Saturday, August 15, 2015

Amekua!

Jambo from Arusha! Hope all is well amongst you! I am writing to you today at the one-month mark of my time here. The learning curve has been steep in the past few weeks. I have been challenged in many ways, especially working in the Neonatal ICU at Arusha Lutheran Medical Center. As I mentioned in my previous email, the NICU at ALMC is a really incredible place. Even since I last saw it in February of this year, they have made great strides in caring for sick newborns in this young city. Another great joy that I have experienced this month is working in the pediatric’s clinic at Plaster House. The Plaster House is basically a children’s rehabilitation home, providing a beautiful place where children with various medical conditions can stay while receiving medical care. Many come from remote villages throughout Tanzania with conditions like skeletal fluorosis (similar to Rickets), club-foot, extensive burns, cleft lip/palate, intestinal malformations, and others. The house is set with an incredible backdrop of Mt. Meru, a 14,900 ft volcano, in a peacefully removed plot of land. Therapists, medical providers, and other professionals care for the children between their surgeries or casting. One of the incredible things about this place is that these kids, though their medical or orthopedic condition may otherwise keep them on the margins of normal childhood in their village, at Plaster House, they have a place where they can be kids. They constantly run and play with each other in the yard. Laughter, dance, and singing are constant. They have different disabilities, casts, and burns; they each have their own way of getting around, whether crawling, tip toeing on a casted and bowed leg, pushing in a wheelchair; they come from so many tribes and backgrounds, the stories of which I have not even scratched the surface. But they are all kids, and here they are at home.
For today’s Swahili lesson, I would like to share a phrase I learned in the NICU: amekua, which means: he/she grew. This phrase comes from the word kua, which means to grow. Each day in the NICU, we weigh the babies to see how each is progressing. To summarize NICU care into an overly simple objective, it is essentially the goal that each neonate would grow. Most problems occurring in the neonate are a factor of them being too small, lungs too immature, skin and bones too undeveloped. Growth is the answer to making it out of the neonatal period. Simple as it seems, this takes the efforts of many devoted persons: nurses, parents, doctors, and many more. Each contributes in a different way to grow the infant: one may come up with the general plan, but no one person can carry out that plan by their own effort. Growth is a factor of not only nutrition, but of caring for all of the details. For example, the child will not grow if the lungs are not supported, they will use all the calories received for breathing. Thus on a daily basis, the plan may include the following: The feeding must be given correctly, in the correct amount, at the right time, in a feeding tube or by mouth. If oxygen is being used, it must be by the right method, in the right amount, not too much or too little, and the cannula must stay in the nose, which is a constant battle against the tiny, uncoordinated newborn hands. Intravenous lines fit into veins in such tiny arms that a light held behind a hand or foot can display them all like the veins of a tiny leaf. Subtle signs in the newborn’s condition and behavior must be observed (such as breath-holding, tachycardia, change in abdominal distension), as they can herald serious infections, heart problems, or other life-threatening situations. The team cares for these details, amongst innumerably more, each minute, hour, and day. The circumstances in Arusha magnify the difficulties in caring for these little ones. How can one diagnose a serious infection with an armament of lab and radiology tests that can be counted on two hands, compared to the hundreds that we use on a daily basis in the States? How can we teach a mother correct feeding of a premature infant with an exact amount of breast milk fortified with an exact amount of fortifier to achieve 24 calories per ounce in the amount of 30 mL every 3 hours when she cannot read or write? How can you explain the condition of a sick neonate or the medical plan to someone who may have never been inside a hospital before or who does not speak the main language, Swahili? Despite these challenges, it has been a joy to see the staff at ALMC and the parents of these neonates watch their babies grow. Amekua! became a daily reminder of the small victories being observed most days. If the opposite was true, if the child had lost some weight, it was a reminder of the fragility of our work and a motivation to improve our strategy.

Each day here, I am challenged to grow to meet the challenges that the day brings. There are small challenges: dodging motorcycles on the street, finding my way around town, and communicating in an unfamiliar language. Then there are big challenges: how can I help in any meaningful way with these huge problems of poverty, disease, and injustice? what are my true motives for being here? am I becoming the person that God is calling me to be? Each day, I hope to see a bit of growth, to rise to meet the challenges presented. Some days, of course, I don’t. But here’s to hoping that at the end of this, I can say, along with these kids, nimekua! I have grown!

