Swine Flu and other hogwash

Swine Flu is spreading like pork buns in a dim sum restaurant!
As far as I know there have not been any reported cases in Tanzania (yet?). People ARE worried about a possible pandemic. The CEO of VSO sent out a mass email the other day warning people about this possible pandemic. And doctors in the hospital here in Lindi are talking about swine. We are scheduled to listen to a presentation on Swine Flu on Wednesday.

Other hogwash worth mentioning - a bunch of bombs went off in Dar Es Salaam last week, killing about sixty people (I believe that is the number quoted). I don't know how or why the bombs went off but it caused alot of panic among people living in Dar. As far as I know there are no bombs here in Lindi, or so I'm told!

On a very sad note, on Thursday evening, as I was about to go to sleep, I received very disturbing news. One of the VSO volunteers had been involved in a traffic accident and died while riding her bike in Tanzania's capital city of Dodoma. I was shocked and very saddened by the news. I had spent alot of time with this person as we studied Intermediate Kiswahili together last year in Morogoro! Apparently I was told that the tire of a taxi blew out causing one of the buses in the street to swerve and knock her off her bike! I don't have all of the details about this case and I'm told that VSO is still collecting information.

Switching gears, I met my first 'Androgen Insensitivity Syndrome' patient on Thursday. AIS is basically a rare condition affecting about 1/1200 women in which the uterus and cervix does not develop. These people are 'phenotypically' women but have 46 xy chromosomes (genotypically male). The diagnosis has to be confirmed by karyotyping but I'm fairly sure of the diagnosis based on her presentation. She came in complaining of primary amenorrhea (never having a period) at age 21. I had to ask one of the Tanzanian doctors to help me translate counseling this patient as it would be a very time consuming, delicate subject to discuss and necessitate answering many questions! We ended up referring the patient to Dar Es Salaam for karyotyping and genetic counseling. She may need orchiectomy if she is confirmed to have AIS.

Friday was a holiday here in Tanzania. I spent the morning doing a bit of reading on the beach. In the afternoon I went to the 'football' stadium to watch two of the local soccer teams play. It was a blow out, 3-0. The local team lost. There were a few visitors who received nasty looks when they cheared for goals by the visiting team. I captured most of the game on video.

That's all the news I have for you for now. Enjoy the weekend!

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!

Bongo Flava

I arrived safely back to Tanzania 8 days ago. Nice couple of flights on KLM, with a short layover in Amsterdam. I landed in Dar Friday night and took a cab to my favorite hotel, the Econo Lodge. I spent the weekend relaxing and trying to adjust as quickly as possible to the time difference (8 hours ahead) here in Tanzania. The weather has been just as I had left, hot and humid, day and night!

I spent Saturday at the beach relaxing with another volunteer based in Dar Es Salaam.
There are plenty of "resort" style beaches in Dar and if you go to one of the more popular beaches on a nice weekend you'll find a ton of "wazungus" (White European descent) lying out or walking around. Almost gives you a feeling like you are not in Tanzania but at a resort in the Caribbean!

On Monday I stopped by the VSO office to meet with my program manager to discuss how the job in Lindi is going and to discuss other issues coming up in the next couple of months.

I flew down to Mtwara (the largest city in Southeast Tanzania close to Mozambique) on Wednesday and from there I took a dala dala (overcrowded public transportation minibus) to Lindi (about two hours north).

In Lindi I took a cab back to my house in the town of Mtanda. There I met Hadija, my housekeeper who I was happy to see and to hear that everything had been well at my house, i.e, no robberies or attempts at break-in.

I found the house just as I had left it - without water and with very sporadic bouts of electricity that seem to come and go at completely random times. My first night back in the house I had no electricity for most of the night. I spent the evening with my security guard sitting around in the dark talking by candlelight. I was lucky to have about 25 liters of water which had been collected from a recent downpour but that water was soon consumed and I'm now left with buckets of water used very sparingly!

