28 hours on call at Selian

February 23-24, 2010

They say that no American residents or medical students have taken call at Selian in a long time. The American preceptors offer to the volunteers the opportunity to take call, but no one has taken them up it. And why is that? Well, the hospital is not exactly set up for overnight Westerners. There’s few places to sleep that are decent, there’s no food, no source of clean water, minimal lighting between the buildings, and overwhelming mosquitoes with inadequate screens on the windows. It sounds like a pretty miserable place to spend the night.

Although I have been experiencing plenty during the daytime, our rounding teams are so large with Tanzanian interns, upper level residents, advanced medical officers, and American volunteers, that I have struggled to find a place to immerse myself in order to get the most out of my four weeks here. Being in family medicine is both a blessing and a challenge--while the other volunteers have specialized interests and skills, such as in pediatrics, OB/GYN, or surgery, I am a generalist. I can work in any department and would like to gain experience in all parts of the hospital--adult medicine, pediatrics, and OB. However, four weeks does not allow a whole lot of time to do this. After spending my first two weeks on the OB service, I started to feel like I was missing out on the adult and pediatric services. I am going to start on medicine this week, but that means rounding with the large ten-plus-person team in the mornings. In order to get my hands on some admissions and emergencies, I knew that the best way to do this would be to take an overnight call.

Sanaa is one of the brightest interns of the current group of Tanzanians in training. She typically takes call every fourth night without an upper-level resident in house, meaning that the doctor’s call room is available. A group of Colorado volunteers just installed new screens on the windows of the wards as well as the call rooms, thus the timing was perfect for me to move into a mosquito-free space. On the morning of call, I packed up three bags of gear to survive the night--clean water, food for dinner and breakfast, mosquito net, head lamp, bug spray, scrubs, and reference books--and headed to the hospital for the next thirty hours.

8:30am--Morning report, which included a special presentation on neonatal resuscitation by a visiting Minnesota pediatrician.

9:15am--Rounding on OB starts.

10:00am--Nurse calls us urgently to OB. Leaning her ear down onto the rudimentary fetoscope, she hears that the baby’s heartbeat is very slow, less than 100 beats per minute. The portable bedside ultrasound that we miraculously have in the unit shows that the baby’s heartbeat is 80 bpm, far to slow. We call an immediate stat c-section and run to the OR to tell the staff to get ready. Within 15 minutes the OR is prepped, which is quite fast on Africa-time, and we are scrubbed and cutting. I am first-assisting, and the OB resident I’m working with has the baby out in less than 60 seconds from the first incision. The newly-educated neonatal resuscitation team is there and the baby’s heartbeat is 30 beats per minute--the baby is practically dead. They resuscitate her and bring her back to life. Our emergent operation left the mother in a mess, so we spend over an hour repairing the extension of our initial cuts. The baby survives and within hours is out of the incubator and with her mother who is recovering well.

11:00am--A second woman in labor has gotten stuck at 7 cm for the last several hours. When her water broke, there was thick meconium (or baby poo) in the fluid, which can cause respiratory problems for the baby. Given the limitations of resuscitation here, we decided to do a C-section. I assisted again in this surgery and everything went well.

2:00pm--The other American volunteers leave for the day. I am anxious to see them go as I won’t have them to lean on during my call!

3:00pm--Called to see a man who was admitted earlier in the day. He is very ill-appearing and is in respiratory distress. His oxygen saturation on room air is 65% (normal is above 93%). We put him on oxygen and check out his chest x-ray seeing that he has signs of TB. We start him on anti-tuberculosis medication and increase his antibiotic regimen. His saturation rises to 79%. With no treatment beyond oxygen, there’s not much else we can do.

3:30pm--We admit a 74-year-old woman to the medical ward with advanced cervical cancer that has diarrhea. I just had her on the GYN service last week so I know her story. Sanaa writes up her admission note and we talk to the family about getting her set up with hospice for symptom management at home.

4:30pm--A 2-year-old boy in the outpatient department has a broken upper arm above the elbow--a displaced supra-condylar humerus fracture. We lightly sedate him with valium, reduce his fracture, get his arm as straight as possible, and put a back-slab cast on it. All while he is screaming. His mother comforts him by saying in Swahili, “Look at the Mazungu (white person).” I feel like a circus monkey. The x-ray technician has left for the day and this is not an emergency, so the patient will come back tomorrow for another x-ray to make sure his fracture is lined up well.

5:30pm--A dalla dalla bus pulls up in front of the hospital with a family carrying a 15-year-old girl who is unconscious. Within 20 minutes she wakes up and acts normally. After getting the full story, it sounds like she is having seizures, but we have to rule out meningitis and malaria. I write up her admission note while Sanaa does her spinal tap.

