Day 13)

                Well…we did it.  Successful elective surgery done at Samfya District Hospital.  Everyone showed up on time (including the 2 new nurses to staff the OR), and there was no middle of the night c-sections leaving the OR in disarray.  We started by orienting the new nurses to the OR layout and protocols that Holly and I put in place.  The first patient was an inguinal hernia repair on an 18 y/o male. We utilized all the new protocols as well as the new post-op recovery area.  We then proceeded to do 2 circumcisions (Dr. Lushiku performed alone), a condyloma excision, a sebaceous cyst excision on the back of the head, and finally drainage of a perirectal abscess.  Mike actually was the one who referred the cyst patient through SCCP.  We had a small procedure room open for the small cases so we had 2 rooms going at the same time.  The day was icing on the cake for the time spent here. There’s lots of work still to do from getting reliable sterilization, to expanding anesthesia to include regional blocks/spinals and general, and providing formalized training for the nurses.  I was quite sad leaving the hospital at the end of the day, but I know that with God’s help, we were able to establish a starting point for improving surgical care for the people of Samfya. 

                Between cases, we had a goodbye/thank you traditional Zambian lunch with SCCP.  The staple of the traditional diet is something called Nshima, a polenta like cooked corn meal that you roll into little balls and scoop up other sides.  Right before dinner, we were invited to one of the SCCP volunteer’s house for tea, biscuits and the best roasted peanuts I’ve ever had.  I wish there was a way to get them in Chicago.  Dinner at Mark and Carmen’s was nice, a time to reflect on all the work over the past 2 weeks.  Lily and Nala were sad when we left.  They are really great kids who are extremely imaginative and content with what they have.  It must be boring often, but I feel they’re so lucky though for not having to deal with all the materialism and peer pressure that comes with living in the US. 

                Tomorrow we catch a small charter from Mansa to Lusaka (should be bumpy and exciting) and then take an overnight flight direct to Amsterdam (mini pancakes here I come) and then Chicago.  We’ll have some time during the afternoon to visit the main Lusaka market to pick up some souvenirs. 

Thanks for reading……until next time!

Day 10/11/12

                Well, the last 3 days have been very busy and quite an adventure.  The autoclave and sterility issues have persisted, but that did not prevent Dr. Lushiku from abruptly scheduling an emergent c-section.  It was definitely a chaotic event.  I started my second IV of the trip and then scrubbed in and assisted as best I could, only having seen a few c-sections.  Seeing a child being delivered (despite the hardships he will face here in Samfya) always brings a smile to my face.  The smile quickly turned into concern and panic, as the nurse who was given the child was more concerned about weighing the baby and not that he was blue and not breathing.  We had set up an Ambu bag to assist with breathing, but she had moved it, getting the mother’s “home linens” ready to swaddle the child, and couldn’t find it.  I quickly broke scrub and found the bag and started resuscitation.   The baby’s pulse was initially about 60, but came up after about 5 minutes of bagging and suctioning. 

                After the case, we started again on trying to figure out the autoclaves, but could not get an adequate result.  We decided yesterday to take our surgical instruments to Mansa district hospital, 1 hour away, and use their autoclave machine and get equipment we needed to perform 2 hernia cases and a lipoma resection scheduled for Thursday.  We left for the hospital in Dr. Lushiku’s car, but then turned around because he forgot gas money.  We then got a third of the way to Mansa, when he said he forgot to stop and get gas before we left Samfya.  I guess there is no gas available anywhere on the road to Mansa.  I just assumed that he knew of a stop along the way.  We were at the point of no return and would have run out either direction, so I suggested that we call Carmen (yeah Carmen!), who rushed out 10 liters of “petrol” to us on the side of the road in a tiny village called Mibenge.

                In Mansa, nothing really went right.  The autoclave guy did a hurried, shotty job and we still got some wet packs.  We then got the” pleasure”, unexpectedly, to accompany Lushiku on his weekly grocery and clothes shopping, as well get his spare tire fixed.  We then had to drive home in the dark on the unsafe road over 2 hours later that we expected.  Needless to say, Holly and I were not happy, not to mention Mike and Shannon who could not get into the lodge rooms since we had the keys.  Holly then told me Lushiku had put his groceries on top of the “sterile” surgical packs.    The team got into a huge discussion about how we should proceed and decided that we would advise Lushiku we were not comfortable proceeding with operating Thursday and should concentrate on training the nurses on OR techniques and Lushiku on how to use the electrosurgical generator I brought. 

