Kabarak University Family Medicine Residency Funding Appeal

The medical needs facing sub-Saharan Africa are immense and complex. With the world’s fastest-growing population and some of the world’s fastest-growing economies, there are ever-increasing needs for medical providers. Many people in rural villages still lack access to basic healthcare for common infectious diseases like malaria, while richer places and urban areas are struggling to cope with the growing burden of hypertension, diabetes, and heart disease.

Most doctors don’t get to do more than one year of postgraduate training, and thousands of doctors trained in sub-Saharan Africa have left to practice elsewhere. While every health professional is a necessary part of making any health system work, doctors are necessary to manage more complex patients, stay on top of the medical literature, and help to keep medical teams organized. Unfortunately, there simply aren’t enough doctors and they are rarely able to get the training they need to do all of these things.

At the Kabarak Family Medicine Residency, we are training family doctors to fill this important and enormous need. Our residents learn the clinical skills necessary to manage a variety of patients over the lifespan — they can handle acute emergencies in a district hospital and carefully manage chronic diseases so that adults can live longer and happier. They can help hospitals use research and quality improvement to make their systems serve patients better, but they are just as capable at building relationships with families and communities in remote clinics to promote healthy behaviors. Our four-year program trains doctors capable of strengthening health systems, not just filling in a slot.

Unfortunately, our funding streams have prematurely and unexpectedly been reduced at a time when we are needing to add more residents to cover the program’s ongoing expenses. We are trying to develop long-term funding strategies, but Family Medicine is still mostly unknown in Kenya and it will take time for our graduates to trickle out and help people understand how family doctors can help build better systems wherever they are. We have worked from the beginning to ensure that residents are paid a monthly stipend throughout their training so that they can focus on their education.

In Africa, residents pay tuition for their MA degree in Family Medicine or any other specialty. Government sponsorship is sometimes available, but some of the most qualified and capable  Tuition is slightly over $3,000 a year for four years. We have used a scholarship fund for the first three classes of residents, but continued support is needed to offer any support to future classes. A commitment of $1,000 a year for tuition support from an individual or group will be matched two ways- $1,000 from the scholarship fund and $1,000 from the resident. The applicants for our 12 program spots of the next class starting in September are all doctors with exemplary Christian character and a passion to serve their communities when they finish training.

You can donate online here. Donations are received by World Gospel Mission, Acct. #125- 25246 – “Kenya INFAMED Resident Tuition”. An IRS tax receipt is issued. If you are giving for a specific resident, please specify on a separate note from your check. You can send your check to:
WGM, PO Box 948, Marion IN 46952-0948.

We appreciate your prayerful consideration of support! Please feel free to contact me (loftus dot matthew at gmail.com) with any questions about this.

Support Kenyan Family Medicine Residents!

Pictured: Rising 3rd-year residents along with faculty in May 2018

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making the little things available for little people

The smallest things can be a big deal. Just ask my son, who this weekend had a piece of raw carrot no larger than his thumbnail go into his trachea instead of his esophagus. Maggie and I had just gotten back from an afternoon down at Tenwek Hospital, about an hour from our hospital in Litein, where we were visiting this weekend. Tenwek was instrumental in starting one of the first surgical residencies in Africa and has already trained many African surgeons, including our friend and future next-door neighbor in Litein, Dr. Blasto.

As we walked into the house, my son Leo (almost 3 years old) was enjoying a carrot. Now, we eat a lot of carrots in our household – about 2 kg a week. They’re not messy, they’re healthy, and they won’t spoil your dinner, so that 2kg actually ends up running out after about 4 or 5 days on an average week. My eyes turned yellow when I was younger from all the carrots I ate, and I’m kind of surprised the same thing hasn’t happened to my kids yet.

But on this particular night, somehow (perhaps he was just too excited to see us?) a piece of carrot went down the wrong hole. Leo began coughing and would not stop, no matter how hard I thwacked his back or attempted to give him a Heimlich. He managed to breathe and speak in between coughs, so I knew that he was okay but it was still a little disturbing to hear my child constantly coughing.

Eventually the coughing settled down and the audible wheezing and stridor began. Leo was happy, content, and no longer coughing but as he sat reading a book to himself I could hear him breathe from across the room, whistling and honking with each relatively comfortable breath.

Uh-oh.

