Jill's Reflections before leaving

Getting very excited to see old friends in Ilula and meet new friends from our group!  Looking forward to showing our PharmD students all that Ilula, Iringa and Tanzania has to offer- the experience is so rich and rewarding.  My next challenge is to pack VERY light- I always say that but somehow.....One suggestion for the team is to bring a few snacks for the bus- protein bars, beef jerky and of course sweet things work well too. It is amazing how a taste of home can quell a tired or unfamiliar feeling on the journey. 

Maasai Preaching Point Photos

 They sang and danced for us.

 What a basketball player!

The men danced for us.  Wow can they jump!

 A couple of our own level-headed women!  Mahveen ^ and Lauren ->

Above, the men danced for us.  The women responded in like manner. Well, not with the high jumping, but up close and personal, for sure.

 And they are tall too!

Ndio, Tanzania, mimi nakupenda!

The Close of our 2017 Ilula Medical Experience

As deeply as the death of our smallest charge affected me personally, I cannot let that be the last entry in the blog.  A couple others are on the list of contributors, but I know they are consumed by travel weariness and jet lag.  Hopefully, they will add their reflections too.  Thankfully, Dan McIntyre notified me that our intrepid travelers, you recall AKA “the fun group,” arrived home unscathed, though not without a little scare when two nearly missed the plane in Amsterdam.

Birdie and I remain in Iringa until Friday when we will indulge in a new experience and fly from Iringa to Dar es Salaam.  As an aside, we have contemplated using this transport both ways, to and from Iringa to Dar.  However, we tend to bring significantly extra baggage that does not return home with us, e.g. computers thanks Dan, Gary and Margaret!), some medical supplies, scrub suits intended to be left behind, this year hospice kits (thanks Jill Strykowski and Allina Friends!) and quilts for the new nursing student class, a donation of 17 stethoscopes (thanks Dan and Sue McIntyre and 3M!), 2 soccer balls, (Dan and Sue), some resuscitation equipment (thanks Jon Koratoff and Nadia Juneja), education supplies from Lauren Turner’s boyfriend’s church (Mike, I hope).  And that was just with the fun group and with apologies to those I may have missed!  So it should be apparent the difficulty we would have on the entrance trip.  And the group would miss the thrill of Mikumi National Park and the surprise of seeing African animals up close for the first time.

All in all, it was a terrific experience for me as always.  I miss being with the larger group more.  Cannot be helped, I suppose, being relegated to the fun group.

We (the collective, not the Royal) continue to learn things as our experience grows. Well, duh, you say. Me too.  As an experiment this year, because in the end we had the room, we had a couple non-medical personnel with us.  As always, this had some unexpected consequences.  Dave diligently walked daily to the Ilula Orphans Program (IOP) where he learned vernacular Kiswahili and worked hard.  Dan made forays to several schools and was the resident computer expert. Obviously these were highly useful things to do, but could be done anytime other than the medical trip.  We have had students in the past who stayed at IOP and occasionally visited us, an altogether different experience.

This time after the official experience has inspired, or perhaps incited, the contemplative side of me.  I am trying to write a “Code of Conduct,” and also a specific waiver regarding use of the public transportation.  Having a coaster bus at our disposal, mostly unused on a daily basis, is a burdensome expense; our travelers have been quite insistent that they want to ride public transportation. Yet our biggest risk in Tanzania is (motor vehicle) accident, not TB, HIV, malaria or the other maladies we tend to worry about (not even Zika or Ebola).  Bummer, since the crashes are virtually all preventable.

I will end on a high note. Once again, the trip was rewarding and memorable for me.  My hope is that our crew feels the same way!  We have met lifelong friends here in Tanzania that we look forward to seeing every year.  I truly hope my path crosses those of all our travelers’ soon and often in the future! 

Enjoy the photos below! Or above.  I will publish them separately, since Blogger is misbehaving.

The Baby Died

Just back from the toughest morning report since I have been here, especially in contrast to the celebratory atmosphere as we gave some of the things we brought: protective eyewear – we need to bring these annually, scrubs - always welcome for the OR, miscellaneous alcohol wipes, gloves - non-sterile and sterile, etc. Dr. Sovelo was presented with a couple good 3M diagnostic stethoscopes for distribution. And all these things bringing kudos from our colleagues.

