Well, the interwebs must be clogged…

Quick update: the internet here has been laboriously slow, so I have slowed down updating – it’s a little frustrating.  Takes a long time to load the editor and I can’t put up pictures.  We’ve been having fun and have wrapped up at Selian. Safari to Ngorongoro and Serengetti on Fri/Sat/Sun, then flying home already Monday night!  Updates will eventually follow with a better internet connection.

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I Have Not Forgotten

Busy weekend, will update soon; just wanted everybody to know Jana made it here A-OK.  Yay!

More Pics, Brief Update

So, this weekend was good.  Didn’t go into Selian because apparently that’s not how they roll here, so spent the day being lazy on Saturday, hanging around the house.  Sunday, went to church at ACC and then ended up exploring Arusha with Sarah and Beth.  Sarah is a PT from Germany (south of Stuttgart) and Beth is a social worker from Colorado.  Both have been here a few months already.  We ended up eating at a random street cafe called the Washington, D.C. Bar and Restaurant.  They had 3 choices on the menu – rice with fish, rice with beef, and chapati bread with veggies.  I opted for the fish – pic to follow.  Amongst the 3 of us we had my meal, 2 sodas, and 2 chapatis with beans, and it cost 12,500 Tshillings ($1 = 1560 Tsh), yet the girls thought they charged us white people prices.  Even so, still cheap.  We then wandered to the market because they wanted to buy cloth to have made into outfits.  I ended up buying some veggies while we were out, and I was glad they were there to help me because otherwise I’d’ve paid 10x what I should have, and I’d’ve had no real idea I was getting ripped off.  I still need to learn numbers in Swahili.

Monday, I was the American pediatrician as Janna stayed home.  She has a cold (I think she caught from me) and she ‘didn’t want to give it to the kids’.  Interpret that at your discretion.  Anyway, rounded with Winnie the AMO and made pretty good time.  Had a few admits over the weekend, mostly respiratory stuff and one kid with what sounds like a febrile seizure, although she was on the old side for a first febrile seizure (5yrs) and she also didn’t have any symptoms aside from fever.  No malaria, no pharyngitis, rash, otitis, dysuria, nothing.  Developed a slight cough on day 2 of hospitalization but no fevers after admission, UA dip was pretty unremarkable.  So, the mystery patient went home today.

Had another kid, 4yo, immunized, with good nutrition, with measles.  Or at least, it sounded like measles, but she got over it awfully quickly and didn’t have a rash by the time I saw her, so who knows for sure?  She got sent home today also after 48hrs observation.

On a sadder note, 2 peds deaths in the last 24 hrs, a 3mo with pneumonia, admitted after-hours and only lived 3 or 4 hours so I’m guessing was in extremis when they showed up.  No ventilators, limited IV fluids, drugs, monitoring, and nursing staffing puts a limit on what you can do, I guess.  The other case bothers me more, because I saw the child, a 1 day old boy.  Born around 5 AM, Apgars reported to me as 7,8,9, had a little respiratory distress after delivery which they thought was due to ‘amniotic fluid aspiration pneumonia’.  The child improved with suctioning of secretions but had some acrocyanosis so they sent him to the ICU for oxygen.  When I saw the baby 5 hours later, grandma had taken the cannula out of the kid’s nose (why I do not know) and he was fussing a little and rooting.  His exam and vitals were normal (although the pulse ox was too big for him, so couldn’t get sats), and there was no cyanosis; so, we let grandma take him to breastfeed with mom.  Apparently, however, mom developed post-partum hemorrhage – from a uterine rupture (the second case in the last 5 days) – and had to be taken to the OR emergently.  Long story short, the baby died for unclear reasons around 5 AM.  I suspect it was hypoglycemia from prolonged periods without feeding (no formula available here) but it could have been sepsis or something else, and there’s not really a way to know.

On a happy note: 1) CME this morning was on rectal prolapse, which stemmed into a conversation about constipation; I finally got to add my 2 cents worth of educational info for morning report, and 2), Ron and Ingrid took me and Janna to the grocery this afternoon, so I am stocked up; they even treated us to pizza at the Masai Cafe, downtown.  It was pretty good!

 

 

PIC TIME:

From L to R: Sarah the German PT, Mr. Fish and Co., and Beth the Colorado Social Worker, at the Washington D.C. Bar and Restaurant

As a typical American, I am thwarted by the presence of bones and/or a head still attached to my food.

The Selian-mobile, Ron’s chariot and our ride into work in the mornings.  Caution to riders > 6 feet: road bumps may lead to concussions.

A little park in the middle of a traffic circle in downtown Arusha.  Note, elephant and rhino are not real.

