Happy Australia Day

Yesterday was Australia, and since my roommate is Aussie, I got to celebrate too. We went to a restaurant owned by an Aussie and they had a special menu that night of prawns on the BBQ or beef and mushroom pie and pavlova for dessert. It was pretty good food and fun to meet new people; Aussies and other wannabes.

I've made many new friends here through people who work at the hospital, neighbors, and others I just bump into while playing soccer or hanging out in town. There's a pretty small ex-pat community here. I have an Italian neighbor, Lupo, who is a professional hunter and he had Eric and me over the other night to eat eland and buffalo. I'll try any food once and eland is surprisingly tender and not gamey. People pay lots of money to go hunting here and there are many restrictions. You can't hunt rhino, cheetah, or wild boar and animals like elephants and leopards have to be a certain size and therefore age. So you need to go with a guide and you pay for a 21 day permit, even if you hunt for a shorter time. I think it's about $5,000 for the hunting permit so it's about $200-$300 a day. It's very expensive and the money is supposed to go toward park preservation and such, but every government in Africa has its problems with corruption so I'm not sure how well used the money is here. Park fees have gone up all over the country. It's now $100 a day to be on Kilimanjaro, making the climbs very expensive as well. I figure what's a couple thousand more in student loans when you already owe too much to count.

I'm not sure I could ever drive here. There are no stop lights, stop signs, or any form of conducting traffic and the rule is the bigger vehicle has priority. The one thing they do have is speed bumps. Even though the roads are meant to be 2 lanes, you usually see 3 cars wide because people just honk their horn to pass whenever they feel like it. They're all driving on the wrong side of the road too and I still get confused and go to the wrong side of the car when I'm riding with someone.
The transportation here in Tanzania consists of privately owned sedans and lots of safari type 4-wheel drive vehicles, lots of white taxis, and the dala dalas. Dala dalas are mini vans with seats for about 17 people in them, but they never carry less than about 25. They have specific routes they drive, but there aren't strict designated stopping points so you can hail them down to get on and yell at them to stop when you need off. They cost 300 Tsh a ride (about 25 cents) and they really cram in their moneys worth. There's a driver and a guy who hangs out the window or even the open sliding door who tells the driver when to stop and go by hitting the roof with his hand. Eric and I took the dala dala home from the hospital one day and all I can say is people here have a smaller personal space bubble than I do.

It has dried up here and it's very dusty. I blow dirt clods out of my nose daily and when I use a Q-tip to clean my ears, I get dirt out. When I shower, my tan washes away. Our road is dirt and therefore very dusty. This picture will give you an idea of the dirt that accumulates on the plants along the road.We live in a neighborhood called Ilburo and there are acutally a number of white people around. There are 3 houses that people who spend time volunteering at Selian can rent rooms from. Eric and I are the only people in our 3 bedroom, 2 bathroom house and we pay $150 a month. This includes utilities and our nightly guard. We also pay our housekeeper 7,000 Tsh (less than $7) a week to clean the house, wash dishes, and do laundry. She's really great. We have a nicely groomed yard by our landlord's son who lives next door. We have some citrus fruit trees and what we think are papaya trees that Eric tried to climb to pick the fruit. He didn't make it up the tree, so we ended up shaking the tree until some of the fruit fell. It doesn't seem ripe yet so we're going to wait a few days before we give it a try.

More about the hospital:

Jetlag sets in

I spent the week with a plastic surgeon, Bill Brown, visiting from Denver, CO. He comes to work at Selian twice a year for a week each time. This time his team consisted of an oral-maxillary-facial surgeon, Jim Lessig, a pediatric anesthesiologist, Andrew Veit, and 3 surgical assistants: Vann, Amanda, and Sherrie, all from Denver. Bill's priority is to repair cleft lips and palates and he'll add on other surgery after that if he has time. Even though Bill has been coming here for 10 years, he still sees kids who are 10 years old and have never had their cleft repaired. I guess it's better than when he first came and he saw nearly geriatric patients too.

Monday and most of Tuesday were all cleft lip and palate repairs and after that we saw mostly burn contractures. before and after

