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.

Radio Furaha and Idete Dispensary

I spent last night at the Lutheran Center so I could be here in the afternoon for a meeting with Joan Mayer from USAID and be ready this morning for the Radio Furaha broadcast about nutrition and breastfeeding.  Joan had to cancel.  So I had a nice dinner with the Como Park group.  There was a rousing discussion on many topics and all left as friends.  It is so stimulating to hear many thoughtful perspectives, all right in so many different ways.

This morning started bright and early with me waking up just after 5 AM.  I reviewed the material I wanted to cover and had a little breakfast.  The Radio Furaha studio is inside the gates at DIRA.  The manager is Protas Kanamela.  I don’t know if he is on air anymore, but he definitely has a great voice for it.

The studio room is very quiet.  Two radio jockeys broadcast the morning show, also with great voices.  There is a desk with lots of equipment and a computer and very official looking radio gear.  For the call-ins, they cover a cell phone with a foam damper, like the kind we see on the microphones.  Well, the other stuff looks official.  But no more effective that this innovation!  To get to the sound booth, you enter through an anteroom.  Shoes are removed outside.  My friend Maria Biswalo was there to assist me.  She is Tanzanian whose early schooling was at a boarding school where all the kids spoke German.  (Her husband is the son of our German friend Beate Mundt.) She spent another four years in the US at University of New Orleans.  She speaks English with no accent.  It was great to have her help!  We talked about nutrition and breastfeeding and then answered call-in questions.  As far as I am concerned it went well.  But then, how would I know?  Although, I think Maria would have been kind enough to tell me if they were talking about the weather in, say, Minnesota.  Apparently it was live-streamed over the internet.  I may never know that for sure either, unless some English speaker who knows me actually tuned in.  The gang from Como Park tried to catch it on the internet but were unsuccessful.

From the road overlooking a valley near Idete

When I finished with the radio show, Dr. Saga and the students were waiting for me.  We bustled off to Idete in two vehicles.  The old Land Cruisers are quite serviceable, but may be of a vintage prior to shocks and springs.  It is a much shorter trip than to Idunda and only 15,000 bumps were recorded by my FitBit.  Idunda is a 25,000 bump trip.  Of course that is both ways.  One of the students tells me there is an app (of course there is) that turns off counting when you are in a vehicle.  No way, Jose!  I earned those bumps too.

The old ward

We brought a bunch of medicines to Idete purchased by Randy Hurley (and possibly SOTV).  We had a little tea.  But not just tea; actually, tea, chicken, potatoes, vegetables and assorted sodas.  Never just tea!  This is Tanzania where hospitality, relationships and generosity reign supreme, immediately under religion.

Labor bed in the old ward

The dispensary at Idete is extremely nice.  I was there in August with the Lake Park folks when they delivered a lot of new equipment, supplies and medicines.  Many doors are narrow in Tanzania.  We had trouble getting all of the beds into the wards, especially the two-ton Tilly of a maternity bed.  The only thing we could do was to tip it on its side and scrape it through.  Thankfully, nothing broke off.  For most doors, the width doesn’t matter much.  Tanzanians themselves mostly aren’t very wide.   But I hope the builders follow our suggestion of putting a narrow stationary side door along side the entry so we can get beds and stretchers in and out when necessary. 

Idete Clinic

Dr. Saga and I spent a lot of time going over the new plans and even then we forgot something that others noticed immediately.  (This would be “the forest for the trees” syndrome, I think.)

They should be extremely proud of the Idete Dispensary, the doors not withstanding.  They started with a couple of huts for labor rooms or ward beds.  You see the photo!  Then they constructed the old one, still serviceable.  The new digs are terrific.  The maternity ward has two delivery beds and an exam table and an indoor choo.  Outside they have a choo building with 5 or six in a line.  There is a recovery room attached to the labor room.  I might add that the door has a stationary side door that opens to widen the space to accommodate the delivery bed.   Two more wards for males and females allow plenty of growth.

