April 26th, 2018 by Daniel Boron-Brenner
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Things are coming to a close here in Macha and for the first time I feel some stirring of competency regarding what I am doing. When I first arrived, I felt myself clambering over a hump, albeit one with a steeply ascendant, and seemingly perpetual, learning curve carved into its side, in my attempt to treat patients. New medications, new dosages, new responsibilities, all of these accompanied me (sometimes overwhelming me) in my first few weeks in Zambia. Over the last few days though, I finally felt myself coming, however briefly, into my own.

For example, during clinic on Tuesday, another unconscious child was brought in while I was taking care of patients. I quickly moved him to the exam room, called for the doctor, and began examining him while the nurse queried his grandmother about what brought them to our hospital. As the doctor joined us, I started a line, we checked his sugar (and, finding it low, ordered dextrose to be given,) and I admitted him. His eyes were open and he was moving as I finished the paperwork and his grandmother carried him out the door to the pediatric ward. A small victory to be sure but I did it almost without reservation, something that I have worked on (and struggled with) since first learning to follow, and give, orders.

Fittingly, as all this is happening, my time in both Zambia and medical school is coming to a close. Both experiences have moved lightning fast and, in their inexorable demand for personal refinement, have reflected each other more than they will know. On the one hand, Macha is a medium-sized, rural institution in the Zambian bush. On the other, it is still a hospital, with a dedication to healing the sick and aiding the infirm. Like most medical students, I have pushed myself since the beginning of med school, sometimes past the limits of what I think is possible, in order to make myself better for my patients and the world we both occupy. I have felt that at Macha too. The notion that taking care of the people here demands as much skill as I can muster is a feeling that is always at hand.

Some observations then.

Infectious diseases account for most of the fulminant pathology that I have encountered. This primarily includes tuberculosis and HIV (whose diverse presentations I’m starting to count on multiples of fingers and toes). Two days ago, I helped dress the wounds of a woman with HIV whose leg has started to decompose because of her advanced disease. Yesterday, I saw a patient with TB of the adrenal glands, who was sitting up and speaking to me with blood pressure that was not far from unrecordable. Tomorrow? Who knows. The one certainty I have taken away from seeing all this is that poverty, the destitute, living-on-a-dollar-a-day kind that I have seen here, is inordinately responsible for the advancement of such awful diseases.

Another observation. By helping move patients through the wards and clinic, we have made an undeniable quantitative impact on the hospital. But I question if four weeks is enough time to make any kind of qualitative mark on a place, especially one that is used to visitors coming and going in a relatively short period of time. We’ve heard stories of other visitors, people who stayed for just a week or two and then returned home, and I have to wonder if our passage will be recounted with the same kind of half-exasperated laugh. Probably (hopefully) not. Nonetheless, my gut tells me that the next time I leave the country to work overseas, it will have to be for longer than four weeks if I hope to effect any kind of lasting change. Right now, in grand cosmic terms, my journey here has been a blip but at least one that has had a lasting impact on me.

And what is that impact? As a student in the last days of medical school, I am passing through a kind of emotional membrane as I transition from learner to provider. Granted, I will still be learning during residency but it will be an active kind of education, an engagement with patients and hospitals that I have already started to practice here. Consequently, I will be forever indebted to the hospital for encouraging me to think and act like a physician. In years to come, as memories grow short and start to dim, I feel one constant will remain: that I started the job in an unlikely place, with people and patients who put their faith in me because they saw something that I could not yet comprehend. For that, I am grateful.

April 19th, 2018 by Daniel Boron-Brenner
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After a frustrating few days at work, I finally had a good day. In fact, today might have been the best day I’ve had at the hospital so far. I saw enough patients to keep it interesting without feeling overwhelmed, I did a procedure, and I went to the operating theater. All in all, everything I’ve wanted out of this trip.

