Recently in Partner Site: Tanzania Category

Posted on behalf of Danielle Dhaliwal (PL3)

Medicine at Selian hospital in Arusha has truly proven to be an exercise in delivery of care to children in a resource limited setting.  I have several cases to share that I have experienced while here that I believe demonstrate this concept well.

The first case was of a child who was born prematurely at what was estimated to be between 26 to 28 weeks gestation.  The mother presented with premature onset of labor and, despite bed rest and tocolytics, she dilated quickly.  She was able to receive two doses of prenatal steroids prior to delivery of the infant (hydrocortisone is used here vs betamethasone - not sure of the difference in lung maturity outcomes with this).  We were called to assess the infant soon after delivery knowing that it was possible, and likely, that if the infant was 26 wks it would likely not survive.  But also knowing that dating was just as likely to be inaccurate.

Immediately after the infant was born she was cyanotic, hypotonic, and grunting with poor respiratory effort and an initial Apgar score of 4.  For me previously in the NICU this would be a routine resuscitation requiring temperature stabilization, blood cultures and antibiotics, close oxygen monitoring, CPAP, possibly some manual breaths, and likely surfactant administration.  Here these options were not readily available so creativity and temporary stabilization until the infant was able to transfer to higher level of care was all we could hope to achieve.  

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Our infant ambubag was broken and we had no ability to titrate the oxygen percentage so could only deliver 100% oxygen.  Despite giving the best breaths we could the infant's perfusion was worsening and her heart rate began to decline.  Joseph (the pediatric registrar) began doing CPR while I continued bagging the infant.  We did not have any umbilical catheters and instead used a small 4 fr nasogastric feeding tube and gave a 10 mL/kg NS bolus.  I attempted to draw up epinephrine to give however noticed that the only vials we had were 1:1000.  To deliver the correct dose I needed to dilute this to 1:10,000 - I learned to never do math under pressure!!!  (by the way, mix 1 mL of 1:1000 epinephrine with 9 mL NS and this makes 10 mL of the 1:10,000 concentration - estimating the weight at 1 kg you would then give 1 mL of this solution)    The infant's glucose was also low so we wanted to give a dextrose bolus.  We had D50 so Dr. Swanson had to quick figure out how to dilute to the proper concentration while Joseph and I continued CPR.  Thankfully the infant's heart rate and color improved and she began spontaneously breathing although she continued to have significant grunting and hypothermia and so we decided to transfer her to ALMC where they have a NICU and ability to do CPAP.

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Me warming the baby until she was stable enough to go skin to skin with mom

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Getting ready to transport infant to ALMC 

In prep for transport I ran through a checklist:

  • Oxygen - check, no,wait - tank is empty and need to get a new one
  • Ambu bag- check. 
  • Pulse ox - check. Adult sized but will fit over entire foot and work, hopefully.  
  • Thermometer, check. Given disease rates and reuse of thermometers between patients, only rectal and oral temps are taken. 
  • Planning to have mom do skin to skin throughout the bumpy ride.  
  • Stethescope - check.  
  • Unfortunately our low UVC fell out so I had IV epinephrine in my pocket ready to inject directly into the heart if CPR and bagging were not working.  
Thankfully HR and sats were stable the whole ride!

I checked on this infant yesterday and she is doing great!  Still below birth weight but otherwise a successful resuscitation and one that reminded me of the basics of infant resuscitation and taught me how to do so with limited resources. Helping Babies Breathe was a great resource as well.

Here are some closing pictures of the hike I mentioned in my last blog post to Mt. Meru.  

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View of Kili from top of Mt Meru

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Danielle Dhaliwal (PL3) describes her time in Arusha

Posted on behalf of Danielle Dhaliwal (PL3)

Jambo from Arusha!

The house we are staying in in Arusha is up a steep hill away from town but it is on a bustling street - between barking dogs, nightly music, honking horns and pouring rain we are thankful to have ear plugs to allow some quiet sleep .  The house is adorable and we are currently sharing it with a 3rd year medicine resident from Denver, CO.  A medical student from Australia will also be joining us this week. 

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The living room in the Exempla House where we are staying.

In Arusha we began our time at Selian Hospital.  As Danielle and Emily mentioned, it is about an hour and a half walk up a muddy hill but, fortunately, there is a retired Medicine physician from MN, Ron Eggert, who is here for the next year and he and his wife are kind enough to pick us up and drop us off on most days.  
 
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The walk to work this morning.

