Saturday, February 11, 2017

Mt. Meru Regional Hospital

One more week in Tanzania!

I spent this past week working mainly in the "Prime Unit" which is basically the NICU. I wanted to share a bit more about the hospital to showcase some of the differences and how little the doctors have to work with.

Mt. Meru Regional hospital is a government-run state hospital so all funding is allocated by the government. It is a tertiary hospital so it gets referrals from other smaller clinics and hospitals and offers surgical, OB-Gyn, and ophthalmology services in addition to pediatrics, medicine, and emergency services.

The pediatric wards (P-block) consists of an ICU area, P-1 which is for the kids who are sick and need observation but not really critical, P-2 which is for the kids who are almost well enough to go home, and the Malnutrition Ward. Then there is the Prime Unit with the critical babies, premature babies, babies under observation, and even a Kangaroo Mother Care unit (google it)!

Each ward is just one big room with a few beds, if there aren't enough beds then there are 2 kids to a bed. This is so scary to me because sometimes you have 2 really sicks kids sharing a bed, or you have one kid with TB meningitis in the bed next to a baby with pneumonia. There is also no such thing as heart monitors so if a child or baby in the NICU stops breathing... you don't know until someone goes to check...absolutely terrifying.

I spoke before a bit about how some of the pathologies I've seen here are ones not commonly seen in the US. All children are screened for HIV and malaria upon admission. There is an entire TB ward and all meningitis kids (which are a lot more than in the US) are also tested for TB. Diarrhea is usually a result of dysentery and typhoid. Most of the neonates admitted in the Prime Unit have "septic cords" after being delivered at home in non-sterile conditions. Even conditions that are typically seen as being pretty routine to treat in the US, like DKA, sickle cell, and pneumonia, become a lot more complicated and life-threatening when resources are so scarce.

Each morning all the mothers take the kids out into the courtyard so the nurses can clean the wards (except for the ICU) and then they come back in in time for rounds. If labwork is needed that our lab isn't able to do (which includes CBC differentials and basic metabolic panels...something done for almost every patient in the US) then the parents take the blood samples to other labs and bring back the results. The mothers also take the kids to radiology themselves if x-ray or ultrasound is needed (only imaging available here) and bring back the results. If they can't afford the cost, it doesn't get done.

The options for medicines are also pretty limited and the hospital's stock is extremely low so the doctors write prescriptions and the parents have to go to the pharmacy, buy the medicine, and bring it back to the hospital for the nurses to administer.

Because it is a government hospital it is where people come when they can't afford to go to a private hospital. Therefore, many patients are from poor rural areas, or are Maasai, which is the largest tribe in the area. This means that we see a lot of malnourished kids and kids who are really really sick after parents went several days or weeks without seeking treatment. Maasai are historically nomads and herders so there diet consists mostly of ugali (porridge made from cornmeal) which is also then sometimes mixed with cow blood (an intern asked if I wanted to try). So, basically, a diet without much protein and nutrients. Kids are then brought in bloated, severely underweight, anemic, and with Rickett's Disease (osteoporosis for kids...not good). More so if a new baby was just born in the family, then the next youngest may become more neglected. Yesterday I even saw a 2 day old with bloody gashes on his stomach that were Maasai tribal markings.

I don't mean to give the impression that anyone here is is unkind or neglectful. All the parents care about their children, all of these things are simply a part of their culture and they were never educated regarding the health risks that can result from some of these practices.

I must say the doctors here are quite astounding. The interns work incredibly hard and everyone makes the best of what is available to help provide the best care. It's certainly not easy.

Sunday, February 5, 2017

Tanzania - Week 1

Oh boy, where to begin?

I can't believe I have already been here one week! I have so much to tell!

If I had to say one thing about Tanzania it is that the people here are so incredibly nice and welcoming! As I mentioned on Facebook, the word I hear most often is "Karibu" which means "You are welcome". It is said in response to "Thank you", when coming home, when sitting down to eat, and to any and all guests and visitors.

