Buying groceries

Buying groceries is an all-day affair here. I caught a ride on the bus
to Solwezi, which leaves at 4:30 in the morning. Sort of. Actually, it
leaves in front of the hospital at 4:30 (this is what wakes me up most
mornings with its beeping as it backs up outside my door) but then
drives around in hopeful circles, trying to entice people out of their
homes for an early morning jaunt on the bus for 4 hours. I can't
imagine that this strategy of passenger recruitment is very successful,
but it seems to be the SOP around here, with the effect that the bus
leaves at 4:40 from the hospital but 6:00 from the town 3 minutes away.
I was the last guy on board, so I was stuck on the broken seat that
leaned to the side and was balanced on a plastic jug, a problem which I
felt in my lower back for several days afterwards.
Solwezi is a whirlwind tour, as you have to get your shopping done
between arrival at 9:30 and 1pm or you miss the only bus back. I was
again the last person on the bus, which was 'oversold' this time, but
without the nifty gift certificates and travel vouchers that you get at
home for oversold flights -- just a hauling up of your luggage onto the
roof and an offer to stand for the 3 hour trip back. Since most of the
people around Kasempa know me by now, I got a seat as they made the 12
year old kid stand; selfish of me, but I accepted the seat.
I don't have to go to Solwezi to eat; just to buy fancy things like
olive oil or chocolate or cheese. You think long and hard about how
much you want that cheese, though, when it takes that kind of effort to
procure. And of course my yoghurt containers exploded over the rest of
my groceries on the way home, giving my backpack a 'mango-pineapple'
sort of smell. Not bad, but hard to get rid of.

cultural disconnect

I've been struggling with differences in viewpoints as I begin working
on the malnutrition ward. In general, the malnutrition ward is where
many, if not most, of our patients die, but it is also the ward where
you feel the most helpless. Up to 80% of our in-hospital deaths have
malnutrition as one of their diagnoses, if not the primary diagnosis.
You see and treat children who badly need food and hydration, and yet
you have to struggle and struggle to convince the parents to do anything
to save them -- place an IV, feed them properly, put a feeding tube into
their stomachs. I honestly can't understand their viewpoint at all, but
it is frustrating when their children die. I don't know if it is
apathy, or a feeling that we are treating them too aggressively, or
something else, but when the children die, it's very difficult for me.
Similarly, I accidentally ended up making a cultural faux-paux today
while I was covering for another doctor who's had to go get his visa
sorted out. We have a patient who's been struggling with upper GI
bleeding and we did a laparatomy on, which revealed inoperable cancer.
This was 8 days ago. The surgeons went to talk with the patient and the
family, and I assumed everyone was aware of what was going on. Today he
began to have worsening vomiting with blood, and I had a discussion with
him about where we should go from here, because we didn't have medicine
or surgery that would help or cure him. Turns out, the family had
refused to tell him what was going on, but was waiting for the 'right
time'. I'm all for preparing someone for bad news, but waiting 8 days
while someone is dying seems a little cruel and goes against all that
we're taught and learn to value in medical school about patient choice
and informed consent. There's a paternalism embedded in the culture
which is hard to understand at times, and although I regret
circumventing the family's wishes, I don't regret letting the man know
what is going on. But it's a situation where you don't even realize how
different your viewpoints are until they come head-to-head like that.