Jamie and I started the day on the men’s ward, which had three new admissions overnight. One was for a man with organophosphate poisoning (organophosphates are commonly used in insecticide and cause your parasympathetic nervous system to go into overdrive. You essentially drown in your own secretions). He had received the antidote on admission and looked fine, watching us as we walked by. The other two were much sicker. One was a fifteen year old boy with a history of cerebral malaria. I had actually seen him a few days prior and sent him home after consulting with one of the Zambian doctors. To my regret, he came back in an ambulance and we were treating him for another bout of the disease.

The last patient we almost didn’t see. Without a Zambian doctor present, we typically stop by the wards in the morning to check on any new lab results or to see patients that the nurses are particularly concerned about. That’s about it. The nurse thought this patient has an upper respiratory tract infection and wasn’t worried about him. We only checked on him because one of the clerks we work with stopped us in the hallway and asked us to take a look (they are related.) When we arrived at his bed, we found a circle of concerned family members and an emaciated, unconscious man lying under a pile of blankets. It turns out he has HIV and a history of tuberculosis. He was brought to our hospital after he stopped walking and then stopped speaking. We ordered a full work up on him, including a lumbar puncture to rule out meningitis, which I later performed. It wasn’t a “champagne tap” (just cerebrospinal fluid and no blood) but it was my first and I won’t forget it.

The rest of the day passed smoothly. We checked back in on the men’s ward to see if the results of the LP had come back and I saw the fifteen year old with malaria sitting up and eating. Small victory, he still has a long way to go, but it was a country mile from what he looked like in the morning. Then we went to the outpatient clinic and there were several Zambian doctors working (this is a far cry from the norm, where there may be one, sometimes two.) It was crowded, and between the patients sitting down or standing up in every corner of the room to talk to a provider, a little bit busy but we churned through the waiting room and then left for lunch. When we came back, the LP results were back, showing us that something was brewing but nothing conclusive. Then we were invited to theater.

We had been told that an emergency came in and we found a man prostrate on the surgical table, his abdomen grossly distended and tight like a drum. The doctors suspected he had a sigmoid volvulus, when the distant portion of your large intestine twists on itself and begins to die. Three Zambian doctors, Dr. Mulangi, Dr. Munga, and Mr. Hachobe (“Mr.” being the preferred nomenclature for a surgeon trained in the British system) were prepping him for surgery. Soon, they began. They dissected his abdomen and began making a path towards the colon. What they found confirmed their suspicions. Normal bowel is flush with blood, a healthy, almost velveteen red. This man’s bowel was enormous and black, so tightly expansive that it looked like a balloon ready to pop. It was dead, and they began running backwards to find the nearest viable tissue. When they found it, they began cutting the dead part away. They were going to create an anastomosis, a connection between the two ends of still-living intestine that bordered the dead section. Soon, they were cutting and sewing, cutting and sewing, creating a junction out of what remained.

For a while, things proceeded smoothly. The surgeons operated and made jokes, and the rest of the room joined in. People were still laughing when something, perhaps a suture or a scissor, slipped and nicked an artery. The man’s open abdomen began filling with blood. The pulse monitor, normally sedately pinging along, began sounding an alarm as his blood pressure dropped and his heart rate shot up to 150 beats per minute. The room grew quiet and the surgeons quickly started suctioning the blood and working feverishly to find the bleed. Mr. Hachobe (having deferred operating for anesthesia) secured a second line and we began pouring liter after liter of saline into the patient, trying to prop his blood pressure up until we could stabilize him. Seconds passed like minutes. Eventually, the surgeons found the source, staunching the flow with sutures, and the patient leveled off. We gave the patient a unit of blood (all that we had available) and the surgeons finished the operation without further incident.

The patient was wheeled out to the front of the theater, awaiting transfer back to the surgical ward. I went to change out of my scrubs. As I left the dressing room, I noticed it was dark. Mr. Hachobe was calmly speaking to the man’s family, a cluster of heads peering out of the night at us. I didn’t understand him, he was speaking Tonga, but I got the sense he was telling them everything would be fine. I slipped around him and we went back to the wards to add final orders for the night. As Jamie and I walked back to the guesthouse, the stars came out, shining brilliantly. The moon was brighter still, a silvery arc set against a blazing nighttime sky.