The best example of the kindness of Tanzanians I have is when I first arrived. My flight got in at 2 am and there was supposed to be a driver waiting to take me to the house where I am staying. Up until this point I had had absolutely no problems traveling, which, if you know me, is kind of unheard of. All my flights were on time, I had no problems with customs or security (I usually get picked for special searches), and all my luggage made it! But when I walked out of the airport into the warm night air, I couldn't find my driver. There were many drivers there waiting to pick up people who were traveling for safaris and Mt. Kilimanjaro, but no one for me. I decided to wait for a bit before panicking and calling the contact numbers I had. As I waited other drivers kept coming up and asking if I was okay and what company I was waiting for. In other places, this could have been simply an attempt of others to drive me and overcharge, but here the drivers were genuinely concerned for me and wanted to help. When I got out my phone to try to start calling numbers one of the drivers took out his cellphone and started calling for me. He eventually got in touch with the director of the Child Growth and Development Center, Father Faustine, and it was arranged that I would be driven into town to meet him. It turns out there was confusion with my arrival date and they thought I was coming the next night. Despite the fact that I was by myself, at a foreign country's airport, at 3 am, I never once felt scared...I think I would have been more nervous in the same situation in the US.

I ended up having to spend the night at Father Faustine's parrish since the house was not yet ready. The next morning I had breakfast with Father Faustine and he showed me around his church. He told me a little about local culture and the mission of the CGD. He explained that women are still very much considered second-class despite the fact that they do the majority of work. Polygamy is also still common in rural areas and men like to have lots of children because then they have more animals and more prestige. But then women struggle to care for and support so many children. So the main mission of the CGD is to empower both women and children; to teach them how to raise themselves up rather than simply providing charity and then leaving. #girlpower

I eventually got to Tulivu House where I'm staying for the next few weeks. It's in a rural area between two villages (one of them is called Chekereni, because a railroad runs through it...get it? Chek-e-reni...check for train? Hahaha it kills me!), and about 20 minutes outside of the city of Arusha. The house is very nice and meant to sleep up to 6 people but since it's just me this month, the housekeeper/cook is also staying here so I'm not alone. There is normally running water and a shower but there has been an 8 month drought and so I'm currently taking cold water bucket-baths.

Actually, my first day here we got some rain, and then it has rained at least a little every day since (it's currently summer here) and so Father Faustine said that I'm a blessing since I brought them rain. You know where this is going right??

I blessed the rains in Africa. (mic drop)

Sorry, but you had to have known that was going to come up sooner or later!

Judita is the housekeeper, and guys, I swear she's like a ninja! I don't even notice that my shoes are gone until they're back in my room all clean. And she keeps me very well much food! She also always has hot water for coffee out on the table morning, noon, and night and gives me fresh mango and avocado with every meal because she knows I love them. I think we pretend to understand each other more than we actually do, but she is teaching me some Swahili and we go on walks to the villages some times.

I spend my days in the pediatric wards at Mt. Meru Regional hospital in Arusha. It's a government hospital at the state level (there national level hospitals as well). I'll talk a little more about my time at the hospital in a different post, and if you read my last post then you already know a bit.

I haven't ventured out much besides going to the hospital and around the house mainly due to a cold that kept me home-bound this weekend. It's also a little nerve-wracking to go out and explore on my own in the city. I stand out as a foreigner even though there are tourists here and so I get a lot of stares and people greeting me. Again, it's part of the culture of everyone being so welcoming, and I love having kids always waving and running up to say hello, but as someone who gets nervous even talking to people I know, it's a little unnerving having men come up and want to talk to me or invite me in for a soda. On Friday at the hospital someone walked up, asked how I was doing and then said "let's go!" When I asked where, he said "The canteen!"

But overall I love it here! Everyone is kind and so happy and grateful for whatever little they have. It's incredibly humbling.

My neighbors!

That's certainly plenty for now. I'll be back to talk more about the hospital and hopefully have more pictures!

Friday, February 3, 2017

The Laundry Basket

Let me say straight off, this is not a happy post or an easy read.

I will write a happier post tomorrow recounting and describing everything I've seen and experienced so far (with some pictures) so please feel free to just come back another day for less serious things.

But for now, I just need to write about this.

