Because we have been trying to figure out our routine still, we’ll just catch you up on some of our experiences so far. Hopefully the future blog posts will have a bit more focus.
As previously noted, we spent the first week in Harare trying to get some logistics figured out and allowing some work to be done at the house we are in now. Also previously noted, and worth mentioning again, is how much we enjoyed connecting with Washington and Alice and how wonderful it is to see their servant hearts in action! They are such an example to us!
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| Medical mission in Harare |
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| Current building on the church site. |
We moved to our new home at Nhowe Mission Brian Lemons Memorial Hospital at the end of last week and on Saturday I went to back to Harare as part of a medical mission and evangelism effort in an area of town where people live on less than $30/month and at the site where there are plans for a new church building as they have a young, growing congregation. The drive is a little less than 2 hours, thanks to a speed limit of 120 km/h (though the multiple random police road blocks trying to eek out a few dollars wherever they can does slow down the voyage). It was extremely well put together and it was my first experience with medicine in Zimbabwe. There were 8 other cuban doctors there as Cuba and Zimbabwe have an exchange program. There was also an informational session with a few different speakers and so interesting to hear what the general population knows about malaria and HIV, or rather, lack thereof. The public education on these diseases an area that needs improvement.
Most of the patients were there with new onset hypertension or new onset diabetes. The first patient I saw, with the help of one of the Cuban doctors who has been in Zimbabwe for 3 years, had a RBS of 21! What the heck did that mean? The abbreviations, the units of measurement, and the medications are all very different! I learned quickly that RBS was random blood sugar and that normal fasting glucose was below 7 and random should be less than 11 (I don’t even remember the units right now). I also learned that there is no diphenhydramine (Benadryl) or pseudoephedrine (Sudafed) at all in Zimbabwe. Oral nifedipine is also the most common second anti-hypertensive behind hydrochlorothiazide (not common in the U.S.).
Monday was the first day to work at the hospital with Dr. Mundiya (a.k.a. Jonathan). About 90% of the patients in the hospital are pregnant, post-partum, or newborns. All medical decision making is directed by the financial impact on the patient. Well, most of it. The other factor is whether the medication or test we might want to order is available at our hospital. There are only 4 IV antibiotics available: benzylpenicillin, gentamicin, erythromycin, ceftriaxone. While rounding with the nurses, an order is written (yes, no computers here – I actually forgot to sign the note/orders a few times that first day in Harare since a physical signature is almost a thing of the past in the U.S.) and it won’t be done until the patient has paid for it. That is exactly the opposite of the care in the United States. Wednesday we rounded and I was surprised to see that almost every investigation ordered the previous day was not done. Jonathan noted that day was an exception to the norm, but it portrays the system that cannot afford to provide free care for everyone and if they don’t pay up front, then they likely won’t pay at all. And you might be thinking that payment up front isn’t even possible for most healthcare in the United States, but the cost of a night in the hospital is $6 and you can see the prices for lab work in the picture.
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| Click on the picture and it should get bigger. |
Also, to put this in perspective, Zimbabwe’s economy crashed hard in 2008 and they have been using the U.S. dollar since then. Inflation was so bad that they actually had to print $100 trillion notes and that wouldn’t even buy a loaf of bread so people found more use for the bills as a means to start a fire. I actually had to look up how to say the final exchange rate in words: one U.S. dollar was worth more than two decillion Zimbabwe dollars. “The country’s central bank could not even afford the paper on which to print its worthliess trillion-dollar notes. …shopkeepers would frequently double prices between the morning and afternoon, leaving workers’ pay almost valueless by the end of the day,” as describe by an article from The Guardian. Just imagine that you had a few hundred thousand dollars saved for retirement and ALL of your savings were gone when you woke up one morning! So with the U.S. dollar, some things are cheaper, like a loaf of bread for $0.90, but gasoline costs $5.56/gallon and I just saw a box of Kellogg’s cereal for almost $10! In fact, most things in the grocery stores are at least as expensive as in the States if not more, but produce like bananas, tomatoes, and avocados on the street are much cheaper. Even living here and seeing it with my own eyes, it’s difficult to understand how anyone can live on $30/month.
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| $9.59 |
Regarding the cost of healthcare, Jonathan noted that there are some people in the surrounding communities that think the hospital should be providing free care since it is a Chrisitian mission hospital. That obviously isn’t sustainable and Jonathan went to the local chief and explained that they could provide free healthcare at the hospital, but that when resources run out, there would be no healthcare at all! The chief agreed that minimal costs in order to keep the lights on was reasonable and it sounds like the hospital does make a big difference for the quality of life of the people around here since the next nearest hospital is 70 kilometers away by vehicle on extremely bad dirt roads… but vehicles are nearly non-existent for most rural Zimbabweans, which only adds to their culture of very poor health-seeking behavior.
So getting back to the first day at the hospital, the very first patient I saw was this cute little girl with limb abnormalities and a heart murmur. Possibly syndromic so we recommended that she go to the next bigger city for an echocardiogram.
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The next morning she was still in our hospital because she didn’t have transportation. There was another patient during that first day who had improved to the point of being discharged home, but she was also still in the hospital the next day because she was unable to pay her bill. It is literally a hostage situation until the patient’s family can bring the money to bring her home. Interestingly, it was the same way in Congo when we were there with the Tenpennys in 2014. Obstetrics and neonatology is an enormous part of this practice and I have learned a lot already, including a Cesarean delivery that first day due to meconium and fever - rather, pyrexia. I am very thankful to have had a refresher on C-sections last month before leaving Mankato! There are two newborns with fever in the hospital, too, one for 11 days! Neonatal sepsis is a big deal in the United States and there are multiple guidelines involving numerous expensive tests, but here we just assume the worst and cover with antibiotics without any investigations at all. A bit different for my neonatologist friends, eh?
