly to the babies that don't receive enough social stimulation.
We also visited some patients on nutropenic diets, immuno-compromised patients who must reduce bacterial exposure, so bacterial culture in foods such as yogurt and unprocessed fruits and vegetables must be avoided. We also noted that patients treated with steroids have greater appetites, so they are often fed according to diabetic guidelines (low fat, low added sugar). Tuberculosis patients are typically placed in the sunniest rooms of the hospital in rooms that also have blue lights, as light kills a lot of harmful bacteria and somehow contributes to recovery. Heidi showed me around the dialysis center, which is definitely one of the most interesting but most depressing units in the hospital. If I was ever diagnosed with end stage renal failure, I think I would just eat whatever I wanted and die quickly. In the end stage, there is no hope for ever regaining renal function or qualifying for a transplant. Even the patients with higher renal functionality who qualify for a transplant may have to wait a while remaining on the chronic program. End stage renal failure patients do not qualify for the chronic program, so if a patient wants to continue dialysis, he or she must pay out of pocket. I know the wait list for a kidney transplant in the US is at least 7 years. In the public sector of SA, there are so few donors that Heidi couldn't give me an estimate. Certainly longer than 10 years. On hearing that, I was introduced to an end stage renal failure patient that also suffered from diabetes.
After that depressing prognosis, Will brought me to the kitchen to meet the foodservice manager, Thelma, and to retrieve the nasogastric feed that he had prescribed earlier. At this hospital, there is some form of a computerized system. The dietitians input general diet orders for patients receiving something other than the house diet. Listed options were endless and included diets order such as "Diabetic 7000 kJ" or "Low fat low sodium cardiac diet 8000 kJ." If the dietitian really wanted to, they could fill out diet cards with specific menus for every meal and snack that a patient receives and submit to the cafeteria, but that would be insanely time consuming. He fills out a diet card every now and then for a patient with mild renal failure. All of the items prepared come from Cook-Freeze, a foodservice company right by the university that prepares foods six months in advance and freezes it with nitrogen before distributing. Hannelise has actually been stationed there for the past couple of weeks. Will also explained the "Kangaroo Mothers" initiative for breastfeeding. Mothers are encouraged to hold their babies skin-to-skin for at least 2 hours following the birth, along with all the other breastfeeding guidelines that I've talked about previously. All of the hospital's nurses are required to be trained in breastfeeding and bottle feeding is heavily discouraged. When a baby is given a bottle or a pacifier, the sucking reflex is encouraged, rather than the suckling reflex needed for breastfeeding. Once the baby learns to suck, the ability to use the whole mouth and tongue to suckle is reduced, and the baby may refuse the breast. If the baby cannot be breastfed, cups are used in feeding, because cups still require the infant to lap up the milk using the tongue. Apparently in many grocery stores, you must request infant formula from behind the counter, because it cannot be found directly on the shelves.
Today (Tuesday) kicked off with a visit to the plastic surgery ward with Will, a unit usually host to patients with cleft palettes and breast cancer survivors. There was however, one outstanding patient who came in for a sex change, because he had previously visited a sort of village wizard called a "sangoma" who had given him funky tea and and then advised him to cut off all of his genitals. Unsurprisingly, the home operation was unsuccessful and landed him, who is now a her, in the hospital due to infection of the wound. He was referred to the dietitian due to increased protein needs while recovering from surgery. Village sangomas have the potential to be quite problematic for the health of rural communities. In addition to infections caused by primitive surgeries, some pregnant mothers are given strange teas and herbs that may cause fetal deformities. We also visited the CVD ICU unit and the cardiothoracic ward.
Monica and I visited the prem clinic again and checked on some babies who suffered from the blinding effects of congenital rubella. Then Marli took me to the gastrointestinal ward and pop quiz roasted me about paraenteral nutrition, total gastric outlet obstruction, ulcerative colitis, Crohn's disease, refeeding syndrome, Billroth 1 and 2 procedures, and the Roux and Y procedure. I haven't yet taken medical nutrition therapy or nutrition counseling, but I did my best to infer and maintain a minimum level of dignity. One thing I learned that really stuck with me while in that ward was the importance of maintaining a positive attitude and what I like to call 'doctor etiquette.' Doctor etiquette usually means avoiding habits like standing by a patient's bedside and saying to the intern, "Very few people recover from a condition like this," or "Hopefully the nurses don't forget to flush the tube this time." It kind of frightens the patient into thinking that they are not receiving adequate care and that their illness is terminal, which doesn't quite improve the odds of recovery.