When airflow through one’s lungs is turbulent but not entirely blocked, it produces a variety of weird sounds (mostly high-pitched), which meant that even though the coughing spasms were no longer an issue, there was clearly still something in his windpipe causing some turbulence. Given the physical properties of both the carrot and tracheal tissue, this was an issue that was not going to resolve on its own and would probably just get worse as bacteria built up around the little hunk of carrot.

I called Dr. Blasto for his opinion, which was that we drive back to Tenwek Hospital. Since a foreign body like a piece of carrot that is only partially obstructing the flow of air can rather rapidly move to a position where it completely obstructs the flow of air, he felt it best to get Leo to a hospital where the carrot could be removed as quickly as possible. So an ambulance was called.

 Leo was excited to ride the ambulance, though he was a bit unimpressed by the fact that the ambulance did not light up or make the same “WEE-OOH WEE-OOH” sound that he made in between wheezes as soon as we told him that he’d be riding an ambulance. Dr. Blasto graciously agreed to come along for the bumpy ride; it took us about half an hour (in the dark, no less) to make a journey that we had made earlier that day in twice that time.

Once we got to Tenwek, Leo was evaluated by the medical team there and they decided that since it was late on a Friday night and he was perfectly stable, they would do a bronchoscopy (sticking a tube down his throat to look for the errant piece of carrot) in the morning when they had more staff immediately available. Both he and I were quite tired (and his audible wheezing had stopped after the bumpy car ride), so were glad for some time to rest and relieved that it wasn’t bad enough to require immediate surgery.

We stayed at a lovely guest room for the night. Sleep was difficult for Leo – not sure if the carrot in his trachea was bothering him on and off or it was just an unfamiliar environment, but we eventually managed to get to sleep and then get up in time to get over the hospital. We had to wait a few extra hours because of an emergency our surgeon had to attend to, but eventually Leo got in, got the piece of carrot out of his trachea, and got to the recovery room. We spent the rest of the afternoon chatting with another family teaching in the Family Medicine residency before heading home.

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Leo in the recovery room.

One of the worst parts about being a doctor is being aware of all the terrible ways that my child could suffer a medical emergency without any warning: a piece of food in the wrong place, a head colliding on the cement floor, or an infection out of control.  So I know it could have been a lot worse and I’m thankful that it wasn’t, but the whole episode was disquieting. We were miles away from the nearest bronchoscope, just as we were miles away from many other medical interventions that we might possibly need at a moment’s notice.

The human body is as resilient as it is fragile. It is a wonder that our bodies can heal and protect themselves, but the cruel realities of the world are such that many people – especially children – are vulnerable to disease and trauma. We can recover from many injuries and illnesses, but others not so much.

In the West, we usually take access to certain medical interventions when emergencies strike, but these interventions are still beyond the reach of many children. Even those who live near a hospital may still be in danger – last week I saw a child who had been brought to a government hospital in the middle of the night with extremely high fever and rapid breathing that was not even seen by a medical provider. She was later taken to a mission hospital and admitted to the pediatric ICU immediately.

The harsh sounds of my son’s breathing reminded us quite viscerally of the risks of living in a place without quick access to medical care. Yet it also reminded us of why we came to live here in the first place: many of the children around us don’t have a surgeon on speed dial and don’t have someone who will just arrange for an ambulance to speed through the night. If it wasn’t for the work of the PAACS residency doing what our family does except for training surgeons, we might not have had a capable African surgeon ready to evaluate and treat our child right away.  Our work is only a tiny, tangential part of equipping and strengthening the health system here, but we believe that the little bit we can do might better equip health practitioners and the hospitals they work in to better serve their communities.

Our son recovered from his procedure very well and was peeling himself a carrot to eat on Tuesday morning. (Why we left the carrot peeler out where a child could cut himself with it and necessitate another emergency intervention is beyond me.) Our scary little interlude was mercifully short and not nearly as scary as it could have been, but it reinforced for us how tenuous our life is – and how important it is that we are here.

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Sewing and Shame

Honor and shame dominate many cultural interactions here. High-status positions within medicine bring honor and occasionally a sense of entitlement. Correcting anyone in front of other people is felt to be shameful, which makes the back-and-forth of medical education quite difficult. In my residency training, the best teachers were the ones who interrogated my diagnoses and treatment plans until they had found holes in my reasoning, pointed them out for everyone to see, and challenged me about how to think differently about clinical problems. Even changing previously written orders while on rounds together can bring shame to the clinician who wrote the now-abrogated order. (To be fair, my experiences in the American medical system had plenty of hurt feelings over honor and shame!)