Over the past year, I've seen some pretty sick kids. I spent a month in the ICU at the Children's Hospital of Pittsburgh. I spent time on the Neuro-ICU service at CHOP. And I spent last month on the Pediatric Rehab team at DuPont Children's Hospital. I've worked with children that I knew were going to die, that were abused, and that were permanently impaired simply due to bad luck. But as odd, as it may sound to some... these are the patients I love to work with. That doesn't mean I don't feel it or that it is by any means easy. I can't begin to describe how it feels. But I want to take on the really sick kids because they need the most help; they have the most to lose. And they are proof that no matter how bad it can get, they are still just kids first and foremost.

But the kids I've seen already in one week here are a different kind of sick. We do see the typical pneumonia and GI bug kids (although more likely to be typhoid than just a virus) but we also see TB meningitis, severe malnutrition, heart failure due to rheumatic heart disease, and severe anemia. These are kids who are sick due to severe poverty and lack of resources. And while the doctors and nurses that I have worked with are wonderful, there simply just isn't enough.

On Monday we admitted a 5 month old with an ear infection. But she was also so malnourished that she was smaller than most newborns I've seen. It turned out that she was a triplet and all three were malnourished since the family couldn't afford to adequately feed all three. We admitted and treated her and she moved upstairs to the malnutrition ward. All three babies were with the mom in the hospital and on Wednesday the mom came down saying one of the other triplets had been eating and then vomited and had trouble breathing. We admitted this baby to the ICU (just a room with less beds and and closer to the medicine and oxygen concentrator) and hooked her up to oxygen but she had a low heart rate and extreme difficulty breathing. She was also severely dehydrated from having several days of diarrhea which we were not previously aware of. She was a sweet little thing, responsive only enough to wrap her tiny hand around my finger.

We went on with the rest of morning rounds and admitting new patients. Shortly before leaving, a worried mother came in with her 9 month old. She had had a fever and decreased appetite for a little more than a week and was brought in after having a seizure. She was given a dose of Valium to prevent more seizures and so when we examined her she was asleep but still arousable and responsive. She fit all the criteria for meningitis. After crouching down to examine her as she slept in her mother's lap, she kept stretching out her legs and resting them on my arm. So I sat there and held her little feet in my hand as we finished the admission. I took her and her mom to an ICU bed where we planned to do a lumbar puncture to confirm the diagnosis of meningitis. I went with my intern to try to go track down some blood for another severely anemic patient (the intern ended up donating her own blood since there was none). When I got back, the girl was still calmly sleeping in her bed with her mom and it was time for me to go home.

When I came in the next morning, I didn't see her anywhere and I asked where she went. I was told she passed away the previous evening. All I could think about was her feet in my hand.

But work for the day had to continue. I went to see the triplets. The little girl who was really sick was struggling to breathe and not reacting at all. She did not move or make a sound as we tried to get blood samples. I kept thinking how she should have been intubated and placed on a ventilator the day before. But there were no ventilators. Children don't get intubated here.

I went upstairs to start rounds with my intern, and when we came back down about an hour later, we learned she had also passed away.

I don't want anyone to think that the doctors and nurses and families here aren't unfeeling. Everyone was upset. But child deaths are not uncommon here, especially for young babies, so it's not necessarily a tragedy, it's just another part of life. We carried on with taking care of and admitting other children.

In the afternoon, I sat in the ICU. The curtains had been drawn around the baby's bed but I could still see the small wrapped bundle laying on the bed. Then a man and woman came in carrying a laundry basket. I watched as they gently placed the baby in the basket and covered and tuckered her up with a black cloth. The nurse asked the mother, still caring for the other two babies in the ICU 2 beds away, if she wanted to see her one last time. The mother said no. And then they carried the laundry basket away.

I knew this was something I would likely encounter here. In fact, it's partly why I came here. To learn from and help with and see the difficult cases. But it hurts so much. It hurts that children dying are not uncommon here. It hurts that both of these sweet baby girls would likely still be alive had they been in a hospital or country with better resources. I don't even know how to describe exactly what I'm feeling but I don't think I'll ever get the picture of that laundry basket out of my head.

I apologize to anyone reading this. It's not fair to put this burden on others but I needed to say something for my own sake.

And I also hope it may serve as a reminder of just how lucky we all are. So go hug your loved ones a little tighter for me please.