This is just for now

My thighs ached like wet rags being rung out. The chills took hold.  My sense of smell dissolved. And the shortness of breath... the shortness of breath was unmistakable.

Count the respiratory rate. I instruct medical students, new interns. That's the vital sign you want to pay the most attention to.

I counted mine, last week, when I was sick. Like a systolic murmur it crescendoed to a peak on days 4 and 5, before normalizing again shortly thereafter. It was strange to be tachypnic -to be breathing fast- when I was walking to the bathroom, pouring myself some juice, simply lying still in bed. It was hard to ignore.

But with rest (and with time) it slowed. And with Tylenol (and 45 minutes of time) the chills and the aches and the sensation that my head was heavy and light all at once would cease. And during those moments of feeling better, I found myself looking -quite literally- to the past, as well as -a little more abstractly- to the future.

This, all of this, is just for now.

How to be so sure? While sick, I did a lot of scrolling through the photos on my phone, through thousands of squares of color and light. At those depicting medical school and residency, I stopped short.

In scrubs and long white coats. On night shifts and short calls. In clinic and the ICU. Each photo served as a launching pad, jogging memories of the moments seconds minutes hours that led up to the pose, as well as those that followed. I know we all have these images in our minds, and saved to our camera rolls. Of those days we worked relentlessly hard but yet found time to smile, to put our arms around each other, to be -without trying- care free.

There's a photo of me as an intern on night float, with a stack of patient lists in one hand and a birthday card in the other, because the clock struck midnight on my 28th birthday while I was on call.  There's a photo of an East River sunrise through smudged window glass and plastic blinds, signifying day break on another overnight ICU shift.

There are photos of the hospital decorated for Christmas. My friends and I gathering in the hospital garden. Of white boards with lesson plans I didn't want to forget. There are close ups of unusual CT and X-ray findings. Screenshots of Duke's criteria. Stethoscope selfies.

All these moments came, and went. As well as so many more that though not captured with a click nor easily recalled in photo-like detail, have still managed to invisibly contribute to who we are today.

Our emotions are defining this moment. Our actions and roles keep us present, bound to this phase in our careers and our lives. But it's been helpful for me to know this is not how it always was, nor how it always will be. 

This... this is most definitely just for now. And soon? Soon we will be close again, care free, with our arms around each other. Perhaps the future doesn't feel so abstract after all.

Pink sliver is the sun rising on a long call ICU shift

Luck in the time of corona

Like an obsession I check my hospital's electronic medical record app on my phone. Like a compulsion, the numbers keep rising. The names I know ricochet back and forth: their room numbers flip from those I know to be on the regular floor to ICU-capable beds, some back and forth and back again. Is this for real?

I felt that about my symptoms, too, that began last Monday. It's cold in here, right? I asked Michael, as we were falling asleep. Hours later I was up for the night with a feverish feeling, chills, and muscle aches. I trecked -ok I live in a studio apartment so in reality I walked the 10 feet- to my couch and tried to fall asleep there. I am achy and feel hot and cold, I texted one of my best friends, as well as my dad. I don't know what to do. Up hours later still feeling unwell, I emailed my department's directors. I'll probably be okay by the morning, but in case I'm not, I'm not sure if I should come to work. 

Michael and I have nicknamed it community covid, I think we like the alliteration. And though my swab has yet to result as the days creep forward it has become more and more clear that even if my symptoms may be slightly amplified by anxiety, even if I think this can't be for real, I'm checking all the boxes that make this disease process very likely. Muscle aches, fatigue, slight shortness of breath, joint pain, diarrhea, dry cough. All mild, but I have to say I've never quite felt like this before. I can't do half a jumping jack, I told my mom. Stop trying to do jumping jacks, she replied.

I am fine, though- because I am young and healthy. I am fine, though- because I speak English and understand health and illness, warning signs, the importance of staying hydrated. I am fine because my family and friends have sent me enough food and love to get me through 3 pandemics. Because I live in a luxury apartment and building staff are leaving my deliveries outside my door. 

