The road less traveled

 Karibu! 

Being back at the hospital has been so fun! Yesterday, Cole and I got to spend time with Joshua in OPD and see how even the most general of chief complaints (cough, fever, nausea/vomiting) produces a vastly different list of ddx in Tanzania then in the US. We chatted a lot about the two different healthcare systems, what common diseases/cases we see, hobbies, traveling, etc. Questions like: How do you treat parasites? How you do treat psychosis? Emphasized the difference in our countries and available resources. We don't see parasites very often and if we do it's likely from travelers. I think we saw 3 patients yesterday that had hook worm and entamoeba. They diagnosed a 65 yr old female with depression and were unable to offer an SSRI or SSNRI or any type of therapy. However, we also discussed Jason Mamoa (who my mom loves), Kevin Hart, the Marvel super hero films and the tv show The Good Doctor - he loves American tv and movies. He also said if could travel anyway in the world he'd go to Canada. While in college in Duluth, me and my friends have joked many times about just trying to Canada for fun on a weekend. We're 8,000 miles away from home, everything seems so different but maybe it's a smaller world than we think? Maybe people, regardless of what country they live in, are more alike than we think? 

Another familiarity for me here has been the agriculture. Growing up in a rural farming community I'm very accustomed to seeing acres of corn and soybeans along the roads. It's been comforting to see so many in/around Ilula and southern Tanzania. This afternoon Cole, Janet, and I decided to go on a walk around town. We've gone several times while here so Cole offered to take us down some trails and more rural roads behind the hospital. So, we followed and first found an...interesting (I saw gross, they say awesome) creature on the fence. We tried to make a big loop around to the hospital instead of an out and back hike. So, we took a left then continued on a path that got progressively narrower and narrower then all of sudden we were in a corn field. There was in fact not a road going the direction we thought there *should* be so naturally we continued trespassing through several other corn fields in hopes of finding this would be logical place for a road. All in all we laughed and embraced the road less traveled. Crops looked pretty good, rains been plentiful here. I supposed they can't really say "knee high by the fourth of July" since that's their dry season...nor would America's independence day be relevant for them...but that's what I kept thinking of when we walked through the knee high corn anyways I digress.,,ugali for everyone soon I'm sure! 

We ended up walking an easy 6K or so in total and made it back safely to the hospital. Luckily, we made it back well before the intense rain & lightning too! 

Of course no "opportunity to practice being flexible on this trip" could pass without a photo op. 

Also, here are the interesting pictures Janet sent to me to be shared on the blog. Cole and Janet thoroughly enjoyed this moment. I very happily declined a photo or any physical contact with the chameleon. 

Asante Sana for reading! Lala salama from all of us in Tanzania.

Pharmacy Day!

 Tuesday, I worked with Rachel in the pharmacy- Finally! 

We filled the order for the Pharmacy Store which functions as both the inpatient & retail pharmacy for Ilula Hospital.  The pharmacy store sent us an electronic request for meds. We printed the list and then went to the storeroom to fill it. Each med we filled was recorded on the paper inventory document for that medication. It didn't take much to deliver the meds since the pharmacy store is just across the hall from the store room.

For hospital patients, a relative takes the doctor's prescription to the pharmacy store and buys the medication, then takes it back to the patient ward for the nurse to administer. If there is no relative, then the nurse will come to the pharmacy-  but this is rare. 

Next we were visited by a pair of pharmaceutical representatives. They were peddling many products and promised a 'cheaper price' even though they did not know how much Ilula pays for the same medications. After Rachel shook them off (another similarity to what we do in the US), she told me she and Frank (head pharmacist) would review the current pricing from the government supplier of meds and if these were cheaper - they would buy from these reps.

The outpatient department (OPD) came to the office with a list of requests for both supplies and meds. We filled most of their requests- but we were out of artesunate injection which is the treatment for severe malaria. So Rachel and I got a ride from the ambulance to Ilula Health Center (clinic/dispensary) about 10 minutes away to borrow the drug. This med is provided free from the government to make sure everyone can be treated for malaria. They gave us 50 vials (about half of their supply) which will hopefully last about 1 month.

Rachel and I talked about what we liked about being pharmacists and about the similarities & differences in our healthcare systems. We both agreed . . . the worst part of our jobs is running out of the medications we need. I am so grateful to Rachel for teaching me about pharmacy in TZ and letting me help her for a day!

SafarI Adventures

 

As we reached the end of the paved road on our drive to Ruaha, our driver Ole, told us to get ready for a 'natural African massage'. We spent the next 4 hours bumping & bouncing along and I have to say I think I prefer the Swedish version. 

Mwagusi camp is amazing - especially the food. 

Because monkeys are curious, we were instructed to lock up any loose articles, especially shiny things, whenever we left the room.

Anytime it was dark, we also had to have a staff escort to move around camp. They would scan the area along the path to make sure none of the native inhabitants were waiting to initiate a meeting. The final 'rule' is to never leave your banda at night. There is a whistle in your room to alert staff if you have an emergency or need help at night.

Our guide, Val, and driver, Eli, were amazing. Their ability to spot, name and teach us about the flora & fauna of Ruaha was incredible. Since our visit was about a month into the rainy season, roads through the park were getting quite soggy. Eli miraculously kept us unstuck and safe despite some very treacherous conditions. We did end up with a flat tire (during a thunderstorm) on our last game drive. Hamna shida* for our dynamic duo, though. 

*No problem

Words cannot describe the feeling of seeing this beautiful landscape filled with birds & beasts in their natural habitat. The following photos are just a fraction of the incredible sights we witnessed. 

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