Christmas Time is Here

Merry Christmas!  Our version of poinsettas here -- the flame lily, or 'Doctor's Joy', as Gwen Amborski calls it (she should know, having lived here all her life).  Poinsettas actually bloom around Easter time, so we've got our lilies and Christmas flowers backwards.  These grow wild in the fields around the hospital, and my other Christmas colors are being supplied by the red and green of the gigantic watermelons growing in my garden, the green and gold of the mangoes, and the silver of the evening rain on the trees in the mornings.  (Thank goodness for our internet access, because otherwise no one seems to know when a watermelon is actually ripe.)  Other than that, I've got lots of recordings of Bing Crosby singing about a White Christmas and such to get me in the mood.

Last time I wrote to you all was back in October; we've now passed the one year anniversary of my Mukinge stay.  I got the news that I passed my ER boards, which was good, although a near thing, having momentarily forgotten about the presence of things like CT scanners during my test.  The tests here are still challenging as well, although of different natures, like what's the proper food to serve to a Chief, what is causing the raging fevers of a patient, how best to support the people who come knocking on my door asking for help, or what decision to make about my future that's coming up in now less than a year.

Christmas time for me is always a time to remember gifts that have been given to me; I cannot even believe how blessed and lucky I am to have so many of you thinking of me, giving me the gifts of packages, time, emails, and prayers.  Rarely a week goes by when I don't have some kind of package slip waiting for me in my mailbox here, and it's been a joy to share some of the things from home with the people here from Zambia and elsewhere.  My big load of kids toys is especially fun around Christmas time.  Many of you have supported the work out here financially as well, allowing us to buy a water pump to supply running water to over 30 houses here at Mukinge, several different purchases of much needed medications for the pharmacy, 4 oxygen concentrators, and to remodel an entire house to help retain needed nursing staff for the patients.  Coming up in the year to come we're hoping to remodel two more staff houses as well as the male ward of the hospital.  Potentially we may have found a donor to help us upgrade our operating room facilities as well.  And I think I may redo the tennis court as a Christmas gift to the mission complex as well.

A year has gone by quickly; I blogged a few months ago about lessons that I've learned in a year and I'm struck by how much I've learned and changed in just a short amount of time.  We continue to serve and help as best we can for the people here.  Thank you for your service to me and us over the year.

With much love,
Matt

hail to the chief

We've been having sermons the last few Sundays in chapel on
relationships in various parts in our lives -- with family, friends,
workplace, government -- and one of the things that keeps hitting home
is the importance of respect. I remember in college how my friends from
the East Coast would make comments about relationships in the south as
'fake' or superficial because they placed a emphasis on respect, even
when you don't necessarily like the person who you're dealing with. All
I can say is that the issues you might bring up with Southern culture
are magnified to the Nth degree here.
For example, two weeks ago on Wednesday one of the district chiefs from
north of here showed up to have eye surgery. Unfortunately, he hadn't
coordinated with anyone at the hospital, so the eye surgeon was gone on
a trip, the cell phone service was down, and he had not arranged for any
place to stay or any provision for food or shelter. So I go to meet him
in the reception area, crouch down to the ground, clap my hands, and ask
his entourage what I can do for him, to which I am told 'whatever you
think is appropriate'. I am thinking to myself that it would be fairly
inappropriate in America to show up unannounced and uninvited and expect
someone to take care of you for two weeks, but I remember our chapel
talks on respect and wisely keep these thoughts to myself. I ask them
if they would like to stay in the hospital or stay in the guesthouse in
town a few kilometers away, to which they say 'whatever you think is
appropriate'. I think to myself that probably making him walk the 5
kilometers to town will be seen as 'inappropriate, so I start working to
find a private room for him to stay in. We have two -- one on the labor
ward and one on the female ward. I decide that the female ward room
will be more 'appropriate' than screaming women on labor and delivery,
so we go there. I then ask if they need to eat, to which they say
'whatever you think is appropriate.' I now explain to them that a 33
year-old American male take on appropriate might be a little different
than a 60 year old , requesting a bit more clarification on
'appropriate' and find out that yes, he hasn't managed to pack lunch for
himself. It now being 3 o'clock, our evening meal won't be served for 2
hours, so I go home to find something to cook for the chief. My
refrigerator contains mustard, eggs, green peppers, and potatoes, so I
decide that eggs are probably the safest of those options and make some
scrambled eggs for the chief, with some peppers mixed in. I deliver the
eggs to the private room where he is settling in, thinking that I can
now possibly go see the other 200 patients in the hospital, when the
chief's staff comes out and says that he is not happy because there is
no table on which to eat his eggs. The nurse in charge of the ward and
I look at each other. I suggest the rolling trolley that the nurses
dispense medicine from, but that suggestion is rejected as not
respectful enough. Eventually we decide to move my doctor's office desk
into the room, where he then happily eats his eggs.
Two weeks later, after his eye surgery but not quite long enough for him
to arrange a ride back to where he came from, my desk still missing from
my office, we have needed to spray for cockroaches in the ward. We
arrange for the chief to move to another room so he won't asphyxiate
from the fumes, but again we are told that we are not being respectful.
Fortunately, in the two weeks since his arrival some of the senior
Zambian staff have returned from their meetings and the cell phones are
working again, so I can defer this discussion of respect to one of
them. I am sure that it was handled better than my initial attempts at
appeasement, and we did manage to avoid cultural crisis and still spray
for cockroaches.

cockroach trouble

We've embarked on a number of building projects/remodelling the past
year -- repainting the chapel, installing cooking pots and remodelling
the kitchen, renovation of the Mwilu house, building of an ARV center.
After the kitchen remodel was finished, we decided to use the small
amount of excess money left to conduct a spraying of the entire hospital
to try to cut down on the cockroach numbers. Unfortunately, in order to
spray properly, you have to move all of the patients out of the ward for
3-4 hours, which can be a little problematic for wards like maternity.
Anyway, this week was the turn of the TB ward and peds 2, our
malnutrition ward. The TB ward spraying went smoothly, but peds 2 was a
bit more of a problem -- we sprayed overnight but the cockroaches there,
perhaps stronger from all of the malnutrition food they've been feasting
on for years, merely got angry, starting literally coming out of the
woodwork, covering the walls, jumping out on you, so forth. It was like
a bad scene from Indiana Jones. After some emergency purchasing of
additional bug spray, we managed to collect a bit of cockroaches 2 feet
across and at least 6 inches high. Pretty impressive. This is the time
of year where the bugs rule -- flying termites littering my doorstep
every morning with the remnants of a thousand shed wings, mosquitoes
giving malaria to close to half the hospital, black ants boiling out of
the ground in huge trains, ready to devour anyone who is slow enough to
pause accidentally in their path. I guess the cockroaches were just
upset about being left out of the fun.

the truth is sharper...

