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IM resident Daniel Townsend's Week 3 Update from Tanzania

The Jolly White Giant

                                                                                    
Another week down. I'm just starting to settle into the routine of living here and I'm headed into my last week!  I spent several days this week joining the hospice team. It was a very unique experience to say the least. I'm actually working on a short story about it. In short, I worked with a woman named Paulina. Some call her Saint Paulina and when you get to know her you see why. She's a strong woman, but has a gentle touch and soothing voice. She is greatly respected in the community and has invested her life's work in bringing hospice/palliative care to the rural Maasai communities. We did home visits one day this week. She wore bright pink dress flats... it had rained the night before... I was skeptical. Somehow she managed to expertly navigate the fields of bean, corn, and coffee to arrive back where we started with shoes relatively unscathed. I was now a believer. "Hospice care" is actually not hospice care, but more like home visits with a little palliative care mixed in. We saw a wide mix of patients, all meeting them in their little mud huts scattered throughout the country side. Some were near death, but most probably had years to live (which initially confused me because I thought we were doing Hospice visits). For instance, we met a young women who was a widow, as her husband died from AIDS. She was HIV positive. She had been faithful in taking her medications however and her CD4 count was in the 800's. She was otherwise doing quite well. Her neighbors helped her out some now but she had been a widow for over a year and had managed to maintain a fairly good life- she had a cow, and a goat, a few chickens who ran around my feet as we chatted. She had a small plot of land but it was enough to get by. Paulina said she was happy. I towered over her, hence the title of this update, and in fact, I tower over most of the people here. I figure I get as many stares because of my height as I do my skin color. I don't want to give away too much more about Paulina since I'm writing a story about her, but when it's done, I'll let you read it. :-). Needless to say it was a good experience. In some ways palliative care is more advanced here than any other medical field. Mark Jacobson believes it is the work he is most proud of accomplishing over the last 30 years: his help in building up the palliative care/hospice program in Arusha.
                                                    
I saw interesting cases of tetanus and TB pericarditis. I diagnosed a lady with complete heart block using a little ekg reader attached to Ron Eggert's iphone. We are low on pacemakers though.  I have continued to work on teaching the residents (registrars and interns) ultrasound skills. They seem pretty excited about it.  I hope that energy will keep up after I leave. I think they are really starting to see the benefit of using it. I had them ultrasound me this week so they could see what normal looks like (at least I think I'm normal- I thought my aortic root looked a little big.. plus I'm kinda lanky and flexible so now I'm convinced I have Marfans. I have also discovered that my oxygen saturations are 91-94% at rest... I feel like that's a little low for a young healthy guy...am I becoming a little hypochondriac?).  I think the patient's got a kick out of seeing me take off my white coat, take off my shirt and start having the African doctors examine my heart. 

I did medicine clinic on Friday. I met this Maasai woman who had traveled 3 days to get to clinic... she got a PPI and seemed pretty happy about it. This interesting elderly Maasai gentleman also lumbered into our clinic- he was unusually overweight by Tanzanian (especially Maasai) standards so he seemed to be well off financially. He told me he had a breathing attack the previous day (he has a long history of asthma), so in order to cure it, he went out into his fields and performed a Maasai ritual that involved him killing a few cows. It didn't work. I asked how many cows he has: hundreds.  "Whew" I thought, I was worried he slaughtered his only two cows to cure his asthma and that would have been a poor trade off. He said he had 5 wives and 30 children. I told him 1 was enough for me and he laughed. I asked if he could remember all his kids’ names. He didn't answer right away on this one... then he said, yes, but it would take him a while.  Then he let out a deep belly laugh with a gaping smile that revealed only about 2-3 teeth left. He got some steroids and albuterol and was on his way. I think we would be friends if I were staying longer. 


I went on Safari this weekend to Ngorongoro crater and Tarangari national park, it was quite fantastic and an enjoyable experience getting out of town for a few days. Chris (the surgery resident) arrived Wednesday night so he joined me on Safari.  I told him I wanted to see a black mamba, but the best we could do was find a small dead one on the side of the road. We did also see a pride of lions munching happily on a water buffalo- that was pretty neat.  



That's all for now. I hope things are going well in the good ol' U.S.of A.
Sincerely, 

the Jolly White Giant.

