Pharmacy is ready to go!

Pharmacy is beyond excited- I actually could not sleep until 3 AM last night going over details in my head.  We have a wonderful team that is very prepared:  3 students, Emily, Sarah and Grace as well as Astrid, a PGY1 resident.  And....Nick will join the second half of the team as a preceptor!  Presentations are well underway, I am working on a Medication Safety presentation- Tanzania actually has a and FDA equivalent aptly named the TFDA. 
My hope for students is that we have an opportunity to understand the supply chain challenges.  Given that Ilula is a government hospital, the majority of medications are sourced out of the Medical Stores Dept in Iringa- I hope we can visit.  A second source is a private pharmacy and at last visit - they employ two pharmacists which is quite wonderful for the local folks; only one in ten pharmacies has a pharmacist!  My second hope is that everyone has an opportunity to see how medications are distributed in the villages in particular HIV medications; TZ has recently had a robust process for doing so and we may help with some of the documents. 
I look forward to introducing everyone to Frank and Rita.  Frank Sanga is the pharmacy professional on the campus and is very skillful at inventory management.  Rita is a leader in the new Nursing School which will be dedicated during the students stay.  Rita and Frank have 3 darling children. 
Please remember to download the 2013 TZ Treatment Guidelines to either a smartphone or tablet- and familiarize yourself with the medications at the end of the guideline.  The government of TZ has a listing of medications that are to be supplied depending on the size of the hospital.  For example, Ilula has two narcotics at last visit (morphine and pethidine) as no chemotherapy.  The medications for tropical disease management are robust:  Ampiclox and Alu will undoubtedly be new to everyone! 
Looking forward to both sharing past learnings, and learning new things with everyone as we work shoulder to shoulder with our colleagues in TZ!  Sleep well the next few days!  Jill

My Favorite Event

Since we didn't have much internet in Ilula, I will share what I wrote on January 26th.

My favorite event thus far has been hospice outreach with Dr. Nixon, two Ilula nurses, Cole and Erin.  We saw 4 patients one day and then the last patient the following day.  The visit included a nursing assessment followed by a physical exam by the physician/medical students and then ended with medication counseling and prayer.  As Dr. Nixon explained, each hospice visit addressed the physical as well as the psychological and spiritual health of the patient.  Many of the bibis (grandmas, plural?) were immobile from previous strokes and needed physical therapy.  Although physical therapy is not currently available in Ilula, many of the family members played a great role in the healthcare of the bibis .

There were many differences from the hospice care that I experienced in Tanzania versus the US.  Many of the hospice patients that I saw in Tanzania had illnesses that I thought were very manageable in the US.  It was puzzling to me at the time, but when you compare the resources and the cultural differences, it makes more sense.  Aspects that I thought that we can learn from this experience is how to better integrate all aspects of a person's life into their healthcare and making their goals our priority as the medicine team.  For example, one of the bibis was in great pain from multiple abdominal masses, most likely metastatic cancer.  We gave her pain medications and then did our physical exam.  Afterwards she was tired and just wanted to rest.  We offered prayer and then asked if she wanted us to sing a song of worship.  She picked out the song and then midway through the song, you could see her spirit lifted.  In fact, she got out of bed and started dancing.  It was such an incredible experience to see someone who was ill and in so much pain praise God for the goodness in her life.  The joy that this bibi brought to me during our visit reflects many of the moments that I have had here in Ilula.

PS.  Kari, one of the bibis asked about where you were.  She remembers you from last year.

Quick Note

We are at Schipohl (ski-pole is close)Airport in Amsterdam.  Boarding is soon!  All are well and excited to see loved ones.

Home in a day

It is 10 PM in Tanzania and we will be home in about 24 hours.  All are happy to go.  We are at the airport, checked in, luggage checked, chilling by the AC and sippin' RC Cola.  Wait, that is a different song.

We awoke this morning to rain.  It rained through the night.  By the time we left Wista, the rain had stopped.  Our plan was to go to Slipway then to Bongoyo Island for some sun.  It was cloudy all day and the ferry was not running to the island. 