I have never seen such terrible contractures from burn scars leaving people with a constantly flexed elbow, wrist, or knee or unable to turn their neck or use their fingers. One 20 year old boy had 90 degree flexion contractures of both his knees and has been carried everywhere by his friends and family since wheelchairs aren't common here. We released contractures on many patients, some with some skin grafting. One patient even had a reverse forearm flap to give him function of an opposable digit. All his other fingers auto-amputated some time after the burn. I got to do some sewing with the contracture releases.There were also keloid excisions and injections, including a huge one from behind this old man's ear about the size of my fist. The most interesting case was the removal of a 4kg sarcoma from a woman's abdomen. It was nearly the size of my head.The OR, or theater as they say here, functions very differently here than in the US. First of all, the turnover is very slow and there isn't a very organized system for supplies so a lot of time is spent running around looking for equipment. Supplies that are disposable in the US are sterilized and reused here. There are drapes and gowns with holes in them and plenty of sharp instruments that aren't so sharp any more. There were a couple occasions where I saw a little ant crawling across the sterile field. I'm sure it had been through the autoclave. The power also goes out here often and so your light may cut out or your suction or your cautery. There is a generator, but it takes a little time to get that going.
The dress code is also different here. The men all wear scrubs and some of the women do too, but many wear dresses made out of scrub material that are just below their knees, leaving their legs exposed. Also, many wear open-toed shoes and at home I can't even wear those in the hospital, let alone the OR.

Here I am doing some sewing

Eric and I got hats from the visitors

The medicine team has also had some interesting cases. The 2 women with suspected cholera I spoke about last time ended up having cholera and were sent to a government treatment center. I checked the incubation time and I'm in the clear. We had another patient in a myxedema coma from profound hypothyroidism and a young woman with brucellosis. Brucellosis is treated with at least double drug therapy and one of those is rifampin. However, rifampin is only available here in a combination pill with other anti-TB drugs and we can't get it separately. So we ended up treating here with a second line agent and she improved and was sent home.

Shop Talk

My roommate, Eric, and Dr. Johnson from Minnesotta

Yes, the nurses really do dress like this.

Selian Lutheran Hospital is a 120 bed hospital just outside of the town of Arusha. As the town of Arusha grows, so does its need for medical services and a new hospital is under construction in town, right next to the current Arusha Town Clinic that is staffed by Selian doctors. The new hospital will serve the city population and the existing Selian hospital will continue to serve those who travel from far. Selian is in Maasai country so many Maasai people come to Selian for their health care and will likely feel more comfortable at the existing hospital than the new one in town.

So far, I have been spending my time on the medicine wards, seeing both male and female patients. I see plenty of malaria, diarrheal illnesses, and complications of HIV/AIDS. We offer HIV testing and counseling to nearly every patient that is admitted and we have many new diagnoses. It is interesting to me how many patients come in saying that they have been unwell for months to years. It makes me wonder why they came in today. Why not a year ago and why not tomorrow? I see the late stages of many conditions that have gone untreated for quite some time. I see patients as young as 45 with severe congestive heart failure due to untreated hypertension for years. We have a 12 year old boy with CHF, likely due to rheumatic heart disease. I see cirrhosis and massive ascites due to chronic hepatitis infections, alcoholism, and schistosomiasis infections. I have never seen so many enlarged livers and spleens because so many tropical diseases can cause hepatosplenomegaly. I see peptic ulcer disease from Helicobacter Pylori infections and plenty of abdominal and chest pain due to gastroesophageal reflux. I see pneumonia, TB, and patients with reactive airway disease. I have seen terrible thrush in an HIV patient and many patients with wasting due to HIV, TB, or malignancies. I’ve seen cerebral malaria and coca-cola urine due to hemoglobinuria from severe hemolysis. I also see the results of untreated or poorly treated diabetes with peripheral neuropathy, retinopathy, and nephropathy. Insulin is not used as commonly in the out patient setting here as in the US as clean needles are more difficult to get and disposal is also a challenge. I have seen some crazy x-rays of fractures from accidents as well. We have a patient who fell off the top of a land rover and has the worst displaced bimalleolar ankle fracture most people here have seen. My roommate is doing orthopedic surgery right now and he’s loving it because he gets to do so much, but he expresses frustration at the lack of resources here. They often don’t have the correct size of screws or wires and they always have broken or missing pieces of equipment. As a result, some people don’t gain full functioning as they might with proper hardware.

It is often difficult to obtain a good history from a patient, even if you do speak the same language. Some people do not keep track of time in weeks, days, and months so some Maasai will talk about bring sick for 3 market days, which basically means 3 weeks. Also, some people are unsure of their age. If you’re born out in the bush, it’s very likely there will be no record of it and so you may not know your birth date. We had a patient who claimed she was 110. She looked really old, but I’m not sure that I believe 110. On the other side, we have a woman who looks close to 40 who claims she’s 21. I already commented on some of the difficulties in diagnosis due to limited labs and imaging. Nearly everyone we admit gets a blood slide for malaria and all else is ordered depending on their presentation. Patients must pay for their x-rays or ultrasound before getting it done and that can delay diagnosis. There is a CT scanner at Kilimanjaro Christian Medical Center (KCMC) in Moshi, about an hour drive from Arusha. We rarely need to refer patients to another hospital, but we are currently without a pediatrician so we sent a sick 9 year old boy to KCMC this week for further evaluation. Some patients would not be able to afford a transfer.

