More photos!

These are some photos from when I was in Lusaka, driving to Macha, and where I live!

Zebra

So in medicine, we have a saying "When you hear hoofbeats, think horses not zebras" meaning think of the most common causes first.

In Zambia, they say "When you hear hoofbeats, think zebras not horses"

:-D

Zambia Culture

So I knew the culture would be different and laid back. But I didn't know how this would really look or how this would play out in the hospital or in the culture of medicine. Oh but what a difference it makes. So there is no sense of urgency here. None. Everyone strolls, almost to the point of shuffling. Lunch is 90 minutes long. Everyone is always late. All of that is fine...great actually. Except when there is something medically emergent going on...thats when you would like that to change. So the nurses will not call the doctors for anything. The doctors will always take their lunches...no matter what is going on. No one is rushed into surgery...it could always be done later on in the day. Rounds are only done 3 times a week because you can wait that long to see how a sick kid is doing. It is hard to get anything done because no one is really working very much, but yet they think they're working very hard. Its going to be a very frustrating six weeks

Baby Update

So update on the baby....
Baby is still alive but has a high fever. Yesterday I asked the main doctor to take a look at him. He said he would (not enthusiastically). Later the main doctor came to pediatric rounds to ask the pediatrician to take a look at the baby. I told the doctor about what had happened the day before and he told me to come with him when we went over to the maternity clinic. When we got over there, the nurse had no clue the baby was even there. The baby didn't even have a chart made up for him. We changed his antibiotic to Ceftriaxone. But there is not a lot to do. The doctor explained to me that with neewborn failure to thrive it is most likely one of three things: anoxic brain injury, metabolic disorder, or infection. The only thing they can treat here is infection, so they give antibiotics and sees what happens. The most oxygen they can give is nasal cannula besides manual bagging. The IVs are only continuous, so not good for babies, so all antibiotics are given intramuscularly. Resources are just so limited here. Training of the nurses and medical students is poor too, but more on that later!!!

Pediatrics in macha

So this morning has been better than yesterday. I did rounds on the pediatric wards where I should be spending the majority of my time besides the ART clinic. Dr. Thuma led rounds. Dr. Thuma is from Pennsylvania and is a Pediatrician. He has been in Zambia since the 70’s and can speak Tonganese. Rounds last from 8 until about 11. Dr. Thuma does a lot of teaching which is wonderful since I haven’t seen many of the diseases before. There are two other Zambian medical students that were also working in the pediatric ward today. There were so many interesting cases today, but I will only mention a few.

There was a two year old girl who has been short of breath, sweaty, cyanotic, oxygen saturation of 45%, and poor growth since birth. She has a loud holosystolic, decrescendo systolic murmur: a VSD. Most likely she has Tetralogy of Fallot. She has an enlarged heart and liver on chest xray. We put her on Digoxin but that is all we can do here.

There is a six year old boy with sickle cell crisis only mild from pharyngitis. The interesting part is last year he had such a bad crisis that he had a stroke leaving him with a hemiparesis and blind. The blindness has improved. During that crisis he also had a bone infarct in his other leg that led to osteomyelitis. He now uses a wheelchair.

There was a little girl with meningococcal meningitis, which I hadn’t actually seen before.

There was a four year old boy with cerebral malaria. He had come in with a coma and seizures. Today he was improved and was alert. But he cannot hear anything. The doctor said often their hearing will return a month later. He is also very ataxic.

There was a little boy who came in with seizures and then developed diarrhea. This apparently is from the Shiga toxin from Shigella diarrhea. I hadn’t heard about that before.

There were two whole rooms of children with failure to thrive. The worst case was a four year old that was only 7.5 kg…that’s the size of a small 1 year old. That boy also had rickets of his ribs where the cartilage meets the bone; it looks like rosary beads so they call it rosary rickets. All of these children either have confirmed HIV or suspected. They all likely have another illness as well that causes them not to gain weight. Most of them appeared to have TB on their chest x-rays as well. The TB doesn’t show up as it does in the US- in the upper lobes- it shows up throughout the lung. I have already seen PCP in a baby with HIV as well.

Okay happier things....

Okay more about the hospital... It is actually a series of buildings connected by outdoor walkways. The buildings are pretty much big rooms filled with patients all in a row. The beds are metal beds with peeling paint. Most patients have a family member with them to take care of them and bring them food...otherwise they dont eat. There is a men's ward, women's ward, TB ward, maternity, and pediatric ward. There are also outpatient clinics including the ART clnic (anti-retroviral therapy). In each ward, there is a large inner room and a outer room that is almost a porch. The patients with TB and are unstable or are coughing are put out on the outer room. There are salemanders or lizards crawling up the walls. The smell is well, like the psychiatry ward at harborview...enough said! There are mosquito nets above each bed. Okay more later...time to shower!

baby oh baby

Oh what a way to start off the trip. I will only tell you this story at first, because that will be enough. When I was first getting shown around, at 830, we saw a woman who was fully dilated but having no contractions. Later on in the day, during rounds, at about 11, the nurse came over to saw that even with the pitocin on at full there were no contractions. We went to go see her and decided to do a c-section. The c-section didn’t start for awhile because the doctor couldn’t place the spinal anesthesia. Finally he decided to just give her general anesthesia (ketamine). Then the doctor asks me if I can resuscitate a baby. Yikes! There were a lot of nurses around so I figured they would help….wrong. The incision wasn’t big enough and then the baby slipped back in and they couldn’t get him. The amniotic fluid was yellow rather than clear. When they got him out, he was grey. They flipped him upside down, suctioned his mouth and handed him to me. The nurses was of resuscitating is to hold the baby by their feet upside down and slap the back. Probably works sometimes, but not when you’ve used ketamine and been in stage 2 labor for 5 hours. So I start bagging and telling them to rub vigorously. They pat his head. He has a heartbeat. I had to bag him for 25 minutes before he started breathing. They immediately wanted to take him somewhere else. I said yes because I was hoping it had a warmer since he was still blue and cold. We walked outside for a 5 minute walk to the maternity ward. The nurse put him in the warmer. Then the oxygen with the canula wasn’t working. So I had to bag again. Finally oxygen working. Baby is getting warmer. Now has retractions, nasal flaring, stridor, abdominal breathing. I suction every few minutes getting yellow amniotic fluid out. After an hour, he starts having tone in his legs. After three hours, he has slight tone in his arms. No reflexes. All this time I am on my own, with a nurse popping in and watching and then leaving. I kept asking when the doctor was coming and they kept saying soon. Then they said he was went home for lunch. And they refused to call him. You can probably guess how I feel about that, so I won’t say anymore. At three and a half hours after the baby was born with still no crying or reflexes, I found the doctor, who said “oh well, probably asphyxiation. You can only give him oxygen with a canula”. And that has been my first day.