Missionary Doc in the Making

So yeah, I definitely ate something I shouldn’t have because today I woke up with explosive diarrhea. After taking some Cipro I went to the hospital to see if anything was going on. There were 3 OR cases today, 2 of which needed spinal anesthesia. The first spinal anesthesia stick I did the nurse anesthetist walked me through it. The second one I did without his direction. The most amazing part is seeing the CSF flow out of your needle. Its also amazing to me that the women aren’t screaming as I push this 3 inch long needle into their spine. Even though technically it shouldn’t hurt, I could see myself being a very difficult patient to do this on.

My wife and I will be celebrating our 1 year anniversary while we are on the mission. I think that I will take her to the game park for about 2 days. Hopefully we’ll see some cool animals.

I just found out that the mother (who’s C-section I assisted on…you know the one that my wife helped me suture up) decided to name her little boy after me. My wife and I befriended her during her labor and prayed with her before the C-section so I was truly honored by the gesture. The pictures below are of Jaysson Mwale!

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Today was outreach day, so we piled into a bus and set off. Its truly a wonder to me how the people that live in these remote villages make it to the hospital for emergencies. The roads are really just that bad. I honestly think it would be easier to ride a bicycle than to drive a car on these roads. The video below barely shows you how bad we were bouncing around: (VIDEO HERE).

When we arrived to the village we set up shop. We started off with an educational talk about malaria, HIV, diarrhea, etc. Then we started screening the patients, diagnosing them and writing prescriptions. I began to get the idea (which was confirmed by the clinical officers) that we were writing prescriptions for people that didn’t actually need them. Just about everyone got Paracetamol because they had “pain” or a “fever”. But you can’t blame them; we were giving free meds and if they didn’t have pain or a fever at the time, eventually they would. When you read stories about multitudes and crowds pressing in on Jesus it really becomes real on these outreach days. Everytime you look up the huge crowd of patients gets closer and closer. At one point a little boy was right under my arm at our makeshift pharmacy.

Besides that, my tummy ahces because i ate something I shouldn’t have. The docs at LLU gave us some Cipro before we left so hopefully that will help.

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The story of Zaccheus can be found in Luke 19. You know, Zaccheus hadn’t exactly lived a good life. He wasn’t an upstanding Christian or Jew. But when Jesus toldhim that He was coming to his house that day, Zaccheus was overwhelmed. That Jesus thought enugh of him to visit himmelted Zaccheus’ heart and he gave his life ot God, receiving salvation that day. I really think that this story really highlights the importance of visitation. Visiting someone starts the formation of a relationship, and people are more easily brought to Christ when you have formed a relationship with them. Physicians should always kep in mind the poer of visitation. My wife and I visited the home of one of the many young single mothers for Sabbath lunch. I can already see the doors opening for the Word to be shared (even if we don’t crack open a Bible).

I got to deliver my first baby today!!!!!! It was just me and a nurse. I had actually gone into the hospital to see if the premature baby we cut out yesterday was still alive; he was and I was thankful to see his color finally there. A nurse walking by told me of the mother who was close to delivering. She was fully dilated and the secretions were pouring out. I set up my camera to catch the whole thing but I forgot to press record (like a big dummy), so I only got the unexciting part. What I did get is in the video below: (VIDEO HERE ). So yeah I got the clamps and stuff out that I needed and I waited for nature to take its course. Her water roke and blood literally exploded out of her vaginal opening. Somehow no blood got on me, but a nice amount got on the nurse’s lip! She of course went crazy and went to wash off her mouth, leaving me alone. The baby popped out seconds later; I put two clamps on the umbilical cord and cut in the midle to minimize the bleeding. I gave the baby’s butt a slap and it barely cried, it just wimpered. The nurse came back and noted that the baby was tiny. We asked the mom how many months pregnant she was and she told us 7 months. "My God", I thought, "another premature baby!" I started to suction the baby’s mouth and nostrils but the baby still didn’t cry. When we put him on the scale, he started to cry a little, but then he stopped; he weight in at 1.7 kg.

