Back from safari and had a blast. Pics are up at: https://plus.google.com/u/0/photos/113979206884651606903/albums/5834838552272766513?authkey=CMviyoX1rsiPigE Remember to scroll to the bottom for the most current photos.
We started out in Tarangire which is quite famous for its baobab trees and herds upon herds of elephants. It was so amazing and probably my favorite out of all the parks because getting so close to so many beautiful creatures was just awesome. We also saw several lions, baboons, warthogs, ostrich, and giraffes upon other things. After Tarangire, we drove up to a campsite atop a mountain that overlooks Lake Minyara which was fun for watching the sunrise the next morning. We also spent a good day in the Serengeti, which we had to drive through the Ngorongoro crater conservation area to get all the way out to the Serengeti (Masai word for plain). And boy, the Serengeti is the African Kansas, a vast expanse of grasslands with the occasional tree and watering oasis scattered about. We saw tons of wildabeast and zebra on our drive out; the wildabeast migration from Kenya is about to peak here in March/April, so it was a great time to see literally a countless number of these creatures. The Serengeti was also great for leopard spotting as they sleep in the trees (we saw 3 which is quite rare to see so many on just one trip). We also saw more lions, water buffalo, giraffes, another elephant or 2, lots of hippos in those watering holes I had mentioned. Serengeti was a fantastic time, but the population of animal life was not nearly as dense as in Tarangire, where there were animals and elephants around every bend in the road. Lastly, after departing the Serengeti, we spent a night & day in the Ngorongoro crater where we got to see even more herd animals, hyenas, literally thousands of flamingoes blanketting the lake at the crater floor (a carpet of pink!) and 1 black rhino! With our finding the black rhino we completed our task of catching a glimpse of Africa's BIG 5: the elephant, water buffalo, lion, leopard, and the rhino. So exciting and all of us on the trip were hoping and praying that we could at least do the top 5! In the end, we got to see so so much more, a very successful safari to say the least. Pics that you won't see are of the leopard (well, there's a poor one in the album I shared above) and then the rhino is completely missing because we only got a good view through binoculars. More on the Ngorongoro Crater, it is a very interesting geological feature b/c it used to be Africa's largest volcano before is spewed out all of its internal contents which left a hollow cone pillar that then imploded, collapsing in upon itself to form the bowl shaped feature, a flat plain making up the valley floor with impressive mountains all surrounding.
Besides the animal life, I will comment that the star gazing and sunrises in the Serengeti and Ngorongoro were absolutely incredible. I was most impressed with the stars. About 5:30am each morning the moon dipped below the horizon leaving the brilliance of the milky way completely uninhibited. I've never seen stars so bright, and the milky way looked like clouds in the sky; it was so prominent. Furthermore, I got to see something that can only be seen along the equator, the southern cross on one horizon with the big dipper on the opposite horizon. Absolutely spectacular!
Here is a pic of my safari mates; 3 Australian medical students from a school in Sydney who were heaps of fun! Henry, Henry, & Sheektah, and that's our beige colored (not the green one...that one just pulled up as I was snapping the pic) Toyota land cruiser in the backdrop. Cheers guys!
Tuesday, February 26, 2013
Sunday, February 24, 2013
Peds snapshot
I’ve seen some shocking things while working on pediatrics
so far. I went to the NICU last week on
Friday, but to be honest, I couldn’t really stand the humid 90F incubator room for
too long; widespread heating is required for lack of individualized
incubators. While there isn’t much we
can do for them medically given our setting, we ended up feeding this little
babe who was found back in January, lying (and crying) in the waste contents of
a latrine. Maggot scars are all over his
body, and while he seems fine medically (at least from the basic investigations
that they can do here) he is failing to thrive.
But that is no wonder. The
hospital is understaffed, and so he may get fed every 3 or 4 hours but
otherwise, there is no one to pay him attention and show him love. Also, because he is without a birth mother,
he only gets this cow milk based formula, which I’m pretty sure is lacking in a
lot of the essential vitamins (and fed from a little cup…they don’t even have
proper bottles here!) Cows milk is
really bad for infants in general. Food
products aren’t fortified like we have come to expect. When working on the pediatric floor, I’m
amazed to see so much marasmus, kwashikor, and rickets (diseases of
malnutrition). And when I ask about
incorporating vitamins into the diet, the interns and attendings just laugh
because vitamins apparently are not even an option here, not that they are too
expensive for any local to afford, but literally there are none for
purchase. It’s incredible to me that so
many of the wretched diseases that I am confronting should not even be an issue,
and it’s heart breaking that once these children do succumb to disease, there
is very little that is offered for intervention (as is all too commonplace). The money and the resources just aren’t
available. For a lot of these sick kids,
the crux of the matter is social and economical, requiring a bit of education
and money.
