April 30th, 2018 by jamiefelzer
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I can’t believe my rotation is completed. This last week has been another successful one. On Tuesday morning the head doctor asked us to accompany him to a meeting. They had advisors for surgery coming to visit that come once a quarter to help ensure everyone is up to par on their techniques and equipment. It was good to see that there are groups checking up on all these rural health centers to offer some aide, however it was also quite evident that sometimes their expectations were different coming from a city hospital. Even from their last visit, the doctors had made some adjustments based on feedback and were continuing to work towards some other changes. When the inspectors brought up certain practice patterns, I was even a little defensive of Macha and wanted to say that they did a great job given their resources (but I kept my mouth shut). I had planned on going to theatre that day, but once they arrived I didn’t want to get in the way of any official visit so ended up seeing all the patients in OPD that day since many others were in surgery. Mondays and Tuesdays are often the craziest days in clinic due to the break on Sundays, so we were powering through a large number of patients.

Now that I’ve been here for a month, I’m already having repeat patients and people will come up to me to ask questions. I even had one find me before I left asking for my email address so she could follow-up regarding her son. I tried to say that I wasn’t a pediatrician (and had just remembered some key management from medical school), but she thought that I was wonderful and insisted upon following up. Obviously I stick out like a sore thumb around here, there are a total of 3 white people at Macha, including myself. I now have some understanding of what black people go through in predominantly white communities, everyone knows who you are.

We were asked to do a presentation on a topic for the medical officers here on any topic of our choosing. We weren’t quite sure what to expect for attendance because our friend had done it a few weeks before and nobody showed up. Instead of choosing one topic, we decided to start (and focus) on one area- Tuberculosis as all my public health flags were going up when actively infected TB patients were sitting next to the immunocompromised patients, as well as some other little things I had noticed. Daniel and I did a joint presentation on TB, where he talked about the pathophysiology and I focused on the epidemiology and public health interventions that could be used in resource-limited settings such as theirs. Every time I was on the wards where there was a TB patient, I talked to the nurses about moving them out to the veranda so hopefully between that and the talk, some changes can be implemented, as people seemed to be receiving them well. A big limiting factor was the lack of outlets on the veranda, and often the TB patients require oxygen, which is delivered via portable O2 tanks that must be plugged in. We tried to see if utilizing extension cords would be a feasible solution to this problem.  During the talk, I also touched upon some other updates in medicine, such as treatment for rheumatic heart disease and congenital heart diseases, and how best to treat some of these things based on more current literature.

Before leaving, we were fortunate enough to get a tour of the Macha Research Trust laboratories. MRT is funded through a large grant from Johns Hopkins Bloomberg School of Public Health. They have accomplished remarkable tasks by significantly reducing the incidence and prevalence of malaria, so much so that they are now focusing on HIV work due to the low numbers of malaria in the area. They study the mosquitos under real-life conditions in an enclosed arena that has multiple houses and mosquito nets around the beds where paid volunteers sleep. They test to see if mosquitos are able to get in the houses, in the nets and then how many die (the nets are also treated). We got a tour of the remarkably modern laboratory facilities where they have been testing and archiving mosquitos for about 10 years. They check for levels of parasites, can see if they recently had a blood meal, test the genome of the mosquitos, and so many other details. They have all the modern microscopes, centrifuges and PCR that we are used to in our labs. On the HIV side of the research we were able to see the rapid test they are currently using for adults in the clinics. We also saw the new fancy machine that they are trying to get approval for, as it would be able to give a rapid diagnosis for infants born to HIV-positive mothers. Currently, it may take months to get the gold standard test back to know if infants are actually HIV-positive because they are born with their mother’s antibodies. This new test would allow them to know within a half-hour on site. The problem with getting approval for usage in Zambia lies in the fact that they have been so successful in reducing the mother to child transmission that there are not actually many proven positive infants. Hopefully, this device will soon be available for usage as it would truly be a game changer.

On my last day I walked around with a very heavy heart. Macha Mission hospital will always hold a special place in my heart. There were many sad goodbyes to all the people who made my month here an incredible one for my learning about medicine, myself, African culture and so much more. I know it may sound cheesy, but all the stars definitely aligned for me to come here given all the connections of my past decisions, and hopefully some will be part of my future. I am incredibly grateful to my residency program for allowing me this unorthodox, but completely invaluable medical training that will hopefully allow me to become an even better physician for all my patients in any circumstance.