A random shop along the Moshi-Nairobi road.  What you see behind the woman in yellow is representative of non-main roads here.

Mt. Meru, in the clouds, watching over Arusha.  I’ve only seen the top of it once so far, because it is usually in the clouds during rainy season.

On the road into Ilboru.  The Dutch Tilt is not for dramatic effect – the car is just pitched like that.  You get used to bumpy rides pretty quickly here.

An out-the-window shot driving home from Selian on the road from Ilboru.  I like this shot because I caught the Masai kid mid-stride running down the hill chasing our car.

Candlelight Dinner

Candlelight dinner during a power outage

 

Arusha Community Church: a multi-denominational, Christian, ex-pat church.  VERY diverse.  Comes with a mirror-on-a-stick bomb search of your car before the service, and chai tea afterward.

 

ACC, interior

Simonson House: Easter Sunrise service was hosted at a famous missionary home, about a 15 minute, all-uphill walk from where I’m staying.  It’s a pretty amazing building, with a view down the hill overlooking Ilboru and Arusha in the distance.

Weekend Update, Part 2

WEDNESDAY

Census still low, no new patients.  We did, however, have some AMO students join us today, and they are pretty sharp!  They asked very good questions and were very attentive.  But they don’t know some basic things, like how to write a good SOAP note.  Janna is making that the first point to teach.  No new admissions, so we carry on.

Starting to feel better at this point, too…

Ventured into the city this afternoon, with Noel once again my bold taxi driver.  Found out that you can’t just take cash to any bank to exchange currency – you have to be a member.  So, with less cash in tow than I’d have preferred, I went to the grocery, Pick & Pay.  It’s actually kind of a haul to get there, so I’m glad Noel knew where he was going.  The grocery is interesting – it’s stocked with some familiar items, some random foreign stuff, and has one little shelf with bread and NO produce except for one crate of apples.  Everybody buys their produce from local farmstands or the occasional produce market, apparently.  I will have to find some fruits and veggies–don’t want to come down with scurvy.

THURSDAY:

Another short day at the hospital.  Sadly, one of the patients died in the night, and we’re not really sure why.  14mo with AIDS and severe malnutrition (weighed about as much as a healthy US 6 month old maybe).  The possible reasons are numerous, but we’ll never really be sure why at this point.

No AMO students today – it was a little perplexing, but we finally found out that Mondays and Thursdays are all-day lecture days for them.  I don’t miss those days very much at all.

In the evening, the Jacobsons had us all over for dinner, which was delicious.  Asian vegetables in peanut sauce, curried chicken, salad, ice cream.  It was pretty awesome, and I got to meet a few other people visiting here from abroad, including a CT tech from Tennessee, and PTs from Germany and New Zealand.

Pretty much over my cold today, but I did have to take a dose of my Cipro to settle some…issues.

FRIDAY:

Another quiet day on rounds.  The AMO students were back, so we had them see one patient each and present to either me or Janna.  Their note writing will need some work, it seems, but clinically they are making good assessments, and their plans are reasonable already.  Also, Winnie apparently tried to take today off, but she wasn’t allowed for some reason.

After rounds, Janna gave a presentation to our AMOs about respiratory illness in children.  It was a broad topic to try to cover, but I think the students picked up on a lot of it pretty quickly.  Some analogies that are commonly used in the US, however, don’t work so well here, like describing subcutaneous air as “rice crispies”.  We managed to get the point across, though.  Even though Janna led the discussion, I couldn’t help myself but try to add some additional pediatric wisdom at times.  Next week we’re going to talk about malnutrition, and at some point I think I will try and give an overview of TB in pediatric patients–conveniently enough, a talk I already gave last year for which I still have the powerpoint.

Kelly and Lauren left the Minnesota house today, so we pulled a room swap and now I have an upgraded pad with a queen bed, a better mosquito net, and a desk.  Most importantly, this bedframe doesn’t squeak every time I move, and the curtains are dark so they block the light better.  No master bedroom for me, but I think I can live with this.

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Pictures will follow soon.  And sorry to disappoint you, mom, but I’m not in any of them (yet), since I’m the one taking the pictures 😀

Weekend Update, Part 1 (Long Post Ahead)

So, it has been a while.  I got behind on posts because I think I managed to catch African RSV as soon as I got off the plane. By Monday I had a a head cold with cough and sore throat that was pretty miserable.  However, I think my immune system had seen one of it’s cousins, because I recovered quicker than I usually do from such things.   It still made Mon and Tues a bit of a drag to learn a new and completely different hospital and team.

For the record, I didn’t really expect to be working in a team.  Not sure what I expected, though.

