Happy New Year

The interntet's been down for the past few days. When we arrived back in Ndanda, a bad storm passed. Thunder and lightning struck one of the computer lines. IT department seems to have it fixed.

Work was busy the last couple days - went to theatre for another ruptured ectopic pregnancy, and a couple of c-sections. One molar pregnancy presented and had uterus evacuated.

Tonight's agenda - Party at the abbey - told to bring instruments?? Expect to be singing (or at least listening to music).
We are planning a new years eve dinner here, everyone's pitching in to make some pasta, i'm bringing the alcohol.

The pictures from Zanzibar should be up in a few days...

Hope everyone is doing well. Happy New Year!!

All the best for 2008!

Best wishes,
Neil

Zanzibar

Zanzibar is awesome! Friday morning took an early morning ferry from Dar Es Salaam to Zanzibar. Disembarked from the boat and walked across the street to find myself surrounded by what seemed like thousands of people buying/selling items in the markets that fill the maze of narrow winding streets that make up Stone Town. After a little shopping i checked into Maruhubi hotel a short distance down the road and spent the afternoon swimming in the pool with a few of the other VSO "volunteers". More of the same on Saturday and then went for dinner at a little more upscale hotel Mtoni Marine's to celebrate on of the vol's 50th birthday. About 12 of us sat out on the beach under the stars listening to a few Tanzanian's play local music and then sung happy birthday to Corrie. The next day I took a taxi across the island due west to the town of Uroa to meet Sheena, Francijn and Diane, my next door neighbors in Ndanda who were staying at a little cheaper hotel on the east coast (Santa Maria Coral Park). This hotel is very quiet, secluded hotel with little cabanas scattered about the beach. There is a beautiful beachfront view of the Indian Ocean. We spent one afternoon snorkeling and the other days swimming in the ocean during high tide and relaxing out on the beach.

I was feeling a little ambitious with my photography and decided to take the camera out into the ocean with me to capture the amazing blue colors of ocean against the horizon. I was in the midst of telling myself to be careful not to drop my camera because there are many hidden rocks covered in sand which are not visible under the water. The next moment I tripped over the rock and found myself searching the ocean floor for the camera! Unfortunately with high tide, and sand covering the ground it was impossible to find.
There is a village on the coast and a couple of locals were out on the shore. I mentioned that I dropped my camera into the water. One man told me to wait until low tide and then look. I searched a little more without luck, and when I looked back on shore, more people in the village had come out of their homes and into the water to look for the camera. I offered 50,000 shillings to the person who could find the camera. I told the people of the village I would return just before sundown. I walked back to the hotel and saw about 50 people(men, women and children) in the water on a hunt for my camera! I returned to the village just before sundown and a little boy told me a little girl had found the camera. I walked into the village and met the girl who gave me the camera. I was surrounded by the people in the village and then I gave the girl the money. The next moment it seemed like the whole village began shouting and cheering - Of course the camera was broken but I felt that giving the money to this girl and seeing the joy on her face was worth it - I thought it would make a nice christmas present to many people. I lost a lot of pictures of the hotels and beach but I bought a new digital camera today in Stone town and have taken plenty of photos of stone town. I will download the pictures from stone town and my friends' pictures from the resort when I'm back in Ndanda. Happy Holidays!!

Post AVC

Returned from "AVC" (Annual Volunteer Conference) this afternoon, very interesting meetings... See Photo Gallery for some new pictures.
Tomorrow is a bank holiday here, most of the shops are closed. Luckily made it back in time to go to the medical supplier to buy doppler ultrasounds. Tomorrow going to buy ferry tickets for Zanzibar and then probably wander around a bit. Hope everyone's doing well.

Dar

Back in Dar Es Salaam for AVC (Annual volunteer conference), a 3 day conference for meetings and sharing placement experiences. The Beachcomber Hotel is host to this years VSO Tanzania conference, attendance of ~ 70 people. Located right on the Indian Ocean with spectacular views, nice pool and conference room. Just finished dinner buffet. Entertainment tonight - "African night" theme.....instructions are to wear traditional African attire (for me that means polo and kackis:). More meetings on the agenda for tomorrow and Wednesday. Thursday is a free day so i'm hoping to buy some doppler ultrasounds for the hospital and do a little more shopping in Dar. Leaving for Zanzibar on Friday to celebrate Sikuku (Christmas holiday). Expect to have plenty of pictures to share when I get back to Ndanda, maybe I can post while in Zanzibar, but not on this computer - connection is too slow.

Hope everyone is well back home.

Internet

This post has to be very short and to the point. Partner hospital in Ndanda provides 100MB/ month free internet. Surprise phone call from the hospital administrator informed me that I have used 750MB the first week of December (1/3 of entire hospital MB). The extra internet equals my month's salary!

Aside from internet, have been busy with work. Was on call last Thursday and had another ruptured ectopic. She came around 9pm, with classic signs - acute abdomen, CMT, and free fluid in the pelvis. Went to the OR for salpingectomy. I'm surprised how many ectopics I see here, although not quite as surprising considering prevalence of PID is high.
Today was another busy day - TAH/possible Myomectomy on the schedule. The patient was thirty four, never pregnant and desired fertility, she had symptomatic fibroids, so I told her I will try to do a myomectomy - she had a large pedunculated 18 week size uterus, and a few smaller intramural fibroids; removed large pedunculated fibroid. Hopefully she can become pregnant. I saw a couple outpatients after that then the word from maternity came that there was a c-section for obstructed labor. I was told she came in labor and made it to complete but could not push. I did the c-section, unfortunately the baby had apgars of 0,0! probably chronic hypoxemia! I have to review the chart and see what the problem was.
Heading to Dar Es Salaam on Sunday and then to Zanzibar for holiday next week. Will take lots of pictures. Hope everyone is doing well back home.

