Missionary Doc in the Making

I can’t believe that it has taken so long to post again on this blog. I’ll try to hit everything that has happened.

Vajay jay Time continued

So as I mentioned in my last post, this year is wrought with countless labs. I guess they don’t want us to study all day and actually master the information so we have to go to these labs. Some are pretty useful though, like the lab on pelvic exams. I was pretty uneasy about it to be honest. I mean I had always figured that I would have to do this as a medical student and doctor but its different when thought has to become action. As silly as it sounds I was asking myself whether I was being faithful to my wife since I hadn’t “seen” another woman since I got married. Lol, if I applied that feeling then no doctor has ever been faithful to their spouse. Anyways, the lab started off with a focused gynecological interview in an examination room that looks like a normal hospital room, but that has microphones and cameras hanging from the ceiling. They have me a sheet of paper, a clipboard, the patients name, and her chief complaint and told me to go in there and figure out what was wrong with her just from the interview. Her chief complaint was dryness and lots of itching in her vaginal area. Now most women (and some knowledgeable men) probably already could have figured out what was wrong with her just from the chief complaint but to be honest I’m not very knowledgeable about vaginas gone wrong so I had no idea. I walked in and interviewed her (in the 10 minutes allotted) all the while trying to write all the important stuff down while figuring out good questions to ask her. After I walked out of the room, I started to kick myself while thinking of questions I should have asked her. The nurse practitioner who runs the lab took me into a room which had the video recording of my interview and gave me pointers. She also showed me the written evaluation that the lady I interviewed wrote about me. Here’s the written comment that my first “patient” made:

Yes I was pressed enough to take a picture, lol. It really made me feel good to read this. More important to me than being the at top of my class is that my patients actually feel comfortable with me. Its something that I always saw with my mom’s patients. They would come to her and not only tell her their ailments but also about their son’s baseball game or their daughter’s recent wedding. I’ve always loved the openness her patients had with her and I hope that this is a sign that I’m on track to do the same.

So yeah, after the verbal interview then I was sent to another room to do the actually vaginal exam. They verbally walked me through everything (the instructor and the nurse that I was doing the exam on) and then I had to do it. So I learned how to do a breast exam, how to examine the outer genitalia, how to feel for the Bartholin’s glands, how to insert the speculum, how to examine the cervix and take a swab from there, etc. It went pretty well. I must admit that I can’t really see myself doing that for the rest of my life as an OB/GYN but I feel a little less nervous about it now.

First Test Week Over

Normally I post in the days preceding our test week and I post during the test week and after also. I just finished my first test week of my 2nd year today and I am truly exhausted. On Tuesday we had Pharmacology, Wednesday we had Biochemistry, Thursday we had Microbiology, and today we ended with Pathology. You may say that it was a pretty lax week since we only had 4 tests compared to the 9 we would have during some test weeks in my 1st year, but I can truly say that these 4 covered way more info.

-Pharmacology: I can honestly say that I like this class. Its the one class that makes me “feel” like a doctor because now the many drug names I hear make a little more sense. Unfortunately there are these big pharmaceutical companies out there and all of them are making drugs so learning them is very tedious. And of course we need to know the mechanism for each drug, including when it is given, its major side effects, its contraindications, etc. This pharm test covered 72 drugs and unfortunately, they taught us like 60 of the drugs during the week right before our test week so we really had to cram them in and learn them. How did I study for the test? Well I took the advice of the professor and I made my own note cards. Many of my friends used the Lippencott cards but I believe that the best cards you can study from are the ones that you make. You learn as you make the cards. I used some flash card software for my iPhone which allowed me to study my flash cards where ever I went, so it really helped. I ended  up doing pretty well on the test with this method.

- Biochemistry: Sometimes I get really frustrated with this class because what I need to know for their tests isn’t really what I need to know for Step 1 boards which is ever in the back of my mind. This test didn’t go so well but such is life. It was only 25 points, so if you miss more than 5 you are already in the C range. I think that I’m going to have to dual study in the class. I’m going to read First Aid and Lippencott’s biochem for Step 1 prep and their notes for class; hopefully their is some intersection.