Ron's wife Ingrid works at the Plaster House, and we had the privilege to get a tour of the facility the other day - what a beautiful and inspiring place.  The Plaster House is a home in Arusha for children from around Tanzania to recover in after they have had corrective orthopaedic surgery, plastic surgery or neurosurgery for a disability.  The Plaster House is particularly busy this week - a group of surgeons just arrived last evening and will be performing a number of complex surgeries over the next 4 days.  

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The Plaster House

Today was the screening clinic and Dr. Swanson and I helped in seeing some of the pediatric cases to ensure they were safe to proceed with anesthesia.  We saw so many children today who will benefit immensely from their being here, I was so happy to be a part of it.  A majority of the cases were cleft lip/palate and burn contracture revisions.  One of the cleft kids was referred to us for a heart murmur.  Not only did she have a 6/6 holosystolic murmur but she had a webbed neck, short stature, shield chest, and other features possibly suggestive of Turner's syndrome. Another child had fallen several months ago onto her chin.  She had fractured her mandible at bilateral TM joints and without proper physical therapy her TM joints fused and she was unable to open her mouth and her mandible growth had been stunted.  Another child had sustained burns to the back of her legs and sadly developed severe burn contractures and was only able to walk with both of her knees bent.  

One patient had been seen by the plastic surgeons however was referred to us because of severe and poorly controlled atopic dermatitis.  The patient had been seen in clinic before and was diagnosed with urticaria but had not received topical steroids and has since developed superinfection of many lesions and possibly eczema herpeticum.  

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Poor guy was so itchy and uncomfortable and so inflamed that I could feel almost every lymph node he had.  It was my first time feeling epitrochlear nodes.

We prescribed a number of medications and to ensure that this infant received what we had prescribed I walked with her and her child to the pharmacy down the street.  Between the topical steroids, antihistamines, emollients, and antibiotics the bill at the pharmacy was 45,000 Shillings (the equivalent of ~$30).  Given that most Tanzanians make less than 5,000 shillings a day this family was unable to pay and so Dr. Swanson and I split the cost for the medications.  I only hope that when the time comes for refills they will be able to do so on their own.  I am having them follow up with me in two weeks so I will let you know how he is doing. 

We do often walk home and when we do we are always called into the home of an elderly man sitting on his porch.  He has severe bilateral lower extremity pitting edema, JVD, and a necrotic ulcer on his calf.  We gather from these findings and what we can understand of his Swahili that he was diagnosed with diabetes, hypertension, and heart disease but only was able to pay for one month of his medications and has not been seen in clinic since.  He is such a sweet man and clearly is suffering despite the fact that the hospital is a 20 minute walk from his house.  Treatment and monitoring of chronic medical conditions is something that we struggle with even in the US, however in Tanzania it is profound.

We spent our first weekend here in the Zanzibar archipelago.  Stone Town is the main city.  It is a UNESCO World Heritage Site due to its being a former center of spice and slave trade and it is rich with diverse influences of Swahili culture with a mix of Arab, Persian, Indian and European influence.   We spent most of our time soaking up the perfect weather and relaxing on the beaches of Jambiani. 
 
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This is actually a real picture I took

I have so many more stories to tell but I need to finish packing.  Tomorrow morning we head out on a three-day hiking expedition up Mt. Meru, a volcano that looms in the distance at 14,800 ft. Can't wait!

-Danielle

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.

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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.

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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.

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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.


Emily Hall (PL3) shares 3 memorable cases

 Posted on behalf of Emily Hall, DO (PL3)

To be truthful, I have no sense of who reads these blog posts. Perhaps you're
  • a fellow resident or medical student thinking "Should I do my International Rotation in Tanzania?" 
  • or a faculty member thinking "Emily, you should be spending more time talking about your experience at the hospital" 
  • or my distant relative motivated by guilt, worrying about my well-being and thinking "how am I related to you, I would never associate with such impulsive travel plans and decision making." 
Regardless, I hope you've found my ramblings both interesting and of some value. 

I have packed my bag with the anticipated return to (the frigid) Minnesota and find myself with a few moments for reflection prior to catching a taxi to the airport. I have had incredible opportunities to see the country, develop relationships, and further my knowledge of medicine. I'll highlight some of the memorable patients that have taught me most about the art of medicine and the unique challenges of medicine in low-resource settings. I should note: the following pictures were obtained with parent permission and an understanding the photos would be shared with others who were interested in tropical medicine.  

CASE ONE: 9 year old with unilateral eye swelling. 