Our challenge is to work within the existing culture and recognize its strengths (America is learning what can happen when you keep saying “anyone can be President!”) while encouraging people to take on Christlike humility. It is not easy to be humble in any culture, but it’s particularly challenging in a place where saving face is more important than getting things done and throwing one’s weight around is often the only recourse for maintaining a high standard of care for our patients.

I wasn’t really thinking about this at 4AM on a Sunday morning when poor Graham got roused from sleep to come help me with a surgery, but he was.

I had already been awake for two hours, trying to get the c-section done quickly enough to go back to bed before church. It seemed fairly routine, though I was having trouble controlling the bleeding after I got the baby out and I didn’t know why. I’ve now been doing c-sections on my own routinely, trading off cutting and sewing with some of our clinical officers so that they can grow in experience, too. I hadn’t called for help from one of the more experienced doctors in over a month, but after I had already done all I could do, I felt like I had no other choice but to call for assistance.

One of the great strengths that both expatriate doctors who have both been here for years share is their sense of calm in life-and-death situations. (Read more about Jeff here and Graham here.) It was no different this early Sunday morning as I held pressure and Graham ambled into the operating theatre, putting on a mask and leaning over to look into my surgical field as I threw my hands up in exasperated fear that I had done something wrong.

In a manner meant as much for the staff gathered in the room as for me, he mentioned a time when he had made a mistake at the step in the operation I was stuck at. After a few minutes of looking around, I realized that I had followed in Graham’s footsteps and made exactly the same mistake!

This was my first time that I’d had to cut my own sutures in the middle of an operation. It was not a pleasant experience to undo my very thorough (and very wrong) work, then keep the rest of the surgical team up for an extra half hour while I fixed my mistake. The patient and her baby did fine, but I was of course ashamed and discouraged because I’d made such an ugly mistake.

 

When I got home, Graham had already written me an email. It was a perfect example, he suggested, of how peers correct each other and accept correction while maintaining mutual respect. While I would personally like to have opportunities to be a light and a witness in ways other than “models humility when wrong”, I was really thankful that we were able to have that interaction as an demonstrate something that the long-term workers have been talking about for years.

Every medical team, no matter where they are practicing, will make mistakes. And no matter where you are, the people involved will feel the urge to save face and resist correction instead of being honest and working together to find a solution. We need good systems and protocols in place to catch mistake before they cause harm, but we also need humble-hearted clinicians to take responsibility and change course, even if it might mean admitting you were wrong in a culture where doing so brings shame. I don’t know when my next opportunity to learn something the hard way will come (hopefully at a more reasonable time of day), but I’ll certainly look at it as an opportunity to teach, too.

The gift of a safe delivery

As Dinya, the clinical officer, prayed, I quickly pushed the ketamine into the patient’s IV. I watched her carefully; she was struggling to relax.  After thirty seconds or so her face began to relax. Dinya began pinching folds of skin on her abdomen, while I watched her body language for tension, to ensure she was numb enough to begin the c-section.

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Five months in, it was my first time running anesthesia for a c-section independently. Since we’ve moved here, I have been working at the hospital on Thursdays. Matthew stays home with the kids and I am grateful for a husband that’s willing to jobshare a bit so I can be part of the action. It is true, though, that coming in only once a week has made for a slow onramp to feeling anywhere close to confident. Anesthesia in particular feels like something a nurse should have, oh, at least an additional Master’s degree in.

My preceptor, Kitty, poked her head into the OR. “You ok?” she asked. But I was; I was feeling like I could anticipate solving several problems independently before I’d call her for backup. It had helped that we’d been together with some difficult cases. “All right. Let me know if you need me.”

I turned back to the patient, and I watched the monitor as her oxygen level promptly dropped from 100… to 96… to 92… to 87. Right. I propped her jaw forward to open her airway further. Nothing. Time for oxygen. I watched her oxygen saturation rise again, and offered a quick prayer of thanks.

It was clear even a few minutes in that she was metabolizing the ketamine quickly. She began to grimace a little, to sing a little. I watched her carefully and prayed; sometimes ketamine just makes you talk. It can also cause uterine tension and make baby a little slow to start breathing. I really didn’t want to have to give her any more if I didn’t have to.