one for the team

Friday was exciting, which is never really a good thing if you're a
doctor. I had been covering maternity while one of our docs was on
vacation and had gotten a phone call from the charge nurse that a
patient had arrived who was pregnant, had a goiter and had been coughing
for a couple of days. I was busy on another ward and promised to get to
see the patient, but it didn't sound very urgent to me and I went home
to grab a bite to eat. While I was at home eating my left-over soya
pieces I got a second phone call asking me to come in and see a patient
who might be having a miscarriage.
I grabbed my black bag (yes, I really have a black bag, although it's
now seen better days, with the stuffing from my shoulder strap hanging
out and the zipper broken) and head for maternity, when no sooner do I
get into see the second patient when the first patient starts coughing
up blood. A lot. She has a massive goiter the size of a medium to
large orange on her neck, and she's managed to fill an entire kidney
basin with her lung blood, and is now working on her second kidney basin
in about 5 minutes. The blood was bright red and shiny, frothing with
bubbles and gleaming in an eerily beautiful way against the silver of
the basin.
I call the nurse, who works on putting in an IV, and go to our OR, where
there's an ultrasound machine. Our visiting surgeon is there with the
bowels of the electrocautery machine spilled out on the back table while
he's trying to fix it. I mention that there's a case that's a surgeon's
dream, between the pregnancy, goiter, and now coughing up blood, and he
comes along.
In the time that we take to bring the ultrasound machine she's filled a
third kidney basin. I put the ultrasound on and get a quick estimate
that the baby is term, the heartbeat is okay, and I put in a second IV
while the surgeon notifies the theater team and we decide to head to
X-Ray to see if we can figure out why she's coughing up so much blood.
We trundle her into the wheelchair and set off, kidney basin in hand,
trailing blood, people moving anxiously out of the way on the walkway
when they see us coming. This is a shuffle I am familiar with from my
ER experience: we leave behind a trail of detritus and blood from head
lacerations, disconnected IV's, and chest tubes when our patients make
their way to radiology. Here we set off right at the beginning of
visiting hours, so there's a sea of women wrapped in brightly colored
cloth chatting and walking past as we head to the X-ray machine.
Warren, our surgeon, and I struggle to hold her up against the X-ray
tube as he tries to figure out how to develop the X-ray once it is
taken. She has collapsed at this point and is doing nothing to support
her own weight; I now have an X-ray with her lungs and Warren and my
fingers on the sides as we hold her up during the film. We decide to
head back to the OR to decide what to do at that point.
On arrival to the OR she's managed to fill this last basin and her
oxygen level is 40%. Warren and David, our resident surgeon, do a crash
C-section under ketamine while I help the RN intubate her and suck out
her lungs. Her oxygen level has improved to 60%. The surgeons get the
baby out in under a minute after the ketamine, and our pediatric nurse
begins to resuscitate the baby, while the fourth doc, John, helps to
plug in the warmer and check with lab to make sure we can get a blood
transfusion for her. The lab (we can now only transfuse 8 more people
until more blood bags become available in the country of Zambia -- right
now we can't purchase or appropriate any) gets us two units, which we
give quickly, and watch her oxygen levels climb to 70%. Curiously,
there's no blood coming from the endotracheal tube but there is
occasional blood coming from her mouth. The surgeons finish their
C-section, we send the child off to maternity, and now sit back and take
stock. Her bleeding is decreased but her lungs sound awful, especially
the right lung, and her oxygen levels still suck. We take a look with
the gastroscope at her esophagus (we actually don't have a gastroscope
but we have a sigmoidoscope that we use for the same thing) and don't
find any bleeding. I look in her nose, but nothing. We try to extubate
her and her oxygen levels drop to 50%, so we re-intubate.
Many times in Africa you feel like you're making decisions on your own,
with little information, and the stressful part is having to make these
decisions on your own. Making decisions is what I do in the ER -- ER
docs make about 10-20x more decisions/day than other doctors -- but at
home I have a lot more information to help guide me, and it takes some
of the stress out of the process. Here, there's no threat of litigation
but there's the pressure to not get it wrong for some very sick
patients, and the knowledge that there's no-one looking over your
shoulder to catch things you might have missed. It was a good
experience, however, to get together and make decisions as a team,
scratch our collective heads. It makes the process easier and helps you
live with what you decide.
Surprisingly, we were able to extubate her and watch her on the wards
with a oxygen level of 70% after she woke up from the anesthesia. Today
she's up to 90% on oxygen and the baby's doing okay. Unfortunately, we
didn't know before the surgery that she has had 13 children and wanted
her tubes tied. This one nearly killed her, but if she makes it we'll
have to tie her tubes later. Hopefully that will go more smoothly.

guava guano

Mango season has come and gone, but we are currently in the thick of
banana, citrus, and guava season. The proliferation of local fruit
attracts a variety of scavengers to my front lawn. These range from the
polite -- the two girls who knocked on my door and asked if they could
pick my guavas -- to the not so polite -- the young boy I had never met
before who ripped off three branches to get at fruit he couldn't reach
from the ground -- to the unusual. I think due to my extra fruit I have
attracted some sort of nocturnal animal visitors to my tree. For the
last several nights there have been curious rustling sounds from my tree
and tonight, as I was coming home from a delivery (after celebrating one
of the missionaries' birthdays!) I got dive bombed by a large bird that
I got a brief glimpse of as it flew in and out of the dim yellow glow of
my front porch light. It could have been anything from an owl to a
REALLY big bat to even a flying squirrel, although I suppose those don't
really fly, do they. Anyway, in the morning my grass was littered with
the leavings of some avian visitor, and I am glad that someone besides
the rude boy is enjoying my guavas as well.

How far do you go?

