Another beautiful day

The days start out sunny with fluffy clouds in the sky and hazy over the mountains or are they very large hills? By 1 pm the dark clouds have rolled in and then the downpour begins. We can get 2 inches in a very short time and the water containers under the gutters fill very rapidly. The water cleanses everything, with small streams turning into rushing rivers. When it clears, the air smells fresh and all is bright again. The temperature seems to be high 70's and cools at night. Couldn't ask for any better weather! Adrianne

30jan2018 tuesday ilula, tz blog

30jan2018tuesday  ilula, tz blog/michael madalon reporter today (he doesn't have a google account and likes  small case letters....deep apologies)

education is a progressive discovery of our ignorance---- will durant (this is a quotation on the cover of a child's writing pamphlet....the pamphlets are used as the medical record for inpatients on the hospital general ward)

the rosy fingered dawn is about the same as last year....the avian morning alarm clocks (read roosters) start crowing about 04-something....often the first bell chimes at 0545 and the second longer bell chimes at 0600, but some days the clangs are also earlier....cole had already started his lengthy run by then, but margaret, lisa, and michael start theirs at the usual 0615, all to return to the guesthouses about 0715 to prepare for the day

anna's 0730 breakfast today includes warm hard boiled eggs, fried donuts, a local cooked sweet potato, and of course, coffee or tea....bananas/peanut butter are always available as well

the half hour weekday worship service at 0800 in the hexagon room has about 30 hospital staff attendees, but our crew tends to be a tad late....this could be because it is in the swahili language....the service is followed by the morning report for the medical/nursing staff (a case today discussed a 17-25 week pg abdominal bleed patient who was hypotensive even after 5 liters of nss....transferred to iringa)....our group has had some discussions about the format and use of the morning report (the quality seems variable and purpose unclear)

the morning report room has 2 wall boards with hospital information (lab test availability and hospital event tracking for the previous day).....presently creatinine, sickle cell, iron, gram stain, and cryptococcus testing are unavailable....the hospital had 157 opd visits, 58 ipd visits, 13 admits, 20 discharges, zero deaths, 5 vaginal births (no c-sect), zero neonatal deaths/sepsis, 3 injuries, and 8 dental visits on 29jan2018

after the report ken directed a tour to the underground mortuary (although it was locked) followed by a brief tour of the laboratory guided by one of the technicians there....the lab was fairly neat and looked organized

elizabeth and bree then attended the ctc clinician/patient visit for  follow up and drug refills (adult hiv clinic) while the remaining members (cole, addrienne, lisa, margaret, aneudy, michael )of our group made up 2 teams (with medical staff members benjamin and kiwono) for general ward rounds until completion about 1230....cole also performed a chest/cardiac ultrasound for one of his team's heart failure patients (wider use of ultrasound skills would be very useful here)....rounds would not be nearly as colorful were it not for the dresses, wraps, and linens that the ladies wear and bring to the hospital....the top ten admission categories (as listed on a ward room poster) are, in declining frequency, malaria, accidents, diarrhea, pulmonary tb, pneumonia, asthma, hiv/aids, anemia, congestive cardiac failure, and stroke

anna's lunch included spaghetti and white rice, mushroom sauce, potatoes + sauce, beans, and avocado

the quarterly hospital staff conference in the hexagon room was to start at 1400, but was a bit late....many of our group attended....it was mostly in the swahili language and lasted until 1645....it was difficult to endure

before today's evening meal most of the group took our customary late afternoon hike to some part of ilula or surrounding land....these walks have little purpose short of an excuse to explore together so we do for an hour or two....thus far we have not been inclined to stop at an amber fluid parlor (safari, kilimanjaro, tusker, etc.)....so it goes....there are a few healthy and similarly appearing dogs around and even fewer scrawny cats....some of the trees around ilula look like they have been through a lot, could be described as gnarly, and likely have stories to tell

ken provided an exciting and early evening film to watch ("taken 2") and this kept our attention until anna and the kitchen crew served us her special potato-egg pancake, spaghetti, a bowl of roasted meat nuggets, and  avocado and mango chunklets

it seems to rain nearly every day, enough to give the soil a good soak

the purpose of education is to replace an empty mind with an open one----malcolm forbes (another writing pamphlet quotation)

signing off, michael

Magafuli Day

That was last Saturday in all of Tanzania. In fact, every fourth Saturday is Magafuli day, from 7 AM to 10 AM. All citizens and a few wazungu visitors are expected to participate.  This is a litter clean-up and general effort to spruce up Tanzania.  Each person does something to help improve their area. In addition to the routine cleaning that people do, additional efforts are made on Magafuli Day. I haven’t seen any signs that say, “The following mile is supported by…,” however.

