Home sweet home :)

Sorry for the late post, but we made it home safely last week in one piece. =) It has been great to be home and see friends and family, but it's definitely going to take awhile to decompress and put some final thoughts together about our experience.

In the meantime though, we had a great time on safari and were really blessed to have such an amazing experience. We saw pretty much everything except a rhino and had some fun encounters at one of our campsites with zebras, an elephant and a bushpig. All in good fun though! Nothing dangerous. We also got to see 4 lions stalk and kill a gazelle which is apparently a pretty rare occurrence so that was pretty neat! Our guide and cook were amazing and really made our safari fantastic.

I hope that everyone is doing well and enjoy the pictures!!

Lions, Cheetahs and Leopards... OH MY!!

Well we've finished our time at the hospital and have managed to unload the 3 large suitcases full of supplies that we brought. I spent one last day in surgery yesterday and observed a successful excision of a lipoma (benign fat tumor) from a woman's clavicle and an above the knee amputation turned hip disarticulation. The lipoma excision was the first time I actually saw them use a general anesthetic for a surgery. Most likely because of the proximity to her head. For the most part, the surgery went quite well and the surgeon very skillfully removed the lipoma being careful of all the nerves and arteries that could have been nearby or wrapped around in the tumor. The anesthesia wasn't exactly top notch, but they do have limited supplies to work with and are also probably trying to conserve the anesthesia gas as well as not put her under too deep since they don't have the means to support her if it's too much. All in all, success.

The amputation was a long process. The elderly gentleman had been in a bike accident either this May or last, we're not exactly sure which, but regardless, his femur was not repaired at the time of the accident and he was now in very bad shape with his lower leg twisted 90 degrees inward from the break and open infected wounds. Dr Lee wanted to do a hip disarticulation from the beginning, but the anesthetist was concerned about how weak the gentleman was from low hemoglobin. They had 2 units of blood ready to transfuse as well as general fluid support. Dr Lee began with the above knee amputation, but once he started trying to clean out the necrotic tissue after removing the lower leg and broken part of the femur, he began having trouble tying off arteries and getting the bleeding under control. Mid-surgery, Dr Lee made the decision to do the hip disarticulation because he was able to tie off the main artery and control the bleeding better from there. The rest of the surgery went quite smoothly as he removed the rest of the femur and dislocated it from the hip joint. He ended up having to cut off quite a bit of skin to get the closure just right. The finished product looked much cleaner than when he came in, but I'm sure it will be an adjustment for him only having one leg. No idea how he's doing post surgery, but I'm quite confident that Dr Lee made the right decision and that he will fare better in the long run.

There is usually very little going on at the hospital on Fridays so we opted for cleaning out what was left of our supplies, donating our scrubs, stethoscopes, hand sanitizers and white coats and saying our good-byes. It has been an incredible experience that I'm sure I will think back to often throughout my training, but I am ready to come home.

We have one last adventure before heading home and that of course is our safari! We head out tomorrow morning for a 3 day safari to the Serengeti and Ngorongoro Crater with Soko Adventures. We've heard great things from people who have used them before and we are very excited. I think one of my favorite parts, besides the animals of course, will be not being stared at and called "mzungu" all the time!

Will try to post one last time before heading home on Wednesday, but no guarantees. It's actually gotten a bit cold here so it will be nice to be home in Portland's beautifully warm weather!!

Kwa heri!!

Coming down the home stretch...