Tanzania

Karosho

Call night on Sunday was not too bad. I had one c-section for CPD. The mother was a G6P5 (5 children - all born by normal vaginal delivery). But this baby did not want to deliver - suspected asynclitism. The night was quiet after that. Only a couple of patients before. Got called around 10am to pronounce the death of a man in the male surgical ward. 63 year old s/p motorcycle accident.
Today it was not too busy, apparently December is a light month for surgeries and deliveries, I guess partly because many patients don't have the money this time of year and just don't deliver now. Almost all of the patients rely on their farming of cashew nuts (karosho) to earn a living. One of the nurses asked me to buy some, so I bought a bag for $5,000 schillings (a little less than $5). They taste pretty good, very fresh.
Yesterday, I was post call. After morning conference went to round on the patients in maternity. Then one patient sent to W8 for evaluation. First trimester pain and a little bleeding. Tried to take her by wheelchair to the theatre to do an ultrasound but en route her head fell backwards and eyes shut, so we rushed back to W8, took vitals, placed a line and did a bedside ultrasound there. Was pretty confident by the exam/ultrasound she had an ectopic pregnancy. Went to OR for laparotomy and found ruptured ectopic (two this week). Again ~ one liter of blood in the pelvis...
One of the volunteers working in Mtwara is here visiting for a few days. She is from the Phillipines and is a lab tech, actually has a masters in blood transfusion services (?). She is working in a gov't hospital in Mtwara - where staff, support, supplies are not as good as Ndanda. She is leaving to go back home early (in April). Just came to visit the lab here. We had dinner last night with her, Mr. Piet the hospital administrator and two of the volunteers here - Sheena and Diane. Gnochi, and salad, one of the first good meals I've had in a long time. I asked Sheena for the recipe, maybe I can add some variety to my meals.
Received the first package from the states the other day - what an ordeal. I went to the post office about half a dozen times because they are very specific about documentation. First the package had not arrived, and when it finally did, I needed to get a key from the hospital warehouse and an "authority card" from the hospital administrator..... The post office was reluctant to give me my package, but I insisted that I have received authority and work for the hospital and need to get back to my duties......(it took about 3 weeks to arrive - about a week to get to Tanzania and then about two weeks from Dar Es Salaam).
Hope everyone is doing well at home. Remember you can visit me in Tanzania whenever you want......except for August - Ellen is getting married! Scary to write let alone think about (Congratulations David and Ellen).
Another couple of weeks in Ndanda before my 10 day holiday in Dar and then Zanzibar - which I'm definitely looking forward to....

Out of Africa

Video Soundtrack

TGIF

Images from top down - the church, houses occupied by doctors/hospital staff, a typical mango tree. More houses.

Warning - this blog has a lot of medical jargon - sorry in advance to non-medical people, just came off of a long call night and work day today!

Hope you had a good week back home. I am definitely glad its Friday! The past 24 hours have been a blur because of a very busy call night last night, and work day today! And to top it off, my work day ended arguing over a chicken..... I admitted two patients last night s/p trauma. Having to rely on my med school trauma and ortho experiences is difficult and to make it more interesting I usually understand about every third word when I take a history in Kiswahili!

The first trauma case was s/p MVA came with a compound fracture of the humurus and femur. He was transferred from a nearby hospital......Later in the evening a 5 day old girl came with abdominal distention, constipation and nausea/vomiting, most likely an obstruction. An NGT put out 150 cc of fecal material; she received an enema this morning. The highlight of my call came around 4:15 this morning. Our teenager who induced an abortion with local herbs, and then had a D&C had been spiking fevers, without responding to antibiotics. She developed an acute abdomen and we took her to the OR at around 5 for laparotomy/lavage for peritonitis and she had a ruptured abscess with purulent fluid filling her abdomen.

There were no gyn cases on the schedule today, so I assisted on a laparotomy for a enterocutaneous-fistula repair that developed after a hysterectomy. Interesting case!

The work day was almost over until I glanced at the last patients chart. She was lying on a stretcher outside the theatre. The history said abdominal pain, and vomiting. There were no vital signs, and a one line exam, then impression - ectopic pregnancy. We took the patient for an urgent ultrasound that showed free fluid and an adnexal mass, consistent with ectopic. She was pale and tachycardic so we called for emergency laparotomy. Emergency ended up taking about one hour because soon after diagnosis, we had a downpour of rain. The nursing staff and anesthestists must have taken that as a sign for a break and did not transport the patient back from the ward. Nevertheless, about an hour later, we suctioned out about a liter of blood from her abdomen and removed the left tube and ectopic pregnancy.

Regarding the chicken - Yesterday I was walking down the street to the post office with one of the local boys who works in the kitchen and has the one and only key to the post office. Making small talk, I asked him if he knew where I could buy some chicken. He said he has some and told me to stop by the store tomorrow (today). Just before going back to the OR with the ectopic one of the nurses stopped me and told me a man was waiting to sell me his chicken. I was in the midst of trying to get the patient back to the OR and mistakenly told him to wait until after the operation. I walked out of the OR heading home when I saw the boy and an older man with a live chicken. He stopped me and insisted that I buy his chicken. I tried to explain, I did not want to buy a live chicken because I don't want to kill it, and more importantly have a live chicken running around in the house! He was very dissapointed, but I think I learned my lesson - careful what you wish for in Kiswahili. I walked back home with the tune of Curb your Enthusiasm ringing in my head.

Hospital

(From top down) 1. The procedure room in labor and delivery - where all of the D&C's take place.