We took the little baby boy to our “nursery” and wrapped him in blankets. The baby’s nostrils were flaring and his abdomen was retracting which each breath, indicating respiratory distress. We needed to give the baby oxygen via a nasal canula but we only had the adult size. So we made due and jammed it into one of the baby’s nostrils. I prayed over both the premature babies in the nursery, praying that they would make it through the cold night.

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Today was pretty good (I say that alot huh, lol). We rounded on the OB ward first, seeing all the patients who had a C-section done. The lady who I did the sub-cutaneous suture on is in pain from the surgery but she is doing fine. Her would looked beautiful if I should say so myself :). Another patient (an extremely young mother) had been in the ward for 9 days but we couldn’t send her home because the bottom of her C-section would wouldn’t close. The doctor asked me to suture it closed so I did it. Saying that the young mother was difficult would have been an understatement. She cried and squirmed from the time that she got on the table to the time that I finished. The clinical officer walked me through the procedure and then left. So I began anesthetizing her would by inserting a needle filled with lidocaine in the skin around it. Somehow I ended up spraying the lidocaine all on my face but eventually she couldn’t feel anything (although she still continued to cry). Then I had to take a scalpel and cut the margins of her wound so that it would be symmetrical. After that I started to put the sutures in (Silk 2-0). No matter how many times I locked the knot it wouldn’t hold as tight as I wanted. One of the scrub techs who works in the OR was walking by and told me that I was biting too deeply when I was going through the skin. I started to pass the needle right under the skin and the knots held perfectly. I think it is important to be open to all counsel as a physician in training. The more you listen, the more you learn, the better doctor you will become. Ego and pride can hurt you and the patient.

Being out here is really great. You can just aobut do anything after they show you how. On my list of to dos is:

• lumbar puncture/spinal anesthetic
• periocentesis
• start an IV
• more suturing
• more vaginal exams
• more baby deliveries

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I fit in a nice hot shower around 16:00 hours because we hadn’t had a power interruption in awhile, meaning that it was going to happen soon. We went down to the hospital to see what was going on. A mother had just come into the OB war and was experiencing contractions. This patient was odd; she didn’t know how many months pregnant she was, she didn’t know how old she was, and she didn’t even remember how many children she had. From looking at her abdomen she had obviously had a previous C-section so as the contractions grew worse we took her to the OR. My wife assisted the surgery and I assisted the nurse anesthetist. I inserted the spinal anesthetic needle but I didn’t feel the pop that I expected I would (signalling that I was in the sub-arachnoid space where the CSF lies). The nurse anesthetist took over and it took him some time to get it too (so I didn’t feel as bad, lol). I’m going to try until I really get it.

So yeah, they cut the baby out of the uterus and pulled out a silent premature babe. We had no idea the baby was premature because we had no idea how many weeks pregnant the mom was. I worked with the nurse anesthetist to revive the little baby boy. At certain points her O2 saturation was around 4%. After 10 minutes of her O2 sats were in the 80s and I felt like God was answering my prayers. I truly did not want to go to sleep after having a baby die in my hands. I stuck the section deep down into the baby’s throat and finally he eeked out a small cry/wimper. We took him to their “nursery room” which really showed the problem many mission hospitals have. As you can see in the picture:

the nursery has two incubators, but they are both broken. So the baby instead had to be wrapped in like 5 blankets, and then they put on a floor heater in the room. Like I said before, there is room for many medical professions on the mission field. Someone who has been trained in maintenance and repair of medical instruments and machines would be just as vital to the hospital as the doctor. If the Lord is calling you, don’t resist. You can touch so many lives when you are working in His will.

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Today was a good day. I woke up nice and late after being called in for the C-section and praying with Mr. Myembe. My wife and I started rounding in the Peds ward. We checked the two kids that we operated on yesterday (the forehead cyst and the inguinal hernia). Then we went to the nutrition section and checked out the kids to see if they ere gaining weight. From there we stalked out the OB ward to see a vaginal delivery. While there I did a vaginal exam and I realized that I’m still very bad at figuring out the dilation of the cervix. I wanted to get one of the vaginal births on tape but both of the mothers ended up needing a C-section, so we went to the OR.