Because last night, already in bed at 7 o'clock, I heard cheering outside. I made my way to my balcony -7 strides from my bed, 3x6 feet in size- and I realized from porches and fire escapes and open windows all around people were cheering, both literally but also symbolically, for the change of shift at the nearby hospital. I greeted my neighbor, on the balcony right next door. What are they cheering for? I asked her, more out of awe and marvel than because I didn't know. They're cheering for you, she said. I'm fine because this neighbor texted me shortly after to ask if I had a sore throat and would like some lollipops. 

Suffice it to say, I am fine because I'm really, really lucky.

It goes without saying not everyone is getting this lucky. People of all ages are sick, and that they are sick alone in hospital beds is a heartbreaking reality that I think has made my colleagues and my heart ache as much as any piece of this. More than ever, in this age of digital connection we are appreciating the importance of true connection. Of our health. Of getting really lucky.  

My view from the E Team

I’ve been asked by all my loved ones, my family and friends, what it has been like. Now that I spent one day on ‘Team E’, the COVID team (both confirmed cases and those being ruled out but sick enough to require hospitalization), it still remains pretty hard to describe but I can try to write down some thoughts. Of note I’ve done so much less than other people.

Hospital life has truly turned upside down. Every aspect of what I’ve been trained to do -and do well- every convention and protocol and all the structure, is literally gone. Both physically and mentally, the space has changed in the most palpable way.

Almost every patient room door is now closed and has 4 signs on it- denoting that it is an isolation room with a COVID patient (again, either confirmed or being ruled out. A lot of the cases we’re ruling out, almost certainly have it though- we can already just tell based on signs and symptoms). For now, each COVID patient is being roomed separately. Though eventually (soon) we will probably have to cohort multiple positive covid patients together, just given the numbers. So on a door there’s a stop sign to catch your attention, a sign in sign (which we’re not really using- a pen would be another thing requiring disinfecting), and then a sheet or 2 describing how to wear our PPE (personal protection equipment) properly.

I haven’t been down to the ER or this area we denote the EW which used to act as a low acuity ICU but is now entirely a respiratory unit. As is the ER. They’re both only for patients with respiratory symptoms. I’ve heard they’re both very intense places now.

Basically yesterday, on Team E, my friend/colleague Jon, 2 PAs and I went down a list of 20 patients and saw all of them. The PAs stayed outside and wrote notes, fielded and made calls, handed us supplies, put in orders… and Jon and I (sometimes both of us, sometimes one of us) gowned up and went into each room.

Throughout the day, there were probably 5 SPRT (special pathogen response team) alerts. They’re like the rapid responses/codes I’ve told a lot of people about, but they’re on the COVID patients, and instead of a dozen or more people rushing in the room, since we are being careful with preserving our PPE, only 2 or 3 of us go in (2 doctors, a nurse, a respiratory therapist) and everyone else stays outside and peers in through the door window. The anesthesiologists (who intubate) are part of that group who stay outside- waiting for the go ahead as to whether or not we think the patient needs a breathing tube (a sacred vent) immediately. Thank gd no one needed that escalation of care at the SPRTs yesterday.

All the patients have similar symptoms (though they don’t all have all of them)- bad headache, myalgias (muscle aches), high grade fevers, dry cough, and difficulty breathing. A lot of them have diarrhea too. And we’re noticing that there are a couple patterns in terms of how patients do, like how their illness evolves. 

But the scariest symptom is the hypoxia -low oxygen- as patients just become more and more hypoxic over time, some leveling out and some crashing typically around day 7-10 (my sense at least). Again, that’s day 7-10 of symptoms, so if they come in on day 3 or 4 you have to account for that.

Now of note these people who are hospitalized have a coronavirus *pneumonia*, which is different from the pattern that people have in the community, the pattern -thank gd- my colleagues and I would almost certainly get.