April 15th, 2018 by Daniel Boron-Brenner
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This post is one I’ve been ruminating on for a few weeks now. Ever since I got to Macha, I’ve noticed that time moves, well, a little differently here than in other hospitals (and places) I’ve been to. I don’t know if this is due to something endemic to the culture, to the low-resource setting (where things like immediate blood transfusions are necessarily held up because of a lack of supplies), or because of my own, perhaps rigid, concept of punctuality and time. Regardless, things move to their own rhythm and it has taken a little while to get used to.

Ward rounds nominally start at 8 am but can begin at 8:30 (“half 8”) or even 9. Clinic is open 6 days a week, from 8 am until around 4, but doctors may or may not appear. People work 6 days a week, but just a little longer than half days, and the only truly free day off is on Sunday, where most people spend their morning (and part of their afternoon) in church. In the United States, I am used to a strictly enforced work schedule, particularly when on a busy service. During internal medicine, I would get to the hospital around 6:30 (for a rounding start time of 8 am), and work until I was dismissed, usually 4-5 in the afternoon. To be fair, the Americans have a bit of flexibility regarding their start and end times too (things get in the way) but the residents and attendings always showed up. To do otherwise would be to invite disaster.

Urgency in the hospital is also in strange supply. Yesterday, during rounds in a side ward, a nurse walked up to the physician we were working with and quietly asked him to come take care of something. I didn’t think much of it, her voice was much too low to discern anything concerning, and so we finished rounding without him. When we were done, we went to find him in the main section of the ward and discovered that he was attempting to resuscitate a pulseless patient by himself. A cardiac arrest in the United States is (rightfully) a cause for excitement, people descending on a recently lifeless body and attempting to push life back in with medications, electricity, and CPR. Here, it was almost sedate. He gave epinephrine and performed chest compressions but the understanding that she was “gone” had already settled in.

It was a shock to see the scene unfold. While I understand that this approach is predicated on a number of considerations–the lack of resources to continue care should her heart start beating again being a big one–for a second, I couldn’t understand what was happening. As both a former EMT and a medical student, I’ve participated in many cardiac arrests and I am used to the intense focus that settles on you when a pulseless patient comes in. Because of the critical nature of the arrest, time is parsed into the smallest discernible moment because even seconds count with these patients. Instead, as I felt my heartbeat pick up, I looked around the room and I found the ward trundling along much as it had when we first started. A nursing assistant came up to me and politely asked if I needed anything. Sensing that things would not go the way I was used to, I very hesitatingly said no and went back to the patient. By this time, the code (such as it was) was over and the doctor was pronouncing her. He wrote her death note, they erected a screen around the body (which, a few minutes later, fell down on the patient in the next bed) and that was it.

Fortunately, things are not always so grim or confounding. Outside of the hospital, there is a gentle cadence to life here. There is not much to do in Macha, and so we take walks and have game nights for fun. There is school for the children but they are on break right now and I see them running around constantly. There is also some electricity in town, enough to illuminate houses and shops and a few spare street lamps at night. Outside of work, and even sometimes inside of it, I feel like I am moving slower here, as the sense of distraction, of immediacy, is less apparent than at home. I once lived in a tent for almost six weeks in college while working construction in a small town in southern Colorado. We had few amenities, mostly flashlights, sleeping bags, and canned food, and we tethered our days to the rise and fall of the sun. That was probably the last time I felt the same way. I suspect that by the time all is said and done it will be a shock to go back to the States and see how rushed things are there. And then the re-adjustment will begin again.

April 13th, 2018 by Daniel Boron-Brenner
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We rounded on the women’s ward today, specifically checking up on the patients we admitted yesterday. One of them, the woman who was brought to us septic and practically unconscious, was smiling at us as we passed by her bed. Although I know by now that any successful resuscitative effort has to be considered in the context of a patient’s entire hospital course, and that people that sick can go south on you again, it was lovely to see her feeling so much better.

