Posts filed under ‘University Teaching Hospital (Lusaka, Zambia)’
Only in Africa
5/7/12
Posted by Ajay Patel, MD (a second year internal medicine resident from Kaiser Permanente, San Francisco) reflecting on his global health elective at University Teaching Hospital in Lusaka, Zambia.
First impressions: Out of Africa
The expression, “only in Africa” is an interesting one and has become a part of my daily vocabulary since I arrived. I landed in Lusaka, the capital city of Zambia and home of my new place of work, University Teaching Hospital (UTH) where I will spend a month learning how to treat ill patients in a foreign country.
First, I should say, I am expecting a lot out of this experience. I have been told that it is the only tertiary care hospital in the country and the nervous system of the entire Zambian healthcare system. UTH is also home to the only medical school in the country and has a reputation of having amazing physicians due to its sheer volume of patients and their experience at UTH.
My first day at UTH was a page out of a novel, the hospital was buzzing at 8AM, and people were everywhere. I attended the daily morning report, which consisted of residents and consultants only along with the head of the department of medicine. The residents on call the day prior would review all critical patients they have seen and deaths. It set the tone for the rest of my day, which would be high-fun-paced action and a punch to the brain.
The inpatient medicine service at UTH was a bit confusing and took me a good week to understand, but essentially this is the breakdown. There are 5 teams and one team is on call every weekday. The teams are also on call on weekends (they rotate at times). The admission day starts at 7AM until 5PM the following day. You start the day in filter clinic (basically a ED outside the main hospital). The patients are assessed and we determine if they require admission. If they require admission they are admitted to the filter clinic for about 24 to 48hrs, while they are treated and worked up (investigations as we call it here in Zambia). After that time the patient is rounded on and either admitted to the wards, discharge or pronounced dead. Death rates in the filter clinic were alarmingly high, some say 50%, but what I have seen was more like 10 to 15%.
The rest of the week the team would round on patients on general wards, ICU and high cost (wards service for those who are willing to pay extra for privacy and cleaner beds), while attending clinics such as general clinic, cardiology clinic, echocardiogram clinic and HIV clinic. It is a busy world for a resident in Zambia and the patient volume is intense. There are no limits to how many patients you can admit or care for on a team.
I must say, the hospital is what you would think of when one thinks of a hospital in the middle of nowhere, like Africa. It is old, in need of some serious TLC, overcrowded and understaffed – this is going to be an authentic African experience.
The daily grind: the day-to-day aspects of working at UTH
It is literally an understatement to say I have seen some unbelievable pathology; I am after all in AFRIKA! At this point, I have seen at least 25 patients a day and the majority of the cases I will never see again in my life; such as disseminated TB, cerebral malaria, tertiary syphilis, disseminated KS involving the entire body, systemic fungal infections along with AIDS and severe OI (opportunist infectious). There are a lot of sick people in Zambia and many of them do not seek care until they are at deaths door and the odds of health care making a different is marginal at best.
The medical services are much different to what we are used to back home, let me explain: At UTH there are 5 medical units (teams) that admit patients. Each unit is on call once a week and once every other weekend. The team consists of 2 consults (any specialty ie: cardiology for unit I, renal for unit 4) then registers (what we call attendings), at least 2 residents (PGY-2 to PGY-4) and finally 2 interns and medical students that assist them with their mountains of investigations. I know this seems like a massive team, however there was a reason for this madness, it is known as call day.
Call day at UTH is a major event; it begins at 7:30AM when you get sign out from the previous on call team for only the acute patients. This takes place at “the filter clinic”, which in essence is their admitting building just outside the main hospital, it is a large clinical office converted into the medical admitting office – aka – emergency department. There isn’t a profession known as emergency medicine in Zambia. This filter clinic gets patients referred from all over the country for medical admissions as most of the other public clinics cannot deal with simple issues. At the admitting bay, we triage patients to those that require intervention and admission and those that can be sent home. From those we deem admission worthy we admit them to the filter clinic – essentially a unisex ward with about 100 beds and in a pinch we make more beds by placing a mattress on the floor, (we did this on every call day). The patients would spend about 24 hours in the filter clinic and if they didn’t die they were either admitted to the wards or sent home. This continued until 5AM the following day. We would divide our massive team, where half would do the afternoon and the other the night. During the day, half the team would eyeball the patients in the hospital and the other half would man the filter clinic. We would round in the filter clinic 2 to 3 times in a day to make room for more admission, that way if we deemed someone required admission we would admit them earlier to make room in the filter clinic for more admissions. It was common to see a large line of patients outside the clinic at all hours it never ended and we just plugged away the best we could.
