May the road rise up to meet you.
May the wind be always at your back.
May the sun shine warm upon your face;
the rains fall soft upon your fields and until we meet again,
may God hold you in the palm of His hand
Hello Everyone! I hope you are well! I appreciate all the great feedback and words of encouragement everyone has sent, know that none of it goes unnoticed. Please forgive me for being so late with this post. I have so much to share, accordingly this update is a LONG one, so I have a great deal of admiration for anyone who can make it all the way to the bottom. Additionally, this post has a couple of hospital/ medical stories, so I had some internal debates about how much I should and shouldn’t share. I have tried my best to take out most of the technical jargon and make them readable/ engaging to the everyone. That being said, I understand for some people medicine might be the most boring thing you have ever read about (though I don’t see how, I think it’s pretty awesome) so in the interest of everyone’s time (and for any family members interested in whether or not I am alive, and enjoying my time down here). I have put the fun, social, part of my adventures first, followed by the medical aspect if you are interested.
Just keep swimming, just keep swimming, just keep
As far as miscellaneous details on my personal life go, I want to thank everybody who wished me a happy birthday from thousands of miles away. My birthday was relaxed, but fantastic. I turned 23 years old in a local African coffee shop watching the sunrise, convalescing from some travelers diarrhea I had the day before. Over the past couple weekends I have gone SCUBA diving around Zanzibar and Dar Es Salaam. A Masai tribe adopted me while we danced at an African block party. I went on a biking tour around the different neighborhoods of Dar, stopping to drink local turkish coffee, eat a traditional swahili breakfast (the same thing we get every morning at home, so it must be legit), and stopped by a traditional healer’s shop. I walked around the Mwenge woodcarvers market, and watched local woodcarvers sculpt some cool souvenirs, visited the local village museum, and traveled to a local island where I swam in the crystal clear Indian ocean for the umpteenth time. So all in all I am still having an incredible time just exploring the city of Dar Es Salaam, and getting in touch with the local culture.
A Masai barbecue, its the circle of life.
I still feel obligated to tell the internet again how great the Tanzanian people are. Now that I understand more Swahili, I appreciate more of what the locals are saying in everyday encounters. If a local sees you working while they are not, strangers frequently say Pole kwa kazi (I am sorry you have to work), then extol their admiration for you keeping you nose the grindstone. While doing some revising on this update, I was sitting in a local coffee shop. The guy who works in the store next door has come up to me three separate times; initially saying Pole kwa kazi, welcome to Tanzania, the second time saying, my brother! You work too hard!, the third he offered to pay for my coffee (even though he makes 2 dollars a day).
With a sea like this, why wouldn’t everyone go there?
Another example occurred while I was walking down the street. A group of traditional Swahili women walked by, nodded and said Mzungu Kaka. I must confess I did not know what Kaka meant, and assumed it was an expletive (I mean come on, doesn’t KAKA sound kinda dirty?). I went home determined to find the precise definition, and determined should I ever see them again to have a classy Swahili comeback on hand. Much to my chagrin, when asking our host mom to define Kaka I discovered it means elder brother, and is reserved as a sign of great respect within Swahili culture. Instead of telling these women off, I have to thank them. Well played locals, well played.
- I am still so happy to be here
- Dar Is a blast
- Come to Tanzania, no seriously do it
It really does look like this
The following are some interesting medical stories from the last two weeks around Mwananyamala. Nothing is graphic so don’t worry about being grossed out, but there are some incredibly happy moments mixed with some extremely sad. A paramedic gave me a quote he referred to as the fundamental law of keeping your sanity while working in medicine, “Tell the bad stories if you learned something and make sure you always tell the good ones. In the spirit of this, I present the good and bad fortunately diluted in a 2 to 1 ratio.