Internal Medicine Resident Daniel Townsend's week 2 update from his international rotation in Arusha, Tanzania

“There are two sides to everything" Cultural highs and lows. As is the norm when you immerse yourself in a new culture, at first the newness/excitement carries you as you soak it all in, but soon after, there usually is an emotional low as everything catches up to you.

The electricity goes out pretty much every day, and usually in the evenings when I'm home. In fact I'm writing this in the dark with a headlamp, hoping that the power will come back by the time I finish this so I can send it. At first it was somewhat exciting, "I'm reading by candlelight!", but now I just have questions and a faint annoyance that I try to keep at bay. Why does it go out every day? Why is their infrastructure unable to support uninterrupted power? What if they invested more in solar energy since it is almost always sunny here? Why do I feel entitled to electricity in the first place?

Work is a continual reminder of how lucky I am to be in the Western medical system. They do their best, but there's just so much that's lacking. The chemistry machine is still not up and running. It was supposed to be working on the second day that I arrived. The reasons for delay aren't worth mentioning but needless to say, there is no major setback that would have made it impossible for the machine to be up and running a week ago. Everything moves slowly, and I am learning patience. I saw cutaneous anthrax and cerebral malaria for the first time. I have found that although resources are lacking, one resource that they do have, but is underutilized is ultrasound. I have taken this on as my project for the month, and I am doing an informal ultrasound training course for the interns and registrars. Ultrasound adds so much ability to their physical exam. For instance, they are often diagnosing heart failure based only on the patient having peripheral edema. We've now gotten in the habit of looking carefully at the jugular vein for added diagnostic value, and now we can do a bedside ultrasound. I hope to also teach on abdominal and lung exams as well. I hope that with some further coaching that it will become a part of their routine. Since Dr. Eggert will not be here this next year, it's on us to push this and develop this. They also do not have an EKG machine at Selian, which I think is something that might be a manageable goal to attain over the next year. Thanksgiving week. Mark and Linda Jacobson have a massive feast every year, and they have about 50-70 people show up at their house. They hand carry a turkey from Nairobi, Kenya (because there aren't any turkeys in Tanzania apparently?) and it truly was a great time. Things I'm thankful for: normal bowel movements (no diarrhea yet! I always get diarrhea when I travel, TMI?), my family, my medical education, and clean water. I had a chance to meet a lot of interesting people who are here in Arusha for various reasons at the thanksgiving meal. I got into a discussion w ith several others about their opinion on constantly being called "Mzungu". For me, as I walk along the rural back road to Selian, I am constantly battered with this word. I have not been in this culture long enough to feel like I can have an opinion on it, but it does often seem to be directed at me in a more condescending way. Some of the expats found it offensive, and interestingly mentioned that it had less to do with the actual word, and more to do with the way in which it is said. In this culture, you never yell something at your elders, so when someone yells "Mzungu!" at you, it is disrespectful. On the other hand, other expats, felt it did not have any negative connotation and simply was a word meant at getting your attention. I will say, at a very basic level, it doesn't feel great to constantly be lumped into a category of being different (whether by race or economics etc, but there are two sides to everything, so I have chosen to think that the word is not a negative term, and even if it is, I have spent my entire life in a position of privilege, so on some level, I get it. So I have come out of this week that had plenty of emotional lows believing that I can in fact look at the situations around me as two sides to a story. I can either see inefficiency, lack of accountability, and slow delivery of care, or I can see it as- hey, maybe we need to slow down a bit in the states, start actually listening to people, and stop hiding behind our lab results and computer screens. I can look at lack of electricity as an annoying infrastructure deficiency, or I can look at as an opportunity to find some peace and quiet, when my life in the States is often cluttered and noisy.

Hope all is well back home! I'm ready to start a new week. I'm planning on doing some hospice work this week. 

Internal Medicine Resident Daniel Townsend's week 1 update from his international rotation in Arusha, Tanzania

I arrived safe and sound in Tanzania on Wednesday, November 19th at night. A blast of warm moist air hit my face as I got off the plane and all I could think about was how could I have ever ended up in Minnesota. The following day I met with Mark Jacobson who told me as we were driving along a very busy/bumpy road that Tanzania was "a little bit of order and a lot of chaos- although the chaos is usually predictable". We spoke about the mission of ALMC/Selian and my role in experiencing the health care system here, he said that Tanzania and Africa in general tend to have very relational cultures, and that to engage in healthcare here, you must first know your culture/know the people you are trying to serve. ALMC is a fee for service hospital that does some charity work, although only about 5-10% of Tanzanians have health insurance. Selian is mostly free and government subsidized and serves the more rural Maasai community. Mark spoke about wanting the hospitals to be "potentially sustainable", meaning not reliant on western assistance.