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Clinical Course. Febrile, sick appearing child (39.7) presents with 4-day history of fever and unilateral eye swelling. Temporal relationship to fever and initiation of eye swelling was unknown. Eye swelling progressed with bilateral involvement the day of admission with associated active serious drainage from the superior eyelid. No obvious skin lesion. Child reports eating cooked meat from a deceased calf approximately 1 week ago, the calf was notably sick prior to dying. No one else in the family or village has been ill; other individuals ate the same meat and did not develop illness or facial swelling.

On admission, the intern overnight believed this was a case of cutaneous anthrax (despite there being no classic eschar lesion). Child was started on high dose Penicillin.  Two days later, child's fever and facial swelling was persistent. Differential diagnosis was considered including H. flu or staph pre-septal vs orbital cellulitis. Antibiotics were empirically broadened. Within 1 week she developed a classic eschar involving the superior eyelid and her fever curve normalized. She was discharged home on mono therapy with high dose Penicillin. She was instructed to follow up within 2 weeks; she was lost to follow-up, presumed continued resolution of her bilateral eye swelling. 
 
Lesson Learned: Trust your colleagues, regardless of their 'rank' in medicine. The intern overnight reported seeing a similar presentation of cutaneous anthrax. Despite this, many (including myself) thought broadly about the differential and given the sick-appearance of the child promptly advocated for empiric antibiotic coverage. In the end, the intern made the astute and correct diagnosis. In retrospect, he had much more to say regarding how he came to this conclusion and demonstrated a sound thought process that was initially overlooked. 

CASE TWO: 4 year old with chronic constipation

Clinical Course: Child with developmental delay presents for repeat admission for withholding stool and abdominal mass. On presentation he last passed stool 14 days ago. No history of vomiting, anorexia, or weight loss. Review of systems notable for gross hematuria. Abdominal ultrasound obtained to rule out mass was normal. Abdominal x-ray with dilated bowel loops filled with stool, no bezoars noted. 

Despite aggressive attempts at a bowel clean out (NG placement, repeated enemas, etc). A bowel regimen was established, but would be required for many months duration. A referral to pediatric surgery was obtained to rule out low-lying Hirshprungs disease. Decision was made for colectomy--which came as quite a surprise to me. 

Lesson Learned: Accept clinical management differences. Though a colectomy seems like an incredibly invasive treatment approach for a child with chronic constipation, it prompted investigation into management options and approaches in Tanzania. Turns out, a colectomy is not an uncommon treatment modality in this area. Instead of trying to be understood--I found in this instance and many others the value of seeking first to understand...and then if prompted invite further discussion. There are many ways of 'solving' problems in medicine. It's refreshing and interesting to see new approaches even if at times they are counter to previous ideas.

CASE THREE: 26 month old with bilateral lower extremity pitting edema

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Clinical Course: Well appearing child was brought to the hospital from a rural by family after a medical worker had seen and strictly advised the family to seek medical evaluation for the child. Mother reports personal history of bilateral lower extremity pitting edema as well as siblings (child's aunts & uncles) with similar presentation since birth. No facial swelling. No change since birth. Does not bother the infant. On exam the child has 3+ bilateral pitting edema from the toes extending past the patella. 

Within 20 seconds of seeing the patient, the Australian pediatrician looked at all the trainees and said "there is only one diagnosis possible, I know what it is--and so should you." I looked at her blankly as if to say, "Please don't call on me." None of us came to the correct diagnosis--but after she stated the obvious, my love for physiology resurfaced. Congenital lymphedema. 

Lesson Learned: Hold dear in your heart the knowledge of physiology--and take time to think through problems for yourself. Even if it is a diagnosis you have never seen or read...you can still come to the most logical answer, even when no or limited lab/imaging studies are available.

These cases illustrate both the challenge and the privilege of augmenting traditional pediatric training to include a global health focus. Building relationships and working with physicians who have diverse training and experience is eye opening and valuable. It isn't always easy to find time to make an International Elective experience come to fruition, but experiences such as this I find to be professionally enriching. If you ever find yourself contemplating spending time in East Africa, I certainly would encourage you! 

Emily Hall's (PL3) Dreams Take Flight Again in Tanzania

Posted on behalf of Emily Hall (PL3)

If you had asked me 20 years ago what my life would look like if I were to become a doctor--flying into remote areas of Africa and providing medical care to those in need would have been on my short list of career ambitions. Decades later a dinner conversation and some networking led to the opportunity of a lifetime. 