Amazingly enough we have entered our last week at the hospital. I was hoping to be in surgical clinic on Monday but couldn't find dr lee, so I decided to spend a bit more time in the labor ward. It's always interesting being inthere because you're never really sure what's going on or who's closest to giving birth. Many of the women scream and moan for hours on end before they actually give birth and others wander in and give birth as they're setting up their bed without saying a word. On this morning it was fairly quiet except for one loud and exuberant youger woman and after morning rounds there were two women who started giving birth one right after the next. I was able to help get supplies ready and got to carry the baby into the newborn room where they get weighed and then just snuggle under a blanket. The first mom did quite well and was up and walking within a half hour of delivering but the second mom seemed to be suffering from post partum hemorrhage. Several of the nurses gathered around to get an IV into her and start pushing fluids. Once she had been given a full IV bottle, they started to help her up to take her in a wheelchair down to the postnatal ward. As she tried to move from the bed to the wheelchair, she collapsed on the groud at the nurse's feet completely weak from losing so much blood. They put in another IV line and drew some blood to check her hemoglobin count to see if she needed a transfusion. Once she was in the wheelchair and blood had been drawn, I got to help carry her newborn baby girl down to the postnatal ward as one of the nurses wheeled her down. After that, there seemed to be very little going on and the nurses didn't seem very happy to have me there so I headed on over to casualties (aka the ER).

Just after I walked in to the casualties area, a woman was wheeled in looking barely conscious. 4 of us medical students gathered around trying to get vitals on her. We couldn't get a blood pressure and could barely find brachial and carotid pulses. One of the British medical students wandered over to the supply cupboard to find some fluids which then drew the attention of one of the doctors. As she came over, we explained that we couldn't get an accurate blood pressure because it appeared to be so low and we could barely get pulses. She then helped Lindsay to start an IV and push fluids into her as fast as they would go. "This is a resuscitation!" in the words of Dr Janet. Then, of course, when her first course finished, we went to get more normal saline to continue to boost her blood volume, there was no more. So instead of normal saline, we used ringer's lactate, which, fortunately, is a perfectly acceptable substitute.

Tuesday is surgery day. We walked in, changed into our appropriate scrubs and rain boots and got ready to see what was on the schedule for the day. A scar repair and 2 amputations. Sweet.

As the woman came, prepped to get the scar removed from her face, one of the other surgeons came in and started discussing alternative options with Dr Lee. Why wasn't this discussed prior to her laying on the operating table you might ask? Good question. We're still wondering the same thing. She ended up walking out of the OR with the plan of simply getting a steroid injection. Of the other 2 operations that were scheduled, one refused surgery and the other was postponed until Thursday. So we spent the day watching many broken bone reductions and casting.

One of the more involved ones included an older man who has apparently been in some type of motor vehicle accident and suffered a fracture of the calcaneus which is the main weight bearing bone in the foot. The injury was such that there were two huge flaps of skin even though he was now 10 days post accident. Also, the way that the bone broke the Achilles tendon is pulling up on the bone putting it at a suboptimal angle for weight bearing and also decreasing the function of the achilles tendon. Normally, a surgeon would have put a pin through the two halves of the broken calcaneus to stabilize the fracture but alas, this is Africa and mt meru is a government run hospital that is out of supplies.

I spent today rounding with the surgical team and saw one example after the next of decries that need surgery to heal properly but they are out of rods to stabilize femur fractures. There were no less than 50 patients, all with severe breaks that will likely heal well enough but definitely not back to optimal function. One of the patients was being seen for a proximal tibial fracture and had a cast on but he had also suffered a fracture of the radius which also resulted in a dislocates elbow. The complication is that he also had a prior fracture that twisted the bone and didn't heal right. There is really nothing that they can do now as the repair would be a lenghty complicates surgery that they do not have the supplies nor the staff for. It has been A very eye opening experience to see the extent to which seemingly simple fractures can interrupt and ruin someone's life here and I hope that there are things that we'll be able to do in the future to help a bit more.

Maasai village, Zanzibar and back to Arusha...

Pole sana! So sorry for the delay!! We've been without internet for about 2 weeks and there is much to catch up on!! The Maasai village was quite the experience. We were greeted and welcomed like royalty and fed like kings and queens the entire time we were there. It was crazy. Tons of really really good food though. The first night we spent some time talking with some of the village leaders via a translator, mostly Dr Lace talking, but it was very interesting hearing about some of their concerns and also seeing how much they love Dr Lace.