I then met up with Ron Eggert (rheumatolgist from the States who does long term volunteer work at Selian) who drove me out to Selian hospital in time for rounds. Selian is what you think about when you think "third world hospital". Open air. Scarce resources. However, there is something strangely satisfying about holding up an x-ray to the Tanzanian sun to interpret it, rather than sitting in some dingy computer room like we do in the States.

A few cases that stuck out to me from my first day on the wards. A young male presented with clinical signs of heart failure. Extreme JVD, tree trunk legs, ascites, crackles, hypoxia. Apparently had been admitted several times before over the last year with the same symptoms. lasix and captopril were the treatments initiated. He was sating 70% and just looked miserable. My mind raced through the causes of nicm in a young male. All I could think was this guy needs an LVAD STAT (too much Cards II training)-- ahh but no such luck. Lasix, ACE and a bed are the treatments we can provide. I wanted to scoop him up and take him back to 4E at the U. For learning purposes, he had a fantastic gallop I'd never heard an S3S4 like that before.

Middle-aged patient presented with SOB. CXR showed complete white out of the left lung. Massive pleural effusion. Tapped the effusion- frankly bloody, no history of trauma. Took off 2L. Pt had been losing a lot of weight and felt weak over the preceding months. Differential for bloody pleural effusion? Cancer, trauma, parapneumonic effusion... maybe TB if it eroded a vessel. Can't really analyze pleural fluid easily (or cheaply), so can't really send for cytology. Pt can't afford a CT (which would have to be done in town at ALMC anyway). Tough situation. My palliative care self was happy he felt better after taking off 2L though. :-)

That was just day 1. So much HIV/AIDs. So much TB. Over the next few days I continued to work at Selian. The interns seem hungry for knowledge and appreciative of any expertise I can provide. I try to approach this humbly, as I am not there to take over or act like I have all the answers. I did ask if there are subjects they would like me to do some teaching on and they gave me a long list of subjects. basic stuff, like DKA, stroke management, cardiac physiology as it relates to heart failure.

I visited the plaster house. This is the organization that Ingred (Dr. Eggert's wife) works at. It is a compound of sorts where they bring children with various deformities (club feet, bowed legs, many different burn victims- lots of burn victims due to the open fit pits the Massai use to cook) that would otherwise be shunned by their communities. They pay for their surgery and then they stay at this house for the remainder of their recovery/rehab before they send the kids back to their villages. They do some schooling and feed them good food. It's quite remarkable. I met one little boy who had his entire face burned off when he fell into a fire pit that had a burning tire in it. He’s undergone at least 5 surgeries and has several more planned. He acts as an encouragement to the younger children and helps out a lot since he's been there a long time. I was quite impressed with the organization, although, for better or worse, it is highly dependent on western donors/volunteers. It costs about $1000 dollars to sponsor a child from start to finish (including surgical costs).

The weekend service was run by the interns (there are 2 right now), as the resident (or registrar) and Dr. Eggert weren't coming in. The interns asked if I wouldn't mind coming in, so I worked on Saturday too. I walked to work (about 1 hour each way) which was a beautiful walk through the countryside with Mt Meru in the background. 

Tools for Improving Vaccine Uptake Among Somali Immigrants

 

 

 

 

 

 

 

 

 

2014 State of World Population Report

State of World Population 2014

The Power of 1.8 Billion: Adolescents, youth and the transformation of the future

http://www.unfpa.org/swp/

http://www.unfpa.org/public/home/publications/pid/18634           
Author: UNFPA
No. of pages: 136
Publication date: 2014
Publisher: UNFPA
ISBN: 978-0-89714-972-3

DOWNLOAD REPORT:

http://www.unfpa.org/webdav/site/global/shared/SWP%202014/Report%20files/EN-SWOP14-Report_FINAL-web.pdf   

Congratulations to Dr. Mike Westerhaus!