Those leaving had an opportunity to say thanks and goodbye.  I was pleased to offer appreciations to the staff for their good work and pointedly let them know they are role models for the nursing students.

Then we heard morning report.  First, a man died in the night.  He had complained of chest pain earlier and multiple other problems, including HIV at age 36, which was why he was admitted.  His death diagnosis was asystole.  It happens. 

Next, we heard what none of us wanted or expected to hear.  Our eight-month old patient, Adonis, with the severe malnutrition (marasmus) had died.  We all thought the baby looked slightly better after getting therapy started.  We learned some additional history too.  This was at least the third time the infant had been admitted to the hospital, the first two times at the Regional Hospital in Iringa.  Despite the efforts we made, he had a couple chances before he reached us. Did someone drop the ball at Iringa? This is information we cannot know.  It is tempting to climb the ladder of inference, but there are so many explanations!  Was this an unwanted baby?  Munchausen’s by proxy? Poor care at the Regional Hospital? Inadequate resources? Inadequate teaching? All of these things?

All I can say is I am deeply saddened at our failure to save this child, but perhaps it was inevitable. I know he would not have died in the US.

To make things worse, if they could be worse, Sovelo had a disaster too.  A woman with 2-3 previous C-sections and only two prenatal visits, presented in labor, an indication for emergency surgery.  The nurses noted fetal heart tones (FHT).  Unfortunately, at surgery, Sovelo found extensive adhesions (scarring) that made access to the uterus very difficult.  He delivered a macerated baby, indicating previous intrauterine fetal demise.  The baby was grossly deformed, with brain, meninges and heart malformations externally visible.

That tragedy was not enough.  The mother had severe bleeding. With heroic effort, Sovelo got that stopped, some blood transfused, the uterus removed, and the woman transferred to the Regional Hospital.

The case prompted a tirade from one of the nurses about patients who do not do what we say is best for them.  This happens at home too: competition between the medical professional principles of primacy of the patient, autonomy of the patient, and social justice, sometimes causing a clash that may be unresolvable.

The FHT disparity raises questions too.  Obviously, the baby had died before the FHT were recorded as present. What is the explanation? Shortcut? Lack of synchronization with maternal pulse? (This was kindly Sovelo’s explanation.) Again, it is difficult but essential not to climb the ladder of inference.  Handheld electronic Doppler Ultrasound fetoscopes may not be the perfect answer, however, they are durable, portable, reliable, quick and pretty inexpensive – under $100, I think.  Perhaps ILH should have one or two and each of the eight Lutheran Dispensaries should have one also.

We will debrief these cases this evening, perhaps mainly for reflection.  Now we have all seen such cases in our experience here.  Still I had a lot invested personally in the case of Adonis.

A Mixed Blessings Birthday

I am writing this the day before my birthday and my coincidentally assigned blogday. Perhaps I will make an addendum.

Today I went rounding with Dr. Benjamin.  He had already begun his work. Others of the team were distributed amongst the various other ILH functions so I was with him by myself.  I heard there was a child with a substantial burn that I was anxious to see.  He had basically finished with the little girl. I decided to take a peek. The 3 1/2 year old girl had somehow splashed boing water on herself.  This is a very common problem in TZ.  The wood or charcoal stoves are low to the ground and sometimes the pots tip.  There was an infant that died of an extensive burn a week or so ago.  Fortunately, this little girl has mostly superficial second-degree burns with some deep second degree, about 18% body surface.  Of course, the important concept in treatment is to keep the second degree burns from becoming third degree, i.e. full thickness burns.  They know what they are doing here. If only there were fewer of them to know about.

I tried to make myself helpful and saw a couple kids with respiratory problems.  Both were stable; both had pneumonia. Both should do fine.  We moved on.

The Growth Chart

In the next room we went to, there was a baby, an eight month-old who was sick.  The mama was young – I do not know how young at the moment – and accompanied by bibi (grandmother).  I am not even sure why mama brought the child in now and not last week or last month. The baby has marasmus.

About 38% of children under-five years of age in Tanzania are stunted, i.e. short for age.  Stunting is a surrogate or indirect measure of chronic under-nutrition.  Wasting, low weight-for-height, is a measure of acute under-nutrition. (Remember that obesity is also malnutrition.)  Marasmus is the extreme case of wasting.

