life...

I found out today that the smaller 28-week-old twin who was gasping away with lungs too young for air on Friday died over the weekend. 

I had another intense experience today.  At the end (finally drawing to a close long after we were supposed to be in OPD at 3 p.m.) of an unusually long day in the operating theatre this afternoon, a woman came in at 19-20 weeks pregnant with vaginal bleeding and crampy abdominal pain who had been sent over from OPD.  An exam had been done, finding the cervical os (opening) open, showing she was probably in the process of miscarrying.  She hadn't passed any larger tissue yet, though, but it was decided to take her for a D&C (dilation and currettage to clean out the uterus) since left-in parts can become infected and cause sepsis and even death.

After we got her into the operating room, though, feet up in the stirrups and under anesthesia, she started to pass something more than blood.  I realized it was the fetus and had gloves on and so happened to be the one to catch the baby and then placenta as it came out.  It was a tiny baby boy I could hold in one hand with his little feet dangling off the edge towards my wrist.  He was alive still, heart beating away with the impact of it visible on his chest wall and occasionally giving a visible but inaudible gasping attempt to get oxygen into lungs much too young that contracted his entire rib cage, which is probably still mostly bendable cartilage at that age anyway. 

Early in my third year in medical school on my OB/gyn rotation I heard the story of a late second-trimester abortion that resulted (accidentally) in a live fetus, disturbing everyone involved (and sending me home to cry in anger and helplessness to a friend on the rotation).  I remember wishing I could have been there at the time to hold the baby so that at least it didn't have to die alone as well as unwanted.  The image of that little one set aside somewhere to breathe its last breath completely abandoned was more than I could take.

This baby was not unwanted (that I know of), but his mother was under anesthesia, and his grandmother was not interested in holding or seeing him when I showed him to her, including pointing out the beating heart.  So in an oddly gratifying though tragic closure to my experience at the beginning of my clinical years, I ended up holding this little one, simultaneously delighting in and sorrowing over his perfectly formed ears, fingernails, tendons, visible heartbeat, and even sticky immature skin, wishing he had stayed safe inside his mother for another six or eight weeks even, until I didn't see that heartbeat anymore.

This picture (or one like it) sits on the mantle of my parents' home, and I have been told it reminds them of me when I was born prematurely and very small. 

     from: http://blog.cornerstorkbabygifts.com/wp-content/uploads/2008/10/premature-baby.jpg

As much as I am sorry for the parents' loss of this little one, the whole experience reminds me of Psalm 139:13-16 and God's ultimate control over the days of our lives, as many or few as they may be:
"For you created my inmost being; you knit me together in my mother's womb.
I praise you because I am fearfully and wonderfully made;
your works are wonderful, I know that full well.
My frame was not hidden from you when I was made in the secret place.
When I was woven together in the depths of the earth, your eyes saw my unformed body.
All the days ordained for me were written in your book before one of them came to be."

link to another blog

A friend sent me this link, and I felt that the blog post summed up much of what I wanted to say on Friday and said it better than I could.  So for your edification:  http://mccropders.blogspot.com/2010/03/cotw-10-months-old.html.

Zambia slideshow 3

Here are the pictures from this weekend.

Linda is here!

I had an uneventful (thankfully) trip to pick up Linda in Livingstone.  She had managed to meet up with Macha friends Abby and Christina on Friday night before I got there, so I knew from Abby she was there safely, albeit minus her checked luggage.  We found each other without problems at Jolly Boys hostel on Saturday and proceeded to the airport and then the Falls.

We enjoyed a(nother, for me) visit to the Falls, including seeing the Boiling Pot, the place at the base of the Falls where the water swirls around like crazy.  I'll have to get Linda's pics of it since I left my camera safely in the Ziploc bag.  Then we went through the Falls lookouts themselves, getting soaked along the way, and walked back to see the Zambezi as it drops over the edge.

Before heading back to the lodge, we braved the sometimes-aggressive artisan-sellers outside the entrance to the Falls in an effort to get fair (but not insulting) prices for things to take back to the States.  We met up with the other two girls there, who had taken a different route at their Falls visit, including bungee jumping.  Then we all headed back to Jolly Boys and out to eat for great Italian food for dinner.  We had a smooth trip back today via Choma.  Below is a pic of us eating at the Italian restaurant run by at-risk youth who are trained in life skills with work at the restaurant as their final step in the program.