2. Beds in labor and delivery - deliveries performed here.

3. More beds in L&D

4. ? A fetoscope - Nurses use this to record/monitor fetal heart tones! **

5. Ultrasound machine in labor and delivery - a newer, nicer machine is located in the theatre.

6. Main outdoor corridor through the hospital - usually filled with patients and families

7. Benches outside of the theatre. By mid afternoon filled with patients referred with surgical issues.

8. Conference room - morning conference takes place here

9. Physiotherapy department

10. Pharmacy sign

** One of the biggest "challenges"/frustrations of working in the maternity department here is this instrument. Fetal heart tones are monitored once per hour in laboring patients and once daily in antepartum patients! Standard of care in western countries is "continuous monitoring" of all laboring patients and much more frequently in antepartum patients.

I was on call Monday night. Soon after my shift started our triplets ruptured membranes. I delivered the triplets (33+ weeks) by c-section and the three babies did well. All delivered breech (2.6kg, 2.0kg, and 1.6 kg). Mother and babies doing well. I asked the mother if I could take a picture of her and the babies but she declined. Sorry no evidence!

I am looking forward to my "annual volunteer conference (AVC)" coming up next month. All of the volunteers in Tanzania (about 65) are meeting in Dar Es Salaam for meetings and to share experiences. I'll be in Dar Es Salaam from December 17-20th for the conference.

I'm spending one day in Dar to look around at medical suppliers, hoping to buy some dopplers for the maternity department!!

After AVC, I requested a little holiday because most of the volunteers have time off during christmas. So I'm going to go to Zanzibar over this holiday period. I'll be in Zanzibar December 21-26th.

Shangani Beach

This weekend I went to Mtwara, the largest city on the south-eastern coast of Tanzania. With three of the other "volunteers" we drove about two hours east to reach Mtwara. In Mtwara we stay at one of the villas owned by the Benedictine Fathers, located on Shangani Beach. The beach house has 5 bedrooms - (perfect for our group of volunteers to share) and these spectacular views of Shangani Beach and the Indian Ocean. The gate leading to the beach is about 10 yards from the back door.

The hospital administrator Mr. Piet, myself, Sheena (lab tech), Francijn (Dutch doctor) and Diane (community HIV coordinator) shared the house Friday night along with the former ambassador to China who is temporarily living in the beach house.

If you read the Bradt Guide to Tanzania, the South Coast of Tanzania is described a "fascinating, thought-provoking and often enchanting area, endlessly rewarding to those with a sense of adventure and curiosity."
This is definitely true. The highlight of the weekend was by far the snorkeling. Shangani Beach has a magnificent, beautiful coral reef that is perfect for snorkeling. During low tide you can snorkel for a couple of hours.... The reef has an amazing variety of fish, and aquatic life. I couldn't name a quarter of the fish we saw but the bright fluorescent colors are awesome. Among the fish were a lot of jellyfish! Scary at first but they are really harmless. The sea urchins are amazing with sharp shiny blacks spikes and bright orange eye. In one picture we are heading back from snorkeling (Mr. Piet, Francijn, Sheena and I).

The coast line is amazing ~ 360 miles of pure white sand along the Indian ocean - also amazing is that there are virtually no tourists! There are a few Tanzanian boys running along the beach and a few fisherman. There is a rare sailboat visible along the horizon.

After snorkeling we drove into the city of Mtwara (population ~100,000) to do some shopping. A very productive shopping spree- I bought a bike and a lot of food, pasta, cereals, noodles, tuna fish, etc, lot of canned foods, and some wine to last a while.

In the afternoon, its high tide so we went swimming - the Indian Ocean is not only amazingly blue this time of year but the water is "soupy", the warmest natural body of water I've been in, felt like a heated pool!

We ate dinner at the Southern Cross Hotel - described as the best restaurant in Mtwara - and the food was certainly good - but what is the best is ambience - we sat outside on a large outdoor patio overlooking the Indian Ocean. At night when there are no clouds the sky is filled with stars. Last night, a full "golden" moon arose from the horizon and lit up the sky. Quite amazing site. We enjoyed Indian food with a nice Chardonay overlooking the Indian Ocean.....

For after dinner entertainment we drove to one of the other volunteers' (Mikaa) home for a little party. Mikaa is another dutch doctor/HIV coordinator who has been living in Mtwara for almost two years. She had a party for one of the volunteer's birthday, so we stopped by her house to catch the end of their dinner and then we stayed to watch a movie.

Today was more R&R. Snorkeling this morning during low tide and then relaxing by the beach with a book this afternoon. We drove back to Ndanda late this afternoon. I unloaded my new bike, all the food, + wine, + liquor into the house and then went to the Abbey kitchen down the road to buy my milk, jam, and bread for breakfast tomorrow.

I'm on call tomorrow so I'm going to sleep early tonight, to be rested and prepared for the unexpected tomorrow.....
http://www.flickr.com/photos/21232655@N07/ If this link works I'll try to put up more pics!

City Slickers

Last night I was on call again, and it was almost the best call night I've ever had......until about 3am.

At 3 am labor and delivery called to say that twins were in labor. Excellent I thought! But the presenting twin was breech. When twins are in labor and the presenting twin is breech, that means one thing - warm up the OR and get ready for a c-section.

By the time all the necessary people arrived (nurses, scrub techs, anesthestist, ect) it was around 4). The c-section went well and both babies had apgars of 9 and 10. I was back home by about a quarter past 5 and then slept for another hour, with many fond memories of residency calls doing c-sections at odd hours of the night.

I was walking home from the market the other day and passed this herd of cows and goats as they were passing by my house. I happened to have my camera with me, so a good time for a photo op. The herd reminded me of one of the scenes from the movie "City Slickers".....