In the OR I assisted in two C-sections. The first one I got to put in normal non-continuous sutures to close her up. The second one was done with Dr. Peduche and she taught me how to do a cosmetic subcutaneous suture. That suture is so freaking pretty. While I was closing up, my wife (who acted as the scrub tech for the surgery0 was assisting me. You can see the picture below. To be honest, my wife is a much better and meticulous suturer than I am, so when she said, “Good job babe, that looks really clean”, I was beaming, lol. I want to take a picture of my first sub-cut suture when we round on her tomorrow. Time really does fly when you are in the OR.

One thing that has been a breath of fresh air while I have been operating at Mwami is that everyone stops and prays together before the first incision. I didn’t see this happen during my freshman rotations at Loma Linda University Hospital which is sad. I guess people don’t want to stand out or appear too spiritual in the hospital. I would personally want to pray before every surgery. I probably won’t have the pull to get this happening until I’m a senior resident or an attending. We’ll see though.

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Today was actually a pretty good day. I woke up, had personal devotion and then prayer with my wife (something that husbands as priests and heads of the household should strive to do). Today was Dr. Ang’s last day in the OT (operating theater as they like to call it here; we call it the OR) before he leaves for his yearly furlough. We were taken on a tour of the OT by George, the scrub nurse. Here’s the video: (VIDEO HERE). Their operating room really isn’t all that bad. As I observed the surgeries I noticed things that they just had to deal with due to a lack of resources. For example: 1) Dr. Ang needed a certain suture but they didn’t have it 2: also the scissors they gave him had been in use for so many years that it couldn’t even cut the suture thread 3) They ran out of scalpel handles, so with a clamp and scalpel blade, they clamped the scalpel blade and made a makeshift scalpel 4) They have to sterilize and reuse lumbar puncture syringes, etc. etc.

Today was lecture day, where Dr. Ang made a presentation to the clinical officers and the nursing students on the topic of an acute abdomen. The story Dr. Ang told us about one of the acute abdomen patients that came in was quite amazing. Here is what I remember:

A woman named Mary wakes up with severe pain in her abdomen; she definitely needs to go to the hospital. She lives in Chipata (a nice sized city) so her husband got ready to take her to Chipata General Hospital. HIs wife however absolutely refused. She told her husband that she wanted to go to Mwami Adventist Hospital. This request was quite unreasonable because Mwami was a 40 minute drive away on a dirt road, with no lights, with potholes so terrible it would make a New Yorker cry. The husband tried to reason with her, but she said, “No! I am very sick…if I go to Chipata General Hospital I may die, but if I go to Mwami I know I will wake up after the surgery.”

So they took off; by the time she arrive to Mwami she was almost completely pale (they could tell that she was bleeding out somewhere). When they opened her up her abdomen was filled with blood from an ectopic pregnancy. There was about 3 L of blood inside her abdomen. Her blood was type O positive and Mwami’s blood bank was out of her type and Chipata’s blood bank was closed. She was losing blood too quickly so what they did was they sucked the blood out of her abdomen, then they poured the blood through a gauze into another container. They then sucked the filtered blood into a syringe and pushed it right back into her veins. This worked for awhile (as they operated) but she wasn’t going to last til daylight unless she got more blood. Dr. Ang remember that he was also type O, so he left during the surgery and gave a liter of blood. This gave her enough volume to last until the morning when the Chipata blood bank opened.

She did survive and I think this was a testimony to all medical students, physicians, and nurses that God can do amazing things through you when you serve him. Chipata General Hospital was much newer and closer, but Mary knew that God was guiding the surgeon’s hands at Mwami.

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At 23:45 ours my cell phone started to ring. I couldn’t understand why my parents were calling so late so I just ended the call. At 24:47 my cell phone rang again…I actually looked at the phone and realized it was a Zambian number. I had forgotten that I gave the nurses my number and told them to call me if any cases popped up. My wife asked me whether I was going to go in. I replied much to harshly and sarcastically, “Does it look like I’m going in? I’m tired.” She bore with me and encouraged me to go. Eventually we both rolled out of bed and went to the hospital. The patient, a young mother, couldn’t deliver because her pelvis was too small, so she needed a C-section to save the baby. It was my first time viewing one and it was truly amazing. You can view the video here: (VIDEO HERE).