Ryan Fabrizius
Me with some of the kids at Plaster House (http://www.theplasterhouse.org/)

Me with some of the NICU nurses

Saturday, August 1, 2015

Karibu Tena


Jambo from Arusha, Tanzania! I returned here to Tanzania three weeks ago and I have been so blessed to reconnect with friends, reacquaint myself with the neighborhood, and reintroduce myself at the hospitals Selian and Arusha Lutheran Medical Center (ALMC). For those who do not know, I have recently finished my training in Internal Medicine and Pediatrics, graduating from the residency program at the U of M, and I have taken a role this year of Global Health Chief Resident. Essentially, this means I will be in Tanzania from July to December, then return to the U of M from January to June to work in the hospital and help manage the residents at the U of M, namely those interested in Global Health. It is a joy to see certain things have changed for the better since I was here 4 months ago, namely the NICU at ALMC is setting new standards in Arusha for neonatal care. When I first saw the NICU in January of this year, it was a cramped room about 15ft x 15ft, there were a few oxygen flow meters and an eclectic group of donated incubators that seemed to be in different states of disrepair. The lighting was poor and the general mood was tainted with general unease and despair. One of the big projects for Steve Swanson and Derrick Matthews, two of the visiting physicians to ALMC from the States, was to renovate a new space and to begin to develop the first truly functional NICU in the Arusha. The city has such a need for good maternal and child care; Selian alone sees about 180 deliveries per month, which is a small fraction of the whole city. The new space has two rooms, about 8 incubators, a plethora of oxygen sources, and the ability to do CPAP and rated CPAP. The nurses and local doctors have gained a huge amount of confidence and pride in working with the babies, which is even more inspiring than the space itself. There is a general feeling of positivity, among staff and parents alike, that even a few children born at less than 1kg (less than 2lbs), stand a chance to grow up. This would not have been possible by any stretch of imagination, even 6 months ago. I believe they are beginning to see the possibilities now that there is a functional space, support from Drs. Swanson and Matthews, and an excellent group of detail oriented and caring local healthcare workers.
As I did last time for blog posts, I would like to continue to relay some Swahili lessons that I have learned. I find my language skills are still comprised of basic survival phrases, but I wish to continue to learn and experience the richness of the language and culture. This week’s phrase is Karibu Tena, it means “welcome back”. There are a few uses of this phrase, such as when you are leaving a store and the shopkeeper hopes you will return for more business or when you are leaving work for the day. The context I have experienced these past two weeks is a “welcome back to our community”. Having spent two months here earlier in the year, I have been so happy to reconnect with friends that I made at that time. As many of you know, we hosted two Tanzanian doctors in Minnesota for the Global Health Course, which is offered through our Department of Medicine. We were so happy to have David and Joseph visiting during the month of May, to share the sites of Minneapolis, show off our Midwestern cultural quirks (they can’t believe we eat cold sandwiches and drink “foul” tasting beer), and give opportunity to continued cultural exchange. It is now full circle to see them and our other colleagues back here in Tanzania. Some are surprised to see me return (some of the shopkeepers and kids seem to remember me); some may not have noticed I was gone. My favorite is the child at the top of big hill on the long walk to Selian who always jumps out to karate chop me. He did not miss a beat, welcoming me back with an array of chops and kicks. Coming back has made me feel closer to Arusha and to my colleagues than I ever did last time. I have a bit more comfort, knowing some of what to expect on a daily basis. But it is more than that experience which draws me closer. When people say Karibu Tena, I can feel their acknowledgement that I have a vested interest here. It reaches out to challenge me with the notion that change does not always come quickly. Being in a relational culture, I can see that working towards the common goal of improved healthcare in Tanzania involves committing to each other. The “welcome back” recognizes a bit more commitment, hopefully a bit more trust, and ideally will advance our mission together. Until next time…


Ryan


Drinking Chai with Dr. Sameji, pediatric registrar

The NICU with Dr. Linda, pediatric registrar, and Sarah, NICU nurse

The walk to Selian with Lizzie, medical student from New Zealand

Monday, April 20, 2015

Update #3 from Global Health Chief Resident Hope Pogemiller working in Arusha, Tanzania

Habari ya Tumaini

So, it’s been quite a while since I’ve written.  Life has become quite busy, and I have wanted to be thinking clearly before sitting down to write to everyone again. Today I realized I’m not sure I’m one to think clearly…linearly…  So, I’ll write a little on a more serious note.  Life seems so much more serious when you are freezing in the house with fuzzy socks and heavy sweater shawl in place and with a cup of tea.  (Yes, I know it’s 73 degrees. But, can you really put a number on “cold?”) As the content herein will be serious, I’ll attach a few pictures in a lighter vein. 

