Harvest Festival

After a very entertaining day at the ACC Harvest Festival auction (where I bid on a couple of very nice melons and have received several compliments on them since) I am back at the Oasis, getting ready to leave again to meet Rob at the airport. I am excited, and a little nervous, to see what he thinks of this place. It's definitely unlike what we are used to at home...
But first things first, I'll be happy to see him after 5 weeks apart.

And a correction from my brother: only certain types of bananas are going extinct. Never fear - at least certain species of bananas will outlast all of us.

Have a great Sunday, everyone. More pictures later.

Sun Salutations

Baobob Tree. One of the Wonderful Trees of the World.

This morning I woke up and waited patiently for the cramps in my abdomen to start again. They didn't. You see, yesterday I spent the day at home, sick. I've decided that being sick is much more fun on a Tuesday or a Thursday around here because the maid isn't milling around all day while i'm trying to mope privately. Yes, I said maid. We pay a woman to clean the house and do laundry for us three times weekly. She's a lovely woman and sometimes brings us sweet bananas. (Brenden said that bananas are going extinct - which is truly tragic when they taste as good as they do in Africa). Anyway, having an african maid isn't as politically incorrect as it sounds. That's the way it's done here. We provide her with a job...and around here that's not always easy to come by. Unfortunately i'm getting quite used to this...I'm not looking forward to doing my own laundry when we get back. Fortunately we have the luxury of a washing machine. Christine washes our clothes by hand.

So I feel better today - even well enough to eat a piece of sweetbread with peanut butter and Nutella on it. Who says i'm roughing it here?

I did yoga in my backyard, facing the sun. It's a very different experience than being in Jeffrey's studio at home - here, when i do my forward bends and peer through my legs i see a rooster and flock of baby chickens scavenging the ground about 10 feet behind me. And the background during Shavasana (sp?) at the end is a chorus of cows mooing and cock-a-doodle-doos.

But the sun feels just as warm here and yoga can always help me back on my feet. Now off on a trek into town with my roommates...we'll see what kind of adventures befall this troup of Wazungu today...

This is the rickshaw full of cabbage that we helped push up the hill.

What's that smell...

...? Oh, it's me. When i first got here, i made a note to myself about the way people smell here. it's different. and, well, it's not always entirely pleasant. Kent warned me that I'd get used to it, and he was right. After 4 1/2 weeks of drinking the Tanzanian water and eating Tanzanian food, I too smell like a Tanzanian. Rob, this is a warning to you. No amount of fancy western deodorant can beat this. It's just the way it is.

I got done with work early today - the kids are all doing well and I figured I'd take advantage of the afternoon. I met up with Kent - speak of the devil - and we went to McMoody's for a late lunch. Only they don't have sandwiches that late in the day, so i settled for a strawberry milkshake, which was quite possibly the best milkshake I've ever had. (keep in mind, it's all relative. i've been drinking mostly water and tonic water here it was a veritable tastebud-explosion at first sip) Then we stopped for gas and were, as always, hit up by a couple of women carrying baskets of food on their heads and begging for us to buy some. Actually it was a pretty sweet deal - specifically the passionfruit which (once you get past the slimy texture) is absolutely delicious. I can't wait for Rob to see all of this. The people on the street willing to chop fresh sugar cane for you, faster than you can eat it - the little kids who run after us yelling "Mzungu!" and just want to shake our hands and then run away giggling - and how graceful the women are, walking down a rutty street with a full basket of fruit or water on their heads.

I feel like my blog entries are too depressing. I don't want to give the wrong impression - being here is actually a lot of FUN. Most of all, it's a privilege to get to live and work here, rather than in a hotel or just pass through on vacation. I do not regret a moment of it. Yes, work is frustrating, but there are more successes than failures. And the people, Tanzanian and otherwise, really do make the experience a great one.

