Lily’s Blog

Adventures in Livingstone

28 April 2011.  We’ve had a great day and a half in Livingstone!  We hitched a ride with the weekly shopping trip to Choma from Macha and then caught the bus to Livingstone. We arrived in the early afternoon and got some food at our hostel.  I had wings!  After the intermittent water and electricity situation at Macha, the hostel seems like a 4 star hotel.  There’s HOT water!  That comes from a showerhead!  And strong wi-fi!

Anyway, after our lunch we went for a three hour walking safari in the Mosi-o-Tunya national park.  We saw a rhino, impala, baboons, giraffes, warthogs, wildebeest, and a lot of birds.  I can now distinguish the droppings of male and female giraffes.  After our safari, we came back to the hostel and ate again (more wings!).  This morning we took a shuttle to Victoria Falls.  It was incredible.  The view is unbelievable, and we got completely soaked crossing the Knife’s Edge bridge.  After getting our fill from the top, we walked down a trail to the Boiling Pot, at the bottom of the falls.  We bought some souvenirs at the market there.  Back in Livingstone, we went for a walk to another market and went to the Livingtstone museum.  It’s been really fun, and it has gone by very quickly.  Tomorrow we catch the bus from Livingstone to Lusaka (about a 6 hour ride), then get our plane on Saturday afternoon.

The return of functional internet has necessitated taking care of some business that has been on hold while I’ve been gone, which is a little overwhelming.  A lot of emails to answer, and my next (and last!) rotation which starts on Monday morning (at which time I expect to be completely and utterly useless secondary to jet lag and sheer exhaustion from traveling for over 30 hours and not arriving home until 9:30 p.m.).

The long journey begins tomorrow… I’m glad I still have a few books to tide me over for the trip.

Last day

26 April 2011.  It’s my last day in Macha.  It’s an operating day.  As I feared, the woman with the canteloupe sized mass in her belly, plus an 18 week pregnancy did not come to the hospital in time to be admitted for surgery.  She was rescheduled for next week, and I hope she comes then.  Otherwise, it was a pretty busy day in the operating theatre, and a very busy afternoon in the outpatient department.  I spent most of the evening packing.

It feels bittersweet to be leaving.  Don’t get me wrong, I have missed hot water (that always comes on when I turn the faucet) and fresh milk and I will NOT miss armoring myself with DEET and SPF 50 sunscreen every morning… but this is not an experience I will forget, nor do I regret coming in any way.  I have learned things here that I could not learn in the U.S.  It will make me a better physician, and will most certainly make me appreciative of the technology and infrastructure we have in the U.S.  It will also make me more conscious of the things we take for granted and the incredible amount of supplies that we waste.

Tomorrow we’re getting a ride to Choma, then a bus to Livingstone to have an adventure or two before heading home.

Slacking on the blogging

25 April 2011.  A long time has passed since I blogged last.  I’ve been busy on the maternity ward, delivering nearly 10 babies.  It has been a long Easter holiday.  Friday was a holiday, and so we only worked a half day.  Saturday was also a half day, and after rounding on the maternity ward we went to help with rounds on the women’s ward which is currently the busiest ward in the hospital.  Yesterday was a full day.  We were invited to a sunrise service at the Macha dam with a few of the other American’s working at the hospital and the malaria institute.  It was about a half hour walk each way.  We also had coffee and breakfast with them before church.  We went to church later in the morning.  After that, we walked about an hour to the village where the guest house housekeeper lives.  She made us traditional Tonga food and drink and we spent a few hours with her and her large extended family in their village.  The drink is called bwaatu and it is made from ground corn meal, a pounded root, sugar and water.  After that, we walked 45 minutes back to Macha.  By then we figured we had walked about 8 miles.  It was hot and very sunny.  I sunburned in patches all over.  We treated ourselves to hot baths when we got home.  After a long day of walking and a warm bath, we slept very well last night.

