Goodbye

As we hurdle through the early morning darkness, our Zambian taxi driver expertly maneuvering between potholes and goats I am afforded time to reflect on our visit to Zambia. It has been a wonderful experience for us.

Stats:
Admissions - 35
Deaths - 15
Malaria - over 30 cases
Births - 41

Dan and I are so thankful to the long-term missionaries and Zambian nurses and midwives who have been so patient with us as we adjusted to the Mukinge manner of doing things. A few Mukingeisms that I will remember are:

“The patient has collapsed.” – the patient has died
“The patients condition has changed.” – same as above
“BID” – brought in dead (not twice daily)
“The patient is from far away.” – the patient is going to be admitted, they have traveled too far to go home today.
“Maybe you can do this.” – DO THIS! (usually directed by a nurse)
“Shintai” – push!
“Mwa bu ka vyepi” – hello how are you.
“Twa santa mwane” – thank you.
“Ko sy di queppe” – where is the bathroom?

Anyway we have enjoyed our time here and look forward to some day returning. The Zambian people are gentle people who have not known recent war. They have been very patient and kind with us.

Note from the night charge nurse requesting me to come to evaluate a patient,
I was referred to as "Dr. Ricky"

Post-partum women awaiting discharge.

Post-partum women awaiting discharge.

Basic Life Support in Obstetrics

Zambian style amniotomy tool.

Dan teaching BLSO

Dan teaching BLSO

 We had an opportunity to teach basic life support in obstetrics to a group of nurses and midwives. Topics we reviewed were: "shoulder dystocia", "post-partum hemorrhage", and "neonatal resuscitation".

Malaria

The emergency department is a ZOO. At any moment it is not uncommon to have a patient be carried into the ED completely collapsed and be really, really sick, or alternatively may not be sick at all. In the midst of this the ED physician is also seeing overflow patients from the outpatient clinic or patients that are referred from the clinical officers (essentially US equivelant of a PA) because they have a question. Fortunately the documentation is on paper and not the extensive dissertation that is required in the US EHR’s and for my friends in the military there are no AHLTA tier I errors.

I have seen over twenty cases of malaria this week alone, the majority of which are sent home on oral antimalarials, a practice pretty much unheard of in the US, where likely all patients with malaria are admitted to hospitals for treatment and observation. While that seems like a lot to me, those who have been here long-term state that malaria season is actually slowing down.

According to the CDC, in Zambia HIV/AIDS is the leading cause of death (20%) and Malaria is #2 (12%). Both of these illnesses are entirely preventable. Many of these deaths from malaria result from either absence of access or limited access to health resources. There are on average 6-7 physicians for every 100,000 Zambians (if memory serves there are >100 for every 100,000 in the US). Most of these physicians are concentrated in Lusaka, the capital city, which is a 10 hours by road from here.

Zambia tries to push health resources out into the community, with nurse aid workers, however with limited financial resources they are limited to some degree by international aid.

Happenings

Women grinding nuts for porridge

Mukinge Hospital was originally founded in 1952 by Dr. Bob Foster, whose parents were missionaries in Zambia. In 1973, the hospital was turned over to the Evangelical Church in Zambia which continues to run the hospital in partnership with SIM (Serving in Missions). The hospital receives resources from overseas donors in the form of monetary gifts, as well as equipment. The Zambian nurses, midwives, and clinical officers (PA’s) are assigned to this location and their salaries are paid by the Zambian government. Western workers are all volunteers.

The hospital provides services without the expectation of reimbursement. In order to alleviate some costs on the Labor Ward, pregnant women are required to bring: plastic sheets, three packs of sterile gloves, and a bottle of bleach. When women come in for an evaluation of labor they first lay down a plastic sheet on the bed, and then, over this they place a thin cotton sheet. If they are in labor they stay, if not they are either admitted to the antepartum ward (primarily if they are in latent labor or otherwise ill, i.e. malaria), sent to the Kelata, or sent home if they live close by. Distances here are primarly calculated in the time it takes to arrive; 15 minutes by car, one hour by bicycle, or three hours by foot, may all be equivelant. So when sending a woman home it is important to know their transportation status, as ten miles can be a long way if she does not have access or resources to get a vehicle in which to travel.

Dan was observing one of the midwives during a delivery and upon the delivery of the head the mother stopped pushing. The midwife promptly smacked the patient on the thigh forcefully and commanded her to push. At which time she imediately delivered a healthy baby. While an effective means of communicating the need for improved maternal effort, I doubt this would go over in our western culture, though I am sure some of the nurses back in the states have thought about employing this measure more than once.

I have been continuing to round in the PEM ward in the mornings and have moved to the emergency room in the late morning and afternoons. In the PEM ward, we have added four more patient to our roster, however we lost Justin last night. He had been doing so well, actually come off of his treatment for pneumonia and need for supplemental oxygen. He had concurrent HIV and was on ARV’s and Septra. Yesterday morning he spiked a fever, then started requiring increased supplemetal oxygen again. We started him back on antibiotics, however within 8 hours he passed away. These children are so fragile and each is on the precipice of death.