One of the things I've been learning is which limitations I should try
to tackle and change, and what I should just allow to be. This past
week gave a good example. We had a sick man sent to us from one of our
referral hospitals who had clearly not done well with the trip. He
arrived on our doorstep acutely short of breath, with an oxygen
saturation of 52% (normal is above 90%). We placed him on a bed on male
ward and hooked up our oxygen concentrator to him. Unfortunately, we
only have one working oxygen concentrator for each ward (the one for
male ward has since made an awful noise, emitted sparks, and started
smoking, but that's another story) and there was a man who was already
using it, so we had to hook up a Y connector and split our maximum of 5L
of oxygen between the two of them. The power to the hospital then went
out, and we started the generator. We were told that the power company
didn't know where the fault was, however, so they were projecting that
it could take several days to fix (remember when I arrived in December
the power to everywhere went out for three days). We, in the meantime,
only had fuel to run the larger generator for around 16 hours (80L of
fuel). The local filling station has shut down, since it doesn't get
regular shipments of gas from the city, so all we can buy is black
market petrol, when it is available, which it wasn't at the time. We
could, however, run the smaller generator much more efficiently which
powers a few electrical outlets on pediatrics, maternity, the OR, and
the lab. So I made the decision that we should move this man to
maternity, fire up the smaller generator, and put him on the oxygen
machine from labor and delivery. This process consumed most of my lunch
hour, and his oxygen levels got very low while moving him. However, we
did get him on to maternity, at which point his IV pulled out during the
transfer to the other bed. After we got a new IV placed, the power came
back on. We wanted to give him a rest on maternity, but he started to
deteriorate and the nurses were uncomfortable having him pass away in
the middle of a bunch of pregnant women, so we moved him back to the
male ward, where he died in about 30 minutes.
You can go through these sort of lengths for almost every patient,
trying to maximize your limited resources and using your staff's energy
on what are likely hopeless cases (O2 saturations of 50% need to be
intubated and on a ventilator, which we don't have available here). Or
you can give them up for lost, but have to live with the thought that
maybe you could have done a bit more for that patient. There's no easy
answers, and you do what you think you have to in order to look at
yourself in the mirror the next morning.

the pain of medical education

Part of what I agreed to do when I agreed to work as the manager of
clinical services at the hospital was continuing medical education.
Now, considering that I'm the youngest doctor on the staff, and just
about the youngest medical person at the hospital, it feels a bit
presumptuous. One of the challenges of working together with other
doctors is what to do when your management is different from theirs;
trying to be sensitive to their management styles and yet not do any
harm to the patients. We basically all share a medical practice here at
the hospital, since we cover call for all of the wards when we take
call, but you don't get a chance to pick your colleagues like you would
in a private practice at home, and our training and experience levels
are highly variable, even when there's just a few of you. So you try
to hold your tongue when things are being done differently than the way
you'd do them, and you give your opinion when asked for it, and if
things seem like are being done very badly or they are dangerous for
patients, you try to speak up in a tactful way. And of course, teaching
people and calling their attention to medical errors that they've made
is also part of that job. It's a difficult job for a junior doctor to
do, though, especially in a small community where you work and live and
play together.
At home, the standard of care is much easier to determine, and it's
easier to show someone where they went wrong if they did something
wrong. Here, you have incomplete information, so it's usually just your
opinion that something was done wrong, but there are disturbing cases
that pop up along the way that make you worry that as a hospital we
aren't doing as good a job as we could to take care of people. I saw a
woman last night who presented with abdominal pain and said that she was
late on her period. The clinical officer had seen her that morning and
sent her home with treatment for giardia, but she came back with
worsening abdominal pain, localizing to the lower part of her belly.
The first on-call was notified, and she gave a set of verbal orders from
home and made arrangements to come see the patient in an hour or two. I
was rounding through the hospital before I left for the evening and
asked if there was anyone I should see. The nurse in the ward pointed
me to the woman, who was moaning on the bed. Her abdomen looked
distended, and I grabbed the ultrasound and found a tubal pregnancy with
about a liter of internal bleeding in her abdomen. We rushed her to the
OR, where her blood pressure was 70/40. I took out her ectopic
pregnancy and she did well, although she needed a blood transfusion.
Now, at home, it would be easy to go and yell at the clinical officer
who sent her home earlier that day, and the first on-call who didn't
come and see the patient when she was admitted. And, believe me, in
every training institution in America, that would happen, and they'd be
forced to stand up in front of a bunch of people and try to explain why
they screwed up. Here, however, it becomes a little harder, as the CO
didn't do a pregnancy test because we're running low on pregnancy tests,
so we're trying to save them, the blood pressure cuff is broken in the
outpatient department and we can't replace it yet, and he hasn't been
trained to do ultrasound. He's also just two months out of training.
And the first on-call had been on call for the past two nights because
we're short on RN's, and wanted to eat dinner before she came in to see
her, and knew that she'd already been seen once today. So when I go and
talk to them, it's hard to know exactly what to say, and how to say it.
Most of my attendings would have gotten angry, which I can understand,
because it's a simple solution to a complex problem, but I'm not sure
it's the right one. On the other hand, that fear of getting yelled at
has caused many lessons to stick in my head that otherwise probably
wouldn't have. As the most junior member of staff (in some ways; I'm
also curiously the most senior member of the doctor staff, by about a
month) it also feels inappropriate to be throwing my weight around like
that. So I approach these things prayerfully and carefully, and try to
choose my words well.