Despite all the differences working in a hospital in Zambia versus back home the thing that drove me crazy were the paper charts. I have got to say the EMR – electronic medical record has been a godsend! I don’t think I will ever practice without an EMR. It was miserable dealing with acute patients with no history and no one knowing what’s going on, I must have seen 25 deaths in front on my eyes that I could have prevented if we had known the patients history and if they had sought care in a timely manner. Sorry, It is a bit frustrating at times to admit defeat when you know you could have saved lives if you had access to a certain medication in a timely manner or if the patient would have sought care when they first presented with their illness and not have waited a month or if your orders were done in a timely manner and there where more than 2 sisters “nurses or RNs” for over a 100 patients. Good, I miss nurses.
On a interesting note, a few of the cases I have seen thus far:
A 80 yo women with a STEMI, 5 days out with on going chest pain and unable to control pain due to lack of medications in the ICU.
A 17 yo boy who looked like he was 6yo stating 78% on RA with a large right pleural effusion on exam who refused oxygen and CXR and left AMA. (suspected TB)
A 31 yo female stating 85% on RA with PCP pneumonia – did not intubate and she got better!
A 24 yo with heart failure, a EF of 25% – unknown etiology and didn’t work him up. The average life expectancy in Zambia is about 40 and given that this patient didn’t have money he couldn’t afford a work up. Stay tuned for the dramatic conclusion of my trip.
The Afrikan People
The Zambian people are wonderful! The majority of Zambians as you can imagine are poor – living in poverty and living hand to mouth; however everyone does have a cell phone (its prepaid in Zambia and actually very affordable.)
Zambia is home to about 14 million people and officially about 20% have HIV/AIDS. The country has 72 official languages, but 4 major ones that are commonly spoken along with English (the British did something right?). The major tribal languages are Nganja, Tonga, Lowsee and Bawse. Interesting fact: the Tonga are polygamists (common in southern Africa) and commonly have 5 to 20 wives. The majority of the population is rural and uneducated. Although Christianity is the dominant religion in the area it is clear that traditional tribal beliefs are still practiced today and quite strong in the rural community.
I have to say, although the official numbers for HIV in Zambia is around 20% or something low, in my experience at UTH it was closer to 90% of all patients. The 10% who did not have HIV, likely were not tested. I think I saw 2 patients out of a couple hundred that were HIV negative. It is an epidemic in Zambia and I am glad that it is being addressed and accepted by the community. All in all, I think its major health pushes like USAID and other NGOs to treat HIV in Zambia that will make the biggest dent in mortality.
The phrase, “you had to be there to understand” is a bit of an understatement. I was in Africa for a month; it felt like a lifetime of experience (yet, not long enough). By my last week working with Unit I, I felt like I knew what was going on, how to order tests, how to work within the system and it was time to leave. I must admit I have seen things that I will likely never see again, specifically the pathology and severity of illness we just don’t see in the states. I will avoid talking about the hundreds of interesting cases I came across and focus on the experiences that I felt made this trip worthwhile.
What can I say about working in an African hospital for a month? I saw things I never imagined I would. I treated patients with what little I had around me. I performed all my procedures with a 16-gauge needle (thoracentesis, paracentesis and LPs – who needs a kit or spinal needle). I got all my own vitals and walked around with a pulse oximeter and bp cuff and it saved lives!!! In the end I learned more then I bargained for not just about medicine, rather about people and living in a society where health care is not a right, but a privilege and how grateful I am for all I have seen and learned.
I highly recommend traveling aboard with global health; it will change your world! I have so much more to say, but I think I will end here on a happy note.
“With the grace of good,” (my favorite saying from Africa).
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Another long week…
The theme of the week is malnutrition, as we seem to have an unusually high percentage of admits so far off the growth curve that conventional percentiles are meaningless (we use number of standard deviations down, with my personal worst being -5.61 SD). The residents here can spot them a mile away, and I’m starting to pick up the signs- the weak high-pitched incessant cry, the (sometimes horrific) skin problems including frank sloughing/denudement, the peripheral edema, the general wasted appearance, the skin that sticks straight out after you’ve pinched it like play-doh. Often the scalp veins are the only ones we’re able to access, I guess it cuts down a bit on lice (at least for half the head). There’s a whole protocol for treating the kids with conservative fluids, low-electrolyte oral feeds, antibiotics, usually antifungals, vitamins/minerals, etc. The malnutrition ward is absolutely overflowing to the point where only the most tenuous infants are admitted there (the rest triaged into the general wards). There’s a geographic progression in the malnutrition ward- as the babies are able to tolerate PO’s more they graduate to the next row…then the next… until they’re against the windows and the next step is freedom back into the real world. I’ve never really cared about whether kids are picky eaters or not, but here it is literally the infant’s ability to tolerate the taste of the little nutrition paste packets that determines whether they live or die.
