Forward Thought Blog - This Week's Clinical Update (by Anna)

This Week's Clinical Update (by Anna)

I have been in charge of the “female ward” for most of the week now. This was exactly what I hoped for, but never-the-less it is a daunting amount of responsibility. Three times per week, I round with an American medical student (this is her second time here) and several nurses on 35 or more patients. The women’s ward patients have a wide assortment of medical problems, not a single one to be trifled with. Most of these are related to infectious diseases of the very poor and very malnourished, and HIV. The ward itself consists of a large room with the beds lining two of the walls and the length of an enclosed veranda, with maybe two feet of space between each bed. There are neither dividers nor white noise machines to provide privacy for any conversation or exam. We round by walking bed to bed, picking up charts and talking with the women. Their family members and bed neighbors help answer questions, such as, “I saw her walking,” or, “She’s not eating, and only drinking a bit.” I don’t speak the local Tonga language here and very few people in the villages speak English, though it is one of the official languages in Zambia. There are about 30 local languages, and English is not taught in school until the upper grades which are very expensive and not possible for most. A nurse or translator typically helps with both social and language translations for our conversations. This all may seem a horrendous breach of privacy, but in the words of the chief medical officer here, “In western culture, if you see me walking out of a hospital and ask ‘what’s wrong’ I would think you’re meddling. In Tonga culture, if you don’t ask, they will think you don’t care.”

Along with the actual patient in each bed, there is usually a female family member or sometimes a husband sitting on, under, or near the bed (or on a Tonga stool). Patients very rarely come to the hospital alone. Each woman is accompanied by several members from her family village to cook for her at “the fires.” The fires are simply a big open field settled by people while awaiting an appointment at the outpatient clinic or for their ailing family member. People come from distances as far as 100km away to be seen by the doctors at Macha. They are referred from the clinical officers (a two-year degree with some medical training, providing ninety percent of medical care to the people of very rural Zambia) for unclear diagnoses, for surgical needs, for medication shortages, and for those patients that keep coming back with the same problem and “pestering” their clinics. These patients would not be able to cover the distance, carry all the necessary provisions for a several day travel and stay, or make food without their support team. Additionally, women typically have five children each, so someone has to come along to help tend to the children as well for the ailing mothers. Over the years, the fires have become more developed; there are now half-open long shacks that are used for storage and shelter from the weather. Around them, a food and goods market has popped up, as all these guests will need supplies for the week to month long stays. Visitors outside of the permitted one or two are only allowed during meal times This allows for medical attention to be rendered by the doctors and nurses without literally hundreds of people crowding in the one room wards. Meal time is announced by beating of stick on a pan, and immediately followed by a rush of people carrying bags and bowls of food they have been slaving over at the fires.

My last visit was during July and August of 2007, during the Zambian winter. This time it is the peak of summer in February and the sun is unforgiving here. During my many hours of rounding, I drip sweat and constantly have to right my glasses that constantly slide down my nose as I inspect patients and write. I wear my white coat because of its many useful pockets and to prevent anyone from seeing me sweat through my shirts. The nurses dress in all white and some with a sweater vest as a fashionable addition. Patients wear layers of skirts covered by several chitongas (cloth material used to carry babies, clean ground, clean children or dishes, etc.). Their loved ones cook and live at the fires cooking over open flames in kettles balanced on sticks. I can barely survive cooking rice on an electric stove due to “the heat in the kitchen.” I complain about the hard bed and chairs around our lovely small brick apartment here; my patients’ families sit on wooden stools or concrete floor without shifting. I am amazed at the endurance and stoicism of these people.

After attempting not to faint from heat during rounds, I go to the outpatient clinic (the “outpatient department” or O.P.D.) to see countless more patients for the balance of the day. I have also been precepting three physician assistant (PA) students and a medical student who are also here, thus I am “seeing” maybe twice as many patients as I would on my own. The outpatient experience is equally interesting; we are essentially all crowded into one room and see the referrals or local patients that are too medically complex for the clinical officers here. These range from simple high blood pressures and blood sugars, to unusual bodily swells and masses requiring further thought or study, or adults and babies requiring admission or surgery. The more complicated cases are discussed among those in the room, x-rays reviewed by whoever happens to be around. Patients are questioned and seen by several of us at once while other patients and interpreters standby if a particularly unusual or complex situation arises. Once again, there is little privacy. On the other hand, these patients are given the most expert care and consideration outside of the capital city of Lusaka. For more specific medical details, feel free to send me an email for the “clinical notes.”

On a non-medical note, my free time is usually shared with Mark. During the two-hour break at 13:00, we go to the market, cook, read or hang out. He knows where I am working each day and we are staying a brief five minute walk away. He stops in to say hi if he’s working at the pharmacy or just happens by. We go for longer walks at night when it’s a bit cooled off, mostly in search of the mini-safari experience offered by the lizards, bugs, and birds in the numerous trees and bushes. We carry two cameras to capture interesting sites and document the many faces of sunset that the big Africa sky has to share.