At about 0:57 hours when the surgery was done my wife and i started to walk back to our guesthouse. Dr. Ang however told us to wait because he would drop us home; he just needed to finish a chart in the office. He was in there a long time so I decided to go to his office and tell him that we were going to just walk back. When I walked in, Dr. Ang was listening to Mr. Myembe talk. As I walked in, Mr. Myemba was saying, “Doc, I just can’t take it anymore. Just give me enough meds so I can die.” He was in constant pain all the time; you see Mr. Myembe (a life long Adventist Christian and clinical officer at Mwami for 32 Years) had been diagnosed with autoimmune chronic pacreatitis 4 years ago. He was truly slowly and very painfully dying. To be honest, I was very tired and I just wanted to go to bed. Not wanting to really interrupt I closed the door to Dr. Ang’s office and proceeded to leave. However I only walked away about 10 steps before I couldn’t continue. The Lord had been truly speaking to me through the book, Jesus, M.D. I just knew that if the Great Physician was there that He wouldn’t have left that room. To be like Him, I too needed to be sensitive to human suffering. My wife and I walked back into the room, sat on the couch with him, and put our arms around Mr. Myembe.

Mr. Myemba was truly have a Job experience. He had been an active Christian for just about his whole life. He never smoked or drunk his entire life. He had only been with one woman his whole life and that was his wife. He had faithfully worked at Mwami for 32 years winning many souls to Christ. At his home he had a huge farm with vast acres of bananas and orange trees and all other sorts of fruits and vegetables; the farm brought in good money too. Four years ago, just when he was about to start a doctorate he came down with the autoimmune pancreatitis. He was in so much pain that he couldn’t work at Mwami or at his farm, so all the fruit trees and vegetables and cattle died (working the farm was his main hobby). Medical bills were rising so he decided to take all of his money out of his savings. When he went to the bank, the bank said that someone had already withdrawn all the money out. Everything seemed okay on their end so the bank sent him away. After Mr. Myembe finished telling me all of this he asked me, “Doctor, I have tried all my life to serve God completely and live a life that is acceptable to Him. What did I do to deserve this?”

I looked at my wife and she was speechless; I looked at Dr. Ang and he was quiet. I didn’t know what to really say either. I mean I had honor my Behavior Medicine class so I should be able to figure out something right? But real life practice is much different than class. I asked him if he had heard of the story of Job. “Yes I’ve heard of it,” he replied, “I’ve heard and know all the stories in the Bible and I can recite them for you.” The Lord spoke to me and told me to be silent. You know, sometimes the best comfort you can give someone is a loving arm and your silent company. So I listened to him; he talked about his lost hope and his despair. He just wanted Dr. Ang to give him enough meds so he could die. He didn’t understand why some were lucky to get sick and then die 2 hours later Why did he have to continually suffer? What was he to learn from this? Is this how God repays his servants? As in the story of Job, he knew that he wasn’t with God when he made the heavens and earth, so he knew he had no right to think that God’s ways were unfair. He knew that he couldn’t understand God’s actions all the time, but he just wanted to know how could a God who claimed to love him allow this to happen?

In cases like this you have to get to the soul of the matter. Does the patient know that God loves them? Does the patient still love God? You can’t end the conversation without addressing these issues because if they don’t love God, they won’t be happy to see Him when He comes back. So we comforted him, shared our love and empathy (empathy is most important here), and encouraged him not to end his life. Dr. Ang, my wife, and I prayed with Mr. Myembe and then we departed. (He was admitted and given pain meds too).

If I had been my normal selfish self, I would not have gotten out of bed tonight and I definitely wouldn’t have stayed with Mr. Myembe. But I didn’t, and I was blessed much more than any sleep I lost. We must remember to always emulate the Great Physician. He was always on call, and always interupptible. His sleep and his eating schedule could wait if it was for a soul in need. Let us strive to emulate the Greatest Attending that ever lived.