April 12th, 2018 by Daniel Boron-Brenner
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Today was a busy day in the clinic. Typically, clinic is where we go after we have finished seeing the patients on the wards and there isn’t something else to do. It’s a kind of default place where everyone, from the medical students to the visiting residents to the physicians, will see patients. There are two regular desks, a smaller desk for our nurse Victor (or his alternate, Gift), and a small exam room. We have basic supplies (mercifully, gloves are rarely absent), a blood pressure cuff, a combination otoscope/ophthalmoscope (brought by one of the visiting medical students), and equipment to start IVs. There’s a light box for x-rays that sometimes turns on, opposite a window which lets in the breeze and sun. Most of the time there’s power.

People come for all kinds of ailments, from medication refills to vaginal bleeding during pregnancy to wound checks for old snake bites. There are also emergencies that come to our door, typically people presenting late in the disease process, to the point that they are burning with fever, unconscious, or (as we saw several times today) both. We deal with them as best we can but, given the low-resource setting Macha finds itself in, this typically means approaching each of these cases with our eyes wide open, examining judiciously (and trying very hard to broach the language barrier) for any clue we can find that will point us towards the cause of their condition. We initiate management in clinic–placing an IV, ordering some blood tests (relatively few available), and either starting fluids, antibiotics, or other medications (perhaps all three)–but the bulk of our interventions revolve around furiously admitting them to the wards for comprehensive management. All in all, in spirit if not in scope, not that different from an American emergency department.

As I mentioned before, today was something extra. The morning was relatively calm, just a 15 year old who may have had TB and another patient with very elevated blood pressure who we considered admitting but eventually let go home, and then we had a break for lunch. When we came back, we found Dr. Munga working and a waiting room full of people. We quickly got to work divvying up patients.

I was seeing a man with HIV and suspected urinary tract infection when someone was carried through our door. An old woman, emaciated and frail, was in the arms of one of the security guards. He placed her in our exam room as Dr. Munga examined her and quickly decided to admit her. While he was working on her paperwork, and the visiting resident and I scrutinized the vital signs and lab work for my patient (also deciding he needed to be admitted), another unconscious patient was carried into the exam room and placed in a chair next to the first. Eyes fluttering, she was barely responsive to my voice or the vigorous sternal rub I gave her. With Victor translating, we learned she had HIV, had been complaining of abdominal pain for the last few days, and had been like this (essentially unconscious) for a day. Between her presentation, her obvious fever, and some tenderness around her bladder, it quickly became clear she was septic, probably because of a raging urinary tract infection. With the visiting resident admitting her (and all of us now wearing TB masks because we honestly didn’t know what these new patients had), I finally sat down with my patient and told him, via Victor, we would also be bringing him in. He looked around the room, gave a half-hearted shrug, and said “ok” in Tonga.

April 10th, 2018 by Daniel Boron-Brenner
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Eating lunch in Zambia, especially while working at the hospital, is a hit-and-run affair. Today, I spent three and a half hours helping see patients in the ART clinic, the facility designed for HIV/AIDS patients on anti-retroviral drugs. After I was done there, I thought I could slip out to an early lunch but something told me the outpatient department (our clinic) would need some help. I stopped there and saw only one physician, Dr. Msani, working while a roomful of patients sat patiently nearby. So I ended up helping see patients with him and instead of a regular, noon-hour lunch, I ended up having a meal of boiled eggs, sausage, cabbage, and pasta around 3 pm (more on that later.) So it goes.

I typically take a minimalist approach to breakfast here. The facilities at the guest house aren’t particularly robust (we have a hot plate sitting on top of a small oven and a microwave) so it’s easier for me to load up on coffee and then start the day. Lunch is typically at the hospital guest house (a separate facility) prepared by a wonderful woman named Esther. Esther is Zambian but spent a year learning “the Western style” of food preparation and more than capably dishes out lasagna, pizza, and other carb-heavy cuisine I never thought I would find in rural Zambia. Sometimes the dishes tend to skew a bit more local, as with the plate I had today, but it was still tasty, albeit with closed eyes and an open heart.

I make dinner, with supplies gathered at the supermarket in Livingstone before I left for the hospital. I have one seasoning, salt, and some olive oil, in which I liberally sauté the vegetables that I purchased. Everything turns out to be some variation on stir fry but its tasty. Between that, and Esther’s cooking, I’m doing fine.

