hmm...sterile

hmm...sterile, originally uploaded by mattcotham.

No wonder our post-op infection rate is so high....check out that

spider. Like a lot of the stuff in the theater, no idea what this is

actually the lid to, which is probably why it hasn't been used since

1999. There's a definite reluctance to throw anything away, though,

since you never know when you might need it. You could almost employ

someone full-time just to sort through equipment and repair things that

are broken. I never realized how important the biomedical maintenance

side of things was until I got out here. Our resident, surgeon, David,

has made it his mission to sort through all this stuff in the year he's

here, since we haven't had a permanent surgeon for several years here at

the hospital. David's a very optimistic person. :)

Naphthali

Naphthali, originally uploaded by mattcotham.

One of the pleasures of working here is the chance to get to know a few

of your patients a little better. At home, in the ER, you maybe get to

spend a few hours with someone, usually at a pretty traumatic time;

here we have some kids who are in traction for 6 weeks since we don't

really have the capability to do internal fixation of long bone

fractures. So Napthali has been hanging out with us for the past month

-- his time is up on Monday, and he looks like he'll be fine. We have a

variety of things to help keep the kids at least a little entertained,

but nothing beats having your picture taken.

Gary

Gary, originally uploaded by mattcotham.

I had written about Gary earlier and tried to send the photo through

(see blog 1/9/07) but I wasn't able at that time. Here it is. Updates

on Gary; he seemed to respond to chemotherapy briefly, but quickly

relapsed and had increasing growth of his tumor. He went home about 2

months ago after we had to break the news to him that he wouldn't make

it and there was nothing we could do for him. We haven't heard anything

since. We've got a new boy on the ward who likely has a similar tumor

to Gary; we started chemotherapy today and are hoping for the best.

I'll send pictures soon.

M&M

M&M is a medical term for conferences where you discuss patients that
had bad outcomes (usually death, about the worst outcome you could think
of) and it's something that I was dreading having to do in the
hospital. It is one of those things where it is very easy to feel
defensive and attacked, especially if you were involved in the care of
the patient who turned out badly. Certainly most American residents
have very negative memories of standing up in front of a room of 50-100
people and explaining why they made a mistake, or things didn't go
well. We're required (as I found out in our most recent
inspection/visit) to have these conferences every month, so I started up
with them last month, fearing that people would be upset and defensive
and unwilling to share. What I've found, however, is that it's been a
really good forum for the senior clinical staff to come together and
discuss issues and how we can improve on patient care, with everyone
putting in a bit to the discussion. One of the really nice things about
working in a small hospital is that it's a small group of people;
although this has its downsides, overall, everyone can feel involved and
have a say in what is going on, which is very nice. And we can continue
to improve the care we give to people here at the hospital.

the face of poverty

the face of poverty, originally uploaded by mattcotham.

I've been working on the malnutrition ward for the past several months,

and have treated scores of children who look like this because they

don't get enough protein in their diet to make the necessary parts of

their blood. I find that figuring out exactly what caused their

malnutrition can sometimes be a tricky thing, since often it's

complicated by occult tuberculosis or HIV. TB was on the way to being

eradicated in the world even 20 years ago, until HIV came along and the

numbers for TB exploded. Now we see a fair amount of TB in people who

aren't even HIV positive because of the resurgence in the HIV population.

This child looked like a normal kid after about 2 weeks on our

high-energy protein diet, which the nurses make on the malnutrition ward

from peanuts and soy beans and sugar. I wish I'd take an after picture

to show you as well....

tennis, anyone?

Just so no one thinks I'm suffering too much here, we had our spiritual
life retreat this past week, where the mission organization that I came
out with got together and shared notes and generally enjoyed
themselves. Of course, my participation came at the expense of two of
the other docs who had to stay behind to man the hospital. That
not-withstanding, I overcame my guilt and enjoyed a few games of tennis,
even though I hadn't played since I was a kid. In fact, I think the
last time I may have played was in a mother-son tournament where we
managed to get some kind of trophy, a feat I can only imagine was
possible if my mom hit all the balls at the other kid.
Here back at Mukinge, I'm starting on rehabilitating the tennis court,
and buying some paint to repaint the lines. Now all we need is some
fencing. I'll send you some pictures of our beautiful pool as well if
this new photo blogging works out okay.....

photos galore

photos galore, originally uploaded by mattcotham.

We will try one more time to flesh out the blog with a little

photographic evidence. This is a photo of the night-time assault on the

beehive next door, dripping molten honey and charred honeycomb as sleepy

bees tried to figure out what was going on. If this is successful, I'll

update a few of the other ones.

Staff Appreciation Day

Staff Appreciation Day went off this Thursday, and was an adventure.
You try to delegate things to other people, but things often require a
fair amount of improvisation here in Zambia. Case in point: I wanted to
have Cokes for the staff at the party on Thursday. In order to get
Cokes here, you have to have a bottle to deposit. So I tried to
delegate the rounding up of 200 Coke bottles to one of our staff
members, was assured that I'd have the crates by lunch time, and then of
course they don't show up. So I scrounge around myself, find seven
crates, only to find that the transport I'd arranged to carry them was
full of people it had offered a lift to the town, so I had to arrange
for a different car. Then I get to the BOMA to find out that there's a
national shortage of Cokes (American imperialists, watch out! Your hold
is slipping). After a brief moment of panic that an atomic bomb had
been dropped on Atlanta, I went for plan B -- buying juice. But you
can't buy disposable cups in Kasempa. So I considered having everyone
bring a cup, but then spied some bottles of orange drink in the corner,
bought them, and got them back just in time.