5/24
So I am trying to document all that has happened since Tuesday, and I finally just gave up on trying to describe everything in detail. Let's just sum up the week by saying that Universitas was a difficult place to work. The workload was heavy and individualized patient care was often compromised for the sake of time. Not to mention the poor students Johanrè and Shannon are always stressed, always working on blue books for the patients that the dietitians assign. Wednesday was a bit more relaxed as I visited National hospital, specifically the branch associated with Universitas' oncology patients that were referred here but still classify as Universitas patients. Rianna showed me around the oncology department and I noticed that most of the inpatients had esophageal, mouth, or lung cancer due to excessive alcohol consumption and smoking. A lot of patients smoke sketchy things rolled in newspaper and drink homemade brews, which increases the exposure to toxins and carcinogens even further. I try to be very good about greeting all of the sisters because otherwise they get very offended. But of course, the one time I forgot was on my way to the bathroom. I noticed one sister outside the bathrooms intently reading, so I thought it best to not disturb her, but afterwards when I was trying to exit the bathroom, the door was locked. I voiced to the sister my concern and she said she locked the door because I didn't introduce myself, to which I responded, "Oh sorry! Hi, my name is Jordan. Nice to meet you. Can you please unlock the door?" Her name was Gladys, and I picked on her later in the day when she couldn't remember my name, "...even after all we had been through together." We laughed about it and all was good at the end of the day.
Thursday was an easier half day at Universitas. After going through the ward rounds with Heidi, Monica, and Marli, we went to a guest house for a seminar on polycystic ovarian syndrome and insulin resistance, an interesting combination, though we also sat through a drug representative's presentation for Inositol and a presentation about PEN, a dietetics database of evidence-based research compilations. It was actually quite a relaxing event as there was abundant tea, milktart, salad, and quiche prepared by a catering service that Carlien was stationed at this week. I am beginning to understand why companies like interns so much. Unpaid, obedient employees that desperately seek your approval and positive evaluation are stellar for workplace efficiency. I stayed with her until the place closed up, which wound up being around 5:30 pm. Afterwards, I went to learn some field hockey moves from Hannelise and got some sushi with her and some friends after the hockey game.
Friday, I went to the department presentations just like last week, but Marli wanted me to come in afterwards. When I arrived, she handed me a thick textbook and a couple pages of questions that I was to look up and define. I did about a page before it occurred to me that I was at the hospital for clinical experience and I was not receiving grades from the distributor of said busy work, so I asked Marli if we were going to do any more clinical work such as ward rounds or counseling sessions. I had not planned on staying past 1:30 pm anyways, because our daily itinerary that I had received at the beginning of the week said that I would stay no longer than 12 pm on Friday. She didn't have any other work for me, so she let me leave, and I was thanking my lucky stars that I did not need her evaluation. She doesn't seem to favor the other two students despite their desperate efforts to appease, so I'm not exactly sure how fond she is of the American who couldn't even remember the difference between a Billroth 1 and a Billroth 2 procedure. I was just proud of myself for knowing what a Billroth procedure was, because we've not yet discussed it in any of my classes.
Monday, May 18, 2015
Weekend 2: Good Company in Bloemfontein
5/15
I was really hoping that today would be
the day that Hannelise, Wieda, and I go to the cheetah park, but it looks like
that may have to wait. Rather, the morning was mostly occupied by dietetic
presentations. Only five of the dietetic students gave presentations on their
case studies, but it lasted from 8 am to 12 pm. It was not a bother though,
because I had very little concrete plans for today, and I was really enjoying
everyone's presentations. Unfortunately, the alcohol presentation was given in
Afrikaans, so I only got a few key messages from the talk here and there. It
was strangely comforting to hear some biochemical references in the
presentations. It was also assuring to know that America is not the only nation
to use the IDNT manual and the nutrition care process. I got to meet a couple
of the lecturers there, and the ones I met seem very nice. Hannelise said that
she really likes her department, and I agreed, because I also really like the
nutrition department at Appalachian State. I do wish that our department was a
bit smaller so that I could be closer friends with everyone in it, which seems
to be the case for the dietetics department at the UFS. It is a rare a
wonderful thing when you can say that since entering the department, you've
only ever had high quality professors who genuinely care about you and your
education. (Subtle shout out to Dr. McAnulty, Dr. Ball, Dr. Gutschall, and
Prof. Casey). Maybe it is just a dietetics thing.
