I hear today that perhaps the rumors of Judith's death were premature; I
certainly hope so. It made me think about how often I don't really get
follow-up on a lot of the patients that I see; because they live in
rural areas, many times the parents or family won't bring them back to
the hospital if we've told them it's an incurable illness. So then we
only hear through the grapevine that 'that child with X died' from
someone passing through. And with the way communications sometimes work
at Mukinge, even that information might be garbled or not passed on at
all. Anyway, I hope that she's doing fine.
Tuesday, July 31, 2007
Saturday, July 28, 2007
what to do, what to do
Warren Cooper, the visiting surgeon that we had out in February, said
that he dislikes the weekends the most when he goes to visit places,
because he gets bored too easily. I've been filling my time this
weekend watching M*A*S*H on DVD, where they complain about how little
there is to do in Korea and invent little farces to keep themselves
busy. They seem to spend the rest of their time staying up all night to
sit at the bedside of a patient who's sick or operating '17 hours
straight'. I feel a little bit guilty spending my Saturday watching a
70's TV show when I'm supposed to be 'doing something' with my time
here; the simple fact of the matter, however, is that a day to sleep in
until 8am and not be hounded by folks asking for money or favors can be
a real blessing at times here. I'm certainly not cut out to stay up all
night multiple times during the week; even this week after spending just
part of 4 nights up doing anesthesia I was tired. Even though I'm on
call and have to stay close to home, the difference psychologically
between going into work and not going in can be very important. I try
not to feel too guilty that I don't measure up to the standards of the
TV doctors or even some of the missionary doctors you read about, at
least the way that their biographers would like to make you think they
worked. Certainly most days I enjoy the visitors and kids playing and
the work and the patients, but you do need a break. So here's to BJ and
Trapper and Hawkeye for another weekend or two.
that he dislikes the weekends the most when he goes to visit places,
because he gets bored too easily. I've been filling my time this
weekend watching M*A*S*H on DVD, where they complain about how little
there is to do in Korea and invent little farces to keep themselves
busy. They seem to spend the rest of their time staying up all night to
sit at the bedside of a patient who's sick or operating '17 hours
straight'. I feel a little bit guilty spending my Saturday watching a
70's TV show when I'm supposed to be 'doing something' with my time
here; the simple fact of the matter, however, is that a day to sleep in
until 8am and not be hounded by folks asking for money or favors can be
a real blessing at times here. I'm certainly not cut out to stay up all
night multiple times during the week; even this week after spending just
part of 4 nights up doing anesthesia I was tired. Even though I'm on
call and have to stay close to home, the difference psychologically
between going into work and not going in can be very important. I try
not to feel too guilty that I don't measure up to the standards of the
TV doctors or even some of the missionary doctors you read about, at
least the way that their biographers would like to make you think they
worked. Certainly most days I enjoy the visitors and kids playing and
the work and the patients, but you do need a break. So here's to BJ and
Trapper and Hawkeye for another weekend or two.
Tuesday, July 24, 2007
just couldn't resist
A few of the patients that I've taken care of recently. This is Judith,
who had severe nephrotic syndrome. She died a few weeks after this picture.
a few more
I sent a picture of Tom a few weeks ago; he was affected paralysis of
unclear cause. Despite a lot of prayers and exploratory surgery, he
never got much better, although remained cheerful throughout it all. He
went home today.
Maize collection
We are currently in the process of buying the 400 odd bags of maize that
we will use for the coming year to feed our patients. Here's a few of
the bags.
the spectacular sunsets continue
Still getting beautiful sunsets nearly everyday. This is my backyard again.
Coming soon....bungee jumping video!
maternal death
We had our first maternal death in close to two years in the hospital
yesterday, a fact which is remarkable in itself, although we did have a
second case about three months ago of a woman who died en route to the
hospital. Most hospitals in Zambia have maternal deaths approximately
every 2-3 months, so a stretch of 24 months is really exceptional and a
testament to good medical care over the past two years by our maternity
staff. Our case yesterday was a difficult one where the woman came in
talking and in labor; Dr. John was discussing tubal ligation with her,
turned away for a few minutes, and when he came back she was not
breathing and had no pulse. I got a call while working in the theater
that they needed a laryngoscope and someone to help, so I grabbed the
equipment to find John doing CPR on a blue patient in the dim light of a
60 watt bulb with about a dozen of the nursing students and nursing
staff standing around looking frightened and unsure of themselves. I
tried to intubate her without suction and was unable to see the cords, I
asked for a scalpel and after a couple of minutes was brought one; a
minute later we delivered the baby but it was dead as well. We managed
to get the suction working and intubated her and continued CPR for a few
minutes, but didn't manage to bring her back. I stitched up her wounds
while John went to talk to the family and the nursing staff helped to
clean up the mess of blood on the bed.