General Thoughts, Reflections & Responses to Commonly Asked Questions

• The human body is incredibly resilient. Situations where we would’ve given up or gone to heroics such as ventilation or even ECMO people managed to live here.
• I saw more cachectic people (body fat of -0%) in 4 weeks than I have in the past 6 years of medical training
• Families are incredibly close here; they live together and take care of one another. Polygamy is common here so there are often families with 3 wives and 30+ kids. Given that most families have 4-10 kids everyone has many cousins and grow up playing together. People typically go home to visit their families/parents no matter how far away they are.
• People typically start having kids in late teens or early 20s. They have 4-12 kids for the most part, with most averaging around 6 or 8. We made a few jokes about how most of my patients were younger than me with more kids. After 3 c-sections or per patient request (typically after 10 kids) women would get a bilateral tubal ligation. Men do not get vasectomies here, and when I asked about it people looked at me like I was crazy.
• Most people live on the equivalent of a $1-3 a day. They walk far to get water every day and eat nshima (corn meal mush) for 2-3 meals a day
• I think black people either have more rods in their eyes (night vision mechanism) or are just less afraid/more used to the dark because they walk around at night in the pitch black with no lights while I have 2 bright lights and still get freaked out
• I’m probably the only Jew in the whole country, or at least in my area. (I actually learned that there was a big population of Jews in Livingstone, and there were multiple synagogues that I would’ve liked to visit if I had more time there)
• There is a different view of death and dying here, given the life expectancy is in the 50s and the infant mortality rate is high, people are more accustomed to the realities of death
• Drivers signal to each other that it’s okay to pass because all the paved roads (and there are only a few of them) are two lanes and there are many slow trucks
• There are still chiefs and on every admission form they asked for the village and chief. The chief is like the king from the olden days where people bring presents and kneel before them. I believe it is an election process but am not sure on that. The Macha chief is very well know because of MRT and Macha hospital.
• The official language is English and that is what is taught in all schools, however each Provence has their own dialects. In Macha and the surrounding area, the language was Tonga. The words I learned were Mobooka – good morning; baloomba- thank you; gujesia- pain; huega- deep breath.
• Every morning people greet each other with a true smile and say good morning.
• Every few years there is mass distribution of mosquito nets, which are typically also treated with insecticide. MRT inspects these as part of some of their projects and finds people are using them. In return, rates of malaria have significantly decreased and this year there have only been 4 cases where there are normally closer to 50. People often stay in the compound behind the hospital if they have family in the hospital or are following on lab work the next morning, so in those cases they don’t have a net and sleep in trees or on the ground, sometimes they bring tents. They cook with charcoal out in the open  for all meals, unless they are the more fortunate few who have a stove.
• A lot of people make an income by selling items on the side of the streets, hence why it is better for people to live closer to the main highways. Unfortunately, transmission of HIV has also seemed to follow the highways and trucking routes.  The food selling was significantly curtailed by the recent cholera outbreak where people had to stop selling foods on the road due to risk for contaminated products. The cholera outbreak was actually quite promptly resolved
• Personal space is different here; transportation is often with the masses on the back of a trailer truck as people sit on their bags of rice and potatoes holding on for dear life.
• Communities have been formed in the mountains because of the frequency with which trucks would break down and people would raid the trucks
• Meat is all free range here…goats, cows and chickens all freely roam the land and eat all the grass they want. Generally, people live off the land with gardens and eating the vegetables they grow. Corn is rampant here, hence nshima being the staple here. Kids will often be the ones responsible for herding the animals and are pretty good at getting them out of the roads quickly as cars come. Cows are used more for eating than milking.
• We don’t need to talk about all the terrible bugs and gross animals such as bats and rats that are here. Despite pre-treating everything with Permethrin and wearing DEET at all hours, I have somehow still managed a few bites, but nothing too bad.
• The landscape is simply beautiful. Untouched open plains either wildflowers and sunflowers free for miles in every direction. Blue skies and pretty clouds in the sunlight adds to that beauty. I haven’t seen a sunset or sunrise that didn’t leave me in awe yet, every one is simply breathtaking.
• HIV and all related care/medications are all covered for patients through the government and non-profits, so that cost doesn’t prohibit people from getting the care they need. Through organizations like EGPAF, there has been a very significant decline in the number of mother to child transmission! During my time in Dance Marathon/Pediatric AIDS Coalition at UCLA, we always talked about the power of ART in reducing transmission, so it is so very exciting that this has been made more of a reality. DM just happened this weekend actually at UCLA!
• The diagnostic tests available and treatment regimens are very different than those we use at home. Every decision requires a more thorough clinical examination and history, as well as clinical acumen for the underlying disorder. We had to be a little more creative with medications, and be smart of our usage of certain expensive, IV medications. They were often out of key medications, such as Metformin (a standard Diabetic medication) or cephalexin (an antibiotic we use for skin infections, UTIs especially in pregnant ladies) and every decision required creativity and smarts.
• Mothers will often stay near the hospital as they get closer to delivery, especially the higher-risk mothers. Each mother will get a pre-natal card giving their birth history, LMP, EDD (however, I’ve found that many of the dates were wrong) and the card also states if they have a birthing plan in place. Mothers are advised to go to the hospital for delivery to prevent risk of complications, but many use midwives or family at home. Many places don’t have ultrasounds so they wouldn’t routinely get an ultrasound, unless there was a perceived problem. They use a fetoscope to listen for the heart rate, something I never quite mastered. Whenever we have pregnant ladies in our clinic, I would automatically check them for syphilis, HIV and anaemia.
• Everyone was very grateful for the medical care they received, even if they had to walk for days and wait for hours to be seen.

If you have any questions or comments please feel free to comment or send me a message. If anyone feels inclined to make donations to any of the organizations that I’ve mentioned during my time here, I know any of them would of course be grateful. I’ve tried to include links during each blog post of any key organizations if anyone want to learn more about a particular group and their projects.

Baloomba. Thank you.

April 25th, 2018 by jamiefelzer
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It’s hard to believe this is my 4^th week here in Macha! As it always goes, I was starting to get the hang of things around here and getting to know my colleagues much better. This weekend I was lucky enough to go on a one-day safari with two colleagues from the hospital and the research center. It’s pretty rare that one can just take a day and go on a safari over the weekend, so I had to take advantage! It was my first safari and probably one of the most spectacular days of my life. At one point a bull elephant was less than 10 feet from our boat and I thought we might get charged (the guide assured us that the elephant was on too high of a bank to jump into the river). Baby elephants played with each other in the water and through the tall grass played hide & seek. During our picnic lunch an elephant was only across the shallow river watching us eat. The hippos were fun to spot from afar as they popped in and out of the water, it was also hilarious watching them plop into the water with a big splash. I’m not normally a bird person, but even those were so colorful. One of the most interesting parts was the ride there in a 30-year old Corolla that definitely had some loose ends as we bumped across the terrible roads of Zambia. The main road to the capital is full of huge potholes and gravel filler for 70km of the 2-lane highway. It was interesting to watch how everyone drove across the area, as some went slow while others zoomed across even if they were in an old sedan versus a big 4×4 vehicle. It was all definitely part of the adventure! I should also add that my DSLR camera came back from the dead!!! I soaked it in rice for 2 weeks and crossed my fingers it would come back, and luckily it did so I could capture the beauty of these animals (although it can never truly be captured on film).

First wild elephant sighting!!

The wards here have been quite full, so rounds have been taking a few hours each day. We’ve been splitting it up so that I see half the patients and the head doc sees the other half, which at least helps us get through the large number of patients. Often the family members or nurses give me a weird look as I’m rounding, and at first I wasn’t sure if it was just because they weren’t sure who the sole white girl running around in a white coat was, but then I remembered I was wearing an N95 mask. There is a lot of circulating TB on the wards recently, whether it was TB rule out, extrapulmonary TB or confirmed pulmonary TB and I didn’t want to take any chances! Glad that again, I was a nerd and brought a bunch of these with me. Healthcare workers don’t wear the N95s here because they think they all probably have latent TB from being exposed so frequently Although, in doing research for a presentation I am giving at the hospital, I learned that adequate ventilation in a large room is best way to prevent TB (where negative-pressure isolation rooms aren’t available) and that PPE is the last resort. The ventilation system here is via open windows on the wards and through the veranda, where the TB patients are supposed to go if they don’t need oxygen (there are no plugs outside). I’ve tried to use some of my public health skills by working on the infection control practices a bit, and although I’ve made a bit of progress, I know it may be hard to maintain due to logistics. Nonetheless, I am giving a talk on that to the staff this week.

I’ve found that lately the Zambian doctors have been asking my advice of what I think is going on with a particular patient, or how I would treat a certain disease. While it is certainly an honor that they have come to think of me as a colleague, it is definitely a little scary as I feel like I am speaking on the behalf of the American Internal Medicine physicians when I’m just a second-year resident. While we were rounding on women’s ward, a lady came in from OPD to seek the advice of the head doctor I was working with, who in turn asked me what I made of this kid’s symptoms and potential treatment plan. It was a 7-year-old boy who had facial swelling, a UA showed protein and blood in the urine. Upon further questioning, I found out he did recently have an exudate on his tonsil, indicating he likely has post-strep glomerulonephritis.  As it’s been a while, or ever in real life, that I actually treated someone with this. Remembering from med school days, I thought the answer was just to treat the underlying infection to prevent rheumatic heart disease while otherwise managing supportively. Not wanting to give the wrong answer though, I luckily pulled out my phone and double-checked myself on up-to-date which confirmed my thoughts, phew! The mother then found me later in the day to ask if she could follow-up with me. While I was certainly flattered, I told her that I wouldn’t be here and that I’m not a specialist in pediatrics, (and just happened to remember some details from medical school boards).

