Monday, August 30, 2010

Zambia: Monks among the Mosquitoes & Rumble in the Jungle

It’s been a long while since I have posted; my apologies. After graduating from MBA school in May, it’s been a hectic summer. Last week, I went to Macha, Zambia for a humanitarian medical mission doing eye care and surgery. By way of background, about 45 millon people are blind in both eyes around the world (25 million from cataracts which is typically a straightforward surgery in the West and eminently treatable). I will share our experiences & impressions in a “log” form and then write a bit about what I thought about what we accomplished and some of the medical ethical questions that tug at your conscience.

Day 0 (land in Livingston, Zambia). My contact comes about half an hour after I reach arrivals. I had half a mind to get back on the plane and go home, but did not. We saw Victoria falls – it is duly spectacular. Lots of mist. At the nearby trail, baboon attacks 2 of our group 4 pushing 1 close to the edge (the one who’s afraid of heights). Later, a different baboon steals our bread by doing a Houdini over my shoulder , jumping into the back of our car, and then scurries away after taking the loaf of bread, evading 3 of us (Lloyd, the organizer, David the dentist, and me). After Victoria Falls, we went to mosi-o-tunya park; saw impala, giraffes, zebras, elephants, rhinoceros, darter. Mosi-O-tunya is the Chitonga name for Victoria falls, literally meaning storms & thunder. It was a self-driven ride, so it was tons of fun. The guards did escort us to the rhinoceros, who enjoyed a nice wallow in the mud.

Day 1: 80 patients. LOOONG Day. Crazy stuff – never have I seen so much trachoma (chronic scarring by an infectious parasite) and so many stick to the eye injuries. On the stranger side we saw an Intracorneal beetle shell fragment. Multiple previous ruptured globes which have healed on their own with traumatic cataract or iris incarceration. One patient was wearing an arctic coat and a scarf (ok it was Zambian winter but it was 75 degrees!). 35 cataracts. 5-6 foreign bodies. 30 or so trachomas (including one with Herbert pits). Took a tour of the dungeon ORs to get ready for the rest of the week. A few people just needed refraction. One hard cataract with really bad phacodonesis. Needed lots of doxy and erythromycin. Never ending sea of patients. Had 6 patients at 6pm. Saw 4 of then. Checked waiting room at 630, still had 6 patients! We scheduled a white cataract removal on a patient with full ptosis. Handwashing required going to room 2 doors down.

Day 2: Cows kept us up with clanging their bells overnight. 1st case; got vitreous loss. Whole day was hard. Last case (done by a visiting doctor who I was teaching some cataract maneuvers too) – we couldn’t put the lens in after taking the cataract out, and unfortunately, this was a functionally monocular pt . Really tough day. Is substandard medicine really better than no medicine at all? My nice instrument tray and instruments got mixed in and banged up with the rest. Cataracts are big and hard. 2nd microscope came but we had to sit on a microscope facing straight down. Everyone’s neck and back is sore. Some of the nurses are ok but most are just really inexperienced. The crew brought dinner back from restaurant but we had sheema from the nurses.

Day 3: No water this morning. Managed to wash face, brush teeth, and wash hands with 1 cup of water. Cases went better today. The lady who we left aphakic – I paid $60 and we gave a MA60 lens (I think) to get her travel covered to Zimba where they supposedly have a vitrector; will the patient really use the 250,000 kwacha to go to Zimba or for something else (she seemed a bit too happy at getting the money). Improvised a near-clear 6 mm wound (under peritomy) closed by a buried horizontal mattress suture. Worked pretty well I think for SICS. Flipped a huge lens out of the bag through a small pupil. The visiting doctor slowly got the hang of the capsulorhexis but one of them ran way out on both sides (flag sign). She recovered well. Cases coming into OR who we had never seen (can the scheduler do that? They can do anything).

Most notable case – this gentleman came in with a history of stick to the eye 10 days prior. He had a ruptured globe (iris prolapsed through corneal 5-6 mm cornea laceration). Try stuffing an iris back in with no general anesthesia, the patient moving, no assistant, bad scope, bad viscoelastic, and trying to close cornea too at the same time. Held iris back with iris spatula on my left hand and did no touch suture technique with my right hand on the corneal wound over the spatula. Nuts! Saw a girl with keratinized corneas (I mean, skin over her eyes – terrible). Got internet for a few precious minutes in the evening but Andrew hogged the bandwidth. Shirley (the med student from Holland) made a nice dinner for everyone. Andrew regaled us with stories of cabbages from the book Primary Surgery. Apparently I need to see the gods must be crazy.