7:00pm--A few admissions have come to the pediatric ward through the afternoon, so finally Sanaa and I have the time to tackle them. She admits a baby with gastroenteritis while I admit a 6-month-old with respiratory distress, likely pneumonia. I put the baby on ampicillin, chloramphenicol (which is no longer used in the US), and albuterol nebulizers. Luckily, a medical officer student is on call with us to translate for me.

9:30pm--Dinner! The interns invite me to their house behind the hospital for chicken, vegetables, and rice. They always eat together and include the intern on call. I don’t have to eat my pre-made peanut butter and jelly rolls.

10:30pm--Throughout the afternoon, four women came to the OB ward in labor. The OB nurse sends me a text message (on my borrowed cell phone), that one of them is ready to deliver! I run out of dinner and make it in time to deliver the baby. A girl! The woman suffers a terrible second degree perineal tear that takes hours to convince her to repair. In the end I repaired it, she was grateful, and she named her baby Jackie. This is a story that I will tell later…

3:00am--Two of my other laboring patients have mysteriously been stuck at 4cm of cervical dilation since they were admitted in the afternoon. I start them both on pitocin via IV. There is no electronic fetal monitoring here, so I keep my fingers crossed that the babies will tolerate it. The only monitoring is my ear against a plastic cone fetoscope next to their bellies.

3:30am--I go to bed and set my alarm to wake up and check the laboring patients. The doctor’s room is comfortable and quiet, and there is a mosquito net already hanging. There is a decent-sized spider on the ceiling in the bathroom, but I am too tired to care. She will eat the mosquitoes for me. (Those of you who really know me will understand that I must have been exhausted to not care.)

5:30am--Alarm wakes me up. I walk in the dark with my headlamp up to OB. One of my laboring patients is in a constant contraction of pain from the pitocin--hyperstimulation. The OB nurses don’t even know what that means. They look perplexed. I turn down the drip, but then decide to turn it off. She goes back into a regular pattern of contractions every 2-3 minutes. The other woman is barely contracting. Her pitocin drip is increased. Neither of these woman have made any cervical change. Another laboring patient has also been admitted, she is at 6cm.

8:00am--I check all three laboring patients. The first two still have not changed, but the babies have normal heartbeats and seem to be doing fine. I turn all pitocin off. I will talk to the team about doing C-sections. The third woman is at 8cm of dilation.

8:30am--Morning report. I present the admissions I did last night.

8:50am--The morning OB nurse Dorah pulls me out of morning report. The first laboring patient is having trouble--Dorah believes the baby is in distress. I grab the ultrasound and check for the heartbeat--it is too slow at 100 beats per minute. We call the OB team together and decide on an immediate C-section. The intern on the service and the upper-level resident does the surgery, while I and the other American resident prepare to resuscitate the baby. The baby comes out crying! We all sigh in relief.

10:00am--The second laboring patient has made no cervical change despite pitocin. We determine that her pelvis must be too small which is keeping the baby from descending. The team takes her for a C-section. Both the mom and the baby do well.

10:30am--The OB nurse Dorah calls for me in the operating room--the third laboring patient is ready to deliver. The delivery is smooth and uncomplicated. A baby boy is born.

12:30pm--I’m tired. I feel done. At home I would be meeting the limit of work-hour restrictions. For once, I decide to abide by this rule. I catch a ride with the other Americans home.

Hospice and giving bad news

February 18, 2010

In the local Tanzanian and Maasai culture, bad news is a taboo subject. On multiple occasions in the hospital, I have witnessed this difference in custom from my own. I have helped to care for a premature baby girl who was delivered by C-section at 28 weeks because her mother’s placenta abrupted, or dangerously separated from the uterine wall. The baby’s name in Maasai means “Blessing.” Day after day she has been struggling to survive, sharing one of two functioning incubators in Selian Hospital’s “NICU.” Yesterday, after finishing a 10-day course of antibiotics for sepsis, she was gray and barely breathing. Resuming antibiotics, giving oxygen by nasal cannula, and starting medication to stimulate her breathing was all that we could offer her. Amongst the group of American and Tanzanian residents and medical students, we prepared ourselves for her likely impending death. I suggested that the Tanzanian intern explain to the mother the situation in Swahili. She curtly responded, “No, I cannot do that,” and walked away.

I returned in the afternoon to check on the baby, and she was in her mother’s lap attempting to take drops of breast milk from a syringe. She continued to look awful, barely breathing and unable to swallow. Again, I asked the nurse to explain to the mother in Swahili that her baby was very ill and even though we were trying everything possible to help her, she might not survive and she should prepare herself. The nurse rattled off in Swahili to the mother. She then looked at me and said, “I told mama that everything is going to be okay,” and turned away.