We spent the next day at the clinic and basically saw a lot of malnutrition, pneumonia, eye and ear infections, ringworm and intestinal worms. Almost all of the kids complained of eye pain and difficulty breathing and when we got a chance to go visit one of the huts, we found out why. They live in huts filled with smoke 24/7. We were only in there for 5 minutes and our eyes were burning and we felt like we were suffocating. No wonder they complain of eye pain and difficulty breathing!

Friday morning we woke up to find out that someone had died in the night. Dr Lace and Kurt had gone to attempt milking a cow only to find the women in hysterics and the men talking trying to figure out what to do. They saw the body and the most likely cause of death was that he had had a seizure during the night and fallen off his bed since he was a known epileptic. Dr Lace left clinic early that day and went to help clean up the body and prepare it for the funeral. After lunch we got to witness a Maasai funeral and we were the first outsiders to ever attend a funeral in their village. It was pretty crazy. We also found out that what they usually do is take the body outside the village and wait 3 days, then go back to see whether or not the animals ate it. If they did, it means that the deceased was a good person. In the last year or so, many of the villagers have become Christians and they've started having burials, so this was probably only the 11th burial in the village. Pretty crazy.

Afterwards, everyone gathered to eat together. The men ate separately from the women and children and likely got most of the meat. Thankfully though, we finally got an opportunity to serve them. Lindsay and T went around and washed hands of the women and children and I helped hand out the food. When it came to our turn, we were absolutely stuffed and begged our host, Gladness, to let us feed the kids. Of course she obliged and the children were thrilled to be served by wazungu, white people.

We got a couple chances to walk around the village and just observe and meet people, mostly on Saturday morning when we went and handed out candy and coloring book pages to the kids. It was mass chaos. They absolutely loved us and followed us around in herds begging for more candy. We tried to distribute it as best we could, but it gets difficult to tell who's already had a couple helpings and who's new. We also found out that they think cameras are hilarious and love to see their pictures and we enjoyed toying with them a bit and singing funny songs to them like "In the jungle..." and maybe some Backstreet Boys songs thrown in just for good measure.

All in all, we had a blast and learned a lot. Gladness is doing some amazing things and trying to help the women gain more rights and independence. Our first night there when we were served dinner, the women actually got to eat before the men and then the men had to serve themselves!! Apparently that was a really huge deal and had never actually happened before. Usually women are served after the men and before the children and get whatever's left of the meat which is usually very little. Hence malnutrition being a huge problem. The men also typically have many wives and force themselves upon the women who have no choice as to whether or not they want to participate. They really have no say as to who or when they have sex and whether or not they get pregnant. HIV and STDs are a really big problem and it's difficult to talk about because there's such a stigma attached with it that no one wants to seek help or admit any problems. Female circumcision is also still a huge problem in the village. According to Gladness it's practiced to keep the females from enjoying sex so they don't cheat on their husbands. It's a barbaric method of control and enslavement. However, methods of circumcision have at least improved in that they are starting to use a new clean knife instead of the same one to circumcize multiple children at the same time. It typically takes place for girls between 11 and 13 years of age and for boys between ages 14 and 17.

Zanzibar was a fantastic break and a chance to relax and soak in some sun and delicious seafood. We spent most of our time in the north part of the island where we found a cozy little hostel where we all shared one big bed and took cold showers every day. Not really a problem since it was constantly so hot and humid. Our "innkeeper" really enjoyed having us there and was always joking with us and very nice. He would also climb up a coconut tree near us, knock down a bunch of coconuts, cut them open with a machete and then give them to us to drink the fresh coconut milk and then he'd open them for us to eat the coconut meat inside. It was a delicious treat that I think we're all going to miss a lot!