Today John and I had a discussion about doing the peri-mortem C-section
on the patient; it's one of the heroic measures that I've been taught in
emergency medicine but I had to admit that I had the thought about
whether it was the right thing to do -- possibly deliver the ninth baby
to a father without a mother, little funds for infant formula, probably
limited family support, and so forth. But I just couldn't be that
utilitarian in the situation without more information.
The father is a local elder in a nearby church; he was remarkably
phlegmatic about his wife and child's death. We will have a lot of
processing to do as a hospital staff about how we feel and if we could
have done anything differently.
yesterday, a fact which is remarkable in itself, although we did have a
second case about three months ago of a woman who died en route to the
hospital. Most hospitals in Zambia have maternal deaths approximately
every 2-3 months, so a stretch of 24 months is really exceptional and a
testament to good medical care over the past two years by our maternity
staff. Our case yesterday was a difficult one where the woman came in
talking and in labor; Dr. John was discussing tubal ligation with her,
turned away for a few minutes, and when he came back she was not
breathing and had no pulse. I got a call while working in the theater
that they needed a laryngoscope and someone to help, so I grabbed the
equipment to find John doing CPR on a blue patient in the dim light of a
60 watt bulb with about a dozen of the nursing students and nursing
staff standing around looking frightened and unsure of themselves. I
tried to intubate her without suction and was unable to see the cords, I
asked for a scalpel and after a couple of minutes was brought one; a
minute later we delivered the baby but it was dead as well. We managed
to get the suction working and intubated her and continued CPR for a few
minutes, but didn't manage to bring her back. I stitched up her wounds
while John went to talk to the family and the nursing staff helped to
clean up the mess of blood on the bed.
Today John and I had a discussion about doing the peri-mortem C-section
on the patient; it's one of the heroic measures that I've been taught in
emergency medicine but I had to admit that I had the thought about
whether it was the right thing to do -- possibly deliver the ninth baby
to a father without a mother, little funds for infant formula, probably
limited family support, and so forth. But I just couldn't be that
utilitarian in the situation without more information.
The father is a local elder in a nearby church; he was remarkably
phlegmatic about his wife and child's death. We will have a lot of
processing to do as a hospital staff about how we feel and if we could
have done anything differently.
the magnitude of the task
Having Hilary and Tay out here for a visit gave me the opportunity to
reflect on the way things are at Mukinge. Working in a hospital like
Mukinge is a challenge, because in order to stay sane and not completely
frustrated with things, you have to be willing to accept things as they
are. Otherwise, you get this mounting frustration which is compounded
daily by the way things are done or not done. Everywhere you look at a
place like Mukinge there's room for improvement -- better screening for
our HIV infected mothers, better management of seizure disorders, better
referral systems for people that are too sick for us to take care of,
better nursing care of paralyzed people, better education of our student
nurses, better use of our pharmacy and stores equipment, better upkeep
of our infrastructure, better records keeping for our patients, better
educational programs for our clinical staff. And you can pick one
project and try to make it work, and make little progress, and then get
distracted or put onto another project which seems more urgent. A great
example of this is the reform of the records system which I tried to
help out back in February (see the blog 'computer seances'); we had a
computer donated and tried to put together an electronic register.
However, there was a feeling by the clerks that they didn't have enough
time to do it, there was little supervision of the project because I was
too busy, the computer started to malfunction, and eventually it was let
to die a quiet death as I got caught up in trying to improve our airway
management skills, and so forth. Now we have hired a new stores manager
to help manage our inventory and help plan for shortages, something we
desperately need at the hospital; he was sent for a course by one of the
departed missionaries to help him learn. However, the quality of
education in Zambia is such that he learned little useful for working in
Mukinge in his course, so we have to redo the education that he went
through. Now, I could choose to help him learn his job, but it would
mean the neglect of the rest of my duties at the hospital to a certain
extent. So instead I choose to meet with him for an hour or two per
week, which is not nearly enough to get the job done, but is the most I
can spare for now. You pick your battles, and hope they don't pick you.
reflect on the way things are at Mukinge. Working in a hospital like
Mukinge is a challenge, because in order to stay sane and not completely
frustrated with things, you have to be willing to accept things as they
are. Otherwise, you get this mounting frustration which is compounded
daily by the way things are done or not done. Everywhere you look at a
place like Mukinge there's room for improvement -- better screening for
our HIV infected mothers, better management of seizure disorders, better
referral systems for people that are too sick for us to take care of,
better nursing care of paralyzed people, better education of our student
nurses, better use of our pharmacy and stores equipment, better upkeep
of our infrastructure, better records keeping for our patients, better
educational programs for our clinical staff. And you can pick one
project and try to make it work, and make little progress, and then get
distracted or put onto another project which seems more urgent. A great
example of this is the reform of the records system which I tried to
help out back in February (see the blog 'computer seances'); we had a
computer donated and tried to put together an electronic register.