My calzone (on the right) was deeelicious!  We all shared around, too!  What fun!

hope

I wanted to clarify something after my last post as I thought more about it this evening.  Two things.  One is that my hope in the face of suffering, although based in a future hope of when all things are made right (and I do need a future hope because the present problems are pretty daunting sometimes!), is also something realistic here and now, not merely an escape from reality.  It must be.  Jesus came to bring the Kingdom of God - God's rule, the place where the reign of God as King is shown, where his laws are followed and his desires performed - and those of us in the Church have the privilege of being part of making that happen.  So medicine is part of that, bringing wholeness to people's bodies.  And so is loving people, making right broken relationships.  And so is prayer, aligning our hearts with God's loves.  And so is working for justice.  And so many other things...

Second, for the here and now, this is my hope for me, for that mother in her grief, for the many questions and problems I don't know about or can't solve.  From Romans 8:38-39, "I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future, nor any powers, neither height nor depth, nor anything else in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord."  May that love spur us on to continue to care when it would be easier to be cynical, to work for the Kingdom when it costs us, and to hope with a strong and sure hope for the day when God's rule will finally and fully be made manifest in the midst of all evidence to the contrary.

loss

I lost my first patient today.  In some ways, it's a bit surprising that it took almost two years of clinicals for me to be on the team taking care of a patient that died.  But I wanted to acknowledge it and tell the story.  It feels like a way of doing something more, even when nothing more can now be done.

Today was my last day on pediatrics since I will be gone tomorrow picking up Linda in Livingstone.  So after OPD finished around 5:30, I figured I'd go check on a few patients that seemed less stable before heading home.  I checked on the premature baby on maternity ward (probably about two months early, but mom is really unsure of dates for her last period) who probably has respiratory distress syndrome due to lack of surfactant, which we don't have and can't give.  She's still really tachypneic (fast breathing) with lots of retractions and a sternum out way further than her ribs, pushed out by air trapping, but she's still breathing.  So I moved on to the peds ward with the room where we can give oxygen.

I asked one mother whose toddler I've seen for the past two weeks how her child was doing, and she said a little better today.  So that was encouraging.  But then I heard the second mother in the room crying. 

I turned to see the second child on oxygen without the oxygen on but the machine still running, covered by his blanket.  Apparently he had just died recently.  I stood there for a minute or so, not sure whether to go over or not, when the doctor and peds nurse came in to pronounce him dead.  She looked at his pupils, which were dilated and non-reactive, and left.  Then the mother really started crying, and I also started crying.  I did go over and give her a hug.  Then more family came in, beginning the traditional wailing, and I left the room, still crying, trying to pull myself together to walk out the peds ward past the other moms sitting out in the fading sunlight of the day.  I could hear the wailing escalating around the hospital campus as I walked out for the day.

I had worried that facing suffering here, especially children dying, would make me question my faith.  I did ask God briefly, "Why?" but it was more of a question about suffering generally than this specific instance.  And I still believe God is good and cares for us.  I still believe someday all these things that are wrong in the world will be made right.  I still believe that somehow, one day, the Light that shines in the darkness, breaking out in vivid brightness that allows us to see in color for second, will one day provide so much light that there will be no need for the sun, and darkness will be no more.

This was the sky on my walk home tonight.  Light breaking out.  Beauty in pain.  Thanks be to God.

patient stories

I am amazingly finishing my two weeks on pediatrics in a few days. I've learned a lot (like how to read a pediatric chest X-ray) that I wonder how I didn't learn it before, and Dr. Thuma has been a great teacher (and very patient with my apparent inability to learn and remember how to do the seemingly endless calculations involved in pediatric drugs and fluid dosings). I've also seen many children with protein-energy malnutrition (PEM, or kwashiorkor), including one today who was 18 months and 7.8 kg (about 15 pounds) and another 12-month-old who was 4.5 kg (about nine pounds).

We also have a two-month-old baby in with PEM whose mother died two weeks ago. The family has been giving her cow milk because what else do you give a motherless baby when formula is either unavailable or unaffordable? In between desperately trying to remember why you're not supposed to give babies cow milk and wishing they could reasonably boil the bacteria-laden bottle and nipple, I wondered what realistic chance this little one had at a future with no mother and little access to nutritious food already at two months of age.