The new dispensary

While our pharmacy students restocked the shelves with the medicines, Chandra, Deepthi and Cole saw a few patients, including a spry 90 year-old with knee problems, a 75 year-old with cough, probably TB and a baby with a stooling problem.  (Well, yes, I was there too).

Our Crew: Astrid, Cole,Chandra, Deepthi, Shana, Tuli, Kelsey and Dr. Saga

After a few photos, we headed out.  Now we will head back to Ilula after a couple hours in Iringa.  The students thought the drive to Idete was beautiful.  Of course I agree, but I do have a bias.  It was nice to be home after a successful outing.  And the rain held off.

Water?

Maybe tomorrow.  A piece was supposed to arrive from Dar tomorrow, but I have no idea how long between now and it is installed and working properly.  This is always an “iffy” proposition.  I am not sure which “fundi” (mechanic/technician/craftsman) will put it together.  It cannot happen soon enough, of course.

It did rain the past two days.  Neither was a taunt like the day before.  We had a gully-washer yesterday and as Cole said, the buckets filled in five minutes.  The 1.5 liter bottles filled in about 5 seconds.  Really.  So we have had nice soft rainwater for showers and washing.

Our little peanut of 34 weeks gestation is now a week old.  The baby is now over the hump for birth-related infection and has survived long enough so the lungs are no longer a problem.  However, mother’s milk is not in and if it does not come in, the baby will die.  We have started to push her to drink fluids, in hope that will help.  We will see.

Dr. Leslie Pratt will assist (or do) a C-section tomorrow for twins.  It is risky waiting much more.  I am not sure of the due date, but apparently they are confident she is far enough along.  I think there was a hint of BP elevation, so this is the reason not to wait.

Our boy with marasmus is still here, but the doctor wanted to discharge him.  We asked him not to, because of the high risk of rapid relapse.  We are trying to set up Home Based Care through Amani Orphans Home Mbigili.  The child needs monitoring and balanced FOOD, not only ugali.

Mary Thompson and Dede Ouren have been diligent about work on Premature Rupture of Membranes (PROM).  In September, I worked with Dr. Rite on a checklist, but it was not implemented.  Now there is a new edition of Standard Treatment Guidelines for Tanzania.  The medicines are just a bit different than we had put in the data prompt tool.  So I rewrote it.  Tomorrow I will present it to the medical staff and hope for buy in.  The OB nurses are already on board, I think.  Dr. Rite suggested we put it in every chart and ask the delivering doctor to circle the answers on the checklist.  Couldn’t be easier, right?  We will see.  This would be an opportunity for them to get a paper published possibly.  Again, we will see.

All our students are terrific, devoted and smart.  We are having a good time.  Chandra, our third year FP resident is a real star.  He is smart and inquisitive and so knowledgeable!

Tonight we had a movie night and watched Elysium.  All enjoyed it.  I could refine the system a bit with a dedicated extension and plugs, but we make do.  I would like an even better speaker than my excellent tiny Boomz.

As you can see, water or no, we are surviving well.

Ground Hog’s Day

Certainly the Ground Hog saw its shadow here in Tanzania!  It began bright and sunny here, although it is now threatening to rain on our parade, I mean drying clothes.  I think it is a bluff.  Several times in the past two weeks we have seen this pattern only to watch it blow over.  We have had no significant rain since the Hurleys left.  I blame Randy.  Of course it has been rather nice, however we really do depend on rain right now for water.

I cannot remember if I waxed philosophic or prosaically on the water situation: there is none.  That is to say, the water system has been broken for several months, in fact, since Birdie and I were here in September, possibly before.  So I have felt quite chagrined to find this out on arrival.  I toured the nursing school with Dr. Saga, Mwamoody and Mchungaji Lamont just before leaving at the end of September.  We knew the water supply was having trouble.  We had no idea of the extent to which the well had failed.  It was not simply the leaky pipe we saw.