We have also seen the typical pneumonias and bronchiolitis
and maybe even some unconfirmed malaria cases; nothing here is legitimately
diagnosed. Again, it’s the best guess
based on the limited studies we have at our disposal (and the history and
physical, of course). AND when we do get
labs, even labs as simple as a blood picture, we can’t really trust it. Every practicing physician at Mt. Meru knows
that the laboratory is unreliable, so order tests at your own risk. Absolutely mind-blowing. Anyway, I’m digressing, let me expound upon
these before mentioned febrile illnesses.
Several of these children with the probable pneumonias are seizing from fever. It looks like here instead of treating the
seizure by decreasing the fever with Tylenol, they go for the big guns
(completely contraindicated) using a heavy duty sedative and anticonvulsant,
phenobarbital. Now any doc knows that
phenobarbital also decreases respiratory effort so watch out when using
it. It is horrific that so many of the
kids I’ve seen here are getting phenobarbital to treat their febrile
seizures. Apparently, when diclofenac
(another NSAID like ibuprofen that they love to use) or paracetamol (Tylenol)
doesn’t do the trick, they reach for phenobarbital and Valium. CRAZINESS!
Here even the simple treatment of bronchiolitis (which back in the
States is inhaled albuterol and maybe a course of systemic steroids to calm
down the inflammatory process) baffles me.
I think their medications are in such short supply or the parents can’t afford
the medications, the staff have to resort to nebulized saline solution and hope
for the best. I’ve also seen oral
albuterol being given which takes a lot longer to take effect and is not nearly
as effective. I was told also, for a
child with bronchoconstriction that epinephrine instead of albuterol could be
used because albuterol is ineffective in children under 6mos of age. That’s really quite false and is not the
current recommendation back home, but again, I don’t have to understand
everything that goes on here. I’m just
taking it in and pondering my reflections.
The most shocking thing I’m seeing by far is the nutritional
deficits that are killing these kids. We
had a child on the floor who died just a day or so ago from rickets (Vit D
deficiency which interferes with bone mineralization). And since we have no vitamins, the best we
can do is educate about proper nutrition and hope for compliance, truly
shocking.
Besides the bleak yet beneficial hospital experience, I am
truly enjoying life here. I wrote a
couple weeks ago about settling into the rhythm of African life. I love that Witness gives us a predictable
breakfast variety depending on the day of the week, yet provides consistency
with brewing coffee each morning. I love
that Polo is our day security guard who comes every Wednesday to relieve
Innocent on his day off. Polo is a dear
older Tanzanian who doesn’t speak a lick of English but is so friendly and
reminds me a little of my grandpa. I really look forward to our meetings each
week. And I’ve been having fantastic
discussions with my ‘lover friend’ Emanuel our night security guard, hearing
about his aspirations to start up his own real estate company and maybe do
schooling to become a teacher. His was
the church I visited my first week in Arusha.
Sunday evening is Emanuel’s night off, so that’s when Solomon comes who
has given me equally intriguing conversation telling me tales of his father’s
death at an early age making him grow up all the faster to support his mother
and sister; and yet all the hardships of life have not squashed his aspirations
of being something more than a night guardsmen; he too wants to further his education,
a privilege that we too often overlook as such, instead calling it by another
name, drudgery (at least I have). And
the conversations are not one sided; they like to ask me about America aka
Obamaland (as they call it) with questions like ‘why do you like guns so much?’
or ‘why don’t you like Obama?’ Even if for but a brief time, these Tanzanians have
been my family, and as I’ve settled into the ebb and flow of the slow-going
lull that is typical of Africa, my Tanzanian family has been a welcomed
comfort.
***I am fully aware that some of my housemates might read
this and take offense to that last paragraph.
All you Aussies, Brits, and fellow countrymen have been a fun-loving
bunch as well :) Still, I think I depended on your company too heavily, when
the whole point of being in Tanzania is to experience the true flavor of the
land, which is at the heart of the locals NOT the other mzungus. Still fun getting to know you all! ***
Thursday, February 14, 2013
A Valentine's Death
This story begins the day before Valentine’s; there wasn’t
much happening in the Gen Ward, no organized rounds since my favorite doctor
and chief of medicine, Dr. Mcooley was absent.