I’ve always quite liked sea slugs, and as it is the rainy season, slugs are abundant. One of my pastimes has become stalking slugs and taking pictures in the foliage.
One of my favorite people from New Zealand posing with me in the matching skirts we had made
My favorite New Zealand couple with me at a fabulous Ethiopian restaurant
F75 is a dog living near the canteen at Selian who was quite malnourished in January as she was breastfeeding her puppies. We named her after the initial formula fed to children with severe acute malnutrition—F75.
View from one of my flights with the flying medical service to transport patients from the rural areas of Tanzania to a hospital. The pink dots are flamingoes
More flamingos
One of the planes was owned by Wings of Hope previously… but I found the tail comforting ;)
Another view from one of my flights

In my short time in Arusha, I’ve been impressed with the lasting, positive impact made by the revolving door of residents and medical students at Selian and ALMC. They arrive with eyes wide open and energy. There is a general eagerness to help in addition to learn—many are surprised that they have plenty of knowledge to share with medical trainees.  The knowledge gained when visiting Selian and ALMC extends far beyond the sheer volume and serious medical acuity of patient interactions.  I watch as people absorb the community-centered culture and are introduced to the medical system headed by a government who has a strong desire to provide affordable care to the vulnerable populations as well as those in upper socioeconomic status.  This idealism is a laudable goal, but lack of resources in necessary areas results in a medical system for the vulnerable that seems to limp along at times.  It can be discouraging operating within this context, with a serious lack of trained medical personnel in the country.  I think this is one realm in which cultural exchange can be quite valuable.  The influx of positive energy and new eyes analyzing dilemmas from clinical cases to medical systems to clinical education promotes patient explanation from Tanzanians which spurs creative new ideas and approaches that help in the brainstorming process that can “fight the unbeatable foe.”   This truly helps to subdue that nagging feeling that your team is simply “rearranging deck chairs on the Titanic.”

On a more personal note, friendships form quickly here, and many of them continue after resident/med student departures.  Likewise, it’s been very encouraging to find consultants in the US who are happy to help with tricky cases despite the lab and imaging limitations.  Forging friendships and professional relationships between hospitals in Tanzania and between specialists across countries is one path to a brighter future in the realm of medicine. 
I feel honored to work with so many Tanzanians and expats who are deeply devoted to medicine and the improvement of lives for individuals and the population as a whole.  It is not infrequent to feel incredibly inspired and unbearably frustrated simultaneously.  The rollercoaster of life somehow seems more intense here than it might elsewhere.  As in any medical practice, some weeks are much more discouraging than others in terms of patient outcomes.  However, keeping a list of patients who left the hospital or clinic with a clear improvement in health has been invaluable.  As in the US, debriefing with hospital staff and families is cathartic for all parties involved.  

Monday, April 6, 2015

Update #2 from Internal Medicine Resident Elizabeth Gulleen during international rotation in Damak, Nepal

Hello again from Nepal. Things have settled into a bit more of a routine here and I am now working full-time at Life Line Hospital, where I will spend a total of 3 weeks.  Clinical responsibilities include rounding on the inpatient medicine wards inpatients and working in the outpatient clinic (OPD). Census varies from 3-10 inpatients and 15-30 outpatients seen daily.  The work is done by three internal medicine physicians who divide the responsibilities (including overnight call) equally.  In Nepal, internal medicine is a subspecialty that requires 3 post-graduate years of training.  Physicians must first complete 4.5 years of medical school to receive their MBBS, complete an intern year, and pass the national exam medical exam. The applications with the top 10-20% of exam scores are eligible to complete a residency and become consultants.  As there are limited training spots in Nepal, people often go overseas to China, India, or even the Philippines for advanced training.   Ideally, the physicians then return to Nepal to practice, but often the lifestyle and pay in other countries is preferable and so the physicians will stay in the country in which they train. 