Mike and I gave powerpoint presentations earlier this week on acute rheumatic fever and rheumatic heart disease. He told me today that two of his patients on men's ward (age seven and up) with rheumatic heart disease died yesterday and today at around 14. There is no way for patients in this country to get valve replacements, which is what they would need to repair the damage done to their heart by untreated strep throat infections as children.

All it takes is some penicillin, the first antibiotic discovered years ago. But we almost never see sore throats in the outpatient department (I'm sure their parents have other things to worry about besides a little sore throat), and so some number of those untreated strep throat cases end up showing up a few years later in heart failure from damaged, leaky valves. Besides optimizing heart failure management, there's nothing we can do, and it sometimes feels like we can simply watch them die.

I feel that way with some of the really late-presenting, malnourished kids on peds, too. Sometimes it's just too late, and their immune systems are too far gone, and we can't intubate or ventilate anyone that might need it, and so some of them die. I haven't been there for any deaths yet, but I notice the empty beds.

One of the hardest things to face in medicine (at least for me) is finitude.  I feel like I've mentioned this before, but I can't remember if it was in conversations only or in the blog, too, so bear with me if this is repetition.  But I still have to grapple with the fact that I am finite.  I can't learn it all, can't remember all the things I did at one time learn and know, can't save every life, can't impress or please everybody, can't know what is going on with all the patients I encounter or even sometimes make a diagnosis, can't make a difference in every life, can't pick up on every physical finding, etc., etc.  It is daunting, and humbling.  A resident-in-training once told me that he had grown to appreciate the fact that he could ask forgiveness of God both for sins of COmission (things he had done) and for sins of Omission (things he had left undone - forgotten, chosen to ignore, didn't know about).  I am also growing in my appreciation of the fact that I do not have to carry the burden of either the things I do or that I do/can not do but can be free.

overdue thoughts

Sorry to have had so much time between the last real post and this one, which will be relatively brief since it's almost midnight here.  The combination of lack of functioning internet, sharing Mike's computer with him (thank you, Mike!) since mine continues to refuse to turn on, and the recent inundation with residency-related matters to try to handle at a distance has left little time for blog postings.  But here we go.  I'll do it in a bullet-type format since that seems like it might be most efficient.

* I have now heard the wailing that Zambian women do when someone dies after hearing about it from my parents growing up.  I don't know that I've heard a more poignant sound than the almost-musical mourning that goes up and travels with its producers around the hospital campus announcing the family's new grief.  It never fails to make my throat tighten up and sometimes bring tears to my eyes.

* Bryce visited Macha last weekend after our trip to Livingstone with him the weekend before.  Mike was happy to have another guy around, and the two guys, Heidi (a SALTer), Abby (an MCC nurse and Jeff grad), and I had fun playing Dutch Blitz one night. 

* Recent meals with both the Thumas and the Spurriers, the two long-term expat families here, were helpful in building relationships and also in providing cultural and historical insights.  It made me proud of the way the church here is national-run (and the services much different from churches in the States) and nationals and expats work together in the hospital.  Their stories of long-term successes against measles, neonatal tetanus, and now increasingly even malaria were also inspiring tribute to the benefits of working in one community for years and years.

* We came back from Livingstone last week to find that Carl, Mike's cozy immobile wall spider, was gone.  He hasn't shown up again, which is probably to his health benefit.  That said, there are apparently still-living spiders now on Mike's side of the room.  And Mike reports he barely notices the spiders on the walls in the lounge here in the dorm.  Progress has been made.  :)

* Mike leaves tomorrow (and with him my access to a computer for a few days) for Lusaka, and Linda arrives in Livingstone on Friday.  I will go down to Livingstone to meet up with her, and then we'll meet up with a couple other Macha expats to travel back to Macha on Sunday.  Hopefully that will make the apparently-inevitable taxi ride (~$50-80/trip vs. $3 for the trucks) cheaper to split up since the trucks don't run on Sundays.

Zambia slideshow 2

here's the pics complete with labels from our trip last weekend.  I think they tell better stories than me trying to detail the weekend.

match

I matched to Lancaster General Hospital for family medicine!  :)  And Mike matched to Cornell for internal medicine.

brief update

We are back safely from Livingstone as of Monday night.  Internet connectivity has been absent.  I'm working on uploading photos and will tell more stories when I can post pictures, too.  Adrienne, our fellow medical student, leaves tomorrow.  I also find out where I will be for the next three years for residency tomorrow.  So many updates to come.  :)

weather, money, and medicine

India was definitely getting hotter by the time I left, so it was a bit of a shock to come here to a week of rain and cool temperatures that made me wish I'd brought more ankle-length skirts and long sleeves.  This week, though, it's been warmer and sunny.  I'm back to being happy to be in short sleeves.  I anticipate getting wet again this weekend, though, with some great views at Victoria Falls.  I just hope the sun holds out for our anticipated trip to Chobe Game Park in Botswana.