a man for all seasons

No, no Sir Thomas More allusions today. I have changed my job
description once again this week, to resident pediatrician. Currently I
have now covered the male ward, maternity, and now pediatrics and the
malnutrition ward. The pediatric ward is a challenging one, although it
is nice to talk with the (relatively) healthy mothers in between the
screaming children. And occasionally I can coax a smile from one of the
little ones. One kid that struck me is Josua, a 3 month old child whose
mother died about 10 days ago while in the hospital. We haven't seen
any relatives who have even come back to the hospital to take care of
him since, so we care for him as a hospital, and hope that someone will
come to take him in. He's a cute little guy, wish I could show you the
pictures.
Gary, who I mentioned in a previous blog with the facial tumor, went
home last week after we had exhausted all our options to treat him.
Lisa and Michelle, the pediatrican and chief pediatrics nurse, had to
explain to him that he would die from his tumor, something which must be
really scary to hear as a 10 year old. You wish there was more to be
done, but for those tumors that are chemotherapy resistant, we don't
have much to offer. So he went home with his family to be someplace
more familiar. We gave him a yo-yo to go home with, although he's not
very good at it.

cat saga, part II

So it turned out the cat hadn't escaped after all, just was hiding out
in the shed behind some boxes. (BTW, to clarify, it's for my host
family in thevillage to help with their pest problem, in case I hadn't
made that clear.) So I embarked on my best program to domesticate it,
hampered by the absence of a litter box or sand/litter to fill it with.
I was doing okay until day two, when the excitement got to be too much
and there was a urinary flood on my pillow, soaking down all the way to
the mattress. Needless to say, I quickly washed the whole mess and hung
it out to dry. The near continuous rain this week hampered that plan,
however, and it wasn't until three days later that I had a pillow to
sleep on again. Of course, despite my best efforts, the kitten escaped
the next day, an event I viewed with mixed emotions after my pillow
disaster, and I have seen it hanging around the malnutrition ward since,
seeking sanctuary from my evil boxes and plaited hair strings. I think
he's safe, at least until the rains let up a bit and I can make it back
out to Lubofu.

cat saga, volume 1

Okay, ether was unsuccessful, mostly due to difficulties cornering the
cat in an area where the ether could work. So I decided to take a page
out of my boyscout handbook, and set up a trap. The market sells a
variety of dried fish, ranging from minnows to more substantial perch;
the smaller sized ones are called kapenta, and for about 3 bucks you can
get a grocery sack full of it. The kittens have been hanging around
outside the nursing college, next to the malnutrition ward of the
hospital, so I went with my sack of kapenta to win the cat's trust.
It's a little cat with big ears, mostly orange and black, and it seemed
pretty friendly.
I hadn't counted on the kids from the malnutrition ward coming wanting
to eat the kapenta, so I had to give some away, and try to reconcile
with scattering food on the ground outside the malnutrition ward. We do
provide food for all of our patients, with special supplements for the
nutrition ward, so I didn't feel too bad.
After about 30 minutes squatting even closer to the kittens as they ate
the fish, I then went in search of a box on the wards, which I propped
up with a stick. Unfortunately, I couldn't find any string, which is
tough to come by at times. Fortunately, the girls at the nursing school
had recently re-done their hair and there were synthetic hair extensions
in the trash, so I made a string out of hair, sat back and waited, and
-- voila! -- I caught the kitten!
After a careful transfer with various pieces of cardboard, I brought the
kitten back home, where I put it in my shed in the back, which is a
pretty reasonably secure area. I didn't carefully inspect the roof
line, however, and it got out through the crack between the wall and the
ceiling. So tomorrow I will return to the nursing college, armed with
fish and box and stick and hair. We'll see if I can be more successful
tomorrow.

baths on the beach

Mukinge was built in between two hills to take advantage of the natural
springs here and ensure enough water in the dry season. We get a little
inundated during the rainy season, though, and the water pumps and
filters have trouble keeping up a little bit. When that happens, we get
some 'friends' in the bathwater, so that after I finish my bath, the
water looks like I came home from the beach and brought a load of black
sand with me. At least that's what I tell myself, because I hope that
I'm not carrying around that much dirt on myself before I get in the
bath. I have developed a pattern of filling it with extra hot water
(the hot water heater tends to collect the dirt) and letting the dirt
settle out and cool off a bit. You can't totally avoid the dirt, though
-- when we scrub for surgery and rinse off the soap, there's usually
some pieces of dirt stuck on our arms from the rinsewater. People seem
to do okay, though.

communication issues

Well, the aftermath of the buying trip to Ndola was less successful than
I hoped. I purchased the wrong type of tape, and several parts of the
order were missing, despite the multiple checks at every level. We have
a lot of packing tape, but no masking tape, unfortunately. These sort
of things seem unavoidable, but are still frustrating. Never having
thought of myself as having a real strong accent, I've had a lot of
people frustrated with me this week as they haven't understood what I'm
trying to say, the colloquialisms/slang/accent getting in the way, I
guess. Of course, I take solace from other people's similar struggles
-- the Indian shopkeeper from whom we ordered a lot of bleach -- 'JIK'
-- who didn't have enough and sent his shop boy to the store down the
road to buy more to fill the order. The shop boy returns with a pile of
soap -- 'CHIK'. (try saying the two with your best Indian accent, and
you'll see what I mean).