April 10th, 2018 by Daniel Boron-Brenner
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Yesterday, I went to church. Here at Macha church functions like an orienting force (or perhaps THE orienting force) for life in the community. The hospital sits on mission land and although the church’s reach is gentle, it can be felt everywhere. Handwritten exhortations of love and healing, underscored by Biblical authority, pepper the walls of the hospital. Hospital staff will casually mention where they go to church, or turn to you and mention how they saw you there the other day. For a non-religious person like myself, the effect was initially surprising. I am used to a religious presence in the hospital–the institution I rotated through for third and fourth year was a Catholic hospital replete with nuns walking the halls–but this type of religiosity is not common in the United States. However, after a few days it fades into the background and, as long as you observe the golden rule, even non-believers like myself get a pass.

Church itself was an experience though. For one thing, it was long. The service clocked in around three hours, only the last hour of which actually featured any type of preaching. For another, the service was packed. Singing, full-throated and with the entire congregation often joining in, was woven throughout the service. As were moments of prayer, exhortations to donate, a biblical quiz (more like jeopardy, it featured two teams and took between a half hour and 45 minutes to compete), and a short, one-act play by a troop of local children.

At one point, they asked for any new guests to the church to stand up in front of the entire congregation and introduce themselves. I had been warned about this but I stood up quickly, thinking there would be other people joining me. There were not. Nonetheless, I was treated to a lovely “Welcome” song and a short round of applause when I mentioned my name and that I was working at the hospital. Then I sat down and the deacon and a Tonga translator took turns reading off church announcements about the effort to fund a new bus.

I wasn’t raised in a religious household so for me experiences like these are refracted through an outsider’s lens. I have a hard time differentiating between what is sacred and what is quotidian, doubly so in a country (and language) that is not my own. Even so, I could feel something, the throb of collective belief maybe, while I sat in the pews. It was a little like holding your hand over a running stream and feeling the push of the water as it races past your hand. I didn’t feel like getting wet (and I don’t think I ever will) but I could appreciate it for what it was.

April 8th, 2018 by Daniel Boron-Brenner
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During one of my previous posts, I mentioned that I participated in a bilateral tubal ligation where the patient was anesthetized with a spinal anesthetic. Which means she was effectively awake as we operated. The idea of a patient watching me as I helped operate is disconcerting to say the least, as much as for the existential creep I imagined the patient experiencing as they saw me pull here or press there (“here” and “there” being their exposed internal organs) as for the notion that they were conscious to begin with.

But this post isn’t really about operating on patients who are awake (and just to clarify, the patient wasn’t watching while everything was exposed. She was covered by a thick, sterile, canvas sheet with a small field, so that she could see me and the surgeon but that was about it.) This post is more about what led to the spinal anesthetic, and other forms of pain control at Macha. Analgesia, the ability to modify the body’s response to painful stimuli, is in short supply at the hospital here. Thus, while a spinal anesthetic is routinely used for C-sections in Zambia (as it is in the US), other operations utilize it when they can, or else a mixture of ketamine (a dissociative) and diazepam (a long-acting benzodiazepine.) That’s it for anesthetic agents. It’s not uncommon to see minor (“minor”) procedures performed with a local anesthetic like lidocaine and a pinch of ketamine if things start to get out of hand.

For patients on the wards, we have paracetamol (the international name for tylenol), ibuprofen, diclofenac, and diclofenac gel. Both ibuprofen and diclofenac are NSAIDs, good at treating pain and reducing inflammation, and paracetamol is good at treating pain and reducing fever. But, again, that’s it for analgesia in the rest of the hospital. There are no narcotic agents, even in cases where the patient requires stronger pain control (such as a fracture.) Patients are frequently left to sit with their pain, utilizing what we have but essentially taking our help, at least in this regard, at a loss.