So this means the Ilula Lutheran District Hospital has been without a reliable water supply for four months.  On arrival January 6^th and discovery of the problem, Dr. Moody consulted with Shoulder to Shoulder to fix what needed to be fixed (about $4,000). In February.  Well it’s February and it isn’t fixed.  OK, I acknowledge that it isn’t very far into February.  OK, also that today is a Sunday.  However, can you imagine a hospital without running water?  We have had water carried in for nearly two weeks.  At 500 TZS per 20 liters, it is pretty expensive to do this.  We conserve as best we can.  I can shower with less than 1.5 liters of water.  Carl Sherman, thanks.  Two years ago Carl put several holes in the plastic bottle caps for each of us making a very efficient shower vessel. 

The town’s water supply is no better.  Apparently it failed also but not necessarily at the same time.  When it was running, Ilula still got only a trickle; hence its own well and pump.

Oh, and it just rained for nearly 5 minutes.  This does not count.  I think we collected a total of 5 gallons.  “In a real rain, we could collect over 50 gallons in 5 minutes,” Cole explained, experienced from before we came.  So, this one was only a taunt.  Still looks promising for more, but my challenge holds until then.

Dr. Jill (Stebbins) and I did Maternal-Child rounds this AM.  I was not exactly useless (perhaps “useless” is a little too self-deprecating), but she carried the ball, in part because I bailed to do a couple other things. 

In this ward are the post C-section moms and their babies.  If they live close, they can leave on Post Partum Day #3 (PPD) and return PPD #7 for suture removal.  If distant to ILH, they stay until PPD #7 and have their sutures removed then and home.  Today we saw a 16 year-old mother and her baby.  It happens here too, just like at home.  She is doing well physically.  I do not know if there is a baba (baby’s father) in the picture.  Also saw a mom whose milk has not come in, so baby is a little disinterested.  Dr. Furaha did an excellent job of helping her.  Left breast seemed a little awkward and a bit dry.  He switched her to the right and with a little more expression of the nipple got some milk.  This little boy knows the good stuff!  Maybe all the suckling stimulated a little let down to help out, but not before this concerned new mom shed a few tears.  She looked much happier when the baby was latched on.

In the nursery is a newborn a few days old now, born at 32 weeks gestation.  So far this little peanut is doing well.  She is breathing well and has good muscle tone when stimulated.  Since virtually all of the moms do round-the-clock care, there isn’t much need for the bassinets.  However, also there are two simple but elegant warmers with fluorescent bili lights and incandescent warmers.  However, I learned a couple months ago that even the special blue fluorescent lights (these have standard fluorescents) must be within a specific distance or they do no good.  Unless the placebo effect on the medical staff somehow helps the baby, but I doubt it.  This will be something we can repair easily!  Thank you Kiwanis Netherlands!

 

Oh.  And the storm blew over.  No more rain.

Fast and furious, Tanzania style

Things have been fast and furious here, in a Tanzania sort of way.  I now have a modem, which allows me to post to the blog.  At least as I have energy to do so.  Since there has been much water under the bridge since we arrived a week ago, I have much to recall.

This is likely to be a chronological mess, so dear readers, just understand that it has all happened in one week.  From the perspective of geological time,  it would appear as an instant anyway.

When we arrived, we learned that tragedy had struck the family of one of our team.  Randy and Kari informed us that the brother of one of our students, Sandy Lee, suffered serious injury in Afghanistan.  He is a medic in the Minnesota National Guard.  He was seriously injured by an IED.  Consequently, he was air-lifted to Germany and then flown to Walter Reed in Washington, DC.  He suffered multiple life threatening injuries.  I believe he is stable now.  Sandy was able to arrange travel to join him Saturday morning.  MwaMoody, Dr. Kvasnicka and Pastor Lamont Koerner have shepherded Sandy home.

We are not without local tragedy surrounding us either.  One bad car accident took two victims, one of Dr. Saga’s relatives (half-cousin) and a pastor’s wife, when the car’s brakes failed.  Another car wreck put at least two people in the hospital here and one of them needed to be transferred to Iringa.

We lost a three-month old and several other patients for various reasons.  This how life is in Tanzania.