Wazungu wazee Adrianne na Dr. Ken

For this brief blog entry, I submit a photo that demonstrates the wazee contribution. Mzee (singular and wazee plural) is the Swahili word for “respected elderly.” That’s what my Tanzanian friends tell me when I ask them, but that may be more connotation than denotation, since all I can find online for mzee is “old person,” and perhaps closer, “elder.” Regardless, I am mzee.

Adrianne and I joined the crew “mowing.” Both of us suggested goats would be a better option. We thought a mobile pen would be optimal. The administrator assured us that no animals would be allowed on the hospital grounds. I had noticed there were fewer cucu (chickens) around the hospital proper than in previous years, though there are still a few that will likely be invited for dinner at some point.  Of course, there are many around the grounds away from the hospital and they grace us each morning with their wakeup calls.

Late entry!

Observations on the laws of Physics at Ilula:

Fighting entropy and fortifying gravity

 

Saturday 13Jan2018

 

For a moment I was sure we were fighting the forces of entropy as chaos was beginning to erupt during the health assessment session we were doing for 40 children at the Huruma orphanage on Saturday.  As I understand it, entropy is the universal force that drives everything from a state of organization into an increasing state of chaos.

Huruma Orphanage is an Iringa Diocese Program supported by Minnesota-based Friends of Huruma.  We had been asked to provide health assessments for the 40 children ages 5 to 15.  The hospital medical director, Dr Sovelo organized an agenda and appropriate laboratory investigations to provide for the children.  Things started out well organized.  We had a diverse team including an Ilula physician, nurse educator and lab staff, six nursing students to function as interpreters and our team.  We were greeted with song and performed introductions. We began with health education for the children. Dr Damaris, from Ilula, spoke about several health and sanitation issues with the children and Nurse Sophia, also of Ilula, gave a breakout session to the older children regarding sexual health and HIV.  Then we proceeded to the health assessments and that is when the physical force of entropy became evident.  We tried to herd 40 energetic kids into getting registered, getting heights/weights, having labs drawn, having a vision test and having a physical exam.  Kids were running around everywhere and we were chasing after them: “this one needs a vision screen; has this one been to lab yet? I need an interpreter for this one…”.  Anne and a nursing student manned the registration table, Bri and Elizabeth performed heights and weights; Evan and Mary ran the vision station and the physicians (Dr Damaris, Jen, Gary, Abby, Lindsey and Randy) performed the physical exams.  Amazingly, we got all the children thru each station and completed vision tests on all who could read.  Fortunately, an extensive laboratory battery of tests did not identify any serious health problems; several children will need glasses; we issued a handful of prescriptions for minor infections.  We learned a lot about how to organize such an event

 

Currently we are working on fortifying our gravitational influence as other team members begin coming to Ilula.  Gravitational force is that physical force that draws a body into a larger mass or energy.  The first team to Ilula this year has congealed into an impressive unifying energy/mass and we are looking forward to drawing others into this energy; Dr John Kvasnicka is drawn to us Sunday;  Dr Jose Debes and Tara Rick arrive on Tuesday.   The rest of the team arrive on Wednesday when  our gravitation pull will swell to twice it’s size!

1/27/18

This morning from 7am-10am (which corresponds to 1-4 o’clock Tanzanian time given the day starts at sunrise) we rounded on only the sickest patients and helped “clean”.

One day a month the entire country of TZ is now mandated to clean for three hours one Saturday a month (per the new government). This includes hospital staff; no one is known to be exempt. Many men used long scythe-like tools to hack down grass (their version of cutting grass) and females cleaned indoors.

We are now down to 10 people in our group, this will be unchanged for at least another week.  Many of us go for a walk/run as the sun rises each morning. When not cloudy the view is incredible. Our breakfast over the past few days is unchanged, consisting of mostly carbohydrates. This has been more tolerable recently as we’ve cut up ~5 mangos daily to eat each afternoon.

We received a phenomenal 2 hour introduction to Swahili course taught by a local named Joyce.

Yesterday and today on the general medicine wards we saw interesting/heartbreaking patients.  In regards to the general wards (which do not include outpatient clinics or obstetrics/L&D), there are separate rooms/units for general pediatrics, children with malnutrition, infants with breast-feeding mothers, patients with known/suspected pulmonary TB, HIV/AIDS positive patients, and adults with uncomplicated illness. Men and women are always in separate rooms.  There are far more adult patients then pediatric patients..