Well, I hope everyone is well back home. In case you don't have my new email, neil@ndanda.net or we can talk with Skype (Skype is free to download and lets you talk online anytime). Please keep me in the loop of all of the news/events/rumors/gossip that is going on!

Good news, bad news, and.....peanuts?

This is a photo of the butcher's shop. Its just down the road from my house but I've only been once because he closes at noon and I'm always working then.

I've chosen to post this picture because I simply don't have anything more exciting at the moment.

OK, So do you want the good news or bad news first? Well I'll start with the good news.....

I found out today that I will make $3,600 schillings everytime I'm on call at the hospital!!

Bad news - that equates to about $3 US dollars! Almost enough to buy a loaf of bread.

Speaking of bread, I went to the kitchen to buy some bread, eggs, milk, sausage and jam today for $7,900 Schillings. I gave the sister $8,000 and said thank you, and was about to leave but she insisted on giving me 100 Schillings - a little less than a dime! When it comes to money and budgeting I think I still haven't adjusted my thinking.

Ok here is some news that is not bad, its worse! I agreed to take call almost every third night the rest of this month! Partly because one of the AMOS (Assistant medical officers) is not going to be here for the rest of the month. I think he is spacing his calls because he is leaving.

I'm going to play it by ear and see how the calls go.....

Today's surgery schedule included a hernia repair, tibia fixation, atheroma removal, repeat c-section and total abdominal hysterectomy. I was hoping to do both the c-section and TAH. I did the repeat c-section and then I went to the other operating room and the gen. surgeon (Sr. Regina) was almost finished with the TAH.

I'm on call again tomorrow. When you take call you have to work until one pm. The call starts at 4 pm until 8 am the next morning. Then you have to work until 3 pm the next day. I'm starting to wonder if the 80 hour work week during residency was better!

Actually the call is not that bad, and my house is next to the hospital so if its quiet I can go home and try to sleep.

New to my cooking repertoire - red beans and rice! I went out on a limb and decided to try to make red beans and rice. The rice tasted like rice but the beans a little more like peanuts. Any suggestions on how to cook beans?? Your humble chef, Neil

Surgical call

Another picture of Chemchemi - I'm heading there in a little bit to go swimming - its hot today, feels like around 90 degrees. There is usually a slight breeze during the day and it cools off during the night.

Ndanda is about two hour west of the coast and at a higher altitude than Mtwara, (the larger city on the coast) - so the climate here is a little more temperate with a little less humidity.

I took Surgical call last night. I'd say it was a successful call night. For one I managed to stay out of the operating room and two I did get a little bit of sleep:)

The first patient I admitted to the male surgical ward; he fell off a motorcycle and landed on his head/back....he actually had been admitted to a close regional hospital and referred to Ndanda because his condition was "deteriorating". According to his transfer papers, he had a fractured tibia. He also had a lot of bruising around the eyes, and had old stitches. He was actually conscious and clinically stable, with normal vital signs and benign exam. I'm not sure why he was "deteriorating", but I admitted him for pain meds and to get xrays today. He will probably go to the theatre tomorrow with the orthopod.

Things had quieted down until about nine and then four patients arrived almost the same time.

Two patients were referred together from a different nearby hospital. One, an old woman who had sprained her knee and a yound girl who came with pain and swelling of the vulva. I believe she had a Bartholin gland abscess. I tried to I&D the lesion but didn't get much fluid back. Plan to do an exam under anesthesia, and either word catheter placement or marsupialization tomorrow. A couple women came in labor and delivered normal vaginal deliveries. A young girl came after she delivered a nonviable fetus at home, with the placenta in-situ. I gave oxytocin, but did not have much hope that the placenta would deliver spontaneously. So around 1am I got a call that she had started bleeding. I went back to do an evacuation - was more difficult because the placenta had to be extracted in pieces... she was feeling fine this morning and bleeding had stopped so I hope all of the membranes are gone.

My relief was supposed to come at 8 but I didn't see him, so I hung around until half past then was told he might be in church. A woman arrived with three prior c-sections, full term, rule out labor. Fortunately she was not in labor and could wait until the next shift.

About to go to the pond for a swim because its beautiful today.....I certainly can't complain about the weather!

BTW many of the volunteers here have been having visitors come, so I expect you to start getting your vaccines now and make sure your passport is current. I have a spare bedroom waiting for you. I can provide you with the food and accomodations - but not making enough money to pay for the airfare, sorry:)

Kanga

Here I am at Chemchemi (sp?) the pond where I go to swim in the afternoons. I just arrived after a 45 minute walk along a dirt road. I usually listen to my ipod along the way, sometimes to music other times to medical lectures that I have downloaded.... I have about three weeks of obgyn lectures downloaded on the ipod so the long walk is a perfect time to study :)

Its difficult to see in the picture, but the priests are swimming in the pond behind me. Its just after 4 pm and a perfect time to swim. It was a beautiful day today, probably in the low 80s, and then cooled off to maybe mid 70s by the time I walked home.

Today I started in maternity rounding on labor and delivery/antepartum/postpartum and then went to the theatre as usual. There was a vaginal hysterectomy on the surg. schedule today which I was looking forward to doing. After I finished in maternity I went to the theatre hoping to find the patient, but I saw the general surgeon already in the middle of the case, actually almost done. I was a little disappointed, because vaginal hysterectomies are not that common and I was looking forward to doing it, but the surgeon told me she had to cancel the first case because of a fever, and not to worry I would have plenty of opportunities in the future...... After the case, maternity was quiet so I just assisted the surgeon on the remaining cases today - a herniorraphy, followed by the removal of an obvious cancerous tumor from the buttocks of an elderly lady. Finally a toe amputation in a young girl after a snake bit her and caused gangrene and osteomyelitis. The girl was amazing in the sense that she was so calm and appreciative of everything the hospital staff was doing for her, in the moments before she was about to loose her big toe!

