Danielle Brueck (PL3) tells us about the people she met in Tanzania

I suppose it is a common experience to struggle a bit with
how to explain and portray an experience such as this. Ok, ok, maybe I struggle
with the right words frequently in life.  For my last post, I described a
typical day here in Tanzania.  As I near the end of my time here, I have
been reflecting on what I will remember the most, and much of it comes down to
this -- the people.  That has been a recurring theme in life and most
frequently what I walk away remembering. I have been humbled and learned much
from the people I have encountered here.  In describing them, I hope you
will see the Tanzania I have grown to love.



From left to right Joseph, Emily Hall (PL3), Dr. Mantz, Danielle Brueck (PL3) and Maneno


Joseph:  Serving as the pediatric registrar, Joseph is at Selian Hospital
6 days per week with rare exception. He trained in China and is fluent in 4
languages (wow, I'm behind in life). When on call, he also covers medicine,
surgery, and OB/GYN.  He is smart and dedicated, challenging the interns
to think through a differential diagnosis themselves and not simply repeat what
others have said.  He enjoys teaching and has been ever so gracious to
accommodate and answer my frequent questions (which, no doubt, make rounds last
much longer).  If he is told the hospital does not have a medication, he
walks over to the pharmacy himself to check on the availability.  When he
finishes his own work, he can often be found in the outpatient department
helping others with the clinic patients that need to be seen.  During our
rounds, he will pick up a child and set him or her on his lap. He truly enjoys
caring for kids and reminds me of the simple joys found in pediatrics.
 Joseph excels and pushes learning forward in a system where it would be
easier to settle quietly into the background.  I admire the responsibility
he has taken.

Joseph teaching some local students about malnutrition


Maneno:  The intern on the pediatrics team, much of the "scut"
work falls to this guy. You would never know it, however, as he is persistently
eager to learn.  He wants more patients to come, saying that is how he
will learn about what to do.  Being from further away in Tanzania, he
stays in a room on the hospital grounds. But this doesn't bother Maneno; it
means he is available to see more patients. He asks the other interns to call
him if an interesting case arises. He is selfless, willing to pick up an extra
shift if others must go out of town or have another obligation.  Maneno
has reminded me how fun learning can be.



Cifa:  I met Cifa at church.  He is a generous Tanzanian who is full
of life.  He has fostered/adopted many Tanzanian children over the years
and truly has a desire to watch them succeed.  He cares for them and
teaches them to care for one another, the older ones assisting the smaller
children.  What struck me about Cifa is how passionate he is about caring
for the less fortunate of Tanzania and what little regard he seemed to have for
his own interests in this.  During my time in Tanzania, I read a book
called Toxic Charity (thank you, Dr. Kate Venable, for this excellent
suggestion).  It addresses the sustainability of charitable efforts and
discusses how to avoid creating dependency.  The book challenged my own
motives and forced me to ask myself some hard questions.  In the context
of reading this, I had such a moment of clarity when meeting Cifa.  He
genuinely embodied a sustained, grass-roots effort to impact those in need.



J:  J was just one of many patients I will remember from my time here.
 He taught me a lesson in communication.  J is 4 years old and has
been in and out of the hospital over the past several months and was admitted
for approximately 3 weeks during my time at Selian.  He has developmental
delays and is non-verbal.  Not knowing much Swahili, I have felt the
language barrier more than I would have anticipated.  For me, so much of
the joy of medicine lies in talking with people.  I have been able to have
fantastic and academically stimulating conversations with my colleagues here
but have truly missed just sitting to talk with patients.  With J, the
non-verbal parts of communication became even more evident to me.  I loved
walking in each morning to see his smile.  He would peer up from the bed
through the window at me as we gathered our things for morning rounds.  I
would duck down, then pop my head back up to find him laughing.  This game
never got old.  J was scared of us at first, but it turns out that coin
magic tricks and juggling are universally loved despite the language.