He’s the one to keep things organized and actually takes the time to
talk us through his thought process concerning each and every patient. And he’s quite good despite the ever-limited
resources he has at his disposal. Since
there wasn’t much keeping me on the general wards yesterday, I decided to mosey
onward to casualty (their ED) where I no sooner stepped into the department, I
saw a few guys carrying in a 20 something man who was clearly unresponsive and
just writhing about. Initially, my first
impression was that he was seizing, but after we extracted a very limited
history from his non-English speaking friends and family, apparently he was delirious
and agitated, possibly from alcohol withdrawal.
He was a chronic consumer of the local gin (Konyagi) taking
approximately 500ml or more each day. 3
days ago, he grew sick with headache, fever, vomiting & diarrhea and
stopped consuming his regular alcohol intake as a result. For the past 3 days his agitation and altered
mental status had only worsened, and upon his presentation to the ED, all of us
medical students were thinking that this was probably a case of delirium
tremens from alcohol withdrawal. With
the onset of his other sxs occurring prior to abstinence, there could be
another etiology to consider (and the docs here were great to think about
cerebral malaria and typhoid) BUT they completely dismissed the idea of alcohol
withdrawal, which delirium tremens (DTs) if not properly managed will kill a
person. Yesterday, I left the ED
thinking that I would follow up with the patient in the morning since he was
admitted to the men’s ward. When I left
him, he was properly sedated with benzos (fills a similar receptor to alcohol
and helps offset the withdrawal syndrome that causes sweats, tachycardia,
delirium and seizures and potentially leads to death). Anyway, I went to the ward this morning and
found it odd that I couldn’t find my patient.
As soon as I stepped into morning report though, I heard them talk about
my guy; he was treated with quinine to address possible severe malaria and was
also given cipro to address a possible typhoid.
I don’t think any definitive tests were actually done. They cost money that most cannot afford; also
the tests are rarely done in an expedited manner as to actually help in
appropriate management. We did do a
rapid antigen test for malaria while in the ED the day prior which was negative
(yeah, it’s a poor test in a high prevalence area…whether it be negative or
positive, doesn’t really matter. If the
doc thinks it’s malaria, that’s the treatment the patient will get…which begs
the question, what’s the point of the test???)
In morning report, after the intern expounded upon what was done for the
patient, she nonchalantly continued that at 0100 this morning, the patient
died; there was no discussion as to why the patient may have died, no question
to what could have been done differently in patient care. I asked them if alcohol withdrawal and
management was a consideration during the whole event. Apparently b/c the sxs of headache and
vomiting began BEFORE the patient stopped alcohol, there had to be a better
explanation for his current condition.
They didn’t seem to get that alcohol withdrawal could be a huge
complication of the patient’s condition independent of WHY the patient stopped
drink, and so he died. He died I believe
from the dangerous DTs that he was experiencing because the doctors refused to
address his alcohol abuse and withdrawal.
Instead they fixated on a possible infectious cause. So yes, I believe there was patient neglect
and mismanagement and he died needlessly on Valentine’s Day. I will add that although I am here seeing all
this happen before me, I am still trying to put the pieces together. I have not personally reviewed the patient’s
full chart, but I have only heard from the medical student and intern after
asking them about the case.
I will further add that from a couple of posts ago, I was
shocked about the management of a patient with thrombocytopenia (low platelets)
of unknown cause and bleeding. Since there were no platelets available to do
replacement therapy, the attending ordered that Vit K be given. I had said that this would do nothing for the
patient b/c it acts in a totally different way that can’t substitute for platelet
deficit, BUT I found out that this attending is Dr. Moshi, a known drunk on the
wards. He was probably intoxicated that
day as he is most days (which doesn’t make it right, but gives me some kind of
reasoning behind his crazy decisions!) And I kid you not! All the med students and interns have come to
expect this behavior from their attending.
This is one incredible, unforgettable place I’ve found myself the past
several weeks!
On a lighter note, I wanted to mention some cultural
differences I’ve observed between Americans and Tanzanians concerning the word
love, fitting for today : ) My local
friends have come to call me ‘lava friend’ as so the pronunciation sounds in
their local accents, but they really mean ‘lover friend.’ To my Western mind, lovers are people who
have sex, definitely something MORE than platonic friendship anyway. Not here.
Yesterday the night security guard Emanuel took the night off, and I
asked our cook Witness where he was. She
questioned me concerning my inquiry about Emanuel and went on to add, “you love Emanuel.” Initially it felt weird how loosely they
throw around the word ‘love’ here, but I’m getting used to it, and I know that
they mean nothing by it. I think it’s
much easier for this people to be affectionate since their society is still quite
closed off when broaching sex…and thus the lines in the sand are rarely skewed,
and they have the freedom in their usage of ‘love’ expressions. That’s my observation anyway…Happy Valentine’s
Day everyone!