Some updates on some of the patients I posted about earlier…the gentleman with paralysis, I thought likely had neurosyphilis unfortunately passed away over the weekend.  Even on Friday, I could tell he was decompensating and didn’t think he would still be around when returned. However, the lady who had a GCS of 3 who we also performed an LP on and started on Acyclovir (and continued Ceftriaxone) has turned the corner! Not sure exactly what made the difference but she is waking up a bit!

We never know what will walk in the door in clinic, and probably half our patients are pregnant ladies and pediatrics which I am not trained in but have had to learn here! In this time, I’ve become a little better at managing them. Still not completely comfortable beyond ordering some tests for the pregnant ladies, but feel as though I can handle the kiddos alright by now. And, they’re typically pretty darn cute, so that helps matters! My pocket pharmacopedia has helped me immensely as I try to figure out dosages of medications for the kids. Needless to say, OPD is always an adventure where you never know what will come in. It is virtually an ED where some are unconscious while some are walking and talking. There are also Clinical Officers (CO’s) that will see the more straightforward patients (sometimes). Occasionally they’ll start the work-up and send ‘em our way afterward for further treatment. Still, the hardest thing about clinic (and the hospital) is not being able to run the diagnostic tests I am used to running. Despite the fact that we probably run too many tests and extraneous labs at home, it involves a lot of guess work here without further imaging or testing. Much of the diagnosing here is more based on clinical acumen and gestalt. When you’ve seen it all that works great, but I am used to data, and I can’t always elicit the data I want just from the physical exam so I am working on making that and my history my main diagnostic indicators. That is after all, a big reason why I wanted to come here to learn and practice my skills while helping those who truly need medical care.

April 20th, 2018 by jamiefelzer
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Today was a great day! It was how I had hoped more days would be here, where I felt proud of what I had accomplished and had made a difference. The day started at 8 when Daniel (med student also rotating here) and I started our rounds. We checked in at men’s ward and found that there were 3 new admissions overnight; one was a teenager we had seen in clinic with recurrent, severe malaria (likely cerebral), another was an organophosphate poisoning and a third we were told was just a respiratory tract infection with anal sores who was stable. We went around checking on our other patients, who were a TB patient who was just now starting in improve; a bounce-back with heart failure who also had pneumonia this time, but was doing significantly better; an HIV positive young adult who was doing quite poorly and since he hadn’t responded to any other treatments and all of our tests had come back negative, we started him on anti-tuberculous drugs a few days ago for extra-pulmonary TB.

Then we went to check on the guy who we were told was just a respiratory virus, but was in fact very ill. We proceeded to ask the family a multitude of questions and found out that he was HIV positive, had been treated for TB three times in the past, had a history of being positive for syphilis but unsure if was treated. His HIV meds had also recently been changed and they knew his CD4 count was low (tells us how advanced his HIV is). He came in because a week ago he had paralysis of his right side which then progressed to his left. A rural clinic said that he likely had a stroke because he had also been found to have high blood pressure a week ago. Concomitantly he also had a minor cough and a recent history of diarrhea. His anal sores the nurse was trying to tell me he should’ve been admitted to the surgical ward for, were actually condyloma lata which is a sign of syphilis. His son told me that prior to this he had still been sexually active with his two wives, and added that he had divorced three already. So many red flags went up after hearing his story. There had been no diagnostic work-up ordered upon admission, so I immediately ordered some STAT labs and told the nurse and family he was going to need an lumbar puncture because I was concerned about meningitis vs neurosyphilis. Since he received much of his care at an outside facility, they gave us his Care Card so that we could plug it into the computer and see all of his records. On the way to the HIV clinic, we luckily ran into the head of the hospital and told him about this patient and that he needed an LP. He agreed with everything I had already ordered and said he would be by shortly for the LP.

Before seeing that patient, we stopped by the female ward to see two of the sickest patients. One of them was a lady I admitted a few days ago who has had a GCS of 3-6 on a good day (completely unconscious for the nonmedical folk) for 4 days now, and I’ve been suggesting that we do an LP on her, but the nurses and family were concerned she was took sick for this. Finally the head doctor agreed that we should just do it since she wasn’t improving despite being on medications that should’ve treated all the usual suspects. I was happy to see that the nurses had been diligently recording her turnings every 2 hours to prevent bed sores, the feedings through her NG (mostly porridge and protein shakes). Luckily, I was easily able to get a clean tap on the first try for the LP and we sent it off for studies. Since I did that one, I let Dan do the other guy so he could do his first ever LP! We then went back to round on the sick patients in women’s ward before going to outpatient clinic.

One of my first patients in clinic was a guy who had a motorcycle accident  a few weeks ago and was coming to follow up with the orthopedic doctor who was supposed to come today. However, there was no fracture and a very large effusion so they asked me if I could just tap it. So in the middle of the clinic where there were 3 providers simultaneously seeing patients, I tapped his knee and was surprised to encounter a lot of blood that was in his knee joint. I pulled out about 25ml of blood from his knee and had to ask someone to come over and help hold a container so I could keep dumping my syringe and refill it, since they only had 5cc syringes in clinic. Already today, I was busting out procedures well on my own and was hopefully making a difference in getting these people feeling better. Early in the day, one of the house mothers from the orphanage came to check in with me about her health and showed me her log of how well she had been doing exercising. I was so very proud of her!!

We worked in clinic for a while longer before breaking for a late lunch. One of the doctors calmly dealt with a lady that came in on a stretcher for severe hypotension due to an incomplete abortion. He promptly took her to surgery and stabilized her we learned as we were leaving for lunch. Ester had prepared a delicious meal for us, and had just finished serving lunch for visitors from the CDC Zambia who were here doing some work.

Everyone told us they would be back at clinic at 1430, but alas we got there and there was not a soul to be found. Without a nurse or clerk to translate for us, we sadly couldn’t see patients. I felt bad for the bunches of people all sitting in the waiting room to be seen, but without speaking the language there was no feasible way to see them, regardless of the fact that there were no Zambian doctors there. One of them later arrived and told me that, “white people in America are too punctual and that’s why blacks don’t do well there; because black people are lazier and always arrive a bit late, while whites arrive before the stated start time.” He told us this as we were all walking to theatre for an emergency laparotomy for a sigmoid volvulus.