E:  We saw E in clinic one Tuesday afternoon, and he quickly captured our
attention.  At 4 years of age, he is extremely small (7 kg or about 15
lbs) with a disproportionately large head.  His mother brought him to
clinic for a completely unrelated complaint, and we wrestled a bit with how to
broach the subject of his odd appearance.  E taught me about the ethics of
practicing medicine.  I found his case particularly interesting from an
academic standpoint and had to ask myself if meddling in his previously happy
and fairly uncomplicated life was for his best interest or merely an indulgence
on my part.  He came back to our clinic 3 other times during my 2 months
here as we arranged to have some testing completed.  He was always a
joyful and cooperative child, bright and slowly taking in the unfamiliar world
of the hospital.  His family seemed genuinely appreciative though I
continued to wonder if any actual good or benefit would come from having a
diagnosis.  Sometimes, both abroad and at home, I feel better having an
answer for myself.  E makes me more aware of how my actions can affect
others.

Team rounds in the ICU discussing causes of heart failure



David:  David is a taxi driver and was the first person Emily and I met in
Tanzania and will be the last we say goodbye to as he drops us off at the
airport this evening.  He was immediately friendly and welcoming.  He
gave us just 2 pieces of advice to consider during our time in Tanzania -- pika
pikas (motorcycle taxis) are dangerous, particularly at night.  And be
careful of the local alcohol; it is strong and causes many a problem.  We
decided to heed his advice on both these matters.  David is an extremely
hard worker with a day job in an office and then driving as a taxi many
evenings.  He never complains but is eager to meet opportunities.  He
chooses good company and sets high goals.  His father once told him
"If you do not clean the dirty dishes at night, you will have no plates
for food in the morning."  His parents provided a constructive
environment where he learned responsibility and discipline, and he looks
forward to doing the same for his children someday.



The stories of others have long intrigued me, and these are just a few that I
will carry forward.  These stories inform and shape my own.  There
are many others (Tanzanians and ex-pats alike) who have made my time here a
wonderful experience.  I am grateful to have been so included and welcomed
here and will certainly miss the beauty of this place.

A Day in the Life of Danielle Brueck in Tanzania at Selian Lutheran Hospital

Posted on behalf of Danielle Brueck (PL3)

The task of trying to capture in words all the sights and sounds of this place is daunting.  The days have started to carry much familiarity yet never quite enough to feel like home. Tanzania - as a country and as a people - is beautiful.  I have felt very welcomed and am grateful to have this opportunity.

In an attempt to capture the experience of the past month, I will walk you through an average weekday.  Please allow for some creative licensing on my part to help condense the experience of many days down into one day, recognizing that each day is not actually as glamorous or exciting as this may lead you to believe. 

6:15 am: Wake up.  Eat some toast and surprisingly good peanut butter.

6:45 am:  We are supposed to be leaving.  I am living with Emily Hall (Peds Resident - PL3) and Caroline (Medical Student from Holland).  I realize I am the only one actually ready, probably because I wake up the earliest every day.  Then I realize this is because Emily and Caroline can actually walk much faster than I can and plan to make it to the hospital in less time than I thought possible.

6:55 am:  Actually leave our place and set out on our 7 km hike to Selian Hospital (uphill both ways, obviously).  During our walk, we have the excellent opportunity to practice our Swahili with the school children who are walking along the fairly car-devoid back road.  We are met with "mzungu" (Swahili for white person) and "how are you?" and are spontaneously hugged or touched.  This is often followed by much laughter from the children.

Walking to Selian Lutheran Hospital

8:15 am:  Arrive at Selian and attend chapel.  The singing is beautiful and allows us all some time to relax after the long walk.  Chapel is attended mostly by the medical staff (nurses, interns, etc.) of the hospital, and they are most welcoming to us as we fumble to figure out which hymn number we are supposed to be singing.

Selian Lutheran Hospital

8:45 am:  Morning Report starts which entails a brief reading off of the admissions, discharges, and deaths for the past 24 hours.  I hold my breath a bit, hoping that the neonate with seizures and hypopnea is still alive.  He is not called out when the deaths are read, and I feel relieved.  An interesting admission of a patient with sagittal sinus bleeding after trauma is discussed.

9:00 am:  X-ray rounds.  The power is out so we step outside to view the x-rays in the light of the sun.  Interns take turns giving their impression of the films - pneumonia, congestive heart failure, femur fracture.