the local walmart

There is no such thing around here, however, we do have some interesting
combinations of stores -- my favorite is the shop that provides arc
welding, haircuts, and car washes. I mean, what else do you really
need? The BOMA is bustling these days with several new stores,
restaurants, and all the local produce. I've been buying tomatoes by
the bucketful, especially since now I don't have to carry them all the
way home on my back or in a flimsy plastic sack. Now I pile them all in
my plastic carton on the back of my scooter and rush back home -- what
used to take 2 hours for shopping now takes me 30 minutes.
We tried eating out for the first time the other week -- Ghanian feast,
to be exact. Not bad, although a bit pricey for what I expected.
Certainly no Chinese Peking Duck feast or anything like that. I think I
saw a new restaurant open up last week, though, so maybe I'll check that
out.

names

A few of my favorites:
Blabby
Fatness
Skinny

Can't wait for the first kid to be named after me, although I think I
may be waiting awhile. Fortunately, I have a leg up because one of our
nurses' last name is Matthews, which I am going to shamelessly count as
my own name if someone is named Matthews. In fact, Matthews seems to be
a much more common name here: I'm not sure if that's because Jan's been
around for so long or if it's a trick of Kikaonde pronunciation. But
it's the book of Matthews in the Bible, and most people are named
Matthews, not Matthew. Most people think that my name is Matthews as
well when I introduce myself, so I think I'm perfectly justified in
claiming any newborn Matthews while I'm working on maternity.

business in Zambia

Well, my trip to Ndola was eye-opening, to say the least. (it looks
like my pictures didn't make it through, either -- bummer) Here's a
example of me trying to buy some cloth to make some OR drapes:

Go into store, where there are about 9-10 men standing behind various
counters. No one makes eye contact.
Go up to man, ask where the heavy-weight calico is, get vague gesture
towards cloth bolts across the room
Go over to other side of room, begin looking at cloth, none of which is
labelled
Ask second man where the heavy-weight calico is, get vague gesture that
intersects the line of the other man's gesture about halfway
Look around in general area, find some canvas and silk.
Ask third man to take me and show me the calico
He takes me over to a bolt of cloth standing literally 1 foot away from
where the 1st man was
I ask how much the cloth costs
I am told 14,000/meter. I frown. I am told 13,000/meter. I frown. I
am told 12,000/meter.
I say I would like to buy some cloth, and ask how much is on the bolt.
He says around 30 meters.
I say okay, I would like to buy the bolt. He takes the bolt over to the
table, and begins stripping it off the bolt, measuring it in a vague way
by arm widths.
I am told there is 40 meters. I say I would still like to buy it. We
then proceed to roll up the bolt and now measure it again using a ruler.
I am told there are 49 meters. I say I would still like to buy it.
They begin folding up the cloth.
I say I would like the cloth to be put back on the roll. They recruit
three other men to help them roll it up, foot by foot. I am told the
price will be 14,000/meter.
I frown. I say they agreed on 12,000/meter. The boss comes over and
agrees to give it for 12,000/meter.

Pretty much everything I buy works the same way. Tiring, to say the least.

photos a-comin'

Think I may have figured out how to email photos to the blog. Let me know if there's some pics....

On the way to Ndola

Got out and took a road-trip today to Ndola, a town in the copperbelt
region of Zambia. It was my first time on the road out of Kasempa, the
town where Mukinge is located, and it's always good to see the
countryside from the window of a car instead of flying over it. I am
going on the trip to buy supplies for the hospital. We don't have any
sort of supply mechanism to ensure regular deliveries of our medical
supplies or maintenance needs, so someone from the hospital (usually our
pharmacist, Tamar) goes on these buying trips to purchase what we need
about once a month. We were due to gather supplies from about 5
different pharmacists along the way; they have names like "Chemopharm",
"Pharmaking", "Briking", "Biochem", and "Netpharm", and are all run by
expat Indian shopkeepers. The first place we stopped wasn't expecting us
until the next day and hadn't prepared anything; the second one we
couldn't find, when we called for directions he would not give them but
rather wanted to come meet us where we were, and after an hour wait he
arrived and told us that he wasn't ready and we needed to return later.
I was a little irritated that we had now been travelling 6 hours and had
nothing to show for our efforts so far. The places in Ndola, however,
have been more prepared.
We can only fill the back of one Land Rover, so that limits what we can
buy. I am responsible for about 8 million kwacha of the hospital's
money in addition to various checks for at least that much. Needless to
say, carrying around a stack of cash around 4 inches thick makes me a
little nervous, especially since our hospital executive director had his
car stolen and money robbed waiting at the gate of the guesthouse where
we are staying just last fall. I feel a bit like George on Seinfeld
when I try to stuff all that cash in my wallet and sit down -- not too
comfortable.
But it's good to have a few more of the comforts of life; we ate at an
Indian restaurant called Country Fried Chicken tonight when I had good
Chicken Tandoori; I haven't eaten out at a restaurant since I made it to
Mukinge. Tomorrow I will try to use the high speed internet and perhaps
clear away the updates for my antivirus program and windows which
continually remind me that I haven't updated now for three months. We
have a TV in our room at the guesthouse, and I watched the news for the
first time for awhile. Zambian TV news is luridly shocking; they will
regularly show pictures of half-charred corpses and
death/destruction/mayhem. The lead story tonight was about a woman who
was murdered and had her 'private parts' cut away. I can't say I miss
not seeing that on a daily basis. On the more positive side, I enjoyed
my first shower in Zambia today; think I must have used my entire
allotment of hot water for the week at once. Can't wait to do it again
tomorrow.