As a generalization, patients here are alot more appreciative of the care they receive compared to those in the States, which is definitely nice. Side tracking a bit - its interesting that although patients get preop counseling on all the risks/benefits/indications to surgery there is no consent form that is signed. I guess I should not be that surprised given that I am working in Africa, but still the documentation of informed consent is a big deal.

Its a three for one special today, with three pictures. I was hoping to put the pic without the shirt on beneath the other one, as a before and after, but I can't figure this blogger posting picture thing out.

The top picture is of a Kanga; A Kanga is a lizard that looks exactly like a crocodile or alligator only about 10 or 20 times smaller.

There is a baby kanga that lives in Chemchemi. I almost tripped over him when I arrived because I did not see him in the sun while he was sunbathing. After a little while he jumped in the water and I swam with him to the other side of the pond.

This evening I did not make it to the kitchen in time to tell the sister that I wanted to eat in the Abbey because I did not have any food in the house, so I went to the one and only restaurant in Ndanda, Subiaku. Some nights they play music, tonight they had live music because there was some sort of hospital party.

I'm taking surgical call tomorrow. So I'm going to go to sleep early tonight. I'm not sure what to expect on surgical call - it could be an adventure! I'll keep you posted! Again, thanks for writing comments; Hope all is well in North America!

The priests and the quadruplets

The black shirt is used to hide any evidence of weight loss/gain on my new diet of carbohydrates and more carbohydrates:) This is my "pre-blog" pose and if you look closely you might see a smile :)

Yesterday afternoon I went for a swim in "Chemchemi" (sp?) the man-made natural pond in Ndanda, aka our swimming pool. From my house its about a 45 minute walk along a dirt path through some bush.
The pond is roughly the size of a football field, maybe a little larger and is surprising always very clean and Very refreshing during these hot humid afternoons. Almost every afternoon at four o'clock a group of four or five priests from the Abbey go for a swim; and unless the other couple of volunteers come with me, I'm swimming alone with the priests......

Last night I visited with two of the other "vols" who have been here now about a year. They have acccumulated quite a DVD collection......there is not a lot to do here at night. So after so many days of reading and studying Kiswahili, I took a break and watched A Beautiful Mind (again). The girl living next door to me is a Dutch doctor from the Netherlands. She arrived about a year ago and is focusing on improving the HIV program at the hospital. Next to her is another girl who is a "vol" from Colorado, also here since about Oct. last year. She is a lab tech, here to strengthen the lab. The two of them must have a love for cats, because they share four cats that stay in the houses. One of the cats gave birth to quadruplets the other day. One of the kittens died yesterday but the others look healthy. We are not expecting any more kittens because the girls performed a vasectomy or something similar on all of the males. (Not sure who the father of the kittens is:)

I think I'm starting to get into a routine. In the mornings after conference, I round on maternity patients. There are usually about forty to fifty patients to see. Usually three or four patients in labor and delivery and twenty-somethinng patients on both post partum and antepartum. I round with one of the assistant medical officers who has been covering maternity. And between the two of us, we split the patients.
Rounding takes us until about ten o'clock and then its time for the mandatory "tea break" which I believe all Tanzanian's believe is a necessary part of their day. I usually skip tea and go to the theatre.

In the theatre today, we had a laparotomy, oophorectomy for a large ovarian mass in a sixteen year old girl. She had a fifteen or sixteen centimeter mass that occupied almost her entire pelvis. Fortunately it was obviously benign in appearance, so it was easily drained and removed.

After operating we see the outpatient surgical patients. Outside the theatre are benches filled with patients. Usually there are thirty or forty patients waiting to be seen, referred from an outpatient clinic, or sent from the ward. There are four or five exam rooms, one gyn room and ultrasound. We document all of the findings/exam on a little card, that the patient keeps with them. Seems to be a very efficient system.

The short rainy season has started. We had a sprinkle yesterday afternoon while I was walking back from the pond, and a downpour this afternoon for about an hour. The short rainy season is supposed to last from about November through January. It is definitely nice to get a little bit of rain to cool things off in the evenings.

Hope everyone is doing well. And let me know when you plan on visiting!!

Theatre

Finally I started work in the OR (aka the "theatre).

For me it was a perfect day to start in the theatre because we had one scheduled total abdominal hysterectomy, and one emergency c-section for fetal distress... in between there was a minor orthopedic case that I scrubbed to assist the general surgeon....

The first patient was severely anemic due to fibroids with a hemoglobin around 6. (There is blood available in the hospital but its used very sparingly). Fortunately, the case was uncomplicated and we finished within an hour. The patient did not loose that much blood but she received a unit of blood immediately after the case. (BTW there is no offical Estimated Blood Loss documented), infact a lot of information is just not being recorded by the anesthestists or even some of the doctors....

Supplies are limited, eg - preop antibiotics are not given (because the hospital is in short supply) and lower extremity sequential compression devices are not available. Surprisingly, I'm told that there are not that many post op infections or DVTs......

Second on the OR schedule was an orthopedic case - removal of a plate after an ORIF. A short, straight forward case for the general surgeon, who I was definitely pleased to see has very strong surgical skills.....(BTW I just assisted on the ortho case today to get more time in the theatre....)

Soon after the ortho case, a woman was brought from L&D for an "emergency c-section."

For an "emergency c-section" the nurses and anesthetists worked very slow, but we were quick to deliver the baby who had apgars of "10 and 10" :)

The working day ends at around three or three-thirty which is definitely nice! However, I'm going to be working six days a week. And, seems as though I will be taking some "surgical calls"....