People ask us for money a lot here.  Or they ask to do our laundry or sweeping for money.  I tell them I do my own laundry (by hand), which is true.  I haven't found the best way to deal with or think about being asked for money.  Obviously, the perceptions of Western wealth on one hand are inaccurate - at least in my case, since I'm >$200,000 in debt for med school.  On the other hand, I do live a life of incredible privilege in so many ways, partly shown by the very fact of my being in this country.  So I simply smile apologetically and say no for the most part.

Medicine is quite different here.  Not so much because we see different diseases, although we do (I've seen at least four cases of cryptococcal meningitis in a week and a half, which I never saw in the States, although I know it happens; I've also seen lots more TB, HIV, and rheumatic heart disease here than in the States).  But because of the setting, even our first-line medications for common conditions are often different - for pneumonia or PID, for meningitis or CHF.  So it takes some adjusting and insecurity can come with that.  But I'm learning and thinking and asking questions, and I suppose that is good.

spiders, part 2

Mike has named the spider on his wall.  Its name is Carl.  Mike gives us daily updates on Carl, and they apparently have an "agreement" about the rules of Carl's living in Mike's room.  1) You don't move.  2) If you do move, you stay on the side opposite Mike and his bed.  3) If you do move to that side, you die.  These rules have apparently been broken at least once by Carl's "son," Scotty.  He is now dead.  Carl remains immobile.

Despite the above, Mike is actually doing quite well with the spiders.  I have heard no shrieks or even requests for help, and he has killed several spiders already (unlike me).  He even got closer to one we saw when walking yesterday to get a picture.  :)

Zambia slideshow 1

Here are the pictures and captions of week one.

spiders and fears

Mike is scared of spiders.  I knew this before coming here since he told me, and I told him that I remember blowing on the wall spiders that abound and eat mosquitoes, so we don't usually kill them.  We have a difference of opinion about them - I like to blow on them to make them go up towards the ceiling and further away from me; Mike likes to leave them where they are so they don't move, even if that means they're at eye level.  Thankfully, we don't live in the same room, so this doesn't come up often, but our dealings with spiders in the lounge of our dorm building do differ a bit.  :)  We share a fear of the camel spiders, or wind scorpions, that apparently also sometimes share our living space, and I've already decided to call Adrienne, the other med student, if one of them shows up.

The fact that I don't fear the wall spiders, though, reminds me of how conditioning affects our fears.  I probably would be afraid of them if we hadn't lived here and my parents hadn't taught me to blow on them for fun as a child.  The Zambians think chameleons, which I think are really cool (they change colors - how do you get cooler than that!? - and we even got to see one eat a few tiny ants) and gorgeous, are as gross as cockroaches, and I had several women gasping the other day when I wanted to pick one up.  (Mike stopped me before I caused any heart attacks.) 

Which of my fears are truly fear-worthy?  Which fears are innate, and which are taught/learned?  Do I fear things I shouldn't?  Do I allow fear to control more of my actions and choices than it should?  How do these thoughts extend into the less entomological parts of life - are my more basic fears well-founded?  Just some thoughts.  The Bible talks a lot more about fearing the LORD than it does about fearing other things.  For example, Psalm 27:1 says, "The LORD is my light and my salvation; whom shall I fear?"  I get the impression that fearing (living in rightful respect/reverence) the One worthy of it puts all our other fears into perspective.  May it be that way for me and for you.

patient stories 2

A few more patient stories have come to mind over the past few days as I've been thinking about my last post.  One is a young woman (perhaps 21 to 23 years old) who came in pregnant for the second time out of wedlock to use the old terminology.  Her parents are apparently prominent in the church here, and the shame of her first pregnancy five years ago resulted in her being kicked out of the house to go live with her grandmother for the duration of her pregnancy and the first year of her baby's life.  She does not want to tell them about this pregnancy, which is six weeks along.  She wants termination, but our hospital as a mission hospital does not provide that.  She cannot afford the trip to or procedure/drugs in Choma to terminate her pregnancy there, nor could she hide the length of the trip from her parents even if that were possible.  She threatened to go eat from a tree whose bark or something is lethal to commit suicide if she cannot avoid this pregnancy. 