Now, I don’t see many surgeries any more, but I think that was definitely near the top of my most impressive surgeries. Three of the docs were there, two as the surgeons and one as the anesthesiologist (spinal block and then ketamine). The guy had come in from a rural clinic for apparently 2 days of abdominal pain, but we later learned we think he was probably taking some herbal remedies for this for longer. He already had an NG tube in and foley catheter and his stomach looked like a balloon. They opened him up and then instead of nicely colored pink/red there was black. They pulled it out and the black colon that was blown up the width of my thigh (pretty big) looked like it was about to pop open. I was so very glad that yet again I had my eye shields on and a thick face mask! The dead balloon bowels just kept going and going! They eventually were able to clamp it and cut it off and oh boy, did it smell! Right about the time of removal, the patient started hemorrhaging. His vitals quickly showed this so we bloused fluids, started more IVs and gave him Ketamine at that point to actually sedate him. Luckily, a shipment of 3U of blood had been delivered (we had to transfer two patients to another hospital earlier today because we had no blood), and one was reserved for him. Things were taken control of somewhat quickly and the surgeons masterfully stopped the bleeding and sewed his bowel and abdomen back together. We all had some laughs as they were trying to figure out how the new drain bag worked, and when the patient was trying to remove his restraints and grab the surgeon from behind (he wasn’t intubated or paralyzed because they use Ketamine for general anesthesia, although I tried to encourage usage of at least an oral airway). These docs here do deserve a lot of respect, even if they do tend to show up late. They can manage almost any aspect of medicine in a snap!

All in all, this was the kind of day I hoped every day could been; full of interesting diagnostic dilemmas and actually making a big difference by seeing very sick patients that may not otherwise have been seen for quite some time and adding to the treatment decisions.  And it’s also quite exciting that this weekend I get to go on safari! Not many times can one do that during a rotation!

April 17th, 2018 by jamiefelzer
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I’ve gotten lots of questions about what life is truly like in Macha, so I figured I could dedicate a blog post to them…

The MRT hostel

My living quarters are part of a nicely constructed brick hostel that can house up to 36 people. There are two wings, men’s and women’s and within each wing there are shared rooms and individual rooms. I am in a shared room with 2 bunk beds, although luckily, I do not have to share. Each bed comes with a mosquito net, and being the OCD person I am, I patched up a few tiny holes on mine. They provide us with sheets and a towel. Each room has a sink, light and fan. Our power works at all times of the day and we’ve only had one very brief power outage because there is a generator. Down the hall in each wing is a bathroom with multiple toilet rooms and showers (there is even a handicap accessible toilet). We are the lucky few that have running water and overhead showers at all hours of the day. Most people take bucket showers and don’t have running water except for 4 hours a day. The water isn’t always warm, but it isn’t frigid either generally. The complex I am staying in is part of the Macha Research Trust, which has gates on all sides and is locked from 2200-0600 every night. From what I understand, we are the only ones that have running water at all hours of the day, and our water is safe to drink since it is from a deep well, not the local borehole that most people’s water is fed in from.

Ester in her amazing garden

We have a kitchen in the hostel complete with microwave, toaster oven/stovetop, fridge/freezer, water boiler. We have been cooking most of our meals with our very limited non-perishables because there is not a real store for over an hour away on a very bumpy road. There is a small market behind the hospital where we can get rice, beans, some tomatoes and there are a few little general stores with peanut butter, soap and an assortment of other items.  We had thought that we would be able to get cooked meals here, but that hasn’t really come to fruition. Instead, we’ve been going to the hospital guest house which is run by the wonderful Ester. She is a fabulous cook and we’ve been enjoying getting lunch from her. This is now her third guest house she has run, and the first that she has started from scratch. Prior to starting this, she was actually working at New Day Orphanage, where I was last week. However, she is from Macha and her mother is elderly so she wanted to be here to take care of her. Outside of the hospital guest house, she has a very impressive garden which we were fortunate to walk through the other day. There were all sorts of vegetables, herbs that she uses to make her sauces from scratch, and there was even a natural squash luffa that she gave to us! Meals will generally consist of a protein, rice or nshima (the local dish that people generally eat for 2-3 meals a day, made of corn into fluffy cake) or pasta and a veggie. At home for dinner, I make an odd conglomeration of canned veggies, rice/quinoa and canned chicken if I treat myself. Peanut butter was definitely the smartest thing for my to bring as it goes well with any meal, dessert or snack! In the mornings I have some instant coffee and either some instant oatmeal I brought (but am now finished with sadly) or some granola (without any milk or yogurt) so I just have crunchy granola. We did find some eggs at the market the other day, so were able to treat ourselves to an egg scramble which was lovely!

entrance to the hospital

The walk to the hospital from MRT is about 7 minutes and is over a dirt road that for part of the way is lined with gorgeous yellow-flowering trees that always make me smile. I’ve already spoken about the set-up of the hospital in my initial post so I won’t bore you with that again. Typically, the doctors round on each ward 3 times a week, so what I’ve started doing with the medical students is rounding on any sick patients or those with new labs every day and we will make any changes if necessary. For anything major of course, we run it by the local docs. During rounds I’ve been typically splitting up seeing patients with the attending when it’s busy, as it has been, so rounding doesn’t take 3 hours in one ward. I’ll briefly run the plan by him after I’ve seen my half of the patients and then take care of the rest, as long as I have a translator (which is often the limiting step)! The outpatient department is a first come, first serve set-up and people may come from all over. Sometimes people are referred there from another clinic, sometimes they come in unconscious, or with products of an abortion, or ready to deliver, or with terrible non-healing wounds, or fractures that they’ve been walking on. We literally never know what will amble through the door when we sit down!

My favorite part of the walk

In the evenings, we’ve been doing a lot of reading on topics of diseases we don’t typically encounter, or new iterations of diseases we’ve seen, or trying to find out if there is any literature to support certain practices that are performed here. Between that, blogs, and doing my various research projects that keeps our nights busy. We only purchased 25 GB of data for 2 of us to use for the entire month, so have to be careful on how much we use. We were so very lucky that somebody had an extra router and sim card for which we could just purchase time, otherwise we’d totally be without connection to the world! There is really nothing much to do here after dark, and I don’t like to be out after true dark as there are no lights outside our complex, which does have street lights. We have gone to a game night and a movie night which were both wonderful, but the walk back seemed so long despite bright lights we carried!

April 15th, 2018 by jamiefelzer
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Friday reminded me of why I went into public health and medicine, and seemed to connect the puzzle pieces of my life choices. One of the many reasons why I went into public health was my experience in Dance Marathon (DM), where we focused on HIV awareness and education, and our main beneficiary was the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF). Through my involvement on the Operations Committee and DM as a whole, I realized I loved where medicine intersected with the public in education and programs. Both in college and medical school, my love for making medicine available to a wider community of people came to fruition when I had the opportunities to go to Peru and Ecuador. It was full circle going to the village working with the ART clinic because it seemed like all my life choices were coming together in one point. The doctor running the ART clinic in the villages was working in the pediatric department and we started talking a lot about the prevalence and incidence of HIV in the area and how treatment was affected by various programs. I then mentioned about EGPAF, not really sure what to expect when he answered, but was certainly surprised to hear that there was a multi-disciplinary partnership with CDC/PEPFAR/EGPAF for management of HIV-associated care with Macha Research Trust for 5 years. Right there I felt that all my life decisions including Dance Marathon and its affiliation with EGPAF, working at CDC, and now coming to Macha hospital and the research trust were connecting and making sense. Coincidence? I think not. I think it was a sign that all these decisions I labored over throughout the years had  happened for a reason.

