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.

Testing, Testing 123

Welp, about 3 months till departure...getting excited and wanted to set up a blog for picture share and documenting my impressions.  I hope you will enjoy it!