Day 4: cows kept us up again. Power went down in clinic once. Lloyd apparently chased them away with dirtbombs. Today was minor OR day. Thought it would be easy. Postops were fine from day before. We cleaned up the clinic room. Lloyd did 2 bilateral lid eversions and a trauma repair of superonasal periorbita from stick to the eye (once again – that stick to the eye) (really tough as the poor kid was getting hit from wearing a winter coat and we had a surgical drape and just local anesthesia; no sedation). I did a double pterygium relocation (no AMT, no MMC, and better to leave superior conjunctiva for future cataract or glaucoma surgery). Then we had a couple of surface –omas to remove. 1st one was a squamous cell on an HIV patient. Without 5-FU, MMC, and poor systemic prognosis, I thought it would be best to close (no invasion seen after I took it off). Thought it would be easy. Once the tumor was off, microscope light 1 went down, then light 2 went down. Try closing conjunctiva with 10-0 or 9-0 nylon (the 8-0 was useless, and the 6-0 had a massive needle). Insanity! Only the 2nd time in my life I have cursed in the operating room (Lloyd was amused that I did that at a mission hospital). Lloyd and one of the helpers alternately helped with a direct and an indirect for some extra light. Managed to get it done and lloyd got the microscope back on eventually (after I had controlled the bleeding and got some stitches in). Last case was a melanocytic mass which we got off and closed within 20 minutes. Had dinner at the director’s house (a very interesting gentleman who has spent 22 years at Macha and is a native of Pennsylvania). His wife is very sad about leaving Macha. Learned a lot about NGOs, foreign aid, health care personnel market, medicine in Zambia. Shirley and Abby (the visiting nurse) made banana bread and chocolate cupcakes with icing and sprinkles!

Day 5: slept thru alarm. Woke up late. Took care of final things in Macha. Then Drive to Lusaka. Had a crappy half-donut in Zambia. Almost got arrested for taking picture of police car with cops riding in the back of the pickup truck. Found university hospital. Not bad actually. Got a nice tour of the place. In reasonable shape. Could definitely be a teaching facility.


My main ethical dilemma I faced is: is substandard medicine worse than no medicine? I don’t want to think about all the violations of sterile technique I encountered and was party to (flies settling down onto the instrument tray just as an example). We had a couple of complications which probably would not have occurred had we had the regular equipment and instruments – one of which was in a monocular patient. The first part of the Hippocratic Oath is to do no harm. Clearly we did some harm. Did we do more good than harm? I think we did. We were able to do 26 cases out of 40 or so cases we had hoped to complete. I think we helped the vast majority of those people, along with the 80 or 90 patients we saw in clinic who we treated for infections, foreign bodies, and so on. But of course I don’t know the postoperative outcome.

I console myself with the fact there is no ophthalmologist for about 200000 people in this catchment area of Macha (in the US there is usually one ophthalmologist for 16000 people) . A famous ophthalmologist once said 50% success is better than 100% blindness. Is that truly consolation to the fact that I know I did not the best that I could in normal conditions and that some people may have been better off by not having met me?

Why would people go to a place like Macha? Mosquitoes, intermittent water, intermittent power, bad internet or phone service, grossly inadequate equipment/instruments/infrastructure/pharmacy, inexperienced staff. There’s nothing in the way of fun or sights or so on. You get bruised – physically, emotionally, and you risk malaria and dengue fever. The cases I did were not showmanship by any definition – they were tough to get through and not pretty. Do you go to run away? Maybe, but this is not a fun place to run away to. Do you go to feel important? Well, you are far richer than the natives and they are very dependent on you for medical care, but the mosquitoes and living conditions bring you down to earth real fast. Do you go to do the Lord’s work? That is all I am left with. Hopefully you made a difference to someone in that instant when you were the only person in the world who could that surgery at that time. There is no one else around. For a few days are you an instrument of God? I hope so for that patients’ sake.
As for as job satisfaction, it eats you up that you know you can do so much better, but cannot because of limitations. You know the bar you set for yourself in normal conditions but here you must accept humble pie and frustration. It leaves a bitter taste in your mouth. The creativity of improvisation that you devise is but a momentary respite from the sea of suffering that hits you day in and day out. From a systems perspective, are we just a band-aid or a crutch? Does the presence of volunteers and NGOs reduce the country’s capacity or interest for self-reliance and development? Perhaps as there is the potential to feed a culture of dependency. But there are so many who need help. Is it ethical to walk away from the suffering in the here and now in the faint hope that a better future could arise if the country had to bootstrap itself?

The trick may lie in training and education. But there is an intrinsic conflict between maximizing surgical volume and teaching trainees. It is not easily resolved in the US, with the benefits of facilities, personnel, and resources. It is infinitely more complex when power is failing and flies are flitting about the operating room.

So I return home with more questions than answers. Part of me does not wish to go back after the bruising several days but part of me wants to go back for a rematch – normally we get to wage war on cataracts, but this time the cataracts waged war on us. We brought knives to a gunfight – running out of supplies and without the full complement of equipment and instruments; we were outmatched on more than one occasion by the pathology and outgunned by the intensity and lack of resources. Perhaps I should go back with a full team and full force of stuff that we need and could have used. Stuff to think about!