While we were there we also got to go snorkeling and saw some amazing fish that were almost too close for comfort. We were also served a yummy spicy octopus lunch with rice, a salad and fresh fruit. We also went on a spice tour and got to learn all about the local spices, what they're used for, how they grow and how they process them to be used. It was really interesting and then we were again fed a delicious lunch along with some fruit sampling including some delicious custard apple type thing that I don't even know how to describe.

Stonetown was also pretty amazing and we got to take in most of the sights in one day. We got to see the spice market, fish market, meat and chicken markets and then we went to the Anglican Church which is the sight of the former slave trade. It was pretty eerie walking around a place where so much violence has occurred. I took quite a few pictures, but it's really nothing compared to seeing the shackles and holding chambers for yourself. We also went to the night seafood market and got to try some really delicious shark, baracuda, lobster masala and the ever so fantastically amazing zanzibar pizza with nutella and bananas!

We got back to Arusha on Wednesday night and went back into the hospital for Thursday and Friday. Since we hadn't been into the casualties (ER) area yet, we decided to check it out. Not a whole lot going on, but it was a pretty big wake up call seeing them remove stitches on wounds that still were not fully healed, brutally shove a girl around who had just been unconscious and leave a guy laying on a bed for 20 minutes who had been brought in on a stretcher and didn't seem to be conscious. We later found out that he had fallen down a well, but we didn't get much more of the story or the extent of his injuries than that. Mostly seeing how they treat patients here makes me so thankful for the care and compassion that we have in the states. We went to a talk hosted by Dr Lee on Thursday and they even mentioned during the talk that one of the huge obstacles to care here in Tanzania is the attitudes of the staff and the lack of supplies. I think that's been the most frustrating thing about being here, there is a HUGE lack of care and concern for patients as human beings. It's hard to know how to help change that attitude.

A great example of their lack of supplies is that apparently a man had come in just after we left from an accident with a bus and he had 2 transverse fractures of the femur, one proximal and one distal, both completely displaced, transverse fractures of the tibia and fibula on the same leg as the femur fractures and a fracture of the tibia on the other leg. Obviously this guy needed surgery immediately to stabilize the femur. However, doctors and hospital staff had already left for the day AND, they didn't have rods, nails or screws to do either internal or external fixation. What I gathered from the conversation was that he had to be transferred to a private hospital where he is likely going to be unable to afford the care that he needs. It was a very sad story to hear, but just goes to show how important it is to have supplies and staff that are available.

I think that's all for now, but hopefully that gives you a pretty good idea of what we've been up to for the last couple weeks!! We have one more week at the hospital before we go on safari for 3 days and then a couple days in Arusha to do our last shopping for souvenirs and then it's time to head home. Crazy to think that we'll be back enjoying the comforts of home in less than 2 weeks!! We are definitely enjoying our time here but are getting excited to be back home.

Hope everyone is enjoying their summer back home!!

Time for a mid-trip break

Hey friends,

It's been a short week in peds but a couple of highlights include that we were able to diagnose our kid with fevers for 3 months with TB using a PPD skin test. The TB coordinator didn't exactly agree but after Dr Lace talked with the chief medical officer, I think we made our case and the child will be able to get treatment and go home as she is not all that ill with the exception of the fevers. Another interesting case that came in yesterday was a young boy with some sort of movement disorder. We're still not entirely sure what is going on but it is mostly likely a case of rheumatic fever. Maybe we'll have some
answers when we get back and see how he is progressing. Then this morning we saw a rare occurrence: a child with chicken pox. For whatever reason, chicken pox is actually very rare here and the doctors actually weren't quite sure what to do with him!!

We also saw our first case of pediatric HIV. Very sad. He's very ill and has likely progressed to AIDS but we're going to do all we can to get him healthy: anti-retro virals, antifungals, antibiotics and hope that we're able to give him enough of a fighting chance to recover. We still haven't had a chance to visit any of the HIV clinics here but that is definitely on the list before we leave.