Another common lengthy hospital stay is the dreaded FUO (fever of unknown origin), where kids have daily fevers for 10+ days (I think my little 4 yo girl in ward A08 is going on >30 days now) without an identifiable source of infection. As someone who enjoys infectious disease enough to handcuff myself to it for a fellowship, I’ve always enjoyed a good FUO. It’s a license to break out all the zebra infectious diagnoses from medical school- has the patient had contact with rabbits? Animal urine? Eating queso fresco? Hanging around in barns with birthing livestock? Bitten by a tick? Unfortunately, here a vast majority of the population is routinely kicking around waist-deep in rainwater (+/- human waste, depending on how deep the pit toilet (if any) was dug), has close contact with rats and vermin, eats and drinks from highly questionable sources and walks miles through high grass for miles every day. Without much diagnostic testing (we get blood counts pretty consistently, everything else is roulette), you have no choice but to pick your best-guess initial antibiotic and then upgrade every few days based on clinical progression.
In contrast to the paucity of laboratory facilities, there’s a decent stockpile of drugs here. For antibiotics, we have pen G, amox, gent, chloramphenicol (a great drug that’s even better since nobody’s going to diagnose any bone marrow failures you cause), TMP/SMX, keflex, cefotax, ceftriaxone, and cipro. For antiepileptics we have phenobarb and tegretol and sometimes valproate (leading to the dilemma of whether you start a home anticonvulsant for a child that might not be available next week). We’ve got valium (IV, which can be used rectally in a pinch) and oral morphine. We’ve got IV and PO steroids, PO albuterol, and last week we got one albuterol inhaler for the hospital (with spacer!)- previously I was using my own inhaler and a rolled up piece of paper- who would’ve thought having asthma myself would be so useful? We’ve got theophylline that scares the heck out of me after seeing a patient develop seizures and SVT, possibly from the drug. There’s no lidocaine so LP’s and minor procedures are done without anesthesia, 1800′s-style (and not even a swig or two of brandy available!). Some drugs (inhaled steroids, acyclovir) have to be bought by parents downtown and then brought to the hospital for use. Benadryl isn’t available and apparently is a controlled substance here. All in all though, it’s quite a workable formulary.
While a huge pile of cash for education and infrastructure would be great, there are many opportunities for improvement that don’t necessarily require substantial capital investment. It’s really quite frustrating to be attempting a resuscitation only to find that there are laryngoscopes, but they are locked up in another unit and when found, have no batteries. Maybe there’s an ambu-bag, but maybe the seal is broken and useless. With a 3 yo girl with pulmonary edema and foam pouring out of her mouth and nose, we had two suction machines available but neither worked. Of course, as one resident astutely pointed out, there weren’t many options for care even with successful intubation- there is one ventilator in the PICU but no blood gasses available, and nobody (myself included) is too excited about hooking anyone up to it given the situation. We have 2 O2 sat monitors in the PICU but none in the ED where they’d be more useful. All in all, it’s a pretty sobering reminder of just how dependent we are on technology to provide even the most basic critical care.
We might be lacking in potential interventions, but there’s no shortage of physical exam findings. Abdominal distention is pretty much a given, hepatosplenomegaly is near universal, murmurs abound, and last night I for the first time saw a poor little boy with suture diasthesis and a “crack-pot” sign- a distinct coconut-on-coconut sound when his head was tapped- his separated sutures hitting together (he had a neuroblastoma with metastasis). We have a girl with rheumatic heart disease and cardiomegaly who probably tossed a clot and had a CVA due to atrial fibrillation uncontrolled on the antiarrythmic available (digoxin). There’s a guy with Grave’s disease whose family couldn’t source his meds and so is flagrantly symptomatic. A little baby vomited worms all over the ED exam table the other night, I almost did the same (hopefully without the worms). Oddly, I don’t see a lot of dermatologic chief complaints- perhaps a wicked case of whipworm isn’t considered worth the journey (one mother this morning walked 21km to the hospital!).