Monday, February 11, 2013
Weekend in Kampala, UG
I'm currently typing on the plane ride back to Tanzania. It has been a good trip , and I am quite sad to say good bye to Joshua as well as his family that I had the privilege of meeting this time. I met his great grandmother and grandmother (whom he calls mom sometimes since she raised him) aunt, uncle and several cousins. His biological mom died of AIDS when he was quite young, and his dad stays uninvolved in his life. I also made friends with his soon to be fiancé Tabitha. She is Rwandan whose parents were killed in the genocide of the early 90s. We hear on the world news about such tragedies of Africa such as the civil wars and the AIDS crisis but I've been given a more personal perspective meeting people who live out the very stories that we only can imagine from our tv and computer screens. I also got the chance to see Moses again who I met on my first trip here when the orphanage in Mityana was still up and running. He was care taker and mentor to the boys who stayed at the home. Very happy to reconnect with him. He is currently working Uganda's coffee industry several hours outside of Kampala city center but one day hopes to attend seminary. He feels lead to be a preacher. Moses has an inspiring story of how Christ worked in his life. He too was orphaned like so many here bc of AIDS, and when he was in his darkest hour, God sent him Joshua who was pivotal in Moses' accepting Jesus. And that's sort of how these two got together and worked in Mityana to develop the orphanage. (And so fitting I think to have a modern day tale of Moses and Joshua : ) While the orphanage is no more, these two are still as close as brothers, and I'm confident that they will begin working together again towards community development sometime soon. Joshua continues to labor on in his village outreach project based in Senge, an outlying suburb of Kampala. We went there on Sunday to attend church, meet the pastor, and see the well that they just completed at Christmas. The pastor was kind enough to have us for dinner afterwards consisting of the typical Ugandan cuisine of mitaki (cooked mash of plantains) potatoes, rice, greens, steamed pumpkin, beans, as well as chicken and some beef. Quite nice! We get more western style food at the house in Tanzania, so it was fun for me to eat more traditional food this weekend. I'll add one other quick tale concerning my birthday. The last time I was here, I wanted a Ugandan soccer jersey but failed to acquire one. Joshua remembered this from 2.5 years ago and when I said it would be my birthday on Saturday, he went out and got me the jersey for my gift. I was completely unsuspecting and couldn't believe he remembered, so thank you Joshua. I was really touched. I had a great time hanging out this weekend, and I am hopeful we will meet again in the not too distant future. Joshua also told me that he and Tabitha will probably be 'introduced' soon...their version of a public engagement before friends and family and that he would want me at his wedding, so guess I'll be keeping that in mind for a future visit!
Thursday, February 7, 2013
Thanksgiving tainted by a little bit of frustration
Since
I've gotten older, I have come to appreciate my mornings more and more, the
daily routine of awaking refreshed to a brand new day. The possibilities
of a new start are endless. There is nothing better than easing into the
day just as the sun is coming up over the horizon with my cup of coffee in one
hand and my Bible in the other. Even here in Tanzania, where coffee is
not a part of the normal wake-up routine, and definitely not the drip coffee
that we Americans have grown so dependent upon, I have found that our kitchen
is equipped with a proper coffee maker, and our house mom Witness has realized
how important my coffee is to me each morning. She brews a half-pot that
is ready for my consumption by the time I even walk down the stairs. I'm
quite thankful for this small gesture! My coffee along with the fresh
fruit (mangos, pineapples, and watermelon) served at every breakfast as well as
the warm summer sun shining in through the open window makes me so thankful to
be here. I hate winter and being cold, and this place is the exact
opposite, perpetual tropics. I am settling into the natural rhythm of
life, having adjusted to the 9-hour jetlag weeks ago. I get a great night
sleep most nights, and try to maximize my day in and out of hospital. And
I feel blessed. The house has been somewhat full (12 people total this
week and more dudes (about half and half now), so balance of the sexes
restored!) Most of them with the
exception of 2 are Aussies who are all quite enjoyable people...I'm just
getting to know some of them. So bottom line, things are good, and I have
so much to be grateful for!