I took overnight call at the hospital for the first time on Wed. night and it was quite an experience. The 3 interns have living quarters next to the hospital and they made a bed for me, but I never saw it that night. We had 17 admissions to keep us busy and some very interesting cases as well. There was a cute 2 year old boy who swallowed a little bit of kerosene and substances like gas and kerosene are worse on the lungs if aspirated than on the bowel so these are the few substances where you don’t want to induce vomiting. He’s doing well. We also had a 13 year old boy come in with a urinary tract infection and I noticed something was off about him. After taking a more detailed history from birth and doing a lengthy neurologic exam, I realized he has cerebral palsy that had been previously undiagnosed. I guess it’s common here to have cerebral palsy and not know it.

There was a woman laboring for about 20 hours with her 4^th child and the baby was found to be presenting with its elbow. There’s no way this kid was coming out elbow first, so we had to take her for a C-section. The intern called the doctor on call to come in and she assisted him. They are short on gowns, so I didn’t scrub. Instead, I held the patients hand and watched the procedure. Most C-sections here are preformed with a vertical skin incision and then a horizontal uterus incision, which I’m not familiar with. Surgical scars aren’t as big of a deal here. I became very scared when they were having trouble getting the baby out and after 3 or so minutes of pushing on the uterus, the baby came out not breathing. 2 nurses alternated bagging and suctioning the meconium from the baby and the mother was looking at me and probably asking me what was wrong, although I couldn’t understand her. All I could do was squeeze her hand and pray that this baby lived. A wave of relief came over both our faces as we heard the baby cry. I kept thinking how this birth wouldn’t have been so scary in the US with all the technology we have, but then I reminded myself that the baby, and likely the mother too, would not have survived if they were out in the bush without medical attention.

The two most interesting cases of the night were of suspected cholera. 2 women came in with what seemed at first glance like gastroenteritis. There are plenty of bugs here to give you diarrhea and neither had fevers or blood in their stool. Hours after admission of the first woman, we got a report that she had 10 liquid bowel movements and that’s a lot of diarrhea for gastroenteritis. Within an hour of this, the second woman started having watery diarrhea without effort and also vomited profusely, about 1.5 liters. We opened 2 IV lines on both patients and attempted to give the recommended 10% of their body weight in the first 4-6 hours. They don’t do central lines here so we used peripheral IVs and other options would be parenteral or interosseous rehydration. These 2 women are isolated in a room together and cholera patients are sent to a government designated site for treatment, but we don’t have the results back from their cultures for confirmation yet. I hope they don’t have cholera because I really don’t want to get that. I’d pick malaria over cholera any day.

Clinic: As I stated previously, I see a more affluent population in clinic and many speak English. I see many of the same problems here in clinic that I would see in the US, only the treatments may vary. I’m having a tough time with medications here because either the drug I use at home is not available here, or the name is different. They use many medications here that are older and no longer used in the US, but they’re often cheaper and they may have an undesired side effect that makes them unpopular in the US, but the benefit often out weighs the risk here. So I’m learning about some new drugs and new ways of treating familiar problems. On Tuesday, I treated a wart on a 4 year olds toe with silver nitrate. I’m used to liquid nitrogen, but we don’t have that in the clinic so we’ll see how the silver nitrate goes.

My spell check really doesn’t like this post and I apologize to those of you who aren’t in the medical field and find this post boring. I promise to write of some more fun things later. I’ll be working with a plastic surgeon from the US this week so I’ll also have a few more medical stories.

Chapel

Good morning teacher

Being blond with blue eyes and pale skin, I stick out here like a sore thumb. This means I get lots of attention from kids especially. Kids aren't afraid to stare at something new and interesting and they yell "mzungu" or "wazungu" (whiteperson/ people) when I pass. Eric (roommate) and I walked down our street the other night and a group of kids started running after us yelling, "good morning teacher" repeatedly. Never mind that it was after 6pm and neither of us are teachers.
There are some social norms in the US that are completely lacking here. I would like my mom to know that it's not rude to burp here, eat with your hands, or pick your nose. It throws me off a little when I'm talking to someone and they start digging for gold up a nostril, but I'm getting better at keeping the conversation going. When you meet someone or run into a friend and you shake hands, you keep holding hands as you talk. Even 2 guys can be found holding hands walking down the street or standing around talking. People here are just very casual and very friendly.