Despite this cultural resistance, Selian Hospital has become the epicenter of a hospice and palliative care movement in Tanzania. Today, I had the incredible opportunity to join the hospice team on a home visit. Ten of us climbed in a truck and drove up into the hills of Maasailand--the Tanzanian team included two palliative-trained nurses, a clinical officer in training, a social worker, and a community volunteer. While we waited in the truck for the patient to give permission for us Americans to enter her village (Wazungas, or white people, would perhaps draw unwanted attention to her), I opened a conversation about the local refusal to discuss bad news. Tumaini, one of the hospice nurses, explained that indeed her people were afraid of hearing about diagnoses or poor outcomes. She said that most would prefer not to know, to keep the truth hidden away from their own minds and the attention of their family and friends. Since the hospice service was created, this team serves thousands of patients in the community who are suffering from either cancer or severe, uncontrolled HIV. Tumaini described that the team approaches discussion of illness at a slow and cautious pace, taking cues from the patient and family about how much to disclose and when. She said that it often will take five or six visits with the patient to establish trust and friendship before the severity of the diagnosis can even be explored.

Sitting in a circle in one of two tiny rooms of her mud brick house, we listened to the translated story of Elizabeth. Her husband died last year after a long illness, leaving her with six children. After several hospital admissions for supposed malaria and multiple sero-positive tests that she refused to believe, she was diagnosed with HIV. She connected with the HIV clinic and just two months ago started anti-retroviral therapy. At that time, her CD4 count was 36 (in a normal healthy person, the CD4 is above 350). This was the first visit from the hospice team, and she was shy, concealing herself and her child in the darkness behind the door. The hospice nurses reviewed her medications--she assured them that she was taking everything prescribed. But this afternoon happened to be the time for the HIV clinic at the hospital, and she had forgotten her appointment.

The nurses then called upon me, the only physician in the group, to review and record her history and her symptoms, and to examine her. When I shook her hand, she smiled and stepped out from behind the door into the light. She then allowed me to examine her, sitting on a low stool in her cooking room and then lying on her bed abutting the muddy walls of her dank bedroom. As the hour-long visit proceeded, her face and body relaxed, becoming more comfortable with our imposing presence. The nurses then fully addressed her emotional and spiritual state. She felt she was coping better than several months ago, but she still had not shared her diagnosis with those in her village. We prayed over her, saying the Lord’s Prayer in Swahili, and the team sang out in bright tinny voices a hymn they all knew by heart. In the end, we decided that it was most important for her to make her appointment at the afternoon clinic. So she gathered herself, left her children with the neighbor, and climbed into the van to ride straight to the hospital. This is the first of many hospice visits with Elizabeth, but clearly a door was opened by the team that will allow her to regain her health and her confidence about living and surviving with her disease.

The Trek to Seliani

Selian Lutheran Hospital is approximately 3.5 miles from our house in Il Boru. My housemates love to walk in the mornings, so I have been joining them on the hour-long trek through the hills of Arusha into Maasailand. Not only is it good exercise, but walking is a great way to explore the area and be part of the community. In one hour walk, we say "Habari" (the Swahili greeting meaning "How are you?") about a hundred times. The children laugh and scream when we go by, shouting "Mazungo!" (Swahili for white man), sometimes grabbing our hands and walking with us. As the road approaches Selian, which is on the edge of where the Maasai live, we see elderly Maasai men and women with stretched earlobes and beaded jewelry, wearing draped plaid cloth and walking barefoot. Once out of the city, the rural road reveals an incredible view to the north of Mount Meru, the 15,000-foot sister mountain of Kilimanjaro. Jason climbed Meru in 2001 when he first visited Aunt Nancy.
Nestled among tall shade-bearing pine trees and fan trees, Selian Hospital is a small campus of buildings on two quads. There's the medical and pediatric ward, the OB ward, the surgical ward and ICU, and three operating rooms. The patient rooms have 10-15 beds each--often which have two patients per bed in the pediatric ward. Routine care includes daily rounds by the team and nurses, and medication administration by the nurses. Vital signs are not routinely taken except when requested by the physicians. Intensive care at this hospital includes more regular nurse monitoring with vital signs taken every four hours and the option of giving oxygen up to four liters, but there are no ventilators. The neonatal intensive care unit is a small room with three working incubators, often which have two to three babies per incubator. The hospital has an intern training program, and currently four interns are at the hospital, taking call every fourth night for the entire year! On call, they cover the whole hospital--all admissions, any problem deliveries, and emergency surgeries. If they are in over their heads, they contact the Registrar on call, who is one to two years out of intern year. The interns do not get the post-call day off; they have to work every day. Luckily, they all live behind the hospital and often help one another out if the person on call is swamped.