We still fight the struggle of getting people to come to grips with HIV
here in Mukinge. This is very much a person-by-person struggle, as all
of the posters and advertisements in the world seem to do little to
convince the village wife that she could conceivably be HIV positive,
much less need treatment for it. We have mandatory offered HIV testing
for all of our TB patients because the co-infection rate is around 70%;
one of my patients today became very angry because we were drawing blood
from her on the ward. This was a blood draw to determine if she would
be healthy enough to start on anti-HIV meds; she'd already had her HIV
test last week. To our surprise, however, she got very angry, claiming
that she'd never given consent for an HIV test and had never been told
her test results. Now, we pretty clearly document our counseling
process, and there were notes from our HIV counsellor on the chart, so I
was pretty sure that she'd been told both about the first blood test and
the results. But she was very adamant, spitting out Kikaonde far too
rapidly for me to follow, so I brought in the HIV counselors to come
talk with her again. After some further questioning, it was pretty
clear that she had gone through the whole counseling process as usual,
but was in such denial about her positive test that she couldn't even
admit that she'd been told the results.

As I was standing there in the nursing station with her and our
counselor, I keep thinking about how I could 'force' her to hear her
test results simply by repeating them again there until I was sure she'd
heard. I really wanted to, to a certain extent. I mean, shouldn't her
husband and children have the option of being tested, even if she was in
denial? Plus, it just seemed like cowardice to run away from the truth
like that. But for her, the truth was really a weapon in the truest
sense of the word, and to wield it like that against her would probably
do irreparable damage to her, as well as to our doctor-patient-hospital
relationship. So we left it alone, with her in her denial.

a disaster in the making

We had our disaster/emergency drill yesterday at the hospital, where we
practice what to do with mass casualty incidents. I had asked one of
our visiting docs to help me plan it and so she had organized several of
the nursing students to come and help. We had notified the nurses to
let them know we would be practicing today so that they could be ready.
What I didn't anticipate was the acting skills of our nursing students.
We drove up a carload of them to our outpatient department, where they
started wailing and keening after having tangled themselves up and
squirting ketchup all over themselves. Our watchmen went into a panic,
as did the chaplains, carrying the students out of the back of the
truck. Someone said that they had seen them all gathering in the
nursing training school just a few minutes before and 'there must have
been some sort of electrocution' that happened there. People were
scurrying left and right, I later found out that the staff in the
business office stopped their work for 30 minutes to pray for the
injured nursing students, and we called a halt to the whole process
after about half an hour to discuss some of the issues that came up.
Note to self: make sure that EVERYONE knows there's a drill on before
conducting one again.

the life you save may be your own

Always wanted to have a Flannery O'Connor title in my blog. This week
has been exhausting, but also pretty satisfying. One of the problems
with medicine at home is the sheer distance of it -- your doctor
presence has to be mediated by white coats, scrubs, ultrasound machines,
tubes, oxygen and so forth. Most people's impression of going to the
hospital is of finding yourself or loved ones 'hooked up' to various
machines, pumps, IV's, catheters, and so forth. Here, some of those
barriers still exist, but often the distance is frightening close --
frightening because it remind you of your own mortality, and frightening
because as a doctor you are working with so little reserve. At home, we
think little of transfusing 5-10 units of blood in the ER, to be
followed by another 30-50 in the OR. Here, I donated blood on Monday
afternoon and transfused that unit of blood that evening while doing
anesthesia on a sick C-section patient, since it was the only unit of
type O blood that we had. On Tuesday I was called to obstetrics because
of a baby who was born who wasn't breathing -- we put a tube down into
his lungs and I spent my lunch break acting as a ventilator until he
picked up enough to breathe on his own. What happens when you're not
there to be the blood bank, or the ventilator, or the doctor to do the
C-section?

Flannery O'Connor was trying to say that our actions have a much bigger
impact on us than they do on other people; perhaps not a complicated
idea, but a profound one nevertheless. The corollary I think also holds
true, however -- if you don't save the lives that you can, you may lose
your own way in the process as well. I think that what I struggle with
here is how exhausting that process can be, especially when you are
stretched thin between work and life and interpersonal relationships
which sometimes take a lot of effort to keep smooth. I have to think
that the lives of others are worth it; what I don't often remember is
that truth that when I seems like I'm just spending myself to the limit,
I'm also saving myself from callousness or ineptitude as well.

email slowdown

Sorry if the blogging has been sparse -- we're having some trouble with
our internet these days, which means I have to travel to the airplane
hanger to do my email, something which is rarely convenient and often
impossible when you're on call, since no one can get in touch with you
there. So sorry if the communication hasn't been so prolific.

malnutrition miracles

We've recently had some opportunities to apply to increasing assistance
and funds to help with the malnutrition problem we see here at the
hospital. For various reasons -- farming patterns, soil deprivation,
cultural stubbornness, chronic diseases like HIV and TB -- there are few
protein sources in Kasempa with resultant rampant malnutrition and
malnutrition deaths. We've recently gotten some help via surprise
deliveries of things like Plumpy'Nut and have also been offered
additional assistance via some of the HIV programs in the area.
Previously I am told that we had been declared a 'malnutrition free'
area by the World Food Programme, so our food supplementation funds had
been cut off. Most of the external donations by private individuals for
the hospital are actually designated for food of some kind.

