"But this is Tanzania, my dear"

Only in Tanzania will I see the head of the labor ward cleaning department jump in and take charge of a delivery AND sew up the vaginal tear afterwards.  It was quite weird to say the least.  There Mallory, one of the medical students, was standing over mom ready to catch baby when the janitor just comes up, shoves Mallory out of the way and does the job herself, so matter-of-factly.  Quite strange indeed.  I thought I had seen it all, but that takes the cake for now.  When we questioned a nurse about what we had seen, she shrugged her shoulders and responded in her Tanzanian/English accent, " But this is Tanzania, my dear!"

On a more somber note, I spent a couple hours in the neonate/premie unit the other day.  I could only bare an hour or 2 b/c since they don't have individual incubators, they turn the entire room into a sana of 90+ degrees.  Makes rounding and evaluation quite uncomfortable!  It's sad, b/c there isn't much to be done for these children.  There are no resources here that can simulate the NICUs we have back home.  I am doubtful that I will go back there b/c I don't see the point.  They can give antibiotics to suspected septicemia (triple drug regimen that I can't remember presently), and they do have a half-way working bili light if there is fear of kernicterus/hyperbilirubinemia.  I saw a lot of cerebral palsy, which not much could be done for, and there was an unforgettable case of spina bifida with a big gaping hole over the back about 5-6cm diameter, a myelomeningocele; not certain if this child will get surgery to repair the deformity or not.  I'm sure there will be long term neurological sequelae, even if it does get repaired.

Also, I spoke with some of the nurses in the post-natal ward today, and I asked them what kind of care the neonates get before they are discharged.  It sounds that if there are no problems, they get their oral polio and BCG vaccines, then will be seen again in 6 weeks by the clinic who will give them more vaccines per the Tanzanian vaccination schedule.  If there are no obvious concerns, the child will only be seen when vaccines are required, and the only vaccines that they give here (from the best I can follow) are measles, neonatal tetanus, diptheria/pertussis/hep B, polio, & BCG (for TB).  This is better than most African nations, but this level of care is hardly the standard in the rest of the world.

Birthing Mothers, the True Heroines of Tanzania!

Today is my last day in Obstetrics.  I will miss working with the midwives and nurses.  It’s done differently here with the majority of the deliveries conducted by the nursing staff.  The only time the doctor gets involved is if a caesarean is recommended. (We’ve been seeing pre-eclampsia and pregnancy induced hypertension as big causes for c-section.)  Otherwise, the women labor on without the obstetrician’s presence.  I think it’s similar practice in Australia and Britain where the midwives take on a huge role in routine deliveries, at least that is what my fellow Australian and British students are telling me.  And at the public hospital of Mt. Meru Regional, the mothers come down from the overcrowded antenatal ward when they are 4-5cm dilated.  They find an empty bed in the delivery room, which is rather small, just 10 beds all in one room and no divider between the beds.  Modesty is completely out the window.  There are no epidurals or pain control.  The woman bring there own birthing blankets (congas) to lay upon while in bed as well as to use as swaddling clothes.  They bring their own canister of something to eat/drink while there.  They even bring their own suture material in case they tear during the delivery.  There are no electronic fetal heart monitors, just the old school fetal scope funnels to check for heart tones now and again.  The staff is supposed to check fetal heart rates every 30 min, every 15 min when the baby is getting close, but that rarely happens, especially when it gets busy, 3 or 4 births all happening simultaneously.  In the states, my obstetrics month was somewhat weak.  I never got to catch a baby b/c the patients build up a good report with their doctor; it was never my place to conduct the delivery.  After being here, I have done several and have really enjoyed the hands-on learning experience.  It has been quite scary at times since these mothers get very little prenatal care before they deliver.  I never know what’s going to pop out.  I don’t think they do quad screens here; maternal healthcare can be quite expensive apparently, and I’m not sure even how many mothers get their ultrasounds done.  The delivery room could very well be the first time these patients are being seen for their pregnancy. We have had several neonates born this week where resuscitative measures were utilized.  The extent of resuscitation that I’ve seen is suction and oxygen.   They don’t utilize CPR, and any medications that might be used are quite scarce.  And intubation?  What is that! I haven't seen any vents here.  We did have a fetal demise.  The hospital just does not have the resources to live up to the standards we in America have come accustom to.  There isn’t really a NICU, at least not what we would call a NICU back home, therefore the babes either make it or they die.  I have noticed too, that the neonates don’t get screenings.  We do no heel sticks to check bili levels and other blood/electrolyte abnormalities.  We give no Vit K; no erythromycin eye drops, no Hep B vaccine before departure from the hospital.  6 hrs later, if the mother and neonate are doing well, they are sent off.  I’m not sure of pediatric follow-up.  To an up and coming pediatrician, the care these children get is quite unacceptable! 

