July 2011 Archives

Andy Keenan: A Day At Selian

Fourth-year Medicine-Pediatrics resident Andy Keenan is currently abroad in Arusha, Tanzania, completing a month of peds and a month of internal medicine at Selian Lutheran Hospital. Here's his most recent blog entry:

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Things are going great here in Arusha, albeit with unpredictable internet.

Selian is a small hospital just outside the village of Ngaramtoni, near the town of Arusha.

It is a semi-private entity that receives support from the Lutheran Church and the Tanzanian government. Among the hospitals in Arusha, it does not offer as much subspecialty care as Arusha Lutheran Medical Center (ALMC), but often acts as a referral center from small local and regional hospitals.

The hospital is made up of a number smaller buildings, with an administrative offices, outpatient/casualty, pediatric/adult medical ward, OB/GYN ward, surgical ward, radiology, and a number of other smaller buildings for support services and living areas.

Each day starts with chapel at 0815. Some people skip this, but it's a good way act as a part of the hospital staff, and you'll get some good Swahili practice. It's also a great place to find people in the morning.

After chapel, there is morning report in the same building. They usually briefly review the hospital stats (admits, discharges, transfers, deaths), and admissions from the night before.

More complicated admissions are discussed in some detail. This can get sometimes get pretty animated, and is usually conducted in English. It can be a good time to learn about management styles, and the staff here are generally interested in resident input, as well.

Occasionally MR is followed by a presentation by one of the attendings, interns, or other staff.

Usually after MR we'll go over to the radiology building to review x-rays. It's a pretty open format, and they will often ask us to read the films. I hear the term "micro nodular" a lot.

Rounding can vary widely depending on who is present, what you view your role as, and several other variables that I have not been able to define for myself yet.

Usually the team is made up of an intern, a doc who has finished internship and is working in that department (senior medical officer), and an assistant medical officer (somewhat similar to a PA here).

Like in the U.S., the level of knowledge for interns can depend on the time in their training cycle and interest in the given specialty. They are my main resource for how things get done in the hospital.

The senior medical officers are also an excellent resource. Many of them have an interest in eventually pursuing specialty training in their field, so they are great to work with.

The assistant medical officers (AMOs) have a wider range of clinical skills. I've been told that many were initially trained to primarily manage common infectious diseases, but that their scope of care has increased significantly.

Some AMOs are among the longer-standing medical staff of the hospital.

When a patient is admitted, they come through Casualty, where they are evaluated by an AMO (usually) or intern (occasionally), who starts the initial workup and management, with the ward or on-call intern to review after admission.

This is where you can find the age and weight. The weight is especially important, as there is not a functional scale in the Peds ward. Often under DOB it just says the year, which can be a challenge when coming from the Peds side and it just says 2011. With the prevalence of malnutrition it can be more difficult to eyeball the age based on the size and development stage.

After evaluating the patient, the orders and documentation are done on the fly. Usually the nurse is updated on any changes or discharges, and you move on.

After rounds, the schedule gets a little more variable.

Most of my regular duties are on the wards, which are usually done by 12:00 or 1:00. My team (intern) is on the hook for reviewing admissions until 1530 when I'm not on call. Some post-rounding options are clinics, ultrasound, heading over to ALMC, or working on research.

The bus driving back in to town usually leaves between 3 and 4 in the afternoon. Given the challenge with getting back in another manner, I have been arranging my schedule to allow for this.

That's a day at Selian!