April 25th, 2018 by jamiefelzer

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.