However, there was a feeling by the clerks that they didn't have enough
time to do it, there was little supervision of the project because I was
too busy, the computer started to malfunction, and eventually it was let
to die a quiet death as I got caught up in trying to improve our airway
management skills, and so forth. Now we have hired a new stores manager
to help manage our inventory and help plan for shortages, something we
desperately need at the hospital; he was sent for a course by one of the
departed missionaries to help him learn. However, the quality of
education in Zambia is such that he learned little useful for working in
Mukinge in his course, so we have to redo the education that he went
through. Now, I could choose to help him learn his job, but it would
mean the neglect of the rest of my duties at the hospital to a certain
extent. So instead I choose to meet with him for an hour or two per
week, which is not nearly enough to get the job done, but is the most I
can spare for now. You pick your battles, and hope they don't pick you.
Sunday, July 22, 2007
back to the grind
Back in the hospital after my respite. Had some magical moments with
Tay and Hilary, some of which were captured on film and some of which
will remain only in my head, and then packed them back on the mission
plane and headed back to the hospital. We're changing things up again
in terms of assignments (the ER doc in me can't stay in one place too
long) so my workload should get more interesting and more varied
starting tomorrow; not as much inpatient work, more surgery, and more
time in the outpatient department. I've got it structured so I can
spend an afternoon a week doing a little language study as well. I'd
like to continue to improve my Kikaonde, although it feels a little like
learning cuneiform or something like that at times; useful in a small
set of circumstances, but not exactly generally applicable.
Tay and Hilary, some of which were captured on film and some of which
will remain only in my head, and then packed them back on the mission
plane and headed back to the hospital. We're changing things up again
in terms of assignments (the ER doc in me can't stay in one place too
long) so my workload should get more interesting and more varied
starting tomorrow; not as much inpatient work, more surgery, and more
time in the outpatient department. I've got it structured so I can
spend an afternoon a week doing a little language study as well. I'd
like to continue to improve my Kikaonde, although it feels a little like
learning cuneiform or something like that at times; useful in a small
set of circumstances, but not exactly generally applicable.
Having vacation has reminded me of a lot of the things that I love about
this place; I need to work to enjoy those things more while I'm here and
back off a little on the work, I think. Zambia is full of incredible
moments like dancing with the kids in the village to the radio of the
truck, seeing the sunset over the Chobe river, or picking my lettuce and
snap peas out of my garden while my cat chases the chickens. I think a
little healthy balance is good.
Wednesday, July 18, 2007
Vacation shots, part 1
Despite the risk of making you think that I've got it too easy here, I'm
sending on a few photos of my recent trip to Victoria Falls and Chobe
National Park in Botswana. Pretty spectacular trip.
zambian solidarity
Bought a new Zambian hat like lots of the guys wear around here.
Nothing like rubbing shoulders with a Zambian for 7 hours in the bus to
make you feel connected with him.
Monday, July 09, 2007
7/7/7
An auspicious day for a 16 hour bus ride, if any day could be an
auspicious day to sit on a bus for so long. When you travel via bus to
Lusaka, you get up at 3:30 to catch the 4am bus to the nearby city,
Solwezi. This is the same bus I took back in March, which has to be the
most maddening bus ever because it picks you up at 4, but doesn't leave
until 6. You may ask, 'Matt, why don't you just catch it at 6, then',
but it drives 5km away and sits there for the 2 hours, so that it's not
really practical to go find it at 6am. Anyway, I made it onto Mark's
Motors (pronounced Max Motors, don't ask me why) at 8:30, managed to
score the seat on the back row that faced the aisle so I could stretch
out my legs, and settled in with my iPod for the trip.
Travelling by bus is one of the best ways to get a sense of the country;
you see Africa 1st-hand, sometimes really close-up, like when I was
holding the baby of the woman sitting next to me, or reading about the
uncle who wanted to marry his niece on my next-door neighbor's paper
(the lead article for the day). But nevertheless, I was ready for a
break from Africa at the end of all that time, so I was glad to see the
smog and lights of Lusaka in the distance.