Today was a holiday also, so another half day in the hospital.  This has caused quite a few hiccups in the flow of medical care since Friday.  Because of the half days Friday and today, and the weekend, most of the tests and imaging that we ordered Thursday or Friday has not been done yet.  This is a problem when a lot of your decisions are based upon some very rudimentary tests.  Many patients could probably have been discharged or some other treatments started if we had some basic information to use.  It’s frustrating, but it’s part of the way things work here.

Tomorrow is my last day of work.  It’s an operating day, with clinic in the afternoon.  There is a patient who is supposed to come for surgery who has a large benign ovarian mass that was first diagnosed back in October.  At that time, she was supposed to have surgery to have it removed.  She never came to have the surgery, and instead came back last week 18 weeks pregnant and with the ovarian mass now the size of a small cantaloupe.  We can take the mass out now, while her fetus is still small.  The risk is that the mass will cause her ovary to twist on itself, which would be a surgical emergency, or that it will interfere with the pregnancy because of its size.  If she waits much longer, her pregnancy will be a barrier to safe surgery.  I am afraid she will not come again, but I had no choice but to tell her the information and hope that she would turn up.  We’ll see tomorrow.

Mommy’s here!

19 April 2011.  My mom arrived today, bringing some excellent groceries from Choma.  Cheese, meat, some fresh vegetables, and chocolate for Easter.  Her journey to Macha was similar to mine, but she didn’t have to wander around the hospital complex trying to find me, someone saw her as she got out of the taxi and said, “you must be Lily’s mother, here I’ll show you the way to her” and brought her right to the guest house.  I can hardly wait to cook with some of the things she has brought.

Becoming a Tonga

17 April 2011.  Well, I would say that preparing the nshima was 95% successful.  The texture was just the tiniest bit too hard.  Next time will be better.  I attended three deliveries yesterday, welcoming two healthy girls and a boy to the world.  Here, it is tradition to show the baby to the mother before it is taken to the nursery and to say, “Thank you, mama, you have given us a son/daughter”.  Otherwise, it has been a relatively calm day.  We went to church again today.  Today’s service was lead by the youth group, so there was even more singing and dancing as well as some skits and games.  I’ve been working on my presentation about post-partum hemorrhage that I’ll give later this week.  It’s hard to believe that it’s been two weeks already, and that I’ll be starting my journey home in 11 days.  My mom is arriving on Tuesday, and will hopefully be bringing some groceries from the outside world. 

Keeping busy

16 April 2011.  Today has been a busy day.  We had rounds in the morning.  Today on pediatrics, I discharged a little boy who had been in the hospital since March 28^th.  He had initially been admitted with severe protein-energy malnutrition (a common diagnosis), but he failed to improve with refeeding, and he also had a long history of cough and fever.  He got a chest x-ray and tuberculosis was diagnosed.  Once he started on his TB medications, he started gaining weight and becoming more alert and playful.  Today was his 12^th day of TB meds, and with his weight gain he was deemed ready to be discharged.  I got to see him walk out of the hospital, smiling and happily waving his packet of Plumpy Nuts (a high protein, high calorie peanut butter that is given to malnourished children to boost their nutrition) at me.  It made me feel very happy, because there are some children who will still not be ready for discharge even after my four weeks here are up.  If a child fails to gain weight on fortified formula and Plumpy Nuts, often another underlying cause is looked for including TB and HIV.  Another happy story was a 10 month old girl who I admitted for dehydration and sepsis from the outpatient department earlier this week.  For a few days I was afraid she was not going to survive, because all we can do here is give oxygen, fluids, and broad spectrum antibiotics.  Today, though, she is looking much better and I think she will pull through.

After rounds, it was time for outpatient department patients until around 1 p.m.  After that, I had to go shopping for some more supplies.  I bought some more long-life milk and some ingredients to make dinner.  I plan to make nshima tonight (we’ll see how that goes).  I also plan to start on the maternity ward next week, and I want to take part in some deliveries this weekend.  So I went to the midwives in the labour suite and asked them to call me when deliveries are close.   I even bought some cell phone minutes for them so they will call.  I’ve already been called for one delivery, and I expect a couple more today.  Then it was time to do laundry.  Doing laundry by hand is tedious, so I tried to only wash the things that really needed it.  Like underwear.  Then I had to hang my underwear out on the clothes line for all the passing world to see.