The picture is of the market that I go to to buy my fruits and vegetables. Everything is very fresh, and now its mango season, so it is the best time to buy fresh mangos in Ndanda.

My next post will have to have a picture of me, or at least the hospital as requested by Justin. (BTW, Justin and everyone else thank you for reading and writing comments) Justin, I didn't get a chance to talk to you before I left, I hope you and Jaime are doing well. Stay in touch.

Jumatano

A view of the front of my house. There are 3 "houses" in this building. I live on the far left side if you are facing the house.

The path from my door leads to the hospital which is about a two minute walk to the morning conference room - a little better commute than I had in Chicago:)

Today I rounded in Wodi 2 - the male surgical ward. There were 54 patients today - mostly orthopedic cases, but some general surgery and urologic cases. I rounded with one of the Tanzanian Assistant medical officers and the orthopedic surgeon. Most of the orthopedic patients were s/p fractures that had been internally fixated? (Sanders - i'm sorry if you read this and I'm wrong with the ortho terminology, its been over four years since my ortho rotation). Many patients were post op after having an ORIF - open reduction, internal fixation. There were a couple of post op prostatectomy cases, hernia repairs and hydrocele repairs. Two boys had been admitted after snake bites to the feet. Both had a large amount of soft tissue damage in the foot. One man was admitted after an aligator attacked him and injured his arm/shoulder.

This afternoon I was walking back to the hospital to go to the surgical outpatient department, when I walked past one of the german nuns, who stopped me and introduced herself. She has worked as a doctor/teacher at Ndanda for the past 35 years. She was on her way to the nursing school to give a lecture and invited me to listen, so I came with her. This nun is also a doctor and at one time practiced gynecology, now she works in the family planning department.

Her lecture today was given to the 4th year nursing students on a very interesting topic - "cervical mucus":) She introduced me to the nursing students, who looked like they were pleased to have a visitor in their classroom.

The nursing school class had about 30 or 40 students that are probably in their late teens, mostly girls. Most were busy taking notes, some looked interested, others asleep during her lecture. I was curious how much of the lecture the students understood as every word was spoken in English.

After the class I met one of the other clinical officers who works maternity and also surgical outpatient department. He is older and told me he's going to retire in a couple of years. He was absent from morning report this morning because he was doing a repeat cesarian section late last night. His afternoon clinic was very slow, so a good time to chat and get to know him. He told me that the administration is setting up my office next to his. I was surprised to hear this, as I was not expecting an office of my own.

The afternoon clinics usually run until about 3:30 and then most people are done with their work, unless they are working a night shift or on call.

Its hotter than usual today so I went back to the house. I keep the fan on while I'm in doors because even with the lights off and shades closed, the house gets pretty hot. Today Janet, my housekeeper came to clean. She charges 5000 shillings (a little less than 5 dollars). Obviously way less than any American, but probably more than most house cleaners make here, and on my salary it probably evens out.

Dinners for me are still a dilemna/challenge. Until I learn to cook I expect to loose a few lbs's. Last night I walked to the (only?) restaurant in Ndanda, which is just down the road. They sell chicken, meat, fish, rice, etc.....I was craving chicken but they were out of chicken so I ate the fish - edible, but not good by american standards; however, much better than my spaghetti and tomatoes!

(BTW Jumatano is Kiswahili for Wednesday. The thought of "cervical mucous" as a title for this post crossed my mind but then again Wednesday is a safe enough choice:)

Wodi 4

Today I spent the morning in Wodi 4 (ward 4). As a part of my two week orientation, I rotate through each of the wards in the hospital to become better acquainted with the staff and patients.
Wodi 4 is the pediatric ward and was managed by Victor today. Victor is one of the local "clinical officers" working in the hospital. St. Benedict's has a number of Assistant medical officers = 4 years of training, Clinical officers = 3 years of training and medical officers (4 years of school + training). So I believe that I am one of 6 medical officers. There is one visiting orthopedic surgeon, one general surgeon, two medical doctors, and one HIV/tropical medicine doctor (also a VSO volunteer) and myself. (The maternity ward is run primarily by two assistant medical officers who I have not met yet).
Victor and I rounded on about twenty -two peds patients this morning. Like most of the wards in the hospital, Wodi 4 has roughly about 30 beds, arranged almost side by side in one open room, which is "relatively clean" but does have a lot of flies swarming around.
Most, if not almost all of the children are admitted with malaria, which is by far the most common illness children get admitted for. Most children present with fevers, malaise, body aches, and GI or respiratory symptoms.
As an aside, what becomes obvious very quickly when working in this hospital or in countries of "tropical medicine" is that so much of the day to day care/treatment of patients relies on the clinical judgement of the doctor, i.e. the routine labs and imaging are not being performed. Sometimes its hard to imagine what limited resources this hospital is faced with, but it is a reality!
At around 11:30 after we finished rounding, one of the nurses came in to tell us that there has been a change in the status of one of the patients. A young girl who had severe malaria and hydrocephalus was brought into the "intensive room". Her eyes were closed and she did not move. It was obvious that she had passed. Victor confirmed that she died and we told the father, who was appropriately sad.
According to the St. Benedict's Ndanda Annual report, last year 87 children died. I will never know how my impressions/feelings about death compare to those of the people of Tanzania who are faced with this reality each day. When there is a death of a patient, the nurses end their notations in the log book the same way each time, let us pray for him, amen.
On a little lighter note, I had the afternoon free so I went for a walk around the town. Its definitely getting hotter here (i'm sure you feel sorry for me:) and I wished I had some sunscreen on; I feel a little bit awkward walking around because people I meet or have not yet met, seem to already know me. I went to buy some milk and eggs from the kitchen and when I asked the sister if I could have milk without cream, she said "why don't you like cream? you are a doctor, you should know its ok". I was surprised to hear this from someone I had met only once before!
On a different note, I expect to have some new pictures up next time. I've been spending a lot of the down-time studying Kiswahili because its becoming very apparent that to gain the respect of my colleagues and patients means speaking without an interpreter. I will try to take a break from studying/working and re-enter tourist mode with my camera tomorrow!

