Minnesota-Ilula Medical conference 1/11-1/12

The group i came to Tanzania with sponsors a medical conference for regional healthcare workers. Our MN team along with .ocal doctors & nurses present on topics requested by attendees the previous year. 

Each hospital that sends a delegation then chooses a quality improvement measure to focus on and begins developing a project for their site before they leave the conference. The meeting is a great way for attendees to gain new knowledge & skills and network with other providers in the area. 

In researching my presentations, I learned  that the maternal mortality ratio (maternal deaths per 100,000 live births) has decreased from 760  in 2000 to 238 in 2020. From one of the other speakers I learned it further decreased in 2022 to 104! The global goal is to be < 70 by 2030. Medical care in TZ remains very resource limited, but just by this one number (MMR) you can see they have made HUGE progress.  This progress comes from their own initiative & investments but also from groups like Shoulder to Shoulder who support education & development of the healthcare system. 

After the  conference, the Ilula & MN team went to dinner at a swank pizza place called Mama Iringa's. Great food & great conversation filled the evening. 

Same & Different - *karibu

 Post for Wed 1/10 (no internet last night so I'm a day behind)

After chapel & morning report, we rounded with the OB medical officers (MDs). This was a fun day for me because I felt like I was in my element. I could really follow what was happening and the doctors did a great job of including us in the patient discussion. They often asked how our US healthcare system compares to what they do in Tanzania. 

The most surprising thing about today was noticing how many things are the same. Many times we use the same (or very similar) medications for the same conditions. Some meds we (US) use more broadly - for example, vitamin K is given to all babies in the US, but in TZ they only administer vitamin K to small or preterm infants. In other situations, TZ uses meds more liberally such as continuing antibiotics after all c/sections - even if there was no sign of infection. Postpartum length of stay is the same, but antenatally most women come to the hospital 2-4 weeks before their delivery just to wait. They may be having contractions or need monitoring for another reason, but most often it's because they are from a remote village and they want to be at the hospital before labor starts.

Towards the end of the morning, we saw a new patient with pre-eclampsia with severe features. Just like at home, this patient was started on magnesium sulfate. But after the bolus, instead of a continuous infusion, she was getting 10g as an IM injection (5g/10 mL in each buttock). I have never seen such large IM injection doses in the US - for magnesium or any drug. Jaci and I stopped by later in the day to see how the patient was doing. Her BP was down from 163/120 to 118/80 - much improved! While I have known for some time that you can give Mg IM, now I have seen that it actually works.

Today was also filled with non-medical tasks. Jaci and I took morning & afternoon walks into Ilula. We saw many tuk-tuks - 3 wheeled scooters with enclosed cab used as taxis. The people were also super friendly- especially the children.

It was also laundry day for me. I was able to get about half of my clothes off the line before it rained this evening. The rest just gets an extra 'rinse cycle' I guess.

The highlight of the afternoon was our Swahili lesson from Joyce. She was a great teacher and really pushed us to create sentences that we can use. I already found myself recognizing more words during our afternoon walk. 

Thursday & Friday will be busy & long at the medical conference in Iringa. Then we head to safari camp for the weekend.  Asante** for reading along with my journey! 

*Karibu - you are welcome

**Asante - thank you

Tuk-tuks 

Learning the system - Day 2

 

We kicked off today with morning report. Two C.O.s presented patients who were admitted overnight. The head nurse, Rita, was not impressed with their presentations and made sure they knew what to improve for next time.

Next we rounded with Gloria, one of the physicians, on the inpatient wards. The women's ward was full of patients, one of whom had come in with a hemoglobin of 3 mg/dL - yes I said 3! She received 2 units of whole blood and was being referred to a bigger hospital in Iringa due to the limited ability for further work-up of her anemia in Ilula. Another woman came in for headache and epigastric pain, but was incidentally discovered to have high blood pressure.  She was started on treatment overnight but still had elevated BPs (174/107) so additional medications were being added.

I got a kick out of the paper charts used on inpatient wards, including the vital signs 'flowsheet' - the back page of the paper booklet with hand drawn lines to create columns. I also learned that patients take the booklet with them when they discharge, so if they seek additional care - they have their records.