I was invited by the Flying Medical Service (a NGO based in Arusha, Tanzania) to fill a last minute need to see patients in rural Tanzania. A pilot, a pilot in training, a local chief medical officer, and I traveled for two days landing in remote areas to see patients and provide medical care. Much of my role was to complete prenatal assessments and serve as a pharmacist of sorts--counting pills and dispensing medication. It wasn't pediatrics per say, but I was eager to be involved and willing to help in any capacity. Despite no formal plans to see pediatric patients there always seemed to be a sick child (or many) in each location inviting me to jump into a more familiar role.

We landed in various regions of the country and I felt literally "dropped" into the Maasai culture. The beauty of the villages and people mesmerized me. Their dress and way of life is so contrasting to anything I'd witnessed before. It was such a privilege to be immersed into the culture in this way. They believe pictures capture and take away their soul; so out of respect, I did not photograph any people during my visits. However, the images of the experience are imprinted in my memory. I apologize my writing ability cannot portray the pictures recollected in my mind--you'll just have to trust me: it was incredible.

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Aerial view of a Maasai village as we fly low alerting inhabitants that clinic will soon begin

Returning from this experience I couldn't contain my enthusiasm. Bush flying had proved to be all that my childhood dreams had imagined. It provided an element of danger, fulfilled the desire to do good work, and allowed me to be surrounded by like-minded people. A few weeks later I found myself discussing the opportunity with a midwife at the hospital over tea. She herself has lived quite an adventurous lifestyle, which is reflective in her career endeavors, and I was eager to hear her perspective of medical humanitarian aid. 

I left the conversation identifying with her ambitions and taking away a new understanding of why some people are drawn to global health. In a career field so formulaic -- blended with my personality that is anything but -- I crave to connect with people to have alternative medical perspectives. The global health community embodies this notion. People who have sought and created an alternative career path surround me here and being in Tanzania has allowed me to learn from many who have found their way in medicine despite not conforming to a linear trajectory. 

On reflection, I realized the rigors of medical school and residency had quickly quieted my childish idealism. The perceived ability to make a change in the world and the naïve enthusiasm that surrounds such big dreams was a feeling I had nearly forgotten. Returning to Africa has been oddly rejuvenating and in some ways has given me permission to again have lofty and alternative career goals. So again, I find myself making a list of career ambitions. This time, becoming a Bush Pilot/Physician in Africa probably won't make the shortlist but I'll credit the experience with making me a bit more prepared for whatever opportunity comes next. 

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Emily beside the Foreign Medical Service plane

Posted on behalf of Danielle Brueck (PL3)

The task of trying to capture in words all the sights and sounds of this place is daunting.  The days have started to carry much familiarity yet never quite enough to feel like home. Tanzania - as a country and as a people - is beautiful.  I have felt very welcomed and am grateful to have this opportunity.

In an attempt to capture the experience of the past month, I will walk you through an average weekday.  Please allow for some creative licensing on my part to help condense the experience of many days down into one day, recognizing that each day is not actually as glamorous or exciting as this may lead you to believe. 

6:15 am: Wake up.  Eat some toast and surprisingly good peanut butter.

6:45 am:  We are supposed to be leaving.  I am living with Emily Hall (Peds Resident - PL3) and Caroline (Medical Student from Holland).  I realize I am the only one actually ready, probably because I wake up the earliest every day.  Then I realize this is because Emily and Caroline can actually walk much faster than I can and plan to make it to the hospital in less time than I thought possible.

6:55 am:  Actually leave our place and set out on our 7 km hike to Selian Hospital (uphill both ways, obviously).  During our walk, we have the excellent opportunity to practice our Swahili with the school children who are walking along the fairly car-devoid back road.  We are met with "mzungu" (Swahili for white person) and "how are you?" and are spontaneously hugged or touched.  This is often followed by much laughter from the children.

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Walking to Selian Lutheran Hospital

8:15 am:  Arrive at Selian and attend chapel.  The singing is beautiful and allows us all some time to relax after the long walk.  Chapel is attended mostly by the medical staff (nurses, interns, etc.) of the hospital, and they are most welcoming to us as we fumble to figure out which hymn number we are supposed to be singing.

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Selian Lutheran Hospital

8:45 am:  Morning Report starts which entails a brief reading off of the admissions, discharges, and deaths for the past 24 hours.  I hold my breath a bit, hoping that the neonate with seizures and hypopnea is still alive.  He is not called out when the deaths are read, and I feel relieved.  An interesting admission of a patient with sagittal sinus bleeding after trauma is discussed.

