close to home

I suppose that after a year of working here, and having hundreds of
patients die under my care, I should be more used to the idea. I don't
go to the death scenes of my patients very often, simply because it's
too hard to do it over and over again. It's difficult to be in the room
with six wailing women, rolling around on the concrete floor, unable to
stand, staring up at you with questions in their eyes. I unfairly
interpret this as a kind of accusation, and I feel that every time
someone dies it undermines the work that we're trying to do here at the
hospital to provide hope and comfort to sick people. In fact, I was
told when I arrived that about a year prior to my arrival, when someone
died in the OR, the next day half the hospital got up and left, whether
they were finished with their treatment or not.
Yesterday I was forced to operate on a very sick 70 year-old man who
came in with signs of intestinal obstruction -- vomiting feces,
distended abdomen, no bowel movement for 3 days -- but when I made the
decision to go to the OR, we couldn't find a reversible cause and so we
closed him back up after rooting around for 30 minutes. This would be a
case where slightly more advanced imaging like a CAT scan would be
invaluable in preventing an unnecessary operation. He continued to get
worse and worse throughout the day and about 10 hours after going to the
OR he died. Like many of the cases I've seen here at Chitokoloki, he
was the family member of one of the staff here and it's very difficult
to go to church and see them the next day when you know that they died
under your care, whether you did something right or wrong in that care.
In a case like this where you're inexperienced and the usual doctor
isn't there, there's the questions of whether you know what you're doing
as well and whether the family member would have survived if the 'real'
doctor had been around.
I'll go to the funeral today and stand with the family of the people who
may or may not be harboring these thoughts about me. It's easier to not
go, knowing that people will probably forgive the omission as a white
man and a visitor from somewhere else, but it still seems like a
cowardly thing to do to avoid the family and the situation altogether.

Some people will do anything....

Some people will do anything...., originally uploaded by mattcotham.

Many of our patients don't like to take their medicine, which isn't
surprising when you taste most of the medication formulas used here --
very bitter, none of the candy coatings and flavorings like you get in
America. Today I went to see one of my post-op surgical patients and
when I examined the wound I found it smeared with a thick white paste.
I'm thinking to myself that he's brought some weird African medicine
from home, so I go and get the translator. Turns out he had been
chewing up his Tylenol, making into a white paste, and then smearing it
on the wound to make it hurt less. This is a similar approach to the
witch doctors whose remedies for most illnesses is to simply cut the
skin in small cuts over wherever it hurts. We explained the idea that
the medication needs to be swallowed, so we'll see how well we do tomorrow.

TB trouble

TB trouble, originally uploaded by mattcotham.

As many of you know, TB, HIV, and malaria have become the focus of
international attention and research over the last five years with the
advent of the global fund, emphasis on research, and increasing funding
sources from places like the US and the WHO. We are beginning to see
the tip of what will likely be a increasing scourge of MDR-TB, which
stands for 'multi-drug resistant' TB. Because TB is so common in places
like Zambia, we don't go around treating contacts of people with TB,
which means that occasionally we will see entire families, one by one,
as they come in and are diagnosed with TB in the hospital. This
particular lady was the wife of a man I treated 2 months previously, and
who's brother I also treated 2 months before that, and who I'm sure also
has several infected children running around their home, not to mention
neighbors, extended family, and so on. We are unfortunately
short-staffed in our ability to do community follow-up, which would be a
place I would like to increase hospital services out and about in the
area if we can find funding for a program like that. But I'm often
struck at how deep the iceberg goes when I scratch the surface in the
hospital.

TB trouble

TB trouble, originally uploaded by mattcotham.

As many of you know, TB, HIV, and malaria have become the focus of
international attention and research over the last five years with the
advent of the global fund, emphasis on research, and increasing funding
sources from places like the US and the WHO. We are beginning to see
the tip of what will likely be a increasing scourge of MDR-TB, which
stands for 'multi-drug resistant' TB. Because TB is so common in places
like Zambia, we don't go around treating contacts of people with TB,
which means that occasionally we will see entire families, one by one,
as they come in and are diagnosed with TB in the hospital. This
particular lady was the wife of a man I treated 2 months previously, and
who's brother I also treated 2 months before that, and who I'm sure also
has several infected children running around their home, not to mention
neighbors, extended family, and so on. We are unfortunately
short-staffed in our ability to do community follow-up, which would be a
place I would like to increase hospital services out and about in the
area if we can find funding for a program like that. But I'm often
struck at how deep the iceberg goes when I scratch the surface in the
hospital.