As soon as the baby is born, we are cleaning up mom, asking her to stand up, get dressed, and get out, since we must make room for the next mom.  The mother quickly departs from L &  D to the postnatal ward (where there is easily 3 or 4 to a bed) where the moms are monitored for 6hrs post delivery to ensure no post-partum hemorrhage or other obvious problems.  Then they are discharged home.  It’s incredible how these women are treated like the laboring process is no big deal.  If they scream too loudly in their pains, the nurses yell at them to be quiet.   They aren’t allowed visitors while they are laboring.  At least in this public hospital, the father is not permitted at the bedside.  The women labor in pain, completely alone.  It’s incredible, and that is why I have called them the heroines of Tanzania.  All mothers are heroines but the pain these women have to endure here is unfathomable to us Westerners.  Today, since we were out of lidocaine, I even watched a vaginal tear get sewn up without any local anesthesia whatsoever.  Yep, they are my heroines, handling the whole ordeal very courageously.  

Hospital Sanitation and Obstetrician Headspin

Hmmm...yeah there isn't any sanitation really.  I was actually appalled the first time I stepped in the men's general medicine wards.  It was dank and dark, absolutely no air conditioning anywhere (and it gets 90+ degrees here during the day).  Oh, by the way, there is no air conditioning in the hospital, period, no matter the department.  At least in general medicine, there was only 1 patient per bed, but the sanitation is scary.  No infection control.  The room is filled with maybe 30 patients, and at least one of them I know is suspected of having tuberculosis, yeah no infection control whatsoever.  They may have a sink here and there, but no soap, no towels.  We foreigners bring our own hand sanitizer and try to make do with that, but after several alcohol washings, the film build up on the hands is pretty gross, and I feel like I need a good scrub with old fashioned soap and water.  While general med is rather dingy, obstetrics is in a new edition to the hospital, so it is relatively more modernized (still no central air) but at least its brighter and whiter.  Same sanitation laws apply, sinks with running water, but no soap anywhere to be found.  It's incredible, especially in an environment where I'm up to my elbows in maternal blood, fecal matter, amniotic fluid, and baby poop, that after every delivery, the best we can do is clean our hands with some alcohol sanitizer that we've brought along.  Still, given the circumstances, I think the staff do a pretty good job keeping things clean.  And we do use sterile gloves and personal protective equipment, eye shields, gowns (that we have to bring for ourselves!)  This hospital has very limited resources.  I guess it is to be expected, but actually living it out is quite hard.  I mean, we don't even have clean drinking water at this place.  There is no cafeteria to provide any kind of patient nutrition (or staff lunches).  The patients provide most things for themselves.    

Since I've been working in obstetrics for almost 2 weeks, I'll give you a better idea of the obstetrics system at Mt. Meru Regional Hospital.  The woman may have had 1 or 2 (or no) prenatal visits before getting admitted to the hospital in latent phase of labor.  When they are approximately 5cm dilated, they come down from the antenatal holding area (where there are 2 or 3 mothers or more) to a single bed.  Then they come to labor and delivery until they deliver.  After the delivery they will literally no sooner pop out the placenta then we are rushing them out to make way for the next woman. They gave birth literally 5 min ago and already are standing up, getting themselves dressed, and gathering their items to move over to the postnatal ward, where again there are 3 or more mothers to any given bed.  There is no such thing as local anesthesia (no epidurals).  We do give lidocaine if we have to conduct episiotomies.  These women even need to bring along their own suture in case they lacerate and tear during childbirth.  I have seen the nurses sew with and without the use of local anesthesia.  They bring their own congas (birthing clothes) as well b/c there are no linens on the beds.  And that is how they can tell which baby is theirs, no name tags needed.  They recognize the conga cloth that their babe is wrapped in!  In ALL of these wards, including labor ward, there are 12-20 beds per room.  It's only in labor ward that I've seen only 1 patient per bed.  This is a public hospital, so from my understanding, the conditions are much nicer in private hospital.  Still, even in public systems in America, the things done here would NEVER ever happen.  It's quite horrific at times.  Today we had 15-20 babies born in about 5 hours.  It was literal chaos, exciting, but chaotic.  I never had enough equipment to do what I needed to do, very frustrating!!!  And several of the babies needed resuscitative measures (suction and oxygen) and probably intubated, but we don't have the resources for that here.  It is amazing to me that the children can be in respiratory distress, and the nurses in L & D attend to the child, but after they do what they can do and the child is still pale and limp, they go back to attending to the mother's and doing their job without even a care.  From my viewpoint, the child is not at all well, but their feeling is Akuna Mitata (no worries).  To give them credit, the nurses are very busy people, and I guess in obstetrics the mother's should be the priority when there are so many of them birthing one right after the other, but still, CRAZINESS.  TIA...this is Africa.  