However, the
challenges of the hospital ensue. Since
starting Gen Med I have realized that this hospital has very little resources
to spend on its patients. Internal medicine is a field highly driven by
imaging (XRAYS, CTs, MRIs) and labs (CBCs, BMPs, CMPs, UA); if these basic tools
are not available to the physician, medicine becomes very much a guessing game
(and a frustration!) Thus is the case here at Mt. Meru, where patients
must pay for EVERYTHING before it is actually ordered and done. No money means one less resource from our very
limited toolbox. I am finding that anemia and thrombocytopenia are quite
common on the floor. While they are able
to get a FBP (full blood picture) here apparently, they can't do the
differential, at least not these past couple of days. The machine is
broken or they just aren't doing the diff in the lab for whatever reason.
No one seems to know, nor do they seem to care. Case in point, we have a patient who came in
with the chief complaint of bleeding from the gums and fever. She was
anemic (a Hg of less than 5, normal in women is 12 or 13) and thrombocytopenic
(platelets around 20,000 normal being above 150,000 so pretty low!) We
have no means available to determine why she is thrombocytopenic, but the
anemia is probably secondary to her bleeding.
We have no platelets at the hospital to replace the ones she is lacking.
Instead, the attending told us to give Vit K and whole blood (to help her
anemia) and let's hope for the best. I’m sorry, but if there are no
platelets, you can push as much Vit K as you want, and the result will be quite
unsatisfactory. Whatever. Our hands are
tied. I felt that modern medicine in the
States is lacking at times. This is just
downright ridiculous. Furthermore, this
patient has fever with her bleeding, so hemorrhagic fever is on the
differential (not that we can do a proper work-up to prove or disprove.) I found it quite odd how nonchalantly
everyone was throwing around the possibility of Ebola without any thought to
maybe doing infection control, moving the patient, doing some kind of isolation
if it were Ebola. Nope, she remains on
the women’s ward in a room filled with all the other patients. At least she has her own bed unlike
some. Maybe that’s enough infection
control to keep everyone satisfied…
Needless
to say, I’m trying to stay positive, but with the situation being as above, I
had a difficult time yesterday. God has
brought me here for some good purpose, and I’m still trying to work it all out. The best I can do for now is to continue to
be thankful for all the things I’m enjoying and even be grateful for the
challenges that seem like thorns in my side.
What doesn’t kill you only makes you stronger, character building :
)
I should
have known something about yesterday was just off; the day felt weird from the
start. The annoyance at the hospital
only put fuel on my fire, and it all culminated yesterday evening when I got
word that my friend and landlord in Crossville had just passed. He had been sick for a while, chronic kidney
failure, and while I know that his suffering in this life is over, it doesn’t
make the grieving process any less difficult.
I’m more grief stricken for his wife who married him even before she
left high school. Gosh, they’ve been
together for nearly 56 years! My mind is
filled with wonder of how she might get on without him now when he has been her
whole life for practically all of it!
Also, I’ve never had to do this from such a far distance, confront
death. Thankfully I was able to get
ahold of my mom who will be sending cards and flowers for condolences, but I
feel quite helpless here. I knew that he
had been sick and getting worse, but I never thought he’d pass while I was
away. I will admit that for now, from
here, it is much easier to deal with than if I was actually back in
Crossville. I can be somewhat distant
from the whole situation for the present time, but my mind still wanders to
those age-old fears of loss and change and wonder of what the future will look
like now for me and mostly for his surviving family.
Saturday, February 2, 2013
The Importance of a Good Name
I know that I said I would be doing gen med this week, but I decided to stick around in obstetrics one more week since this was also my mid-wife friend Kelly's final week with us. Kelly has been a great resource on the labor wards and has talked me through several of the births I conducted. Gonna miss her! Also, I will miss one of my favorite labor and delivery nurses, Hilda. She seemed guarded to our presence at first but has really warmed up to us by the end. She was also a great one to learn from.
Upon saying our goodbyes yesterday, I bumped into one of the Kilimanjaro Christian Medical College (KCMC) students named Treasure, who I've been working closely beside these past couple of days. Yesterday was the first time I asked his name and did proper introductions; I almost choked up when he said his name. I know the scripture verse that talks about how valuable it is to have a good name. Now the interpretation of this verse can go 2 ways, having a name that literally means something special and good to declare over a person's life. (For example, Glenn's literal translation means 'Prosperous One'). Or having a good name could just mean having a solid reputation, one of integrity, honesty, and trust. In this culture, I think that the former is what most hold to when naming their offspring. So many names have been Emmanuel, Noel, Innocent, and now Treasure. What a beautiful name for parents to bestow upon their child, that they can know just by their name alone how much they are loved and valued, and reminded of such every time their name is spoken.
This is Hilda; she was such an awesome lady to work with! |
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