OK, we can deal with that.  Hang around Slipway, eat lunch and go to to Coco Beach on Oyster Bay.  Cool.  Kulwa, our driver, had noticed a couple of the tires on the bus were bad and Dennis told him to get them fixed.  Good idea!  Kulwa said he would pick us up at 2 PM.  Great!  Three pleasant hours.  Of course, TIA.

We did some shopping.  Well, Deepthi and Chandra did some shopping.  We think they can get it all on the plane.  At 12:30 we had lunch.  There is a nice restaurant with great pizza, and it was too.  Two o'clock rolled around, but no bus.  We wandered around the Slipway.  We had already had our gelato before lunch.  Yummy!  Always have dessert before you eat your meal or you might not have room.

I called Kulwa.  Airtel serves had quit suddenly awhile before.  It still is not back on line. I used Laura's Mwamoody phone.  "Ten minutes," he said.  Ten turned into 20, then 40.  At 60 minutes I called him.  The traffic had tied him up for the hour.  He did arrive in another hour, but now there was no beach time left.

We could deal with that.  We went to Sea Cliff and had a great meal.  Even dessert.  Everyone (well, two of us, one of whom shall remain unnamed, me being the other one) was a bit skitterish after the long wait for Kulwa.  I think he was too.  He endorsed leaving the Sea Cliff about 7 PM. We got here with over four hours to spare.  Hmmm.  Better that than heart attack from a traffic jam.  (No chest pain at all in the end.)

So here we are as close to home as we can be without having boarded the plane.  In a short time we will board and fly faster than time for eight hours and be home by 12:30 PM.

Looking forward to cold weather and warm family!

Man plans, God laughs

Even after the big party feast she prepared for us last night, Anna made doughnuts for us, hard boiled eggs and sliced watermelon for breakfast.  At morning report for the hospital we said our goodbyes and prepared to board the bus scheduled for arrival at 9:00 AM.  We waited. And waited.  Someone pointed out worrying about the bus would not get it to us any faster.  TIA.

At 10:30 AM, our driver Kulwa arrived with Tatanca's big bus.

I am so happy to be returning home to my lover and my family!   As I write that, I think of what I love here, certainly the people who have become our friends, so new, some longtime.  We have been discussing the beauty of Ruaha, its wildlife and luxurious Mwagusi.  We have just traversed the hairpins of the river valley.  The mountainsides are lush and their is a canopy of acacia trees.  Now the Great Ruaha River runs along side and the baobabs have leaves for a few short weeks of the year.  Yes, this is really Africa!

The roadside has many fruit and vegetable stands.  So far I have seen buckets of green peppers, onions and potatoes stacked in the typical pyramids above the edge of the bucket.  Little blue bags hanging from a line hold nuts for sale.  Sugar canes in a row are ready for sale.  I still have not tried this delicacy.  Next year.

We pass many big rigs hauling lumber from the south and west. We meet many tanker trucks hauling oil.  These tankers collectively seem newer than other rigs.  No surprise, I suppose.  We meet and pass the Maasai walking along the road, dressed in the garb that so characteristically identifies them, usually with deep blue or deep burgundy cloth and sometimes plain or patterned, sometimes plaids of the same rich colors. there is often a knife hanging from a belt on one side with a cell phone on the other.  There are about 44 million people in Tanzania and 26 million cell phones.  Half the population is under the age of 15.  Three-quarters are under 25.  There's the market!  Of course, cell phones have leap frogged the landlines with nearly all people having access and mobility as features of the cell phones.  It is a prepay system with many simple phones available for SMS texting and voice.  Yes, there are a growing number of smart phones too, of course available to the wealthy.

One of the joys of the trip between Ilula or Iringa and Dar is Mikumi National Park.  For newcomers, seeing giraffes, zebras, elephants and even baboons out the window is a real treat.  Sometimes the treat extends to other animals, like warthogs today.  And it is just as exciting for the repeat visitors.

Many of the vehicles we see have slogans on them.  We jut met one that said, "God will make a way."  Yes, I believe that, but then I admit to hoping that didn't mean for him in traffic with his eyes closed.  Then again I suppose they could all be less subtle and say, "Move over Buster."