                We arrived finding the OR in disarray with blood everywhere this morning.  I guess Lushiku did another C-section in the middle of the night with only 2 general nurses.  We had an easy out for not proceeding with surgery today.  While the process of decontamination proceeded, Holly and I made signage for the OR and created instrument cleaning, OR cleaning, patient pre-op, and patient post-op checklists with the help of the OR nurse from Mansa. These will be used to train the incoming nurses in some proper OR processes.  I also did a training session (on a chicken thigh) with Dr. Lushiku on use of the electrosurgical generator.  By the end of the day, we thought were ready to proceed with a few small cases tomorrow and allow the trainees to see the checklists in action.

                When we got back to the lodge, we saw a great example of why the lake is called Benguolu, which means “where the water meets the sky”.   There were no clouds, but you couldn’t distinguish the horizon. (Sorry, but I couldn't get the picture to rotate)

Day 9)

                Well, I feel like I’m on a roller coaster when it comes to the Samfya District Hospital OR.  Every time is seems like we’re making progress, we hit another dip.  When Holly and I got to the OR this morning, we were exceptionally pleased with the amount of work that was done by the hospital staff Saturday afternoon and some yesterday.  Everything was moved to the proper places, and looked like it had been cleaned.  We started putting the final touches on everything; Holly learned how to start the generator if power went out, the suture boxes and other disposable items were sorted for easy access, and we accessed and downloaded some practice standards guidelines regarding sterilization procedures and verification.  This confirmed that the presence of a chemical indicator within the sterilized surgical pack is “best practice” to confirm sterility.  That’s when the dip came….

                Dr. Lushiku showed up and we started telling him about the indicators.  I started sensing some push-back, as he said that the current state of this OR (particularly re: cleanliness) is better than any he has ever trained or worked at in either the Congo or Zambia, and that we just needed to trust him that we should proceed.  I suggested that we find out if any of the top “level 3” Zambian hospitals used the internal indicators to make sure they were not standard of care there.  None of the hospitals we contacted were currently using them. 

                I realized that the “American standard” can’t necessarily be the expected Zambian standard, and we just have to do the best we can with what we have.  Ironically, that very issue was the topic that was assigned by Mike for me to lead tonight’s bible study/debriefing session for the team.  It was built upon Phil 3, v 3-4 that we are to accept and humbly serve others with a loving heart, and not push our own agenda without thinking of others first.

                We all agreed as a team that we would accept the Zambian standard, and felt good again, but then the OR nurse from Mansa showed up.  She will be with us the rest of the week to assist with any cases, but more importantly train the Samfya general nurses in OR practices.  She examined the surgical packs and discovered that about half were still wet, indicating a potential problem with the autoclave machine or cycle.  We started to trouble shoot them and saw that they were not able to generate the appropriate temperature or pressure required. At that point the power went out and it was time to quit. More trouble shooting tomorrow.  We are going to closely watch the temperature and pressure gauges during a couple of test runs.    

                One really cool thing happened today: we used the ultrasound that Mike brought for the first time clinically on a full term pregnant patient.  She is the first woman EVER from Samfya to see an in-utero image of her child.  She kept wanted to see the images between contractions.   

                Mike and Shannon went to Chipako, a village 1 hour down a bumpy dirt road, with a drama team from SCCP that put on an HIV sensitization program that drew a crowd of about 200 people.  After that program, free HIV screening was offered and 30 people wanted to get screened.  4 were positive, which is just about the district prevalence.  Mike and Shannon then saw about 90 patients in 6 hours, and even found me a couple of potential surgical patients.  They looked very tired.

Another beautiful day in Samfya.  We headed to the United Church of Zambia for worship after my first really restful sleep.  I guess I’m finally fully adjusted to the time difference, and I’m sure the manual labor of cleaning the OR helped.  A couple of observations about worshiping in the Zambian church: 1) it was very long (2.5 hours), 2) the music was excellent (mostly Zambian sung in Bemba, but they did sing My Remeemer Liver by Hillsong in English, 3) we were welcomed as official visitors and asked to come to the front of the church to be formally greeted by the church leadership and 4) it reinforced for me the broad membership of His universal Church

Mark and Carmen then took the team via boat to a nice beach for a couple hours of fun and relaxation.  The beach was beautiful with soft white sand and a long shallow area where we tossed the Frisbee and swam.  On the way back we started taking in a fair amount of water (luckily we didn’t have to start bailing the water) but made it back to the dock.  I guess the right lateral weld in the hull cracked for about a foot.  This will affect the medical team’s plan to travel by boat on Wednesday to the island in the middle of the lake for Hut calls, unless they’re able to find another boat.

Everyone is rested and fully charged for a intensive week of serving the Lord.  The next few days will be critical if we are to do any operations during our time here. I pray that we will be able to gather all the necessary resources and put systems in place to make that happen.