Since we have nothing else to offer, the other med student and I talked to her for about an hour and a half at the end of a day, trying to explore other options or sources of support for her while she continued to voice her one and only request.  We voiced our emotional support and tried to come up with strategies for her to find resources to help her with this pregnancy and the baby that may be born.  It was a frustrating experience in patient counseling, somewhat like refusing antibiotics to a patient with a viral infection except on a much larger scale.

Another patient was a baby born with probably hydrocephalus with widely separated skull sutures.  I learned that parents do not name their babies here until they are sure they will live, an interesting attempt to deal with a life that must be oversaturated with loss.  The baby was tachypneic (fast breathing rate), and the lungs appeared underdeveloped, which we can't do anything for even in the States.  He also kept getting hypothermic, so we'd put him under warming lights and wrap him in blankets to try to keep him warm - but not too warm without a temperature sensor.  I think he just had too many things wrong with im, and he died a few days later. 

One of my favorite patients, a woman who always smiled at me and spoke a little English, was discharged today with a referral to Lusaka, the capital city.  She was found to have pancytopenia (low white blood cells, red blood cells, and platelets - all the major blood cell lines), hepatomegaly, and massive splenomegaly to four or five centimeters below (but lateral to) the umbilicus.  This is a spleen even I could not miss!  One of the major differential diagnoses is a blood cancer or leukemia, or some other myeloproliferative disorder, so we referred her for the bone marrow biopsy we can't do (and probably treatment we don't have available).  I hope she goes and has a good outcome; sometimes even Lusaka seems a world away for these people (and me!), so I'm not sure what will happen.

The final story I wanted to share is a four-year-old boy who came in when I was on call, having stuck a kernel of maize (the staple crop here, which is ground up to make nsima) up his nose.  After we finished rounds, we took him over to the operating theatre and put him out with some ketamine.  Once he was relaxed, the doctor bent a paper clip and snagged the corn kernel, dragging it out of his nose.  It worked!  So, note to self: when in doubt about tools for foreign body removal...

patient stories

Some patients' stories stand out.  Here are some that stuck with me this week.
 
One was a one-and-a-half-year-old child who was admitted with severe protein-energy malnutrion, or kwashiorkor, as well as a pneumonia.  His hair was a silkier light brown instead of the curly black hair the other Zambians have due to protein malnutrition.  We started him on the PEM protocol here, but his prognosis is still guarded. 

Another was a seven-year-old with a broken tibia that was the first patient on whom I have put a cast, or plaster of Paris (POP) as it is called here. 

I rounded one morning on TB wards this week and was struck by the number and diversity of HIV-positive patients there.  It seems that nearly all of the longer-term patients with tuberculosis who stay here for treatment for a time also have HIV.  I am sure that the HIV-positive people in the States are also a very diverse group age-wise and health-wise, but being in health care thus far has exposed me to a small proportion of them, so I am seeing a lot more relatively healthy young and old women and men as well as children here who have HIV than I have previously.  We test about everyone who is sick enough to get admitted to the hospital for HIV.

More stories later when my friends let me borrow their computers again.  I'm looking forward to going to church here tomorrow and hearing the African-style music! 

adjustments

I think I hadn't realized  how much I had grown accustomed to things in India in my short time there.  I found myself the first few days (and still now) constantly wanting to comment on how things here are different than there.  Life here is just less crazy in many ways, partly because there are fewer people - traffic is less hectic and life-risking, people are not crowding walkways and towns, etc.  It's interesting...

I find the juxtaposition of two foreign countries coming up in other ways, too.  I was trying to ask a patient whether she had a headache after a LP (lumbar puncture - spinal tap in common parlance) and ended up combining my newly acquired Tonga word for pain with the Tamil word for head instead of my recently heard Tonga word for head, resulting in a confused patient who then asked me in English what I wanted to know.  Oops. 

Those adjustments aside, life here has been good so far.  The schedule is approximately 7:30 a.m.-5 or 6 p.m. daily with ward rounds in the mornings Monday, Wednesday, Thursday, and Saturday and OT (operating theatre - operating room in the States) in the morning on Tuesday and Friday.  We see patients in the outpatient department (OPD) in the afternoon every day.  Lunch break is some time between 1 p.m.-3 p.m.  Mike and I are sharing call with another fourth-year med student, Adrienne, from the States on a q4 basis, which means we go in for evening rounds (8 p.m.-10 p.m. or so) and are available for any OR emergency cases at night every four nights.  Our two other fellow ex-pat students, Sarah and Beth, left today for the States.  So the remaining three of us are settling in for the next few weeks. 