Our visiting nurse, Kate, who's currently in charge of the malnutrition
ward, and Edgar, the doc in charge, have been working extra hard to come
up with the measurements that they need to secure the funds. These are
things like arm circumference and heights on our adults. Thanks to
their hard work, we're getting closer to maybe getting some more of the
help that we need!

the normal is the weird

People usually ask me at home 'what the normal stuff that you see out there at the hospital?' to which I usually reply things like malaria, or HIV, or pneumonia, or diarrhea.  But in actuality the cases that consume a lot of your time and brainpower are the weird, where you're struck with something you've never had to deal with before and are not even exactly sure where to begin.  Those type of cases are the usual for us, each week having to puzzle through how to take care of a huge urinary mass, or whether you should remove the breasts on a hermaphrodite, or when to do the surgery for a 4 month abdominal gestation.  Those are the things that tropical medicine diplomas can't prepare you for: you rather rely on your ability to be resourceful, puzzle through things on your own, call on remote expert guidance from doctors overseas, and tackle things without knowing all the outcomes beforehand.  Obviously that kind of working without a net doesn't always work out well, but surprisingly it does quite a bit of the time, too.

working life

working life, originally uploaded by mattcotham.

Mukinge is a very out-of-doors kind of hospital; perhaps not as much as
the mud huts that David used to work in with MSF, but I enjoy the
exposure to the wind and rain and sun on my daily rounds. Most ER's at
home have few or no windows -- they were usually added on as
afterthoughts on the ground floors of hospitals and I suppose that the
presence of a window would make sick people uncomfortable, although I
never really understood the logic of that. But here, I can sit out on
the steps outside of ultrasound while I'm waiting for the nurses to
bring a patient for a scan and enjoy the sun on my face for a few
minutes in the middle of my day. Or I can dodge the drips on the
walkways when the rainstorms suddenly hit around 2pm, dancing around the
puddles on the walk and feeling the spray from the gutters on my arms.
It's nice, it keeps me in touch with the outdoors, and it gives some
variety to my day which is sorely lacking at home.

exam time

exam time, originally uploaded by mattcotham.

Right now are the grade 12 exams here in Zambia, which make the ER oral
boards pale in comparison to the amount of stress that these engender.
Try to imagine that your SAT score would be one of the primary deciding
factors for every school you ever applied to and every job you ever took
and you'd understand a bit better. Maybe 10 staff members of the
hospital are studying and retaking their exams to improve their scores,
even at the age of 40 (imagine taking your SAT again at the age of
40!). Just to give you an example of how serious people are, we had a
girl come in from the secondary school with what turned out to be a
ruptured tubal pregnancy -- heart rate in the 140's, pale, dizzy. She
took her grade 12 history exam this morning before she'd let us do the
tests this afternoon to figure out what's going on or operate on her.
Surely that deserves one or two extra credit points on the exam?

how the grinch stole homecoming

how the grinch stole homecoming, originally uploaded by mattcotham.

Well, we made it back yesterday after a long trip where I nearly got
bumped from my flight to Johannesburg, my luggage was deliberately left
behind by United in Washington so that we wouldn't have too much weight
on the plane (they told us about that decision when we landed 13 hours
later), and about $1000 of gifts/equipment got stolen out of my bags
along the way. I'm struggling with thoughts of wishing plagues of
hemorrhoids and ingrown toenails (that would be revenge for us doctors)
on the perpetrator of that deed, since these were things that I had
planned for months to get and some of the stuff were things that people
here had given me money to buy for them. I was feeling a little bit
like Santa Claus bringing it back for people, and now I feel a bit like
the Grinch came and stole our Christmas, and there won't be any little
dog with a large bone tied on his head bringing it back. But like the
Grinch points out, stuff is stuff, and although not always replaceable,
it's not the end of the world when it goes away.

I'm trying to get more photos on the blog; they are not always related
to the stories (I'm not picturing feeding this guy to the crocs,
although come to think of it....)

October updates

I see that it's been close to two months since my last group email -- time flies when you're trying to get ready for ER boards, I guess.  I am currently back in the states for a brief time for my oral boards and then will be heading back to Zambia on Tuesday.  I get a lot of questions about whether I'm struggling with culture shock; coming back to the US, even for a brief time, has its advantages -- I feel like I'm getting a years' worth of shopping done in a week -- but also brings you up hard against American materialism and excess.  Although I don't deny that I think salad in a bag is a modern miracle, especially after the 5 step process of washing and disinfecting that I'm required to do, we spend a lot of energy on activities which are of little profit, I think.

I guess the two biggest questions I get when I'm back are 1)"What's it like over there?" and 2)"How can we help out?"  I find myself wishing I was more charismatic to go out and 'sell' a project or need for the hospital, but the bottom line is that both questions are problematic at best.

What's it like in Zambia?  It depends on what aspect you look at.  I would say overall that it's just more extreme than life over here; I think I've said this before.  In terms of work, it's more satisfying in many ways, because it allows me to be more holistic as a doctor, incorporating who I am into what I do, and the patients are more grateful and more engaged with their doctor.  It's a throwback to the trusting nature that people used to have with their doctors here before the age of the internet and information overload where they depended on their doc to do the right thing and know what was best.  At the same time, work is much less satisfying, as patients die or you can't help, and they are often very young.  I can give many examples of patients who were just tragically cut short, and it's difficult to care for them and feel very helpless.  Life outside of work is better, more simple, more fulfilling than the American pursuit of entertainment and so forth, but it's also more frustrating, more boring, and more difficult to get things done.  I blogged about this recently in 'native soil', if you want to read more. 
Anyway, you want to put a 'positive spin' on things so that your parents don't get too worried :), supporters don't get discouraged, and you don't give the impression that Zambia is falling apart and incredibly frustrating, because it's not.  Many stories end up sounding that way, however, and it's sometimes difficult to find a balance.