Elisa

Pat, the director of the Flying Medical Service, picked us up at 1:15 today to make the trip to Haydom. Elisa's uncle Emmanuel came along for support and to give a history. He was pretty excited to fly in a plane, as he had never been on one, or even outside of the Arusha area in his life. Elisa was, at best, mildly interested. Fortunately she slept during most of the flight. Ironic thing - when I got to the ward this morning, Elisa looked better than she ever has. Of course that's a good thing. But I have to admit, it shook my already uneasy sense of confidence in this grandiose plan that we'd hatched on Sunday to fly this child over the African countryside for a head scan. Never fear - I was still supported. So we went.
The view of the African landscape is amazing from that height - below the clouds but high enough to see the to the mountains in every direction. Around Arusha the ground was a quilt of browns and yellows - barely a hint of green anywhere. Occasionally I could see a small tasmanian devil-like swirl of dust on the ground moving across the fields. It was a reminder of why kids like Elisa are so malnourished. It's hard to raise a family at a time like this, when your income depends on your crops.


The facilities at Haydom were very impressive. After an amazingly soft landing on in an open field (If anyone from the Flying Med Service sees this, I want to point out that it is actually a landing strip. it just looks and, well, feels like an field of dirt and dried grass), we were escorted to Haydom Lutheran Hospital. They led us directly into the radiology department and laid her on the CT scan table. Within an hour we had a complete head CT and a radiologist to interpret it.


















Everyone was extremely friendly and - might I add - efficient. They clearly have a lot of respect and admiration for Pat there. Who wouldn't.


Elisa does not have brain cancer. Instead it looks as though her brain has suffered from a previous infection, although it's impossible to know what kind. The good news is that we have treated her for most infections and are in the process of treating her for Tuberculosis, which is one thing that could have caused this. With therapy and some serious attention to her nutritional status, she will likely get better. The bad news is, she might not. And she will likely continue to have seizures, although the medications we have her on have mostly alleviated those.


Elisa will probably go home from the hospital this week on medications for TB and seizures. I sincerely hope that she continues to take them. The question is, how will her family afford to refill them when she runs out?


I am so grateful to the Flying Medical Service for taking us to Haydom today. And thankful for the people around me -- Dr. Matthews, Megan, the nurses, my roommates, the families of the kids who are sharing a hospital room with Elisa -- for believing that pursuing an answer for Elisa's health is necessary and worthwhile. At the end of today, I feel good and so does Elisa's family. Maybe with some rain, a bottle of multivitamins and a reliable follow-up plan, she'll do okay...


What Tanzania lacks in resources often is replaced by the will and the generosity of the people here.

Flying to Haydom and Billy Goats Gruff

Below is a photo of Oskar Wendell, the tortoise living in our yard. The Wendells have lived at Exempla house for many years. (Wife Chloe not pictured)

For the past couple of weeks we have been treating a little girl named Elisa, who is so weak that she can barely walk. Using what limited test we had available, we have treated her for everything we can think of that could be causing her to be so sick. But despite our efforts, she has gotten sicker and weaker and I feel like we are watching her waste away. As is the case with many of our patients, her family has no money.

So some of us decided to find a way to transfer Elisa to a hospital with more resources, including a CT scanner (that's the same as a "cat" scan), to see if she has something fix-able wrong with her brain. Here is what has transpired since starting to make those plans:
I met some amazing people. A taxi driver offered to drive me and Elisa to Moshi without charging a return fee. A pediatrician offered to help facilitate her admission at Moshi. An occupational therapist gave me contact information for a neurosurgeon who could assist. My colleagues offered to help pay for the trip. These are the people i've been writing about -people who have moved here, whether temporarily or long-term, to help improve the lives and health of the people of Tanzania. The answer came from the folks with the flying medical service, whom i happened to have dinner with last night. Pat is one of the pilots and just happened to be flying to Haydom Lutheran hospital, where they happen to have the right resources for us, and there happen to be seats remaining for me, Elisa and one of her family members. We leave tomorrow afternoon and will fly over Lake Manyara to a little town called Mbulu. Look it up - it's southwest of Arusha, toward the middle of the country.
I don't know if we'll be able to fix this child but for some reason i feel like we have to keep trying.

Elephant (Tembo) in Tarangire National Park

On a lighter note, here are some photos of the Tanzanian wedding I attended with my roommate, Babu Kent, on Friday:

This is a picture of the "Cake." As you can see, it is actually 3 goats, roasted and mostly skinned and positioned as though they are running. When the bride and groom "cut the cake," they actually cut a piece of meat off of the goat.