Yesterday was a difficult day.  A young man came in to the hospital after being kicked in the abdomen during a soccer game.  He was very ill, but because diagnostic imaging is so limited we were unable to find out what was wrong.  We suspected bleeding, or a perforation of his bowel.  The medical officers wanted to wait for an ultrasound before performing a laparotomy, but before these things could happen, the patient died, probably from sepsis due to a bowel perforation.  It is difficult to see an otherwise very healthy 23 year old man die from something so simple as a kick to the belly.  We also saw a woman in the outpatient department who came for an ultrasound at around 40 weeks gestation because the referring clinical officer had thought the baby was in breech presentation, but the ultrasound revealed that the baby had died in utero.

Deliveries here at Macha are not warm and fuzzy affairs.  The women labor in a room with three other beds and are not gently coached through the birthing process but are told that they must push the baby out no matter what and to hurry up about it because someone else needs that bed to labor in.  Once the baby and placenta are delivered, the nurse or midwife checks for tears or bleeding then instructs the mother to get dressed and walk herself to the post-partum ward.  They are often discharged 6 hours after delivering.  I am eager to learn more about deliveries this weekend.

Settling in

13 April 2011.  It has been a busy couple of days.  I’m starting to get into the rhythm of the wards and other work.  I feel overwhelmed by my lack of knowledge in diseases that I am not familiar with, and I feel sometimes lost because of the few diagnostic and treatment options for diseases with which I am familiar.  I admitted a man yesterday with what I suspected was congestive heart failure, but my diagnostic options are limited to a chest x-ray.  I am honing my physical exam skills, however, and learning to use and identify signs that we only read about in textbooks.  We see a very wide variety of medical problems in the outpatient department, from children coming in with severe dehydration to diabetic patients.  Here, patients carry their own medical record around with them in a notebook, and clinical encounters are recorded there. 

In this part of Zambia, there are many rural health centers which are staffed by a clinical officer and a nurse (and occasionally some other staff).  A clinical officer is about the equivalent of a physician’s assistant.  They take care of certain problems, and if they encounter something they cannot handle, they refer to a hospital like Macha.  Macha also has a rural health center, and they refer to the medical officers (the equivalent of physicians) in the outpatient department which is down the hall from their offices.  The catchment area for Macha is about 25-50 miles in diameter.  Patients who are sick get admitted from the outpatient department, or by clinical officers.  The medical officers round on the wards 3-4 times per week in the morning, and a physician is on call every night and rounds on all wards in the evening to see new admissions or patients who are unstable or have new diagnostic information.  They are also called for difficult baby deliveries, emergency surgeries, and new admissions overnight.  After rounds, they work in the outpatient department from 11-1 p.m. and from 3-5 p.m.  If someone comes to the outpatient department who needs a procedure, they will often just walk over to the operating theatre with the patient to perform the procedure (especially things like dilation and curettage for incomplete abortion, incision and drainage of abscesses, setting broken bones and putting on casts.  Lab tests can be ordered from the outpatient department, and often the patient will come back later in the afternoon with their results to finish their appointment and get the appropriate treatment.

The outpatient department has been very busy lately.  We’ve seen a lot of measles cases.  In Zambia, children get their measles vaccination at 9 months, so most children are younger than that when they are admitted.  They are mostly treated supportively, but are kept in isolation from other children.

Days off

10 April 2011.  The public computers were closed all weekend, so I still haven’t had a chance to post my blogs.  Yesterday was a half day of work, with ward rounds in the morning and then clinic until around 1 p.m.  We also did a cesarean section in the afternoon.  After that, I was invited to dinner at one of the American nurses’ homes.  She has been here five months, and is getting pretty good at Tonga and also treated us to Zambian shima for dinner.  Shima is the local staple food, and is made from ground maize.  It is served as a hot paste with different kinds of meats and sauces.  Interestingly, this nurse lived for 8 years in Enterprise (for those who aren’t so familiar with Oregon geography, that’s only an hour or so from Baker City), so it’s very funny to run into a fellow Eastern Oregonian in Zambia of all places.  We also played Settlers of Catan, Blitz, and Mexican Train.  It was fun to get out and socialize.  I am also becoming friends with the other guests at the guest house.   The two other people here now are tutors at the nursing school, and they have been here for a few months.