Kerala slideshow

Here's the slideshow from Kerala.  Internet connection is too slow to tell lots of stories tonight, so I'll let the pics speak for themselves.  Thanks to Sarah for letting me use her computer!


        

Zambia info

So I wanted to include some of the initial info about Zambia that I did about India, so here's the images of the flag and maps as well as some of the country statistics.  All info is again courtesy of the CIA World Factbook, and the pictures are as well.

• size:  752,618 sq km - slightly larger than Texas 
• population:  11.8 million
• median age:  17 yrs (cp. 36.7 yrs) 
• 35% of population is urban 
• health statistics 
• infant mortality:  
• age structure:  45% 0-14 yrs, 53% 15-64 yrs, 2% 65 yrs and older 
• birth rate: 40 births/1000 population 
• infant mortality rate: 101.2 deaths/1000 live births (cp. US 6.22) 
• total fertility rate: 5.15 children born/woman (cp. US 2.05)
• HIV/AIDS adult prevalence rate: 15.2% = 1.1 million people living with HIV/AIDS]
• life expectancy at birth: 38.63 yrs 
• major infectious diseases:  bacterial and protozoal diarrhea, hepatitis A, typhoid fever, malaria and plague in some locations, schistosomiasis, rabies 
• religions 
• Christian 50-75%
• Muslim and Hindu 24-49% 
• indigenous beliefs 1% 
• languages 
• Bemba 30.1%
• Nyanja 10.7% 
• Tonga 10.6% (the language of southern Zambia where I am)
• Lozi 5.7% 
• etc. 
• education 
• literacy - 80.6% (87% male, 75% female) 
• school life expectancy: 10 yrs 
• politics 
• 9 provinces 
• capital: Lusaka 
• independence: October 24, 1964

I'm somewhere about halfway between Lusaka and Livingstone, two hours from Choma.

arrival #2

Mike and I have arrived in Zambia.  After about six hours (for me - four for him) of sitting and waiting and walking around looking for Mike (me for him), we found each other in Heathrow in time to head out to our gate. An uneventful flight followed, and I got to sit next to a friendly Malaysian ex-pat living in Lusaka about her life and insights into Zambia and its cultures around sleeping about six hours to make up for my one to two hours of sleep the night before.

After arriving in Lusaka and changing money, we caught a taxi to the bus station in Lusaka to head to Choma.  The next available bus was air-conditioned and beautiful, and the road was also in good condition.  After a month in India, I was astounded to be in a taxi and a bus with no honking and maintenance of one's own lane on the road!  Mike and I met a friendly other makua (spelling? - white person) on the bus who turned out to be a Mennonite from Lancaster County living in Choma for about ten months with the SALT program through MCC. We'll see if we can manage to connect with Bryce again for a trip to Victoria Falls or a game of Dutch Blitz at some point if he visits the other SALTer in Macha.

Bryce helped Mike and I run errands in Choma and then connect with a van to Macha.  The van's readying for departure was a cultural experience in itself, and I decided I was going to learn a lot about patience and waiting while here.  First we waited in the van for something unknown.  Then we waited for the engine to turn on, which it did after lifting the front seats and pumping something in the engine.  Then we sat with the engine running for a while longer.  Then we pulled out and drove to the gas station, where we waited.  Then we drove to a local shop and the driver got out and did something unknown, and we waited.  Then we pulled back into the original spot, loaded three more adults plus a baby in, and finally departed.  The initial 45 minutes were paved and smooth, but the final hour and fifteen minutes on unpaved, pothole- and stones-ridden dirt roads, gave me renewed sympathy for my dad's experience going on the six-hour drive from Lusaka to Macha 23 years ago with a broken leg.

We are now settling into the very nice MIAM dorms.  I have a room to myself with three other unoccupied bunks, and Mike (as the only guy right now) does, too.  There are three other female students here, too, two of whom share a room and one on her own.  They've been very friendly as we settle into the details of life here (when to eat, where to eat, how to use the internet, when to show up tomorrow morning, etc.).  I'm excited and looking forward to some exciting stories in the near future whenever the internet is working.  :)