9:00 am:  X-ray rounds.  The power is out so we step outside to view the x-rays in the light of the sun.  Interns take turns giving their impression of the films - pneumonia, congestive heart failure, femur fracture.

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X-ray Rounds at Selian Lutheran Hospital

9:20 am:  Round in the ICU.  There is just one Pediatric patient with likely bronchiolitis but requiring oxygen therapy.  We check her vitals and finagle the adult pulse oximeter to pick up a reading on the child's foot.  She looks better today.  Perhaps this whole bronchiolitis peaking on day 5 thing is true here too.  Maybe I have learned something in residency; I feel excited that Emily agrees that the right upper lobe infiltrate on the chest x-ray could just be shifting atelectasis.

9:40 am:  Chai break.  Besides, they are cleaning the hospital floors.  I begin to wonder whether it is a worldwide phenomenon to clean hospital floors during prime rounding hours.  Oh well, chai sounds great.  And the floors do need cleaning.  

10:00 am: General Pediatric Ward rounds.  Emily and I are working with a fabulous intern and his supervising equivalent of a senior resident.  We grab the paper files (charts) which the nurses have neatly stacked for us and the equivalent of a WOW (workstation on wheels) which is a huge cart with drawers filled with cotton swabs, discharge forms, pulse oximeter, etc.  The children, many of whom have been sitting outside in the grass, trickle back into their beds as they realize we are starting our rounds.  Some of the patients come with complaints that are familiar to us - chronic constipation, bronchiolitis, diabetic ketoacidosis.  Yet we are also challenged with more unfamiliar cases - Kwashiorkor malnutrition, cutaneous anthrax, tuberculosis.  We scratch our heads a bit about how to treat diabetic ketoacidosis with subcutaneous insulin and not an insulin drip.  The patients , their parents, and our fellow Tanzanian colleagues are kind and patient with us, answering our many questions.  The intern is eager to learn, explaining to us how he has been taught to approach a problem and then asking questions about how we would approach this problem.  The more senior resident helps guide and make management decisions on each patient.

11:30 am:  Baby checks.  We head over to the obstetrics unit and inquire if there are any neonates with acute concerns.  Two are currently being treated for likely sepsis with a presentation of fever and increasing fussiness.  There is no microbiology lab or ability to grow cultures so empiric therapy is given.  We are happy to see that the neonate with seizures and hypopnea is much improved today.  After seeing the neonates with acute concerns, we also do a routine exam on all new babies.

12:30 pm:  Lunch of rice and beans.

1:30 pm:  Follow up on interventions, labs, imaging.

3:00 pm:  Time for the long trek back home.  I think I am in better shape than I have been since residency began.  Maybe I will walk to work in Minnesota.  Then I remember it is at least 40 degrees colder in Minnesota, and I take that thought back.  We stop at a roadside stand along the way to buy some fresh vegetables for dinner.

4:00 pm:  Arrive home.  I am grateful we have such a wonderful place to stay with fairly consistent/reliable internet access.  Check emails, read.

6:00 pm:  Time to make dinner.  I realize the great amount of time and energy that this can require and remember why I cook so seldom at home.  I envision the many canisters of beans at our apartment in Minnesota and recount the innumerable times we have vowed to use these.  We all enjoy each other's company in the kitchen as we cut up our fresh vegetables and cook some rice and beans.  We actually sit at the kitchen table to eat and don't feel rushed to a flurry of other activities.

10:00 pm:  Time for bed.  I am starting to enjoy this whole sleeping thing.

There are already many exciting memories from this place, and I am eager for more to come as we finish up our second month here.  It has been a pleasure to work with, and learn from, our colleagues here.  I continue to think through how global health will have a role in my career moving forward.  Regardless, opportunities such as this strengthen my clinical skills, offer new perspective, and challenge my ability to think critically.  I am hopeful these moments will become a part of how I practice medicine and allow me to provide better care to the children I encounter, regardless of location.

Jambo from East Africa - Emily Hall in Tanzania

Blog Post written by Emily Hall, DO, 3rd Year Pediatric Resident

Jambo from East Africa!

I have spent the first few weeks in Arusha, Tanzania settling in and acquainting myself with the resources, medical facilities, and the community. As true with all my adventures abroad--this has not been what I expected, but equally holds exciting potential and opportunity. In future posts I hope to tell more tales of adventures. However, before things get too exciting...let me explain my perspective of life here in Arusha so if you are considering this as an International Elective you will know a bit of what to expect.