Babu Kent and I with nurse friends from Selian

Bride and Groom sharing champagne with family

Traditional Masai Dancers (Groom was Masai)

Sad and Rainy

I woke up this morning to the sound of rain falling on the leaves of the plants outside my window. The first thought that crossed my mind was to wonder if Oscar the tortoise, who lives in our yard, was out basking in the raindrops or hiding in his shell somewhere under a bush. On the way to church everything looked different - less dirty and somehow like things were moving more slowly than the day before. Maybe it was because it was a Sunday morning, or because the rain was such a relief to everyone. Or maybe because if you walk to quickly on the road you'll slip in the mud. It felt nice though. Much cleaner than usual, despite the mud and the wetness.

Later I found out that Edna died last night. I'm not sure why I wasn't surprised, but just kind of sad and frustrated. We need more resources here. Or Selian does, I should say. It's not really me who needs them. It was Edna and all the other little kids like her who will show up for help in the future and we won't be able to offer more than an ill-fitting oxygen mask and antibiotics.

The Boy Who Stays

The Pediatrics team on rounds


This is the little boy that we treated for heart failure (I used his photo last week, when he was on oxygen). He did well.

Dr. Matthews evaluating a child with pneumonia

The last two days at work have been intense - emotionally draining but still enjoyable most of the time. There were moments during the day yesterday that would be difficult to describe on this blog. The picture in my mind is clear and I go over it a lot in my head, and with Megan the med/peds doc who recently started volunteering at Selian hospital.

The day started without power. There were no lights at Selian and somehow, like turning off the lights in a kindergarten class, everyone seems to stop working when there is no power. You can hardly blame them - the lab machines don't work, the xray doesn't work and if you wait long enough the power will return. But the main problem was that no electricity = no oxygen delivery machine in the peds ward. And might i remind you that, most days, 2/3 of our kids have some sort of pulmonary tract infection.

...and so started the day. We walked into the peds ward and found our kid with severe pneumonia struggling to breathe. No oxygen. And who knows how long that he'd been breathing that hard. Transfer to the ICU. STAT (as if there is such a thing here).

But in the ICU there are no ventilators. So we thought please, God, let oxygen be enough to keep this boy breathing. 3 IV lines and 2 power losses later (the electricity kept turning on and off throughout the day), he looked ok - maybe even a little bit better. Today he is still struggling and all we can do is keep checking on him, give him fluids if he's dry (but not too much because there is no such thing as an IV drip here!!!) and hope that the antibiotics win out over the infection. We gave him what we had: fluids, antibiotics, oxygen and a lot of doting on behalf of Megan and I. I wondered why--on those nights at St. Paul Children's Hospital admitting 20+ kids per night with asthma and bronchiolitis, each complete with his own chest xray and a brand-spanking new oxygen mask shaped like a dinosaur which HASN'T been used by dozens of kids before him--I never stopped to appreciate how lucky we are back at home.

Shortly after that little boy was "shifted" (as they say here) to the ICU, we met a baby girl named Edna. She's one month old. She has a perfect little round face, which I might even say looks well nourished compared to other kids around here. She's been admitted earlier that morning and hadn't been seen by a doctor in quite a while. Edna is the one who got our adrenaline flowing. She was so small and weak and just didn't want to breathe. After a long discussion with the nurses about what we do and don't have in the peds ward (which is not easy in Swahili-English) Edna stopped breathing altogether. While Megan was called away to another resuscitation, Dr. Matthews and I resuscitated her, scooped her up and ran (well - walked briskly) across the campus to the ICU. Let me tell you - due in large part to the lightness of my skin i already feel a little bit like a fish out of water here sometimes. Imagine the looks when the locals sitting around the grounds (they spend a lot of time sitting and waiting here - the most patient people on the planet i think) saw us sprinting down the sidewalk with an infant and a confused mother, trying to hold on to her skirt and her shawl, trailing behind us.

In the end, Edna did okay although she's still not really out of the woods. But i feel good about her, and so should Megan and Dr. Matthews. It's good to know you did your best.

And sometimes it doesn't.

Shortly after we resuscitated Edna, an adult woman was wheeled into the ICU. An admission for the adult medicine team, who must be on their way. She couldn't breathe either and in the midst of taking care of our kids, I wondered if she needed help too. The nurses eventually got her hooked up to oxygen, but before she really stood a chance, her heart stopped. We tried to resuscitate her too...but she died. And all of this happened in one big barren white room, in front of Edna and her mom, as well as our boy with pneumonia and his mom too. It was sort of strange and sad and tragically uneventful after that. No one really said anything. A reminder that this is Africa and people here aren't strangers to death.