I am not blaming Macha for the lack of pain control. There are much, much larger forces at work responsible for the paucity of resources. Poverty is the primary culprit. Ketamine and diazepam are cheap drugs to produce and in ready supply. Other drugs that I am used to in the United States, such as any opioid, are just not as easy to come by and so the doctors here use what they can to get the job done.

Still, it gives me room for pause. On one level, it’s difficult to acknowledge a patient’s pain and give them what we can while understanding there are more effective agents to be utilized. On another, it is, like the patient watching me as they are being operated on, a bit unsettling to help the providers. I know the patients are in pain, yet my hands are tied when it comes to offering more effective medicine. I can only continue the course, doing what I can to help and offering condolences when I can’t.

April 5th, 2018 by Daniel Boron-Brenner
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Today’s post will be a case of the day, specifically an emergent C-section. The case came in while I was rounding in the pediatric ward with Dr. Mbanga, the ward rounder and also a general surgeon and anesthetist (many of the doctors seem to occupy several roles at once here.) After hearing about the case of “fetal distress”, we interrupted rounds to hurry to the operating theater. We found Dr. Msani, the men’s ward rounder, already scrubbed in and ready to go. After changing, we helped prep the patient. She was anesthetized with ketamine (after several unsuccessful attempt to use a spinal) and then we began the surgery. With Dr. Mbanga monitoring the sedation, and Dr. Msani performing the operation, I was the first assist, holding retractors, suctioning, and helping where I could. He quickly found the uterus, made the incision, and pulled the baby out. Although the baby was initially listless, I suctioned the mouth and nose while Dr. Msani clamped the cord so that we could move him to the nurse’s arms. As soon as the nurse took him, I heard a little cry and then they whisked the baby away to the warmer. We turned back to the mother and Dr. Msani began closing the incision in the uterus with a thick suture. As he closed, we realized that her abdomen was slowly filling up with blood and that we had missed a bleed somewhere. Minutes of careful inspection ticked by, all the while accompanied by careful suctioning, and we finally found it hiding deep behind the left Fallopian tube. Dr. Msani placed several more sutures, stopping the bleeding, and then we placed the uterus back into the abdomen. As we did, I felt it start to contract, something I will never forget. Then we closed the abdomen, cleaned the patient up, and transferred her to her bed to recover. Another C-section came in while we were closing but I was unable to participate, having gotten blood on the only pair of shoes I could wear for operating (for the curious, they happened to be Crocs, like you might wear for gardening.) I changed and made my way back to the pediatric ward as they wheeled the next one in.

April 4th, 2018 by Daniel Boron-Brenner
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At the end of the day, my boots are covered in a fine powder of red dust, except for the place where the hem of my pants fell over them. My white coat is, surprisingly, untouched, despite the ring of sweat that rode under (and later through) my collar. I am finished with my first day at Macha Mission Hospital and it has been an experience. I spent the morning in surgery, the afternoon in clinic, and the rest of the time wandering around the grounds, picking my way through buildings as I tried to connect Point A to Point B in a place, and country, I have never been to before.

To start, there are three American medical visitors working here, two medical students and an internal medicine resident. Including me, there are two of us living in the Macha Research Trust guest house, part of a research compound adjoining the hospital grounds and the town of Macha itself. The guest house is divided between the men’s section and the women’s, with a kitchen and common room in the middle. The floors are poured concrete and the doors all have clabbery, old-time locks, so that we have to carry around jangly sets of keys like little wardens. It’s also a little eerie at night–the bathroom is too big and echoes and the lights have a tendency to hesitate before flickering to life-but I slept reasonably enough despite a spate of Malarone-infused dreams.

After getting ready, we left for the hospital at 7:45 AM, intending on reaching the hospital by 8. We got lost along the way, picking our way across rutted side roads and through cornfields, until a woman who worked at the hospital led us to the campus. It was the first, but not the last time, I felt lost today. After we finally met up with the hospital administrator Dr. DeBoe, we were given a brief overview of the hospital and then we set off for the day. The hospital is divided into a men’s and women’s ward, a pediatric ward, an OB/GYN ward, an outpatient clinic, and an operating theater. With the exception of the men’s and women’s ward (housed together), the other wards each occupy their own buildings, all connected by raising concrete paths passing over plots of vegetation and red dust. There are people everywhere, a mixture of patients, doctors, and hospital staff, and everyone said hello to us as we passed.