The surgery department. On the left, anesthesia. On the right pediatric resuscitation, also featured a modern take on the traditional stethoscope (the metal thing)
The emergency room has not gotten any easier. There is still rampant overcrowding, questionable decisions by doctors, and a complete lack of basic resources. However, my understanding of Kiswahili has improved greatly. While I am not remotely fluent, I am able to “get by” around the city. Recently, I have been able to collect a simple patient history, determine a chief complaint, and communicate with most patients to a basic degree.
My improvement in Swahili was best exemplified around 5 o’clock last Monday. I had already changed out of my scrubs about to head home, when I saw two men wheeling in an unconscious individual into the ER. The man was hardly breathing, snoring with each breath (suggesting something partially choking his upper airway), and unable to respond to any stimulation. The rest of the staff was off with another patient (as is often the case in the crowded ER) so the patient’s initial care fell to another medical volunteer and myself. I asked the two family members Nini Shida? (What’s the problem?). The two men looked up with fear and tears in their eyes, and simply replied Sukari (sugar). I then noticed the brown sugar smeared across the patient’s lips, simultaneously forming a thick paste in his throat responsible for the obstruction in his airway. I tilted the patient to his side, grabbed a suction machine, while the other volunteer ran to grab an IV cannula and additional help. While I suctioned the viscous molasses from the patient’s airway (via a foot powered suction machine) I asked the family members for some more basic information, Amekula? (has he eaten?) dakika ngapi? (How many minutes ago?) the family responded Hapana (No) and ishrini (20 minutes).
You save a lot on utilities out here
The patient seemed to be hypoglycemic with a blood sugar so low, his brain was hardly able to perform the necessary basic functions to support life. The situation can be easily fixed by giving the patient supplemental sugar IV (through the vein). I relayed the suspected diagnosis to the intern doc and other volunteer, who showed up with IV supplies in hand. The Intern doctor quickly spoke to the patient’s family members (in the fastest Kiswahili I have ever heard) and confirmed the man was a known diabetic who had taken insulin and forgotten to eat. The doctor returned imminently with 100 ml of Dextrose 10% (a sugar), and started an IV while I gave the patient 50 ml of D10 as soon as he finished. Giving IV sugar to a patient in hypoglycemic diabetic shock is amazing because of how quickly works. Within two minutes our diabetic friend went from choking on his own tongue, to smiling, giving us a handshake, and saying thank you.
I have obtained an entirely new understanding about the HIV/ AIDS epidemic, seeing the debilitating effects of the disease in person is something a textbook cannot provide. Of the patients presenting to the Emergency Room, I would estimate 60% are from complications associated with the disease. One of the most common complications is Tuberculosis, which easily infects the lungs of patients with a compromised immune system facilitated by AIDS. Once TB takes up residence in the lungs it spreads throughout lung tissue, interfering with oxygen transfer which if left untreated is often fatal.
In case you are wondering, the cot cannot be removed
Such was the case of a woman transferred to Mwananyamala from an outlying hospital. The patient was transferred, due to possible HIV/ Tuberculosis complications. While assessing the patient I noted that she had an incredibly fast heart rate (160 beats per minute, anything above 100 is considered too fast), breathing quickly (once every second), and was blue in her lips, fingers, and toes. When we attached the woman to a pulse oximeter we found that her O2 saturation (a test which measure the amount of oxygen in one’s blood) was at 45%. Putting that in perspective, a human normally saturates at 97-100%, anything below 94% needs treatment, below 85% aggressive treatment, and below 70% patients have a hard time staying conscious. The woman was barely clinging to life at 45%.
Traditional Spices, and a Rocky mountain tradition (this one’s for you sports lady.)
