Intro to A&E

I've reached the halfway point, having just finished my 3rd week of work in the Accident & Emergency Department (A&E).  It's hard to believe I'll only be here for three more weeks, but I think it's high time I post something about my work here in Botswana! (By the way, this is Dan, not Amy.)  

First of all, my schedule is pretty nice.  There are basically two shifts covered by the EM faculty here during the week: 7:30 a.m. to 2:30 p.m. and 2:00 p.m. to 9:30 p.m.  I work three or four shifts per week and none on the weekends!  The primary focus has become supervising and teaching EM residents ("registrars" in the master of medicine (MMed) - emergency medicine program) and medical students.  Most of the work in A&E is done by medical officers (physicians without formal specialty training) employed by the hospital (ministry of health).  The university employs the EM faculty (currently only 3 docs from the U.S. and Australia) and the registrars. The EM specialist faculty are generally available by phone when not working clinically in the ED.  

Left: Empty board = slow morning
Right: XRays on the PACS computers
(some days it works, some days it doesn't)

Around 30,000 patients per year are seen in A&E, so that's 80-90 patients per day on average.  Most of them are seen between the hours of 11 a.m. and midnight.  It's not uncommon for A&E to be empty, or nearly so, from the early morning hours until about 10 a.m. Things also pick up at month's end when people get paid.  

There are 10 bays in our ED and a two-bed resuscitation room.  Relatively stable patients waiting for tests or admission get moved to one of 7 "corridor" slots in either a bed or a chair.  Some patients who are suspected to have TB are kept in the "isolation" room next to the triage area for evaluation.  Most of the bays have a Philips monitors & wall oxygen units.  The university owns an ultrasound machine (SonoSite M-Turbo) that is kept in A&E.  You can also request an ultrasound with report from radiology.  Plain X-rays are available, but can take hours, even if you request a portable film.  There is a CT scanner that has been in and out of commission (supposedly because of problems with the doors containing its radiation) that can be used for head CT from A&E.  Apparently if you want an abdominal CT, the surgeon has to order it.  Labs are available but the reporting time is highly variable.

It won't be long 'til these bays are full.

One side of "Resus".

Medication availability is somewhat variable (like in the U.S. these days!).  We have some antibiotics, but not a comprehensive selection. It seems like everyone either gets oral amoxicillin or IV cefotaxime.  It's on an open shelf in our med room alongside IV diazepam and ketamine.  Apparently normal saline solution is on short supply, or not available, but currently there is Ringer's Lactate and dextrose containing IV fluids.  

Around town there are plenty of fancy new buildings and shopping centers (this is not a remote part of Africa) and yet the hospital (and entire health care system) is lacking basic equipment, supplies and infrastructure.  

The new health sciences building at the university.

Match

On Thursday I found out that I matched to the combined Emergency Medicine/Internal Medicine (EM/IM) residency at Christiana Care Health System in Delaware. Amy and I are now in the beginning stages of planning a move to Delaware! We will miss Baltimore, but are excited about what lies ahead.

worried

Today was my last day working at Macha Mission Hospital. It was a pretty busy day, but it went well. It's hard to believe that my time here has already come to an end. To mark the occasion, here's a reflective quote from Elaine Wynne, a Canadian physician who makes regular working visits to Macha: "At home I take care of the worried well, but here it's the unworried sick."

What's in a Name?

Tonight we had dinner at the MIAM cafeteria and got into a discussion about local names. Some of our favorites have been: Hairness, Loveness, Sameness etc. I've always liked my name and checking my email after dinner I found out that I will actually be allowed to have it printed on my med school diploma. Apparently there was a policy against first initials on diplomas (not middle initials). But now, after several trans-Atlantic emails and "a lot of deliberation and several conversations with other campuses around the system" the policy is (apparently) a thing of the past. It will read: J. Daniel Hess.

Daily Life in Macha

Perhaps you're wondering what our our life is like day to day in Macha. To help with the illustration, we've included some of the differences in everyday terminology below. We both report to work at 7:30 in the morning. Amy rides her borrowed pink bicycle to school about 10 minutes away (20-30 by foot) and Dan walks 5 minutes to the hospital.