How can you help out?  After my friends Hilary and Tay came to visit, I was struck again by how many things go on outside of work that need help as well.  People want to help with 'the kids', but that's a very nebulous term -- the kid patients in the hospital, the local kids of the hospital staff, some of the nearby village kids, AIDS orphans, local schoolkids -- all have different advantages and disadvantages when it comes to ministry.  I am probably too focused on the hospital needs, because that's where I serve and spend my energy.  All of those needs -- housing, electrical transformers, drugs and supplies, incoming personnel -- are ongoing and there are no guarantees that interventions to help will have the desired effect.  For example, we have recently purchased some new kitchen pots and are renovating the kitchen for about $20,000, but our electrician sometimes makes mistakes and there's a real chance that there will be mistakes in installation which could cause lots of damage.  But he's the only electrician around, so we may have to trust him and hope for the best.  We've raised the money for a water pump so that around 20 people can have running water, but we were swindled by the guys who ordered it and so still haven't managed to get the proper pump installed, now two months later.  Projects all seem to have those sort of hang-ups, but you need to get them done, so you do the best you can.  I definitely feel that while I'm over there I can help facilitate things getting done properly.
So how to help?  I guess from a capitalistic perspective, it's a risky investment: no guarantee of success.  Don't be fooled by these NGO's who promise that 'every dollar will be spent on something' because Africa doesn't and can't work that way.  But there are a lot of really positive things.  I'm encouraged by the lack of graft and good accountability on the part of the people that I work with to do the best they can in a tough situation.  And I'm also struck by the huge upside when things do turn out well -- getting water to people, providing good healthcare, giving comfort to patients and families, supporting people in their need -- these are things that we should be a part of as Christians and citizens of the global community.  Because there are so many different ways to get involved -- education, financial projects, nutrition, infrastructure, medical care -- let me know if you have a heart for something and I'll see how I can make it work.

It's really encouraging to know that people are interested and engaged with what's going on out at Mukinge.  That's easily been the best part of this brief sojourn at home.  I'll be headed back in less than a week to Zambia for round 2 of my two-year commitment.  What happens after next November is still up in the air, and I'm pretty content to leave it that way, with the understanding that God will show me the answer to those decisions when they press upon me.

Thanks for your prayers and support.  Looking forward to talking and hearing from each of you.

Talk to you all soon.
Matt

modernization

Not exactly sure that changing the font qualifies as modernization, but
it seems to at least eliminate the irritating page breaks. Hope you all
can still read it -- as my dad's eyes get worse, I get more sensitive to
these things. I've not been blogging much this week since I figured few
people want to hear about my studying habits, and some of you I've
managed to talk with in person. Suffice it to say, I should be ready
for exams on Sunday, I've managed to find most of my gift ideas (anyone
know where I can find a hammock?), and have enjoyed spending time with
family and friends. I'll catch you guys up once I reach Lusaka again!

native soil

It feels pretty good to be back on American soil, even if it was the product of a 17 hour flight from Jo-burg to NYC and I still have about another 12 hours in lay-overs, transfers, and flights to come. I love the fact that the US citizens line in customs looks as diverse as the visitors to the US line in JFK. And, I'll admit it, my triple-shot latte also tastes pretty good after 4 hours of sleep and 11 months delay. These are mid-terms for me, a chance to step back and figure out what the last year has been about, where I'm headed to in the future, and where I am being led from here. We're conditioned to pursue happiness in America. I wish I could say that I was ecstatically happy all the time in Zambia, and I would have to say that I'm pretty content most of the time. But it's a complex place. Let me try to outline some of those ways.

Friendships: Mukinge has been an amazing place for friendships with some really wonderful people who I have grown close to because of all our shared experiences, but also because of who they are. There are people that are really worth spending the time to get to know -- Zambian and ex-pat alike. At the same time, Mukinge is a place where many people are there for a short time and then gone. And cross-cultural friendships are difficult because of expectations of financial/material gain that are often placed on them, differences in cultural backgrounds, family structures. So it can be lonely at times as well.

Work: Work can be really fulfilling. I put together a slide show of pictures of just a fraction of people who've we've helped -- the man who slit his throat in an attempt to kill himself and came back to his family and to Christ after we sewed him up, the woman with the massive hemopytsis holding her baby after her C-section a week later, the man fitted with his wooden peg-leg after his traumatic amputation of his leg, smiling and sticking his thumb up at the camera. I'm reminded of people's lives that I've saved over the year, people who are grateful for a gentle touch or kind word, and families who were strengthened in their faith and love for each other because of work that we did. At the same time, the slide slow reminded me of all our failures -- the immigration officer staring at the camera like he can see his own death in the lens (he died two weeks later), Josua reaching out to the camera and then laying in the high-care area of pediatrics 3 months later, dead from malnutrition, Tom sitting in his wheelchair gradually losing his smile over a few weeks as he's forced to grow up unexpectedly by the tragedy of unexplained paralysis. Some days are really good, but some days I find myself losing hope that what I'm doing makes a difference as well. I find that rationalizations that 'what would it be like if you weren't here' to ring hollow when you know about how much more effective medical care could be if you could bring the funds and personnel to bear.

Cultural adaptation: I mentioned above that we pursue happiness in America; it's in the Declaration of Independence, which in itself is so foreign to many people from other cultures, who live by the Declaration of Interdependence: on friends, on family, on the rest of the world. That transition for a bachelor who's practiced being independent for around 10 years to a culture of interdependence has been rocky at times. Part of the reason is that coming from a position of power, interdependence can very easily become just dependence, a one-way street, especially if you don't take the time to appreciate the non-quantifiable gifts that many Zambians have to offer, and Zambians don't take the time to learn about your non-material gifts as well. I was transitioning from a pluralistic society to a monolithic society, which has its own adjustments in terms of voluntarily giving up your freedoms in order to have cultural relevance. Rural Mukinge is not the cultural melting pot, something which is hard for us to understand when we go because it seems so foreign, such a great 'exchange of ideas'. When I arrived, however, I quickly realized that to make a difference I would have to change myself in order to make the differences that I can't change less obtrusive. Giving up your freedoms to be relevant -- giving up deep friendships with women because of the misconstructions that are placed on them here, changing the way you greet people, structure your day, deal with interruptions -- it's obviously the reason you go, and the lessons you learn are awesome, but it's also a painful process of subjugating yourself in ways where you're taught as an American that you should be able to pick how you're going to live your life.

I think this is going on too long for a blog -- probably half of you tuned out after the first paragraph -- so I'll stop it here, despite the adrenaline that only a triple shot latte can give you after 11 months of abstinence. Hope to talk to some of you in person, or at least by phone while I'm home.

full circle

I am back in the guesthouse in Chamba Valley where I started this trip
ten and a half months ago. In a lot of ways, things haven't changed much
since I was here then; it's still hot, and full of mosquitoes, and I am
fully expecting to have another night spent sitting up and swatting bugs against
the wall. This has been made more challenging since the last time I was
here by the addition of regular power outages, so that you are
trying to swat bugs by sounds and feel alone, which is a distinctly
dicier proposition.