After the presentations, I briefly checked
my email, spellchecked the blog (my tablet does not have that option
apparently), got my UFS student ID card, and finally withdrew a substantial
amount of money (praise the Lord!). Hannelise invited me to go with her and her
sister to a field hockey game at the high school because I had previously told
her how much I hated not having any plans at all for the evening. So we went to
the game and talked a good bit, which was very pleasant and beautiful as the
African sunset painted the sky bright pink and red.
-Jordan
5/17
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| Naval Hill |
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| First time I've ever spotted an antelope on my morning run. |
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| Nelson Mandela Statue on Naval Hill |
It was a bit of a hybrid of a farmer's market and a festival, because there seemed to be
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| Hannelise at Naval Hill |
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| Boere Mark |
Later in the day, Hannelise took me to one of her field hockey games, as she plays for one of the varsity teams just for fun. It did look really fun, and Hannelise said that I may practice with them later this week because her coach is very relaxed. After the game, Carlien and I went shopping because I was looking for maybe a few cheap professional-looking clothing items (because a lot of stuff didn't make the cut into the suitcase), but I didn't find anything that was cheap enough or close enough to what I needed to warrant buying. Regardless, it was nice hanging out with Carlien, not to mention that Carlien loves shopping, and I think she needed to take a homework break. I am very sensitive to the fact that all the dietetics students are very busy because it was only a couple weeks ago that I was in the same struggle boat. I think that makes me appreciate all the more their efforts to hang out with me or take me places. That night there was load shedding, but afterwards the Wi-Fi did not turn back on in the apartment. So Martie (roommate from Holland) and I walked around the block looking for a signal from maybe a different University router. We take Wi-Fi "roaming" quite literally. I found enough to text my mom and Ryan, but when Martie left, I got scared and went back inside as it was a few hours past dark. Rather, I made brownies for Hannelise and her mom and read some C.S. Lewis Out of the Silent Planet for a bit.
Today (Sunday) Shannon, another dietetics
student, took me to church with her and her boyfriend, Tyler. He is very
sweet and polite, though I think Shannon is self-conscious about introducing
him to folks at church because he is colored and she is white. I didn't even
think about that factor before she brought it up. I just thought it was neat
that he could speak Xhosa, an eastern cape language that I really enjoy pronouncing (side click)osa. They go to St. James, an evangelical
church, which was not quite so different from what I am used to at home. It was
contemporary with a live band and full of a lot of young families. The message
on discernment was right on, though briefly interrupted by the astonishingly
loud outburst of a baby, shall we say, letting his burdens go. I discerned that
he and his father were going to have a spirit-filled time in the restroom after
the service. But seriously, the service was wonderful in that it helped me
acknowledge that America is not the only place where the church is thriving.
Afterwards, Tyler, Shannon, and I went to the bridge (school outdoor
cafeteria/mall) to get some coffee and chat for a bit. Then I went to
Hannelise's house again and played dominoes with her mom and mom's friend for a
bit. We then went for a good 2-mile walk and I had to opportunity to talk with
her about faith and about nutrition and their relation, which was really
lekker. We got back to the house and did some pushups, lunges, sit-ups,
blurpees, squats, and step-ups. I am hoping that I will be in decent shape by
the time I leave Africa, but that may be inhibited by all the foods that
accompany socializing. We ate some leftover braai (grilling foods like steak and
sausage and such) and I got to call Ryan for a bit on WhatsApp. Tomorrow I will
be working at Universitas, the hospital across the street from where I am
staying, and I will be working with Shannon and another student named Johanre,
a name that may take some muscle memory development before I can properly
pronounce it.-Jordan
Thursday, May 14, 2015
Week 1: Botshabelo
5/11
So today was a really extreme experience. This is my first clinical experience regardless, and I suspect it will be unlike any hospital setting I will encounter in the future. Because the hospital is public, I expected that the facility would be understaffed and primarily occupied by low-income black African patients. After about an hour drive with Carlien, Lara, and Michelle, the dietitian who drove us, we finally made it to Botshabelo.
