Hope reflects on the impact of visiting residents & medical students in Tanzania

Posted with permission from Medicine Global Health Chief, Hope Pogemiller

Habari ya Tumaini

(news from hope)

So, it’s been quite a while since I’ve written.  Life has become quite busy, and I have wanted to be thinking clearly before sitting down to write to everyone again. Today I realized I’m not sure I’m one to think clearly…linearly…  So, I’ll write a little on a more serious note.  Life seems so much more serious when you are freezing in the house with fuzzy socks and heavy sweater shawl in place and with a cup of tea.  (Yes, I know it’s 73 degrees. But, can you really put a number on “cold?”) As the content herein will be serious, I’ll attach a few pictures in a lighter vein. 

I’ve always quite liked sea slugs, and as it is the rainy season, slugs are abundant. One of my pastimes has become stalking slugs and taking pictures in the foliage.

F75 is a dog living near the canteen at Selian who was quite malnourished in January as she was breastfeeding her puppies. We named her after the initial formula fed to children with severe acute malnutrition—F75

In my short time in Arusha, I’ve been impressed with the lasting, positive impact made by the revolving door of residents and medical students at Selian and ALMC. They arrive with eyes wide open and energy. There is a general eagerness to help in addition to learn—many are surprised that they have plenty of knowledge to share with medical trainees.  The knowledge gained when visiting Selian and ALMC extends far beyond the sheer volume and serious medical acuity of patient interactions.  

I watch as people absorb the community-centered culture and are introduced to the medical system headed by a government who has a strong desire to provide affordable care to the vulnerable populations, as well as those in upper socioeconomic status.  This idealism is a laudable goal.  Lack of resources in necessary areas results in a medical system for the vulnerable that seems to limp along at times.  It can be discouraging operating within this context, with a serious lack of trained medical personnel in the country.  I think this is one realm in which international exchange with the many visiting medial personnel can be quite valuable.  

The influx of positive energy and new eyes analyzing dilemmas from clinical cases, to medical systems, to clinical education, promotes increased patient explanation from Tanzanians which spurs creative new ideas and approaches that help in the brainstorming process that can “fight the unbeatable foe.”   This truly helps to subdue that nagging feeling that your team is simply “rearranging deck chairs on the Titanic.”

 

One of the planes was owned by Wings of Hope previously… but I found the tail comforting ;)

View from one of my flights with the flying medical service to transport patients from the rural areas of Tanzania to a hospital. The pink dots are flamingos.

Another view from the plane

On a more personal note, friendships form quickly here, and many of them continue after resident/med student departures.  Likewise, it’s been very encouraging to find consultants in the US who are happy to help with tricky cases despite the lab and imaging limitations.  Forging friendships and professional relationships between hospitals in Tanzania and between specialists across countries is one path to a brighter future in the realm of medicine. 

One of my favorite people from New Zealand posing with me in the matching skirts we had made

My favorite New Zealand couple with me at a fabulous Ethiopian restaurant

I feel honored to work with so many Tanzanians and expats who are deeply devoted to medicine and the improvement of lives for individuals and the population as a whole.  It is not infrequent to feel incredibly inspired and unbearably frustrated simultaneously.  The roller coaster of life somehow seems more intense here than it might elsewhere.  As in any medical practice, some weeks are much more discouraging than others in terms of patient outcomes.  However, keeping a list of patients who left the hospital or clinic with a clear improvement in health has been invaluable.  As in the US, debriefing with hospital staff and families is cathartic for all parties involved.  

Closing picture of flamingos from a flying medical service to transport run

Megan Hilger's Reflections on Her Experience at Mulago

 Posted on behalf of Megan Hilgers, Pediatric 2nd Year Resident

Hello from Kampala, Uganda!

As my time here is nearing the end, I am thankful for the experiences I've had, relationships I've formed and vast amount of knowledge I've obtained. I spent my first week working on research in the hematology lab with Dr Troy Lund looking at markers of oxidative stress in G6PD deficiency. My remaining time was spent doing clinical work. 