The blood pressure machine was broken, so I assigned a midwife student to take the patient’s blood pressure every few minutes manually for me. I also decided she needed a little more ketamine, explaining to the visiting doula who was shadowing why I was hesitant to do so.

A few minutes after that, Lo and Dinya pulled a 3-kg baby out. The cord was wrapped around the baby’s neck three times. “Right,” Lo said matter-of-factly in her Irish accent,. “this one definitely wasn’t coming out normally.”

In America, having a c-section can be a mark of shame for a woman. My first child was delivered via cesarean; when the doctor announced that, at the eleventh hour, Naomi had flipped into breech position, and with my water already broken, a c-section was our only option, quiet tears rolled down my face. I remember talking a friend through feelings of disappointment that she wasn’t able to deliver her baby vaginally, receiving positive e-mails from a VBAC (vaginal birth after cesarean) support group listing tips for talking to your doctor, reading in a childbirth book about ways to delay c-sections, and trying to drum up as many suggestions as possible for convincing your doctor to give you more time to do it yourself, as it were. To be fair, there are reasons why c-sections are not preferable to vaginal births. I pursued a VBAC with our second child, and was glad for the easier recovery. But as the baby’s cries rang in the air, indicating health and liveliness, I was reminded, again, that having a c-section available to me, done by competent health care professionals was, and is a gift.

It was a gift that multiple competent doctors were ready at that hour of the morning when we went into the OR for Naomi’s delivery. It was a gift when Dave, the scrub tech, walked into the OR and cussed audibly because I was sitting on the table getting my spinal block put in. It was a gift when Rose, labor and delivery warhorse that she is, kept a close eye on my heartrate when it dropped into the 40s after surgery. And my anesthesiologist, Tom, was definitely a gift, as he explained to me what was going on behind the curtain– despite the fact that I had been in c-sections as baby nurse before, being the patient was a little scary for me. He walked me through it with a caring manner and kept me pain-free.

I took the bucket containing the placenta and blood out to the pit behind the incinerator. Emerging from the OR into the sunshine was a breath of fresh air. I made a mental note to bleach my shoes the next day. What a gift.

 

 

Malaria, Typhoid, or Both?

All four of us have had malaria now– mild cases for everyone, fortunately, but I can assure you that it’s no fun. It’s particularly vexing for our family because we use an awful lot of precious Nutella and jam to get the kids to take their awful-tasting Mefloquine every week, and we aren’t the only family taking prophylaxis faithfully to get malaria this year– several other folks here on campus who take medications ostensibly to prevent us from ever getting it have had to settle for “at least we didn’t need to be admitted for it”.

Sadly, children in the community without the luxury of living right next to the hospital or taking prophylaxis haven’t been as fortunate. The rains seemed to have started a little earlier this year, and whether the parasite itself is getting more virulent or the mosquitoes are biting more, we are seeing more cases requiring transfusions and deaths several times a week in young children.

With very little data to work with besides our own overflowing wards (and similar stories from other clinics and hospital all over town), we can only conclude that transmission of the parasite is more frequent and the best we can do is test as early as possible and treat as quickly as possible.

Fortunately, malaria is one of the few diagnoses we can reliably make in the hospital because you can see it on a blood smear. The lab tests we can order all fit nicely on a half-sheet of paper, and half of these we rarely order anyway:

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However, malaria shares a number of clinical features with typhoid– both cause fevers, headache, dizziness, abdominal pains, vomiting, joint and muscle aches. The main differences when taking a history are that typhoid tends to cause constipation while malaria can sometimes cause more diarrhea and malaria tends to be much faster in onset– but that’s about it, at least in the first week of illness.

You can order labs for typhoid, though– the Widal test, an old serologic test that measures antibodies to the Salmonella typhi bacteria. Unfortunately, this test can’t distinguish between current infection, previous infection, or successful immunization, so in a population where typhoid is quite common there are quite a few false positives. This hasn’t seemed to slow down the test’s popularity, as it is still used quite a bit because it is cheap and quick.

