April 4th, 2018 by Daniel Boron-Brenner

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.