Often we come to tropical countries to study the “glamorous” infectious diseases such as filariasis, leishmaniasis, or malaria.  However, this rotation has been a good reminder that non-communicable disease has truly become a global epidemic.  While I have seen a number of TB patients, I have yet to care for a patient with malaria, typhoid, or dengue.  At least 60% of the patients in OPD present for treatment of hypertension, diabetes, or hyperlipidemia and the chronic sequelae associated with them. Inpatient admissions for hyperglycemia and COPD exacerbationsm are common.  Nepali physicians face universal challenge of teaching the importance of chronic-disease management.  Unfortunately, all too often, patients will chose to treat their hypertension with herbal medications and do not have the resources to use life-long medications.   Consequently, it is not uncommon to have patients present with heart failure, strokes, or myocardial infarctions after years of untreated hypertension or diabetes.  The physicians spend much time with counseling about the importance of ongoing medical management and state that they are gradually seeing improvements in medication compliance and understanding of chronic disease.  However, they see this as an ongoing challenge which will take years to improve and feel a responsibility to continue the endless fight against disease.  
Taking a break from clinic duties to watch the cricket world cup. (Yes, I have tried to Wikipedia my way to understanding the game at least three times. No, I still do not have any idea of what is going on.)
The costs of basic laboratory and consulting services at Life Line Hospital. For reference: 100 rupees is about $1 USD.
A view of the outpatient department courtyard.
One of the physicians teaching some medical officer students during a busy emergency department shift.



Wednesday, April 1, 2015

Update #2 from Internal Medicine Resident Matt Goers on International Rotation in Uganda

For the past 2 months I've had the pleasure of working with IOM Uganda. When I arrived in mid-January, I didn't quite know what to expect, but when I walked into the IOM Kampala ofice I was overwhelmed by the number of warm and friendly people I encountered (as well as all the food). My first week in Kampala was a mixture of getting to know the way IOM works as well as shadowing the IOM physicians and staff. I got to sit in during refugee screenings and meet applicants for resettlement from Somalia, South Sudan, Rwanda and the DRC. They had some incredible stories, and by the end of the first week, I was already loving my work. 

Our first trip out to a refugee camp was to the Nakivale Resttlement camp near Mbarara, Uganda. This would be my first visit to a refugee camp and also my first experience participating in refugee relocation screens. We spent nearly 3 weeks screening over 500 patients, and I quickly started to see the purpose for the screenings. We found people with pneumonia, tuberculosis and Burkitt’s lymphoma. We found people in need of mental health services and newly diagnosed pregnancies in need of further obstetric care. I saw how powerful it was to help someone through a new illness, but also move towards a new life in the process.

After Mbarara, we came back to Kampala for only one day before being whisked away to Kyenjojo, Uganda for another mission. This time, we screened around 250 refugees, and began to work on a side project further evaluating applicants who were found to have abnormal findings during their examinations. During a previous IOM mission to the Kyangwali camp near Hoima, Uganda, providers had noticed that nearly 1 in 6 refugees presenting for medical screenings had enlarged spleens. During our mission to Kyaka (near Kyenjojo, Uganda) we found similar findings in Congolese applicants, and by the end of my trip, had begun working on a project evaluating for potential causes in the community. 

It wasn't “all work and no play,” however, and during my time in Uganda I had my fill of new experiences (and new foods). I learned a little Swahli, Lugandan and Somali from some of the refugees and staff, and sampled a lot of the local cuisine (even trying matoke for the first time). Dr. Gladys made sure I was never hungry, and Dr. Saul made sure I was never bored or without a good laugh. During the last week in Kampala a few of us even took a day trip to Jinja, Uganda to see the Nile. We got to go rafting over some of the rapids, and I’m proud to say I stayed dry despite the Nile’s best efforts (mostly). 

I keep telling people what an amazing experience this trip ended up being, but I haven't been able to fully explain it to people back in the U.S. Maybe it has to do with the work we were involved in, helping refugees relocate and start a new life. Maybe it was getting to immerse myself in a new culture, and finding some new friends in the process. But I think what was truly extraordinary about my time was that I never felt like I left home. I had the distinct pleasure of getting to work with a group of people who treated me like a part of their family, and who made sure I never wanted for anything and even humored my silly questions and comments throughout my stay.

I left Uganda with a heavy heart. This experience has to be one of the most rewarding and fascinating experiences of my life. It is possible, though, that somewhere down the road I’ll see some of these refugees in the United States. Many of the applicants I met will be eventually relocated to the U.S., and some may even come to call Minnesota home. If I do see them again, it will just add to the long list of amazing experiences I've had from Uganda. We'll have to find some matoke somewhere in the Twin Cities.