I was very
thankful that Hannelise let me borrow her navy blue sweater and red blouse,
because that matched nearly perfectly the uniforms that the other girls were
wearing. The dietitian there, Michelle, first instructed us to complete
nutrition screenings in the maternal ward in order to assess if the program was
adequately addressing all the objectives of the breastfeeding initiatives the
hospital was implementing. I spoke with a woman who had just given birth the previous day and interviewed her about breastfeeding, maternal bonding, and the
education and care she was given. Because Michelle instructed us to also offer
information to the patient, I encouraged her to continue trying to express the
milk, continue keeping the child close to her chest in skin-to-skin contact,
and continue encouraging the child to suckle in a few different positions so
that the baby's suckling will eventually produce the first milk, which I just
said was very nutritious and good for the baby. The woman was very receptive to
the interview and of course very pleased that she had given birth to a healthy
baby even though he was over a month premature.
Then we were sent to the main ward, which hosted various types of patients,
mostly respiratory diseases and pulmonary tuberculosis patients (PTB). With
these patients we were told to screen them by just asking questions and
visually assessing nutritional status, such as estimating BMI and taking note
of any physical signs and symptoms. If we determined the patient to be of nutritional
risk, we were to note any recommendations and report them to Michelle. I was so
thankful for the classes that I had taken during the past spring, particularly
Nutrition Assessment, Advanced Nutrition, and Health Risk Appraisal, because
the information that I absorbed was immensely helpful in assessing patient
needs and determining if the patient would benefit from a nutritional
supplement. I encountered a COPD patient and a bronchial pneumonia/PTB patient who were both very malnourished and clearly feeling terrible, so I recommended
the "peanut butter" supplement called Imunit. Many of the patients
barely spoke English and only spoke a little Afrikaans, so the other students
had to interview as best they could in Afrikaans. I got used to reading the
medical records that sit at the end of each patient's bed, because it was far
easier to assess nutritional status through doctor’s notes than by trying to
decipher Sotho. Even still, the medical records were very scattered and
difficult to interpret. I now truly understand why digital, uniform medical
charting is a need in hospitals. It is very easy for a patient to be given the
wrong treatment when the medical records are unclear and not in chronological
order. I also visited a diabetic woman who only spoke Sotho, but she was not
properly managing her diabetes according to the charts and needed further
diabetes education. However, none of the dietitians spoke anything other than
Afrikaans and English, so we searched through some pamphlets to find one that
she could read in order to give her clear information about insulin injection.
I may try to learn Spanish when I get back to the states, because I realize
that a language barrier in health care truly can mean the difference between
life and death.
The hardest place to visit was the neonatal unit. I was not excessively emotional, but my heart did fracture in interviewing a mother and reading the charts of numerous infants diagnosed with PTB or pneumonia and were experiencing severe malnutrition because his or her mother did not breastfeed the child for long enough and had switched to diluted formula and pap (porridge) because they believed it was fine for the child to eat solids at ages younger than 4 months. The infants had likely contracted the diseases from either relatives or crèches, day cares that vary from seriously sketchy to reasonably adequate. I saw malnutrition in magnitudes that are unheard of for the United States, but more than common in South Africa. Today I saw one baby who was 9 months old and weighed only 5.2 kg, less than 12 lbs. Her physical and cognitive development was severely retarded; she was still toothless and basically the size of a 1 month old. Her aunt was there and the dietitian had prescribed F75 and F100, a nutrient-dense milk supplement, because the baby was not yet ready for solid food.
I saw another baby with PTB and pneumonia who
was experiencing some sort of vitamin or mineral deficiency (likely pyridoxine)
due to her tuberculosis medication interfering with absorption, and at 1 1/2
years old she weighed about 11.6 kg, or about 25 lbs. Her forehead was
flattened in deformity and her eyes and eyebrows tiled downwards so that she
constantly looked sad. Despite my best efforts to cheer her, she maintained a blank,
emotionless face.