It’s jarring how many patients there are… that we have a zero visitor policy in the entire hospital (so hard to be sick alone). During a SPRT yesterday with a 32 year old patient who was doing really poorly (she has end stage renal disease so has an underlying illness), in the room it was Jon, me, a nurse, a respiratory therapist, the patient (solely Spanish speaking), and on her sparkly pink iPHONE, her brother- translating and asking questions. Doctor, is she ok. Doctor, how are you treating her. Doctor, can I come in and be there with her.  In this moment, I think she will be ok. In this moment, we don’t know how to treat her. In this moment, I am so so sorry but no, you cannot be here with her. So incredibly stressful for patients and their families.

It’s a process to don (put on equipment) but also doff (very carefully take it off). It’s the doffing piece of it that matters, because at that point the equipment has come into contact with the patient. It’s hard to balance when we’re beside with the patients these priorities. Because I’m so wired by that convention, structure, skill, bedside manner that I mentioned earlier. You go in and you want to get close and hold the patients hand or stroke their shoulder. But you’re also making sure the patient has their own mask on, that yours is on tight, that you are safe.

About my grandma but also Africa

And we're off! Ok- full disclosure. It's not all work (I know I've led you to believe it has been) and no play: we've packed a dose of old fashioned fun into this trip. Yesterday we loaded into a jeep (make: Land Rover; model: unclear. It's rugged. From the 90s?) and zipped along a paved road towards the Malawi-Zambia border, and into Zambia. 

En route, Malawi life still unfolded on either side of the 2-lane (1 in each direction) Tarmac (in America, we call them highways. Sometimes they have six times as many lanes): Goats grazing and playing and some dead and hung by the neck, their red meat exposed and for sale. Cows pulling carts and women sitting in the shade dictated by 4 thin cut down tree trunks arranged in a rectangle and replanted in the dirt, like a beach umbrella, with thatch layered along the top. They're selling oranges and corn flour and green beans and groundnuts and potatoes, just as I've watched them sell for the last two weeks, just as they'll continue to sell for so many years to come. 

But have you seen how they arrange the oranges and potatoes into pyramids? It's kinda neat. I didn't buy roadside oranges this trip but small bananas (ntochi) up North were going for 10 Kwacha each. That's 1.4 cents. I'll take ten, tawonga (thank you). 

Also along the banks of the road are lots of bicycles with at least one but more often two or three passengers each; children run around with sticks.

Africa reminds me of my grandma, though she never traveled here, and though she passed away in 2013. Fun fact: I never discarded the printed out eulogy I wrote for her funeral and less than a year after I gave it, when I visited Africa for the first time, I still had the original copy on me. Creased and barely legible, but when I reread it before bed under my mosquito net it was as if my grandma was breathing in this new world with me (is this too macabre?). Eventually too torn and smudged, that original is now in a drawer at home but I've since printed out a new copy. Its with me on this trip too. 

Why does Africa (the Africa I've experienced) remind me of my grandma? I want to say I'm not sure, but that's a cop out. I do know I just have to figure out how to put it into words. Ugh, words. 

I think it's the unconditional serenity. The calm. The natural beauty. The color and the zest. I think it's how Africa makes me feel, in unison at peace but alive. Safe. That's how she made me feel. That's how she made a lot of people feel. 

I think it's that my grandma would have just flipped that I'm having the experiences that I'm having. Upon my return, she would've expedited a brunch. She would've made sure we sat next to each other at the kitchen table. She wouldn't have needed to try though, we always did anyway. 

I can imagine my grandma would've been almost too excited to actually take in all my photos and stories. But, with true awe and palpable excitement, she would've said it was all so incredible. It is all so incredible. In case I hadn't on my own, she would've made sure I realized that. 

I started this post prior but I'm now just back from a cool morning safari drive in South Luangwa national park. I thought about my grandma and Africa during that ride and also realized this:

The way in which my grandma effortlessly viewed the world and its people is similar to how I've managed to take in Africa. With emotions like hope, pride, empathy, awe, and love. With the easy realization that it's all so incredible. 