I don't know that lady's story, or if we could have done something to help her before that critical point. Initially I felt sort of angry about it. Who was responsible for her admission? (Answer: probably someone who had 2 dozen other sick people to tend to). Why wasn't she on oxygen already? (Answer: because we were using the oxygen cylinder for our babies and the nurses needed to figure out a way to rearrange the lines without a consistent power supply). And what would we have done for her if we had gotten a pulse again without ventilators or central lines? (Answer: nothing more than was already being done). But, again, this is Africa. Things are different here. You do what you can with limited resources and then you leave the rest to fate or God or luck or whatever you prefer to rely on.

But boy did I mull that over in my head. What could we have done differently...

Dr. Megan Shaughnessy and Avelin the Intern with one of our best peds nurses

One last thought for now: After all of that drama and disappointment, we returned to the wards today and saw Issaya again - the boy with probably TB causing liver problems. He was discharged on Tuesday, but every day when we get to work, there's Issaya and his mom, waiting. They are waiting to have the money to pay for the hospitalization, so they can go home. Until then, he remains in the ward. And each day his smile gets a little bigger, and he's always clutching the white car that Brenden and I gave him 2 weeks ago-- back when he wouldn't so much as look at me. He makes my day. I'll be sorry to see him go, even though he was discharged 4 days ago. How ironic - a discharge is so much more satisfying back home...

Here is a photo of Issaya, his mother and I. Notice he's holding a white car in his Left hand.

Wonderful Wonderful Water

After 4 days without running water, I am happy to take a warm shower and clean the filth from my hair. The funny thing is, I didn't mind. Perhaps Africa is rubbing off on me...or maybe it seems like something minor like having to cart water into the house in buckets just feels more authentic. At least we have running water most of the time - which i've taken for granted all my life but see now how important it is.

It's the dry season right now, so water is actually quite precious around here. Some of the kids that we see in the hospital are sicker than they might be at other times of year, when families have more time and resources to offer them - when they aren't too busy trying to keep their livestock alive to take their kid to a doctor. but now is a time of famine. And hospitals and clinics are a long way from their homes, so sometimes prayer and home-made medicines are all they have. I'm told that the "short rain" season will start soon. If the rain comes, things will change a lot around here. For me it'll be minor - a muddier walk to the bus in the morning and maybe a shift in the illnesses that i see in the hospital. But for the people who live in remote areas of Tanzania, I'm told it will be reason to celebrate.


Good news - my patient with the hepatomegaly that are treating presumptively for Tuberculosis (TB) is getting better! None of the tests we did explained his huge liver and ascites, and we don't have PPDs here, presumably because all of these kids have been vaccinated with BCG (although it still might be helpful). But he's Maasai and therefore at risk for TB, plus he had bilateral otitis media and his ESR was elevated...so we started TB therapy and he looked great today. I'm proud to say, he is almost EAGER to give me high fives now (used to refuse to even look at me).


Yesterday I spent the day getting to know the palliative care team, whose office is conveniently located just up the street. They have an impressive setup here - a group of nurses and clinical officers who travel to the homes of the sick and dying and provide support: morphine for pain, daycare for the sick to give the families a reprieve, spiritual services, etc. It sounds like many of the patients that they see have HIV, TB and/or cancer. My interest in palliative medicine has grown a lot in the past year - and there is a huge need for this service in a country with such limited access to medical care and transportation - so i'm happy to learn from them while I'm here.


Clinic tonight went late, so dinner consisted of my favorites from home: english muffin with PB, a bowl of cereal (the last the of the "Maximize" breakfast cereal purchased by li'l bro earlier this month), and ice cream. Tomorrow we'll get fresh vegetables, disinfect them, and make a real meal. Although, truth be told, I am just as happy with PB & J as i am with beef stroganoff.


And now, a few more photos, this time not medically related:

Photo with my roommates and the interns at a birthday celebration

The Cabbage Patch that I pass on the walk to/from Selian. There have been no sightings of Xavior Roberts, although i'm told he lives in Georgia.