Nyangao

I'm spending the first week in "orientation" to become more familiar with St. Benedict's Hospital. Each day during orientation I have to round with the doctor or medical assistant in two different wards.
This morning I started in the medical outpatient department.
I introduced myself to Lillian, the medical assistant covering the MOPD (medical outpatient department) and sat in her office while she saw a few of the patients. By the third or fourth patient, she handed me the chart and wanted to me to start seeing the patients. There was some misunderstanding because in my Swahili I tried to explain that I would just be observing her. But she insisted that I see the patients and I didn't mind so I prepared. Luckily all of the charting is in English but of course none of the patients speak English. I tried hard to take a history in Kiswahili, and for the most part, patients understand me, but I still have difficulties understanding the spoken language. I had two interpreters with me......A few of the first patients had multiple problems, diabetes, hypertension and just came for medication refills. The next patient was a four year old boy who was carried into the room by his mother. His eyes were closed, he looked very weak and sick. His mother gave the history - fevers, abdominal pain, sore throat, nausea and vomiting for two days. The nurses took vital signs and I did a physical exam.....I spoke briefly to the medical assistant to discuss my differential diagnosis and possible work up, but she didn't hesitate to say that he has Malaria. I asked if we would get blood tests or do any other type of work up. She said no.... so I admitted him to the peds ward with medication to treat presumptive Malaria.
By ten am, I had to leave to accompany other hospital employees to drive to Nyangao, a sister hospital in the village of Nyangao about an hour east of Ndanda. Nyangao Hospital was host to today's monthly medical conference so about 50 health care workers from 4 regional hospitals met to hear lectures by 3 doctors. Coincidently the lectures today were OB related. A general surgeon gave a talk on wound healing, a gynecologist at Lindi hospital talked on management of normal and abnormal labor, as well as complications in C-sections, finally one of the medical assistants gave a lecture on post op c-section wound infections at Nyangao hospital. Very interesting to hear the perspective and management. There are many differences b/w practices in US hospitals compared to Africa (obviously). Some very basic medications are not available, and as a result there are higher numbers of c-sections and complications. Even pitocin, one of the most commonly used medications on a L&D ward to augment labor is sometimes not used, because it is not available!
By the time I returned to Ndanda it was late afternoon. The hospital administrator and other volunteers living next to me had already left for Mtwara for the weekend. I spent the afternoon walking around the town. The butcher was closed so I went to the monastery kitchen and bought some milk, eggs, bread and some sausage - enough for dinner tonight! Hint - please send recipes and/or the Idiots Guide to Cooking! I don't know how long I will last on scrambled eggs and sausage!

house pictures

Nyumba wangu

I wish I could take you on a video tour through my house. The three bedrooms, single bath and kitchen was large enough for me to get "lost" the first day I arrived. Here you are looking at the front door; the den is to the right and there is a guest bedroom to the left.

The kitchen, behind, has an oven, stove, toaster, refridgerator,+ pots and pans- perfect for someone who does not know how to cook.

I have upgraded learning to cook on my list of things to do after I had an omelette and toast for dinner last night. Don't worry my neighbor gave me some spaghetti so that I won't get discouraged.

Ndanda

I'm in Ndanda, Tanzania now! After a month of training and language classes, I'm so happy to have settled into my house in Ndanda and to begin to start work!
Yesterday I flew from Dar Es Salaam to Mtwara, the largest city in the south eastern portion of Tanzania. The flight was about an hour and a half. We made one stop in Lindi, a smaller town. I wish I had a picture of the airport - on the roof of a small house in big letters reads Welcome to Lindi Airport. It was the first time I've landed at an airport without a runway. The runway at Lindi is barely a dirt road with patches of grass and weeds scattered about. It made for a little bit of a bumpy landing! The flight from Lindi to Mtwara was only about a half an hour but with beautiful views of the Indian Ocean along the way. In Mtwara I met my "line-manager" who is the in charge hospital doctor and we drove about 2 hours to Ndanda. We stopped once along the way to buy some coconuts.
In Ndanda, I was greeted by the hospital administrator, a very friendly dutch man and the three other volunteers working here, a medical doctor from the netherlands, an american lab tech, and a community HIV counselor. I took a little driving tour of the town of Ndanda with the hospital administrator and volunteer doctor. This small town is amazing - both beautiful and very self sufficient! It is more than 100 years since a German mission post, when the town and soon after the hospital was established. There is a large German influence and presence of german monks and nuns that live in the Abbey here. Also an increasingly large African diosese is growing in the community. For a very small town, Ndanda has impressive self-sustaining sites - a hydroelectric power supply, large water filtering system, vegetable farm, stone carving and masonry shop, a nursing school,bakery, butcher, natural pond for swimming, and of course St. Benedict's Hospital.
After a tour through the town, I had dinner with the hospital administrator and the three other volunteers who prepared dinner in their house.
My day started at 8 this morning with morning report. After a quick prayer, a nurse reads a list of the census of patients in the hospital including all recent admissions, discharges, diagnoses, and pt's scheduled for surgery. I wish I had arrived one day prior, because I was told that yesterday a woman delivered twins and she had "two uteruses" or possibly an extrauterine pregnancy. I don't have the story right - what was described in board report was that a laparotomy was performed, and on inspecting the abdomen, two uteruses were seen. Both babies were delivered without complication and are doing well. I wish I was there to see!
Today's surgery schedule included one total abomdinal hysterectomy for fibroids, as well as a couple of orthopedic cases. I met the general surgeon who performed the c-section yesterday, and who was doing the hysterectomy today. She is a german nun who has been working as the sole general surgeon at the hospital for some time. I was told that the last ob/gyn to work at the hospital did so more than 5 years ago and worked for some time until he passed away.
After morning report, I was given a tour of the hospital. For a mission hospital I was very impressed. The 300 bed hospital has a separate medical and surgical ward for men and women, an antepartum unit, post partum unit, Labor and delivery. There is a main operation theatre, where general surgery, gynecologic, orthopedic, urologic, and ent procedures are performed. There is a lab, with blood bank, radiology department, an ultrasound (I didn't see today), a TB unit and an HIV/AIDS treatment care unit. After the tour I picked up some hospital attire and then had lunch in the abbey. I didn't see my line manager this afternoon, so I spent more time getting settled.
I'm going to meet the others for dinner and have an early night to make the most of tomorrow....