In addition to the hospital, I’m starting to get the hang of routine life in Zambia. An abnormally large percentage of my time and brain are devoted to clothing cares- the wash-wring-rinse-wring-rinse-wring cycle of hand washing, the sprints into the yard to rescue items off the line when the afternoon rain hits, the mindless ironing of everything I own to kill any Bots fly eggs laid in the items when they’re drying (the Bots fly larvae are the ones that crawl into your skin and you have essentially no choice but to wait a few weeks while they wriggle around before hatching and flying away unless you want massive scarring). Even the more cavalier Zambians will at least iron their underwear under the theory that some Bots infestation locations are worse than others. I’ve enjoyed learning Nyanja from the cook at the hospital who makes my daily nshima, the absolute staple of Zambian life, a grits-like lump of reconstituted maize served traditionally with beef stew, roast/fried chicken, capenta (little inch-long fishes), or sausage. Local tradition holds that a person is unable to work without nshima (not just food… nshima) as their strength will suffer, and n=1 but it certainly seems to keep me going better than the burritos and pizza back home. Saw Avatar at the local mall, the concession stand of which I was elated to find outfitted with a Slush Puppy machine, something I haven’t seen in the states since maybe the mid-eighties. Zambians are almost universally polite and accommodating, which my Zambian housemates feel is responsible for the very modest (for Africa, at least) history of violence in the country. While some sub-Saharan African nations had their territory parceled out in the European land grab of the early 1900’s to arbitrarily include 2 or 3 major tribes with resultant bloodshed in an attempt to establish a majority by attrition, Zambia has something like 73 tribes living in relative harmony. On my own team, we have 2 members of the Bemba tribe, one from Chipata, and our intern is from Malawi. Everyone speaks a little of all the major languages, and I’m learning a bit of Bemba, Nyanja, and Tonga. Luckily, most people at least understand even if they don’t speak some English, and chances are if one mother doesn’t there’s another within arm’s length who can help translate.
As more and more children with grim prognoses roll into the admitting ward, it’s hard not to contemplate the source of their illness. Education is a big business in Zambia, with the general consensus that you get what you pay for, but in the poorest regions the educational opportunities are obviously lacking and the mothers often have very little knowledge of basic childcare. The medical community is hardly blameless considering our relatively recent (now-reversed) stance to limit breastfeeding as a result of possible transmission of HIV. The vast majority of impoverished areas have no remotely dependable source of clean water, and infant formula is expensive, so if a mother does not breastfeed the child is probably given formula mixed with likely contaminated water, or else some other likely inappropriate food source as formula is quite expensive. By all accounts Zambia, is a success in the prevention of mother to child transmission of HIV with good government policies and antiretrovirals available to all (at least in theory), but the number of yellow dots on charts (indicating positive retroviral status or, in the case of a positive test from the mother, exposure for the infant) the morning after admission seem to paint a less rosy picture. And of course with retroviral disease (RVD as it’s called here) comes the opportunistic infections- such as the infants with horrific pneumonias and septic appearance who die each night in the nursery.
Faced with an endless queue of severely ill patients with preventable disease and a healthcare team that is overwhelmed by sheer volume, I’ve become more interested (as I think anyone with such an experience does) in prevention instead of treatment. Safe water, vaccines, safe sexual practices, education, sanitation, and nutrition would form a cornerstone of health that we take for granted but is unavailable to so many of the families here. Lusaka (and especially Kabulonga, the neighborhood in which I live) is home to a massive number of NGO (non-governmental organization) and government aid organizations, all with good intentions and active projects. I find myself thinking cynically that the outlook for Africa is poor as so many well-meaning, intelligent, well-connected foreigners with financial backing have seemingly utterly failed to promote positive change in this subcontinent. And with teenage pregnancy seemingly the norm and sexual activity described to me as the only recreation available to persons in the poorest areas, it isn’t uncommon to meet mothers of 7 or more children (personal best: 21). The population is booming, so obviously the sad little bundles wrapped in colorful blankets lined up for death certification every morning as I arrive are numerically being replaced and then some. And perhaps that’s the true value to the naïve and cynical resident of a stint in a resource-poor community hospital- the knowledge that the seemingly insignificant loss of yet another child somewhere previously half a world away seems a lot less insignificant when the crying mother looks at you and asks you why her child is cold and grey.