Happy to be on Camera

Sunday night thoughts

My Home in Arusha, Tanzania

"Exempla House"

Sun-dried laundry

Tea on the front porch with my brother Brenden, who spent 2 weeks volunteering in Arusha

Dinner with my housemates Sharon (Indiana Univ MSIV), my brother Brenden, me, Jennie (OT student from Australia and Lena (Germany MSIII)

I've been in Arusha for two weeks now and am proud to have finally gotten this blog up and running. It has been a busy 2 weeks. I have been a member of the pediatrics team at Selian Lutheran Hospital in a little town called Ngaramtoni, which is sort of like a suburb of Arusha. I live in a lovely little house with 3 other international volunteers, who hail from Australia, Indiana University med school and Germany. We have a beautiful lawn and an outdoor pet tortoise, who never seems to want to chat when i see him him. To the right is a photo of my bedroom, complete with giant mosquito net. It's actually quite cozy.

The street which we live on is narrow and bumpy and absolutely filled with people walking up and down it all day and much of the night. There are no sidewalks, so you walk along the street. It only takes one or two brushes with a speeding taxi to learn how to stay "safe" on the Tanzanian streets. As our tourguide Frank would say, "it's all part of the adventure."

This is not a picture of my street, but of the road that we take when we walk to Selian, which is about a 4 1/2 mile walk. Mount Meru can be seen in the background most of the way.

These are pictures of two of the most memorable patients that I've seen so far. The little boy on the left with the sly smile is a Maasai boy with hepatomegaly of unknown etiology. We have limited resources to evaluate for liver and heart problems and no Mantoux testing available. We are currently treating him for extra-pulmonary tuberculosis and so far he's doing well. The boy on the right came to us terribly edematous, as you see here. He had nephrotic syndrome. Tragically, he did not survive.

Both boys come from backgrounds completely different from my own and due to the language barrier, I cannot communicate with either of them directly. But one thing is consistent with kids all over the world: they love toys and they love attention, 2 things that go a long way here.

This is another patient and his mom just before discharge. He was treated for malaria.

At night we drink tea (chai is very popular here, which took a little getting used to as a dedicated coffee-lover) and share our thoughts about what happened during the day...sounds quaint, right? It is, in some ways. It's very easy to live here - life is much slower and simpler than it is in the states. It has to be, when you may or may not have simple luxuries like running water and electricity at any given time. (95% of the time we have both - but i will say that today i chose to swim in a nearby hotel pool because my last shower was 3 days ago and since we haven't had running water all weekend, chlorinated pool water was just the solution to my bathing woes...) But life here is also challenging - especially the work part. We have very few options for lab tests, and even those that we do get are sometimes questionable. Kids are very sick, often with malaria, pneumonia, HIV or a combination of all of them. I'm learning to expect to have less diagnoses handed to me on paper and try harder to make do with physical exams and local epidemiology. I teach the interns and the interns and patients teach me. It is together the most rewarding, interesting and frustrating experience of my career as a medical trainee.

This little girl had severe pneumonia and did very well with just IV antibiotics. I gave her a sticker on this particular day and she immediately stuck it to her forehead.

The boy below was also very sweet. He had malaria and did well. His mom was exceptionally appreciative and showed it with lots of smiles.

Being here - being part of healthcare team - is an unbelievable privilege. There is an intense need for health care delivery and a tragic lack of access. The economic problems of the world are reflected here now - there are fewer tourists than usual, which negatively impacts the tourism industry, and the drought is causing an even bigger problem with agriculture - the other major money maker for the area. And on top of that, there are people who need help but simply live too remotely to receive it. Several outreach organizations fly or drive out to help them when they can, but there is just so much to do...
It is not uncommon for me to be walking down the street at any given time of day and turn around to see several kids trailing behind me. They like to ask me, in English, how I am and LOVE to have their pictures taken. This photo was taken on the walk home from Selian.

I am extremely grateful to have the opportunity to learn and practice medicine in Tanzania. The people that make up the missionary community of Arusha - volunteers and missionaries from all over the world, every denomination and multiple disciplines - are some of the most inspiring and optimistic people that I have ever met. I hope to introduce you to many of them via this blog throughout the rest of my stay. It is clearer to me now than ever before that what brings us happiness in life has very little to do with money.

Photo of new friend Jennie, Cecily (you know her!) and I at a wedding in Arusha