Amy's day at MICS begins with a staff prayer meeting before the students arrive. This is followed by a chapel service with all the students and staff and then classes are underway by 8. There are six grades at MICS - Reception (Kindergarten) through grade 5. Amy teaches sewing (FACS!) to each grade and language arts (spelling & phonics) to grade 3. She also helps with library and art on Thursdays and Fridays. From 12 - 1 she has some planning time, but she's found she often has planning to do at home too. Her school day is over at 13hrs (that is, 1pm).

Dan's day starts with a morning report of sorts with the other students, physicians and medical officers. Then it's off to round on the wards where you're assigned (Maternity, Paediatrics, Male, Female). On Tuesdays and Fridays, rounds are brief and problem focused allowing time to get to the operating theatre (that is, the OR) for the bulk of the morning. There the "major room" is kept busy with exploratory laparotomies, bilateral tubal ligations, hernia repairs, etc, while the two minor rooms are a flurry of dressing changes, wound debridement, incision & drainage, dilation & currettage, casting, etc.

By 11am much of the cases are finished and some of us head off to the Outpatient Department (OPD) to see patients there (OPD is open daily at 11 except for Sunday). If all goes well we can break for lunch at around 13hrs and resume our duties in OPD at 15hrs (3pm) working until there are no more patients to be seen (usually not too much later than 17hrs). If there are other things to take care of on the wards, then the late morning or afternoon is a good time to get that done, OPD will go on without you. Saturdays start with rounds at 8 and are followed by OPD until lunchtime (i.e. whenever all the patients are seen).

Lunch, of late, has been nsima (the Tonga word for cooked maize mealie meal) and relish (sides of veggies or meat). We've hired a local woman to help with some things around the house, namely lunch prep and some laundry here and there. After lunch Dan heads back to OPD while Amy rests from her tiring day (or plans for up-coming lessons), or goes to buy bread, eggs or vegetables from a shop or the market. She can also sometimes be found at the local library - a small library housed inside a large shipping container.

There used to be four med students here, so we established a Q4 (every fourth day) call schedule. Now there are just three of us, but we've kept the schedule. We have a cell phone that gets passed around so that we can be reached if necessary. Being on call means helping the main person on call with evening rounds at 20hrs (again problem focused) and being available if anything (e.g. a C-section) comes up overnight. Sundays the on-call folks make morning and evening rounds and take care of anything urgent in between.

After "knocking off" (finishing) at work the evenings are our own. They are usually filled with cooking, reading, watching a borrowed movie or perhaps visiting some others in the area.

Maternity

(late entry)

Perhaps the most important part of my orientation to the maternity ward was omitted - the women in the labour suite have a little bell beside their bed. They ring it when they need help - like when the baby is coming. Dr. Spurrier walked in for evening rounds to find me and the other med student chatting at the nurses station about the woman in labour with twins. He noticed the midwife, alone this shift, scrambling to put away some medicines in the main ward and get back to the labour suite. The bell was ringing! We all arrived at about the same time to find the first twin (who presented in the breech position) delivered on its own lying on the bed. At first it looked a bit blue, but was just fine with a little coaxing. I examined Mom and determined that twin #2 was coming out the proper way - head first and a few minutes later with out much help from me the second child was born. As this baby was entering the world, the midwife, noting that the membranes were covering its head, warned me that sometimes they tear and can splatter you. Unsure of what she meant for me to do with her warning, I backed away a bit and out it came. It too was just fine. Of course this story provided a good laugh for everyone at our morning meeting the next day.

Flying Soon

In just fourteen days we will be headed to southern Africa for a two month stay. Our first two weeks will be spent visiting friends in South Africa & Swaziland before heading to Zambia for the remaining six weeks. There, Dan will be working at the Macha Mission Hospital, a Brethren in Christ hospital in rural southern Zambia about 70km (44miles) from a town called Choma. Amy will be volunteering at a school called Macha Innovative Christian School (MICS) nearby. Our travel is being made possible through the Mennonite Medical Association's Student Elective Term (SET) and Dan is also receiving credit towards some graduation requirements at school.

We are excited about this opportunity and hope to share some of our experiences here on this blog (and in person when we return).