Still in Mikumi and another sign says, "Don't feed the baboons."  There is less game now and the road is better and we are coming to the unmanned guardhouses.  I wonder if the person who put the red Xs on these little government buildings derived some secret joy in doing so?

Once agin the wildlife consists of the teeming masses of humans, walking, in cars and trucks, on bikes and motor bikes trying to get to their destinations.  In the little villages, commerce continues at whatever level.  By far, the crispest bills are the 10,000 TZS.  This is about $6 USD.  The most crumpled and dirty bills are the 500 TZS, about 30 cents each.  The coins for 200 or 100 TZH are worn to the point where sometimes the denomination is unreadable.  It seems to me that most Tanzanians live in one world or the other, the world of the crisp bills or the worn bills.  We have such privilege.  I learned something from our friend Dan McIntyre this summer about this commerce.  I was complaining about an old woman who never failed to come after me to buy her baskets.  I said "Hapana" or "No" each time she accosted me.  Despite my admiration for the quality of the baskets, I simply did not need one.  Dan said, "I know she is aggressive but I always buy something from her.  It's her livelihood."  Anybody who knows dan didn't need this story to know this man's heart is in the right place.

It is quite easy to see the differences in both classes in rural or urban Tanzania after being here a few times.  Better homes are covered with plaster or stucco-like material.  This waterproofs the brick used to build it.  Most of the homes do not have this feature.  Some of these are crumbling from rain and weather and generally smaller.  Another feature that sets the wealthier from the very poor is the roof of corrugated galvanized iron sheets instead of thatching.  In and near the city the houses may be shanties.  In many cases, even poor homes have electricity and satellite dishes!  It may seem novel to us but I do not see these modernities as a sign of misplaced priorities which is so tempting for us to do, but rather points to the essential importance of communication and even entertainment, regardless of class or income.

We stopped at Glonency 88 for a bite to eat just outside of Morogoro, about midway to Dar.  We have reached the land of mangoes and coconuts, again stacked in neat pyramids rising from their buckets.  We had good mangoes in Ilula too! part of Anna's meal plan.  Coconuts are a staple and used for flavoring in many dishes like beans.

About 100 km from Dar we are meeting a long convoy of trucks marked simply by a windshield sticker with the block letters "UN."  I estimate 50 trailer rigs and a few smallest vehicles.  The trailers had white vehicles on the also labeled "UN."  There were trailers carrying what I would guess to be generators, like the ones construction crews might use to power their tools and lights.  There was a UN ambulance.  A couple of the rigs had flashing lights setting them apart from the contract rigs which carry the same incantations and slogans that we see all the time, presumably contract carriers.  I wonder where that unit is going to set up the new mini city?  I will Google UN mission Tanzania as soon as I can.  Did not look military.

Full Dosse [sic], Allah Malik, Mashallah, Jesus is Lord, Power of God, Passion are just a few of the sayings I saw in the last few minutes. I do notice the petroleum trucks, corporate semis with company logos and newer vehicles are less likely to sport the decals.  Presumably the independents are the ones who decorate their trucks with so many interesting decals.  The population of Tanzania is about equally split, 1/3 Muslim, 1/3 Christian and 1/3 native religion (animist).

There are quite a few speed traps manned by Polisi with guns.  Well, radar guns anyway.  I don't recall seeing armed Polisi, but they do carry nightsticks.  However there are are often soldiers stationed with the Polisi.  They are armed.  Motorists warn each other of the traps by flashing their lights and motioning with their hand in a downward direction.  Here are other police stops also, checking insurance tags on the vehicles for infractions like expirations.  Trucks are checked for weight at a weigh stations.  This can cause globs and traffic jams.  These trucks are typically heavily loaded, so it is probably a good thing they are checked, assuming bribes do not intervene defeating the purpose of checking.
Another weigh station near Dar and traffic has picked up.  We did see our first recent crash, not including the burned out semi not far out of Ilula.  It was a big lumber truck that ran off the edge of the road in a village.  (Texting?)  At the weigh station, trucks jockey for position to get through, but we were finished in no time.  There is a line of trucks coming toward us that must be 30 or 40 trucks long.  Glad we are on this side!