Danielle (another U of MN Pediatric Resident who most of you know) and I initially started our work at Arusha Lutheran Medical Centre, which is located in downtown Arusha and offers more specialty hospital and outpatient clinic care. They have a small NICU which was impressive to tour and have a total of 2 pediatricians on staff in addition to a pediatric registrar. In contrast, we observed and in the past few weeks have found our place at the Council Designated Hospital also known as Selian Lutheran Hospital (subtle name difference to the former mentioned). This hospital is in a semi-rural location in a village just outside Arusha serving both Maasai, Waarusha tribes, as well as people of Arusha. We walk to the hospital with beautiful views of Mt. Meru along the path. (see photo below) The resources here are limited in comparison to the Arusha Lutheran Medical Centre.

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Mt Meru

We have been working with two Tanzanian trainees in pediatrics; one of which received his medical training in China the other from Dar es Salaam, Tanzania. Our primary physician contact here is from Australia; she has been a truly wonderful mentor. We round with two nurses and the four of us trainees. Together we have been discussing and collaborating on patient management decisions with particular consideration of differing International Guidelines of management and factors relating to a resource limited setting. This type of work and learning environment has taken a few weeks to develop, but has recently started to come together in an exciting and highly educational format. Later in the week the physician from Australia has been joining us--by this time we have had some autonomy to make decisions and can discuss in more details questions or concerns regarding patient care that have been debated in her absence. Additional training opportunities have included pediatric HIV clinic, pediatric general clinic, and serving at rural outreach clinics.

There have been several very interesting patients and cases, some of which are still a bit of a mystery. Perhaps in the coming weeks Danielle or I can write about one or two interesting patients to give you a taste of the variety of medicine and the diagnostic approach here at Selian.

Arusha provides quite the balance of work and fun. There are limitless things to do in the city and in the country. It is my hope in the coming weeks we can provide a bit of insight on both the medical and culture opportunities we have explored.

Until then, wishing you all well in Minnesota or wherever this missive finds you.

Emily Hall, DO, PL-3
U of MN Pediatric Resident

It Is Time

The following was submitted by Lauren Haveman, a second-year Medicine-Pediatrics resident on international elective in Arusha, Tanzania, under preceptorship of Steve Swanson, MD.

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Interpreting an x-ray

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Holding a patient in the hospital

Yesterday I spent the day with an amazing and group of women who run the hospice and palliative care outreach for Selian Hospitals. There are over 4500 men, women, and even some children in four districts around Arusha who are blessed by the services of this outreach.

In a place where life is a constant struggle for so many people and it is all too easy for situations to feel hopeless, it was truly humbling to experience the care and compassion provided to so many people. We visited two Maasai men in their separate bomas (compounds or groupings of homes) in a sprawling mountain village probably less than 20km from Arusha Town but still more than two hours away by truck on a road that is not passable at all when it rains.

Both of these men were on their death beds a few years ago, literally dying from AIDS. One man, who is my age, had a CD4 count of 3 when he was reached by the palliative care team in 2008. Thanks to President Bush's PEPFAR, anti-retrovirals (ARVs) reached Tanzania and many other countries around the world for the first time, and both of these men, though still sick, have made dramatic turn-arounds.

Touched as I was by the new life given to both of these men, I could not stop my heart from breaking for the many people, primarily women and children, who still have no way of protecting themselves from this deadly virus.

The first man we visited was in his 40s, and when he was started on ARVs in 2009, his wife and four children were reportedly tested and found negative. Unfortunately, as I also saw in South Africa, some religious leaders here make claims to be able to cure HIV/AIDS with a cup of medication, prayers, or chants. This man visited the spiritual healer, Babu, whom he believed to be an HIV/AIDS healer, in 2010 and stopped taking his ARVs. In October of 2011 his CD4 count was 48 and he was restarted on ARVs, but in the interim he again became very sick and we can only expect that his viral load was sky high, putting his wife (who was previously negative) at increasingly higher risks of infection.

Sadly, hers was not the only life at risk when this man stopped his medications; according to Maasai culture, he has and will continue to take additional wives, usually very young women chosen by village leaders. He told us yesterday that he now has two wives, but the first has not been tested for HIV since 2009 and his "young wife" (who we estimated to be between 15-17 years old) has not been told that her husband is seropositive because he feels that she is too young to understand.

He also shared with us his fear that if his young wife knows he is sick, she might get scared and tell others in the village the secret. In fact, he had sent her out of the boma when we arrived yesterday so she would not overhear any of our conversation.