As for our mid-trip break, we'll be heading to a Maasai village with Dr Lace tomorrow for a few days to put on a clinic. We get back Saturday afternoon and them we'll leave on Sunday morning to meet our new friends in Zanzibar. We're not entirely sure how long we'll be staying but likely for about 4 or 5 days.

Since we'll be out and about, no guarantees of when I'll be able to post another blog so hang in there and I'll update when I can!!!

An adventure to Arusha National Park

Today was time for another adventure. We got up, ate breakfast, got dressed and packed our things for the day, each of us equipped with our cameras. It was time to try our luck with Arusha National Park.

We loaded onto a dala dala, the local "bus system" here and rode for awhile before paying our fee of 500 Tsh. The driver had us get off at what we thought was our stop but then motioned us to the next dala dala that would take us the rest of the way. Classic. This is usually how our adventures begin. Being shuffled around from one place to the next, not exactly knowing what's going on but we seem to be heading in the right direction and have managed to land on our feet each time.

This time was no different. We got off at our stop and then starte walking but realized after a short ways that we had no idea where we were going. Fortunately a taxi driver caught up to us that spoke English pretty well and helped us find a dala dala to Ngongongare Gate, one of the main entrances to the park. Again, we were hesitant but thankful for the direction.

It took awhile for us to get going as they typically wait to pack the dala dala as full as possible and then we were off. We made a couple stops and then POP!! We're not exactly sure what happened but we think a tire popped. The money collector and the driver got out and started jacking up the car to put on what we assume was a spare tire. We knew it was only a matter of time before we managed to hope on a dala dala before it broke down. No big deal though, we were back on the road heading towards our destination.

On our way to the gate a monkey/baboon ran right in front of our dala dala!! So cool!! Then as we pulled in and paid our fare, there were giraffes right there at the gate!! It was amazing! We were within feet of these huge animals!

We wandered around looking at the giraffes for a little bit, talked to a few people to see if there was space for us to bum a ride with anyone and finally decided to just go in and pay the entrance fee and hopefully be able to hire a guide for a walking safari. When we mentioned that this was what we wanted to do, the guy looked at us like we were insane. He couldn't figure out how we had gotten there or how we expected to take a walking safari from that gate. Apparently we needed to go to the Momella Gate. Would have been nice to know but oh well. We walked out and tried to figure out how we were going to get there and just as we were about to start our way back to Usa River where we could catch a taxi to the right gate, a guy came up and explained that he had overheard that we needed transportation and he happened to have 3 extra seats to go through the park with him and his mom. What?! I'm sorry but there's gotta be a catch...

We proceeded to go through the park and ended up being their photographers since their camera battery had died. We got to see giraffes, warthogs, buffalo, gazelles, more monkeys/baboons and tons and tons of flamingoes. The flamingoes smell really bad by the way.

We went through the park and had a great time. Earlier when we had been trying to figure out what we were doing, our new friends mentioned that they were going to the snake park in Arusha. Since they were headed back our direction anyways, they insisted on taking us back and dropped us off at the same dala dala stop we had left that morning. We offered to at least be able to pay them for gas but they simply refused and insisted that we come to Moshi sometime and they would show us around.

I'm pretty sure we could not have planned this day if we tried.

A week in pediatrics...

My apologies that I haven't been able to update my blog as much. We're down to one laptop and an iPhone making it a bit more difficult for all of us to keep everyone up to date. I spent most of this week in peds with Dr Lace. It has been great to have an American doctor here who actually wants to teach.

I won't go over every detail but here are some thoughts and highlights from the week. On our typical day we start rounds in the pediatric ICU and then move through the rest of the ward. Some days it's quiet and other days there are 2 or 3 moms with kids to a bed.