Despite similarities, a lot of things are really different than before, too. My computer is now full of beautiful pictures and also with emails about water pumps and visiting medical students. There is now a separate Zambia folder with funding proposals, memorandum,
minutes from various meetings, and medical protocols.

In a moment of pique last week as my insomnia kicked in and my frustration level was
high, I made a list of all the things I'd had to learn while I've been
here for 10 months. At the time I was mad because I'd been forced to learn so much in such a short period of time; now I'm feeling kind of proud of myself. Here's the abbreviated list:

How to plant and fertilize maize and a garden

WHO recommendations for malnutrition, setting up a malnutrition
protocol, components of mineral supplementation, whether commercial
mineral supplies are adequate for human consumption, price of skim milk
powder, how to purchase and deliver milk powder, where to buy peanuts,
soy, how long peanuts can be stored, where to find containers for peanuts

Basic Kaonde

How to deworm a cat

Where to hire someone to shovel off the tennis court

How to get out of trouble when you're over your head in a C-section

Dosing and monitoring of chemotherapy for cancer, HIV drugs

African vernacular songs on the piano

How to distill water, where to find distilled water for lab and OR use
(the air conditioner, rainwater)

How to sterilize surgical instruments

How to fix a tire on a motorbike

Tennis forehands

A variety of medical conditions: Madura foot, eosinophilic folliculitis,
lymphoblastic lymphoma, leprosy, nephrotic syndrome, acute rheumatic
fever, cerebral malaria, ecclampsia, uterine rupture, snake bite,
organophosphate poisoning, tropical ulcer, pin placement for skeletal
traction, typhoid fever, skin grafting, hydrocoele repair, ultrasound
diagnosis of DVT, VSD, and ectopic pregnancy

30 or so African choruses

How to dispose of medical waste

How to make nshima

Charitable organization legal proceedings

About 200 people's names

The Evangelical Church of Zambia organization and the hospitals' role
with ECZ

How to set up a computer network (well, how to fail to set up a computer network, really)

ER medicine for my ER boards

What SIM stands for, who runs SIM, how to get things done through SIM,
how to request funding from SIM, how to recruit personnel via SIM, old
SIM projects that have been conducted at Mukinge, SIM future goals for
the hospital

Pharmacy ordering systems, contacts of about 5 pharmacy delivery
suppliers in Zambia, methods of delivery, goods received vouchers

Where to find sources of lab supplies, drugs, and stores in Zambia.

The government supplier of pharmaceuticals system, ordering timetables

What is an electrical transformer, how much voltage requirement is
needed to run a hospital

How to dig a VIP toilet

Mukinge history of severe illnesses, malnutrition, malaria, history of
relationships with the local health board

Antibiotic resistance patterns for Mukinge for the last 6 years

How to put someone on the Zambian government payroll, how to find out
how many people they expect us to have on staff

Installing and troubleshooting cellphone modems, wireless cards, and
internet access on 10 different computers

It's a long list, and I edited out a fair number of things. It feels like almost everything on that list I had to figure out on my own when I got here because of the lack of long-term docs to do a
proper handoff. Like I said before, I was peeved at the time I wrote the list because I was feeling that it was unfair to have to study for my boards on top of the rest of the
things that were going on. But now, I'm kind of just proud of myself for
managing all those things. Who knows what the next 14 months will bring?

off we go

Travelling is always a bit of a production when you live out in the
bush; the current crisis is a fuel shortage throughout the middle of the
country, so that one of our doctors is stuck 2 hours away by road and
can't get back. That played a little havoc with my travel plans as
well, and there's the usual last minute changes (my flight time out of
Mukinge has changed 4 times in the last 48 hours). And of course
there's just the amount of time it takes to get anywhere; I will leave
Mukinge today on the 6th, yet not arrive in the US until the 11th.
Looking forward to seeing everyone in the states at the end of the road,
though!

do we all speak English here?

My head cold has made it even more difficult than usual for people to
understand my American accent here; even my Kaonde seems to be more
difficult to understand. It works both ways, though, when I had to go
over the pharmacy orders for the month and was trying to figure out why
we were ordering 'cold cramps'. Alas, the Zambian 'l' and 'r' switch
got me again (you pronounce them the same), and what we really needed
were 'cord clamps', for umbilical cords. I do sort of enjoy the idea of
ordering up a bunch of cold cramps, however, and seeing what happens....

blooming season

My bluebonnets are turning out even better than I hoped they would, and
September, despite the ever increasing temperatures, is an amazing time
where most of the trees burst into bloom. It's actually quite amazing,
considering that there has been not a single drop of rain for 5 months
now, but the trees know to expect the rains in a few months and are
preparing for another season of flowering and growth. It is really
beautiful, especially the jacaranda trees which look like giant purple
afros, the flame trees with their masses of red blooms, and the
beautiful white and yellow tree out in front of my place, which
basically looks like it has grown wedding bouquets at the end of a
hundred dried sticks. I'm proud that the bluebonnets picked now to
bloom as well; it's a testament to American solidarity with the African
plant life.

Kaonde lessons

I've been trying to have a little bit of improvement in my Kaonde by
studying in a nearby village once weekly for the past two months. I
really think that language learning is such a great tool to helping
patients feel comfortable and welcomed when they come to the hospital.
I think learning the language is a great way to get insight into the
culture and ways of thinking of the people that you are working with as
well. For instance, last week I learned that Kaonde doesn't have a way
to express "I have to" -- ie, I have to go now, or I have to write a
blog entry since I have not written one in almost two weeks. You can
say "I should" or "I want to", but the idea that you are at the mercy of
time constraints or external pressure just doesn't exist. Everyone is
seen to have a choice about the way they spend their time and energy,
and circumstances are relegated to a secondary role.

updates

For those who I haven't let know personally, I will be managing to come
home for about 10 days this October to take my oral boards and attempt
to get some early Christmas shopping done for the folks here at
Mukinge. If any of you have a little time in Chicago or Texas during
Oct 12-22, let me know and we'll see if we can get together!

long overdue -- ER days

Well, if anyone is still reading after such a long hiatus, I'm still
here. It's been a busy few weeks with various people out of the
hospital on trips, so I've been playing a few roles: OPD officer,
occasional anesthetist, surgeon, and so forth. But I actually got a
chance to be an ER doc a week ago Monday when we had a motor vehicle
accident appear with 14 passengers at around 4pm. The nature of all
transport in Zambia is that in any one accident there are lots of
victims; all cars or trucks are pretty much filled to bursting wherever
they go because there is no other way to get around. Even at the trauma
hospital where I trained, if 14 patients showed up to the ER
simultaneously it would cause a bit of a stir; here it nearly overwhelms
us every time that it happens. We default to our 'emergency plan' which
I revised a few months ago.