The ride to this rural village of Mobola took at least 2 hours, even though it was only 40km because of the poor condition of their “roads”. There were only a few miles of paved road, the rest was a dirt road that was ravished by bad rain storms and hadn’t been leveled in years. Bumpy is a light term to describe these roads. We had to keep switching sides of the road based on what the best path was at the current time. Luckily, there weren’t too many other cars that we had to pass as we were weaving all over. Often, the smoothest part of the road was on the edge, so we were tipped over, sometimes at a pretty steep angle. There were certain times when we slowed down to only go a few miles an hour because there were massive pot-holes and as I looked around in the van, where I was knocking knees with 7 grown men in the back, we looked like bobble heads on steroids. I told my Zambian colleagues that people at home only do this for fun in an off-roading vehicle. The crazy part was that I could even show them pictures of my brother off-roading in his truck on Instagram in the middle of Zambia. How far technology has come! By the time we reached our destination, my legs and knees, as well as my tush were all hurting. We had brought all the meds and other supplies, including the patients’ charts with us, so we unpacked everything from the roof of the truck prior to starting clinic.

Loading up the van with all the supplies

We set up shop in the clinic, which normally functions as a general clinic that is run by community health workers and nurses. There are generally no clinical officers (similar to a PA/NP) or medical officers (MD equivalent) so there were a couple of sick patients that the CHW came in to ask us to see. The biggest limitation was the lack of medication, especially when trying to treat a pregnant, HIV+ lady with foul-smelling discharge and pain with urination. We had to empirically treat her for a UTI/GC/Chlamydia/candidiasis because we had no culture data and those items were high on our clinical suspicion based on the examination. However, we only had mostly oral agents, some of which were not advised in pregnancy so we had to keep altering our choices based on what was available and safe in pregnancy. So glad I brought my pocket Pharmacopedia and Sanford with me to help in these situations!

In front of the clinic where some local ladies were posing for a picture and wanted me to join

The kids and their parents filtered in and we checked to see how they were tolerating their meds, if they were having any side effects or other illnesses, and on their medication compliance. Each child had to be weighed prior to seeing us, as their meds were dosed based on weight, and medication regimes were altered after a certain age. Most of the children were doing well and just had to get medication refills, most of which would return in 3 months. If changes were made, they were asked to come back in 1 month. CD4 counts were generally checked every 6 months and viral loads every year (which take 3 months to sometimes come back). For the most part, people seemed to be doing well with their treatments. One case that struck me was a 12 year old boy who appeared no older than 8, whose mother had died shortly before the time of his diagnosis with pulmonary TB and HIV at age 8. He was successfully treated with anti-tuberculous medications using DOTS (directly observed treatment) and then initiated on ART. He also unfortunately suffered from ringworm on his head that was complicated by a superimposed bacterial infection, which now left him with huge scars on his head. All of his illnesses have clearly stunted his growth, and he is doing much better now and cared for by his aunt, but it just breaks your heart that this kid at 12, has gone through more than hopefully most of us have to deal with in our lives.

In the room where I sat they also had their refrigerator for the vaccinations, and charts of their vaccine coverage. Again, the public health nerd in me was very excited by this data that they had collected and that was displayed. Some of the staff were doing blood draws for those who were due (and we brought all the samples back to Macha to be run), but there were having a difficult time with some of the draws and needed a doctor to help. Ironic because I haven’t drawn blood in quite some time. Nonetheless, the first was a 4 year old boy who I had to draw blood with via an 18-gauge needle (very large) plugged directly into the vacutainer (so there was no flash indicating when I was in the blood vessel). Every time I got near him he flinched, making things even more difficult, but I was successful. Instead of alcohol, they soak a large container of cotton swabs in purple-colored spirits to clean the site. The even trickier one was a 10-month old who I had to do a femoral stick. I found my landmarks and as I was trying to get blood she starting peeing like a fire hydrant as she wasn’t wearing a diaper which of course made me pause for a moment and try not to contaminate my field. I was glad when that one was over successfully.

The water pump outside the hospital

Today was a crazy day at the hospital! We first rounded on the men’s wards which wasn’t all that out of the ordinary with some sick HIV patients who we didn’t really know what was going on based on our limited testing capabilities. Then I went over to women’s ward, which was sadly like one big TB ward. So glad I brought plenty of N95s! There are only a few places where they have power to give oxygen and they had moved one lady from the veranda (true TB area) because she needed oxygen and was more somnolent. She was HIV+ and hadn’t been eating for weeks. Next to her was a 44-year-old lady the doc called Asthma exacerbation because she had chest pain and shortness of breath but when I looked at her she was very sweaty and breathing fast. I thought she might’ve had an MI, PE or been septic but there was no data, nor any interventions should she have most of those items, so she was treated with some steroids and inhalers. Sadly, by the time we finished rounding we were casually called to her bed because she had stopped breathing and was pulseless. We gave her adrenaline and did some chest compressions, but there was sadly nothing more we could do for her. Even if we had to had been able to resuscitate her, we didn’t have advanced life support or even an EKG machine to see the type of rhythm she was in.  It felt terrible not being able to do anything more for this poor lady, leaving her husband alone with their kids and newborn.  Unfortunately, death is a common thing here as the infant mortality rate is quite high.

Another lady who was HIV+ and previously had TB had an entire lung that was whited-out, which made us concerned for multi-drug resistant TB. We sent off a gene test for resistance patterns of TB but started her on the regular treatment for TB as we didn’t have any more advanced medications. There was also a 24-year old girl with HIV who had a terrible nose bleed and GI bleed with a Hgb of 2.8!!!! (normal is at least 13 in a female, in the US we transfuse at 7, they transfuse at 5 or 6 because so many people are anemic). Her platelet count was also very low, as were her WBCs. With our limited testing capabilities and limited products we weren’t left with many options except to re-check her counts and try stopping her bleeding best we could with packing, treating for parasites and giving Vitamin K.

My success story  of the day was an HIV+ lady that came into clinic virtually unconscious 2 days prior. I did successfully resuscitate her as a septic patient, and was so happy to see her sitting up in bed smiling without any further episodes of fever and only mild hypotension. After 5 hours of rounding on these terribly sick patients where I felt helpless with the limited options, I was exhausted and ready to get some hearty food at Ester’s.