My Australian roommate, Eric and me

There is a school up the hill from us and we walked up to their playing fields the other night to watch some soccer and play frisbee. We didn't dare join the soccer game as it was obvious these kids were very serious about the sport. We did throw a frisbee around and it didn't take much convincing to get the kids hanging around to join us. Pretty soon we had a circle of about 20 kids throwing the frisbee around and laughing hysterically as they threw it into the ground or over a head. The play fields had a great view of Mt. Meru too.Eric showing the kids how it's done

I had Friday off for the celebration of the Zanzibar revolution. I believe this is when Zanzibar joined Tangynika to form Tanzania. I spent some of the weekend with Erik, Bernice, and Nashesha and attended a birthday party for Nashesha's friends where I met many ex-pats. Many of the adults are the children of missionaries who were out here the same time as my grandparents. Bernice's parents were also in town and I had fun hanging out with her family. They're very happy people and even if I don't understand what they're saying, I enjoy listening to them laugh. I went to the central market in Arusha with them and it was quite an experience. I don't think I'd go alone and I didn't see any non-locals there. It's very stressful. When you arrive, there are boys wanting you to pay them to watch your car and others who follow you around with plastic bags, wanting you to pay them to carry the food you buy. The first covered area has the produce, the next area has dry goods like beans, grains, and these tiny fish that are dried and you eat them whole, and the third area has meat and fish in big freezers. I was worried about drawing attention to myself with my camera, but I did snap a couple pictures.Today I ran into my aunt, Naomi, at church and she's leaving for the States tomorrow so I joined her family for lunch. The Simonsons send their greetings to all the Rowbergs.

I braided Nashesha's hair to be just like mine.

Don't we look like twins?

Nashesha jumping rope

Habari ako?

Erik, Bernice, Nashesha, and Erik Mdogo

I had a fun weekend with Erik, Bernice, and Nashesha and I’m nearly adjusted to the time change. On Sunday, we went to Erik Mdogo’s house, which is way out of town, past all the flower farms. For those of you who don’t know him, Erik Mdogo is my uncle’s friend from Minnesota who lives in Tanzania and because they are both named Erik, one must have a nickname. Mdogo means little as Erik Mdogo is both younger and shorter than my uncle. He has a cute red mud house in the middle of nowhere with a great garden. He has many fruit trees including peach, mango, papaya, banana, avocado, and tomato. He also has many chickens and rabbits. He does all this with no electricity and his water comes piped in to a spigot in the yard. It’s beautiful though and he’s got a view of both Mt. Meru and Mt. Kilimanjaro. We had a huge meal that went on for hours with great conversation too.

Erik's "bread-maker"

Erik's veiw of Mt. Maru

Although this is supposed to be the dry season, it has been raining more days than not and when it rains it really pours for an hour or more. It has made everything lush and green and it also washes out the roads and gives rise to a malaria season due to stagnant pools of water.
Monday was my first day at the hospital and I began on the medicine ward. I will spend roughly 2 weeks on each ward: medicine, pediatrics, OB/Gyn, and surgery, taking away from some areas for rural experiences. We begin the morning with chapel, followed by a morning report where we hear about any deaths, serious patients, and interesting new admissions, and then have either x-ray rounds or didactic teaching before we begin our ward rounds. Africa has its own time and it is a much more relaxed setting than in the US. We haven’t finished rounding before noon, but we have a very busy service right now. We are seeing a lot of malaria, acute and chronic lung disease, HIV, TB, peptic ulcer disease, and infectious gastrointestinal problems on the adult ward. Each lab test is ordered individually rather than in a battery like a chem 12 or LFTs or even a CBC. We order only a hemoglobin or a WBC count or creatinine, although everyone seems to get a blood smear for malaria.
Rounds are conducted in English with someone speaking to the patient and translating for the group. There are no hospital employed interpreters and for the Maasai patients who don’t speak Kiswahili, we have to find a relative or hospital employee or someone who can speak both Kiswahili and Kimaasai to help us out. There isn’t the same push here to get patients out the door as in the US because the hospital bed is much cheaper than tests we order. Meals for the patient are the responsibility of the family and that keeps costs down, but also makes it difficult to control the diet of a diabetic.
I spent my second afternoon in the town clinic with a more affluent patient population. I was able to see patients on my own and they spoke English so I didn’t even need an interpreter. There is a lab, pharmacy, and x-ray in the town clinic, just like the hospital. There is a CT scanner in Moshi, about an hour’s drive from Arusha and there are different lab tests that are temporarily unavailable at times due to lack of reagents so a good history and physical are very important here.

My roommate returned on Tuesday after 2 days on Kilimanjaro. He wasn’t feeling well when he left for the climb and found himself very ill on the 2nd day. His guide thought he may have malaria because he was feeling sick so early in the trip and so he came back to town and into the clinic. It turned out to be altitude sickness rather than malaria and he was feeling fine after a short time off the mountain.
There are now way too many Erik/cs I’m associated with as my roommate is Eric with a “C.” He’s an Australian 4th year medical student who will be here into February. It’s nice to have someone else in the house and our 3rd roommate is still on the mountain until Saturday.