Recently the hospital has been filled to capacity; yesterday there were reportedly 23 admissions over 24 hours.

Some of the patients over the past day include a 4 year old HIV+ boy with SJS of his face/eyes (a drug reaction to HIV medication resulting 2nd-3rd degree burn-like injuries) and bilateral secondary orbital cellulitis, 2 year old orphaned severely malnourished boy with kwashiokers, a middle aged rice farmer with presumed moderate systemic schistosomiasis and marked anemia from a GI bleed, a new diagnosis of pulmonary and extra-pulmonary TB (in the setting of not completing TB treatment a few years prior), a middle aged farmer with acute encephalopathy and lower extremity paralysis/paraparesis concerning for  Guillan-Barre vs B12 deficiency vs viral encephalopathy, a new diagnosis of acute/chronic liver injury with marked jaundice, a 25 year old female with acute onset mutism and probable new diagnosis of bipolar affective disorder, a 30 year old female with mutism and probable new diagnosis of schizophrenia, and 5-10 cases of complicated malaria and diarrheal illness. I was surprised to learn that mutism seems to be a common presentation of psychiatric disease.

Of note, two days prior I met with Pastor Nixon Mwitula of Iringa. He is finishing his training as a combined psychiatrist/psychologist; his University is the only training program in TZ mental health. He had a lot of insight into the minds of Tanzanians and shed light onto why mental health, substance abuse, and domestic abuse are so neglected in TZ. Our conversation was slightly reassuring.

Previously, when I asked one of the head physicians in Ilula about mental health and addiction, I was told, “there is no addiction, not here in Ilula”. Those with chronic or transient mental illness are termed “crazy people”. On the wards mental health, substance abuse, and domestic abuse are not addressed; they are rarely even acknowledged.  The lack of awareness/education about these subjects by all Tanzanian healthcare providers is astounding. In addition, even if mental/social health were to be touched upon treatment, psychotherapy, and behavioral therapy are not available. In regards to these issues, it seems TZ is ~50-100 years behind the US.  It was comforting to discover there was at least one University or location to address mental health and addiction (Iringa).

Also of note, we had a long discussion yesterday about the state and progress of Ilula’s hospital. We recently visited Tungamalenga dispensary, which had remarkable cleanliness, documentation, record keeping, and organization. This is superior to that at Ilula despite having fewer resources.

Early Mornings

A group of us have been running down in the valley in the mornings before breakfast and rounds. Some of us jog and some of us walk, but it's always an adventure. Yesterday morning, Michael, Margaret, and I were joined by a group of children from the nearby primary school. While we wazungu were panting and wearing running attire, these children were wearing sandals and sweaters and running without any difficulty whatsoever. When we ran into the valley this morning, we had a gentleman run with us for a wee bit. He was wearing sandals and jeans and carrying a garden hoe, yet had no problem keeping up with us before heading out to the field. 

We usually head out before sunrise to avoid the heat and go past several fields of crops. Farmers are always out tending to their fields and since it's been quite the rainy season, the crops seem to be growing well. There has been some flooding in the area, but most of the crops are far enough away from the river that it doesn't seem to be causing too much damage yet. We have provided the Tanzanians with a lot of entertainment. Running for exercise is an unfamiliar concept to them and oftentimes they laugh at us, especially the children. Everyone we meet on our path is friendly, though. Even if they don't greet us verbally, they acknowledge us with a wave or a head nod. I haven't brought my camera with on a run yet, but I'll be sure to do that in the future!

Tomorrow morning we probably won't go for a run since we'll be helping the community with clean-up. On the last Saturday of the month, the entire country of Tanzania performs a few hours of community service. Based on the most recent update, the females within our group will be cleaning up the hospital and the men will be cutting grass/doing outdoor work. More to come on this topic!

African Adventures

Wednesday, January 24th, 2018

We just arrived back from safari and the medical conference and are back on the wards seeing patients at Ilula. The safari at Ruaha National Park is always a highlight for students and staff alike and this year was no different. It also marks being just over halfway done with the Ilula Health experience and is a good transition point for students.  We spent a total of 2 days on safari, including early morning sunrise and evening sunset trips. Our safari vehicles fit 7 people and have open sides with unobstructed views of the beautiful vistas in front of you. Some of the highlights from this year's safari included seeing a leopard with a fresh impala kill in a tree. The leopard will be working on eating this impala over 3-4 days and it was an impressive site to this strong animal feed out of a tree!  We also had a chance to eat gourmet meals and have a hot shower in a four star canvas tent setting overlooking a river where a giraffe was sighted nearby...not too shabby.