Megan Hilgers with Derrick, the Hematology Lab Tech

Most of my clinical time was spent in the resuscitation room of the Acute Care Unit.  This unit is where the Pediatric ED, PICU and a transition ward are located.  I worked alongside the Ugandan residents, interns and medical students. As you would expect from the name, the patients brought into the resuscitation room are critically ill and require rapid interventions.  After patients are stabilized they are transferred to the PICU or ward where we continue to follow them with the team. The most frequent conditions we care for are sepsis, respiratory failure from pneumonia, severe acute malnutrition, hyperbilirubinemia and severe anemia. Oftentimes, these are in the setting of sickle cell anemia, TB, HIV or chronic malnutrition. Not only have I gained knowledge of these diseases and complications but I've improved my exam skills, procedure skills and even my ability to read blood smears. As a resident in the resuscitation room, I provided full spectrum care and I can now draw blood, place IVs, place I/O's, reconstitute and draw up meds, mix IV fluids and run a code with a lot more confidence.  I greatly enjoyed the mutual collaboration with the Ugandan residents as we discussed various patients and how management differs in the US. 

Ugandan residents with Megan Hilgers and a visiting Anesthesia resident from Stanford

Resources and healthcare staff are stretched thin in the hospital and posed many challenges that often fell to the parents/caregivers. Parents are relied on to monitor their child at bedside, administer medications, purchase certain medical supplies- such as blood culture bottles, pick up test results from the lab and even go to a nearby pharmacy to purchase inpatient medications when the unit is out of stock. Parents form a supporting community together within the unit and I often witnessed mothers teach each other how to express breast milk, use NG tubes, share meals with those in need and care for abandoned or orphaned children.

This is a great setting for residents interested in learning about management of critically ill patients in a hospital setting with limited resources.  There were a lot of opportunities for hands on management and teaching students and other residents.  It was very humbling and I cannot express strongly enough how grateful I am for this experience.

Observations from the Special Care Nursery at Mulago

Posted on behalf of Sarah McIntire, MedPeds 4th year resident

Eighty. That’s probably a good estimate of the average census in the Special Care Nursery at Mulago Hospital in Kampala, Uganda. On busy days, the number of infants can rise over 100. Clearly, there’s no such thing as a cap on the number of admissions we can take in one day, let alone a couple of hours. Here, the babies are divided into two rooms: preterm and term. Preterm infants can be anywhere from roughly 26-28 weeks (here, viability is typically considered 28 weeks), and often come in multiples – twins, triplets, even one set of quadruplets! Term infants can present with problems ranging from low Apgars at birth or respiratory distress, to asphyxia, seizures, or severe sepsis. As Mulago is a major referral center and a government run hospital, many infants are transferred in for complex management or simply because their parents cannot afford step-down nursery care at a private hospital.

The Special Care Nursery, where I work is quite different from the NICU I have become accustomed. There are no ventilators, only CPAP. There are very few continuous infusion pumps. Phototherapy is limited, and labs take about a day to turn around, so if an infant appears jaundiced, they are often just brought to a separate isolette and squeezed together under the lights. 

On my first day in the SCN, I felt overwhelmed by the sheer number of patients, and the limitation of resources. I could only think of what I wouldn’t give for a ventilator, or even just a quick CBC. At first, it was so hard to see past the differences between NICUs in the United States and here in Uganda. But, just like any new rotation back home, I waded right in, and started to realize that just because the care of newborns here is different, that doesn’t make it bad. It’s more about realizing how to make use of the tools you have available. 

Sarah and Kendahl with the Special Care Nursery Nurses

I learned to rely on mothers, who act as bedside nurses, and who don’t need a nursing degree to tell you that their child is too warm, or is breathing funny, or has a distended abdomen. I diagnosed a trachoesophageal fistula on my third day, after learning to place nasogastric tubes and having one that just wouldn’t go into the belly. Chest X-ray confirmed the TE fistula, and surgery was there the next day and ultimately took the child to the OR for repair. Just like back home (although perhaps without a CT scan or prenatal ultrasound).

But the most amazing thing to me about the Special Care Nursery goes beyond the medicine. My contribution of prescribing antibiotics or advancing feeds paled in comparison to the absolute love and devotion of the parents and families caring for these infants. I saw a mother, after breastfeeding her own child, pick up an abandoned infant awaiting placement, and, gently holding him, feed him formula from a syringe. She could have (and should have) been resting, but to her it was more important to care for this child who had been left behind. Another infant, whose mother died in child birth, was cared for lovingly not by his parents, or grandparents, but by his paternal aunt who gladly purchased formula to feed him, and stayed for days in the hospital until he was ready to discharge.