- Microbiology: Last year’s 2nd year class really complained about this class so the administration at LLU has made big changes. I’m not sure what it looked like last year but their class notes are great to me. This year however to increase the class averages on the subject board that everyone takes at the end of the year they paid a large amount of money to the people who write questions for the boards to get access to their question bank. So for now on, all of our tests are on computers, and we are only taking questions written by the NBME! Its kind of crazy because right now, this is the only class in our medical school that is done like this, and we are the guinea pigs. I didn’t do too well on this test, but that is probably due to the fact that I got sick of studying the night before and decided to watch the 2 episodes of Heroes that I missed. I wouldn’t recommend that to anyone. Its kind of rough since we are the first class they are trying this with, but I honestly think its good in the end since we will be very comfortable with these boards type questions.

- Pathology: I really like this subjects because it explains the background behind the many diseases that afflict us. Our teacher is amazing and really helps us get this stuff down. I did very well on this test and since 80% of Step 1 is pathology I hope this is a good sign.

As you can see, the main thing on a 2nd year medical student’s mind is Step 1. Its this ginormous test that generally determines what specialties will be available to you when you graduate. There is just so much to learn and so little time. I hope to post more frequently now that I know what these tests are like.

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2nd year has started and I feel like I’ve been hit by a truck. This is our second week and it is twice the work we had last year and they give us less time to study. They require so much lab time outside of class that its hard to actually study. Part of that lab time for me today is performing my first pelvic exam on a lady who comes in (without pay I think) to help us learn. I’ll post more later on today.

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I have finally uploaded the videos I took while I was in Zambia on the mission. Reread the posts in June and July to view them!

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¹Now a man named Lazarus was sick. He was from Bethany, the village of Mary and her sister Martha. ²This Mary, whose brother Lazarus now lay sick, was the same one who poured perfume on the Lord and wiped his feet with her hair. ³So the sisters sent word to Jesus, “Lord, the one you love is sick.” ⁴When he heard this, Jesus said, “This sickness will not end in death. No, it is for God’s glory so that God’s Son may be glorified through it.” ⁵Jesus loved Martha and her sister and Lazarus. ⁶Yet when he heard that Lazarus was sick, he stayed where he was two more days.

⁷Then he said to his disciples, “Let us go back to Judea.” ⁸“But Rabbi,” they said, “a short while ago the Jews tried to stone you, and yet you are going back there?” ⁹Jesus answered, “Are there not twelve hours of daylight? A man who walks by day will not stumble, for he sees by this world’s light. ¹⁰It is when he walks by night that he stumbles, for he has no light.” ¹¹After he had said this, he went on to tell them, “Our friend Lazarus has fallen asleep; but I am going there to wake him up.” ¹²His disciples replied, “Lord, if he sleeps, he will get better.” ¹³Jesus had been speaking of his death, but his disciples thought he meant natural sleep. ¹⁴So then he told them plainly, “Lazarus is dead, ¹⁵and for your sake I am glad I was not there, so that you may believe. But let us go to him.” ¹⁶Then Thomas (called Didymus) said to the rest of the disciples, “Let us also go, that we may die with him.”

Jesus Comforts the Sisters

¹⁷On his arrival, Jesus found that Lazarus had already been in the tomb for four days. ¹⁸Bethany was less than two miles^[a] from Jerusalem, ¹⁹and many Jews had come to Martha and Mary to comfort them in the loss of their brother. ²⁰When Martha heard that Jesus was coming, she went out to meet him, but Mary stayed at home. ²¹“Lord,” Martha said to Jesus, “if you had been here, my brother would not have died. ²²But I know that even now God will give you whatever you ask.” ²³Jesus said to her, “Your brother will rise again.” ²⁴Martha answered, “I know he will rise again in the resurrection at the last day.” ²⁵Jesus said to her, “I am the resurrection and the life. He who believes in me will live, even though he dies; ²⁶and whoever lives and believes in me will never die. Do you believe this?”

