illustration2

illustration2, originally uploaded by mattcotham.

illustration

illustration, originally uploaded by mattcotham.

Thought this might illustrate my previous blog on child safety. This is

Linus, who fell in the fire after a seizure and burned the right side of

her face. She's a beautiful girl.

grocery shopping

grocery shopping, originally uploaded by mattcotham.

This is the local grocery store; there's a bigger collection about 3

miles away, in case you're out of luck at this one. Fortunately, this

one stocks a good supply of the basics -- candy, flour, and toilet paper

-- so in an emergency you can get fixed up.

Look out Roger Federer

The inaugural tennis match of 2007 came off without a hitch as we found
the tennis net buried in the back of the musty housing container,
nestled between two wasps nests and a hopelessly tangled amount of
clothes hangers. We even found some cans of tennis balls that were
still pressurized from the 1990's; there must have been some serious
tennis players here in the past. After blatantly ignoring the
instructions taped to the cable, we managed to get it strung up and had
our first (sort of) game of tennis, where I lost 3-1. The tennis was a
true African experience, starting off with about 8 people on the court,
wildly swinging rackets and hitting the balls into the surrounding
brush. We still need to fix the fences at the ends of the court, but
fortunately several of the crowd of children stuck around to help
retrieve balls in between their time dribbling the basketball around me
while I tried to hit the ball back to John. Today I must have been
asked by 15 people if I played tennis; I guess news travels fast here at
Mukinge. Next up: wash off the court so you can see the lines well; I'm
currently looking for a hose long enough to stretch from the nearest
house. After that, I think we need to build one of those high chairs so
we can have a proper line judge -- you all know how competitive I am.

child safety

I must admit, I've made a little fun of the over proliferation of child
safety restraints and laws in the US -- I can still remember sliding
around the backseat of our old yellow Buick when I was a kid and the lap
belts were too big to hold me down. And yet I managed to escape serious
head injuries. However, I'm hit by the amount of negligence/accidental
injuries suffered by children here -- hot porridge burns down their
front, crush injuries from putting their fingers in the maize pounder,
broken arms from picking fruit from trees. Obviously children are
expected to grow up faster here -- marriage in the teens, working the
fields when 7-8 years old -- but there's also some room for the
regulations which keep kids safe. On the other hand, it's nice the
freedom that kids have to be kids here as well. I'm sure there's
probably a middle ground somewhere.

poor choices

poor choices, originally uploaded by mattcotham.

This was attempt number three at climbing to the top of the screen door

-- I let him find his own way down this time. He hasn't climbed up

again....

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.

incommunicado

It's been over 2 weeks since the phone line has been working to access
the internet. I hope that you all haven't lost patience with me.
Because we can't call anyone, we can't order medications for the
pharmacy, or check email, or fax personnel requests, etc. I find that I
get less frustrated with it than I used to, but it's still difficult
being close to being able to communicate and still to not be able to get
through. Especially now that I have my own phone line, which seemed to
coincide with the general shutdown...maybe one more phone overloaded the
whole system. Who knows.....

Josua

You'll be happy to know that Josua's oldest brother showed up on Friday
to claim him and take him home, although they don't have enough money to
buy formula, so they're not sure how they are going to feed him. Life
seems to be made up of little tragedies like that, rather than big
ones. I often think of life here as life at the extremes, where little
is necessary to push someone over the limit and strip them of what
little resources they have. Formula is out of reach for pretty much all
of the people that we see here, which is why we see so many kids up on
the malnutrition ward after there's a new kid at home and they have to
stop breastfeeding.

life on the edge

We've had a lot of deaths on pediatrics this week after a few quiet
weeks in the hospital. We've also been stretched a little thin with
various docs going away to get customs cleared, visas approved, go to
clinics in the rural villages, and caught up in the OR. So I often get
an abrupt "We need you in peds" or "we need you in maternity" and have
to shift from laughing with my colleagues to walk in on a situation
where someone is dying in the space of a few steps. The nurses would
like to let us know sooner but we don't have a centralized paging system
or radio so they often waste a lot of time looking for someone to help.
This Friday I got the summons to go to pediatrics when I stepped in the
doors after lunch. When I got there the pediatric charge nurse,
Michelle, was in the resuscitation room with a 3 year old child. He'd
gotten there around 30 minutes before, didn't look very good, and she'd
moved him in to try to do a lumbar puncture. He'd stopped breathing.
When I arrived he had thick white vomit on his face, and there were two
nursing students in the room trying to get the suction machine to work
without really knowing how. He was bradycardic, we gave some atropine,
and his heart stopped and so did we.
I asked the mom if she wanted us to pray with her, and she said okay. I
started to pray, but all I could really think to say was to ask
forgiveness, for my lack of pediatrics training, for the lack of medical
services for her child, for giving up so quickly instead of doing the
full PALS protocol because I didn't have the right drugs, or help, and
knew it was likely to be futile without ICU care, for the negligence of
the folks in America and elsewhere to keep allowing things like that to
happen. She didn't speak English, and I didn't say all that aloud, but
managed to mumble something and left the room to call the chaplains to
come and spend more time while I moved on to the next crisis in maternity.
I don't like giving up on patients. I don't like it even after I've
exhausted the resources of a modern US hospital. I like it less here,
when I feel that I often give up quickly, perhaps too quickly at times.
You tell yourself you're being practical, or pragmatic, but the honest
truth is that you're tired, and stretched thin, and worried about what's
coming in the next few minutes, and trying to save your drugs for the
patients you estimate that you think you can save. It's a curious poker
game where you're trying to call the disease's bluff, you sometimes
don't get it right, and it's hard to meet that mom's eye after you're
finished, even if her expectations were not that high for what you could
do. So she ties that body on her back and starts the journey back home,
and you move on to the other wards, to a lumbar puncture or an
amputation or an I&D, and watch American movies and try not to think
about it that much, and make promises to yourself that you'll figure it
out the next time. And God willing, maybe you will.