Special Care Nursery Nurses with Kendahl and Sarah

In a place where there can be so much tragedy (on reading the death log, it appears that about two or three infants die daily in SCN), it’s easy to feel disheartened. But on the eve of leaving, I can only say that I’m overwhelmed be the love and gratitude of the families and nursing staff here. It’s been an experience I’ve been lucky to have, and I look forward to more to come in the years ahead.

A final Asante from Ryan as he finishes his rotation in Tanzania

Posted on behalf of Ryan Fabrizius from March 6

 

Jambo from Arusha (actually waiting in Dar es Salaam airport at the moment)! 

 

Today marks the beginning of my journey back home. The past two months have so quickly passed, and this week has been a one of good byes and thank yous. I had the chance this week to do some home visits with the Hospice team. Unlike American Hospice care, the hospice team at Selian visits home-bound patients regardless of their life expectancy. For example, most of the patients that we saw have HIV infection as their primary debilitating illness, which, we hope, will not be life limiting if they are able to receive their medicines and routine HIV care regularly. The particular patients were selected because of their poor overall condition and lack of family support and resources. It was a wonderful chance to see a broader picture of the daily experience of these patients, seeing their homes, families, and neighborhoods. In health care, we life to think that the clinic appointments, hospital visits, and medicines prescribed make a big difference in someone's overall health, but seeing the patient's living conditions and imagining their daily life, I can see how far downstream we are from the roots of their problems. 

 

The last word in this series is actually one I have mentioned before, but it is so nice I'll use it twice. "Asante", as I have mentioned, means thank you. I have so much to be thankful for at the end of this two month experience. It has been a great joy to work alongside the Tanzanian medical staff at Selian, to experience their hardships, the challenges to caring for patients in this environment, and the camaraderie of sharing our knowledge, experiences, and goals. To let me follow along on their hospital and clinic rounds, my Tanzanian colleagues gave up their time and departed from their routine. But on top of that, I feel more than just a collegiality was fostered, that it was a lasting friendship. For that, I am thankful. Asante does not seem to explain this gratitude deep enough, but it is the best that I had to offer in return. Asante has been offered so many times during my stay here, both from me and to me. It is often for ordinary services, such as at a store or restaurant. It has been offered from our patients, often the most fervent "asante" coming from the patient and family for whom we have no good option to left. However, when I consider how much I have received during my time here, I wish I had more than just one word. I wish I had the power to help my friends accomplish their goals. I wish I could take the stories that I have seen and strike the problems at their roots. I wish we could all have equal opportunity to quality health care and the basic needs that would sustain that health. But for now, I offer thank you, and resolve myself to not forget what I have seen and the people I have shared life with here in Tanzania.

News from Laos and an U/S Project with Patricia & Junaid

Posted on behalf of Patricia Hickey (PL3) and Junaid Niazi (MP3)

Sabaidee from Laos!

Junaid and I are halfway through our rotation working with local Pediatric residents. Our role is to discuss patients with the residents and teach, as well as learn. These residents are completing 3-year residency programs developed by Health Frontiers, a group based out of the US. The residents are supervised on the wards by excellent Lao “teachers,” as they call attendings, and are also supported in their education by the Health Frontiers coordinator, currently a congenial Australian pediatrician. Visitors like us come from countries all over the world to contribute and learn. The Lao teachers are more patient with random foreigners coming to teach than I think we might be in the US. They trained at a time when resources were even more limited and the country was much more isolated from the rest of the global medical community but they are very competent and experienced. The mob of white coats on rounds is even more impressive here than at St. Paul Children’s as there are more trainees per team here. So there is plenty of teaching to go around...for the most part. This week it turns out most of the residents are attending seminars given by German Neonatologists so there is less for us to do. We can’t participate in patient care directly because we don’t speak Lao and don’t have Lao medical licenses.

