Written by Hongyu Zhao, MD, PGY-2 and Qing Meng Zhang, MD, PGY-2 at Kaiser Permanente…
Written by Tyronda Elliot, MD (2nd year pediatric resident at Kaiser Oakland Internal Medicine Residency Program while on rotation at University Teaching Hospital – Lusaka Zambia)
“You’re going in February? Oh, that’s the rainy season.”
I left San Francisco with a long-sleeved shirt, jeans, Merrell winter boots and a hooded-puffer coat ready for the cold and rain. Twenty four hours later as I walked down the stairs leading from the plane to the ground, Zambia’s humidity wrapped me up and baked me like a heated oven does a pig-in-a-blanket.
This was the first of my many surprises to come…..
I met with the head of the internal medicine department who told me, “One of our units is closed as we prepare for renovations, so the E-block [where internal medicine units reside] is somewhat more crowded.”
As I walked down the hallway to meet the rest of my team, colorful skirts and head wraps turned to meet the eyes of this seemingly African woman from an unknown, far away tribe. Upon arrival to E-11 twenty nurses [known as “sisters”] flurried, pink-covered charts were stacked and scattered across the counters, and eleven patients occupied the space that a single ICU patient would have monopolized back home. Tattered sheets equated to privacy. There were carts, tables with wheels, shelves, and one dedicated family member at the bedside of every patient. This person stayed with the patient around the clock. The sisters were too busy with other responsibilities so family members were responsible for patient feeding, cleaning, transportation everywhere from procedures to the toilet; they were also responsible for couriering over all blood samples to the laboratory. When there was no bed space, mats on the floor became prized real estate. In the midst of this all, there was an attending, a registrar [equivalent to a fellow], a few residents and interns, and several medical students of varying levels who moved together like a school of fish. And then there was me. We all hopscotched on rounds from patient to patient in Zambia’s heat learning about toxoplasmosis in AIDS, disseminated TB, and malaria. Right from the start three patients; three diseases I had only read about. I was fascinated to have such a breadth of pathology to learn about, to actually see, to touch, and to examine. As density rounds continued I developed beads of sweat on my brow, a flutter started in the pit of my stomach and an internal sensation of heat came upon me. The heat started in my feet and rose up. I marched in place to help circulate the blood pooling in my legs. The feeling persisted. I looked left, I looked right and behind me – but I couldn’t move. I was trapped between med students judiciously annotating the attending’s every word, pharmacists flipping through paper charts, and the custodian mopping the floor. I can’t breathe. The crowd, the poor ventilation, the unattended to moans, the temporal wasting and cachexia overcame me.
“EXCUSE ME!” I darted out of the thickset space to track down oxygen. Dr. Violet (an attending) saw me outside in the corridor pacing. She queried, “Getting a bit of air? I understand. You’ll get used to it.”
I didn’t get used to it that day. My second, third, and fourth surprises came all before Noon with this unrelenting constellation of symptoms that plagued me and forced me to keep “getting a bit of air…”
I hadn’t done 30-hour overnight call since my third year of medical school. Luckily for me, I was still jet-lagged so staying up all night would actually be more fitting. From 8:00 to 16:00 we rounded on our unit II patients, from 16:00 – 20:00 we had a break, then reported back at 20:00 for the handoff from the day team.
In the medical admission bay there was a twenty-something year old female with Kussmaul respirations. I noticed her immediately. She caught my eye because she appeared most acute. From the entry way you could see all of the patients in this square-shaped room. There were four beds along each wall. Portable monitors and 5-feet tall oxygen tanks were interlaced without pattern. In the center there was a rectangle table covered with multiple copied pages; the doctors and the sisters sat there. The medications were stored adjacently in what reminds me of a tool cabinet. You know, the large, red ones that mechanics use in their garage? From the doorway, I surveyed all of these things. The young woman named Mwema* was acutely distressed in bed 6. Yet, we started the handoff in routine order at bed 1. There was no urgency. I half-heartedly listened to the presentations of patients in beds 1-5, Mwema needed our attention.
We arrived at bed 6 – the attending, three residents, three interns, and ten medical students. Mwema had been referred at 8:00 from a neighboring village with acute renal failure. It was now 21:30 and she was clinically unchanged. Thirteen and a half hours later. Her slow, deep, gasping breaths illustrated her acid-base status. The attending reviewed the acute indications for dialysis with the medical students. AEIOU. On to bed 7. “But wait,”I thought to myself, “What about Mwema? Can we get an ABG? What do her electrolytes look like? Let’s attach her to the monitor and evaluate her cardiac rhythm. Can we consult nephrology?” All of these rhetorical questions came into my mind, “What just happened here? Why aren’t any of these things being employed?” The doctors there were very smart and I acknowledge their adept clinical skills. I was nearly positive that they considered every question that played in my mind. But, “What is NOT being said,” I continued to think to myself perplexed?
New patients started to arrive – meningoencephalitis, cardiogenic shock, organophosphate poisoning. The patient was wheeled into the admission bay on a table. He was asystolic. My resident walked over, straddled across the patient’s abdomen and started chest compressions. Reflexively I grabbed the ambu-bag and aided in CPR. 15 compressions to 2 breaths. Can we call a code blue? Where is the crash cart? We need to intubate him! Again, my internal questions fired one after another. The other intern placed an IV and gave adrenalin followed by atropine. The man’s wife and teenage son stood nearby. The boy’s angst, anxiety, and fear permeated the room. After a few more rounds of CPR, my resident climbed off of the patient, used the back of his wrist to wipe the sweat off of his brow and returned to bed 2 to complete the H&P. The wife’s knees buckled and the new 16-year old head of the household caught her. Their wails and tears echoed throughout the hall.