After lunch, we got a tour of the lab from Emmanuel. Considering their overall resource level, Ilula has a fairly advanced laboratory. They have a machine to run 'whole blood picture' (aka CBC) and another that can do many chemistry levels along with various enzymes & hormones. They also have GeneXpert, which is a machine that does PCR testing for several types of infections such as Tb and HIV. The government sponsors this equipment and testing costs (so patients don't have to pay) due to the benefit to public health.

We also got to see the blood bank (pictured right) where the 2 units of blood had come from for the patient we saw this morning. The bag you see on the top shelf is the only remaining unit Ilula has ready for transfusion. 

BUT when a patient needs blood, family members are asked to donate 'replacement supply'. And yesterday they got 6 units donated (bags you see on the bottom shelf). Those units have to have testing for infections sent out to another facility before they can be used. They are sequestered until test results are known. If any units are positive for infections, they are destroyed. Regional hospitals also share their limited blood supply with each other. Recently, Ilula requested & received more blood from Iringa. And Ilula will reciprocate when able. If a unit is close to its expiration, the hospital will find another facility nearby that can use it. It is great to see how they work together to share & make sure none of this precious resource gets wasted.

So far I am fascinated by everything. I can't wait to see what tomorrow brings!

Day 1 Brain Dump!

Takeaways from today, our first full day in Ilula and first day at the hospital.

1. the house we're staying in feels homey like in a lake cabin or church camp way. 

2. It's pretty clear we are travelers here and stand out from the crowd but everyone is so welcoming and just as excited to meet us as we are to meet them. Someone says karibu and smiles every time we walk into a room or new space. They're patient with the language barrier and keep teaching us Swahili and HeHe. 

3. Two memorable patients we saw on rounds in the general ward with Dr. Gloria were: 

•  a 60-yr-old male with recent convulsions currently comatose. They diagnosed neurosyphilis and neurocysticercosis at a regional hospital. Also likely had a DVT in left leg due to unilateral swelling and several weeks of immobility. Unfortunately, don't have diagnostic tools or heparin or other anti-thrombolytics available to treat it. 
• a 33 yr-old male w/ hx of Hep B on Truvada had cirrhosis, ascites, and portal vein HTN. Paracentesis was done and started on furosemide and spironolactone. Direutics were increased today but financial issues are a big concern so further management steps are questionable.

4. After rounds and lunch John, Solveig, and I ended up talking about the ethics of our trip and the good & bad impacts of global medical care - so much a little topic clearly. I had thought about this a fair bit in prep for the trip. Is this a self-serving trip? Are we doing harm by visiting for a few weeks then leaving for the year? How can we be culturally appropriate and conscious while here? What is charity vs justice? empathy vs pity? guilt vs beneficence? 

We didn't exactly land on a solid conclusion and solve all the world's problems (yet) but the rationalization I've come to so far is:

• This group/trip is here very graciously and to learn from the Tanzanians. Not just medicine but all aspects of life. Despite some of the very stressful and difficult situations they are facing, everyone here seems happy. They have their friends and family, they laugh and smile a lot, praise God and sign hymns with their whole hearts, and they are kind. It's so easy to think "these poor African people" and while they have major  systemic public health needs, they're rich in many ways too. And I'm sure many people look at the USA and think "those poor Americans" too. 
• Historically, they don't come here and say "here this is for you" instead they ask "what can we do for you? How can we help?". The help offered is intentional and thoughtful. 
• The heart of the trip is to build and maintain relationships with the staff in Ilula. I don't think that's ever the wrong place to start.
• Most of the patients we will never see again. We won't remember their names and they don't know us. But they are going through sickness and we get to bear witness to that. We get to hear their stories, see them, and know them. No one here takes that lightly and I hope they feel seen and less alone even if it was briefly. 

At the end of this long post, I still really don't know! But I'm jet-lagged, sleep deprived, and so green to the US medical field and being a provider let alone Tanzanian medicine so maybe it's not supposed to make sense right now. Fortunately, I have 3 more weeks here and decades as a PA to keep learning and figuring it out! :) 

Jaci 

Persistance pays off

 A lovely morning (1/7) at Schiphol airport gave way to a long day (> 24 hours) of travel for me. Persistence and grit won, and I finally made it to Ilula Lutheran Hospital around 10am Monday 1/8.