Sorry about ending like that, it has been a long week…
Best wishes, Kevin
It rains here. Makes laudry fun.
Kilimanjaro Café in the local mall.
Crafts at Kilamanjaro Café.
Kids loving chasing people on bikes.
Riding in the outskirts of Lusaka.
The callroom at UTH.
Nshima with sausage and my daily Coke.
The Emergency Room at UTH.
My room in Kabulonga (my bunk is the one on the left with the net).
Resident Life at UTH
Posted by Kevin Quinn, MD (a second year resident from Kaiser Permanente Oakland Pediatrics serving a global health elective at University Teaching Hospital in Lusaka, Zambia)
If you like procedures, this is the place. The residents here are absolute rock stars at getting IV access, as every call night is filled with 50-80 admits needing cannulation, the vast majority of them in some degree of severe dehydration or malnourishment. Turns out you don’t need a fancy kit (maybe with one of the new drills I’m waiting to play with back at Kaiser) to do an intraosseous line- a good old 20-gauge needle will get the job done when everything else failed and we needed access pronto. I did an LP the other day (LOTS of meningitis here) where I saw thick yellow, chunky fluid coming out the needle and thought “oh god, I just stuck the gallbladder”…only to realize that it was thick pus from the intrathecal space. I needled an infant’s chest for a pneumothorax yesterday morning (based on physical exam- same x-ray transport problem and it turns out the aforementioned ultrasound machine didn’t turn on). I’ve done an average of probably 3-5 resuscitations a day, complicated by only having a handful of potential code drugs (luckily one of them is epinephrine). Remember back when we thought it was a good idea to use digoxin to convert SVT? It starts to sound like a good idea again when there’s no cardioversion, no amiodarone, no verapamil, no adenosine, no procainamide, not even a bag of ice to have a shot at a vagal maneuver.
The residents and attendings here have been very gracious in hosting me and helping me through the sticking points in the hospital (anyone know how to get the euro-version of Epocrates with all the different drug names??). We’ve been talking with one of the senior residents on my team who is very committed to preventing/prosecuting child sexual abuse which seems to be on a disturbing rise here of late. We’re hoping to get him over to Oakland so he can work with Jim Crawford and Child Protective Services and share strategies. Historically there have been many residents like myself who have rotated through UTH, but the relationship has never been reciprocal.
Having essentially no internet access and with Nelson’s oftentimes being behind locked doors in didactic buildings far from patients, my sidekick on this trip has been my Palm TX with Epocrates and Up-To-Date installed. I’m not really one to fawn over technology, but that combination (along with the growth-BP app, Harriet Lane, and to my surprise, Surgery Recall from back in my med school days) has been a true lifesaver. I highly recommend dusting it off if you’re headed anywhere remote- even the boondocks tend to have cars and so a car charger is probably enough to give you and your patients a fighting chance when it’s the middle of the night and you’re trying to remember the acute care algorithms for stroke (which we unfortunately see a lot with all the sicklers here). If there’s some value I’ve been able to bring to the residents here other than another able body to absorb admits, it’s probably been my Boy Scout/OCD aversion to being anywhere in the hospital without my awesomely cool go-go-gadget utility belt/fanny pack filled with diagnostic equipment and didactic references- most of the residents do have the equipment/handbooks at home from medical school but not readily available. Several have told me that they’re going to start carrying theirs around again after noting the utility of having the tools and references near at hand.
Well, time to get some sleep before doing it all again tomorrow- there are no days off here!
Take care everyone,
Kevin.
Hello from Lusaka!
Posted by Kevin Quinn, MD (a second year resident from Kaiser Permanente Oakland Pediatrics serving a global health elective at University Teaching Hospital in Lusaka, Zambia)
If anyone was eagerly awaiting news, I apologize- internet access here can be difficult to obtain. I’ve been in Zambia for 1.5 weeks now, and have spent the vast majority of that time at the University Teaching Hospital (UTH). It has about 350 pediatric beds, although that can be misleading because when there are more patients than beds you just start putting 2 kids in each bed, then 3, etc. It is the only tertiary care center in the country (of 14 million people or so, of which probably half are children if standard sub-Saharan African demographics apply), but also is the only public health hospital in Lusaka (population 2-3 million) so bears the burden of not only advanced pathology but volume as well.