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So today was pretty routine except that we rounded in the Peds ward today. The theme of the Peds ward is MALARIA, MALARIA, MALARIA. Almost every kid presented as, “This is Jane Doe, age 2years, who presented with vomiting, diarrhea, fever, and splenomegally.” The Lord is good and most of the children service, but some definitely looked like they weren’t going to make it. I realized that I really do like kids. I like picking them up and playing with them. Even after the delivery I witnessed yesterday, I was more interested in the baby than the mother they were suturing up. I don’t think peds is in my future, but I certainly don’t mind it.

After the malaria room, we went to the Peds Protein room. This room contains many kids who were too underweight and malnourished. Many of the kids presented with serious edema in their extremities, due to the loss of protein in their vasculature. Once we fixed their edema we gave them a  nutrient regimen that brought their weight up again. This video shows some of the kids.: (VIDEO HERE). After that we saw a kid with bulbous impetigo. I played with the kid and took a picture. You can see them in the gallery below.

Next we moved into the OB ward. We rounded on the mother who gave brith (the one I saw yesterday). The mother decided to name her daughter after my wife, Brittany. So there will be a Brittany Katombo out there somewhere. When a mother names her child after you, you are obliged to visit the child and bring gifts when you visit (its like you are a godparent). Of course this lady lives like more than 2 hours away walking, so we will have to pick a good day to visit her.

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Today was pretty great. Of course I was up since 3 am because my circadian clock is still completely off. So I continued to read Jesus, M.D. for about 3 hours. I really praise the Lord for his book because it has helped me overcome many of the fears i had about being a missionary doctor.

After devotion I went to check my e-mail and then I went on the wards. The stroke patient that I mentioned in my last post is getting worse and there is nothing we can do about it. The OB ward actually ended up being the coolest part of the day. We were prepping a pregnant patient for a vaginal delivery. After 3 days of labor we kind of thought that she needed a C-section but the main anesthesia person was out of town and the remaining anesthesia guy left suddenly due to a death in the family. Dr. Ang said that this happens often. People tend to put their family emergencies ahead of the patients.

So eventually the pregnant patient needed to be hurried along so we gave her hyoscine and started an IV so that we could give oxytocin. Initially they asked me if I wanted to start the IV but I had to carefully observe one to feel comfortable enough to do it. I didn’t want to be known as the American medical student who killed a pregnant women via IV. So I deferred and watched carefully. We took the mother to the delivery room and waited for it to happen. We were all talking and chatting it up whens meone noticed that the head was already coming out. The clinical officer quickly gloved, unwrapped the umbilical cord fromt he baby’s neck, suctioned, and slapped it to get it crying. It was truly the most amazing thing I have ever seen in my wife. After that I got to suture the tears that were created in the vaginal orifice duirng birth.

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Since today was Sunday, rounding started a little later today. While we were waiting for D.r Peduche to arrive I had a chance to chat a little more with the clinical officer students (physician assistants). Their training is pretty rigorous and similar to medical student training except they don’t get into as much basic science detail as we do. But they do rotations in everything from pediatrics and OB-GYN to dentistry and ophthalmology. They know their pharm pretty well and they can even do minor surgeries. They exist due to the shortage of physicians in Zambia.

So rounding was pretty similar to what you would see in the States except we rounded on all of the services (medicine, peds, obgyn, surgery). Surprisingly, unmarried teen pregnancies are common here also, as I saw while rounding on OB. Many of the patients also require C-sections here. Although the conditions here are not all that great, I do like the face that they keep all the windows open so that fresh air can come in. I feel that our American hospitals could benefit by following his example. Using the bell of my stethoscope I was able to listen to the fetal heart beat of a pregnant mom. In preparation for the C-section on the 19 year old patient we gave her oxytocin. Next we went to the female medicine and surgery ward. On a patient that was recovering from TB, I leaned how to tell her to breath (pemani) in Nyanja as I listened to her lungs.