After a short nap, I got a tour of the hospital complex

from John & Solveig. We met Rachel, the current head

Pharmacist, who I will spend some time shadowing 

while I'm here. 

My favorite quirk so far . . . the operating room is called

the Theatre and the procedure room is the 'minor

theater'. We spent time in the outpatient department (OPD) with C.O. Imelda completing follow-up sessions with patients who had labs done or needed medicines.

We then took a short walk to the Stationary store for more conference supplies. On the way back, we stopped at Dr. Saga's pharmacy to check it out.

Phew - dinner is ready, I'm famished & fading fast.

Blessing backfired

It's been an exciting day and a half. 30 minutes before leaving for the airport, our group of 4 travelers finds out our flight from Amsterdam to Dar es Salaam was canceled.  John scrambled to get us rebooked, but we had to split up. John & Solveig together and Jaci & I together. It's OK (we thought) we can do this.

Once Jaci & I arrive in London, we have to figure out Heathrow airport. I'm sure it's fine if you land & stay in London, but if you have a connection to another terminal - ugh! The bus system takes you to a central drop-off point where you take a 2nd bus to get to your terminal. Each trip takes at least 15 minutes plus the wait time for each bus. No worries - we got this. Jaci & I get to T4 where we have to go through security. Why? You may ask - I don't know. We have not even passed a shop of any kind since leaving T3. It was hallways, escalators, and busses- that's  it. But maybe we picked up some contraband - who knows?

We get through security, make 2 quick stops for the 'loo' and coffee and head to our gate. As we try to check-in for our boarding passes something is wrong ... but the gate agents don't say what. All we get is 'I have to check with my supervisor' and 'please wait'. Less than 30 minutes before take-off, we find out Jaci is good to go; but my reservation and ticket number are 'not properly linked' [please read that in your best British accent for full effect]. I am instantly contacting Delta via phone & text. The text agent says everything looks good on their end, but the gate agent still won't give me a boarding pass & directs me back to T3. Meanwhile, I send Jaci on alone while I continue trying to call Delta.

I start making my way back to T3, and after 30 minutes I get an agent on the phone. She agrees with the text agent - my ticket was fine, but that plane has left so we proceed with finding me another way to Dar. I get back to the transfer bus stop but decide to wait there because it seems like I may still get a flight out of T4. On instinct, I head back to T4 but I wait until I'm sure I have a ticket before getting in the security line. Within 15 minutes of getting back to T4, the agent has found me a path: Heathrow 》Amsterdam 》Nairobi 》Dar es Salaam. There is only 1 problem- the flight to Amsterdam leaves in 30 minutes and I have to get through security with no boarding pass. The Delta ticket agent was a saint for staying on the line with me while I go through T4 security (for the 2nd time in less than 3 hours). While going through, the AMS flight gets delayed by 15 min - hallelujah for small miracles! I get to the gate, check in, and voila! I have a boarding pass (with seat assignments) for my next 3 flights.

After arriving in Amsterdam, I prioritize my next tasks: change flight from Dar to Iringa to 1/8, find a hotel room, update the travel group & my family on my status. On my way to the hotel shuttle, I stop to buy a warm hat because I do not have Amsterdam weather clothing in my carry-on luggage. 

The shuttle wait was long & cold, but I warm up with complimentary tea as soon as I get to the hotel. I have a very American dinner of burgers & fries, then relax in the hotel bar with some wine.

Now it's time for bed so I can get back to the airport by 8am.

Let's hope the next leg of the trip goes better than the first.

See you all in Ilula on Monday! janet

A blessing for our travels

 Good morning! 

I am so excited to be a part of the Ilula trip this year. I have been looking forward to this since last year when 'life' interrupted my plans. In my reflections this morning, a blessing for our trip was forming:

Ilula Friends 2024

May our travels to Ilula be smooth and comfortable 

May the disorientation of a wildly new culture quickly give way to wonder and excitement 

May our group grow in relationship with each other and our hosts

May we learn as much as we teach in collaboration with Ilula Lutheran Hospital staff

May our travelers stay safe and healthy for the duration of this adventure 

May we return empowered by this experience to advocate for improvements in health-care at home and around the world

Let the adventure begin! janet