Rounding

We arrive at the hospital in the morning after the residents have completed their morning report (in Lao) and most of their rounding. They are usually busy filling out fairly extensive paper charts and writing paper orders, which parents take to the pharmacy/radiology/etc to pay for each item of care ahead of time, be it an X-ray or antibiotic. The residents take turns presenting “interesting cases” to us - which as far as we are concerned is all of the cases. Even if it’s something we've typically seen, such as gastroenteritis, there are always discussions to be had about different management in areas with different epidemiology and different resources. Many of the cases have been especially interesting because they represent very late manifestations and advanced disease. There tends to be an additional element of mystery because of the frequent lack of diagnostic tools available. I think sometimes we have had the benefit of correlating history and physical more closely with diagnoses because of the extensive workups our patients have in the US. For example, here they may never know that a patient has Tetrology of Fallot because there is no Pediatric Cardiologist in the hospital and if the patient is too sick to be transported to radiology she won’t get an echo. There is a 6 month old baby here who I suspect has TOF but his last echocardiogram (performed by an adult Radiologist) months ago was read as large ASD which would not explain why he is in heart failure and has a palpable thrill.

The hospital

Resources here are changing frequently as Laos is a country in the midst of change. Construction surrounds us at every corner, from before dawn to well past sunset. We eat croissants for breakfast, walk to work dodging streams of shiny cars, and blend in with crowds of backpackers on our way to the hospital where there is minimal air-conditioning. Where you can be intubated but cannot obtain blood gases or portable chest X-rays. Where you can get a head CT but not an albuterol inhaler. Where we found a brand new ultrasound machine in the PICU untouched because no one was taught to use it. We have discussed the basics of bedside ultrasound with some of the residents and are working on a developing a “how to” guide, as well as planning several practice sessions. I am sure adoption of this technique will require much more reinforcement by people more qualified and more consistently present than we are but hopefully we have at least introduced the idea. This has the potential to be an incredibly valuable tool where portable imaging is not available and imaging in the Radiology department is not always affordable or attainable. We are grateful that we literally stumbled across this project and excited that several residents seem eager to learn bedside ultrasound. Before we leave Laos, we want to ensure that a procurement system is in place for ultrasound supplies—the gel, photo paper for printing images, etc. If we can accomplish this, then we will have given back a tiny fraction of what we have gained from this experience. Until next time!

Patricia & Junaid

Junaid Niazi, MP3 & Patrica Hickey, PL3

Pole - Swahili lessons from Ryan Fabrizius, MP4 in Tanzania

Posted on behalf of Ryan Fabrizius, Medicine Pediatrics Resident in Tanzania

Jambo from Arusha. 

Since last writing, I have been rounding on the medicine ward, which has been quite a different experience compared with pediatrics. While malnutrition and respiratory infections malign the infants and children, HIV devastates the adult population. Surprisingly, non-communicable diseases are just as common, if not more so, than HIV and its complications. Diabetes, hypertension, and chronic obstructive lung disease (emphysema) are much more common than I expected, and unfortunately, with the transition of local populations to urban lifestyles, will likely become the major burden of disease in developing countries like Tanzania. Just as it is in the US, chronic disease is difficult for patients to understand and providers to feel like they can make a difference, but I have been impressed by the knowledge and compassion of the local doctors to not just treat but to educate their patients on how to manage chronic diseases. For example, in outpatient clinic this week, I sat with Christopher, the internal medicine registrar, as he took about 30 minutes of a busy clinic day to explain diabetes type 2 to a patient. The concept of disease occurring without symptoms and not having a onetime solution is a difficult one to grasp, but Christopher patiently reached for common ground in understanding. Despite the myth that doctors in developing countries are "paternalistic", I have found that in this case and many others, doctors like Christopher strive to educate and empower patients and families to understand their condition and proactively participate in their own care.

For today's Swahili lesson, I wanted to introduce the word "pole". Just like "karibu", pole is a common and versatile word that enters into interaction several times per day. It is usually used here for "sorry", like when you bump into someone or walk on a clean floor with dirty shoes (I seem to leave a trail wherever I go). "Pole" also has some unique uses that we have observed. It is considerate to express "pole" when you see someone carrying a heavy load (we get a a lot of "pole"s when we carry groceries home up the hill). Many people will say "pole la kazi" when they see people at work, whether working at the hospital, harvesting roadside crops, constructing/digging, etc... It means, literally, sorry about the work. It feels similar to the feeling of sympathy medical residents give each other during a busy night shift or after a difficult series of events. To me, it seems to be expressing, "I have been there and I feel your struggle, hope you get to finish work and rest soon".