In cases of advanced TB, low oxygen saturation can be difficult to fix. However, the most basic treatment for low oxygen saturation of any kind is putting the patient on supplemental oxygen, which increases the amount of oxygen a person takes in with each breath. Even though resources are scarce at mwananyamala, the hospital still has access to supplemental oxygen. The staff agreed to place the patient, on supplemental oxygen and I ran to grab one of the several Non-rebreather masks for the patient. Just as I was about to place the patient on a nonrebreather I was stopped by the attending physician, and told that I was doing it wrong, the appropriate device for oxygen delivery was actually a nasal cannula. While it is not my responsibility to comment on the decisions of another healthcare provider, this goes against everything I was ever taught. I was trained a mask is 4-5 times more effective than nasal cannula (delivering a potential oxygen concentration of 80-100% as opposed to a NC which delivers 22%). The doctor stated that a nasal cannula was more adequate for delivery, and even though I protested, the patient was placed on nasal cannula O2 at 4 liters per minute. The patient’s oxygen saturation was raised by 10%, a whopping 55%. The patient later died in the ward.
The basics of life support are poorly understood out here. However, another volunteer who is a Medical Doctor came up with a fantastic idea, working with the hospital to potentially change or improve their oxygen protocols. The other volunteer and I have since met with the head of their internal medicine department on ways to help address potential issues with their use of oxygen both in the ER and in the wards. The secret code word is mango. I would really appreciate if anyone has some ideas in regards to this matter, places to look for funding, innovative ideas to stabilize oxygen tanks, etc. If anyone wants to know all of the details, please email me at firstname.lastname@example.org. I cannot say how much change we will truly make in regards to improving Oxygen delivery in the hospital, but hopefully some small step can be taken in the right direction.
I would love to share a final story (and by far the most moving part of my Africa trip) that happened just the other day. A 24 year old woman came into the ER complaining of belly pain, dizziness, and general fatigue. The patient entered the emergency room early in the morning (before I arrived) and sent to ultrasound to determine the cause. The woman returned to the Emergency room from ultrasound walking and talking. The attending doctor was distracted by a cerebral malaria patient, and I couldn’t help but notice the woman was getting more and more sick. Within a few minutes she was unable to talk normally, covered in sweat, and had a highly elevated pulse (150 bpm) and respiratory rate. Speaking with her relative I learned the patient went through a late term miscarriage the day before, and had been bleeding steadily from her vulva ever since.
The storage in this house is spectacular
Lowered mental status (a patient’s inability to talk/ move normally, or remember who they are) and elevated vitals are all signs of hypoperfusion/ decompensated hypovolemic shock. Hypovolemic shock occurs when there such advanced fluid/ blood loss, the heart cannot pump enough fluid to keep the body functioning properly. The brain is generally the last organ to shut down (the body will shunt blood away from other organs, before letting the brain be effected), this woman’s declining level of consciousness means her body is very close to losing the fight. Simply put, the body has tried its best to keep the woman alive, but cannot maintain her current state much longer in the face of constant blood loss, and she is minutes away from dying/ bleeding out.
After inquiring if anyone had taken her blood pressure (the answer was no) I checked it, to find that her BP was 55/40. Normal BP is 120/ 80, and 90/60 requires immediate intervention/ fluid infusion. I told the ER nurse and doctor that she was not only hypotensive, but also on the verge of passing out, the response was, “the ward will deal with it.” Initial treatment of a young hypotensive patient is relatively easy, all that has to be done is replace the lost blood with IV fluid/ normal saline. In spite of the nurses laziness, I quickly started a line and began infusing IV saline as fast as possible, as I was doing this the interpretation of the ultrasound came back. The results were grave, the spontaneous miscarriage had caused bleeding within the uterus, and evidence of nearly 2 liters of blood found in the uterus alone. In America, hypotensive/ bleeding patients (like this) are given two large bore IVs (something the patient likely needs) either in the ambulance or upon entering the emergency room. This is not the case in Africa, as generally the ward (where the patient is admitted) is responsible for starting a second IV. In an attempt to avoid further stepping on the hospital staffs toes, I checked her blood pressure again and found that she had fallen to 50/30. Without emergent surgery to stop the uterine bleeding the woman would probably be dead within the hour despite our best efforts, without another IV line and more fluid the woman would never make it to surgery and be dead within minutes. I made a snap decision and started another IV.