Hossana, a 19 month old boy I admitted through emergency, presented with a 3 month history of decreased appetite. All PEM admits get treated with antibiotics for 3 days, the receive an anti-parasitic medication, if they have diarrhea they get zinc, if they have dermatitis they receive topical antifungals, and if they are septic the get a third generation cephalosporin. Additionally they all get screened for malaria, and their mothers are screened for HIV. If the mother is HIV positive then depending upon the age of the child and the recency of breast feeding the child is either testedfor HIV or a CD4 count is obtained. Unfortunatley Hosanna’s mother is (+) as is Hosanna. He refuses to eat much, anorexia is common with severely malnourished children, so we will likely place an NG tube to start tube feeds.

kwashiorkor - "the sickness the baby gets when the new baby comes"

Children once admitted start on feeds with an isotonic F-75 and once their edema resolves are transitioned towards a higher calorie F-100. Once they are at max feeds for their body weight and tolerate twelve (q4 hour) feeds without vomiting or diarrhea they are then allowed free feeds, which includes porridge. The porridge is made from ground nuts, maize, sugar and water. The porridge is cooked on the ward and the mothers are employed in grinding the nuts. Everyone contributes.





Another Call

Dan has stayed on Maternal-Child, getting to know the various midwives. Mary one of the midwives has been doing midwifery for 40 years. There are very few things that get her riled, so when she called us into a repair at about 10pm we new it was not going to be simple. The patient was actually a successful TOLAC. Unfortunately she had and extensive lacertation. Dan and I started to prepare for her repair when all of a sudden we get a shout from Mary saying “we have a flat baby”, meaning the baby is apneic or flaccid, this was a baby of another women who delivered as we were starting our repair. So Dan and I leave the other patient, or actually we just turn around to the “resucitier” or what we would call the warmer, which is in the same room, and proceed to resucitate the baby. The infants heart rate is initially under 60 so we commense with chest compressions and PPV. Fortunately the baby responds appropriately after about five or ten minutes and we are able to return to our initial patient.

Most Zambians are very stoic, calm people who rarely get worked up or overly express emotions. We however seemed to have found the only female in the country who had a profound phobia of needles. Unfortunately unlike most patients with a needle phobia she did not pass out when they were encountered, but proceeded to climb backwards over the bed. So here is Dan trying to hold her down on the bed, with me trying to do the repair. Finally we just decide to take her to the OR and do it under conscious sedation.

Front of Hospital

Kajo Kona (Food Corner), local restaurant

Malnutrition Ward

I moved to cover the Protein-Energy-Malnutrition ward, approximately 11 children from 6-18 months age who are severely malnourished.  As I mentioned previously malnutrition is a common cause of death among children here in Zambia. Children come in with swollen extremities and belly’s. The goals are to prevent hypoglycemia, hypothermia, dehydration, infection as well as gradually reintroduce nutrition. Feeding too much protein or sodium too quickly can result in worsening of the childs status, potentially leading to death. Many of the children have concommitant HIV and/or TB. So these illnesses must also be addressed or their nutritionl status will never stabilize. The nurses and the nutritionist here are extremely patient with the mothers. Guiding them through the long process of recovery. Children must be maintsined on a low protein, low sodium formula until their edema resolves. While this is occuring they usually are losing weight. This diuresis can take up to 2-3 weeks. Once their edema has resolved their feeds they can then be switched to a heavier formular and then to free feeds (formula plus, either breast milk or porrige).

Wilison, is a 18 month old patient who is particulalry grumpy because he has to be kept on the lighter formula because of his edema. Everyday on rounds he keeps saying he wants “more”. He really is a cute child, with a lot of spunk, despite his severe illness.

Dan stayed on the maternal-child ward, managing post-partum and the NICU. He was called to the bedside of one of the 28 weekers who was having respiratory distress. Concerned that the infant was about to die he ran to the bedside to perform his assessment. Running through all the possibilities and treatment options, which are pretty sparse, he was thinking that this could possibly be the end for this infant…then all of a sudden the baby sneezed in Dan’s face. The infant perked up and has been doing much better.

Wilison

Wilison's puffy feet



Peds II, Malnutrition Ward





Wilison

Saturday Call



 

 

My first call here at Mukinge was on Saturday. During the day all was quiet. Rounded on Maternal Child, we have a set of 28 week twins and another singleton who is also about 28 weeks as well (0.9kg). Amazingly they continue to hang in despite all odds against them. After rounding the admissions started to role in, first there was an elderly gentleman with RUQ pain and a 10 cm cystic structure in his abdomen, then a 50 year old female with splenomegaly and ascites, the suspected etiology is  likely parasitic. Then a couple of children with malaria. One is a 3 and ½ yo boy named Nickson. He appeared very ill; pale, diaphoretic, with a bounding pulse. He is struggling to breath. He had already taken a course of antimalarial medications provided by an outlying clinic, but these had failed to resolve his infection.

Malaria here is almost exclusively falciparum. Of the types of malaria this is the deadly one. While mosquito netting is provided, most people do not use it, not sure why.

 

Anyway Nickson was started on quinine IM and IV fluids. As I said he appeared very pale and I’m guessing he was profoundly anemic, it is not uncommon to see Hgb of 2-3, normal is 12-16. The cause is multifactorial; malnutrition, chronic intestinal parasite infection, recurrent bouts of malaria. Unfortunately the hospital is out of blood for transfusion.

Shortly after admitting him I go back to recheck on him, his breathing is labored, he is vocalizing incoherently, and he appears worse. While working on another admission for malaria, the nurse calls me back to Nickson’s bedside. She says his condition has changed. I wasn’t sure what that meant, but I figured she wasn’t calling me back to tell me he has improved. I now know that what she meant is that he has passed away.

The under five mortality rate here is 89 per 1000 live births. That is 9% of children die before they reach their 5^th birthday. The majority of these deaths are a result of diarrhea, malaria, pneumonia, HIV/AIDS and malnutrition. Illnesses that are treatable, preventable or non-existent in the US.

Just because something is common doesn’t make it easy to process both for the parents as well as the nurses and physicians taking care of these patients and children. The night would bring a few more deaths, a young boy with malnutrition and an elderly female.