X-ray Rounds at Selian Lutheran Hospital

9:20 am:  Round in the ICU.  There is just one Pediatric patient with likely bronchiolitis but requiring oxygen therapy.  We check her vitals and finagle the adult pulse oximeter to pick up a reading on the child's foot.  She looks better today.  Perhaps this whole bronchiolitis peaking on day 5 thing is true here too.  Maybe I have learned something in residency; I feel excited that Emily agrees that the right upper lobe infiltrate on the chest x-ray could just be shifting atelectasis.

9:40 am:  Chai break.  Besides, they are cleaning the hospital floors.  I begin to wonder whether it is a worldwide phenomenon to clean hospital floors during prime rounding hours.  Oh well, chai sounds great.  And the floors do need cleaning.  

10:00 am: General Pediatric Ward rounds.  Emily and I are working with a fabulous intern and his supervising equivalent of a senior resident.  We grab the paper files (charts) which the nurses have neatly stacked for us and the equivalent of a WOW (workstation on wheels) which is a huge cart with drawers filled with cotton swabs, discharge forms, pulse oximeter, etc.  The children, many of whom have been sitting outside in the grass, trickle back into their beds as they realize we are starting our rounds.  Some of the patients come with complaints that are familiar to us - chronic constipation, bronchiolitis, diabetic ketoacidosis.  Yet we are also challenged with more unfamiliar cases - Kwashiorkor malnutrition, cutaneous anthrax, tuberculosis.  We scratch our heads a bit about how to treat diabetic ketoacidosis with subcutaneous insulin and not an insulin drip.  The patients , their parents, and our fellow Tanzanian colleagues are kind and patient with us, answering our many questions.  The intern is eager to learn, explaining to us how he has been taught to approach a problem and then asking questions about how we would approach this problem.  The more senior resident helps guide and make management decisions on each patient.

11:30 am:  Baby checks.  We head over to the obstetrics unit and inquire if there are any neonates with acute concerns.  Two are currently being treated for likely sepsis with a presentation of fever and increasing fussiness.  There is no microbiology lab or ability to grow cultures so empiric therapy is given.  We are happy to see that the neonate with seizures and hypopnea is much improved today.  After seeing the neonates with acute concerns, we also do a routine exam on all new babies.

12:30 pm:  Lunch of rice and beans.

1:30 pm:  Follow up on interventions, labs, imaging.

3:00 pm:  Time for the long trek back home.  I think I am in better shape than I have been since residency began.  Maybe I will walk to work in Minnesota.  Then I remember it is at least 40 degrees colder in Minnesota, and I take that thought back.  We stop at a roadside stand along the way to buy some fresh vegetables for dinner.

4:00 pm:  Arrive home.  I am grateful we have such a wonderful place to stay with fairly consistent/reliable internet access.  Check emails, read.

6:00 pm:  Time to make dinner.  I realize the great amount of time and energy that this can require and remember why I cook so seldom at home.  I envision the many canisters of beans at our apartment in Minnesota and recount the innumerable times we have vowed to use these.  We all enjoy each other's company in the kitchen as we cut up our fresh vegetables and cook some rice and beans.  We actually sit at the kitchen table to eat and don't feel rushed to a flurry of other activities.

10:00 pm:  Time for bed.  I am starting to enjoy this whole sleeping thing.

There are already many exciting memories from this place, and I am eager for more to come as we finish up our second month here.  It has been a pleasure to work with, and learn from, our colleagues here.  I continue to think through how global health will have a role in my career moving forward.  Regardless, opportunities such as this strengthen my clinical skills, offer new perspective, and challenge my ability to think critically.  I am hopeful these moments will become a part of how I practice medicine and allow me to provide better care to the children I encounter, regardless of location.

Jambo from East Africa - Emily Hall in Tanzania

Blog Post written by Emily Hall, DO, 3rd Year Pediatric Resident

Jambo from East Africa!

I have spent the first few weeks in Arusha, Tanzania settling in and acquainting myself with the resources, medical facilities, and the community. As true with all my adventures abroad--this has not been what I expected, but equally holds exciting potential and opportunity. In future posts I hope to tell more tales of adventures. However, before things get too exciting...let me explain my perspective of life here in Arusha so if you are considering this as an International Elective you will know a bit of what to expect.