We were finishing up a case in the theater when we got word that they
were arriving; I scrubbed out and went to the female ward. We had to
stage a little traffic direction to bring everyone to a place where we
could triage them -- sort out who was the sickest, the next sick, and so
forth. Unfortunately, one man had bypassed the queue and gone straight
to the theater, and although he was pretty sick, there were two people
who needed to go to the OR more; one with a bilateral broken legs, and
one with a head injury.

The man with the broken legs had lost so much blood en route to the
hospital that by the time he reached the theater he died. We started
CPR and started four IV's and transfused him, and he came back for about
30 minutes, but we were unable to get enough blood into him and he died
again; this time not to recover. The second man with the brain injury
died the next day. The rest are still mostly here 10 days later,
recovering from their various orthopedic injuries as they try to figure
out ways to get transport back to where they were originally supposed to
be going.

With the arrival of the paved road to Mukinge a few years ago, things
like this will become even more common, but the protective things that
shield people from serious injuries in car accidents at home -- seat
belts, sturdy seats, air bags, antilock brakes, decent tires -- are
still a long way off. Most of these accidents come not from two people
hitting each other, but from the vehicle breaking down en route -- blown
tires, failed steering, and so forth. It's sad, because the things to
take good care of trauma patients are pretty basic: availability of
someone with surgical skill, ample blood supply, and decent transport of
accident victims to the hospital.

Who's who II

The second installment of the who's who for the hospital: mostly our
nursing staff here.

Liz Bennett -- usually introduces herself as 'they call me bossy
Bennett' for reasons that I don't quite understand; not actually that
bossy at all. Has a love/hate relationship with her computer which I
have become embroiled in, and has a huge heart for our nursing students
here at the hospital. Also has a HUGE cat named Tinker who I think
could probably eat my cat in one gulp if he wanted to.

Jan Matthews -- described as a 'real pot of gold' by one of the visiting
doctors, she's approaching the retirement age but still manages to
giggle like she's 16. She has the ability to put on a semi-miraculous
spread of food at her house with seemingly no effort and is the
instigator of many of the cakes that we eat during tea time. She's been
in Zambia for almost as long as Zambia has been a country. A real
prayer warrior with who knows how many notebooks filled with prayer
requests that go back years.

Michelle Proctor -- everyone's favorite pediatric nurse, with a
fantastically happy black lab named Bouncer because he shares a
Tigger-like enthusiasm for chasing such delicacies as small rocks and
pebbles. Amazing gifts of hospitality. Comes from the land of Beatrix
Potter, who's biography we were (forced) to watch one Friday evening.
She braves the spider-filled cavern of our storage area more than anyone
else. Despite being an excellent nurse and friend, I think she'd quit
the whole shebang to open up a Starbucks branch in Kasempa, if the
opportunity were to arise.

Ruth Green -- assumed the role of youngest medical staff ex-pat from me
when she arrived this summer; from Northern Ireland yet is brave enough
to at least consider going to a Catholic church for services every now
and then. Has an unfortunate lack of knowledge for cooking Irish
delicacies, however, so we're having to remedy that little by little
(taught by non-Irish folks). Willing to help me out by putting feminine
hygiene products that I was asked to buy into her own shopping basket.

Kate Stimson -- a Londoner transplanted to rural Africa; spent the last
two years as a nanny in England while taking a break from her nursing
duties. A good source of British slang like 'brilliant' and 'mental'.
The primary tutor for Ruth's Irish baking deficiencies. Also just
arrived this summer.

Alfonsina Tembo -- one of our dedicated locals who's passing up fame and
fortune to work at a place like Mukinge. Full of sensible ideas and
willing to call you out if you're doing something wrong (ie, drinking
your Coke before you eat your meal). My neighbor and fellow gardener,
along with her duplex-mate Susan. A brilliant laugh.

I could continue to go on for the pharmacy staff, lab staff, business
office, maintenance staff, ZEN's, and so forth, but I'm getting tired.
I think you get the picture that it's very much a team effort here.
Even now as we are putting together this planning document for the
coming year we've had so many different people with different expertise
lend a hand. As John said, it's a good feeling when you're able to
pitch in and help out a bit, even in places that aren't your
'responsibility'. Without everyone, we wouldn't be able to do what we
do on a day-to-day basis.

control freak

One of the interesting things I've noticed about myself is that as I get
more involved with the management at the hospital, I find myself feeling
that things which I used to just shrug off now bother me a bit more. I
think this is because of the illusion of control that doing stuff with
management gives me. For instance, when the power went off for three
days when I first arrived, it didn't bother me very much. We've had a
lot of problems with the power recently as they try to fix some of the
power grid infrastructure, but there's an illusion that I can do
something about it by deciding to run the generator, or call the power
company. Even now that I'm in the communication loop so that I hear
that the power will be switched off and back on at a certain time, when
it goes three hours later, I find myself getting frustrated, when I
think if I didn't know anything I would care less. It's an strange
phenomenon, and I need to learn to let go of things that I have the
illusion of control over, but actually have the exact same amount of
control over that I had in January.

the devil you know

I've got a patient right now with a big white spot on his lung, coughing
up blood, and losing weight. He's been gradually getting worse over the
past few weeks. We are having fairly regular doctors' rounds every
Friday where we discuss cases that we're not sure what to do; one of the
things that we find is that we often make decisions not on necessarily
what we think is going on, but what we think we can treat. So the man
with the spot on his Xray; could be cancer, could be TB, but we can
treat the latter and not the former, so we give him a diagnosis of TB
and treat him as such. Same with the woman with the swollen lymph nodes
in her leg. Or the man with blood in his CSF -- could be a bleed, or
could be encephalitis, but we can only treat the second one.
This obviously leads to overuse of some resources on patients that don't
have the diseases that we are treating them for, and skews our success
rates for treatment of certain diseases. It also makes explaining
prognosis to patients and families difficult (e.g. "I'm going to start
you on some medicine, but I don't really think it will help, since I
don't think you actually have TB"). I struggle with the right way to
approach these patients, however, because I think that false hope and
wastage of resources aren't really good things, but missed diagnosis of
treatable disease is also a bad thing. So we usually err on the side of
treating them.