When discussing patients with our clinical officers and nurses, we often have to remind them of this false-positive problem and ask if there are really enough clinical symptoms present to convincingly make a diagnosis of malaria and typhoid. Many of our patients are sick enough to justify using antibiotics to cover typhoid in addition to antiparasitic drugs for malaria, but many aren’t. We certainly don’t want to expose our patients to potential side effects or create antibiotic resistance in an area where few drugs are available. We also don’t want to waste precious resources since the drugs we do get are imported and patients pay more for each drug we order! Thus, in the midst of our current wet season with malaria popping up everywhere and causing more severe cases than usual, I prefer not to even use the Widal test unless I have a really good story that makes me think my patient has typhoid instead. (And even then, I’ll still check for malaria anyway.)

So I when started feeling achy and fatigued, I of course dilly-dallied for a day or two before finally getting tested– and I didn’t bother ordered a Widal, since I was vaccinated. My smear came back positive and I started on treatment. I was especially thankful that we had several other doctors at the hospital who could take over while I was sick– when we came for our survey trip, there were only two doctors working full-time and when one of them got sick or went on vacation, managing 40-50 patients a day was just up to one person!

I finished my three days of medication and woke up in the middle of the night, unable to go back to sleep because it hurt to roll over. I took ibuprofen and paracetamol but still felt awful and got caught up on a lot of podcasts as I gained a new appreciation for why the pediatric ward was always full of shrieking children. I spoke to our wise medical director, Graham, who recommended that with persistent symptoms, I should probably just start treatment for typhoid.

After a day of mostly sleeping and taking Amoxicillin, I felt great. I got up, jumped right back in on the wards, and didn’t take another dose of pain meds. I still don’t know if my symptoms were caused by typhoid, malaria, both, or neither– perhaps I had a virus that got better at the same time I started taking the antibiotic and just happened to have a positive malaria smear– but who knows? Here, we just have to do the best we can with what we have and continue to train enough medical professionals to assess and treat people with malaria quickly enough that they don’t require transfusions or get sick enough to die.

I still don’t order the Widal, though. And I’m trying to teach our staff to be more judicious with it, too!

Cuttin’ for the very first time

When I was making my rank list for residency, we ended up having to choose between a hospital in Baltimore that would let us stay at New Song and a hospital where I could get more obstetrical and surgical experience. We ended up staying in Baltimore to finish my training and I know we made the right choice, but that meant I had a steeper learning curve once we got to Bet Eman.

I spent a lot of time in Maryland learning how to deal with polysubstance abuse, getting patients off multiple unnecessary medications, and managing complex medical and mental health conditions in the primary care setting. Here, there just aren’t very many drugs to abuse, most people have a hard time getting necessary medications, and there’s almost no such thing as primary care. (I’ll write a blog post later about what’s similar between South Sudan and Baltimore, but today we’ll only talk about the salient differences!)

To be useful in our hospital setting in the long-term, I knew I would have to get a crash course in more advanced obstetrics. I got to assist on a handful of c-sections in my training, but I never held the knife myself– until this month!

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As you probably know, South Sudan is one of the most dangerous places in the world to be a pregnant woman or an unborn child. For whatever reason, there’s a certain percentage of babies that, for their sake and/or their mothers’ sake, need to get cut out. My own daughter was born by c-section. Without access to a c-section, that 10-20% of pregnancies will end in death or severe disability for mom, baby, or both. This story from MSF reminds me of a lot of the patients we see on a daily basis.

While we are passionate about preventive medicine and community health to keep people from getting sick or needing to come to the hospital in the first place (and Bet Eman sees hundreds of prenatal patients a month to keep pregnant mothers healthy!), there are sometimes when you need an operation to stay alive. Hence, I’m learning how to do c-sections so we can provide this service to the community– and once I’m fully trained, I can teach others who will work in places in South Sudan I can’t take my family.

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We’ve had a lot of short-term visitors the past few months that have helped to lighten the load at the hospital, so I’ve also gotten to learn from a bunch of different family doctors as well as our South Sudanese medical officer (she trained in Uganda and has been a tremendous mentor in navigating the tough medical and cultural issues I’ve encountered so far!) Everyone does things a little differently, which is great for my education as I learn a variety of techniques and rationales for various decisions.

I regret to inform my mother that all of that hype about playing a lot of video games improving one’s hand-eye coordination and making one a better surgeon is probably not true (although I haven’t tried my hand at laparoscopic surgery yet, so who knows? I still play computer games for fun and relaxation, though, just like I’m sure Jim Elliott did.) Both Dr. Jeff and I have vision issues, so we have to work a little more slowly and drive our nurse-anesthestist crazy by asking them to raise and lower the bed constantly.