There are no appointments, so parents show up with their kids in the morning and wait in line in either the clinic or emergency room- I think we finally got through the queue at 4am last night. Once admitted, mothers (or fathers, or often some random assortment of extended family members) sit next to their child’s bed in plastic lawn chairs. There is usually one nurse per 30-40 patients, so obviously a large portion of the child’s care (feeding, bathing, waving away flies, etc) is done by the bedside parent. There’s an epidemic of ruleout sepsis lately (called “presumed sepsis” here because it’s difficult to rule it out without urine and CSF cultures), reasonably well-appearing neonates who pop fevers and are admitted. It would be fantastic if someone would do a study on these babies to find what the incidence of serious bacterial infection is – I doubt it’s the 10% that we’ve quoted from studies in the developed world. It’s 90+ degrees outside and babies are swaddled in 4 blankets then strapped to mom’s chest as she walks home from the hospital in the blazing sun, maybe these kids should get a degree Celsius or 2 leeway. As it is, the ward is filled with moms on postnatal day one or two, uncomfortably sitting in a plastic lawn chair as they receive some length of therapy from 5-10 days of penicillin and gentamicin.
The most heavily hit unit is the malnutrition ward, which has double or triple booked its beds and has a single sink for sanitation. The mortality is ~50%, and I’ve heard there are issues with culture in that mothers can become disillusioned with care and spread the word that the oral rehydration solution (mixed up every morning and put into bags for nasogastric administration) is killing the children, leading to moms pouring it out instead of giving it to their children then hanging the empty bag back up so the staff doesn’t notice. Knowledge of Western medicine is limited- in the PICU right now we have a girl with vision loss likely secondary to toxoplasmosis infection whose mother is probably going to abscond with the child one of these nights as she believes the prophet in her village will address the issue better than we can. Apparently this is a common situation- a child will arrive at the hospital in either very poor health or with a vague illness, and after a week of care has not returned to normal, so parents lose patience with the care and leave to return back home. Just this morning one of the senior residents on my team was good-naturedly chastising a university-educated mother for thinking her child was the subject of witchcraft when she had a malarial fever and hallucinations of crocodiles in her bed.
I would imagine most medical visitors to resource-poor communities have some sentinel patient who puts the limitations of care into perspective. Mine died last night, a 5 year old girl with possible sickle-cell disease who started complaining of abdominal pain 5 days ago, then yesterday developed respiratory distress, abdominal distention, and then became increasingly tachypneic overnight before tiring out. So much of my training has revolved around recognizing a kid that’s having a bad night but isn’t terribly ill versus a kid that’s about to imminently decompensate that it was difficult to have the knowledge that the girl was critically ill and not have the ability to intervene. I was able to contact the general surgery service who were reluctant to operate without any idea of the etiology of her disease, but the laboratory was closed and unavailable for bloodwork, and the X-ray machine was in the main hospital which I calculated to be at least a 20-minute trip away from oxygen even if I picked the kid up and sprinted with her through the night. There was an ultrasound machine which we didn’t have the manual for and didn’t have anyone trained to use, so maybe the lesson to be learned is that if you have the chance to learn a skill, even the unsexy diagnostic skills like fundoscopy (which I’ve done hundreds of times in a week on kids with possible intracranial pathology), listening to murmurs, or using the ultrasound machine that’s probably sitting in the room next to you right now if you’re in a hospital at home, it might be worth learning it- you never know when it’s going to be the middle of the night in Africa and that knowledge might be the difference between saving a life and watching a 5 year-old girl die in front of your eyes from acute chest or peritonitis/sepsis or whatever she succumbed to.
Working at the hospital can be a bit emotionally trying, so it was great to get out a few times and go for bike rides in the outskirts of Lusaka. The paved roads are a unique opportunity to end up a statistic (the leading cause of death among Peace Corps workers abroad is death-by-car), and so in an effort to stay alive I ditched out on a dirt road as a swerving semi was approaching and discovered a whole different world. There’s a network of cratered dirt roads that are almost impassable by cars but are used by locals on foot and bike to move around. It was the late afternoon and I was surrounded by smiling kids racing next to me (they’re fast), reaching out to crowd around to grab my hands when I stopped, and constantly waving. After a week of caring for horribly sick kids relieved only by sitting in gridlock on the paved roads, it was great to remember that children aren’t always covered in flies and on death’s door.
Dr. Kevin Quinn, center, with fellow residents and the first female Zambian doctor.
Writing a progress note on a pediatric patient with TB adenitis.
Discussing SIADH vs. salt-wasting on rounds.
A moment of humor while talking about acute management of DKA (Thanks Jorge!).
