A Doctor’s Life in Togo

  Greetings are important in Togo.  They are a sign of the priority that the culture places upon relationships.  When I walk into the hospital, I go around to many of the nurses and staff saying, “Hello.  How are you?  And your family?” They reply, “Hello.  Very Good.  Good,” and then ask me the same questions.  It first struck me as formulaic, but as time has gone by I realize there is a warmth in these greetings and that the Togolese really do appreciate these relationships.

  Apparently, the one place greetings are not required is in a medical encounter.  Sometimes I can squeeze in a, “Hello, I’m Dr. Wreesman,” before my translator asks why the patient is here and the patient subsequently goes on a several minute monologue that I’m convinced contains every symptoms they’ve experienced in the past two months.  Sometimes I don’t get in any greeting, not that the patient seems to be the least bit concerned about that.  Maybe it’s just me, but wouldn’t you want to know the name of the person who could be doing a rectal exam on you?

  Another humorous challenge is trying to discern what a patient’s medical problem is through a translator, when your patient has almost no medical knowledge.  Sometimes you’re going through multiple translators (you -> translator -> son -> father -> son -> translator -> you).  It’s like playing a game of telephone, except people’s lives are at stake.  Then there are complaints that you have no about what to do.   For example, “I have total body pain!”  I guess that might be useful a complaint, if the four previous patient’s hadn’t also complained about the same thing.  At that point, I get the hint that there’s something cultural in the meaning of this complaint, and I have no idea what it is. 

  Next, I have to figure out what the patient is expecting me to do about their complaints.  Some refuse an indicated test, saying they don’t have enough money (understandable for people who make only a few dollars a day).  Others demand the test, even when you try to explain that the treatment is the exact same one no matter the results and are just trying to save them a little money.  They (or their family member or friend) usually tell you this after you just wrote their prescription. 

  Finally, people like to convey their medical concerns in dramatic terms.  For example, “I have belly pain.  It hurts very, very much,” as if having moderate belly pain would be grounds for dismissal of the entire complaint.  And this comes from men and women whose ability to endure hard labor, heat, pain, and hunger has my utmost respect for, knowing I could not have lived so well under the same conditions.   I guess no one has explained that hurting “very, very much” may be an indication for surgery.

  (Please note, none of the above is meant to convey a since of superiority.  I just share the humor of approaching medicine from one cultural perspective among a people from another culture.)

  Perhaps the best way to convey the variety of what I’ve been able to do would be to give a brief account of my last call stretching from yesterday to this morning.  Though it was an especially busy time, it shows the variety of medical needs that exist in a place like Togo and the fun of being a family physican in this setting.  Days typically begin with hospital rounds.  We started on seeing our handful of medical patients: an ulcerative colitis case with incidental BPH and urinary retention, a man recovering from tetanus (saved by administration of intrathecal tetanus toxoid a few days previously), and girl with persistent abdominal pain.  After medicine rounds, I went stopped by maternity to say hi to the mother whose twins I had delivered on Saturday (my first breech and first twin delivery).  Then I went to the pediatric ward – which could be better called the malaria and premature baby service.  One young boy had recovered from a case of cerebral malaria (20% mortality).  We also currently have 5 premature babies ranging from 26-29 weeks when they were born.  Our set of 26 week twins started at just 640 grams, but have now reached a kilogram and are doing well 5 weeks into their stay.  There is a 29 week baby that I delivered at the beginning of the month (see previous post) who is growing well and probably will go home in the next week.  One 28 week baby is a month old; thankfully she is still at the hospital because we had to fight with her parent to keep the baby.  Sadly, our 27 week baby is looking pretty sick only 4 days into life and may not make it.

  After rounds, I head up to clinic.  I admit the first patient I see, a 12 year old boy with sickle cell, fever and anemia (likely sepsis or malaria).  I also see his mother who has a 12 year tooth infection that drains from a tract on the bottom of her jaw; the xray she brought in shows an impacted molar with osteomyelitis and extensive erosion of the bone.  Though she isn’t acutely sick, we’ll probably operate on her before the end of the week.  I see a couple more patients, then go back to the hospital to check on our DKA patient that I admitted during rounds (glucose 1540, potassium 7.9, calculated osmolality 419 for those of you medical people).  Forturnately, I get a moment to break for lunch.  After lunch I head back to the clinic and see a few more cases including back pain, infertility, and breast cancer (she had a mastectomy, but unfortunately the cancer has spread and we send her home with pain medications knowing that death may come soon).   Meanwhile, the hospital has been filling up with new admissions.  I go down to check on them.  New cases include the following: a lady with HIV with likely pneumocysitis pneumonia; a man swollen neck and pleural effusion after being “stoned” a month earlier; a lady with generalized lymphadenopathy, giant splenomegaly, abdominal pain, fever, and treated HIV/tuberculosis; a child with an 8 cm eye/cheek tumor vs infection, plus a smattering of gastritis and malaria.  Before dinner, I get called to OB clinic to give some input on a 26 week pregnant lady with nephrotic syndrome.  Apparently being a third year family medicine resident makes you the local expert for this case.  Later, I get called back down to the hospital because my sickle-cell patient had a transfusion reaction.  Then I end up of L&D to see a new patient.  I call the surgeon to come do a C-section because the baby is breech and she is likely preeclamptic.  I go into the OR and actually do the C-Section and tubal ligation with the surgeon assisting and teaching me.  By this time its 1230 am.  Fortunately, there are no more calls.

  Next morning, we’re back rounding in the hospital on the 9 patients we admitted yesterday, plus those already there.  During rounds we admit a stroke patient and a man with cerebral malaria vs meningitis.  On ultrasound, we find that the man who has been “stoned” actually has a giant empyema.  The surgeon lets me place the chest tube with his assistance, and we drain a liter of pus.  By this time, it’s lunch time and I’m more than happy to take off the rest of the day. 

  It has been a blessing to serve here.  I’m thankful to see how much I have learned in the past 3 years and what I can contribute.  Being a family physician, it is exciting to practice such a broad spectrum of medicine.  Additionally, I’ve been thankful to serve at a hospital that doesn’t just treat physical needs but talks with people about their spiritual needs in Christ.  As we sat around dinner last night, one of the doctors shared how a patient he saw in clinic accepted Christ as his Savoir.  After praying, the man told him, “God is good; this is why I had to come here today.”  What a blessing to see this, knowing that in Christ alone is eternal life.  I am grateful to be a part of that process by serving here in Togo.