Time is flying. Gary Moody is going home in the morning, leaving for Iringa at 6 AM. We spent time tonight debriefing the day after rounds in the morning, a visit to the dispensary and school at Image (ee-Mah’-gee, not Im’-ij). The dispensary needs to be replaced. There is land set aside by the community. Now all the need is, you guessed it, money. I wish there was more to say, but there is not. Birdie and I visited the school in 2006 on our first trip to Tanzania with the St. James group. The Headmaster was Ngogo. I remember how impressed we all were with his vision and leadership. But all that was there was a set of three buildings, a few foundations and a lot of strings outlining the future buildings. They had students, but I do not remember how many. Now there are many buildings completed and 840 students! After the tour, the kids sang for us and danced for us. I can confidently report that “a good time was had by all”! When I get home, I may post a little video, but not now because the internet is too slow.
Randy has developed some discussion topics that have produced some lively conversations. No conflict, just some thought provoking ideas, like how do we suggest change without offense. We need to be especially careful of not practicing “knowledge paternalism,” i.e. thinking all our answers are right. Some pretty high faluting ideas came forward. Randy is thinking how culturally contextual the term “corruption” is. Compare our individualism with African collectivism. In the US we may see a manager taking a chicken home to his family as stealing or embezzlement. Here the same action might be seen as sharing the wealth. It is difficult to get one’s head around in one sentence. Each culture defines itself in its social context. I think a relativistic question we can pose to any culture is “How does this practice (insert social norm, more, behavior, custom, etc.) advance its society?”
Tomorrow we have a group of US visitors touring educational and health facilities touring the Ilula District Hospital. They are from Augustana College! What a treat it should be. Well, at least one of our group is looking forward to it!
Ken
Jan 20, 2011
First, happy birthday from Africa, Mom (Esther W. Olson)! The temperature here is about your age, Mom and in Minnesota, I presume about the ages of your great grandchildren.
Dr. Moody left this morning. We had goodbye appreciations for him last night. We miss him already and have been calculating where he might be since he left.
Several of the students had opportunity to go to an outreach clinic this morning and one is a little sick. Our Augie groups will be a little larger than we originally planned, but all will be well.
There is a newborn (NB) we have all been fretting about, especially Sara. We feel helpless. The NB came back at 4 days of age with lethargy and jaundice. We cannot measure NB bilirubin. Clinically, the jaundice spread down the body, even to the feet. We also know the baby is quite anemic and we suspect a hemolytic (blood breakdown) process. We cannot test for that either and if we could test for it, we would be unable to treat it (think exchange transfusion). So we watched as the baby got sicker. The baby got an IV, but without an IV pump we have had easy access to in the states, we would have had to drip it (counting drops per minute). This was standard in adults when I graduated from residency. But with infants, it is too easy to fluid overload. We resorted to small, intermittent fluid boluses, until a nasogastric (NG) or orogastric tube could be placed. (A very skinny plastic tube is placed in the stomach via nose or mouth). We saw the baby get cooler and cooler, heart rate drop, go from poor suck to no suck and become ashen gray. He is on antibiotics and we have nothing else to offer, except continuing the same regimen. We expected the worst. Gave up? No. We have been carefully checking morning and night, primarily Sara.
Amazingly, this morning, the baby seems warmer, has a weak suck reflex and seems less jaundiced. We never would have predicted that. He has hiccups. Could be natural, like every NB; could be related to NG position, or worst, could represent brain damage from kernicterus, as a result of the bilirubin being substantially over 20. My grandson Sawyer got to 13, maybe a little higher. When this happens at home, everyone scrambles and we have these marvelous lights to use. Here we have a 60 watt incandescent bulb and we cannot really have the baby undressed for prolonged periods due to worry about hypothermia, so effectively there is no therapy. So, as miraculous as the improvement is, assuming it continues, there is still a high likelihood the baby has permanent brain damage. If he does not die, we will likely never know the outcome. I think this baby will haunt us. I will upload a photo of this sweet boy and his mom.
My gadgets have been useful. The photo of the baby (and many other people), I have been able to give to the human subjects, thanks to the little photo printer I brought. The people have been very grateful for them. We have taken many photos, but except possibly for a brief electronic peek, they never get to see themselves.
We have used my palm-sized projector a couple times. It works great (at night)! What did you expect? It is the size of a deck of cards! Hooks up to the computer well.
Now I have a phone that works in Tanzania. My iPhone works fine – for its non-phone functions. No, I am not playing the games on it. Well, not much anyway!
The students were here. It was great! There were many from Augustana, several from St. Thomas and a lone Gustie. They seemed pleased to be here and Chery Feinstein, Julie Ashworth, Augustana professors, and Kari, the liaison from the trip planning group seemed thrilled to have been here. I have a mild bias I suppose, but our students were professional in every way. They made a fine presentation to students who were extremely interested. See Randy’s story below. I definitely want to connect with someone in the nursing department.
Ken
DEVELOPING A “CULTURE OF LEARNING” AT ILULA
We officially opened the Peter J King Family Foundation Medical Education (and future nurses training center) last evening with the opening honorary guest lecture, “HeHe Proverbs,” given by Dr Gary Moody. Gary has a list of HeHe proverbs: he and our students have had fun this past week trying to think of American synonyms for some of these proverbs then finding photos to match and placing them in a power point presentation. Example “Roar within your stomach like the cow does” might mean “keep your problems to yourself; “The lead cow drinks the cleanest water” likely means “the early bird catches the worm.” We then had our students give us a power point presentation about the cases they had seen this past week: malaria in pregnancy, malnutrition and malaria, an ultrasound diagnosis of a ruptured ectopic pregnancy, a case of large bowel volvulus that was operated on etc. Several of the students have delivered babies with the help of Tanzanian nurse midwives; one of the mothers named her baby “Sara”, after our student, Sara Tonsager who participated in her care. Sara and Sara are now “soul sisters.”