We slipped and slided around in the mud one morning after a heavy rain and one of the groups got stuck in the mud 8ft from a male and female lion. They called for help and the second safari vehicle bounded to the rescue, only to get stuck in the same place. Luckily these two scenarios scared the lions who decided to leave the scene (thank goodness) and watch from afar. This allowed the drivers to rescue the vehicles from the mud, and the safari goers to continue their journey and start to relax again. Great views of lions mixed with African adventure....and a lifetime of stories. Other animals viewed on the trip included elephants, black spitting cobra snakes, impala, kudu, zebras, baboons, several exotic birds, hippos, croccodiles, and the previously mentioned leopard.

Tanzania is place where beauty, adventure and flexibility are found at every turn. Now it is time to get back to patients and staff at Ilula.

Twinde!

Kristi

A much different day at Ilula

 Although we could consider today pretty routine at Ilula for what we saw and did, it was much different than Sunday.

I do not always go to devotions, but did today. Pastor Kikoti leads and prays and sings. After all these years, though I do recognize hymn tunes and a few words, I still do not really know what he or anyone else speaking Kihehe or Kiswahili, is saying. I learn some vocabulary each visit and some phrases, but no grammar. I am sure the pastor is patient with us wazungu, if not indulgent. Indulgent would be speaking in English, which he knows, or translating along the way.

The group is still at Ruaha National Park and will be home tomorrow evening. Mwamoody, Dr. Gary Moody’s Hehe name, flies out in the morning and will be joined at Ruaha by several of our group. Mwamoody means head of the Moody clan within the tribe, though not quite chief. Regardless, it is a title of esteem bestowed on him.  He has earned it, learning considerable Kihehe and Kiswahili over years.

After Morning Report, which I find leaves a little to be desired, we went on rounds. I think Morning Report is much drier than it needs to be. Many of the statistics are posted on the board, so the report is also redundant and repetitive. (Did you see what I did there?) But there is a little time spent on troublesome cases and deaths, and not dry at all.  The doctors and others ask questions and discuss the case.  This is similar to report that we do at home. Now if we could just skip the redundancies. Oh well, it is their report.

 

Deo, head nurse of the General Ward.

I went off to rounds with Dr. Shangwe and Dr. Glory, two bright young women doctors. (By the way, I have a right to refer to them as young!)  We were in the Post C-section ward. Everyone was doing well and only one patient to a bed at the moment. Here is an odd situation. Technically, mothers delivered, whether by C-section of vaginally, are supposed to be covered financially by the government, along with children under five years and the elderly (that means over 60!). One mother had been in the hospital for the 7^th day.  First, I do not think that everyone understands the coverage, but the story was that she was waiting for someone to come and pay her bill. Sounds like debtor’s prison to me.  I do believe there is some element of patients voluntarily paying what they can, however. What I have heard before and choose to believe now is that she has stayed a long time due to her home being at Image (pronounced ee-mah’-gee, not im’-aj, as in English), which is a very long distance away. This is just a quirk of distances, quality of roads, etc.

I saw Michael and Dr. Benjamin pass by the window and went to be with them. I spoke with one of the ward nurses for a bit and then joined them at the bedside of an undernourished baby. We had some conversation about the various formulas and Plumpy’Nut, also a Ready to Use Therapeutic Food (RUTF). Of course, I whipped out my MUAC tape and asked to measure this pretty little girl’s arm (Mid Upper-Arm Circumference). And yes, she was in the yellow, fortunately not the red. She was with grandma (Bibi) as mother had died in child birth with her.

We saw several challenging cases, but the most challenging was a young woman with KS, Kaposi’s Sarcoma, a malignancy now nearly exclusively found in patients with AIDS. It is treatable, however, the drugs are not available at the level of the Council (or District) hospital.  Essentially, we cannot treat her. Dr. Benjamin presented her with the option to be transferred to the Regional Hospital in Iringa, however, even the Regional Hospital has no access to the oncology drugs. She got the prescription and first round of drugs at a private hospital, Tosamagonga, but we cannot transfer laterally, i.e. to hospital in the same category as our own, only upward.  That hospital is truly “private,” whereas ours, as a district hospital needs to play by the government’s rules (if we could, in fact, get the drugs).

So here is the medical culture shock question: what do we do if she chooses not to go to the Regional Hospital?

Our colleagues do face situations similar to our own. We saw two patients, one 98 and one 101, near death. Both were offered tube feeding. I think the loved-ones both chose “no.”

Challenges will continue tomorrow. I am sure our residents and pharm students will have their own perspectives and equally dramatic stories.