Case of the day

This morning I examined a post op patient who had a c/section 2 days ago. She had difficulty breathing, was febrile with a distended abdomen and rebound tenderness on exam. I scanned the patient and found that she didn't have any significant amount of fluid in the abdomen or pelvis so we treated her as severe peritonitis with broad spectrum antibiotics.

A moment later, I was called to do an emergent ultrasound on a patient admitted in the female medical ward. She was admitted with severe constipation, nausea and vomiting and she too had a distended abdomen with rebound tenderness. Her scan revealed a normal size uterus with what appeared to be a small intrauterine gestational sac without a fetal pole or yolk sac. There was a small adnexal mass and significant amount of free fluid in the cul de sac. I took her to the OR for laparotomy expecting to find a ruptured ectopic or ruptured hemorrhagic ovarian cyst. However, on opening we found diffuse, grossly dilated loops of small bowel with diffuse adhesions throughout the abdomen and pelvis - an acute small bowel obstruction. We ran the bowel and found a small area of ischemia however, no gross devitalized or necrotic tissue, so we performed extensive lysis of adhesions and closed. She'll get a nasogastric tube for at least 48 hours and conservative therapy post op.

The maternity ward was busy. I performed a cesarian section this morning on a patient with cephalopelvic dispraportion (CPD). It was her first pregnancy and she was lucky to have come to the hospital in time to be evaluated before potentially ending her pregnancy with a bad outcome!

More to come...

April Showers

We've had a few days of rain this month and just brief showers today. April is usually the last month of rains before the dry season from the beginning of May until around November.....

Practically this is not a good thing for me because I collect the rain water to use for bathing. Without rain I am buying water. Today I used up the last remaining drops of the water which I had collected from the rains. There was no more running water this morning so I went to my neighbor's house to buy about 20 liters of water (for almost $1).

At work its been busy as usual. There are always about 30-40 patients a day in the outpatient clinic. But towards the end of the week, the numbers usually decrease a bit. On Thursday I went on a "supervision of study", meaning that I travel to neighboring cities of Ndanda, Mtwara and Nyangao to visit the participating hospitals in this study. We are working on the "Misoprostol in Retained Placenta" Study. Patients with retained placentas are randomly given a placebo medication vs. misoprostol at the time of diagnosis of retained placenta. About once a month I travel to the three other participating hospitals along with one of the head Maternity nurses to follow up on the progress of the study. Its nice to get out of Lindi and to see the country and as well see people who I used to work with in Ndanda. But its a long day, we leave around 9 in the morning and get back by sunset.

My last day of work will be June 17th. I'm traveling up north to Arusha the following day and then going on a safari in Lake Manyara, Serengetti and Ngorongoro. June 23rd I'm flying back to the States. This means that I have only about 6 weeks left here in Tanzania! I'm sure the time is going to fly by. There are so many things I'm going to miss and a lot of things I'm looking forward to leaving behind here in Tanzania. I've started to compile this list and I'm going to publish in one of my upcoming blogs!

Duty Calls

Its been so busy at the hospital this week. Maybe because Tuesday was a national holiday and as well tomorrow and Monday are holidays. Everyone who is sick or just passing by the hospital is coming in for a health check up. It looked like hundreds of people had gathered around the reception area this morning to get a chart in order to see a doctor. About forty or fifty patients were seen in the ob/gyn room. Patients had everything from normal pregnancies to various gyn cancers.

I started the day with one elective cesarian section for a woman in her third pregnancy at term who has a "bad obstetric history". She delivered a healthy male who came out screaming.

After the elective c-section, I went to the OPD to see patients and then finished the day at ultrasound scanning patients. I saw a few interesting cases - one patient was a consult - she came with acute appendicitis and one woman I scanned had a bladder cancer.

I was home by about 5 and ate one of my favorite dishes - baked chicken with rice and vegetables.

The sun sets around 6:30 these days and if I'm lucky to have electricity at night I've been spending my evenings relaxing watching the second season of "Dexter" on DVD or doing some light reading.

I've notified the hospital here in Lindi that I'll be returning home to the States early. June 23rd is my expected date of departure from Tanzania. I'm planning to spend the weekend of the 19th up north around Arusha and Serengeti National Park.

For those who don't know already, I signed a contract for work when I was back home in the US last month. I'm going to work for Carlisle Regional Medical Center in Carlisle, Pennsylvania. July 13th is my start date! Very excited! Carlisle is about two hours from DC/NY and Baltimore in Central/Southern, PA close to Hershey and Harrisburg. See the website www.carlislermc.com

April Fools

Yesterday morning my 'program manager' in Dar Es Salaam called to tell me that the VSO office is conducting an Evacuation Test. If, for example, there was political unrest in the country and all volunteers were needed to evacuate, we would need you to follow the following instructions, he said. He told me that I must go to Mtwara right away. From there I would go straight to the airport, board a flight to Dar Es Salaam and get a connecting flight to the US. He asked me if I would be able to leave the hospital right away or if I would prefer he would call the Doctor in Charge of the hospital. I told him to call the Doctor in Charge. Two minutes later he called me and told me that a car would be available for me to leave the hospital. He told me that I should pay for the fuel to take me to Mtwara and then I would be reimbursed once I arrive in Dar. He said that the VSO office will be closed for four weeks during this evacuation, so I should plan to pack my bags to stay out of the country for the entire four weeks! I told him that I am really not ready to take a two hour drive to Mtwara, fly to Dar and then potentially fly back to the US, especially having just recently flown back here from the US. He told me I should go ahead and pack my bags and take the car to Mtwara. He said I should expect a call in two hours to get an update. I said to him, 'do you really want me to take a car to Mtwara even though this is a test?' and he said yes - I should go ahead and do it! I said 'But I don't have a ticket to fly to Dar!' He said yes, you do, an e-ticket has already been issued for you which you will receive at the airport. And once you get to Dar you will receive the e-ticket to return to the US'. He told me I would be flying Emirates and have a layover in Dubai. After more questions and more answers, he convinced me that I needed to get in the car and leave Lindi.

So I found the hospital driver, went to my house, packed a couple of suitcases and then began the drive to Mtwara. Two hours later my phone rings; my program manager tells me that I must return to Lindi right away; this was just a test. A test! What?? He said 'I thought I made myself clear on the phone', you were not supposed to leave Lindi!

I don't know if I was the victim of a bad April fools joke or if I just completey misunderstood my manager in Dar, but what a frustratingly painful thing that was to go through yesterday. I wasn't laughing when we had to stop the car and turn around an hour and a half away from Lindi!

Apparently the program manager's 'Evacuation Test' had the same effect on many of the other volunteers in the region who were also en route to Mtwara! There was an apologetic email sent out to all the volunteers who, like me, took the Evacuation Test seriously.

On a better note, today was a productive day. I had one operation scheduled this morning - an abdominal hysterectomy on a perimenopausal woman with a large fibroid uterus. The uterus was about three times the size of normal with large fibroids. The case went smoothly without any complications. I spent the afternoon in and out of the clinic as well as in ultrasound, scanning a few patients.

Happy April Fools Day!
More to come from the most gullible volunteer in Tanzania!