²⁷“Yes, Lord,” she told him, “I believe that you are the Christ,^[b] the Son of God, who was to come into the world.” ²⁸And after she had said this, she went back and called her sister Mary aside. “The Teacher is here,” she said, “and is asking for you.” ²⁹When Mary heard this, she got up quickly and went to him. ³⁰Now Jesus had not yet entered the village, but was still at the place where Martha had met him. ³¹When the Jews who had been with Mary in the house, comforting her, noticed how quickly she got up and went out, they followed her, supposing she was going to the tomb to mourn there. ³²When Mary reached the place where Jesus was and saw him, she fell at his feet and said, “Lord, if you had been here, my brother would not have died.” ³³When Jesus saw her weeping, and the Jews who had come along with her also weeping, he was deeply moved in spirit and troubled. ³⁴“Where have you laid him?” he asked. “Come and see, Lord,” they replied.

³⁵Jesus wept.

³⁶Then the Jews said, “See how he loved him!” ³⁷But some of them said, “Could not he who opened the eyes of the blind man have kept this man from dying?”

Jesus Raises Lazarus From the Dead

³⁸Jesus, once more deeply moved, came to the tomb. It was a cave with a stone laid across the entrance. ³⁹“Take away the stone,” he said. “But, Lord,” said Martha, the sister of the dead man, “by this time there is a bad odor, for he has been there four days.” ⁴⁰Then Jesus said, “Did I not tell you that if you believed, you would see the glory of God?” ⁴¹So they took away the stone. Then Jesus looked up and said, “Father, I thank you that you have heard me. ⁴²I knew that you always hear me, but I said this for the benefit of the people standing here, that they may believe that you sent me.” ⁴³When he had said this, Jesus called in a loud voice, “Lazarus, come out!” ⁴⁴The dead man came out, his hands and feet wrapped with strips of linen, and a cloth around his face. Jesus said to them, “Take off the grave clothes and let him go.”
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You know, death is an interesting event. As a physician in training it kind of feels like failure. Throughout the ages people have learned to deal with death in different ways. In Madagascar the dead are buried in tombs more elaborate than many people’s homes. Some of them even redress them and keep them in their house, hoping that this will bring good fortune to their household. The story of Lazarus is important for many reasons, especially for us in the healthcare profession. Like my mother, I am pretty afraid of flying in airplanes. If there is any kind of turbulence my hands start to sweat because I am just “sure” that the plane is going down. When I read the passage above on the flight across the Atlantic, the part I bolded really stuck out to me. When Jesus finally went to see Lazarus, He encountered Martha first. Of course she was distraught, and Jesus seemingly gave her the reassurance that all Christians give to friends and family that have lost someone, “It’s okay, it’s okay…one day you will see him again!” Martha knew the scriptures and agreed that she would see Lazarus again at the resurrection/the second coming of Christ. But she failed to realize something quite vital; Jesus IS the resurrection. Life can’t but help to pour from Him.

He who believes in me will live, even though he dies. That seems like an odd statement to make, but I think it is vital for doctors to get this through their skulls. What is the most important endpoint for our patient? Of course we want our patients to stay alive…especially while they are in our care, but is that it? He who believes in me will live, even though he dies. Now I don’t know about you, but as a future doctor this statement sounds like the greatest treatment ever invented. Living even after dying? I wouldn’t mind taking that pill. But seriously…after I started to really understand that once my patient believed in Christ LIFE was guaranteed my outlook on death started to change. Remember, death is not a failure on our part (I guess unless we caused it). Death is a natural part of life; what we have to ask ourself as our patients are nearing their last hours is, “Will he or she live again?” Not asking this question of ourselves and of our patients is the real failure.

So now that I have set the morbid tone of my entry, :), my day actually started out with beginning of two new lives. Today, I assisted in a C-section where the mother was pregnant with twins…two beautiful baby girls. I didn’t expect that my mission trip would basically be an OB rotation, but I don’t mind it too much. I feel much more comfortable viewing vaginas as not just a sexual organ, but also an organ that can expel all sorts of horrifying liquids (including babies ). The pictures of me assisting and the twins are in the gallery below. As you can see, my back was literally breaking while I was sewing up. If I plan to go into surgery they will simply have to raise the table or else I won’t last a month.