This young Maasai girl, who was unable to finish school because it was her time to marry, is unknowingly exposed to the virus every time she sleeps with her husband. She has since had a child who may or may not also have the virus, but we do not know since the child has not been tested, at the father's decision.

In my four weeks working at Selian, Kelly and I admitted two babies with Stage Four HIV infection (the sickest a child can be), neither on ARVs. The first baby was about seven months old and presented with pulmonary tuberculosis, severe thrush, and severe malnutrition with wasting (he was the weight of a healthy newborn in the United States). The mother did not know she was positive.

The second child I met on Monday, a fourteen-month-old female who weighed 5.4 kilograms (the average weight for a healthy three-month-old female). She was too weak to cry, with marasmus and extreme abdominal tenting, and could not hold her head up. Mom told me that she herself was HIV positive and had been on ARVs during pregnancy, but her husband and family abandoned her and she had no resources to feed her child or seek medical care. The infant had not been started on ARVs, and she died three days later.

We also had a sweet seven-year-old little girl who looked about three years old, was known to be seropositive and previously on ARVs. Her mother had stopped her medications more than a year ago because she had gone to see Babu for a cure, but the child has returned to the hospital with severe malnutrition and in desperate need of restarting ARV therapy. I think about the young mother we met at the boma yesterday and how easy it would be for her child to be the next admission.

Interestingly, after I got home from the village yesterday, I opened an e-mail from Dr. Amman, a pediatric ID specialist at UCSF and a man who has been at the forefront of the HIV epidemic since the virus was discovered in San Francisco in the 1980s. He is also the president of an organization called Global Strategies for HIV Prevention and has worked around the world and especially in Africa, advocating for women and children.

I learned that the United States Public Health Service finally released treatment recommendations stating ALL people who are HIV positive should receive ARV treatment: "Antiretroviral treatment is recommended for all HIV-infected individuals."

No longer should we wait for absolute CD4 counts to fall in adults and adolescents or for CD4 counts to fall in young children. However, the World Health Organization's guidelines have not yet changed, and it is these guidelines that shape the ARV policies of most countries around the world, including Tanzania.

What if we did treat every HIV-positive individual with ARVs? Studies show us that transmission rates would fall as viral loads are lowered in infected individuals. We could further reduce the maternal to fetal spread of the virus. The virus would be prevented from mutating into resistant strains if hit hard (and early) by multi-drug therapy. Life-threatening opportunistic infections would be reduced. Infected children would not be as badly plagued by the malnutrition I see here every day. In short, HIV would continue to become a chronic disease instead of a life sentence, transmission could be further reduced, and lives would be saved. This would be an answer to many prayers.

What is stopping us from treating everyone who is HIV positive? For me, the scariest and easiest factor to change is the fact that as a nation and world, contact tracing has never been used in the fight against HIV. Unlike tuberculosis, syphilis, gonorrhea, chlamydia, small pox, SARS, ebola, polio, and other infectious diseases, there is no requirement that a case of HIV be reported in order to trace a person's contacts. Without this measure, there are millions of people in the U.S. and around the world who are HIV positive and do not know it (estimates are that 20% of HIV-positive people in the U.S. do not know they are infected, and up to 90% of infected people are unaware in certain regions of the world). According to the new guidelines, all of these people should be on ARVs now. If universal testing and contact tracing were used, the young mother I met would know she and her child were at risk of HIV. They could be tested and treated now, before they became sick. She could learn how to protect herself from the virus if she were negative and become empowered to advocate for improved heath for both herself and others in the village.

My limited number of years in the medical field have been enough to make me passionate about my responsibility as a doctor to notify and test people who are known contacts of HIV-infected individuals. Unfortunately, while I feel this is my responsibility, I am limited by national and international laws.

It is time for this to change.

As doctors, nurses, and public health providers in an age when HIV/AIDS is a manageable condition, in a time when drugs are available worldwide (though arguably not yet available to all who need them), we are now responsible if the epidemic continues to spread. If we are not willing to do everything we can to stop the spread of the virus--and this includes universal testing and contact tracing--then we are individually and collectively responsible for the millions of people who continue to be unknowingly infected, predominantly women and children.

It is time to change the way we notify, test, and treat people at risk for or infected with HIV. With the resources and knowledge we now have comes the responsibility to do everything we can to put an end to the HIV epidemic. As I prepare to fly back to the United Sates this evening, I find myself wondering, am I at fault if the young mom I met yesterday or her child die of AIDS or related infection, because I did not inform her or allow her to be tested when I could have? Am I responsible for her life and the lives of her children both born and unborn?