After this first week, I am still very much orienting to the different culture and systems processes in place, but after the daily devotional this morning at 7am, Jonathan told me that he would have to leave early today. I was thinking to myself, “I wonder if that means 12pm or maybe 2pm…” Then he said he had to leave in 10 minutes! It wasn’t even 8am yet, so I took the reigns and completed rounds with the nurses, managed a patient in labor who was failing to progress and started showing signs of fetal distress (no strip, of course, just the Pinard horn… nope, not even Doppler), and performed 2 minor procedures.
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| Pinard Horn to listen to fetal heart tones |
In the middle of all this, I participated in an interview for a new nurse and admitted a 70 year old lady with the following vital signs: HR 156 bpm, BP 96/58, RR 48, and temp of 36.9 C. No pulse oximetry – that machine was in a different building. She had a dry cough for the past 4 weeks and denied any other medical problems. Her current symptoms had been going on for the past 3-4 weeks, as well, including her tachypnea. She was with a niece and they agreed she could stay in the hospital after a little deliberation and the nurse who was helping me translate said that during their discussion they commented on selling a cow to pay for it. For my medical colleagues, what would you do to treat this patient without any imaging or labs? Oh, and her heart was regular and lungs clear with decreased right lower lung sounds. No edema or JVD, though she was started on furosemide and spironolactone for CCF (congestive cardiac failure) during an admission last month at a different hospital. She had HIV, malaria, and tuberculosis tested last month that were all negative. She had a chest x-ray last month, as well, but didn’t have it with her. (Actual film x-rays here, but no lightboxes that work, so we just use the window. Such limited resources.) I did discuss the patient by phone with Jonathan about whether she should be transferred to a proper ICU with those vital signs and he told me that there were 14 formal ICU beds in the COUNTRY!
Sorry for so much medical talk during this post, but that is the reason we’re here, after all. That, and trying to live like Jesus everyday. Perhaps the next blog post will be about our first experience at church on Sunday as this is already quite lengthy, but I was asked to preach on Wednesday night and while I am not a preacher by trade, I pray that I was able to share some encouraging words.
I wrote the preceding thoughts late last night and didn’t post it as I wanted Kara to read it first. And by “late,” I mean 10:00pm. We go to bed early and wake up around 5am every day with the bright sunshine. It gets dark around 5:30pm and the main light in our kitchen/living room/main area doesn’t work so we end up eating as it is getting dark, maybe playing a few hands of Phase 10, nightly family devotional (that we copied from Washington and Alice’s family – actually, their 4 children are grown and they are now foster parents to FOUR university students who grew up as part of the Zimbabwe Orphans Project or ZOP), and then after we get the kids to bed, we wind down with a book or studying to refresh on some of the medicine that I haven’t thought about since medical school! It’s not uncommon to have lights off by 9-10pm (some of you might know that is ridiculously early for us).
Wow, that was a tangent, but that probably doesn’t surprise most of you. So, what I was getting at is that I wrote that last night and I asked Jonathan to call me if he went into the hospital at all during the night. Just as we were waking up this morning, my phone rang – around 5:30am – and there was an emergency C-section due to fetal distress. We also had an elective C-section with tubal ligation that was scheduled for yesterday due to being breech but it was postponed until this morning as Jonathan was gone yesterday. Well, as we were closing the skin from the first one, Dr. Mundiya looked at me and said, “Now I will assist you with the next one.” Ha! Now, I had a great experience in medical school and did much more than first-assist during many C-sections and I also had a lot of exposure in residency, but my obstetrics rotation in medical school was 8 years ago! Well, the surgery went great and this was all without suction, cautery, or even cardiac monitoring! First week on the job and I've already done my first C-section!
After the surgeries we went to see the woman I admitted yesterday and the labs were back. All unremarkable: white blood cells 9, hemoglobin 10, electrolytes normal. Chest x-ray showed right pleural effusion, as suspected clinically, but otherwise fine. Jonathan thought it was possible that she had tuberculosis as it is a very common disease in Zimbabwe and she was pyrexial last night to 38.1 C. He noted tuberculosis as one of the most common reasons for parapneumonic effusions here. He did a quick thoracentesis without stethoscope or ultrasound – simply percussion. He pulled off 20-30 cc straw colored fluid and the only things we can do are gram stain and chemistry. It was a pretty good Saturday morning.
Some friends from Kansas arrived to Zimbabwe last night and they are really the reason this hospital even exists. Dr. Steve Lemons, his son Chris (same age as me), and another member of their church’s mission committee, Roy Van Zant, should be coming out to Nhowe in the next 1-2 days. We are certainly excited to see them, but also excited because I was awarded a discounted SonoSite M-turbo ultrasound machine through a grant program for mission hospitals and Steve will be bringing it with him. It would have been useful to have prior to the first C-section this morning to identify an anterior placenta, and also for the thoracentesis.
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| Our house. And the only clouds we've seen since we've been here! |
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| Movie night. Did you know you can download Netflix movies? |
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| Chewing on sugar cane |
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| Best therapy there is for autism |
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| My office for writing this blog post today. |
