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.
Posted on behalf of Abby Montague (PL3)
I am fascinated by ultrasound. In medical school I had the privilege of rotating at HCMC for an ultrasound rotation through the emergency medicine department. I spent a month learning everything from bedside FAST (Focused Assessment with Sonography for Trauma) exams and the basic bedside applications to looking for retropharyngeal (behind the throat) abscesses with intra-oral probe and confirming fracture reduction in the arm. Unfortunately, keeping these skills up during residency hasn't really been a priority due to the ready availability of excellent ultrasound technicians and pediatric radiologists. But I like looking at the images my patients get and guessing the diagnoses before the official read comes back. I occasionally would page through my Pocket Atlas of Emergency Ultrasound (by one of the HCMC faculty among others) to remember how I would do the studies myself.
Then I started preparing for Haiti.
Aside from X-rays, we knew an ultrasound machine was the only available imaging within the St. Damien's. I was excited about renewing my skills and asked Ben Trappey, our MedPeds hospitalist attending coordinating our trip, if the staff at the hospital would be interested in a little handbook on bedside use of ultrasound that I could do for my academic project.
After cramping my wrist at 5 am trying to get good RUQ views with the portable ultrasound in my call room, I had enough images for my project. I put together pictures of the buttons from our machines in the ED and on the floor for a mix of the way symbols appear and reviewed some radiology literature for images of clinical pathology. I printed up the guide on Saturday before we left and Ben presented it to our Haitian contacts when we arrived.
Ultrasound machine with Abby Montague's newly created bedside use of ultrasound booklet easily accessible on the side
One of the first ultrasounds we did here was evaluating a child with TB for pleural effusion (fluid around the lung). It was so grossly abnormal at first we couldn't find our landmarks. As we kept looking, we realized we were probably seeing TB cavitations within consolidated lung tissue (holes in the lung). It was impressive. The next was a child with abdominal distention who ended up having a complex cystic mass that was so large we couldn't tell if it was coming from the liver or the left kidney (on opposite sides of the body). Kids don't come to the hospital until they are really sick and their imaging findings, whether chest xray or ultrasound, tend to be dramatically pathologic. At first, the staff just asked us to go do the ultrasounds which couldn't happen until most people were gone for the day. Gradually, they started crowding around to look at the images in real time.
One of the new residents was the first to accept the transducer. Each ultrasound, I would pass it around to see if anyone wanted to practice, receiving a lot of smiling and head shaking with French explanations I couldn't understand. The resident, Renee, was admitting a child she suspected had intussusception (intestine stuck within intestine). After explaining my lack of training with intestinal imaging again (having attempted an appendix ultrasound the first week), I asked her to just start looking since we had equal lack of experience in this case. I shamelessly endorsed my ultrasound guide and showed her the pages about the difference between the probes and the standard probe positioning. She started scanning the abdomen and found a tubular structure with a target appearance in cross section. Never having ultrasounded a child before, she recognized the characteristic finding without prompting. The staff all came around to look and we had a long discussion about the next steps. With no fluoroscopy available, the child would need to have a reduction through an open abdominal surgery. A stunningly textbook history and suggestive abdominal film would have sent the child for reduction regardless. But I can't describe how satisfying it was to watch the resident add to her own clinical suspicion using ultrasound with minimal help.
One day I was asked to ECHO a cyanotic newborn. I am comfortable with the subxyphoid view but I couldn't remember the orientation of the alternative views of looking at the heart. The very same Pocket Atlas I used in MN had made its way to Haiti prior to our arrival and and I grabbed it from the stack of English textbooks on the registration desk to re-orient myself. Renee and I talked through the chapter on cardiac imaging, each tried a couple views and came to the conclusion the right ventricle was small and we could not determine much else. But the physician I had handed the book to was now flipping through other chapters to see what was possible with this machine they've acquired and now wanders in our direction to look over our shoulders whenever we bring the ultrasound out from radiology.
I have not stopped being completely anxious about people relying on our novicely obtained images. We are asked on a daily basis to ultrasound outside of our scope of familiarity - like the ECHO's for congenital heart disease, the intestinal ultrasonography, and examinations for biliary atresia. I've only turned down one request to look for peripheral pulmonary stenosis since I don't even know how to find the pulmonary arteries. But the giant septated pleural effusions are becoming more familiar and a new staff tried her hand at visualizing one today.
I've revived an old love and maxed out the space on my flash drive bringing home images to share with Ben. But I wish I had an image of the look on Renee's face when she found the right angle to visualize the heart. I felt like I really had brought something to give. Our Haitian colleagues have been most generous in sharing knowledge, skills, and gracious acceptance. My hope is that in this small way, we've shared something worthwhile in return.