We have made a point of telling the staff at morning report this morning that the new Education Center is theirs. It is for all of the health professionals at Ilula, from the medical attendant students, to the nurses and midwives to the doctors and clinical officers. It is also for the people of Ilula: for the secondary school teachers to gather and learn health information that they can share with their students, for education of community health workers, and for pastors to gather to learn health information to pass on to their congregation. We talked about developing a “culture of learning”, how when students challenge and ask questions, that it actually improves the care of patients. After that talk, we all observed a noticeable change in how ward rounds were conducted: a great start!
We hosted a group of 29 college students from Augustana, St Thomas and Gustavus this morning. They are on a 1 month J term trip learning about health and culture in the area and stopped by the hospital. We broke them all into small groups and had our students give them all a tour. Afterward, our students presented their lecture on cases they had seen here at Ilula.
We have an educational theme of nightly discussions going on here at Ilula that hopefully have engaged the students. The focus culminates in trying to understand the meaning of partnership and discussing principals of how to partner well with our Tanzanian brothers and sisters. “How to help without hurting.” Pre-course work included reading a book, “The Fever” (Sonia Shah) about how a disease, malaria, affects a culture. They also read, “Africans and Americans, embracing cultural differences” (Joseph Mbele) to give them a better understanding of cultural awareness. We move on tonight to talking about definitions and causes of poverty and complete our discussions tomorrow with “how to partner well.”
Randy
January 21, 2011
Today is my last day here, and my first post. Ken would not let me procrastinate any more. The day started with some great presentations by our medical students to the entire hospital staff. The presentations covered DKA, diabetic neuropathy, and hypertension. The hospital staff appeared to be very interested in the content of these lectures as well as the process of didactic education, American style. Next we went to a small house in Ilula to visit a patient who had had a stroke. She had been a nurse, but now is unable to work due to being hemiparetic on the left side from the stroke. She continued to receive PT (Amy) and OT (Stacey) treatments in her home. Next I went to visit the CTC (Counseling and Treatment Clinic) where HIV patients are monitored and treated on a monthly basis. They have a great system of record keeping and monitoring the patients to deliver antiretroviral medications according to protocols. Finally, I spent some time with Nixon Mdegella in the outpatient department. He is a clinical officer who has been at Ilula for 10 years. This was pretty much one of the highlights of my trip since, as an emergency physician, this acute care was right up my alley. We saw lots of malaria in addition to trauma (fractures, head injury), infections (hand infection, foot infection from thorn into foot), and assorted sick kids, abdominal pain, and chest pain.
I had to say my farewell to the staff at morning report today. It was a bittersweet moment for me. I told the staff that I wanted to thank them for all the help, learning and hospitality they had extended. I also told them that, having seen how well they took care of us, how well they take care of each other, and how well they take care of their patients, I will be a better doctor and a better person when I return home. The graciousness of the Tanzania people will stay with me for a long time I hope.
John
I spent a little while in the Out-Patient Department (OPD) with Dr. Saga today. I assume I will do this often in the next couple weeks. We saw some memorable cases too: one man brought his chest x-ray which showed a pneumonia (pneumocystis) commonly found in HIV positive people, fortunately easily treated with a common oral antibiotic; a woman came with a whole body rash – Stevens-Johnsons Syndrome. She was checked for HIV (PITC is “provider-initiated testing and counseling”). There is still a stigma being HIV positive. The government supplies drugs for free. The stigma may be changing. One young woman came to the outreach clinic and wanted to be tested. She had been coerced into not telling or being tested by the male who could have infected her. She was of course worried, but when she was tested and despite her fears was positive, she was relieved because now she could be treated.
We went for a walk to the river, currently a trickle, despite the rain we had a few days ago. Today was beautiful with a few scattered clouds and bright sunshine. We walked the travelled paths along the plowed fields an I keep wondering about the ag project and whether they are using any of the practices taught at Tumaini. The soil does not appear to have much humus. I will have to ask.
After the walk, the hospital administrator came to get me to take the photos I had promised to do at the church. Pastor Dani, Alum and I strolled around the church and took some nice photos. There was beautiful singing inside and perhaps a Friday afternoon service. They even allowed me to take a few shots inside.
The Ilula church is partnered with Chisago Lakes. So far no one from there has visited Ilula. I think I have picked up on one possibility, which may or may not relate to the Tanzanian concept of Chisago Lakes. Chisago sounds like Chicago. “Are you close to the Great Lakes?” Alum asked. About 150 miles, I said. Now I am wondering if he may have seen Chicago on the map, next to Lake Michigan. I hope I have the opportunity to show some photos to Chisago Lakes.
This evening we went to Dr. Saga’s home where Dora prepared the best meal we have had. (And our food has been great.) She did tease us a little telling us she had forgotten to make ugali. It was a wonderful night of visiting and eating. As you might guess if you have met the Saga at all, they are truly gracious hosts.
In the morning, we are on the way to Iringa, then on to Tungamalenga and most of us to Ruaha. More after that adventure!
We got word that one of the tour students got a cut with a razor blade, not his own while at a night club. Though his risk is extremely low, he will still be on HIV prophylaxis for a month. I did not like it when I had to take it after a splash in the eye with a patient's blood some years go. It was nerve-wracking, even for the few days.
Ken