It was in the neonatal unit that I truly realized the weight of my position as a dietitian. If there is one thing that I would want people to understand about dietitians, it is that they are health care professionals that do not exist for the shallow purpose of making people feel guilty for eating chocolate cake, rather, dietitians exist to save lives because they care about the welfare their patients and their community. When I changed my major from occupational therapy to
dietetics, (not at all to discount the crucial importance of physical therapies) I never knew that I was dropping the
objective of improving lives in order to pick up the responsibility of saving
lives. It's a pretty heavy feeling honestly. Even still, I believe that this is
the profession that I am called to pursue, because I know that the weight of
life is a bearable burden for Christ, so because Christ is in me, it is a
bearable burden for me. I've been on countless missions trips, led youth and
small groups, participated in numerous dietetic association committees,
volunteered with pretty much any nutrition-related event at Appalachian State,
and even given a sermon series at Wesley called "spiritual
nourishment," but for the first time in my life, I felt abundantly
fulfilled by my actions, like God was approving them by offering me the
opportunity to use the knowledge that I have worked so hard for in order to
tangibly affect and feel the lives of others. And by "feel," I mean
allowing my life to take the shape of the contours of another person's life.
That is the only way I think I can define what true service feels like. I know
it has only been a day, and it was hard and tiring, but I am positive that this
profession is where I am supposed to be.
I tried to express how I felt about the day to Nicole, then Wieda and
Hannelise, but I really wish that Ryan was here. He is wonderful at really
listening with his heart and is probably my favorite person to discuss these
sorts of things with.
On a much less contemplative note, the other roommates are back, and I met one of the Italians after Nicole and I screamed at the sight of a mouse in the kitchen. We frightened the poor thing out the front door, but thankfully he came back in time enough to rescue us from the mouse. I don't remember everyone's name yet, but I know there is another girl from Holland across the hall, a girl from the Czech Republic in the room next to mine, and two Italian boys down the hall. You could say that we live in a melting pot. I was hoping I would meet a student that would go to Cape Town with me, but everyone has already travelled quite a bit and Nicole is about the only one that I think I would like to travel across Africa with. The others are a bit eccentric. They really like to party and have told me many stories of their weekend trip and other various trips just jam packed with wild fun. Personally, I find my frontal lobe to be quite useful in hazardous situations, and I try my best not to offend it.
I also got coffee today at Mimosa Mall with Wieda and Hannelise, which was a really fun time. Both of the girls are really sweet and have been incredibly helpful. Wieda gave me her university credentials to log on to the computers, which I will attempt to use tomorrow, and both of the girls are keen on showing me the activities and sights of Bloemfontein. I also had just barely enough Wi-Fi at the coffee shop to send an email to Dr. Jones explaining why she hasn't heard from me for a while (sorry Dr. Jones!). Anyways, tomorrow I will be at one of the crèches, or day care centers, and I was told to bring my flexible measurement tape, so I'll likely be hanging out with Centi. I heard she is nothing special but I'm still excited to meter.
-Jordan
5/13
So today was a really extreme experience. This is my first clinical experience regardless, and I suspect it will be unlike any hospital setting I will encounter in the future. Because the hospital is public, I expected that the facility would be understaffed and primarily occupied by low-income black African patients. After about an hour drive with Carlien, Lara, and Michelle, the dietitian who drove us, we finally made it to Botshabelo.
 |
| The trip to Botshabelo |
The hardest place to visit was the neonatal unit. I was not excessively emotional, but my heart did fracture in interviewing a mother and reading the charts of numerous infants diagnosed with PTB or pneumonia and were experiencing severe malnutrition because his or her mother did not breastfeed the child for long enough and had switched to diluted formula and pap (porridge) because they believed it was fine for the child to eat solids at ages younger than 4 months. The infants had likely contracted the diseases from either relatives or crèches, day cares that vary from seriously sketchy to reasonably adequate. I saw malnutrition in magnitudes that are unheard of for the United States, but more than common in South Africa. Today I saw one baby who was 9 months old and weighed only 5.2 kg, less than 12 lbs. Her physical and cognitive development was severely retarded; she was still toothless and basically the size of a 1 month old. Her aunt was there and the dietitian had prescribed F75 and F100, a nutrient-dense milk supplement, because the baby was not yet ready for solid food.