I still love the primary care aspects of my job. I miss my patients in Baltimore and their multiple unnecessary medications. However, I also love doing surgeries (as long as they’re short!) and there is a serious need for good surgical care here in South Sudan. (If you’re interested in learning more about how surgeons are starting formal training programs to train the health workers Africa needs, check out the great work of the Pan-African Academy of Christian Surgeons.) I’m thankful that I got the opportunities I had to learn in Baltimore and that I have mentors here at Bet Eman who are teaching me some hardcore obstetrics after I’ve finished residency.

I’ve gotten to hold the scalpel about ten times in the past 3 weeks and I know that I still have a few dozen more to go before I’ll be anywhere near “independent.” Some of the cases had some pretty hairy complications and the physician I was operating with had to take over for a few minutes. But even on my first one, after I got the baby out one of our South Sudanese clinical officers took over to do the sewing. He’ll be cutting himself soon.

[somewhat bloody but tasteful picture of me delivering the baby’s head after the obligatory Weird Al video]

 

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So what are you doing now that you’re finally there?

So after 11 years of feeling called, 7 years of medical training, 6 years of marriage, 2 years of support raising, and 4 months of packing up our house, we made it!

So what we are doing with our lives now that we’re off the plane?

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Not shown: the 16 pieces of luggage we’d been hauling for 3 days

Well besides keeping the ol’ home fires burning (literally), we’re mostly working in the hospital and doing language lessons. Our goals for the first two years are pretty simple: learn how to capably practice medicine and nursing in the hospital, gain a basic proficiency in Juba Arabic, and build relationships with our co-workers, neighbors, and friends. Not as easy as it sounds when you can’t just run out to the store for groceries any time you feel like it and you’re on a multi-cultural team working in a very different culture.

Maggie is working one day a week in the hospital, learning how to do anesthesia for c-sections (hooray for ketamine!) and manage a growing staff of nurses and nurse-midwives from all over East Africa. The rest of the time, she’s at home with the kids trying to figure out what she can cook from our very limited pantry on the charcoal stove in our yard while I work at the hospital. I watch the kids while she works and so far have had one other day off per week to rest; I’m on call 2-3 nights a week depending on how many physicians are around.

I’m also learning how to manage obstetric emergencies and perform c-sections since I didn’t get to do much of either during my residency. Thus, I’ll often be on backup call to get experience in these things (and some other procedures). We expect that it’ll take about 6 months or so before I’m able to work independently (which will give the long-term doctors here a little relief and help us all balance the day-to-day clinical responsibilities with administrative work, family time, and other projects like research).

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I make up for my lack of knowledge with my fundal-pressing skills.

There are technically 42 beds in the hospital split between maternity and pediatric patients, though oftentimes our capacity is exceeded and patients sleep on the floor or in the procedure room. We’ve been blessed recently to have lots of Clinical Officers (roughly the equivalent of Physician Assistants in the U.S.) who see patients with us and assist in procedures, so most days I’m supervising a team of 2-3 clinicians that sees 20-25 inpatients or 40-50 outpatients together. We also have antenatal clinic twice a week where one of the physicians reviews another 40-60 pregnant patients in addition to managing one of the wards. At any time, though, rounds or outpatient visits might be interrupted by the need to perform an urgent c-section, cast a fracture, or attend to a much sicker child who has come in.

Lots of Clinical Officers (as well as a growing roster of nurses) means lots of opportunities for education! In addition to weekly lectures (which have been going on for some time), we are now doing case conferences and grand rounds where we all discuss patients together. Advancing South Sudanese medical education is a big part of what we came here to do, so I’m excited to be doing it every day I’m in the hospital!

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Ward rounds with the clinical officers, nurses, and students.

This is our work and these are our days. I miss the deep conversations I had with my patients in Baltimore and the half-hour block Healthcare for the Homeless gave me to have those conversations. I miss being able to order advanced diagnostic tests for my sickest patients when here I have to say, “If you have enough money, you could go to Uganda and they might be able to figure out what’s going on.” I miss being able to eat a Deluxe Spicy Chicken Sandwich when I had a bad day at work (not as much as the other things, of course). Still, it’s good to be here and we are glad to be figuring out what God has for us here day by day.