I've gotten to know the patiets in the ICU pretty well cuz it's mostly the same ones every day. This week we got to send one patient home who's mom was a doctor so we were able to communicate with her. Her little girl had a presumed UTI and we had her on ampicillin and gentamicin and it seemed to do the trick. It's always a good day when we get to send someone home. Our next patient has been at mt meru for a very long time. He has cerebral palsy and is unable to walk, talk, or feed himself. He is being treated for pneumonia and has many bed sores that get washed and dressings changed periodically. Our big achievement this week was that we finally started him on a regular disingenuous schedule of pethidine (opiate not quite as strong as morphine) which has seemed to help him relax and keep him from crying all the time. His prognosis is not good and the basic idea is to make him as comfortable as possible until he passes on.

Our next patient has been in the ICU for probably about 3 weeks and was being treated for TB and wasn't getting much better until we started him on erythromycin for atypical pneumonia. Since then he has improved a ton and is doing much better.

The next is a baby who came in with bacterial meningitis and we were able to do a spinal tap and get some cultures which confirmed the diagnosis. She was started on ceftriaxone and has been steadily getting better.

Our last constant innthe ICU is a Maasai baby who came in with a very distended abdomen and was not doing well. We haven't exactly been able to figure out what's going on with him but we do know that the abdomen became distended after he was given a local herb named Lamande for diarrhea. He has been up and down but basically we've just been treating with antibiotics for presumed peritonitis and using a nasogastric tube to help relieve some of the pressure. He's also on oxygen. He's been draining bile from the NG tube but we're still not sure what to do with him except treat supportively and hope that his body is able to clear the toxin.

Our very interesting case on the other side was a little Maasai boy who was 2 years old and only weighed 9 kgs. He had been having trouble urinating since birth and his mother noticed some masses in his abdomen. We sent him for ultrasound and xray to find out what was going on. His ultrasound showed severly backed up kidneys (hydronephrosis) all the way down the urinary system to a very enlarged, thick walled bladder. His creatinine was also extremely high. The diagnosis was an obstruction in the proximal urethra which needed to be surgically repaired. So he was referred to another hospital.

We have another child who is 7 months old and has ha fevers for 3 months. No other symptoms and no idea what's wrong with her. We gave her a TB test Friday so we'll see what shows up on Monday.

Other than lots of malaria, diarrhea, pneumonia and malnutrition, we've been surprised to learn that there are no less than 4 kids with heart murmurs that we've seen in one week. I don't know what the statistics are in the US but my guess is that it's higher here and might pose an interesting research project for someone in the future. Another interesting topic could be the prevalence of cardiomegaly among children with malnutrition. We've seen at least one chest xray of a child with severe malnutrition and her heart was HUGE!! She probably has had so few nutrients that her heart has been working mega overtime to get nutrients to all her tissues.

We also had a boy with a very large abscess under his chin which Dr Lace opened up and drained and then we had to come back every day for the next 3 and drain more. The poor kid would start crying every time he saw us! Finally on Thursday, when we went to check on him there was nothing more to drain! We had also brought him some peanut M&M's which he was a little unsure about coming from a white coat but hopefully he enjoyed them.

All in all, it's been very interesting being on the peds ward. There are so many needs, it's hard to know here to start. It's hard to know whether to start with education, remodeling, donating supplies, or new equipment. At times I just feel overwhelmed not knowing what to do for many of these kids but also not having the proper diagnostic tools. So many of the Maasai kids come in severely underweight for their age and often because they have to travel so far to come to the hospital, they're in really bad shape by the time they get to us. How can you change cultural traditions, such as the toxic herbs, when they've been in place for hundreds if not thousands of years? One encouraging thing is that genital mutilation, also practised by many Maasai tribes, has become a severe crime and is becoming much less common. It's a totally different world over here and it's hard to know what would help and what would make things worse? What is sustainable and what would crumble as soon as we leave? Is there anythig that we can do for research that would actually benefit these people? Or is it simply the presence of people that are willing to step into the trenches with them and just be there?

I really don't have answers for a lot of the questions that plague me but I do know that like Dr Lace, I want to keep coming back and do whatever I can to help, both here and other countries like Tanzania.