who's who part 1

As people here at Mukinge get on the internet and take a peek at this
blog, I'm reminded of how often I don't mention the people that I work
with. Part of that is intentional, because I always found it to be very
boring hearing stories about people I'd never met and would likely never
meet. However, it does a disservice to the amount of work everyone puts
in and makes it seem like I'm working in a vacuum, which I assure you
that I'm not. So, at the risk of causing trouble with my brief
portraits of the people that I work with, here's the brief bios of the
admin people and doctors I work with:
Jairos Fumpa: the man in charge, although he refuses to be called the
man in charge, but rather the 'acting' man in charge. That probably
gives you an idea of the kind of man he is: humble, hard-working. He's
been here for a long time now, and is the glue that holds the place
together, the man with the memory of why we decided to do things that
way from 10 years ago. Be careful, though, or he'll whisk that cataract
out of your eye before you can blink. Has about the most outgoing 5
year old son you could ever imagine, who loves his bright yellow
Nigerian outfit.
Kingsley Kuwema: the man trying to keep up with the onslaught of HIV in
the area -- a race against time and before the west gets tired of
funding the effort here in Africa. He runs a math course for adult
education on the side of his house. If you think your building project
was bad, he has been building a house now for ten years in a nearby town
and still hasn't finished -- but he's a man with vision like that. Good
thing for our HIV program, too.
Lynn Hacker: our jack-of-all-trades administrator, nursing supervisor,
OR coordinator, and anesthetist. She's from Wisconsin but her accent
places her someplace between Norway and New Zealand after living out
here for so long. Makes her own bread and seems to have a miraculous
supply of things like decaf coffee which she shares liberally. She
hosts a rather rag-tag group of us every Friday for videos which range
the gamut from a little cheesy to very moving. I'm not sure exactly
where Spy Game fits on that spectrum, though.
David Friend: more African medical experience than the rest of the
doctor staff put together (including our Zambian doctor!). A man with
the ability to make the word 'hmmm" express a thousand different
emotions. Gets big and strong by eating nshima (Zambian corn meal mush)
every day. Somewhat of a health nut (of course, by my standards running
50 feet is a health nut) by getting up around 5:30 every day to go
running in the 40 degree weather. He's the deputy pool director while
he's here.
Edgar Mutimushi: my closest match in terms of experience and medical
training; finished his medical internship last year and reported here in
January out of that. Always with a chuckle and a smile, and a maniac
UNO player (okay, perhaps I exaggerate a bit). Has a very sweet wife
who shares my love for How To Cook Everything.
John Griffiths: you won't see a pair of bushier eyebrows around, but I
should speak softly lest he trounce me even more thoroughly than normal
on the tennis court. I was toying with the idea of making a John
Griffiths day of the week calendar featuring a different button missing
on his shirt daily; the practice of getting them all buttoned in the
morning is difficult for him. Easily the most analytical of us and
well-read; always tracking down answers and challenging you (in a
friendly way) to defend your decisions. Perhaps has a little bit of
poor judgment, however, as he engaged in a American poetry trivia
contest with me, an American and English major. Adopted 2 children from
Russia for a total of 5.

Next week: part 2: the RN's and other folks around the area.

VIP treatment

We had the national police commissioner in the hospital this week after
he arrived after a stroke on Monday. Like most places in the world,
stroke care here is never very satisfying, once the deficits have begun
there's little that you can do, except make sure that it doesn't get
worse. Certainly the lack of CAT scanning makes neurological medicine
feel like you're trying to use an axe to remove a splinter; the tools
you've got just aren't sophisticated enough for the detail that you need
to treat properly.

Certainly we see a fair amount of neurological issues -- right now I've
got 4 women on female ward with various neurological complaints -- one
with high fevers and left arm/leg weakness who we suspect may have a
brain abscess, one with pleasant dementia, not talking, and left leg
weakness who we think may have PML, and two with garden-variety strokes
due to poorly controlled blood pressure. One particularly difficult
situation is the mother whose daughter and mother are both in the
hospital, lying in beds next to each other, one with the suspected brain
abscess and one with a stroke. Her life will change dramatically as she
struggles to care for two invalids at home.

But what was remarkable about the police commissioner was the amount of
people that came by to visit, call, text message, or otherwise inquire
about his status. I'm constantly amazed at the power systems and the
deference given to people of position; from a western perspective it
sometimes seems like toadying, but it's really a different flavor and
emphasis than having a bunch of people come by to see the boss in the
hospital would have at home. It's hard to define, but it's a more
relational concern, and merely marks the co-mingling in so many African
relationships of business and friendship to a degree that we don't have
at home.

Fortunately for me, I survived the onslaught of attention from the
government offices checking up on us (at least I hope that I acquitted
us okay) and he was transferred back to the capital two days ago, where
I hope he arrived well. I'm sure I will hear more follow-up in the days
to come.

the $200,000 patient

Sometimes working in the hospital is like pulling a string out from my
grandmother's crocheted afghan (which I'm missing with the cold weather
right now): you think you're just picking out a loose thread and all of
a sudden whole sections are coming unraveled. Part of the problem of
constantly being underbudgeted (our budget for all the drugs, lab
supplies, X-ray films, and medical stores like IV's, tape, gauze etc. is
$500 this month) is that things are deferred until they can't wait
anymore and then are patched together with whatever solution you can
afford. But later when you try to solve problems, you find that the
problem was actually part of a solution to another problem, so then you
have to fix that one as well, etc.