Updates from Mukinge

Hello everyone!  Thursday marks my four month anniversary here in Zambia, and although it doesn't seem like it, I guess I'm as settled in as I'm going to be.  People say that once you go overseas you shouldn't expect to hear from anyone other than your mother after a month: but I have been overwhelmed by the continued support, encouragement, emails, packages, and phone calls that I get from home.  People are still organizing dinners and fund-raisers and meetings to help me support and care for the needs of the people around me here.  I wanted to say thank you to all of you who have been so willing to help.

I don't really know how to sum up life over the past few months here; it's been challenging, and funny, and confusing, and hard, sometimes all within the space of one hour.  I've been stretched to carry the administrative burden of the manager of all the clinical services at the hospital, a job which has required me to become familiar with things like autoclaves, pharmacy orders, and generators.  I'm slowly learning as I go.  It's been a little frustrating at times, because it has taken away time from clinical duties and teaching, which is the part of being here that I enjoy the most.  But you also feel that you are able to make positive change on a bigger level, and it's been a pleasure to get to know the Zambians who are on the administration team.

We've also had a lot of transitions here, which is the norm for Africa, as we've had two doctors join the staff and three doctors leave over the past two months.  The current physician staff will be here for quite some time, though, so it's good to be settling in with the people that I'll be working with for the next year.  I've been working with the clinical officers to improve their clinical acumen and skills, and we currently have a Zambian medical student that will be here for three weeks, so it's an opportunity to re-invent medical school the way you'd hoped it would be.

I've managed to get out and visit my family out in the bush since I got back, and it's fun to see the corn that I helped weed now be higher than my head.  The rainy season is still here, but the weather is a bit cooler and we're transitioning to the cold season, although it won't be here for a few months yet.  My garden has suffered from water overload, something I thought I'd never have to worry about after living in Denver for 6 years.  I think I will have to try again next year or after the rainy season ends.

Thanks to all of you who've stayed in touch, and for those who have fallen through the cracks of my spotty emailing, I'm sorry.  I hope you're checking out my blog from time to time at mattcotham.blogspot.com.  The funding has all come through for our satellite email setup, so now it's just a matter of getting the equipment here and setting it up; hopefully by the end of next month I'll be able to send you pictures and such on the blog as well.

Keep in touch, and God bless. 

Matt

P.S. -- if you reply to this letter, please, please delete my text and pictures or you will keep me on the internet for 2 hours downloading your emails!!!

inspection time

We had our 6 month visit from the Zambian board of health inspectors,
which are here to see how well we measure up to the hospital standards
set for us by the government. It's a interesting time, a combination
between us being defensive about things that we haven't done, optimistic
about things we think we're doing but not really sure, and cajoling
about things that we think the government should help us with but
isn't. It's also a bit ironic because I'm trying to give answers for
how the hospital performed in the 3rd and 4th quarters, when I wasn't
even here, and have little idea about what went on for various
committees like the quality assurance, drugs and therapeutics, and
infection control. Fortunately, I am able to say that we are doing
these things now, so even if they weren't done before, we can say we are
compliant now.
It's funny, because the hospital inspections in the US by JCAHO are one
of the things that scares every hospital administrator, and people spend
lots of money and time getting ready for them. Here, even if we didn't
meet the standards (which we we told about at the meeting for the first
time), no one seemed particularly upset or worried. Many parts of
Zambian administration seem more interested in making sure all the
blanks are filled, rather than caring how well they are filled, which
leads to the appearance of a functioning bureaucracy but only adds the
paperwork without the substance. I find this all the time on the wards
-- people insist that I fill out some form for the police or whatever,
and I can write one word or three paragraphs about what is actually
going on and everyone will be happy, as long as I put my name and a
stamp on it. But no matter how good the substance is, without a stamp
it's no good. So the bureaucrats don't always ensure the things that a
good civil service should ensure -- like safety checks, accountability,
etc. This is a problem for some things; for example, we've complained
that our blood supply that we get from the district hospital is not
tested or labelled properly -- HIV positive blood, wrong blood type
labelled, etc -- but even though they've known about this for close to a
year, no action has been taken. On the other hand, it seems unlikely
that they'll shut us down for not having the statistics on how many
mothers are being offered counselling on breastfeeding during
admissions. But you never know.

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.