April 13th, 2018 by jamiefelzer
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The Orphanage was not what I expected, but in a good way! I truly had no idea what to expect going here for a few days, but it was a wonderful experience I will never forget! This place is really amazing! I was taken to the New Day Orphanage by the director of my hospital through the really bumpy road from Macha before we reached the blacktop and then went on another dirt road. And that was when we stopped because the bridge that was there is no longer a bridge. Apparently, about a year ago a large lorry went over the bridge (which is just a poorly built concrete slab) and half of it fell in. Ever since then it has not been able to be fixed despite numerous pleas to the Zambian government, and at this point it appears that it could be a few more years until it is fixed. I was met at the bridge by the co-founder of the orphanage, Wes, and some the older boys so that we could walk across and have fun driving through the back country mud road through the bush en route to the orphanage.

The bridge that is broken. And yes that is an ox cart that is crossing the bridge!

I was given a tour of the campus by their lovely new admin assistant who just moved here from Lusaka. On our walk around campus, I was greeted so warmly by all of the house mothers and the children, and instantly felt at home. Wes and Laurie started the orphanage many years ago, but have been at this site since 2011. Prior to them building here it was truly the middle of the bush with nothing around, and now they have completely transformed the area into a thriving community. There are currently 37 children at the orphanage, with the newest edition just a few weeks ago (She is absolutely adorable and I wanted to bring her back with me to friends with my baby cousin who is the same age). Up to eight children live in a house with a Zambian house mother who teaches them local traditions and looks after them. They all eat together in the mess hall where they have a combination of traditional foods as well as some other cultures of foods. Additionally, they have built a wonderful school on the campus, for which Laurie is the school principal and teaches some of the lower grades. The kids are currently on school break, as they are on a year round school schedule. They all seem to excel in their school and typically beat out other kids of their age, or even older ages. School is taught in English, but they also have a Tonga class, which is the local language here. Additionally, they have home-ec, physical education, art, theatre, in addition to all the regular subjects. The teachers are generally Zambian, and the goal is to keep them in their Zambian culture so that after their schooling is completed they can become a vital member of Zambian Society. I have no doubt that all of these children will do great things after being raised here!

The beautiful school library. Definitely one of my favorite places

One of the very neat rooms. I was impressed at generally how clean everything was!

I stayed in the facility called the Ark, which is a house all of their visitors, of which they have many visiting team members to help build parts of the Campus and conduct activities. The Ark was wonderful! There were many modern amenities in the kitchen and room was large, and I even had a full bed with a mosquito net and my own bathroom. In some of the other rooms there were multiple sets of bunk beds to house a larger number of people. There were comfortable sitting areas and multiple tables for eating. They even have Wi-Fi! So even though we were situated out in the bush, I certainly didn’t feel like I was out there! There were no stones left unturned as they even thought to have solar powered lights in every room and bathroom for power outages. They had arranged for someone to come cook some meals for me as I didn’t have any supplies of food that I could bring with me. The food was delicious and well balanced (I had been craving some veggies and they had them!). I was also quite excited about the real coffee that was available instead of instant which was what I’d been having (fine, call me a coffee snob). Wes and Laurie, and sometimes even others, joined for meals and conversation each day, which was so wonderful getting to know them and partaking in lively conversation.

A pano at sunset from the top of the water tower

My first healthcare task was organizing the medicine closet and working on the first aide kits in each house. Being a bit of a neat and preparedness freak, I enjoyed this part a lot. My big health interventions consisted of individual consultations with all of the adults that work there, including the house moms, many of whom had not been to the doctor for quite a while (mostly because they didn’t feel they needed to, not for a lack of access as transportation and some healthcare costs were covered for them). Although my supplies were limited, I was glad that I had a BP cuff, pulse-oximeter, otoscope and ophthalmoscope and limited over-the-counter meds. Many of their blood pressures were quite elevated either due to lack of medication or lack of awareness, or even because they didn’t want to believe that they had a problem despite being told they did in the past. I sat down with them each discussing the importance of dietary and lifestyle management issues, and that they needed to come to the outpatient clinic for repeat blood pressure check and most likely some new medications for many. Many of them had gained a significant amount of weight since nothing at the orphanage because now they had food provided for them (much of which was high in oil and salt), and they didn’t have to walk very far, whereas previously people would walk miles everyday just to get water, let alone go anywhere. After talking to and assessing each of the house parents, kitchen staff and other workers about improving their health, I then talked to the kitchen staff about making some significant changes in the way food is made by decreasing oil, salt and carbohydrates as well as increasing vegetables and whole grain intake. They had a brand new kitchen manager who was very excited about improving the quality of healthy food and was planning on going to the store the day after out talk in hopes of picking up some better options.

Love that all the kids were very excited about getting their check-ups

I also made each house mother/father a sheet to record how much they walked each day for the next 20 weeks, and encouraged them to increase their walking. Each day when I saw them, they were very excited to tell me that they have been working out that day and had already started to feel better. Those that had medications were compliant with their meds, and wanted to keep up the exercise. I’m so excited to see people start to take control of their health after just some good discussions. I’m not sure exactly how long it will last, but I am optimistic! I checked up on the health of all these people throughout my stay come and hope that some of the changes I helped encourage would be sustainable measures for long-lasting health. The kids, of course we super excited to have me listen to their hearts and take their blood pressure as well. I’m always glad when kids aren’t scared of the doctor, because in clinic a baby just looked at me and started crying! Another impressive healthcare they provide, is that they have teamed up with a prosthetic team from Texas, Prosthetic Promises, who comes a few times a year to build prosthetics for locals. New Day has built a gorgeous clinic right outside their property so that the entire community can come to have custom-made prosthetics, amazing!

My first group of kids doing gymnastics

the older boys at the end of their lesson

It also was so perfect that I got to combine my two loves, medicine and gymnastics! As soon as word got out that I was a gymnastics coach, all the kids were asking when they’d get their gymnastics lesson! They had a trampoline on the campus so I took the kids over in groups to teach them the basics. As I would with any classes, started with a good warm-up, teaching them all the positions and the importance of stretching. Then, we went right into the basic gymnastics skills starting with forward roles, handstands, cartwheels and leading into round-offs. I was so impressed that some of them picked it right up! We then moved to the trampoline where I taught different jumps and skills in a brief routine. The older ones even got to work on their flips, some of which were excellent. Seeing the huge grins on all their faces was so priceless.  I taught about four groups like this and the older girls begged me to come back for me, so we went back right as a downpour happened. Like most kids, they didn’t let swimming in the rain stop them and kept on doing all their new tricks together on the trampoline, singing and dancing the whole way through. One of the cutest parts of my gymnastics coaching was when I took the under 3s to a closer grassy area and sat them down to stretch them to my favorite warm-up song, “Head, Shoulders, Knees and Toes” and all the older kids came over to help them. The big brothers and sisters continued to help as we transitioned into some forward rolls. The older children were a huge help and truly relished in helping to teach the little ones. This is what the orphanage was all about, helping one another in this big, happy family.