Danielle (another U of MN Pediatric Resident who most of you know) and I initially started our work at Arusha Lutheran Medical Centre, which is located in downtown Arusha and offers more specialty hospital and outpatient clinic care. They have a small NICU which was impressive to tour and have a total of 2 pediatricians on staff in addition to a pediatric registrar. In contrast, we observed and in the past few weeks have found our place at the Council Designated Hospital also known as Selian Lutheran Hospital (subtle name difference to the former mentioned). This hospital is in a semi-rural location in a village just outside Arusha serving both Maasai, Waarusha tribes, as well as people of Arusha. We walk to the hospital with beautiful views of Mt. Meru along the path. (see photo below) The resources here are limited in comparison to the Arusha Lutheran Medical Centre.

Mt Meru

We have been working with two Tanzanian trainees in pediatrics; one of which received his medical training in China the other from Dar es Salaam, Tanzania. Our primary physician contact here is from Australia; she has been a truly wonderful mentor. We round with two nurses and the four of us trainees. Together we have been discussing and collaborating on patient management decisions with particular consideration of differing International Guidelines of management and factors relating to a resource limited setting. This type of work and learning environment has taken a few weeks to develop, but has recently started to come together in an exciting and highly educational format. Later in the week the physician from Australia has been joining us--by this time we have had some autonomy to make decisions and can discuss in more details questions or concerns regarding patient care that have been debated in her absence. Additional training opportunities have included pediatric HIV clinic, pediatric general clinic, and serving at rural outreach clinics.

There have been several very interesting patients and cases, some of which are still a bit of a mystery. Perhaps in the coming weeks Danielle or I can write about one or two interesting patients to give you a taste of the variety of medicine and the diagnostic approach here at Selian.

Arusha provides quite the balance of work and fun. There are limitless things to do in the city and in the country. It is my hope in the coming weeks we can provide a bit of insight on both the medical and culture opportunities we have explored.

Until then, wishing you all well in Minnesota or wherever this missive finds you.

Emily Hall, DO, PL-3

U of MN Pediatric Resident

Bergmann at Selian Hospital in Tanzania

The following was submitted by Kelly Bergmann, a second-year pediatric resident on service in Arusha, Tanzania, under the preceptorship of Steve Swanson, MD

Kelly Bergmann cares for a patient on the wards at Selian Hospital in Arusha, Tanzania

On the eve of returning to Minnesota after five weeks in Tanzania, my impressions of my time here are mixed. On one hand I'm excited to go back home and see family and friends. But on the other hand, I will miss those friends that I've made, the people, the culture.

Most of all, it's the children in the hospital that I will miss, many of whom were staring death in the face and courageously took on each day with a smile. Their smiles brought joy to my heart and hope for their future, despite the limitation of medical resources and care that we could provide.

Selian Hospital, in my brief experience, does what it can with limited resources. It is difficult to get reliable lab tests and ultrasound reports. The x-ray machine, bilirubin lights and neonatal warmer work only intermittently. Vitals are taken once a day on the ward, usually by our team as we make rounds. Family members provide food for their malnourished children, but if they don't have money for food, the children aren't able to eat.

Just down the road from Selian is one of the top five hospitals in the country, Arusha Lutheran Medical Center. ALMC is actually a partner with Selian, and much of their profit is subsidized to help provide reduced-cost services at Selian.

ALMC is what I hope Selian will become one day: a beautiful new facility with resources that would rival some hospitals in the U.S. IV fluids can be appropriately administered, labs are reliable, x-rays are good quality, neonates can consistently be kept warm. Just a mile away from each other, these two hospitals are worlds apart.

I will miss Tanzania and the serenity I found amidst the sometimes chaotic day-to-day life. Most of all I will miss the children and their smiling faces.

Faratha

Joshua, who loved having his picture taken

Helena

I will miss Faratha, a 7 year-old girl with AIDS whose smile was so beautiful. I will miss Joshua, a 4 year-old with kwashiorkor who finally smiled at me after about a week. Most of all, I will miss Helena, a 4 year-old with kwashiorkor. I took care of her for almost two weeks and never saw her smile, but I imagine it stretching from ear-to-ear, lighting up a room--the glimmer in her eye as she finally has the strength to smile. No, I never did see her smile.

But that is what keeps me coming back, knowing that someday soon, she will feel happiness again.

Another patient at Selian looks out the window beside her hospital bed