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....