A middle class house, with courtyard in the middle
Scrambling to find a fresh liter of fluid to connect to the newly started IV coincided with the patient’s departure from the Emergency room and admission to the ward, where she would wait for surgery (a wait typically ranging anywhere from 2-3 hours long). Admitting a patient at Mwananyamala generally involves handing the patient’s file to family members, who then move the patient to the unit. There is no nurse handoff or doctor’s report, no one is told a current set of vital signs, only a hope that the patient’s file is read quickly enough for the attending doctor to find out about the patient’s severity. Knowing this process and that the patient was critical, I found another liter of lactated ringers, and ran to the ward. I arrived to find the patient slumped over in a wheelchair in a remote corner, completely unconscious and unresponsive, nobody attending to her.
While it is customarily rude, I burst into the ward and informed the staff that the woman had been extremely hypotensive in the ER, along with my concerns that she would die if not give fluid and taken to surgery immediately. After two doctors tried unsuccessfully to obtain her blood pressure (given it was so low) the staff doctor in the OB/ GYN ward (one of the best doctors I have seen at Mwana) recognized that this woman was a critical patient, and immediately moved her to a surgical room on the floor. While the doctor began the process of stopping the bleeding in the uterus, another nurse and I maintained fluid resuscitation in an attempt to stabilize the woman’s blood pressure. Over the next half an hour the doctor, nurses, and I battled to stabilize the woman and get her blood pressure to a normal level, in a desperate fight for the woman’s life. 45 minutes into the procedure, she “woke up,” regained consciousness, asking where she was, and was going on.
A hermit crab, and Hans taking a picture of.... Something..?
The doctor was eventually able to stabilize her bleeding, pulling out a total of 2.5 liters of blood from her uterus. The doctor thanked me for running to the unit and telling him the patient was in hemorrhagic shock. He told me two other patients had died this month from the same condition because they were not stabilized, due to a lack of nurses on staff and communication between the ER and ward. Most importantly, two days later the woman (a nursing student at a local university) was sent home to her three children where she cooked dinner for her husband that very night.
Traditional coffee, and a traditional pharmacy
Every evening the Tanzanian medical students ask me about my day. In typical polepole fashion, they expect not just a response, but a detailed synopsis of the day’s events. A great moment came from one of these conversations. Upon asking Habari za kazi? (how is work) I respond good but difficult. Naturally, the medical student asked me why, and I responded with the first part of my story about the woman with low blood pressure. When I told him that her blood pressure was 55/40 he responded, Pole Sana! (I am very sorry for you) every time I find someone with a blood pressure that low they die within two minutes. When I replied, this one lived. I was bombarded with questions about all the details of the case. How was I able to notice shock? What are the first signs and symptoms of hypoperfusion? Why does squeezing an IV bag keep people alive?
While I have been able to share a couple tips with people on this trip, nothing has ever occurred to this degree.Thanks to the Lumos foundation, 4 more Tanzanian medical students know how to identify potential hemorrhagic shock in patients, and three more children can come home to their mother’s cooking. Admittedly, It is a miniscule step forward, but it is a step in the right direction.
Thanks to the Lumos foundation for making this incredible journey possible, and in case any members of the foundation want to feel better about themselves while going to bed tonight, know they are officially responsible for helping to save a human life.
Real turtle. Courtesy Hans Tvedt
The last thing I want to say again with this post, is Thank you so much for reading! I appreciate all the people who have messaged me, shared these stories on facebook, and even just sent words of encouragement. As always, I love to any and all feedback on the blog, and advice on improvements. I would love to answer any questions about anything. If someone needs clarification on the reasoning behind some of my decisions while I have been here, let me know. Also please email me if anyone has good ideas or wants the full story about changing oxygen protocols, and making it more accessible across the hospital.
I hope everyone has a great day, and if you made it all the way down here I am proud of you!
Also since this is so long, I am going to institute a secret code word to see if anyone truly read this. Email me the secret code word, and you will get a special surprise when I return. Have a fantastic day!