I woke up today to the windiest and coldest morning (60 degrees with a good wind chill).  The wind really kicks up at night, but usually it dies down in the morning.  One of the local fishermen was paddling a hollowed out canoe close to shore. This is the only type of boat on the lake the locals own.  Holly and I went to the hospital to continue preparing the OR. 

As promised Dr. Lushiku was there with a crew to help start the process of transforming the space into a suitable, safe, clean OR.  We hauled all the non-essential storage out to a different building (the hospital is designed in a ward style with 5 separate buildings), and then started the process of cleaning and disinfecting everything. 

We left for lunch, a visit to the local market (photo of open tobacco stand) and the Samfya bible college (picture of the beautiful Frangi Pani tree).  I found out today that Samfya started as a missionary station in the 1930’s at the site of the current Samfya Bible College.  It’s amazing to me that it’s grown to a town of 30,000.

                 

We went back to Mark and Carmen’s for the rest of the night and a barbeque.  They are really special people who are gracious hosts.  They are not overtly religious and you might not think that they were missionaries at all most times.   Carmen is very organized, setting the schedule, making the necessary contacts and facilitating everything.  Mark is quieter, less assertive, but a consistent and tireless worker.  They both are missionary kids from Africa (Mark grew up in Zambia, Carmen in Kenya) who met in African boarding school in high school and have been married for 15 years.  They are incredibly resourceful and adaptable, cook almost everything from scratch, raise animals, farm, dig wells, fix cars, while at the same time raise and home school 2 children and work for SCCP. They’ve all had malaria countless times. 

I was also able to Skype with Sarah, Andrew and Katie tonight.  It was great to see their faces and hear about their week.  Our guinea pig, Brownie, also had an international Skype date with Nala and Lily’s male guinea pig named Fluffers.  It was very cute to see the kids meet and talk about their shared interest in pets.  I hope that we’ll be able to keep that going even after I get back.  We then sat outside under the visible Milky Way and watched the kids roast marshmallows (unavailable in Zambia). 

Mike has been a great team leader, and I feel the trip so far has been successful.

 

One of the c-section patients from last week, returned with peritonitis last night and resulted in Holly and me questioning the sterility of the OR in its current state and have decided that the most appropriate first step is to address infection control.  Holly’s expertise as a scrub nurse and my perspective as a surgeon, with the local MD’s input have resulted in a new blueprint for the OR.  Holly and I spent all morning going through the available space, designating dirty, clean and sterile areas with patient flow, instrument use and processing, storage, etc. in mind.   This process revealed some disturbing findings including insect infestation and dried blood on previously “cleaned” items.   We initially were planning on operating on Monday, but I’ve cancelled that.  In fact, I’m doubting that we’ll be able to perform any operations during my time here.  Tomorrow was planned as a free day, but Holly and I are going to the OR for a few hours in the morning.   I’m praying that we will be able to make some good progress.

We woke up at 7am to a beautiful Samfya sunrise over the lake and had a traditional American breakfast on the patio.  This really could be built up for tourism, except that it’s so hard to get to and the occasional crocodile.  The lake also is used by the locals to bathe and in the picture below to wash the dishes.

                We then went off to SCCP to meet the program directors of the 3 main programs: education, home based care and microloans.  The education program helps subsidize the tuition cost ($50/term) for basic and secondary public schooling and also assists with scholarships for trade school and university.  The home based care program assists with vulnerable (orphaned) kids and adults with health issues, particularly HIV/AIDS.  New patients are given 3-6 month of basic food and are followed by health care volunteers who follow up in the villages.  The microloan program consists of 2 loan phases obtained directly from the locally involved churches.  Willowcreek provides a capital donation to the individual churches, but is the church that provides the actual loan.  The first loan is $40, and usually is invested into a kitchen garden for the family to grow crops to eat with the surplus to sell and repay the loan within 6-9 months.  If they are successful, they are able to take out $150 loans on a yearly basis, as the loans are repaid with 10% interest. 

                We then stocked the nursing clinic with the medicines and bandages that were brought by the team, including the Band-Aids that Andrew and Katie purchased with the money they raised from the “band-Aid for Zambia” campaign.  

                We then went on our first “Hut-Call”, going out to the small surrounding villages and seeing patients.  This was quite a shock to me, experiencing the living conditions: a small 2 room brick structure and thatch roof, dirt floor, outhouse, outside “bathing hut”, trash/fire pit and a small garden.  Despite this, the people were wonderful and had smiling, thankful faces.

                Holly and I then went to the hospital to help set the OR.  We got the electrosurgical generator running as well as a new patient monitor.  We also opened and separated surgical equipment into procedure trays for sterilization.  They only have 2 small autoclaves, so it will take a while to get everything sterile, also for the fact that their tech was fired just a few days ago for stealing equipment. Lots to do.