And we think that we have it bad being US residents!

A Day in the Life in Il Boru

Now that it is Saturday, I finally have the time to sit down and tell the details of our life here. We live in a comfortable house with a beautiful yard in a neighborhood called Il Boru, on the northeast side of Arusha. Our house has four bedrooms and can sleep six people. Right now there are five of us here--Jason and I, two 4th year medical students from Wisconsin and one 3rd year pediatric resident from South Carolina. Our housemates also include many geckos big and small (we just had a 1.5 inch one crawling on a laptop), huge slugs and snails in the garden, and two stunning tortoises that roam the yard.

Communication has progressed leaps and bounds since we were last in Africa. Our house has a direct internet connection that continues even when the power is out! And a visitor from the past left a wireless router, so we are all connected at once. Everyone also has cell phones and constantly sends text messages as that is the cheapest way to communicate. Jason is enjoying using a phone that his parents bought when they were here in November and is becoming agile at texting quickly.

Otherwise, our way of life is as we hoped and expected. Our kitchen has a refrigerator and a stove, but we light the gas burners with a match. We boil all of our drinking water and soak our vegetables in a mild bleach solution before eating them. Laundry is done by hand and dried in the open air. The house has a long tradition of hiring local folks to do chores--so we have a housekeeper who does laundry, cleaning, and dishes, and a gardener who mows the lawn with an
Amish mower, just like we have in Lancaster. We have nightwatchmen as well, to whom we take "chai" (what they call regular tea) in the evenings. Talking with our nightwatchmen makes me think fondly of Etienne, my nightwatchman and close friend in Cameroon.

Jason and I have a comfortable bedroom with a large closet and our own bathroom. We just got rid of an ant infestation in the wood frame of the bathroom window! No wonder there were so many geckos in the bathroom. The photo below on the right is the view from our window with an example of the gorgeous foliage of Arusha.


And here are our yard pets--two tortoises, one big and one small. We wondered about their gender, and then they started doing this... And we still wonder about their gender.

on the ground in Arusha

We have arrived in Arusha! So, much about Africa has changed since I was last on this continent---we have WIRELESS INTERNET in our house and everyone has cell phones (even us, thanks to Jason's parents who gave us the one they used in November). But so much is the same. The roads are crazy, roosters crow at 5am, weird versions of Titanic music are blaring at odd hours, and we are back to boiling water.

After 2 delayed flights that actually got us to Kilamanjaro Airport in one piece with all of our bags in tow (the happy luggage dance was done by J&J), we were welcomed with open arms by Jason's Aunt Nancy. Nancy has been a missionary with the Lutherans in Arusha for 30 years. She teaches English and Communications at the Makumiro University College in Usa River. We spent the night with Nancy, then enjoyed most of the day with her--eating avocados, enjoying her 3 dogs, touring campus and meeting her students.

Nancy then drove us to Arusha which is about 16 km from her campus. Arusha is much larger than Kumbo in Cameroon where I lived in 2004 and it is bustling! Our house is on Il Boru Road on the north side of Arusha--this is an unpaved road that goes up a hill but is packed with people, cars, bikes, motorbikes, and more dogs. We are living in a large house with 4 bedrooms and 3 US girls--2 med students and 1 resident...only one girl is here right now as the others are on vacation in Zanzibar. She is helping us to learn the ropes of this place.

Time for bed as tomorrow is my first day at Selian. Jason plans to head into town and work on groceries. We need to rest up and sleep off jet lag.

Photos: Jason and Aunt Nancy at Makumira Univ College, Nancy's house and "garage," and Nancy in her office creating an exam for tomorrow!

Behind all of those tomatoes, this is my family portrait. The one in the middle is my husband Jason, and the furry one on the right is our wild Australian cattle blend of a dog, Nellie. She's named after the HMS Nelson, a WWII British battleship. Yup, that's right. It's a long story.

Greetings! Welcome to the second blog of my life. For years, I have been intending to create a blog about the epic training that goes into becoming a doctor, specifically a family doctor, but instead life and procrastination took over. However, I am now on my way to Africa for the second time--this time to Tanzania. For some reason, travel causes us to stop and reflect more than we usually do. Looking back to the early days of blogging, my previous journal still exists from my adventures in Cameroon in 2004. Check it out at: http://cameroonjackie.xanga.com/ It's fun to look at this. I am now 6 years older, braving a trip to the dry continent with longer hair and without nuns to welcome me. I am now on the other side of the mountain of called medical school. I am also married and taking my husband with me. I guess I can no longer call myself "Cameroon Jackie," but perhaps the goal of this blog is to define what else I can call myself these days other than a family medicine resident.