book burning

Had my atavistic fill today when I went through and got rid of the
out-of-date textbooks in our medical library. The library is kept on
several white wooden shelves in the doctor's office; it's a mixture of
books from various eras (leprosy surgery from 1930, HIV brochures from
last month), spiderwebs, and old mud burrows from the wasps and
termites. So I went through and swept away the old dirt and culled out
some of the outdated and redundant books that we had around. I'm told
that the last time they were sorted through they used them as ballast at
the end of a lightning rod grounding -- today I had more fun as we took
them out to the dump pit and burned them. It's surprisingly difficult
to burn books, especially without kerosene to douse them with. I think
given how many times I've heard about book-burnings that it would be easier.
The procession out to the dump was entertaining: although it's just a
few hundred yards, we arrived with only about half of the books that we
set out with after being stopped by various people along the way. The
local policemen really wanted both the copies of the PDR (a
pharmaceutical compendium put out every year -- quite massive) from both
1998 and 2000, so if they want to prescribe some viagra, I think they
will be covered. Also escaping the Fahrenheit 451 were two copies of
the Christian Doctor Quarterly from 1992, which one of the guys from the
workshop (his name is Diamond) wanted to have for reading. One of the
local villagers wanted to leaf through Manson's tropical diseases. When
I was in the village I was struck by how people would take anything to
read if it was available. But apparently I underestimated the
entertainment value of new techniques for gallbladder surgery. I will
make sure to check around a bit more before burning any more books.

you're too good to me

Just wanted to put out a public thank you to all of those who have sent
me stuff already, I feel so loved and supported with oodles and oodles
of spices, shoes, books, etc. You are all too good to me.

The river is here

Our daily runs (actually I've become quite lazy over the past two weeks,
not getting out nearly as often since my running shoes were drenched by
the cleaning woman) were abruptly curtailed this week as the bridge was
flooded away. This apparently is a yearly, if not more frequent,
occurrence as I was informed by the man I met crossing the river in a
canoe that he had made from half of a tree's bark, peeled away like a
tamale wrapper and good for about three crossings over the water, I
would estimate (maybe he could stretch it to 4 and get back to the side
he started from). The bridge is usually kind of a miracle of sticks
and logs and tree branches held together with bark rope; it's always an
adventure when we are running in the morning whether it will hold at
all. We occasionally get crocs and hippos when the river is really
high, like it is now, but so far, we haven't seen hide nor hair of them.
The rains, after rotting my garlic, are beginning to show signs of a
little bit of a break; I'm told I will miss them when April rolls around
and I'm shivering in the cold weather (no fireplace at my abode, unlike
most of the places out here). For right now, though, I could do with a
change of pace with the weather.

I fought the law and the law won

Was out joyriding on the motorbike I am planning to buy today when I got
pulled over by the cops for not wearing my helmet. Actually, I wasn't
really sure they were the cops, since they weren't wearing any uniforms,
and I nearly just drove on by, which I'm guessing would have made things
much worse. But they pulled me over and began to harrass me.
Eventually they 'impounded' the bike, which consisted of me hauling it
up into the flatbed of their pickup truck and driving to the police
station, where I commenced to have an interview with the local traffic
officer. I must be becoming more African because I was able to talk him
into dismissing one of the charges, rescue the bike from the impound,
and even drive it back home without my helmet. I am now a proud owner
of a ticket for 'cycling on a motor cycle without a crushed helmet'....

not for the faint of stomach

I know that some of you don't like hearing about the gross medical
stuff, so those of weaker stomachs should probably skip onto the next
entry. The hospital has undergone some big changes recently, with the
arrival of a generalist from New Zealand who feels comfortable in the
theater and a second surgeon from the states who is here for a little
while to help us all get training better in our surgical experience. So
all of us have been trying to spend some time in the theater to improve
our skills, and my big case this week was an interesting woman who I had
seen earlier in my time here with a baby and a large extra-uterine mass,
which was easily the size of the uterus, if not larger. At the time
that I saw her before, she was too early to do much about the mass, but
now with surgical backup we elected to do a C-section and then remove
the mass. Her stomach was so huge that she could only get up by rolling
to the edge of the bed, swinging her legs over the edge, and then
pulling herself up to a sitting position from the side.
Fortunately, the baby did well, and I managed to scoop out a huge tumor
from her left ovary that was the size of two basketballs and filled with
greenish-brown fluid, as I discovered to my dismay when one of the cysts
popped and spilled all over my shoes. Amazingly, there doesn't seem to
be any spread of this thing to anywhere else, and her post-op course has
been fairly smooth, so maybe we were able to help her. And the baby was
named after the RN who did the anesthesia, too!