I went back to work at the hospital on Thursday. I spend most of the morning doing "ward rounds", meaning I see all the Maternity patients (antepartum, post partum and laboring patients) and Gyn patients who are admitted in the ward. Fortunately there were no very sick patients in-house. We had a few patients with prolonged hospital stays due to post op wound infections. There was one patient admitted to the gyn ward with a large adnexal mass awaiting surgery and another patient in preterm labor at 32 weeks of gestation. In the afternoon I went to clinic and saw about a dozen patients. The most interesting case of the day was a relatively young woman who was diagnosed with cervical cancer. She went to Dar Es Salaam last year to receive radiation therapy. She came for a follow up and seems to be doing well with normal blood counts, however on exam she still has evidence of a large residual tumor mass on the cervix. I told her that she should go back to Dar Es Salaam to potentially receive more radiation therapy. There were two or three patients with infertility who came and got a work up. I scanned about a dozen patients in ultrasound and then went home for the day.

Hadija had prepared fish (red snapper) with vegetables and rice. It was plenty of food for me with leftovers remaining for the next day.

On Friday I had two operations scheduled - an elective repeat cesarian section and tubal ligation for a woman who is HIV+ with a history of one prior cesarian section and undesired fertility. She had an uncomplicated repeat cesarian section and delivered a vigorous baby boy.

The second case of the day was also HIV+. She was a young woman with a large ovarian mass. We found about a 10cm hemorrhagic ovarian cyst at laparotomy and performed oophorectomy. She was recovering well when I checked on her at the end of the day.

I saw a few more patients in clinic yesterday afternoon. More infertility patients arrived and a few patients came for regular antenatal care.

Last night I went to the Santorini bar, a nice local hangout on the beach to relax and get a drink. The laid-back social scene here is something that I will miss. There are no "wazungus" which I socialize with outside of the hospital, but there are plenty of friendly Tanzanians who like to relax at the bar and go dancing until early hours in the morning.

I'm heading to the market now to stock up on some fish and meat, fruits and vegetables and then do a little bit of work at home. Badaaye! (See you later!)

A Taste of India

Had dinner at Rasika (http://www.rasikarestaurant.com/) this evening. Excellent food! Their "flash fried" spinach appetizer was voted best appetizer in Washington DC! The cod, chicken and lamb were excellent. Service was good, but we waited an extra long time for the cod to come out.
I say "extra long time" with tongue in cheek because coming from Tanzania, one can expect to wait upwards to two hours for food to be served in a restaurant and then of course you can expect your food to be served cold. Many of the local Tanzanians will jokingly saying "TIT" meaning "This is Tanzania" when referencing the long wait for food at restaurants.

There's no "flash fried" spinach appetizers in Tanzania. Its even difficult to find a good chicken dish. There are a few good Indian restaurants in Dar Es Salaam, and the quality of food seems to be getting better, but the food in Tanzania doesn't compare to the food in the States, as you can imagine.

So, I'll be back in Tanzania in 3 days. Thursday evening I'm flying back. I've got a 10 hour flight to Amsterdam and then about 10 hours from Amsterdam to Dar Es Salaam. Once I'm in Dar, I have an option of taking the 10 hour bus ride from Dar Es Salaam to Lindi (2 hours of unpaved road) or taking a 2 hour flight. I think I'm going to opt for the 2 hour flight!

Besides adjusting to the 8 hour time difference, it will be interesting to see how quickly/how difficult it will be to communicate in Kiswahili again. When I left Tanzania last month I had been almost fluent in Kiswahili. Speaking and comprehending Kiswahili was easy. I was even thinking in Kiswahili! These days I find myself searching for words when I imagine speaking in Kiswahili again.

So, I only have two more dinners, and two more nights to spend with family and friends!!! I'm going to miss the food and the company of friends and family!! And of course the addicting evening TV series "The Apprentice - Celebrity Season". My question to you is, Why did Tom Green get "fired" last night?? He was a good manager, even though his team did loose to the girls by over $400.....

But getting back to Tanzania will be a nice feeling. I'll be happy to be back even if it is for a short period of time. I'm finding myself missing the hospital and being in the clinical setting. Despite the endless lines of patients, the never-ending ultrasound scans, the unpredictability of the electricity and the frustration with medical personnel, I am missing my work which I only remember with great satisfaction and personal fulfillment.

Cheers!