After witnessing two new lives enter this world, I witnessed two leave it. As we were rounding on the male medical ward (which I noticed is composed of mostly HIV reactive patients) we were evaluating a patient who was experiencing dypsnea. About 7 of us were standing around his bed trying to figure out how he got to this point (he had been chatting and joking around with us yesterday). The medical liscensure officer (MLO; the equivalent to a PA, but with more autonomy) said the patient needed a little oxygen, so I ran off to find the oxygen tank. My search was futile since the only oxygen tanks the hospital had were in the OR and the nursery, neither of which was giving up their tank. So I came back empty handed and we continued to watch as the patient struggled to breath. To me, this seemed like what we would call a code in the States, except the resources were no where near what we needed to run a “proper” code. I tried to remember what I saw the resident physicians do (in the States) when they were called for a code, and I remember that they often tried to get an airway on the patient. So I made the suggestion that we try to get an airway, and the MLO agreed. The only laryngoscope the hospital had was located in the OR, so I ran to get it. I saw the nurse anesthetist there and asked him to bring the scope and help us get an airway (I had never tried to do one before and I wasn’t going to practice on a man that sounded like he was drowning in his lungs). He ran and came to the patient with the scope and started to push the tongue aside as he advanced the scope. He got about halfway in when he stopped and said it was useless. I started to get mad; this was the only thing I could think of that we could do to help the patient and he said it was useless, why? He told me to look down his throat, so I looked and didn’t see anything I could discern. He looked at me and said, “Kaposi sarcoma“. There is nothing we could do; the sarcoma had infiltrated his lungs and progressed so far that you could see the vascular papules on his hard palate. He took the scope out and walked away. The MLO told me to feel for a pulse so I tried to feel for the carotid pulse. I didn’t feel anything; then I took out my stethoscope and listened to his heart…it was silent. You know, after practicing auscultation so much for our Patient Diagnosis class during my first year, I was really taken back by listening to someone’s chest and hearing absolutely nothing. Not a murmur, not a split S2, not an ejection sound, nothing. His skin was still quite warm, but he was gone. The saddest part is that I had no idea whether we had the chance to pray with him; I hadn’t yet learned whether he had a relationship with Christ; I didn’t know yet if I would see him again. I was also pissed that even though this patient had been in the male ward for 2 weeks, we didn’t find out that he had Kaposi sarcoma until the nurse anesthetist stuck the laryngoscope down his throat. Lesson learned: its important to do a thorough work up on your patients; you don’t want to let something important go unnoticed.

The second patient that died today, died in the exact same way…gasping for air secondary to Kaposi sarcoma infiltrating his lungs. Both patients had AIDS. There is something about the wailing (and yes it is more wailing than crying) that occurs after someone dies in Africa. The wailing is filled with such sorrow that you can’t help by cry with them. I walked by the family as they received the news of their loved one’s death and I didn’t know what to do. They were wailing so loudly; I could put my arm around them but what do I say? I’m pretty sure that I dropped the ball because I ended up not stopping and at least hugging one of them, but I hope that I do better next time. I’m so happy that one day my M.D. won’t be needed. I’m so happy that one day people won’t die of AIDS anymore. I’m so happy that one day the wailing will stop, and it will be replaced with songs of joy and gladness. But until then, I want to strive to make sure that I see all of my patients again, though they die.

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So yeah, as of today I have been married for 1 year! Time really flies when you are having fun (and when you are in medical school too). We both praise God for bringing us this far in our marriage and with His help we hope to reach many more milestones.