In the male ward we had an elderly man who had a blood urea nitrogen (BUN) of 15.5 (not good, and probably indicated renal insufficiency. ) We had him on diuretics and he had barely urinated all day and all night and he had been complaining of his urine dribbling out, so we suspected BPH. In order to confirm this, he needed a rectal exam (to palpate the prostate). The clinical officers were trying to make each other do it and I decided to volunteer since I had never done it. Since all they had was a size 7 1/2 glove I was praying that my size 8 1/2 hands didn’t pop the glove. I felt what I could feel and it seemed normal for my first try. By the time one of the clinical officers tried, the old man just collapsed in exhaustion from being poked and prodded. I felt so bad for putting him though that but it was necessary.

We moved on to our next patient who reminded me of many of our American patients. He was a middle aged man who had a history of smoking and drinking. At the hospital he presented with hypertension (this was news to his wife since he never got is blood pressure taken before) and right sided weakness. He had obviously had some kind of stroke. In the States we would start him on a blood thinner like Coumadin or Heparin; we might also evaluate his clotting process by checking his PT or PTT. At most rural hospitals this is just not possible. You see, all of the drugs and reagents are supplied by the Ministry of Health in Zambia. If they don’t offer a drug, you probably won’t get it. I realized that they could not even do an EKG or check the cardiac enzymes of a patient to see if they had a heart attack. Now of course if you have an abundance of money (which only tends to include the whites running the NGOs, the Muslims and Indians running the businesses, and the corrupt African politicians) then you can pay to send your blood work to private labs. Most Africans will not have these opportunities; s with our patient who really needed an MRI and Coumadin, we just had to give him Aspirin.

There are so many things I am seeing that it is hard sometimes to remember. Many problems I see are simply due to the patient coming in too late or seeking our medicine after other methods. For example, this one patient in this picture:  decided not to come into the hospital when there was clearly a problem with the birth. By the time she came in, the baby was dead, and we just had to take it out. Also there was another patient who had AIDS and an odd protrusion of his spine and severe abdominal distention. As you can see from the picture:     he had waited awhile to come and see us. You can tell this because the cuts on his stomach and chest indicate that he went to a traditional healer (AKA a witch doctor) to be treated first. Then other sad stories include his patient who’s hand was destroyed in a grinding mill accident:     . There is so much need here.  I hope that I am up to the task which God has called me to.

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Today was my first Sabbath at Mwami and I truly enjoyed it. We woke up in the morning and had devotion. I have been reading the book Jesus, M.D. and it encouraged me to take myself away from everyone else and go on rounds with the Great Attending (Jesus Christ). I would recommend that book for every medical student, especially those who want to fashion their practice after Christ’s ministry. I have found this nice spot where I can truly spend time with the Lord. I realized that back in the States, I would barely give Christ 20 minutes everyday. As the book Jesus, M.D. stresses, would you actually learn anything from your attending if you barely spent 20 minutes with them a day? I realized that I need to get serious about spending time with God, because it is only going to get worse in terms of my busy-ness.

After devotion I started my trek back to our guesthouse. While being here I realized that I had too much of a rigid view of what missionary medicine was supposed to be like. I thought it entailed no electricity, no cards, water from a well, etc. etc. While there are many hospitals like that, this is not ideal. The Mwami Adventist Hospital I see now is the product of years of work. They now have electricity (sporadically however), running water, toilets, satellite internet, cards, an ultrasound machine, etc. Missionary hospitals are supposed to get better as time goes on, and I am seeing that at Mwami.

Today at church I experienced my first communion service in Africa. They do it surprisingly similar to how we do it in the States. The more I stay here the more I could see myself living here. The longest I have every been on a mision at one time is 5 weeks,w hich made me wonder if Ic ould pull off the long term call (10-15 years) like Dr. Ang andhis family have done. But you know what, as long as your home reminds you of the States and as long as your home is a safe haven for you, you should be able to serve for many years. Dr. Ang’s home isj ust as big as the flat homes in Cali or Florida. Of course,many misisonaries live in much less than that but I’m sure their home is still truly a place of rest. Tormorow hopeuflly I will start helping out more medically.

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