What you need

I hear over and over in your emails to me about how hearing about needs
in Africa puts a perspective on our own troubles and tribulations. I am
glad that we each take the time to examine ourselves and think about how
we are provided for, but I think it is a difficult and dangerous thing
to compare 'needs' or to try to rank them, one against another. As was
pointed out by a friend of mine, our ability to live out the
opportunities we have been given to the fullest is the measure of
happiness and fulfillment for many of us, and need is felt more in the
lack of what we know we could be than the lack of what we know we
can't. "To him to whom was was given, much will be expected."
I think Caedmon's Call put it well on their album "Share the Well":
I did not catch her name I did not catch her tears
It hit me like a train when her story hit my ears
Mother of 8 sons father off to war
Got no home address just bricks on a dirt floor
She said "Jesus is all I need"
Tiny plot of land corn stored up in piles
The years it doesn't rain just stay hungry for awhile
No fatted calf to kill she made a feast of qui and corn
Said who else knew my name before the day that I was born
She said "Jesus is all I need, Jesus is all I need"
She bragged about her boys how they're growing into men
How they learned to praise the Lord -- old-style, Ecuadorian
To buy the new guitar they had to sell the swine
Said my boys go to school on a foreign angel's dime
This world calls me poor I bore my babies on this floor
He always provides sure as the sun will rise
So I sing him songs of praise because I know he keeps me in his gaze
Rain fell from the sky, we raced back to the van
Tears in the eyes of this poor, forgetful man
Mother of 8 sons, she knows the peace of God
Lord, help me learn to lean on thy staff and thy rod
Jesus is all I need, Jesus is all I need.

a quick plug

Can't say enough for Mark Bittman's How to Cook Everything, which has
been my constant companion in the kitchen and has plenty of chatty
things to say about nearly everything related to cooking. If you like
to cook, or think you might like to cook, or hate cooking but have to do
it anyway, it's awesome. I have followed his advice on everything from
eggplant curry to quiche to frosting and every time it comes out great.
Okay, that's the last you'll hear from me about that.

The toll of working at Mukinge

As my last post intimated, it's pretty easy for me to get in over my
head here in Africa. Currently I'm juggling a lot of hospital
responsibilities, educational responsibilities, and various projects,
etc which keep me up at night. I was struck by how many of the
long-term missionaries here suffer from chronic, stress related
illnesses -- 3 people with chronic migraines, another 3 with insomnia,
several others with depression -- and I can't help but feel that that is
a direct result of working and living in a setting where resources are
scarce, information is sketchy, and communication with the outside world
is poor. Certainly as I push myself past what I've been trained to do
-- ultrasound for malignancy staging; surgical techniques for which my
training is limited at best, non-existent at worst; pediatric
chemotherapy; gastroscopic endoscopy -- I find myself rather than
becoming more confident, becoming more hesitant, because I never get to
do the things that I'm good at anymore -- ER resuscitation, diagnosis,
etc. Fortunately, my fingernails are still long and my aphthous ulcers
have remained quiescent, so I guess I'm currently being protected
against the ravages of stress myself.

laundry daze

Today was laundry day, which always carries a fair amount of risk with
it. Vegas has nothing on the science of predicting the chances of rain
at any given hour, and success or failure is often measured in seconds,
with cloudbursts appearing from the chronically grey sky with little or
no warning. Today I lost the gamble in a big way, with my laundry
ending up with not just one, but three extra rinses, which was in some
ways good, since it all got splattered with mud after the first
'rinse'. In general we've hit the middle of the rainy season with a
vengeance, with my front yard more often than not having an inch or more
of standing water in it.
Laundry also carries the general risks of bleach spots -- note, black
socks and bleach don't mix well -- various other stains not being
removed, and today we had a new twist, with my household worker deciding
that my shoes were too dirty and washing all of them. I now have very
clean but very wet shoes, which usually take about a week to dry (at
least they did last time) with no sun to dry them during the day. I
would have never thought to ask her not to wash my shoes. I'll add it
to the list.

trials in the OR

This week has been a bit of a stretch for me as I take over the hospital
administrator position from Curtis. Fortunately, we now have excellent
surgical backup which saved me from near disaster from a lady with a
c-section. A combination of factors made it into a bloody mess, but
thank God that he has brought two surgeons here currently that were able
to give me a hand.
I'm struck as I go about rounds about how much less sure of myself I am
here than in the states -- part of it is working so far out of your
comfort zone, part of it is the lack of information and working in the
dark, and part of it is being so newly out of residency and not working
in the specialty that you trained in. It was nice to get some
educational materials from home and listen to what was news in the ER
world in the states, at least in November. I'm sure that I will
continue to get more comfortable about trusting my judgment as time goes
on, but it is hard at times right now.