I also got behind on posting because it is hard to update a blog when the power is out.  Tues and Weds nights the power was off from when we got home until ~9 PM local time for line repairs.  Basically, they took down the wires, chopped back some trees, and then hung the wires back up.

Since there’s not been much updating, I will attempt to recap by the day.  I’ve taken a few pics, too, which I will try to post tomorrow or Sunday (most of pics will probably be taken towards the end of my stay when people here know me better; also, the Masai aren’t keen on photography).

MONDAY:

Got to see Selian for the first time and see the crew at work.  Pretty much everyone here from the US is from, or trained in, Minnesota.  Dr. Steve Swanson is a peds ID guy, with training in tropical medicine, and he was acting attending, but this was his last day.  He’s smart, a good teacher, and ridiculously thorough in his exams.

There’s a married couple of med students from UofM, Kelly and Lauren, but this was their last day here too before heading off to other medical areas in the city.  There are two family med people, a year out from residency, who share the house I’m in, Janna and Eric.  Eric rounded on peds today but goes  to medicine tomorrow, and Janna took a “me” day and just stayed home. :-/

The service has shrank recently.  Steve told me they were rounding on 30+ kids the last week or so, with no help from Tanzanian AMOs (assistant medical officers) or interns.  Now it is getting more manageable, 17 today with a few discharges.  Diagnoses on the ward: bronchiolitis, pulmonary TB, presumed disseminated TB, presumed malaria, gastroenteritis, severe malnutrition (marasmus, kwashiorkor, marasmic kwashiorkor), HIV, presumed malaria, and combinations thereof.  Admitted one myself, new patient in the ICU.  14mo, h/o severe malnutrition, discharged end of last week, with respiratory distress and hypoxia.  Looks pretty sick, visibly pale, Hgb 7.5 if you trust the lab.  Clinically consistent with bronchiolitis, but history is sketchy at best.  Given poor nutrition, and overall status, elect to cover for pneumonia anyway.  No X-rays available today (Easter Monday is a holiday?) and we’d have to take her off oxygen to get the film anyway.

Got a ride home with Steve after lunch (beans and rice at the canteen at the hospital, for 2000 Tsh).  Went to bed early after kindhearted roomies fed me – no trip to grocery today.  Ron (a semi-retired rheumatologist from MN) is planning a group trip to the store tomorrow, have to make a list of supplies for someone to get me.

 

TUESDAY:

Today is my first real day doing clinical stuff – yesterday was just a day of getting my feet wet.  Janna is coming to the hospital today, so I won’t be flying solo.  Also, the pediatric AMO, Winnie, is supposed to be back today.  She was out with an injured foot last week.  We’re going to try to hit the ground running as best we can.  We manage to see 17 kids between 1030 when rounds finally start, and 1:30.  Winnie is helpful at times, but also randomly disappears.  But when she’s there, she’s invaluable, since she is experienced and she speaks the Masai language.  Many of the Masai near here do not speak Swahili, especially the women.  The language barrier with Swahili is rough too, but the pediatric ward nurse, Francesca, is an amazing help.  After an hour I can tell that she’s above and beyond many of the other nurses here in both language and clinical skills, and we’re lucky she’ll be around to help out.

Lunch again is rice and beans.  Simple but effective.

We walk home today.  The road from Selian to Ilboru is basically just a really wide hiking trail, with lots of small farms and the occasional school house or shop (Swahili: duka) along the way.  It is relatively hilly, with a few steep rocky spots.  There are many children out along the way: some too young for school, many more who are old enough for school but are kept home due to the cost of schooling or the need for help around the homestead, and some, later in the day, in school uniforms walking home.  The youngest kids tend to greet us by calling “mizungu” which means “foreigner” but is generally used for white people.  Older kids say “good morning”, typically regardless of time of day, but some of the students get more advanced with “good afternoon” or “hello, how are you doing”.  Many of the children who are not in school also know how to say “give me my money” or “take a picture”.  So far I’ve obliged neither for fear of starting a trend.  I’ll probably give in to the latter, and give away some candy, before I leave.

Ron somehow forgot to take Lauren and Kelly to the store today, and they had my grocery list.  So, the roomies kindly feed me again, and we have a romantic candlelight dinner because the power is out.  We look like a bunch of ENT docs because we’re all wearing headlamps, too.

 

 

The porch chairs

The porch chairs

are made out of cowhide, I think.

The laundry “room”

If you look closely there is a washing machine in the back there.

The kitchen, view 2

The kitchen, view 2

The stove works, but requires encouragement. About every 10 minutes, I walk in and say ‘you can do it, boy! boil that water!’ and eventually it listens to me.

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