We started with rounds on the men’s ward, where we saw a patient with congestive heart failure who syncopized and was later found to be septic. It was a bit bewildering to navigate the the triple challenge of translation (Tonga to English), reading the paper charts (and deciphering the methodology used to record patient encounters at Macha), and examine the patient but we managed well enough. After that, we all went to the outpatient clinic to begin seeing patients. Soon enough, we realized there wasn’t enough space at for three people in the small room to all see patients, so I volunteered to follow a patient with an oral abscess into surgery.

I made my way over to the surgery theater. The theater is amenable to an American operating room in both name and procedure. There is a little area by the front that is separated from the rest of the space by a curtain. Here, people change from their day-to-day clothes into scrubs, caps, and surgical masks (all drawn from a communal pool) before entering the rest of the space. The scrub sink is a scrub sink–exempting a few major differences (for example, almost nothing is disposable and things that can be reused are), the adherence to sterile procedure is nearly the same.

Although I was there to follow with a different case, I was put to work as an assist (first and only) for a bilateral tubal ligation. After gowning up, I made my way over to the operating table and happened to make eye contact with the patient. She was awake, having received only a spinal anesthetic to numb her abdomen and legs. Trying not to smile disconcertedly underneath my mask (even the minor surgeries I assisted with in the US required patients to be anesthetized), I assumed my place at the table and we began. The surgery was done quickly and efficiently. The surgeon, Dr. Mbanga, led me through a brief anatomy lesson as he clipped and tied and soon the whole thing was over.

The rest of the morning passed in a blur. My patient with the abscess never showed but I observed a circumcision on a 20-year-old and assisted with the wound re-packing of a 10-year-old boy who, under ketamine, kept staring at me with glassy eyes and saying “white man” in Tonga. After surgery was over, we dispersed for lunch and I, under a blazing sun, wandered around the hospital grounds looking for somewhere to eat. Still wearing my white coat (my first mistake) and a long sleeved button down shirt (my second), I picked my way across the grounds until finally finding my way back to the guesthouse. Lunch at Macha is a two-hour affair and I managed to cool down a bit before we set back again.

We made our way back to the men’s ward after returning, to see another patient who we had missed that morning. He was also sick, worse than the first, with a cirrhotic liver and a protuberant abdomen filled with fluid. Although we knew what treatments needed to be initiated to help this man, the question of ordering came up. Did we, as an American doctor and an American med student, make recommendations for treatment? Or did we put the orders in ourselves? We didn’t know and we didn’t want to step on any toes (especially as guests here), so, as nothing was emergently warranted, we deferred until we could discuss with a Zambian physician.

After men’s ward, we returned to the clinic. During the morning, if you opened the door leading to the public benches, you could see people lined up to see the doctor. The afternoon wasn’t as bad. The three of us managed to see patients with a Zambian physician; I spent some of the time looking for my oral abscess patient but still had no luck tracking him down. Unlike the American family medicine clinic that I just came from, with its schedule of URIs, physical exams, and other routine complaints, the patient census here was varied, in both acuity and problem. I spoke with HIV patients on antiretroviral therapy, a young, recently pregnant women with non-specific abdominal pain, and a man who carried his catheter in a bag who may have had bladder cancer. Several of the patients seen by the other providers were admitted directly from the clinic to the men’s or women’s wards, which meant either walking or rolling them over the concrete paths to the place they needed to go. The admitting complaints ranged from chronic osteomyelitis to critical limb ischemia and many of the presentations indicated the patients had been living with these conditions for quite awhile.

After that we walked around the back end of the hospital grounds, which bled into a market and also housing for the waiting families of admitted patients. The market had several stalls, selling anything from shoes to vegetables, and the smell of cookfires was everywhere. The families lived in brick longhouses, with high slung windows and people milling or squatting around them. The sun started dipping towards the horizon, a golden light suffusing everything that it touched, and we finally headed home for the day.