These adorable kids wanted to take a group picture after our gymnastics

It was incredibly hard to say good-bye to all these wonderful people and hope that someday I can make it back. We piled into the truck and made it over the bridge that collapsed thankfully, where I was met at the onset of yet another bumpy gravel road so I could make it back to Macha. I was just in time for rounds and a crazy day in outpatient clinic where I was the only doctor, so tried to help precept for the 4^th year med students. This was an especially crazy day as we had multiple people carried in by family members pretty much unconscious. All in a day’s work in Zambia!

The boys helping out with construction… or just playing in the dirt? 😉

April 8th, 2018 by jamiefelzer
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Tomorrow morning, I am headed out to the bush (I know many of you may think I am in the bush now, but am actually in more of a “wealthy suburb”). I have been invited to an orphanage a few miles away, across a bridge that actually has a massive hole in it, so I will likely have to walk across. I am still unclear of exactly what my role will be, but apparently the children and staff have not had a healthcare practitioner in years and they have invited me to help bridge that gap. I do not know what I am getting myself into, but am excited (and a bit nervous of course) about this opportunity to bridge another gap and help more people in need. It is unclear if I will have any medications at my disposal, but I will do the best with whatever I have.  I won’t be bringing my computer with me, as I am unsure of the security situation. I will post once I return about this experience.

Otherwise, it was a lovely weekend. We rounded on patients Saturday morning then went to outpatient clinic, where I ended up admitted a lady with HIV who likely had TB due to her 40lb weight loss in 2 months! We had a lovely lunch at the hospital guesthouse, cooked by the always wonderful Ester and then retired back to MRT for some relaxing as it was quite hot outside. Once it had cooled down a bit, I went on a run with some other ex-pats. The entire way, I felt as though people were staring us down, wondering what these strange white people were doing, and why we would want to run for fun. Saturday night in Macha was full of raging as we played LIFE! MRT has plenty of games to choose from! We had hoped to watch a DVD and after carefully choosing from the selection, we sadly realized the DVD player no longer worked. Sunday was lovely, as I slept in for the first time in weeks, and was actually able to enjoy my cup of coffee and read my book out on the veranda in the lovely cool breeze of the morning. I was able to get some work done and then a couple of us walked around town before cooking a family dinner 🙂

Beautiful wildflowers all over the area, as seen on a walk, with a typical thatched roof building in the distance

April 7th, 2018 by jamiefelzer
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So much has happened since I last updated here! But let’s start with today… Friday is theatre day (OR day for those of you not used to the British terminology). It was a fascinating day filled with many surprises and learning, as well as incredible respect for these doctors here who truly do it all. The doctors I’ve been working with in clinic and on the wards operate and do anesthesia like it’s no big deal. Now I know that’s the epitome of a true general practitioner, but being able to do skin grafts, c-sections, tubal ligations as well as think through the medicine side of things is pretty impressive. The doctors here work 6 days a week, every week, and sometimes will also come in on Sunday or in the evenings if there is an emergency. Now granted, their hours are a little different than mine when working 6 days a week, they typically work from 8-5 with a 1-2 hour break for lunch depending on the patient load. We sometimes get frustrated because they do not show up when they say they will for rounds or theatre clinic and I am left to run clinic on my own, but they do work an incredible amount, are quite intelligent in every field of medicine and take care of quite a lot of patients, so I have a great amount of respect for them.

The beautiful road to MRT

Now back to theatre, so I showed up after rounding on my patients and waited for the real docs to show up. Once they did we got straight to work. Theatre comprises of a separate building, and much like at home you cannot cross the red line without proper attire on. They have their own (mismatched and even dress) scrubs and shoes that must be worn when entering. There is a major theatre and 2 minor rooms, each of which have their own air con. There is a central scrub area, which although slightly different in practice (we scrubbed with a bar of soap and a touch of chlorhexidine rinse), the concepts were the same and everyone was very careful about sterility. Another interesting difference was that most of their sterile drapes and gowns were reusable in that they were cloth and could theoretically be sterilized.

First up was a bilateral tubal ligation for a 35-year-old woman who was in a polygamy marriage where there were 3 wives and 32 children between them, 10 of which were hers. It seemed like they did a lot of BTLs here so I asked if men ever got vasectomies and everyone at the room stared at me in shock. I gave her spinal anesthesia for this procedure with one of the doctors who had done training in anesthesia prior to his general practioner training. After this in rapid succession because the docs split into their own rooms was: a lady with genital warts that hadn’t responded to medical treatment so after a battle trying to get the stirrups in place (that took quite a while!), we were able to cauterize all the lesions off. Next was a 2 month old boy with a frankly purulent abscess that was drained from his neck, dressing changes that I actually did on my own for horrific wounds. The first dressing change was a 9-year-old boy who had a septic knee now status post multiple wash-out for pyomyositis with 3 massive wounds that were packed. I irrigated all the wounds very carefully as I didn’t want to spray anything and then just dressed it so we could start to allow for healing. It almost looked like there was gauze still in there initially, but I quickly realized that was just muscle and tissues that had the imprint of gauze. His procedure was done under ketamine (as all general anesthesia is done here) so he was saying some funny things in Tonga the whole time. At the last dressing change he kept repeating “white man” to my colleague. The next dressing change I did was on an HIV positive woman who had what was presumed to be a venous ulcer that turned gangrenous and by the time she made it here had ulcerated the entire medial portion of her leg and there was absolutely no skin left. She will eventually need a skin graft.

The next case was an emergent c-section for a lady I had admitted from clinic the day prior. She was having failure of labour progression, which we found out was due to a cord being wrapped around the baby’s neck. They decided just to go with GA (Ketamine) instead of a spinal and we were able to get the baby out pretty quickly. Took the baby a little long to really start crying but he did well. Suction was certainly not great and they don’t have cautery, but we were able to stop all the bleeding by tying everything off. We then received a call about a lady who came in from a rural clinic after an abortion at 4 months (which was spontaneous miscarriage) who was hemorrhaging from retained products of conception. She was hypotensive and confused so we bloused her with fluids in both arms and took her in for a D&C. We scrapped out all the products but yet she continued to hemorrhage. It was scary that we couldn’t get her to stop bleeding. She was clearly in pain despite being on Ketamine, so we just kept giving her more. They called in another doc and despite being able to feel the fundus of the uterus without any retained products of conception, the bleeding wouldn’t stop. We ended up putting a condom on the tip of a foley catheter and tying it off twice to obscure it. The first time we inflated it she pushed it out thinking it was a baby so we ended up suturing her cervix closed most of the way so that we could insert the balloon to tamponade the uterus. After that stayed in, we gave her two units of blood and her blood pressure started improving. There were definitely some times during this procedure where I worried we were going to lose her.