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| F-75 formula supplement |
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| Staff entrance to the hospital in Botshabelo |
It was in the neonatal unit that I truly realized the weight of my position as a dietitian. If there is one thing that I would want people to understand about dietitians, it is that they are health care professionals that do not exist for the shallow purpose of making people feel guilty for eating chocolate cake, rather, dietitians exist to save lives because they care about the welfare their patients and their community. When I changed my major from occupational therapy to
 |
| View behind the hospital |
On a much less contemplative note, the other roommates are back, and I met one of the Italians after Nicole and I screamed at the sight of a mouse in the kitchen. We frightened the poor thing out the front door, but thankfully he came back in time enough to rescue us from the mouse. I don't remember everyone's name yet, but I know there is another girl from Holland across the hall, a girl from the Czech Republic in the room next to mine, and two Italian boys down the hall. You could say that we live in a melting pot. I was hoping I would meet a student that would go to Cape Town with me, but everyone has already travelled quite a bit and Nicole is about the only one that I think I would like to travel across Africa with. The others are a bit eccentric. They really like to party and have told me many stories of their weekend trip and other various trips just jam packed with wild fun. Personally, I find my frontal lobe to be quite useful in hazardous situations, and I try my best not to offend it.
I also got coffee today at Mimosa Mall with Wieda and Hannelise, which was a really fun time. Both of the girls are really sweet and have been incredibly helpful. Wieda gave me her university credentials to log on to the computers, which I will attempt to use tomorrow, and both of the girls are keen on showing me the activities and sights of Bloemfontein. I also had just barely enough Wi-Fi at the coffee shop to send an email to Dr. Jones explaining why she hasn't heard from me for a while (sorry Dr. Jones!). Anyways, tomorrow I will be at one of the crèches, or day care centers, and I was told to bring my flexible measurement tape, so I'll likely be hanging out with Centi. I heard she is nothing special but I'm still excited to meter.
-Jordan
5/13
Yesterday (Tuesday) I took a break from
the blogging because I was so exhausted from the day. I don't know why the jet
lag is just hitting me now, but waking up at 6:30 am feels very much like 12:30 am to me.
It takes about an hour to get to Botshabelo, so we try to leave by 7:30 am
every morning. My fogginess made yesterday a very frustrating morning, because
as we were interviewing patients my mind was not as sharp or as clever as
usual, which made interpreting accents and responding accordingly very
difficult. Also, we counseled a couple patients in the morning before heading
to the crèche, and I felt generally useless. Lara and Carlien are very good at counseling
because they have had loads of clinical experience, and as of right now I have
about two day's worth of counseling experience. I am still not familiar
with some of the commonly eaten and available foods here, so I fear giving
irrelevant advice or sounding insensitive to the patients. I have learned that
pap is a very common staple for most of the patients and I am also trying to
understand how and where most of the patients obtain their food. So rather than
counseling or educating, I sat and watched the other students counsel patients
for a couple of hours. It was torture because I wanted to help so badly. I
remained patient and tried to remember that I was here to learn, and that I was
learning by watching them counsel. The first patient who came in was a mom
with an 11 month old baby that nearly exclusively ate formula milk and pap.
After the 24-hour recall, Carlien and Lara explained to the mom that the baby
is old enough to be eating finger foods and soft fruits and vegetables. The
baby was significantly underweight, so they continued the baby's
supplementation of Imunut. Another patient who came in for counseling was a
35 y.o. woman who was referred because of her obese classification. The 24-hour
recall was really helpful in assessing where changes could be made. She had
never received any nutritional education before. She ate 4 cups of pap for
breakfast, lunch, and dinner, as well as 2 cups of pap every time she wanted a
snack. Sometimes she would combine the pap with chicken or beef, and most
always she seasoned it with brown onion soup, a commonly used, high-sodium mix.
She maybe ate 1 fruit a day and very rarely ate vegetables. In addition, she
drank 4 litres of soda every day. I wasn't as much astounded that she ate some
much pap and drank so much soda as I was impressed at her iron stomach. If I
ate like that I would definitely hurl. Lara explained to her some easy ways she
could alter her diet, such as reducing the amount of soda she drank and
increasing the amount of clean, safe water as well as replacing some of the pap
she ate as her snack with a fruit or a vegetable. As Lara talked, Carlien drew
a myplate for the lady and labeled all the commonly eaten foods in each
category. I think hand-drawing the plate and hand writing the recommendations
made the information seem a lot more personalized and prescription-like.
