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.