Background Info

I guess I should have given some background about this trip. I'm in a rural hospital in Zimbabwe. It is a one-month medical school rotation (coming back on March 5) and I'm here with three other wonderful fourth-year medical students: Megan, Lindsey, and Matt. Megan is my roommate/BFF from OSU going into Pathology, Lindsey is also an OSU med student, going into OBGYN like me, and Matt is her husband, who goes to Wright State and is going into Family Med. Megan and I had actually planned our trip separately from Lindsey and Matt, but we all happened to be on the same flights to Zimbabwe, which made traveling pretty fun and convenient.

The hospital is called Chidamoyo Christian Hospital and it is a 5-hour car ride from Harare, the capital city of Zimbabwe. We got in on February 7th late at night. Major, the hospital administrator and chaplain has a son, Michael, in college who came and picked us up from the airport and brought us to Kathy's flat in Harare. Michael was incredibly kind, knowledgable, and goofy, and brought us to a lovely gourmet coffee shop for breakfast the next day. After that, we drove back to the airport and got the bags that didn't come with our flight the night before (nice going, South Africa Air), and I accidentally left my passport at the airport (nice going, Erika), and then we started on the drive to Chidamoyo. The first 4 hours drive from Harare to Chidamoyo were smooth, but the last hour was spent going up and down hills on a road I would never have believed a car could go over. I'm still amazed all four of the car's tires were intact by the end of the drive. There are no street signs anywhere; in Harare it is because they were all stolen to melt down and the metal was repurposed for something else, but in the area surrounding the hospital, I think it's because none of the paths really have names. Directions to locations in a 50-mile radius of the hospital include "turn slight left at the bush" (the entire countryside is comprised of bushes - we are in the African Bush, for Pete's sake) or "go right at the rock" (there are rocks everywhere). I have been meaning to ask someone how they know where they are going, or rather, how they know if they are lost. Also, every car that I've been in has an Obama bobblehead, wearing a Hawaiian shirt, sometimes holding a ukulele, on the dashboard. Michael told us "Obama really likes it when we get closer to Chidamoyo - he starts dancing!"

We are staying at The Guesthouse, a two-story, four-bedroom, four-bathroom, eight-bed house with a kitchen and the highest ceiling ever (that bats like to hang and make squeaky noises from). The beds were made, complete with mosquito nets hanging above each one when we got there. The house is wired for electricity, although for the first nine days of our stay, the electricity was out in all of Chidamoyo. When this happens, the hospital operates without electricity, turning on its generator only for C-sections, but otherwise the nurses use solar-powered lights or candles to do their work at night. Anyway, The Guesthouse is a 3 minute walk from the hospital, and a 20 second walk from Kathy's house. Kathy is the fabulous nurse practitioner who has been in Zimbabwe for 35 years and knows everything about the hospital and the surrounding area. Her blog can be found here: http://chidamoyohospitalinzimbabwe.blogspot.com/ (I think she said she put a picture of us from Sunday on it.) She's amazingly casual about everything. She leaves her front door unlocked and told us that we can come over for Internet or just to hang out anytime we want. The most annoyed I have seen her this trip was on our second day when we cautiously knocked on her door before breakfast and she said, "I told you - this is basically your house. Don't knock, just come in, okay? How did you sleep? Do you want coffee?"

Here's a schedule of a typical weekday:
6:30-7:00 Breakfast at Kathy's. She always makes something delicious, like sausage and eggs or a Dutch baby pancake or biscuits and gravy or yogurt and fresh fruit. She doesn't drink coffee but makes two large Cabela's thermoses of steaming hot coffee every morning for us. It's some of the best coffee I have ever had.
7:00-7:30 Start ward rounds. For nonmedical people, 'rounds' is when the doctors/nurses go around to all the hospitalized patients and see if anything happened overnight or if any test results have come back that would make us alter our original treatment. We start in pediatrics (3-4 patients), then the two men's wards (20 patients), then the two women's wards (18 patients), then postpartum/neonatal (2-3 patients). It's not a huge hospital, but there is a lot to do and the patients are SICK.
7:30-8:00 Devotions in the hospital courtyard, often led by Major, the AIDS chaplain and hospital administrator. This includes some singing and various hospital announcements.
8:00-11:00 Finish up ward rounds (will take up to 1-4 hours depending on which of the two doctors is doing rounds that week), or start seeing patients in the outpatient department.
11:00-12:00 Tea time with the doctors, Kathy, and Major. This includes tea, coffee, hard-boiled eggs, freshly-roasted peanuts, and a bread made from cornmeal, the staple carbohydrate in Zimbabwe.
12:00-1:30 Do any surgeries for the day in the operating theatre (abscess incision and drainage, skin grafting, joint dislocations that need to be set into place while the patient is under anesthesia).
1:30-2:15 Lunch at Kathy's. Once again, nutritious and delicious.
2:15-5:00 Finish up at outpatient, do any procedures (paracentesis, thoracentesis) that don't need to be done in an operating room.
5:00-6:30 Try to cool down and unwind from the day, maybe take a shower or go for a walk.
6:30-8:00 Dinner at Kathy's. So far, the dinners have been totally delicious and usually American - T-bone steak with mashed potatoes, meatloaf, chili, pizza, tacos. Desserts have included chocolate pudding cake, apple cake, peanut butter cookies, and brownies. Needless to say, we are NOT going hungry here. She has a cook named Someka (Kathy said we can remember it by saying "so, make us some food!") whom she has taught how to make American food. Tonight's dinner is tamale pie, salad, and cookies.