Visiting the crèche brightened up my day
as I began to feel useful again and the children there were really adorable. We
couldn't find an operable scale to weight the children with, so we just focused
on mid upper arm circumference (MUAC) and vitamin A supplementation. We were instructed
to sort through about 50 "Road to Health" books, government-issued
books given to all children born in South Africa that mothers are instructed to
keep track of and keep safe. The booklet holds all of the child's immunization
records, growth charts, and medical information. We searched each book for
children aged 5 and under who had not received a vitamin A supplementation in
the past 6 months. Over 2/3 of the children needed their next vitamin A
supplement, so all of the children were sent through our dietetics assembly
line to have their MUAC taken. Those in stack A were sent to Lara and
Carlien to take a dose of the vitamin A. I measured 50 little de-sleeved arms,
each dangling out from under a scrunched-up shirt that revealed 50 little bellies,
about 1/3 of which were abnormally swollen, a sign of protein deficiency. Some
little boys handed me flexed biceps to measure, while a couple little girls
were not sure what I was doing, but were positive that it was going to be some form of torture.
The only doctors in the hospitals and clinics are white, while all the nurses,
the "sisters," are black. Michelle told me that little children only
know white people to be associated with needles or pain. Thankfully, most of
the children were happy to be cared for and maintained their darling smiles. As
we departed, we were bombarded by a fleet of little thumbs, their owners
shouting "shap," which means something like 'all good' in Sotho. We
returned the "shap" by sticking our thumbs and snapping them against
the children's palms. "Dankie, goodbye! Shap!"
When we got back to Bloem I was able to
use Wieda's university credentials to log on to the computers, which was like
taking a breath of fresh air. I was finally able to check my final grades, and
I was pleasantly surprised to find that my semester GPA ended up being a 3.9,
all A's and one B+ in Advanced Nutrition. Not bad for a 19 s.h. workload. At
the point of discovery, my true nature was revealed to my new South African
friends through sudden dancing and cheering. It was mildly embarrassing in
retrospect, but let's be real, if they knew what a GPA was and the same
happened to them, they would be breaking it down in the computer lab too. That
bumped me up to a 3.64, so my day was rapidly re-calibrated to level fabulous.
That is, until I went to the international office to check on my internet
situation. Without going into detail, I think I must have had a really long,
roller-coaster day, because I was not in an emotionally stable state,
especially not in the face of sarcasm. It may have had something to do with having seen malnourished babies all day or missing my family. After the Wi-Fi voucher was sorted
out, Wieda and I went to the grocery store so I could once again take on the
challenge of withdrawing cash. Cash back from shopping with the credit card was
unsuccessful, though I gained a lot of bananas in the process. However, after a
sophisticated process of troubleshooting I like to call "randomized button
input," I was finally able to withdraw 100R from the ATM, which
unfortunately turns out to only be about $8. I'm telling you though, $8 goes a
long way in South Africa. I think I can recreate the process. To get my student
access card, Marleen explained that I needed to pay 65R to the bank while
handing in an account number so that they would give me a receipt that I would
then bring back to Marleen before 3 pm. Since the bank closes at 3:30 pm and I
had no idea when we would be back from the hospital, Wieda said she would do it
for me since her station is on campus this week. I don't know how I am ever
going to properly thank Wieda for all of her wonderful, sweet-hearted help, but
I am brainstorming my hardest.
So today (Wednesday) was a much easier day
at Botshabelo. We were instructed give a breastfeeding presentation and then a
diabetes presentation, both as introductory courses to the topic. The
breastfeeding education was my favorite, because I know that breastfeeding
education is the best way to prevent the severe malnutrition that I saw on
Monday. In areas such as this, breastfeeding is still strongly promoted even if
the mom is HIV positive. We say that as long as the ARVs are properly taken,
there is a very low risk of transmission to the baby. Breast is always best. We
explained that if the mother had cracked nipples or if the baby has sores in
his or her mouth, that the breastmilk should be expressed by hand and heated in
a jar over boiling water for 30 minutes, then cooled before given to the baby.
We also explained how to express the milk by hand by cupping the breast and
rolling the thumb over the glands to release the milk. Instructions for storage
were also given: three days in the refrigerator, three months in the freezer.