I do not need to compare and contrast this to our practice in the U.S., the differences are glaring. What was so incredibly miraculous was that UTH is a tertiary referral center for most of Zambia. The doctors were smart and highly qualified, they were clinical wizards, but, when resources are limited you make the best of what you have available. From that moment I understood that the pathophysiology was the same, but the medicine, the practice, the resources – a world away, and to thrive here I needed to quickly learn to rely less on imaging, ancillary staff and consultants. Clinical medicine with limited resources. If you can thrive here, you can thrive anywhere.
My family is phenomenal. This house is very akin to a home in the U.S. There are about 6 bedrooms and 3.5 bathrooms. The front and backyards sprawl where Spencer and Koko (the dogs) can run and explore. The avenue on which we live is paved with a two-lane road streamed with large houses shielded by gates and cement walls. Some of them even have guards seated at the gate. Zambia is nice! When I dreamed of Zambia, I envisioned large, open planes underneath the sun, without roads and shelter made from natural resources. However, to my pleasant surprise, Lusaka is more developed than that. Every Sunday we go to mass as a family and today after mass we went to Levy Mall so that I could purchase a couple of long skirts. All women here wear long dresses and seldom wear pants. At the mall there were escalators, a MAC counter, shiny floors, center kiosks, and an eatery. This feels like home.
Remember Mwema from my first call day? Her eyes never saw the next sunrise. Her body reached the peak of its compensation then she drifted peacefully into an eternal sleep right there in bed 6. As her breathing became deeper and slower I did query my senior resident, “Mwema is going to die soon from an arrhythmia in the setting go profound acidosis if we do not intervene. Can we temporize her with bicarb? What about potassium binders?
“There is no bicarb,” my senior gently replied. I had a lot of respect for Dr. Sivile. He always followed his statements by the words, “you see?” I thought it was funny.
He went on to say, “There are no dialysis catheters in the hospital and her family can’t afford to purchase one. It cost 100 dollars, you see?”
“100 Kwacha? (the Zambian currency that would be equivalent to about $20),” I asked.
“No, 100 U.S. dollars, you see?” Unfazed, he politely moved on and returned to the work he was tending to before my curiosity and I interrupted him.
Two months before I came to do my elective rotation here in Zambia I was the second year resident in the ICU. I specifically remember assisting the nephrologist with a bedside, Quinton-catheter placement in a patient for hemodialysis access. We opened three separate kits before access was satisfyingly achieved. The first kit had curved ports and straight ports are preferred in the groin lines to decrease the chance of the line clotting. We couldn’t possibly use this one. The second kit, well, he just couldn’t get the line in with that one. Dispose. The nurse went to fetch a third kit. I guess third time is the charm. When I was assisting the nephrologist with the line, I thought silently, “This is somewhat wasteful – we should be a little less liberal with disposal.” I did not know that we had thrown two lives away. Two Quintons in Zambia at UTH equals two lives saved; and there we were throwing kits away because, well because, we didn’t like it. Mwema’s grieving brother and grandmother who sat and watched her die would be appalled, dumbfounded, and perplexed beyond measure if they knew. Kinda like how I am right now…..
A housemate and I went to Livingstone, a city about seven hours (driving) away that is on the southern border of the country. Livingstone is the home of Victoria Falls – one of the seven natural wonders of the world. Our trip was delightful! The falls were breath-taking. We took pictures of all of the different species of flowers we saw; maybe I’ll make a wall calendar using each picture for a different month.
On the way to Livingstone we stopped at four different villages. Here, the produce stands were made of logs and sticks with old sheets of metal functioning as roofs. The children wore tattered clothes and ran around playing barefoot. There were no cars, no buildings, no paved walkways. The miles of clay-colored dirt looked hot under the sun. The women approached the bus creating a pantone with the produce placed in weaved baskets positioned on their heads. They had despair and exhaustion in their eyes. As we rode along the road, a community of straw-hat huts appeared. Wow! How did they build that shelter? The bush that encompassed the huts was vast and went on and on, and on. This is more of the Zambia that I envisioned.
It has all been surreal. The month has passed rather briskly. As I pack my belongings I am feeling quite nostalgic. This has been a fascinating experience. Patients and families approach me in the halls by name to ask questions. Here, the interns have about 20 patients to see per day, in addition to work rounds, so counseling and communicating with families doesn’t make it high on the totem pole. At home, joint decision making seems to be a large part of what I do. I have been taught the concept of patient-centered care. I have learned to include patients and families in all of the care that I provide, so naturally I discuss the plans with the patients and families here. They appreciated and valued the inclusion and often sought after me for answers. The Zambians are no different from Americans, they too are concerned about their loved-ones’ wellbeing and deserve to be informed.
Oh I will miss this place! There aren’t words to illustrate or describe the feeling I have being in a place where 99% of the people look like me. There are just no words. In America, African-Americans comprise of about 13% of the population. Here, the chocolate complexion coats everyone. What joy!
Clinically, I have gained a lot of knowledge on the physical exam (which I have never felt extremely confident in). I have treated and seen disease we only read about in the U.S. I have met people who I now consider friends. I’ve packed with me a bit of African culture. This global health rotation has given me an experience that can never be duplicated. My perspective is vaster. My interest in economics is sparked. My appreciation of things, we take advantage of, is restored. My humility has been challenged. My courage has been proved. My faith re-evoked. My pallet broadened. My fortitude sharpened. My mind opened. I look forward to incorporating all of these in my training and study at home. I am thankful.
“Life is long….” – T.S. Eliot
T.S. Elliott, MD