Coffee Plantation

Went to a coffee plantation in the Arusha suburb of Tengeru yesterday.  Our tour guides Clemency & Noel were very fun to have along.  They actually had prior careers as porters, carrying packs for people up Mt. Meru as well as Kilimanjaro.  Guess they got tired of the heavy trekking and settled for the less rigorous activities.  It was funny b/c I was late waking up, so as soon as I was ready to go, we had to go.  I didn't get time for my usual cup of joe, but I also thought that since we were doing the coffee tour, no problem. I'd just get some along the way.  After our arrival, our guides sat us down on the lawn and brought out cups and saucers and what I thought was surely a taste of their home brewed, home roasted coffee.  Much to my dismay, it was instead lemon grass and ginger tea from ingredients also grown at their plantation.  After having a relaxing tea in the garden, we did our little hike into the woods where we saw the coffee trees and learned a little bit about the harvesting process.  Then we came back to our starting point to shell some raw beans with a large mortar and pestel, roast the beans by hand over a charcoal fire, then hand grind the beans, again using the mortar and pestel.  The whole process took approximately 90min from start to finish, and never had I put that much effort into a cup of coffee.  It was definitely worth it!  This is Africa, and since people aren't big on coffee drinking here, good coffee is hard to find.  Most people just do with instant, which is NOT the same.  I can't even find a French press in this town.  I got to buy some fresh coffee after the tour, and the way it is brewed since it is ground so finely is by boiling without any filtration, the sediment cooks down and sinks to the bottom.  It's quite nice, but rather difficult to do on a daily basis at home.  I may just have to do with instant for now, sadly.  Here are some pics of the day: https://plus.google.com/photos/113979206884651606903/albums/5835199289788376545?authkey=COCJkorgu_2ChwE

Commute

I wanted to give you an idea of my daily commute.  There are several students staying at the Work the World House all of which are Australian with the exception of 2 British students and myself.  Together we set out around 0800 every morning, walking approximately 15 min to the dala-dala stop (or bus stop equivalent) where we hop into what is really just an overcrowded van.  After a 10 min ride on the dala dala, we jump off and walk another 10 min or so to Mt. Meru Regional Hospital (named appropriately since Arusha is at the base of this historically active volcano).  

And I thought I had a bunch of pics to give you a better idea, but apparently I deleted them...

Rough day; it will get better.