After a long drive, it is near dusk and we are only on the outskirts of the city.  We have some mean traffic ahead.  I am thinking of the answer I will give if Kulwa, our driver asks me to drive.  NO.  Wow, that did't take long.

Well, I need to pay attention now.  He may need help with the side friction or maybe I will just need two hands to hold on....

This is really Africa

Anyone from my family will instantly recognize the phrase,"This is really...(insert country name here).  Our dad, my namesake, was awestruck on our family trip to Mexico in the late 1960s.  With each new change of scenery he blurted out, "This is really Mexico!"  It has become sort of a mantra for all of us, remembering Dad's passion and innocence in each new discovery, if possibly with a little humor at his expense.  I have my own foibles.

Cole and went to early church this morning.  I'd say, "Two out of three ain't bad."  It is a labor of love after being to many two hour services when you do not understand a word beyond "Bwana aisfewe" and Mungu.

Astrid was going to come to Iringa with me to grade more papers.  She has done about sixty out of 160.  What a champ.  Kelsey and Cole talked some sense into her and she stayed home.  Don't worry Astrid!  It will be fine.

About noon I started out for Mtua, where the bus stand is.  It is about a half hour walk from the hospital.  Astrid took the bus back to Ilula from Iringa yesterday.  This dad was happy when she arrived at Ilula before dark.  She only saw my missed calls when she arrived home.  She is a seasoned traveler.

As I walked, I had a surreal reaction: this is Africa and what am I doing here?

The road to the hospital is being widened.  Wow!  It is a comparative superhighway now, if still gravel.  The heavy equipment was working today, Sunday.

At the end of the Ilula road, there was a row of motorbikes, the drivers beckoning to provide a ride to Mtua for a price.  Being piki-piki averse, I chose to walk the half mile or so.

On the roadside, as I walked against traffic like a good pedestrian, there was one of many piles of kiln fired bricks.  These are the mainstay of construction here.  There are many piles like the one I saw.  I wondered about their story.  Is the owner alive?  Is the owner accumulating wealth to use them for a house?  Among the many dukas or shops, all of which seem to sell the same things, are many rusting abandoned vehicles and junked equipment.  There will come a time when the threshold is reached and this metal has value enough to recycle it.  Most of the shops and buildings along the road are marked with green Xs to signify they are too close to the road.  Actually the building code (?) had been changed so the buildings now were too close.  I think they have been marked at least the 8 years I have been coming.  No new road though.  And by the way, I hear the county where you live is coming by to put a big green X on your house soon too....  Well, can you imagine it?

As I walked, I noticed 4 or 5 plastic containers along the road.  Presumably someone was watching to assure that no one would abscond with them, but I did not see the owner.  "Hmmm.  That's odd," I thought.  "I wonder what they are?"  I noticed that they were frothing at the lids.  Ahhhhh.  Sun augmented fermentation of  the local brew, pombe.  It is vicious stuff.  Or so I hear.  It smells terrible, like the worst beer you can imagine and tastes worse.  Or so I am told.  And an aftertaste! Whew!  Bad news! As I understand it, of course.

There is another kind of container common here.  It is he freight container.  Many of them are converted into dukas or continue their lives as permanent storage for goods.  At Ilula we have a permanent container used as storage and another building made from one or more freight containers.

Again that surreal sensation, "I am in Africa."

"Kamwene" is the Hehe greeting around Ilula and Iringa, where this tribe is dominant.  The response is "Kamwene."  Then the response is "Nogage," and the other says, "Dimnofu."  Pronounce each syllable and letter and it will be close.  Of course, the Tanzanians will laugh at your efforts, but appreciate it, nonetheless.  I see the black faces and only realize I am different when my Mzungu hand slips into view with each stride.  Well, that and not knowing the language and perhaps the stares of the little children who shout "'zungu!" As I pass.

I am different.  I am in Africa.