The mother had never breastfed the infant.  Dr. Benjamin speculated lack of counseling on discharge from the hospital. Did she leave early? Did she just get missed? She had told someone that her milk did not come in.  A wives’ tale, or should I say “Bibi’s tale,” is that colostrum is harmful.  Was she discouraged in this fashion?  Attempted and persistent nursing is what stimulates milk production.  What happened?  Perhaps we will find out as a few days roll by, but my language barrier will obstruct me from finding out easily.

I do not know what he has been fed. Possibly only dilute ugali.

Marasmus kids look like little old men or women.  The face is drawn, Adonis’ face is drawn and tiny.  Their ribs stick out.  My colleagues noted, “You can count his ribs.” His arms and legs are sticks.  His lips are dry and cracked. A rash is peeling the skin away on his posterior thighs.

The last case of marasmus I saw, a two year-old girl, died within two hours of admission.  Kelsey Watt, do you remember her? I know you do! Her picture, which has haunted me for several years, is now replaced by that of Adonis. Yes, I am using his real name and no apologies.  If he survives and I see him again in a year, perhaps I will apologize. Or just hug him.

Ashura, one of our nurses, is the local authority on malnutrition and knows just what to do.  We recruited the nursing students for round-the-clock attendance to help with feeding and to watch for re-feeding syndrome, intolerance of formula.  I went back to the room this evening.  The nurses have washed him and lubricated his lips. I got to hold him for a few minutes. I told him, “I am Babu,” grandfather.  I will be on edge until I know he has started improving.  This morning, my actual birthday, I am relieved and happy to report that he looks qualitatively better. This afternoon, no diarrhea and no vomiting, the latter the important sign of re-feeding syndrome. 

This morning we heard the second year Nursing Students report out on their field experiences.  The three teams each went to a separate communities where they lived for 4 weeks, assessing the community’s health needs.  They all did a marvelous job – in English.

On a further happy note, we are having a get-together for the entire staff tomorrow (now today).  I volunteered for our group to pay for the sodas and water. That was before I knew there are close to 180 people, including nurses, doctors, aids, volunteers, housecleaning staff, guards, nursing students and tutors and us.  It was also before Kikoti suggested two bottles each.  Originally I coined it a “Soda Party.” I had not connected it with my birthday.  Still it is more apt as a going-away party, since Jon and Mahveen will leave Saturday and the remainder will leave Tuesday next. I will stay on in Iringa with Birdie for another 10 days.

An update on the Soda Party. I am pretty sure it was the biggest thing at ILH since Saga’s wedding, which was BIG!  OK, so that was at the church, not the hospital, but anyway, it was BIG.

There won’t be any photos of Adonis.  You may look at the growth chart, however.  Note that his weight had crossed many lines.  I am not sure why the baby was not sent for consultation at any point in the past.  Possibly he was.  There could be a myriad reasons why nothing happened.  Perhaps I will find out. Maybe not.

Tanzanian line dance

I have a party crowd photo from my birthday party – I mean, the “Soda Party.” You can pick out what you see as blessings above. You should include the birthday present I got from the nursing students, kobe in Kiswahili or turtle in Kingereza.  I am contacting Mr. Magafuli for special dispensation to bring him (kobe) home.  I am tweeting Mr. Trump.

Tadaaahhh!

This post is dedicated to the student project that Prosperity and I have created in hopes of bettering the communication among the appropriate staff at Ilula Lutheran Hospital. Throughout our time at the hospital, which expanded to approximately three weeks, we have realized a flaw within the hospital regarding laboratory test availability and lack of communication regarding this issue.

When Prosperity brought up this issue at one of our discussion meetings, we had decided to brainstorm ideas for resolving this issue within the communication process. Specifically, we had discovered that some staff members (clinical officers, doctors and nurses) were not fully aware of all of the laboratory tests that were offered at the hospital. Among that issue, we became aware that many of the lab tests that normally are available were not able to be measured due to various issues (reagent out of stock or unavailable, machine broken, etc). Therefore, much of the staff were not aware of the lab tests that were or were not available. During inpatient rounds, we had observed that certain labs would be ordered, then the following day would not have been completed. After much questioning, we discovered that certain lab tests could not be completed due to both reagents being out of stock and the machine to run certain tests was broken. Therefore, the communication system between some medical staff (doctors, clinical officers and nurses) and the laboratory staff was flawed.