I am so thankful for the interweb.  I don’t think I could do this kind of international experience without the support (and communication) with friends and family back home.  We have a local bar & grill (quite Westernized) about a 10min walk from the house where I am staying that has wifi that is superb (and is where I am writing this…fully equipped with TVs, one has a cricket match and the other has the Australian open!), especially by Tanzanian standards…and it’s free!  I do try to give them business by getting a Guiness or 2 while writing as to not totally leach free internet : )   Today was first day at hospital, and MY was it interesting.  To be quite frank, I am utterly lost, not sure what my role here is or what I’m doing here.  Tanzanians may be quite polite, but from what I found in the wards, they are quite closed-off also.  I think it takes them a couple days to warm up to new people b/c no one really acknowledged my presence, nor did they offer any kind of instruction as to what I was supposed to be doing.  I did rounds with some docs and local med students throughout all the obstetrics wards, quite appalling.  These were actual wards, including the delivery suite, which housed 12 or so women, their beds barely divided by anything.  In the other parts of obstetrics, patients were sharing beds (again ward style), so maybe 20 beds to a room with 2-4 patients per bed.  Because rounds were conducted in part broken English and Kiswahili, I had a fantastic time trying to follow along.  I think there were several patients with pre-eclampsia, maybe one had malaria superimposed over her pregnancy, some were anemic.  Not sure what they did for each patient; with the language barrier all was quite unclear, I assure you!  At one point, I think the docs were draining some kind of adnexal mass (I’m hoping they diagnosed with imaging rather than just a palpation exam of the abdomen) by sticking a needle and aspirating bloody discharge.  It looked rust colored to me, not typical blood, maybe a mixture of blood and pus but couldn’t be sure.  They looked at the specimen for a moment and shook it back and forth, and then after that, I have no idea what happened b/c we moved onward to the next patient.  I couldn’t believe that they stuck a needle blindly into this patient’s belly.  Like I said, I feel rather lost, but I am hopeful that as the people warm up to me, they will be more apt to involving me in the treatment of the patients.   Yes, interesting day.  I’m a bit disheartened, but all will be okay.  I’m going with the flow and learning what I can, mostly from the differences between our healthcare practices.  

Arrival and Orientation

It’s great to be back in Africa!  Not to say that I don’t have some residual trepidation about what I may encounter in the hospitals, but the warm breeze in the air that greeted me as I stepped off the plane combined with the pitch darkness of a night relatively undisturbed by city lights was enthralling.  Arriving at the Work-the-World house, I found that my program put me up in dorm style housing on the bottom bunk, albeit I’m currently encased in the mosquito netting canopy which is not what I had ever experienced back in PA, but oddly, my room still reminds me of the time my brother and I shared bunk beds growing up, and mine was always on the bottom.   It’s good to have some reminders of home this far away.  Orientation tomorrow then off to 2 weeks of obstetrics, which I’m curious to see what their medical practice is here.  I was talking with one of our program managers who expounded upon the bush medicine and how traditional ways (still practiced) are to limit the mother’s diet to keep the fetus small, thus keeping the laboring simple.  This makes me curious about developmental defects, but our director swears up and down that the children being born are very healthy.  They warned us that there would be striking differences between medical practice compared to back in our home countries (undoubtedly!), and while the urge is to interject our recommendations and state the differences (and possibly do our way while here) most of the docs don’t care how it’s done in other countries.  If we try to resist the current system, we will only get frustrated, so we were instructed to just ‘go with the flow.’  I’m sure I will come to my own conclusions concerning that matter.  More to come…

Anx is mounting.

I'm in the final preparations before my departure to Arusha, and I'm not pretending that I am at all confident in my ventures.  I'm actually quite nervous presently, concerned about the difference in medical practice in TZ, and how I've always done it on this side of the pond.  Will I know what to do?  Will I be of any help to them?  Am I going to fall flat on my face the first day, overcome with jet lag, overwhelmed with the language barrier and the (possibly) primitive practice settings?  What has filled me with even more trepidation is that listed on my placement itinerary, my official position on this rotation is 'Doctor in charge', not 'medical student', not 'visiting student' but 'Doctor in charge'.  I am fully aware that in less than 5 months now I will be graduating and will have the rightful title of doctor, but to see it on my itinerary as the one in charge only adds to the weight of my plight.  I will still have supervision in Arusha from my understanding, but exactly how much supervision is TBD.  I can already guess that this experience will stretch me in ways that I am not expecting.  I guess I am prepared, God will be there (hopefully I do not forget this in my scariest moments).

I remember when I left for my study abroad semester in Ireland, some dear college friends gave me a send off card that I held quite close during the times of struggles and tears.  Included with their kind send-offs and well-wishes, they also wrote down Psalm 139:7-12. "Where shall I go from your Spirit?  Or where shall I flee from your presence?  If I ascend to heaven, you are there!  If I make my bed in Sheol, you are there!  If I take the wings of the morning and dwell in the uttermost parts of the sea, even there your hand shall lead me, and your right hand shall hold me.  If I say, 'Surely the darkness shall cover me, and the light about me be night,' even the darkness is not dark to you; the night is bright as the day, for darkness is as light with you." ESV  So whether I am filled with fear and trembling, I take comfort in not treading alone.