Monday, December 22, 2008

Case #3: Nyanya Means Tomato. (Case Reports from Kijabe Hospital)

Warning: This post is one of a series that describes a patient (case) that I have taken care of in Kijabe hospital, and it may contain graphic descriptions or photos of medical pathology written primarily for clinicians. For my non-clinical readers, use discretion before reading, and please excuse the medical jargon. 

It was Monday…my clinic day. I can’t complain, because the day had gone very smoothly, and I was seeing my final patient at about 4:30pm, instead of my clinic dragging on beyond 5pm (which the staff just love). However, as is often the case with the last patient of the day, her problem would turn out to be a difficult one to treat, and remind me how cruel this world can be to the sick and suffering.

SW is a 90 year old woman who spoke no English and little Swahili, but fortunately had a family member with her who spoke Swahili with whom I could communicate with through another interpreter. As best as I could understand she suffered from a seizure disorder, and unfortunately, she also lives in a home where the cooking is done over an open fire. About 2 months before her visit with me she had burned her left foot in the fire during a seizure. She initially was “cared for” at a district hospital, where she remained for 30 days. I am certain that the burns were full thickness, but she was not treated by any effort to graft this deep wound.  Apparently, she just sat there occasionally getting dressing changes, until they finally discharged her home for more dressing changes (supposedly via home nursing care). 
When I walked in the room, I could smell that she had a bad infection in the foot. The family friend who was with them who spoke Swahili told me that nurses had been coming to change it daily, but when I looked at the dressing, it appeared old and filthy. Clearly she had been walking outside on the ground, as evidenced by the tell-tell red clay dirt that is so ubiquitous in Kenya that was staining the dressing. She was also confused (new in the last 24 hours, and complaining of severe pain). She appeared septic (with systemic symptoms of her infection), so I decided to unwrap the foot and see how bad the wounds were. What I saw was unconscionable…Her entire lower leg was swollen, and cellulitic. The wound was purulent, foul smelling, with desiccated tendons and some exposed infected bone at the base. I could not believe that a nurse had been seeing this wound everyday. I immediately decided to admit her, and began to talk to the family about what would likely be an amputation given her septic picture.

SW with her dirty dressing prior to unwrapping

Purulent Wound 60 days after flame burn

What made this case so frustrating is that this elderly woman did not have to lose her foot. She just made an unfortunate decision of where to go to get her initial care. I have no doubt, that had she come to our hospital after her burn, she would have been debrided, grafted, healed and walking again in a months time. Instead, this 90 year old woman was ignored, and even had to walk around on her infected mistreated foot.
After giving her antibiotics, I did her amputation the following morning, a few days later her mental status cleared up, and she proved to be the sweetest patient on the ward (except when I would unwrap her stump dressing…I thought she was gonna punch me). Eventually she was ready for discharge, but I was hesitant. I know what an amputation means in rural Kenya. It means total dependence, and given what had happened previously, I had my doubts that she would be cared for properly. Unfortunately, I had to let her go, as her sponsor (the British woman who is an employer for her daughter, could not afford for me to continue to hold her). I reluctantly signed the discharge paperwork.

I have not seen her in four weeks, and I am not sure if she got some post-op care at a local clinic or if she has died. I really don’t want to think about it. I want to believe that she is okay at home , but I know the odds are unlikely that this is the case.  There are too many cases like her of problems that are so easily treatable, but the patients get poor care or no care from some place that calls itself a hospital.
But what makes me most nauseated is that this delicate woman was too old to be treated this way. She had to walk around on that painful infected foot, because there is no social insurance for the elderly to help support them in their most helpless days, so she had to go fetch water, and cook, and do everything despite her condition. And it is ironic because there is so much reverence for the elderly in African culture. 
The Swahili word for grandmother is nyanya which also means tomato. I laughed when my Swahili instructor first told me this, but he explained to me that it is a term of endearment, because you handle a tomato with care, so you also treat your grandmother with great love and care. I thought that sentiment was beautiful, and I thought of my own departed grandmothers. And this woman reminded me of them. We could not communicate with one word, but she could say so much with her eyes and smile. She could say “thank-you”, and “I’m glad to see you this morning”, and “you’re okay with me, young man” all with her facial expressions. She was precious. She was valuable. She was beautiful. She was a nyanya, and she deserved better.

Lamenting the bruising of the elderly,

“We should provide for old age that it may have no urgent wants of this world to absorb it from meditation on the next.”
~Pearl S. Buck


At Tue Dec 23, 03:20:00 PM, Anonymous Ashley said...

In French, the most popular term of endearment for a loved one is chou-chou" which means cabbage. I don't think it has as pretty an explanation as that of nyanya, though.

I love your blog, Chad, even if I have to read it through a special feed because I can't handle the pictures.

You are amazing, for the record. But you know that.

At Wed Dec 31, 05:01:00 PM, Blogger Lucy2007 said...

You are doing great work. I am inspired by you to make a difference. Thanks for sharing!


At Tue Oct 30, 03:06:00 PM, Anonymous Anonymous said...

Chad, thank you for doing what you do. As a nursing student, and having a grandma who is going through the last days of her life...I have seen how nurses and physicians have talked and treated other family members, including mine with disrespect and without the slightest bit of care. It makes me so disappointed how people with the knowledge and ability to help others is really taking it for granted. Your posts have reminded me that there is still good in the world and that as an RN I want to be someone like you who continues to make a great impact in people's lives.


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