St. Thomas Kilakala

The view of the front of St. Thomas Kilakala monastery, our hotel for the past 3 weeks.
Today is our last day in Morogoro. The past three weeks have flown by. This morning we had class for two hours, practicing speaking Kiswahili with each other, and then the group met to give the teachers a final evaluation of the course. After lunch a few people went to the pool at the Hotel Morogoro. I am going to get a drink and relax until dinner.
We are leaving early tomorrow morning to go back to Dar Es Salaam.

Malaria

I've got Malaria. There is a mini- epidemic of Malaria going around our compound. As of today 3 teachers and now 6 volunteers have Malaria. I feel fine. I went to get tested because I was feeling very tired the last couple of days and a few other people found out that they have Malaria as well.
My test came back positive 2/7, which is relatively low, but still positive. So, I started taking the malaria treatment regimen.
Its ironic because I went to the dispensary earlier today to speak to the doctor to interview him about medicine and hospitals in Tanzania as an assignment, and I asked him how many cases of malaria he sees a day. Malaria is very common I was told and usually there are about 20 new cases of Malaria diagnosed at the St. Thomas dispensary every day.
Despite taking my Malaria prophylactic meds, sleeping under a mosquito netting, using DEET anti mosquito creams and sprays on clothes I managed to get Malaria. I guess I don't feel so bad because so many people here now have the disease. I'll have to take the treatment and get my test of cure in a couple of weeks.
I'm just wondering if I could make some money developing a t-shirt that reads "I came to Tanzania and all I got was a case of Malaria"

Itinerary

A little bit of good news today-
I was told by my PSO (program support officer) that my accomodations and itinerary in Ndanda has been confirmed.
So this Sunday I'm going to return to Dar Es Salaam for 4 more days of "in-country" briefings and then I'm scheduled to fly to Mtwara on the 31st. In Mtwara I'll meet one of the volunteer leaders who will go with me to Ndanda to get settled in my house.
I know the house is located on the hospital compound and has electricity, and internet connectivity, so I should have my laptop and skype hooked up by then. If you don't have skype, then sign up because calls are free.
Tonight is a dinner out with all of the volunteers and the VSO staff who drove from Dar today. We're going to "Dragonaire's" - a bar/restaurant that serves the best food I've had in this town so far. After Dragonaire's we're going to Kuhumu's Night Park (also known as "The Cheesy Club") because of its "cheesy" night club ambiance. The "Cheesy Club" is a bar with a few pool tables and a large dance floor that often is filled with Tanzanian's who love to dance until early morning!
I go purely to "study" the night life and culture in Tanzania....

Lupanga

Don't let the expression on my face fool you, this picture was taken at the very beginning of my hike up Mount Lupanga. It would be quite an understatement to say I was not a very happy camper by the time we returned home.

Yesterday I hiked up to the top of Mount Lupanga. Lupanga is the tallest of the three mountains that make up the Uluguru mountains of Morogoro, and at its peak it is 2150 meters above sea level.

Our hike took twelve and half hours from start to finish. Seven hours to reach the peak and 5 1/2 hours to climb down the mountain. We made two stops on our way up. By the second stop, two people decided they would not make it to the top but I joined one other person and our tour guide and we did make it to the peak.

Had I known how difficult it would have been to reach the peak and back I would have never decided to do the hike. Approximately the last half of Lupanga involves a hike through the forest, up a very narrow dirt path that twists and turns through trees at a very steep incline. The last hour up the mountain was by far the most difficult as the incline was the steepest, almost 90 degrees, requiring using roots and trees to pull ourselves up. Our tour guide would say "pole pole" (very slowly) and "keep left"; when I saw the cliff falling off next to me, I knew why.
When we reached the peak I was completely exhausted, yet exhilerated and also a little disappointed because we were surrounded by trees with no view. At the peak is a tall ladder like structure which you can climb to get a view, but I didn't have enough energy to do so.
Getting back down the mountain was by far more challenging than reaching the top. A muddy trail, covered with wet leaves, roots and large rocks, falling straight down, made it incredibly challenging. So difficult that I did not hike down the mountain, rather I slid down most of the way.
In retrospect, I don't regret the hike, and I'm happy I made it to the top, but now I'm confident that I will not be climbing any more mountains in the near future, or quite possibly not again in this lifetime. And, if by chance you ever come to visit me in Tanzania, I would not recommend climbing Lupanga unless you are asking for a little bit of pain and a lot of agony!!

Mrembo