Love,

Rebecca

The Level Game

Creativity is a luxury, right? Think about the sensations and emotions that anchor you to the moment, those that bind you like gravity and disable you from thinking about anything else. Hunger or thirst or feeling oily because you haven't bathed in four days or itchy because you're freckled with mosquito bites or uncomfortable because your shoes are in shreds and you have to flex your toes to keep them on your feet. Think about anxiety and fear and fatigue and pain. Honestly consider how these feel, and now don't you agree that creativity is a perk? 

Because when you're feeling these things -and there's no food or water or bath or better shoes or perspective to quell your anxiety or NSAIDs to ease your pain- there isn't really any leftover energy to devote to harnessing your imagination. There isn't actually much utility in breaking the mold, tinkering with your future, thinking outside the box. 

I am so lucky. 

Because when I was little there wasn't a career my friends and I didn't sample, nor a game we didn't play, from the comfort of our homes. We were interior designers and chefs and teachers and veterinarians. We built hotels, homes, and entire cities via computer games. We were sports broadcasters during recess, we wrote limericks for fake TV commercials. My cousins and I invented, evolved, and played the "Level Game" in our basement, the sole purpose of which was, quite literally, to create obstacle courses for one another. And then to overcome them.

In school, we went on field trips. To museums and to poetry slams, to the nature center and to historic sites. We wrote short stories, longer stories; essays, longer essays. And we read; we read and we read. Our reading assignments took us along the Oregon Trail and the Silk Road; we went on witch hunts in Salem, sat for tea with Jane Eyre; we went on the Odyssey, learned why the caged bird sings, read Anne Frank's letters, attended Jay Gatsby's parties. We also explored magical lands: Terabithia, Hogwarts, Middle Earth. We solved mysteries. Yes, we spent a lot of time indoors, surrounded by 4 walls. But we saw the world.

So it takes a second to think about how the children of the villages of Northern Malawi, who spend the majority of their days outside, who in some ways have no boundaries or walls, are confined. Are anchored.

Having the time and energy to make believe is one thing, but knowing the boundaries of what exists so that you can tiptoe beyond them is part of it too.

When we would visit villages in the jeep, the children would literally drop everything and run after it: this was the activity. What do the children of the villages do for fun? I asked Wilson, the graduate student who helped us with our surveys. The children were on holiday from school before the new year, so maybe they had more free time than usual, but by the last day I couldn't bring myself to wave out the back window anymore. 

They do lots of things, he told me. They hunt for mice and rodents, they make small models out of the dirt, they fish. 

And the little girls? 

The little girls tie a rope to the tree and jump over it.

I thought back to what Rosa told us at dinner the week before, about her 4-year-old. Lena likes to make believe cook, she makes nsima out of mud.

In the moment I thought this was sweet, just as for a while the site of the children running after the car, after the White people, didn't faze me. But honestly? What if the village children's creativity is stifled by what they can't even imagine? If Lena wants, she should be pretending to be a doctor or a teacher or a lawyer or a fashion designer or a cook or anything she wants. Because pretending comes first.

Next time, I bring books.

Hoping I'm wrong, and aware that the above has a lot of holes,

R

On the menu

From what I can tell, there is approximately 1 actual restaurant in Mzuzu, the nearby large city. By actual, I mean cut from the same cloth as the restaurants that sustain me back home. By actual, I mean it has menus, and prices, and napkins. An LED sign in the window that flashes 'We are Open', and one over the bar that flashes 'Bar'. The inside and outside walls are periwinkle; the Indian owner emigrated from Gujrat twenty years ago. The restaurant is called A-1.

A-1 serves native Malawian cuisine (chicken, fish, nsima, chips, and rice), but also Indian food and brick-oven pizza. Just flip to the next page of the laminated menu and your taste buds can tour the world. Ironic. The majority of Northern Malawians will scarcely travel and taste beyond their own village. Let alone venture to Mzuzu, or step foot in A-1. 