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Performing a patient exam

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Another patient exam at bedside

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Lauren and Kelly Bergmann distributing charts on the ward

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Writing up a clinic note


Bergmann at Selian Hospital in Tanzania

The following was submitted by Kelly Bergmann, a second-year pediatric resident on service in Arusha, Tanzania, under the preceptorship of Steve Swanson, MD

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Kelly Bergmann cares for a patient on the wards at Selian Hospital in Arusha, Tanzania

On the eve of returning to Minnesota after five weeks in Tanzania, my impressions of my time here are mixed. On one hand I'm excited to go back home and see family and friends. But on the other hand, I will miss those friends that I've made, the people, the culture.

Most of all, it's the children in the hospital that I will miss, many of whom were staring death in the face and courageously took on each day with a smile. Their smiles brought joy to my heart and hope for their future, despite the limitation of medical resources and care that we could provide.

Selian Hospital, in my brief experience, does what it can with limited resources. It is difficult to get reliable lab tests and ultrasound reports. The x-ray machine, bilirubin lights and neonatal warmer work only intermittently. Vitals are taken once a day on the ward, usually by our team as we make rounds. Family members provide food for their malnourished children, but if they don't have money for food, the children aren't able to eat.

Just down the road from Selian is one of the top five hospitals in the country, Arusha Lutheran Medical Center. ALMC is actually a partner with Selian, and much of their profit is subsidized to help provide reduced-cost services at Selian.

ALMC is what I hope Selian will become one day: a beautiful new facility with resources that would rival some hospitals in the U.S. IV fluids can be appropriately administered, labs are reliable, x-rays are good quality, neonates can consistently be kept warm. Just a mile away from each other, these two hospitals are worlds apart.

I will miss Tanzania and the serenity I found amidst the sometimes chaotic day-to-day life. Most of all I will miss the children and their smiling faces.

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Faratha

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Joshua, who loved having his picture taken

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Helena

I will miss Faratha, a 7 year-old girl with AIDS whose smile was so beautiful. I will miss Joshua, a 4 year-old with kwashiorkor who finally smiled at me after about a week. Most of all, I will miss Helena, a 4 year-old with kwashiorkor. I took care of her for almost two weeks and never saw her smile, but I imagine it stretching from ear-to-ear, lighting up a room--the glimmer in her eye as she finally has the strength to smile. No, I never did see her smile.

But that is what keeps me coming back, knowing that someday soon, she will feel happiness again.

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Another patient at Selian looks out the window beside her hospital bed 


Dr. Muthyala Checks In From Arusha, Tanzania

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Kilimanjaro, as seen from Mount Meru

20/12/2011

Today was a regular day on the pediatric wards at Selian Hospital in Arusha, TZ......

The day began with a Continuing Medical Education given by the palliative care teams at the hospital. In the middle of rounds, a nurse informed us about a very ill child that had been brought to the outpatient clinic.

We rushed to the clinic, where we found an infant apneic. At this hospital, the nurses have minimal pediatric or neonatal resuscitation training, so nothing had been done. Quickly we
began bagging the child, found otherwise good vitals, and obtained a history.

A one-week-old boy, born at home without any prenatal care, was doing well until a few days ago, when he began to have fevers and had a seizure today.

The family initially presented to an outpatient clinic, where the child was given oral amoxicillin (a capsule of amoxicillin was opened and given to the child orally) without any improvement.

The child had a strong pulse, good chest rise with bagging but was coughing. Bulb suctioning resulted in the removal of about 2-4 ml of pink fluid, which was thought to be not blood but the amoxicillin that the child was aspirating.

There was no oxygen available in the outpatient clinic, so the child was taken (while ambu bagging) to the pediatric ICU. Oxygen via nasal cannula was started, and the child began to breath spontaneously.

The child was found to be hypothermic and there is no incubator so the mother was instructed to place the child in direct contact with her own skin. After this his vitals stabilized.

We started empiric treatment for meningitis (without an LP or blood cultures, because neither is available or reliable at the hospital) but first taught the ICU nurse how to dilute a vial of 250mg of ceftriaxone into 150mg doses, and then instructed how to mix D5NS and D5W to make D5 ½ NS for maintenance IV fluids.

Then back to rounds.

Doing well here in TZ, have one more month before coming home.. Happy Holidays, everyone!

Brian

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Brian Muthyala doing x-ray teaching at Selian Lutheran Hospital in Arusha, Tanzania