I arrived at  the bus stand and got on.  There is no set schedule.  When enough people have gotten on, the bus departs.  I was delighted to see the familiar face of our housekeeper, Tula.  I sat beside her and as others got on, we snuggled closer and closer.  However, it wasn't that romantic.  Each row is designed to hold four people, including a jump seat.  The conductor demands that each row be filled.  With a minimum of five people.  We had six, including an infant.  It was a slow trip.  As we traveled, some got off, more got on.  I counted 40 in a vehicle designed for 25.

We arrived at the S/Kuu (Main Bus Stand) and parted ways.  I said goodbye to Tula and walked to the Lutheran Centre.  Here two church groups had arrived, Como Park Lutheran from their companion village and St. Paul Lutheran here their first full day.  Both groups were bubbling over with the same excitement my dad had.

"This is really Africa!"

I am the reporter

Today was like the start of any other day.  But this is not Lake Wobegon.  We had morning report and chart rounds and a nice discussion of a difficult medical case in this resource-poor setting that is Ilula.

A twenty year-old man was seen for the third time over several months, condition gradually worsening.  He had severe hypertension and increasing dyspnea with the diagnosis of pulmonary hypertension.  There were several odd items in the history.  First, this is rare in a man although it does happen in women his age more often.  He also had severe hypertension and dyspnea.  When it does occur, it is often associated with HIV.  He was negative.

At home, we would have used sophisticated echocardiography, EKG and CXR to make the diagnosis and then would have wanted him to be in a center where experts could take care of him. We do not have those diagnostic tools at Ilula.  Chandra, our third year FP resident did a brilliant job discussing other likely possibilities.

The young man died.  If the diagnosis was incorrect, in the US several other possibilities could have been managed well.  We are blessed at home to have well-trained and brilliant doctors like Chandra (and no doubt our other students will be equally trained and talented).

Life goes on.  For some.

As I walked toward the ward, I heard the mama’s wails and saw Astrid and Shana standing outside the ward.  The others were still inside.  Astrid told me the story, which I report, not as a witness.  A fifteen month-old infant with a known cardiac problem of some kind had been admitted over night and put on oxygen due to respiratory distress.  Rather suddenly, the infant quit breathing.  Only a moment before Jill had examined the baby who had no obvious chest findings.  The staff began CPR, but ineffective, so our team took over, to no avail.

The baby died.  I do not know what might have happened at home.  Our pharmacy team felt deskilled in this predicament.  Their armor had been stripped away.  They had no crash cart full of life-saving drugs.  They had no team familiar with the protocols of a well-oiled crash team.  The doctors and med students were no better served.  Cole put something hard under the child to augment Shana’s efforts.  There was no bag or mask handy.  It was locked in the surgery theater.

Thus the team’s efforts proved frustratingly futile and the baby died.

Theoretically, each of these humans would have had a better chance if born in the USA.  There are many “ifs” however.  If we had better diagnostic tools (a year or more ago); if they had better training; (if I had better training, etc.); if, if, if.  It will be years before the technology reaches Ilula Lutheran District Hospital.  For now we can only keep on coming, bringing students and residents and faculty dedicated to doing the little things we can, teaching and questioning in a learning, not critical fashion.  Ilula’s staff is just as brilliant as any of us and without the tremendous advantages we have had in our training and careers.  I never forget this, no matter how frustrated I may be.

The whole team was devastated by the infant’s death.  We returned to the faculty house to commiserate and vent.  When we got around to naming the emotions we were feeling, I heard anger, frustration, helplessness, sadness, inadequacy – all our humanness came to the fore.  There were tears and pain.

Friends from Como Park Lutheran came to tour the hospital.  We entreated Pastor Marty Erickson to pray with us about our experience with this small child.  I felt some personal healing in his prayer.

Despite our tragedies today, we had a rewarding and pleasurable visit with The Como Folk.  Truly, a help after trouble.

One life leaves and another arrives.  This afternoon Dr. Leslie and Laura delivered a breach presentation baby by C-section.  It went well.  A fitting end to a trying day.