Last time we were in Malawi, we went to A-1 with Alfred and Richard (our Malawian friends), for our goodbye meal. The pair tried pizza for the first time, and this has remained an inside joke and special memory 3 years later. Last Sunday afternoon, we returned with Alfred. The pizza oven was out of commission (potentially because the power was out in the entire region, unclear), but the back-up generator was humming and Alfred tried Indian food for the first time. In New York we have an entire block of Indian restaurant one after another, we tried to paint a picture. A block, I had described the day before, is like a road. There's also something called a block party...

In the villages, once our program (see prior post) is complete, the women usually prepare a meal for us. Led into a home, the room we settle in is cooled by the brick walls, and is dark except for shy rays of sunlight that creep through the door frame and maybe through a small window. 

It's usually just us visitors who sit for the meal, though even our driver, Sam, is included. Maybe one member of the village joins, but not always. It begins with a woman from the village, making herself small with bent knees and bare feet, circles the group with a bowl and pitcher of hot water. She pours the water over my hands, I watch it evolve from clear to brown as it drips off my sandy fingers into the bowl. A prayer follows and then the food is dished out. 

The meal is essentially identical in each village. Today in the car I grilled (pun) Wilson, the graduate student who helps conduct our surveys, on what the meal entails. 

There's nsima, made from corn flour. Nsima is our staple food, we've heard time and time again, does America have a staple? To prepare nsima, water is boiled and corn flour is added until a porridge is produced. This mixture is allowed to boil, and then more corn flour is added until the desired stiffness is achieved. Ultimately, a lukhenzo (large spoon) is used to shape the dough into bean-bag sized squares. The consistency is that of dense play-dough. 

To cook the vegetable dish, a soup of tomatoes, onions, and cooking oil is heated. Then, chopped pumpkin leaf or mustard leaf or Mpiru is added, and this is allowed to boil for a while. Optionally, chopped ground nuts (peanuts) are added. You prepare the ground nuts in a thuli (large wooden mortar and pestle) until they are very fine. 

We're also served fried local eggs, sometimes with the tomato relish described above. Or local chicken. Though after we politely refused the meat at the first few villages, it notably disappeared from the menu. 

We eat with our hands, ripping off pieces of the nsima and using it to scoop the vegetables and eggs. At the conclusion of the meal we again wash our hands, with the pitcher and the large bowl. 

And to answer the question about our staple back home? Tomorrow, I say, remind me to tell you about the bagel.  

The program

Everything in Malawi revolves around the setting of the Program.

When we first arrived up North the first thing we did was sit down with the Malawians who oversee our project on the ground, to plan a program that would allow us to visit the 21 villages in which our Bicycle Ambulances have been installed during our two week allotted time. Then each day there is a program which involves setting the time and location we will all meet each morning (half seven, at the guest house... or eight o'clock at the filling station), and what time we'd likely arrive in the 2 villages planned for that day. Then, at each village, a program in and of itself ensues, which usually takes the form of: opening prayers, very formal introductions of everyone in attendance, opening remarks, viewings of the bicycles, pigs and logbooks, closing remarks, closing prayers, and then usually a small meal prepared for us by the villagers of nsima, greens, and usually chicken or fried eggs. We then pile into the car, travel to the next village, and start all over again. 

I guess what's interesting about this program concept is another local and commonly laughed about phenomenon, called Malawi Time. And the Malawians laugh the loudest. Contrasted to English Time, everything in the Warm Heart of Africa runs on its own timetable, and the table is chronically tilted towards 'late'.  A for effort, but the juxtaposition of such thoughtful planning and such difficulty sticking to a schedule makes each day.. an adventure. 

In other news, we've been very busy but spending time in the villages and with the villagers has been extraordinary. Look forward to (trying) to write more about it soon...it's in the program for later this week.  

R