Now I'm back at the first place I saw when I came to Zambia. It's not
quite full circle, but it is an opportunity for reflection, remembering
the days of sweating and swatting mosquitoes. Hard to remember all
those too hot days when it's 40 degrees outside now and I've got only
two sweaters to my name. I nearly was down to one after a woman in the
hospital got pretty angry with me this week when I declined to give the
one I was wearing to her. I feel much more comfortable and more
uncomfortable than I did 6 months ago; just having some Zambian Kwacha
and a basic grasp of the language goes a long way to feeling
comfortable. I don't feel nearly as much out of place as I did, and
there are few places that I could go where I wouldn't know anyone
around. On the other hand, I get more uncomfortable with the limits of
what I can provide for the patients at the hospital, more uncomfortable
with the sense of entitlement that I get from some Zambians, and
uncomfortable with how some of the ex-pats have responded to their
Zambian brothers and sisters.
Although there's no more marathon bus rides in the future, I guess my
journey in Zambia still has a long way to go.
auspicious day to sit on a bus for so long. When you travel via bus to
Lusaka, you get up at 3:30 to catch the 4am bus to the nearby city,
Solwezi. This is the same bus I took back in March, which has to be the
most maddening bus ever because it picks you up at 4, but doesn't leave
until 6. You may ask, 'Matt, why don't you just catch it at 6, then',
but it drives 5km away and sits there for the 2 hours, so that it's not
really practical to go find it at 6am. Anyway, I made it onto Mark's
Motors (pronounced Max Motors, don't ask me why) at 8:30, managed to
score the seat on the back row that faced the aisle so I could stretch
out my legs, and settled in with my iPod for the trip.
Travelling by bus is one of the best ways to get a sense of the country;
you see Africa 1st-hand, sometimes really close-up, like when I was
holding the baby of the woman sitting next to me, or reading about the
uncle who wanted to marry his niece on my next-door neighbor's paper
(the lead article for the day). But nevertheless, I was ready for a
break from Africa at the end of all that time, so I was glad to see the
smog and lights of Lusaka in the distance.
Now I'm back at the first place I saw when I came to Zambia. It's not
quite full circle, but it is an opportunity for reflection, remembering
the days of sweating and swatting mosquitoes. Hard to remember all
those too hot days when it's 40 degrees outside now and I've got only
two sweaters to my name. I nearly was down to one after a woman in the
hospital got pretty angry with me this week when I declined to give the
one I was wearing to her. I feel much more comfortable and more
uncomfortable than I did 6 months ago; just having some Zambian Kwacha
and a basic grasp of the language goes a long way to feeling
comfortable. I don't feel nearly as much out of place as I did, and
there are few places that I could go where I wouldn't know anyone
around. On the other hand, I get more uncomfortable with the limits of
what I can provide for the patients at the hospital, more uncomfortable
with the sense of entitlement that I get from some Zambians, and
uncomfortable with how some of the ex-pats have responded to their
Zambian brothers and sisters.
Although there's no more marathon bus rides in the future, I guess my
journey in Zambia still has a long way to go.
vacation time
I left for vacation yesterday for 10 days to clear my head and get away
from Mukinge. As such a small place, it's good to take a break every
now and then; the life gets a bit claustrophobic at times. We had an
extended weekend last weekend; I asked one of the Zambian nurses what
she did for the weekend and she somewhat grumpily replied 'there's
nothing to do here'. Certainly there's more opportunities for
entertainment for me with DVD's and the computer age and the advent of
the internet these days. But it's still good to take a break from
personalities and the grind of work and the depressing nature of the
patients that you can't do much for and don't get better.
At the same time, vacation feels a little bit guilty, just because you
spend a fair amount on yourself. This is magnified by the opportunity
to come to Lusaka where there are well-stocked stores; I've been
accumulating a list of things to get for the past 6 months, so you end
up doing 6 months worth of shopping in one day, which makes me feel
frivolous and like I'm spending too much on myself. It's a lot easier
to buy things here and there; the psychological impact of all that money
that you spend on yourself is lessened and you don't feel nearly as
guilty about it all. And all the stuff is not essentials -- you can buy
flour and cabbage and corn at home -- but the little extras that make
things nice; a mixing bowl so that I don't have to use my stewpot, or
some olive oil, or toys for the cat so he doesn't shred my ironing
board. My biggest guilty pleasure will be a mattress if I can figure
out how to arrange it. It's a tough balance between being comfortable
and being a good steward of your money, especially when there are needs
for people to go to school, or to buy blankets for their kids when it's
cold, or requests for loans to put a door on their house.
from Mukinge. As such a small place, it's good to take a break every
now and then; the life gets a bit claustrophobic at times. We had an
extended weekend last weekend; I asked one of the Zambian nurses what
she did for the weekend and she somewhat grumpily replied 'there's
nothing to do here'. Certainly there's more opportunities for
entertainment for me with DVD's and the computer age and the advent of
the internet these days. But it's still good to take a break from
personalities and the grind of work and the depressing nature of the
patients that you can't do much for and don't get better.