the gas man

Heard that phrase on an old episode of M*A*S*H referring to the
anesthetist; no one here ever seems to get it but I'm going to keep
using that bit of slang until they catch on. Maybe I'll stage a M*A*S*H
marathon to help it sink in. I've been brainstorming about ideas to
help improve and maintain staff morale over the past few weeks, and this
week saw the fruition of two of those plans: Staff Appreciation Week and
participating in the anesthesia call pool. For several years there's
just been two people doing all the anesthesia call in the hsopital, and
they were getting stretched pretty thin, so I volunteered to fall in the
schedule with them to help. So I had a crash course in spinal
anesthetic, reversal agents for paralyzing agents, and infant
resuscitation and started this week. It's been interesting, and a
learning opportunity, but it's probably the closest thing I can do
that's close to ER here, so I've enjoyed it, despite the little extra
lack of sleep it's given me. It's been all C-sections and one
amputation, but the sections have been a little scary since twice the
baby came out not breathing, so I had to try to revive the baby and take
care of the mom at the same time. For various reasons, our labor nurses
here are not trained in neonatal resuscitation, so you end up having to
do both things at the same time, which can be tricky, especially if both
are sick. Trying to make sure that training takes place is one of the
things that I want to make sure happens before I leave.

making a house a home

March was a month of nesting for me, as I tried to make my apartment a
little bit more comfortable for my stay here. This is a mixed bag, as
every convenience entails a certain amount of inconvience. But I
decided to embark on three projects: a telephone line, a shower, and a
cat. I know many of you must be thinking what's the deal with this guy
and the cats, but rest assured the tale has come to an end this month.
First up: the telephone line. I made three visits to the telephone
company, the first two during which the only man who sells telephone
service was missing because he was depositing his paycheck. The third
was more successful, although hampered by my lack of a copy for my
passport. I finally managed to track down the only copier machine in
town, which was low on toner, but when turned up to the darkest setting
could produce a barely legible picture of my passport. I think I could
still deny it in a court of law, however. Armed with my ghostly
reflection of my post-call passport picture from a Walgreens in Denver,
I was able to plunk down my $30 to try to get a line installed. Things
seemed like they were going well, the only service vehicle visited from
the nearby city only a week later, and a hole was drilled in my wall and
a line installed. Unlike home, a line doesn't include things like the
box that you plug your phone into, so it was just a bare wire sitting on
the floor for another week until one of my compatriots made a visit to
the capital and bought me a phone and a 'jack point', that magic box
that allows you to talk. Unfortunately, even though it's a 'new' line,
the cable they hooked into is one of the oldest cables around, and
there's too much noise to call out on the line, or connect to email. I
take a perverse pleasure calling them on my phone line, which they can
barely understand me on, and asking them to come fix it. Unfortunately,
the truck hasn't come back from Solwezi since I bought my phone box, so
we're still at square one, or perhaps square two, since I now have a
line, just one that doesn't work.
Second project: a cat. Actually two, or three, depending on how you
look at it; I caught two kittens, one for me and one for my family in
the village to catch mice. I had placed a bounty on the cats with the
nursing students, a system which resulted in my being called three times
while at dinner at another person's house to inform me that the students
had caught two 2-day old kittens for me. At 2 days old, kittens are
barely able to stand up, much less take care of themselves, so i
returned them to the mother and went back in two weeks. At that point,
they were more capable but also more wild, so I managed to trap them
behind one of the filthy toilets on the closed TB ward and bring them
home. Some of the kids were envious of my cute hissing and spitting
cats, so we went back and caught the third one the next day. Since then
I've had the joys of little kitten claws in my skin, effort of
house-training (concrete floors are beautifully easy to clean) and
trying to tame them and get them to come out from under the
refrigerator. Today I delivered one to the village, so one remains,
Kisela, who looks like she's going to be a good cat. She even wags her
tail and has taken to coming to sleep on top of me at night, which is
okay for now but not that good for my sleep patterns overall.
Third project: a shower. I bought the pieces necessary for a shower
installation, and after five days had progressed to two pipes sticking
out of my wall, pouring water unfettered into my bathtub. This state of
the union has remained for the past week and a half while they try to
replace the faulty part that was bought in the first place, although we
have managed to staunch the flow of water by screwing on two garden taps
to the end of the pipes. Maybe before I leave Zambia I will be able to
enjoy a shower. Until then, we're still stuck with baths.

burning the bees

Wish I could you post the pictures for this -- we've had a huge beehive
gradually growing for the past few months. This week we had people
running in terror as the bees unleashed their vengeance on the local
community outside the hospital. This, coupled with the advent of spikes
next to the wall in front of the hospital (current tires destroyed
count: 3) made it an unpleasant place to be. Perhaps to offset the
negative vibes from the spikes, we hired people from the forestry
service to burn out the bees. A first attempt with a 10 foot ladder was
unsuccessful; armed with a 50 foot ladder, a bamboo pole with
gasoline-soaked rags, and a lighter, the second attempt yielded a fiery
rain of bees, honey, and bark from about 100 feet up one of the local
trees. Unfortunately, it didn't yield the queen, so the bee renaissance
has begun, and a third attempt has been scheduled sometime in the weeks
to come.