A child with marasmus is slightly better, but mama wanted to take him home.  Care is free to children under five but he is six.  Atu, one of our dear ILH nurses intervened and has arranged a week of a free bed with the hospital.  Then we hope he is stronger with good diet and can be discharged to Home-Based Care coordinated with Amani Orphan’s Home Mbigili (AOHM).  They are calling me Dr. Plumpy’Nut, which is fine, just not Dr. Plumpy, however apt.  The supply of P’N has been interrupted, but will resume with the next distribution.

We went to AOHM just after lunch and examined a few kids and an adult.  I value their trust and appreciate being asked, which does not mean I am fully confident of the diagnoses.  Hey!  There are exotic things in Africa!  But also some very familiar things too.  The baby I saw a few days ago, Tuesday if I remember correctly, is better.  Whew!  I always appreciate nature doing her thing.

Late this afternoon we had a big celebration for three retiring staff people, including Dr. Saga.  We thought it was supposed to be at two, then three, then four.  It started at 5 PM sharp (ha!).  It was delayed in part due to a funeral for one of the car accident victims, then the ILH board meeting which went on and on (and on).  Eventually the meeting was over and the dignitaries were all here.  Dr. Saga, Mama Sanga and Eliza Mtweve were all dressed up.  Dr. Saga looked sharp in his black suit, white shirt and red tie.  There was singing and speeches, clapping and celebrating.  I was honored to speak just a little about Dr. Saga.  It was a joy to do so, if not perfect.  The audience did laugh at the appropriate times, but we wazungu are worth laughing at anytime anyway.  They really know how to throw a big shindig! 

We miss Dora Saga.  I know Dr. Saga misses her terribly.  With her absence, the was much laughter about finding a new wife for Dr. Saga.  He is definitely the most eligible bachelor in town and likely all of the Kilolo district and Iringa Diocese!

It is just after 11 PM here now.  We had our second movie night and finished about half hour ago.  In the morning we will take the bus to Iringa, catch up with Dennis Ngede and I hope get a vehicle and driver to take the group to Isimila. Our dear friend, Tuli Hingi, will accompany us to Iringa.  We all love having her.

So, that is it for now.  I will see if I can upload this!

In Iringa today

After a very successful Ilula International Medical Conference, the pharmacy students including myself, are in Iringa to learn more about the distribution of medications in Tanzania. In particular, the MSD distribution center. It is governement run and supplies hospitals wth medications and supplies at a lower cost.

Also, we will be on the radio in the morning.

Will update on that later. :)

The conference
I have added a picture of Tully, a nurse at Ilula Hospital,  teaching others about newborn resuscitation.

In addition, I added a photo of one of our presenters. I apologize for the quality of the photos as they were taken with my tablet from far, but soon we will be able to upload our photos from our cameras.

Two Weeks Later. ..

Hi everyone,
I have updated a previous post due to some missing sentences about my expectations for Tanzania before we left.

Someone shared the following link. I think you will enjoy it.

"Our lives, our cultures, are composed of many overlapping stories. Novelist Chimamanda Adichie tells the story of how she found her authentic cultural voice -- and warns that if we hear only a single story about another person or country, we risk a critical misunderstanding."

http://www.ted.com/talks/chimamanda_adichie_the_danger_of_a_single_story.html

Thursday in AMS

Well, here we are.  No problems with the flight at all.  John Kvasnicka has just joined us in Amsterdam, Schiphol Airport.  I think it is pronounced close to ski-pole.  We didn’t sleep on the plane.  After all, it is only about midnight or so to our bodies, despite the clock here saying 8:30 AM.

We should start the boarding in about half an hour.  The personnel are arriving already.  Quite a few people waiting now.  Lots of American accents in this general waiting area.  Our flight leaves AMS at 10:15.

We are all excited if somewhat weary.  It is always a surprise as to who will be meeting us at the airport.

More soon, I hope.  We will see if we can connect a few times or not!

There must be something else I should be doing…

I am busy with my personal preparations and have now finished my two talks for our First Annual (we hope) Ilula Medical Conference.  I will publish a schedule for the conference in a separate post, after arrival so I can make sure I have all the names in the correct topics.  The students will all be participating (whether they know it or not at the moment) as well as the faculty.  I have only scant information to report at the moment from Ilula.