Case in point: we have trouble keeping our oxygen concentrators working
properly (if anyone knows of a biomedical servicing company that would
be willing to come or that we could send someone to train at, the info
would be appreciated), so back in February I tried to buy three more for
the hospital. One of the nurses that works here, Liz, got her church to
donate another one and pay for the transport. Unfortunately, the
customs clearing house here has a backlog of around two years of
packages that had been sent to the hospital, the local girls school, and
the now-defunct services department, all of which were lumped together
in the same boxes and we owed them around 360 pounds (there's a way to
do the fancy pound sign but I don't know it). So we had to sort out the
different things people owed, much like sorting out a restaurant check
with a bunch of cheapskates who are divving out their 10% for the waitress.

At the same time, we had to get the hospital truck working again so
that we could pick up the boxes; it has two bad tires so we created a
income-generating project to use the truck to raise money for the
tires. At the same time, the battery has gone dead for the truck so
that was borrowed from the generator, but we've had power outages
because the local grass fires have been burning some of the electrical
line poles, so we've needed to use the generator some recently. And of
course, you can't run an oxygen concentrator without electricity, so
we've made it full circle in trying to get the oxygen concentrators here.

Tracing through those threads is difficult even when you've been part of
the decisions to make them; trying to trace through someone else's
decision-making process is nearly impossible. Needless to say, trying
to take care of a small need for one patient often ends up costing much
more and taking a lot longer than you hoped -- I ordered the
concentrators in February, and we will hopefully get them this weekend.

hungry hungry hippos

I took the initiative to expand my language training this week by
scheduling regular meetings with one of the local elders who has taught
several previous 'muzungus' to speak better Kaonde. Steve and Heather,
our local Peace Corps workers, think that it may be effort better spent
elsewhere as there are almost always translators available, and learning
Kikaonde is like learning Icelandic, or Latin -- you're unlikely to ever
find someone to speak with outside of the local area. Even in Zambia,
when I travel to Lusaka I can't really communicate very well. But you
notice a big difference in the way patients see you when you learn the
language; even a few words provokes laughter throughout the ward
(good-natured laughter that you're speaking Kaonde, not laughing because
it's so bad) and smiles and a torrent of information that you just don't
get when you use the translators.

Anyway, I started meeting with Mr. Kapanza this week, and enjoyed my
time immensely. One of the things he's struggling with this year is a
very poor maize crop; although he worked really hard and planted a lot
of maize, about February 3 hippos came and stayed for a week in his
fields, eating all of his hard work, so that he only ended up with maybe
1/10 of what his crop would have been. It's illegal to kill hippos,
although the game wardens are supposed to do it for you if a situation
like that happens. Unfortunately, the wardens didn't show up until even
a week after the hippos had left, obviously at which time the damage had
been done. The hippos returned again 2 weeks ago, a fact which amazes
me since our river isn't that big (maybe 15-20 feet across at the
widest), but the harvest had been finished at that time. The game
wardens once again arrived to late to chase the hippos, so they are
still roaming at large. Maybe they'll show up again if they get hungry
enough....

Holiday time

Hello again to all of you out there in America and far-flung parts of the world!

I realize it's only been a month since I last wrote, and I hope that these emails aren't becoming annoying.  I've been sitting around eating bon-bons this month as I elected to have a vacation and see some of the sights of Zambia with two friends of mine that came out to visit from Denver.  It's holiday season in Zambia as this Friday marks the end of school for 6 weeks until September.  Taking a holiday from work was a good thing just to get a break from the grind of suffering and sickness.  We had our breath taken away by several scenes in the game park and at Victoria Falls, but I won't try to overburden the email server with too many pictures in this email.  Zambia (and Botswana) can be incredibly beautiful, sometimes something you forget when the hospital trash pit smells like burning rubber and you've seen another leg covered in warts, or pus, or burned down to the bone.

That being said, I've been glad to be back at the hospital.  I had missed seeing several of the young teenagers who I had been caring for the past few weeks, and managed to get a few good pictures before they flew the coop.  Hospital life continues to have its share of frustrations -- our water pumps (2 of 3) have broken, so that part of the compound has no water at all, and the rest of us are on water restrictions.  We're trying to get these problems fixed but when things have to come from Lusaka, it moves slowly.  Meanwhile, the people you work with are having trouble even cooking or taking a bath.  I find it difficult to know what the proper response should be -- should I invite 20 people over to my house every day to take a shower?  I think I probably don't end up doing enough for my co-workers.

One of the difficult (maybe the most difficult) part of becoming a government hospital is our requirement to be landlords and provide free housing for all the government staff that work at the hospital, around 100 or so workers.  I feel like I spend a lot of my time trying to solve community living problems rather than medical problems and a lot of our funds are spent on problems like the water pump or fixing toilets, instead of on medicines, etc.  On the other hand, if we are going to make a difference here in Kasempa, one of the major impacts will be how we treat the people that work at the hospital and show them love, provide jobs, allow for fulfilling vocations, and so forth.  You shouldn't run a hospital without first taking care of your nurses, lab technicians, radiographers, doctors, etc, so things like housing are important as well.  But it's a problem that western hospitals don't have to face, and it's frustrating for us, because we don't have the funds to treat all of our workers the way we think they should be treated and we'd like to be treated ourselves.

I've decompressed my clinical workload so that I have more time to spend learning some surgical techniques and so forth.  I'm okay now with skin grafting and closed orthopedic things.  I still need lots of practice with hernias and hydrocoeles, and obviously anything bigger than that is still a little ways off.  But I'm becoming more of a jack-of-all-trades doctor (a 'bush' doctor, as they like to be called) in addition to just becoming a jack-of-all-trades person -- learning some more Kaonde, figuring out the nuts and bolts of computer networks, tinkering with some motorcycle maintenance, doing a bit of gardening, figuring out how to de-worm the cat, learning some African-style hymns to play on piano, and so forth.  I find it difficult to always want to be flexible -- it's nice to be able to define your job and say 'this is what I do', so that you don't get overwhelmed with requests to do other things -- but that approach doesn't work here and you have to be cheerful when something unexpected comes your way (like it does almost every day).

Thanks for your prayers and support.  We are still working on the Friends of Mukinge non-profit donation conduit, thanks to all of you who've been asking.  I will be sure to send out an update when that comes online.  Keep praying for our patients; we have so many for whom we can only do very little. 

I'll close with my GQ shot of me leaning against the frame of the picture with our newly purchased bags of maize.  We are buying up all of our maize for the coming year right now; our cups overflow with corn!  (note the Chuck Taylors)

Love,
Matt