Kathy had to leave to go to California because a family member is sick, so now we are on our own. Major went with her, and he has been our #2 go-to person during this trip. The cook will continue to make food for us, but it will definitely be quieter here without Kathy. She has been our guide, translator, friend, and advocate. Before she left, she drew us maps, gave us keys, and again, told us that her house (both in Chidamoyo and in Harare) is our house. She has never been to Ohio, so we are going to try to get her there, but she and Major both said that they will NOT be visiting Ohio in the winter. I guess that's fair.

We have one more week here, and then we are going to spend a week in Harare, Victoria Falls, and Hwange National Park. We already have our safari booked! Don't worry, Mom and Dad, the safaris here are pretty safe.

Sick or not sick?

Sick vs. Not Sick

In medicine, we describe patients as being "sick" or "not sick". Developing the clinical acumen to collect all the information and then determine a patient's status takes surprisingly long - after four years of medical school, I am just beginning to understand the importance of and the thought process behind a seasoned doctor's declaration that a patient is "SICK". The definition of "SICK" has very little to do with the word's vernacular meaning, and can loosely be defined as "needing to be admitted to the hospital". When I have a cold, I tell my friends I am sick, but when a patient needs fluids, IV antibiotics, and oxygen to survive, I tell my residents the patient is SICK. It's important to note that in the hospital setting, our language can sound incredibly flippant. No daughter wants to hear a doctor say that their father, who she just rushed to the Emergency Department because of his terrible cough and fever is "not sick" but all that really means is that the patient does not need to be admitted to the hospital at that time. He is not in danger of dying if we send him home with appropriate follow-up. An example: If I am vomiting, I am probably sick with a stomach bug, but I am not "SICK" enough to be admitted. If I am vomiting up cups of bright red blood, I am SICK and needing to be admitted to the hospital for urgent intervention. It's an incredibly important, but often incredibly nuanced distinction.

We have been at Chidamoyo Christian Hospital for about nine days, and almost every patient we have seen, both in inpatient (admitted to the hospital) and in outpatient (not admitted to the hospital, as in, coming for a doctor's appointment), would fit the American medicine definition of "SICK". The burden of AIDS and tuberculosis, both separate and concurrent, is higher than I thought possible. Yesterday, we saw a thirty-year old patient in the OPD (outpatient department). Her respiratory rate was 60 breaths per minute, meaning she was taking one breath every second. She was taller than me but could not have weighed more than 80 pounds. When she lifted her shirt up, I was able to count all of her ribs and could see the small bony prominences on her humerus bones where muscles attach, markings that are normally so subtle one can only see after all the skin and soft tissue has been removed from a humerus. Her breasts were long and shriveled, implying that perhaps she had not always been this malnourished. She carried a plump 4 month old child on her hip, and had somehow managed to sustain his life thus far with breastfeeding (no one uses formula here). She said she has been this tachypneic (having a high respiratory rate) for one week.

We are really in the middle of nowhere. There are loose suggestions of paths that the hospital's outreach cars barrel down every Monday and Thursday to administer childhood vaccinations and family planning services to eager children and their mothers. Other than the hospital cars, there are maybe two combis (public transportation vans) that reach Chidamoyo every day. The vast majority of patients, even the "SICK" and dying patients, walk to the hospital. This woman had likely walked a few kilometers, gasping for air, child on her back, to the hospital. In the United States, we would have taken one look at her and sounded the alarm; nurses would have come running to lay her down in a patient bed, take a STAT H/H, chem10, CBC, arterial blood gas, transfuse her with a few units of blood if necessary, take a STAT chest X-ray, and put her on a non-rebreather face mask with the oxygen turned up high. Here, we told her, "You might have tuberculosis. You should be admitted to the hospital. Take your child and walk over to registration to buy an inpatient chart and to be admitted."

Yesterday I came down with a stomach bug, the kind that shakes your body to the core, complete with aggressive vomiting and diarrhea. After three Cipro pills (cause I barfed the first one up), a zofran pill (to help me not barf the second Cipro up), some Flinstone vitamin-tasting Gatorade-like dissolvable oral rehydration, and a good night's sleep, I am feeling mostly better today and haven't vomited since last night. (I have kept down a liter of water and 4 crackers today! Will try for a 5th cracker in a half hour!) I think that was the sickest, both in the medical sense and in the vernacular sense, I have ever been in my life. I had a fever and when I stood up, my heart rate skyrocketed to the 140s, a sure sign of dehydration. I was uncomfortable and scared, but in absolutely no danger of dying. I had the appropriate medications, clean water with which to rehydrate, no concurrent infections like AIDS, tuberculosis, or malaria, and the company of three almost-doctors who are quickly learning how to differentiate sick from not-sick. My body was not worn down by pregnancy or breastfeeding, and has built up more than enough fat stores and good nutrition to support me through a week of this bug. Even in this state, at my most sick, I would not qualify for the hospital definition of SICK.

I didn't write that last paragraph so anyone would feel bad for me. Stomach bugs happen. I'm alive and hardly worse for the wear. I should be feeling healthy enough to eat normally and go back to work tomorrow. I don't want to wrap this entry up with a cute little bow and spell out all the comparisons and differences between my life and the lives of the patients here, mostly because the differences are so painfully obvious. I don't have any enlightened conclusions to share from my experience thus far, except this: Humans are much more resilient than we think we are. If you had to, if there were no other options, you would wait a week with a respiratory rate of 60, before making the long trek to the hospital, child on your back. If you had to, if there were no other options, you would get up from the doctor's office chair, scoop up your kid, and walk to registration to be admitted, while gasping for breath. If you had to, if there were no other options, you would lay quietly as your respiratory muscles got weaker and you decompensated. We all would, if there were no other options.

More attempts at photos

Departure