Today was my first experience in Zambian church.  The hospital is run by the Brethren in Christ mission here, and church is a very important part of the weekend for many residents.  The service is conducted in English and Tonga, and there is a lot of singing.  Visitors are welcomed in a special way, by making them stand in front of the congregation and state their name and place of origin, as well as their purpose at Macha and how long they will be here.  Today was also the day of the big intramural soccer (football) game between the hospital staff and the nursing school.  It was supposed to start at 3 p.m., but it actually got underway around 3:45.  The pitch is just packed dirt, but the players and spectators took it very seriously.  The hospital staff won 2-0.

Tomorrow is another day of rounds and clinic.

First days

7 April 2011.  I haven’t been able to find time to go to the public computers to post my blogs yet, so here’s another late entry.  I had my first day of pediatric wards today.  The peds (or paeds) ward is by far the largest, with about 45 sick children to see today.  The ward is arranged into a more acute side with many different kinds of problems (it’s almost winter here, so it’s RSV season), a few rooms with kids with protein-energy malnutrition (which are kept extra hot so the kids don’t get hypothermic, but makes the weenie medical student from the US feel like she’s going to pass out), a couple of rooms with children who are more chronically ill (TB, HIV) and an isolation room for children with measles.  The medical director tells me that malaria has been almost eliminated from Macha, with only two deaths in the last year.  One major difference in the pediatric wards here is that the ward averages one child death per day.

I also took my first night of call (which technically isn’t over because it’s only 10 p.m.) tonight.  On call, in addition to admitting patients who come during the night, the doctor’s responsibility is to round on all the wards and see patients who are acutely ill or having changes in their status, as well as review x-rays and lab results that were ordered during the day.

We also have clinic every afternoon.  I am seeing patients on my own now, but I need a lot of help from the translator.  I know only a few phrases in Tonga so far.  This weekend I plan to go on a photo safari through the hospital complex and hopefully will be able to post some pictures soon.

Catching up

5 April 2011.  Still no internet, but the wireless is back up and running and I have a voucher for my internet time so hopefully I can get online soon.  I can’t quite pick up the wireless signal at the guesthouse, so I’ll have to try to find some free time tomorrow for it.  I got my feet wet in the operating theatre (it’s a theatre, after the British, not a room) today.  But not before I dropped my bag of toiletries… in the toilet.  Not an optimal way to start the day, but I did get my first actual night of sleep in three days (at the hostel in Lusaka, an unfortunate combination of jet lag, a crying baby next door, and a couple of overzealous chickens crowing in the new day starting at 1 a.m. prevented me from getting more than a couple of hours of sleep).  But back to surgery.  The operating theatre is set up much like in the US with two surgeons, an anesthetist, a scrub nurse, and a circulator.  We did 2 tubal ligations, 2 inguinal hernia repairs, and an attempt at a necrotic tonsil resection.  The tubals were done with spinal anesthesia and the hernia repairs (both on young children) were done with ketamine without a paralytic.  Neither of the kids were intubated.  Theatre turnover takes about 5 minutes.  The operating theatre is very quiet here.  No Pandora radio in the background, very little chatting amongst the providers.  One practice that is present at Macha which every resident and student who has done surgery will appreciate: between-surgery soda and crackers!  This definitely saved my life today because the operating room is HOT.  They sterilize their own equipment  here and everything is reusable except the sterile gloves.  Suture is a valuable commodity, so they are very frugal with it.  By the second tubal, I was allowed to participate more actively in the procedure, ligating the fallopian tubes and closing the incision.  Tomorrow is a day of rounds and clinic.  I’ve decided to do pediatric and maternity wards while I’m here.  I will try to do some deliveries with the midwives as well as the more complicated deliveries with the physicians.  I’ll need to have some Tonga lessons.