IOM vehicle outside of Mayanja Hospital in Mbarara, Uganda
View from apartment overlooking Kampala, Uganda
Panoramic of Nile River from balcony

Monday, March 23, 2015

Update #1 from Internal Medicine Resident Elizabeth Gulleen during international rotation in Damak, Nepal

Namaste from Nepal!  Today marks the one-week anniversary since I disembarked in Damak, Nepal rather tired and disheveled after 48 hours and 3 plane rides.  Since my arrival, I have been overwhelmed by the hospitality and kindness of my hosts.  The people here have gone out of their way to welcome me, from providing endless cups of tea to hosting dinner parties and even acting as weekend tour guides.  Consequently, I am looking forward to an excellent and educational time over the next seven weeks.

My clinical experiences this week have alternated between spending time at Life Line Hospital and working with the local IOM.  Life Line Hospital is the clinical site where I will be primarily based throughout my stay.  The facility has an active outpatient department and a 100 bed hospital divided into medical, surgical, pediatric, and obstetric wards.  The hospital has good diagnostic capabilities including a basic lab, ultrasound and x-ray departments, and even a CT scanner.  It will soon expand to house a 9-bed ICU as well as a NICU.   Next week, I will begin rounding with the medicine physicians here.  I did have the opportunity to attend the annual board meeting of the shareholders, which gave me a chance to introduce the University of Minnesota as well as our global health program.  The shareholders and physicians here are eager to continue collaborating with UMN and hope to develop a long-term partnership with our program.

While I did get a brief taste of Life Line Hospital, most of my time has been spent at the IOM, which is located about 1 block from the hospital.  It has been interesting and informative to experience refugee health from this side of the globe.   Unfortunately, given my limited time with the IOM, I am only able to spend about ½ of a day seeing each portion of the healthcare process.  The first day was spent touring the facility and observing the vaccination program, the second day I observed TB screening facilities (including x-ray and the microbiology lab), and the third day was spent with the IOM physicians observing new medical and pre-departure exams.  I plan to complete this week by learning about the TB treatment program, understanding mental health in the refugee camps, and hopefully visiting the camp itself.

Actually, the resettlement of the Bhutanese refugees here in Nepal is drawing to a close.  Only two of the original seven camps still exist and only about 10,000 refugees need to be relocated.  Consequently, many of those who remain in the camps are older and have more complex health conditions that precluded them from earlier travel.  I had not previously appreciated the coordination it takes to stabilize these patients prior to travel.  During the initial health screening, all medical conditions are evaluated and any necessary work-up or treatment is initiated.  This can include subspecialty consultations, work-ups of malignancies, surgeries, and hospital admissions.  Once the patients are medically stabilized, they are deemed safe for travel.   When the time for departure is scheduled, the patients undergo a final health check with a physician and are sent to a central processing site in Kathmandu 10 days before leaving Nepal for further monitoring.  About once per week, a flight is coordinated for the patients with complex medical conditions such as COPD, CHF, active psychosis or other mental health issues.  Physicians are chosen to fly with the patients to ensure medical stability until arrival.  Depending on the medical condition, subspecialists may be chosen to be among the physicians traveling (for example, a recent flight contained a patient with a complex cardiac history, so a cardiologist was one of the physicians included).

The physicians here are very worried about what happens with the patients’ healthcare after arrival in the US.  Since the IOM physicians serve as primary care doctors from the time of initial health screening through departure, they are very concerned about appropriate follow-up to ensure that the patients will succeed in their destination country.  Every physician I have encountered has asked repeatedly what can be done to better facilitate the medical transfer and to educate the patients about healthcare in the United States.  I was able to reassure them that (at least in Minnesota) >95% of patients have a follow-up visit within the first few months of arrival.  However, it is very telling that one of the universal concerns about patient health is how to best transfer medical information from one healthcare provider to another.  Consequently, we are currently brainstorming ways in which physician-to-physician communication could be improved throughout the process.  

On an exciting note, several of the healthcare providers at the IOM are planning to visit Minnesota later this spring to learn about refugee care in the US.  I am hoping they will time their trip so I will be back in time to return some of the hospitality they have shown me.  Until then, I plan to continue soaking up knowledge, eating plenty of momos (Try some!  They are awesome!), and appreciating this beautiful country.


Elizabeth
My arrival at Life Line Hospital, where I was greeted by Dr. Surya and the staff
Annual board meeting at Life Line. I got a chance to speak and introduce my role in Nepal as well as the University of Minnesota
The TB isolation center for the IOM
Spending spare time sampling local foods with friends