So what did we do for our anniversary? We tried to go to the game park but they were booked, so we’ll have to go next weekend. Instead we went to visit the mother who named her baby after my wife. Since the village she lived in was pretty far we considered not going, but after some deliberation we got one of the local girls to go with us (in a taxi) to the village. It cost us 60,000 K (kwacha) roundtrip which is about $20; you can view the pictures below. The mother was so happy to see us; she told us that she was wondering if we would actually come. Just think of the opportunity for ministry that we would have missed if we continued to make excuses. We had a great time and we presented some gifts for her baby (baby clothes we brought from the US).

In a previous post, I had talked about the importance of visitation, especially on the mission field. As we sat there just talking (with a translator of course) I realized how little this goes on in the U.S. Its not very often that folks just come by simply to talk. Usually something has to be happening simultaneously like a celebration for some event, watching TV together, playing video games, etc. We just don’t come by very often for the sole purpose of talking. Anyway, I enjoyed the time there and we hope to visit the mother who named her son after me this upcoming weekend.

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Monday and Tuesday are national holidays for the country of Zambia and every mother that was in our OB ward today decided to give birth before the long weekend started. Everyone got to catch a baby today. I actually got some great video footage of Jessica and Brittany delivering a baby, and I will upload it when I get back to the states:(WARNING, THE VIDEO CONTAINS GRAPHIC SCENES) 

As you can see in the video, it was kind of interesting to have 2 mothers giving birth in the same room, just about right beside each other. At first I was content to just video tape the 2 births, but when one of the mothers delivered before the other, I put down the camera and helped deliver the other one. We had to perform an episiotomy on the mom because that head was not coming out and vaginal orifice wasn’t tearing either. Once that was done the baby’s head popped out pretty quickly. The clinical officer helped me stitch the episiotomy closed that we had performed. You can see the pictures of me stitching below:

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Below are the pictures of the babies that were born today:

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Yesterday I went with Dr. Peduche into the city as than ran errands and visited friends. In one of the shops I took the picture below:

Does anyone else see anything odd about this picture that was taken in Chipata, Zambia, one of the countries of Africa? The picture pretty much sums up alot of what I learned while tagging along with the Peduche’s as they visited their muslim friends who pretty much owned every corner of Chipata. I learned alot about the problems with the muslims here and the problems with the Africans. I learned more about the tension that you can feel between the groups here. I have alot of thoughts about what I learned, but for now I’ll keep them to myself.

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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:

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 enough of him to visit him melted 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 power 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. So yeah I got the clamps and stuff out that I needed and I waited for nature to take its course. Her water broke 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 whimpered. 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. You can see the baby in respiratory distress in the video below. Normally when you breath in, your abdomen pokes out, but when a baby is in respiratory distress you see the abdomen being sucked in.

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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.  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:

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.:

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 (check out the video below). 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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So it is currently 18:00 hours and I just woke up after taking a nap. Of course the nap didn’t help me switch over to this time zone, but it felt oh so good.

Today was our first day in the hospital. Since it was Friday, the whole hospital got together and had worship. There was song service, a special music via a choir, prayer, and a sermonette.  During the announcement Dr. Peduche introduced us to the whole hospital staff. After that we were taken on a tour of the hospital. It is actually quite big; there is a Peds ward, an OB ward, a physical therapy room, a counseling room, a pharmacy room, administrative offices, an X-ray room, an OT (operating theater), and both a male and female ward.

Everything was alot nicer than I expected it to be. The hospital was built in 1927 but it has been kept up very well. They even just got a satellite which allows them to get internet! So I checked my e-mail today for the first time in rural Africa. Despite the amenities this hospital is still very much in the bush. After our tour I started organizing all the medical supplies we brought over. Then I went to join my wife and Jessica (the other med student) on the wards. On the way I met Humphrey and Peter who are clinical officer students (they are the equivalent to physician assistant students here in the States). Check out the video:

On the wards I began to see what life was like as a missionary doc. There were patients with gangrene legs that needed to be amputated; there were patients with benign prostatic hyperplasia (BPH) who couldn’t pass urine and needed TURP. Other patients had huge gallstones that had to be surgically removed. Mwami didn’t have the fancy machines that blasted the gallstones with sound waves (or whatever they use). One patient was trying to fix a grinding mill and got his phalanges (2-5) crushed all the way down to halfway of his metacarpals. Many of the patients required lumbar punctures to confirm whether they had cryptococcal meningitis. This is a type of fungal meningitis often seen in HIV/AIDS patients. They would typically put these patients on fluconazole and amphotercin B; they would also start them on ARVs (anti-retroviral drugs). In terms of the conditions of the hospital it is good, but it could be better. The patients each have a bed but they are pretty close together. There is no such thing as sperators between patients. They also don’t use gloves when touching patients nor do they wash their hands often between examining patients. Many times they take the saline IV setup (with the bag and tubing), and use it as as a foley catheter. Most of the problems that I see are dealing with not having consistent electricity, inconsistent lab availability, no pathologist in all of the eastern part of Zambia (they have to mail specimens to the capitol and they get the results sometimes months later), funding, etc, etc.

I hae truly seen the need for all types of health professionals here. There was a patient today who really needed a GI fellow so that he could be scoped. They need X-ray techs, radiologists, internists, pediatricians, OBGYNs, surgeons (all sub-types), physician assistants, nurses, etc. They also need civil engineers who can pave roads to make Mwami more accessible. Being here has made me want to learn plumbing, carpentry, masonry, etc. As a missionary doc you have to often do what you weren’t trained to do. Dr. Ang (trianed as an anesthesiologist) is themain surgeon here. Dr. Peduche (trained as an OB-GYN) worked as an internist today. At certain points during the day I wondered to myself whether I could actually come out here and do this full time. It is so different from America, but I believe that the Lord can soften my heart and help me to let go of the pleasures that I cherished in the States.

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I woke up at 2 in the morning today which is about what I expected. My body thought it was really 4 p.m. and thought it was time to wake me up from my afternoon “nap”.

The travel to get to Chipata was quite intensive:

Los Angeles to London: 10 hours 20 minutes
London to Nairobi, Kenya: 8 hours 30 minutes
Kenya to Lilongwe, Malawi: 2 hours 5 minutes
Malawi to Lusaka, Zambia: 1 hour 10 minutes
Lusaka to Chipata (by bus): 12 hours

The worst part of the trip was the bus ride. The driver was great but the road was riddled with so many potholes that you could barely accelerate to a descent speed. Then, when we were about an hour from Chipata (where Mwami Hospital is) we hit such a fierce pothole that it knocked our front wheel out of alignment. The pictures below show what we were dealing with. The pothole knocked our left front wheel so far back that it was rubbing against the underside of the bus.

I swear that these people are truly geniuses. I had made a couple of suggestions which kind of worked, but what they did is that they put a huge rock behind the wheel and reversed the bus on the rock. Each time they did this it knocked the week forward more and more. This idea got us back on the road. Although the road was rough, it was great to finally arrive at Mwami.

The head doctors (well actually the only doctors at Mwami Adventist Hospitals) are both Filipino. Dr. Ang was trained as an anesthesiologist in the Philippines but learned how to be a general surgeon while he was at Mwami. Dr. Peduche was trained as a OBGYN. At many misison hospitals in Africa you will see this kind of set up. The hospital’s doctors are either Filipino, American (white), Russian, Dutch, etc. The Lord has surely led these doctors to their respective mission fields but my questions is: Where are the black missionary doctors? I know that God is not partial or racist in choosing the hearts that He tugs towards mission service. Why are we not heeding the call? You have no idea what it means to the people here to see a black American doctor treating them.

Anyway, I haven’t met Dr. Peduche yet, but we ate at Dr. Ang’s house tonight. Their house is absolutely beautiful. Much more so than the concept of a missionary house that I had. Dr. Ang has been here for 15 years serving the surrounding rural communities. His family is amazing too. They have 1 girl and 1 boy, and their mom can cook out of this world.

There is so much more to write but I have to sleep and get ready for our first day tomorrow!

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I ACTUALLY GOT INTERNET ACCESS HERE SO I’LL BE TRANSFERING MY JOURNAL ENTRIES ONTO HE