 

The most interesting use of "pole" for me has been with patients. When most local medical staff approach a patient on rounds or clinic, they usually begin with "pole bibi/babu/mama" (sorry grandma/grandpa/mother), which acknowledges the fact the patient is having a struggle. The usual response is "asante" (thank you), which feels like an expression of gratitude for recognizing the burden on the patient and family. As medical workers in the US, I think we do recognize the value of this sort of sympathy. Some useful expressions that I have learned from my teachers are "this seems like a difficult time for you" or "i'm sorry you have to go through this", but usually this comes up after a display of emotion from the patient or family that beckons validation. In clinical practice here, I find it most interesting that this validation and sympathy is the greeting, rather a phrase reserved for certain situations. It seems rooted in the community values here, that one person's burden is shared amongst others, not just friends and family, but all people that interact with them. Here in Tanzania, there are so many burdens that people carry, even in daily struggles for basic needs. It is frustrating for me, as someone that takes for granted that my daily needs are easily met, to see the barriers that people have to providing for themselves and their children. On top of that, the burden that HIV, chronic disease, and other medical conditions place on an already struggling people seem absolutely insurmountable. This, for me, stirs up feelings of injustice and unfairness, questions of why? and how?, and often results in frustration and fatalism. But for the people here, they bear with each other in these circumstances, supporting one another and carrying one another's burdens. Linguistically, I do not know if these words have a common root, but "pole pole" is another common expression that means "slowly" or "gradually". It is the unofficial mantra of climbing Mt. Kilimanjaro: gradually, one foot in front of the other. And such is seems with bearing one another's burdens. Sorry for your troubles, but slowly, together, we will carry it together.

Hamna shida. Hamna shida (no problem) and other reflections from the Global Health Chief

Posted on behalf of Medicine Global Health Chief, Hope Pogemiller

Greetings once again from A-town! 

The past few weeks have flown by, and it feels like a whirlwind.  Days are filled to the brim, and I quickly slip into sleep each evening under the comforting canopy of mosquito netting. I gaze at the 1 inch hole to my right, reminding myself that is not large enough to permit entrance of the resident African Hedgehog or the domestic mouse/gecko who leaves gifts in my sink every evening.  Hamna shida. Hamna shida (no problem). 

I've grown close to 2 registrars (doctors who have graduated medical school and 1 yr of residency "intern year") and a few interns.  A few of our sicker patients' families wave and greet me with big smiles around the hospital campus.  These patients and their families speak Maasai, and it is always a little search to find a nursing student or aid who speaks both Maasai and Kiswahili to help communicate at the bedside. Thankfully, greetings and warm feelings have never necessitated a common language.  I feel particularly fond of my older patients.  I've been rounding with the Internal Medicine team for the past 2 wks, and we have had a very low census.  We have a few people in their 30s-40s with gastritis or malaria, and then we have people in their 50s-60s with HIV who are on or off of anti-retrovirals and present with clinical pictures consistent with TB or PCP.  The group of patients that I particularly enjoy are those > 65 years old.  The women often have COPD from years of cooking in an enclosed home with smoke. This often leads to cor pulmonale, and they present with heart failure and/or COPD exacerbation.  One patient in her mid 70s was quite ill, but she greeted me each day with the most beautiful, relaxed smile. Each day she would report to me about her status in Maasai, and then we would begin the search for someone who spoke Maasai and Kiswahili.  My patient and her family recognized quickly that speaking to me in Maasai led to perseverance until we interpreted her message all the way to English and addressed her concern.  It is not an expectation that the medical staff update the family/patient each day as in the States with bedside rounds, but the internal medicine registrar with whom I work is particularly devoted. I watch him including the family in conversation and educating the patient whenever possible.  I often watch the family members during rounds and report to him when they seem frustrated or confused. He immediately takes them aside and explains in more detail or asks them what's on their mind.  He has this calm, quiet, comfortably-paced speech that looks to be greatly appreciated by the patients.  This past week I have learned much about the Tanzanian healthcare system and perspectives from this registrar and a few interns.  Motivations for choosing a career in healthcare vary, as in the States.  The unreliable timing and amount of paychecks for doctors is accepted, while steps are taken for improvement in the future.  In the meantime, the majority the doctors and students with whom I'm working have this thirst for knowledge and need to help those around them have an improvement in their lives.  This core desire combined with an intense community spirit is something incredible to witness.  When I am able to contribute in my part, I am instantly enveloped in this community.  It's hard not to feel very grateful for the opportunity to live here for a few months, making the world just a little bit smaller.