It may be convenient even to put the expressed milk in ice cube trays so that
defrosting in a bowl over a simmering pot of water is easier. We also gave
advice on how to position the baby, how to detect signs of hunger, and how
often/long the baby needs to feed (the answer always being "as long as the
baby likes").
At the end of the session, all of the expecting moms were
offered an opportunity to take the pledge to exclusively breastfeed for the
first 6 months of their baby's life. About half of the 30 women that we talked
to decided to take part by leaving a painted handprint on a signed piece of
paper. The new handprints accompanied several others that already hung on the
wall of the waiting room.
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| Patient breastfeeding pledges |
I was so thankful that I got to talk to my
dad and Ryan this evening. It was good to hear familiar, encouraging voices. It
was also good to hear that we are selling our beat up old Volvo. If you are
reading this and want something to pray about, pray that I find joy in the Lord
through all circumstances, and pray that I serve as a beacon of hope to those
who have so little. I am praying that my heart remains sensitive to the needs
and wants of others, even the people that are difficult to love.
5/14
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| Michelle outside a clinic in Botshabelo |
What was really helpful for me in
understanding poor South African foodways was our visit to a massive grocery
store called Rite Brand. As we have been driving around Botshabelo this week, I
have witnessed the surreal pilgrimage of people from miles around walking
through barren grassy fields scattered with garbage and livestock waste just to
get to this store. The landscape in this area is quite eerie and fascinating
actually, because the land is incredibly brown and flat, except for the occasional
mountain.
 |
| View from just outside a clinic in Botshabelo |
 |
| Carlien outside one of the clinics |
How does a population recover from this?
This is where my various interests begin to merge. The only way for a community
to experience an improvement in public health is if the local economy is
stimulated in practical, strategic, long-withstanding ways. This is one of the
many reasons I wanted to volunteer at Bulembu, Swaziland; I want to understand
specific pathways by which a community as a whole can break away from cyclical,
generational poverty. My goal as a dietitian is to help people maintain a
balanced diet and a desirable standard of health if nutritionally applicable.
Though difficult, it is possible for a family to roughly adhere to the
nutritional guidelines provided to them. Breastfeeding is certainly attainable
for infants. Maybe 3 fruits and vegetables rather than 5 per day is attainable.
Maybe cooking chicken without the fat and replacing the salt in pap with pepper
and herbs is attainable. These are guidelines recommended to prevent nutritionally-related
diseases, but it is important to note that constant worry and struggle do not
contribute to a high quality of life, and the worry and struggle will often
occur regardless of nutritional status. So how do we address the root cause of
widespread poor quality of life?
I attempted a causal loop, so bear with me.
All roads seem to lead to
poverty, and all roads seem to originate with poverty. I know that
unemployment is the primary factor that contributes to poverty, but it is also
important to note that unemployment is caused directly by a lack of education,
limited access to resources, a lack of a skilled workforce, a lack of economic
development, and an increased rate of contagious or psychological/addictive
diseases. However, it is indirectly caused by lack of government support for economic
development, malnutrition, obesity, tight living quarters, and a high cost of
living in comparison to income. The primary factor that can directly contribute
to higher employment rates is an increase of economic development that is
spurred by an educated, skilled, healthy workforce. In my opinion, public
education and accountable educational systems are among the best ways to begin
equipping the economy for stimulation in addition to reducing disease rates.
 |
| Spinach garden outside a Botshabelo clinic |
In any case, we surveyed the prices of
common food items such as maize mill (pap) and various vegetables and fruits to
get a better idea of how far 330R per child can stretch. Not very far, I'm
afraid, though food is significantly cheaper here than in the US. I am going to
continue mulling over the connection between economic development and
nutrition. Bulembu is going to be exceptionally exciting in a few weeks as
their mission is to restore community health, education, and economic
development.
Some additionally important things to
remember about Botshabelo:
1. Always greet the head nurse and the
other sisters before you do anything else.
2. Use visuals whenever possible. Ask the
patient(s) questions to make sure the message was understood.
3. If you ask a patient if they know about
(insert here), and they say yes, ask them what they know. It is highly likely
that they need a refresher course.
4. Research all of the medications that a
patient is taking to make sure that you know what it is, and that it isn't
something that interferes with appetite, absorption, or some other
dietary-physiological factor.
5. Afrikaans is fun to speak initially,
but after a few days the "g" noise is a serious throat hazard.
-Jordan
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