It was definitely an exciting day in theatre, where I was able to see these doctors work a lot of magic, but also often felt disappointed that we weren’t able to help with things like using cautery, eye shields, peri-procedural imaging to find objects or even modern stirrups or suction that actually worked well. I was reminded of how I do enjoy aspects of surgery such as fixing things and reminding myself of the important anatomy of the human body. After not urinating or eating for 12 hours, and remaining on my feet for much of it however, I was very much reminded of why I clearly chose not to go into surgery.

Can’t believe my first week here is already done! So far, we’ve already made some positive improvements at the hospital; using my public health training by encouraging all of the nurses to put our TB rule-out (and active disease) in “isolation” which means on the outside veranda or a side room, as they were previously all in the same big room with everyone. I will continue to work on this and am trying to find ways to make this sustainable, such as finding an extension cord so that they can have oxygen in the “isolation” areas, as there are only plugs in the main ward which is why they are all in the same room. Additionally, I’ve started rounding with the medical students on the men’s and women’s wards every day to ensure that any sick patients, new patients, or patients with updated labs are seen every day instead of every 3 days as they were previously seen. Next week I’m headed to an orphanage in the bush for three days while I will be doing some public health and medicine, so am quite excited about this exciting opportunity.

April 5th, 2018 by jamiefelzer
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As I lay awake in the middle of the night, trying not to listen to the sounds around me so that I didn’t have to think about what they could belong to, I reflected on why I made the decision to leave my life in comfortable suburbia and spend a month in the bush of Africa. In our modern era of medicine in the developed country, we often rely on fancy laboratory tests and complex imaging to make our diagnosis. And while it is not wrong to rely on the wonderful technology we have come to create, I wanted to become a better clinician using my standard history and physical skills.  I also thought about what drew me to public health, which was HIV/AIDS awareness and education.   At the hospital I am working at, they have the Malaria Research Trust which not only investigates malaria, but also HIV and there is an ART clinic at Macha. They have made such strides in malaria here that the number of cases is significantly decreased this year. They are also making remarkable progress on HIV here, with prompt diagnosis and readily available treatment. It makes me so happy seeing how much of a difference some public health campaigns are making, and then realizing that we still have a long way to go.  

My first day at Macha hospital was somewhat different than other first days. First, I was surprised at how Macha is actually a fairly large facility. They have a men’s and women’s wards, OB, Gyn, Paeds wards as well as the operating theatre, outpatient department and ART clinic. The wards are large rooms with beds lined up for the patients, and their families sit around the bed to help feed them. If you need to give someone privacy, there are standing curtains that can be moved around the bed. Additionally, there are some lab facilities for basics, important ones of which include a full blood count, malaria smear, HIV rapid test, syphilis, urine pregnancy. We are also able to get x-rays and ultrasounds of limited types. Already the x-rays proved quite helpful, as we diagnosed a kid with a retropharyngeal abscess that needed drainage and as well as an impressive chronic osteomyelitis.   Things here run on Zambian time, meaning people show up whenever they want and there is no set time or schedule for anything. Hospital rounds on the wards typically occur only a few times a week and surgery happens twice a week. Families of the patients typically have to cook food for them, and sleep outside in the back of the hospital on beds made of branches.

I am staying in the Research Facility housing with a fourth year med student, Dan who just matched into EM (who is also blogging) and we are the only ones at the entire research hostel facilities. I’m really glad to know there is at least one other human in the building with me! So far we’ve been making a great team and improvising when we need to. We needed to pop open the sim card holder in hopes of a sim card that would work (but alas, after hours of frustration, the local sim card we were promised would work, in fact did not). Nonetheless, he whittled down a toothpick with a knife to open the sim card. Accommodations are modest and my room has 2 bunk beds, each equipped with a mosquito net (mine had a few holes, but of course I brought some tape so it’s like new now), a sink in each room and communal bathrooms for each gender. There is electricity and I’m told they have a backup generator here, which is nice. There are fans that generally work in each room to keep us cool in these warm months. There is a communal kitchen which is useful for cooking meals, as there are no such things are grocery stores that are nearby. We did stop at a grocery store in Livingstone to buy canned foods and some produce, but now the nearest stores are an hour away (even though it’s only 12Km it is a terribly bumpy dirt road). There is a local market that sells some tomatoes and a few other minor items. There are a few places around where you can get a home cooked meal, and we plan on doing that once a day or so as a break from the instant rice and canned chicken I brought.

Fruit market on the road to Macha (note: they recently had to change their selling practices due to the cholera outbreak to have all food elevated)

Generally, the preparedness freak in me did well being equipped for being out here, as I was glad to have brought all my essentials plus all the survival items and the OCD items. Additionally, I made sure to bring some masks and gloves so that I could best protect myself, although I’m coming to find out that I may be the only person who wears an N95 when I’m sitting next to a person with active TB. The one place where I majorly failed was that we went to Victoria Falls my first full day, which was an unexpected surprise. Given that I wasn’t prepared for the torrential downpour that is Victoria Falls and did not have any of my water proofing items, I thought my poncho could protect my fancy DSLR camera, but sadly I was dead wrong. The lights started flashing and by the time I had reached dry ground it was too late for my poor camera. I tried soaking it in rice, but alas, the damage was already day on day 1 on my trip and I won’t be able to capture the spectacular animals on safari later in the trip, which was the whole reason I brought it.  RIP in my dear camera, my first adult purchase once I got a job. So, no matter how prepared one can be, it doesn’t matter if you still don’t use your brain in the moment! Live and Learn!

Stunning rainbow at Victoria Falls

April 2nd, 2018 by jamiefelzer
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Hi, I’m Jamie! I’m a second-year internal medicine resident at Scripps Clinic in San Diego, CA. A little about myself… I’m from San Diego, but moved all over the world for 10 years, mostly for continuing my education, but felt as though the traveling and experiencing new cultures itself was what gave me the best education. I’ve been fortunate enough to have two prior international experiences, one each in undergrad and in med school. My first experience was in Cusco, Peru where I spent two months immersed in local life and after this, I knew I would want to continue pursuing opportunities in underserved areas. Then in med school I went with a small group of colleagues to Ecuador where we stayed and worked in a very rural village. Prior to starting medical school, I earned my MPH and worked at CDC with a special interest in infectious diseases.  I was fortunate enough to have a supportive residency program that allowed me to take on this learning experience.  This experience will now allow me to truly combine my degrees and love for public health.

I’ve now made it to Zambia after 4 flights (2 of which were overnight flights right in a row- funny how time travel seems to work)! It was perfect that I had a chance to catch up on some lost sleep after a month on wards. Along the way, I enjoyed chatting with some people from similar and different walks of life, part of the reason why I love traveling. I was greeted at the airport by some members of the hospital and we are staying in a hostel in Livingstone overnight as Monday is a holiday. We were fortunate enough to glimpse Victoria Falls at sunset and are heading to the national park today. Very excited to see the largest falls in the world up close. Then we’ll make the 3.5 hour trek to the hospital. Once we figure out the internet situation and get settled in, will try to keep up to date on the blogs.