We had 20 international expats visiting for a field trip during a class last week, and it was interesting to hear their thoughts and impressions of Selian Hospital.  One doctor noted that it would be easy to know what to do if we only had the resources here.  Discussion with other expats from Minnesota and the graduate of MN residency who began the 2 hospitals in Arusha has covered this territory.  Loads of supplies have arrived at the hospitals in the past, yet they are not found when needed in the process of medical care.  It would be silly to think they would be used exactly in the same manner as in their country of origin. The key is to creatively think through the pathophysiology of the illness at hand and apply resources in unique ways.  It is not too uncommon to hear expats complaining that Tanzanians often have an external locus of control or learned helplessness... not looking to improve situations when barriers to advancement or success are encountered.  I suppose I am am growing more and more certain that human nature is universal.  Culture just wraps up the variety of personalities in any group with different colors, papers, and ribbons.  We had a diabetic patient who took 1 mo of metformin and then did not have access to a refill of her medication (or maybe didn't prioritize it as highly as healthcare providers might).  It is difficult to adhere to a diabetic diet anywhere in the world, but more so in her community.  We were injecting subcutaneous insulin to cover her high blood glucoses, and she was requiring much lower doses after when it was difficult to find food at the hospital.  We found a way to be sure she has food (not all carbs), and we checked her blood glucose three times daily.  One morning she had no blood glucose reading in the chart, and the nurses had not given her her injectable insulin as they had no glucose reading to doublecheck.  We had finished our supply of glucose monitoring strips. The registrar and intern and nurses immediately shook their heads, explaining to me the problem and adding that this is unacceptable.  There are shortages of medicines and supplies at all times, but certain essential supplies and medicines were simply necessary.  The administration of the hospital has a very open door policy, and the intern and registrar walked over to explain the situation. Calls were made, and by the end of the day we had a box of glucose monitoring strips.  Where was the Tanzanian inertia-- the inability of Tanzanians to identify a problem and find a solution?  Experiences like these give hope.  This is the way to future improvements in the system, and the intervention was wholly Tanzanian.  We have nicknamed the exceptional pediatric registrar at Selian Daktari Hamna Shida (Dr. No Problem), as it is his most common phrase.  Instead of panicking and making a ruckus everytime he notes an "opportunity for improvement," he calmly voices his mantra. Hamna Shida. Hamna Shida.  You can see him beginning to brainstorm, and later he can be found in the cafeteria or under a tree with hospital administration discussing the situation and working on a sustainable solution.  Although it might appear at first glance that he is simply dismissing medication and supply shortages, he is carefully working toward improvement with an eye toward sustainability.  People recognize his value, and he is given much respect.  As others follow suite, it is possible to see improvement on the horizon.  Cautious optimism shared among hospital staff.  Cautious optimism allows for perseverance in the face of adversity-- even if the adversity is deeply engrained corruption to the core of the country.  

Ryan and I have been able to try to understand together the current status and future of healthcare at Selian during the beautiful walks to and from Selian each day.  We alternate between learning kiswahili numbers and body parts, greeting fellow Tanzanians sharing the path, and interacting with schoolchildren learning English.  We vary our greetings, trying not to miss anyone...with the responses we receive sounding something like this... "poa, mambo, poa, mambo, jambo, jambo, poa, GIVE ME MY PENCIL!, jambo, jambo... " The spontaneous humor from our neighborhood children never fails to send us chuckling. Creative responses are very appreciated, and we now shout back requests for anything from a book to a bag. Our colleagues from New Zealand have even inquired about the price of a large cow being herded by us on the path.  Some days are more frustrating than inspiring, but one thing we can always count on joyfully unpredictable conversation en route to the hospital each day.

I hope this message finds everyone healthy and in good spirits-- hope

Greenery on the walk to the hospital

The path for walking to the hospital

Mt Meru in the distance

Arusha Lutheran Medical Center Hospital Complex

Hope checking out an x-ray outside the male IM ward