In order to get a better idea of how this issue could be resolved, we decided to talk to Emmanuel, the District Laboratory Manager, to hear his opinions regarding the issue. Fortunately, he was able to find some time in his busy schedule to meet with us and the Ilula Laboratory Manager, Naftal. We discussed the problems that we have noticed in our time at the Hospital. Both Emmanuel and Naftal agreed that this communication gap was largely a “failure in system tracking” that needed to be resolved for the betterment of the hospital and staff. After a very informative meeting with Emmanuel and Naftal, we decided that we had enough information to kick start our project with approval from them. This project was completed with the understanding that it would be easy enough to update on a weekly basis and continue after we had left the Hospital. Prosperity came up with the brilliant idea of creating a board called, “laboratory testing availability.” The idea of the board is to not only have all the available lab tests at the hospital, but also have the information regarding stocking (in/out of stock) and any other important information (example, CD4 – out of stock – reagent out). This white board can be easily updated weekly and can be presented to the medical staff during morning report. We are very excited to present this project to Emmanuel and Sovelo, the medical officer in charge at Ilula Hospital. This project will hopefully bridge the gap in communication between the laboratory staff and the rest of the medical staff and it is amazing to have Emmanuel and Naftal happily on board with it.

Final Supervision Visit for Second Year Nursing Students

Lauren and I had the pleasure of traveling with Tuli and Anifa, the nursing school teachers, to visit the second year nursing students for their final supervision visit. Although it was a long day of travel, the scenery surrounding us was absolutely breathtaking - which made the time in the car that much more worth it!

Loving the amazing views!!!!

So is Lauren!!

Our first stop was to visit the first three nursing students in a nearby village where the students were hard at work at the dispensary. We discovered that during the nursing students' four weeks at the site, that they had three different projects to complete that they would eventually be graded on. The first project was to either create or improve the labor room at the dispensary. The students were in charge of making sure the disinfecting material was properly changed and managed accordingly, labeling materials, and ensuring that the labor room meets appropriate code requirements. The second project involved improving the ease of use of the dawa (pharmacy). This was an especially meaningful portion of the trip, since the nursing school teachers requested our advice as to how the nursing students could improve the dawa. Some suggestions that we made included categorizing the medications into various sections (antihypertensives, antibiotics, etc.), labeling, and alphabetizing. We also suggested placing the bottles of the same medications in the appropriate order by expiration date where the date that is soonest would be in front and the farther off dates in the back. The third project was setting up hand washing stations at the teacher and student bathrooms and to make sure that they were in working order. The hand washing station was to be completely maneuvered by having a stick fashioned as a pedal to allow water to expel from the jugs so that hands could be kept clean and not contaminate the water jugs. The first site also took it upon themselves to complete a fourth project which was to find a new and clean water supply for a nearby section of the village. The teachers were very impressed by what the students had accomplished.

After visiting for a short while, we then left the students and the nearby village to go visit the second group of students in the village of Udekwa. This village was within the mountains, so traveling there took a large amount of time, but was worth the journey since the scenery was so beautiful. Once we arrives, the students were graded on their similar projects. We shared lunch that the students had prepared for us, which consisted of delicious noodles and beans. Shortly thereafter, we visited the nearby primary (elementary) school where we met several of the students. Tuli took the opportunity at the end of the school day to make a speech about "working hard to accomplish goals and reach your dreams". We thought this portion was exceptionally moving. Once visitation was over with, we made our way back to Ilula with the teachers and stopped on the way to grab some cooking charcoal and plantains for the teachers. Overall, it was an amazing experience being able to see the students thriving and helping the community. It also was great to have the opportunity to contribute not only to the students learning but to the betterment of the dispensary and community.
Below are some photos of the projects the students were engaged in.

Thanks for reading!

Prosperity and Lauren

In the Dawa_ Arranging the drugs

Student's Hand washing Project

In search of clean water source for the village

Sanitation buckets organized for the labor room 

Supplies organized for the labor room