At the same time, vacation feels a little bit guilty, just because you
spend a fair amount on yourself. This is magnified by the opportunity
to come to Lusaka where there are well-stocked stores; I've been
accumulating a list of things to get for the past 6 months, so you end
up doing 6 months worth of shopping in one day, which makes me feel
frivolous and like I'm spending too much on myself. It's a lot easier
to buy things here and there; the psychological impact of all that money
that you spend on yourself is lessened and you don't feel nearly as
guilty about it all. And all the stuff is not essentials -- you can buy
flour and cabbage and corn at home -- but the little extras that make
things nice; a mixing bowl so that I don't have to use my stewpot, or
some olive oil, or toys for the cat so he doesn't shred my ironing
board. My biggest guilty pleasure will be a mattress if I can figure
out how to arrange it. It's a tough balance between being comfortable
and being a good steward of your money, especially when there are needs
for people to go to school, or to buy blankets for their kids when it's
cold, or requests for loans to put a door on their house.
Sunday, July 01, 2007
burning days/burning haze
It's been some time since I last wrote; since then the days have gotten shorter and colder (it gets down to 40 degrees at night!) and now that the rains have been finished for about 3 months the burning season has begun. Burning season is marked by the advent of small children running around with flaming sticks and setting the grass and fields on fire. Ostensibly this is to prepare the fields for next year, but as I remember from my days as a Boy Scout where we burned down part of someone's ranch, small boys need little excuse to go around burning things. This season has its good and bad points -- beautiful sunsets at the hospital, but accompanied by the smell of burning rubber.
Work has continued to be a source of challenge and satisfaction for me out here. As you may well imagine, with limited entertainment and diversionary activities, I spend a fair amount of time obsessing about various cases and what to do, with some successes and failures. We've diagnosed a case of leprosy, which was good since we can treat it, and lots of cases of cancer, which are challenging because people often present to the hospital so late that we could do little for them even if we had the treatment. Tragically, in the era of AIDS, many of these cases occur in young men and women who are 30 or below -- lymphoma, parotid tumors, cervical cancer, KS -- and there is a lot of life left to be lived for many of them. As one of the doctors here says, "There's not many fairy-tale endings in Africa", which is very true for most of our patients, despite the lucky few who we can diagnose with a problem that we can fix.
We continue to try to shake things up clinically, so I've been back in charge of the male and female wards and the TB ward, which for the most part I've enjoyed. I've also had a few stints as the acting executive director since the current ED has been away on trips out of the country; it's given me the chance to meet with some of my counterparts at the district and provincial levels, which has been eye-opening for me and also a good source of contacts and information for things that could help out our patients. The meetings themselves are intensely frustrating for me on a personal level, as it seems that very little actually gets accomplished despite a lot of people talking, and also some of the attitudes of the Zambians in charge can be disheartening (the last meeting I was at one mentioned that he'd like to get a scholarship to do some training overseas, so that 'he could get some rest and maybe come home with a car".) That's in contrast, however, with the people that I work with who go very much beyond what is reasonable in dedication to their projects and patients, spending time away from their families, spending personal resources, and extra time on the job here to get things done.
We're at the beginning of planning for the coming year, which is a unique time and I'm glad that I can be a part of that, although who knows whether the promised funding from the government will come through. Finances, as usual, are an issue at the hospital, but fund-raising efforts from home continue to go well and my charitable organization should be off the ground soon. Thanks for all your generous support! We're still progressing towards our goal of around $30,000 for capital projects here at the hospital. We are continuing in need of manpower, especially nurses, a laboratory supervisor, and soon to come, a pharmacist.
I'll cut it short there. If you want more thoughts, etc, don't forget the blog at www.mattcotham.blogspot.com. It's got pictures now. You can also see an aerial view of the hospital on google earth if you look up Kasempa -- we're just a few km south where the airstrip makes a big 'X'. The satellite email system is here, but in a limited capacity; hopefully to be expanded soon.
Talk to you all soon. I'll end with a picture of David, our surgeon, and a man who we constructed a prosthesis for after he got an amputation when he was involved in a motor vehicle crash. It's maybe not that pretty, but he was very happy.
Matt
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