computer seances

We have been trying to modernize the outpatient records system here at
Mukinge this week with the help of a visiting Yale graduate (class of
96) who lives in Denver. Currently, our files consist of a series of
colored index cards with frayed edges stapled together in haphazard ways
and stuffed into dilapidated filing cabinets; some of them date back 50
years. So, in an effort to locate records more quickly, we decided to
make a computer database that was searchable by various identifying
characteristics to help us cull through some of the records that don't
get used anymore.
Yesterday was our first day of on the job training. Our start was
hampered by the fact that we don't actually have a power outlet in the
reception room of the outpatient department; after several visits to the
workshop, a failed work order, and an pilfered extension cord, we're
back in business. We have two clerks, neither of whom has ever worked
on a computer before this. We have about 10,000 cards that need to be
put into the system. Edson (like the car) sits down in front of the
computer and begins his typing ritual -- he gradually sways from side to
side, staring at the keyboard, not looking at the screen, humming to
himself, until with a grunt of delight he finds the letter he's looking
for, which he pounces on like a mouse and begins the same ritual again.
He'll do all this without looking at the screen, until the whole name is
entered in; then he'll inspect his work. He bites his knuckle and has a
childlike expression of horror and surprise that the computer would have
screwed up his best intentions if there's a mistake, then proceeds to
erase the whole thing and begin again.
Needless to say, it may be a while before we get all 10,000 put in the
database.

african pets

As a dog-lover, I find the state of most dogs in Africa to be a sad one, as the flies constantly harrass them to the state of drawing blood. Most dogs have scars on both of their ears where the fur has been eaten away and the flies bite to the point of bringing blood on a daily basis. In the village, of course, the dogs were working animals, and watching them herd goats was one of the highlights of my day, as the somewhat obnoxious beasts ended up bleating and running around into the pen where they headed to.
Currently, I'm trying to capture a kitten for the Yanjishas to help with their rat problem, and I have also become the somewhat unwilling caretaker of a local cat who doesn't seem to have
many people to feed it. It is occasionally nice to have my legs rubbed against, however, while I'm doing the dishes, especially since physical contact is pretty limited in Zambian culture to handshakes. And I feel safer about avoiding the mice....

transitions, transitions, transitions

Africa is a continent of transitions. The population seems to be
constantly on the move, especially if you are well educated, and the
expats often are flitting about from one site to another as they visit
various projects and evaluate potential areas of need. In Lords of
Poverty, this kind of money spent on "fact-finding" was roundly
condemned as a waste of money that would be better spent on in-the-field
needs, not on westerners flying around to see them. I don't know about
that, but the fact remains that we have had 24 people coming in and out
of Mukinge over the past two weeks. At the hospital, 2/3 of our
administrative staff has left for 6 months to 2 years to pursue higher
education; similar things have happened to our nursing staff. Adult
education plays an important role in career development, and virtually
everyone you meet has future plans to better their education in some way.
In similar veins, AIDS and HIV has a similar impact on the professional
staff. The hospital has lost two personnel that had been there for many
years this past two months, and it has taken a toll on the morale at the
hospital. I have been trying to get one of the staff to get himself
tested for HIV for some symptoms he has been having, and after a month
of cajoling and talking him out of statements like 'I think I might
commit suicide if I test positive' I think we have gotten somewhere, but
those two deaths have made my job that much harder. The statistics
published in the Lancet say that we lose more professionals to HIV than
we do to the 'brain drain' that I referenced back in October.
Clearly we as temporary missionaries contribute to the problem, as I
find that I have to reinvent the wheel for duties and information that
was probably known by previous executive directors and doctors but never
got written down, passed along, and the contacts have all changed due to
the transient nature of things here. And I will probably leave behind a
similar legacy, although you try to improve the system a little bit and
make it easier for people to come in and out. I do feel that Zambia
clearly isn't ready to stand on its own, not from intelligence,
training, or force of character, but simply because resources don't
exist in ample supply to get there. It may be quite some time before
that happens, as well. Until then, I think we have to stand in this gap
with our brothers.

rainbows before the rain

Okay, that title sounds a little too Disney for the reality of Africa,
but with all the rain that we have here, you get a lot of rainbows.
Here in the southern hemisphere, weather moves east to west, not west to
east, so that in the afternoon, when most of the rains come, you see the
rainbows before it rains, instead of afterwards, like in the states.
When God promised Noah that the rainbow would be a sign that he wouldn't
flood the earth again, I always appreciated it after the rain happened
at home, because it was like a wink and a nod from God, saying that same
thing again. But I'm struck that here, the rainbow is a promise, a
warning even before the rain hits, that this time won't be the big one,
and we don't have to worry. In a place where it sometimes seems that
the next cataclysm could be just around the corner, I appreciate the
reassurance. And it makes the coming rain seem not so bad (although I
still can't get my clothes dry).