I know they needed to have water transported from the village for non-potable use.  The bottled water is fine for drinking.  Food is cooked thoroughly and water for coffee, essential for the wazungu, or tea is boiled.  That is safety is not an issue, just convenience at this point.

My hope is that the U of M miracle workers have done magic, drilled a new well, replaced the pump and installed a water purification system.  (Well, OK.  That would be magic, even for our intrepid U of M Engineers.)

We were hoping to have things all in order for opening the Nursing School in March.  Unfortunately, even if the building is finished, I believe the water situation has pushed the opening to September.  It was supposed to be two full years ago, but that is another story….

We have planned our departure rendezvous for Wednesday and for all our fans who want to see us off, we will meet at the Delta Group Check-in on the lower level at 12:30 PM.  We are Ken Olson, Leslie Pratt, Jill Stebbins and Norrie Thomas.  John Kvasnicka is meeting us in Amsterdam.

TIA

"This is Africa."

As I prepare for departure next week, I am waiting for news from Ilula.  To be an American visitor in Africa does take a suspension of certain expectations of many things we take for granted here at home and simply do not tolerate in our environment.

The well has failed at Ilula.  I do not know exact details yet and perhaps won't until arrival next week.  I can tell a story about it and correct the details later.

When we were in Iringa last summer, there was a problem with the well at Ilula.  One explanation for the problem was that the pump installed had a capacity too small for the demands on the well.  I presume the well supplies the hospital with water too, not only the residences where we visitors stay.  Water is being carried to the residences and hospital daily for washing and toilet use.  We drink bottled water and soda or beer.

We do have a group of intrepid, heroic engineers visiting Iringa and surrounding area, including Ilula and will commandeer their expertise offering little more than grateful thanks for there efforts.  I wonder if I will be able to bring a pump from the US.  But is it bigger than a breadbox?

Also, on a much less important note, apparently the internet is out at Ilula.  Possibly, there is some electronic upgrade I can bring.  Again, is it bigger than a breadbox?  So that is why, I presume, that there has been no update from the residents of the Ilula Campus so far.

We can only hope...

Update from Kristi

Kristi Hembre has left a new comment on your post "Almost time... but wait!":

I am posting this as a "comment" in place of a regular post because of technical difficulties. (Ed. Note: cut and pasted from her comment post. kpo)

The view form the residences

We are now a week into our trip and have settled into Ilula. Despite Tanzania being insanely gorgeous, the people here have been extremely welcoming and kind. I thought as an initial post that I would quickly introduce the members of our group ....
Sandy Lee - 3rd year medical student at University of Minnesota
Laura Hanson - 4th year medical student at University of Minnesota
Cole Pueringer - 3rd year medical student at University of Minnesota
Chandra Cherukuri - Family Medicine Resident
Deepthi Malepati - Internal Medicine Resident
Jill Strykowski - Pharmacy administrator and frequent Ilula volunteer (and Julie's sister)
Julie Hause - Physical Therapist (and Jill's sister)
Erin Morris - Pastor looking to make ties with local Ilula churches and a US church back home
Treya Connell - University of Iowa student (and Lanette's grandaughter)
Lynette Franklin - Nurse with experience in many fields (Treya's grandmother)
Kristi Hembre - Physician Assistant
Shana Steinbeck - Pharmacy student at the University of Minnesota
Kelsey Bartz - Pharmacy student at the University of Minnesota
Astrid Steffen - Pharmacy student at the University of Minnesota, originally from Guatemala
and of course...
Randy Hurley - Oncologist, Leader of our group
Gary Moody - Family Physician, Leader of our group
Kari Hurley - Nurse, Leader of our group

We have such a great group and have been enjoying a few days of heavy rains lately amidst a recently broken well system at Ilula. We have been introduced to the outpatient and inpatient medical wards/clinics, HIV/AIDS clinic, Maternal and child health clinic, taken a few road trips to local villages and dispesaries, seen several babies be born, c-sections be performed....no shortage of learning and interesting cases to discuss. I look forward to posting more in the future!