a stretch

It's been a hard experience playing at being the only doctor in town
here at Chitokoloki so far. One of the things I've been really grateful
for at Mukinge is the opportunity to do things as a team and bounce
ideas off the other doctors. I can call on the knowledge and experience
of the other ones working there, whether the nursing staff who has seen
so many things, the other doctors which draw from a wealth of different
medical experience than me, or the advice from people from home. One of
the really difficult things that I find about medical work in Africa is
that often times it feels like you're groping around in the dark without
much idea where you are going; this is a stressful experience when lots
is at stake but having other people's hands to hold while you wander
around in the dark makes it more bearable.
Up here, it feels like I'm on my own to screw up or do well, and I've
been faced with opportunities that are past my training. Some of it is
just the struggle of trying to find what you need in a hospital that you
are not familiar with; here they are more concerned with theft than we
need to be at Mukinge so lots of equipment is squirrel away in places
that are locked or hidden, making it difficult to find in an emergency.
I've also had some problems which I've never been asked to solve before
-- for example, the local Zambian hospital was doing a hernia operation
and ran into complications, so they asked me to fix the problem, which
turned out to be a large hole in the bladder. Considering I don't even
consider myself trained to do a routine hernia, trying to fix the
problems in someone else's complicated hernia was asking a bit much.
But I did my best, and the guy is doing well. Another case, a 6 month
old with a bone infection, I've been hesitating about taking to the OR,
but will probably have my hand forced soon.
Anyway, I've realized the crutch of having other people to lean on here
for the past few days. I think that this year will continue to be
tricky at times as people come and go and I lose a bit of that safety
net. I mostly need to take advantage of the opportunity to learn from
people when I can.

stranger in a strange land

After much debate with the mission agency and the church board, I
managed to get off to help up here at Chitokoloki. Perhaps more
beautiful than Mukinge (don't tell her I said that) it's a good
experience to see a different take on how a mission hospital could be
run. It's a very different approach to mission here; more focused on
outside help and working in spite of the government system as opposed to
our approach at Mukinge, to try to work within the system and build it
up. Both viewpoints have their advantages and disadvantages, I think.
But anyway, it will be a stretch as we try to push our way through some
cases and help take care of a few people.

What to say

Haven't had a lot of fodder for the blog recently. New Year has come
and gone, fairly uneventfully, with board games and a few visits into
the hospital after hours. Progress begins on the tennis court, hampered
by the rain, funerals, and would-be thieves trying to take my precious
cement. Today I have staked dogs near the cement to ward them off.
Zambians for the most part retain a large fear of domestic animals, dogs
and cats both, and the Griffiths' dogs are particularly vocal, making
them ideal guard dogs against most nighttime predations.

We had an unusual delivery tonight as the supply truck for medical
stores arrived, unannounced, at 9pm. I get a phone call from the
hospital asking me what they should do so I get out of my house to see
what the deal is. Obviously no one's available at 9 pm to unload
medical supplies or drugs, and I emerge from my front door to see a huge
18 wheeler truck parked outside the hospital, covered with a tarp and
obviously stacked with a fair number of boxes. I'm a little worried
what we're going to do with all that equipment that no one was expected
at such a late hour, but fortunately I don't have to worry long. I
stroll up to the truck to find two very tired drivers who had traveled
over 16 hours that day. Stacked next to them were two small boxes each
about the size of a large shoebox containing some ready-to-use formula
for our malnourished children. The conversation went something like this:

"Hey there, I'm Dr. Matt, can I help you?"
"Dr...?" I repeat my name, but it's clear that they aren't going to get
'Matt' correctly, so I let the matter drop quickly.
They press on: "We've come to deliver these to you."
Me, looking around, seeing the two boxes. "You mean these?"
"Yes."
I'm slightly puzzled at this point, given the size of the truck and the
size of the package, which would have taken up maybe 1/5 of a regular
car trunk, sitting next to this 18 wheeler truck that they've driven all
day. "You mean these? You drove this huge truck all this way to
deliver two boxes?" I ask again.
"Well, we have other places we need to visit, too."
"Umm, thanks very much, then." We look at each other. "Well, have a
safe trip." At which point they climb back into their truck and head
back up the road, and I grab the two boxes and carry them to the
malnutrition ward. I am glad at this moment that I am not a driver for
MSL. I can't help but imagine some UPS supervisor viewing this whole
process and simply shaking his head.