Last Day at KCMC

   Well, sadly, today was my last day. It's been an incredible experience and it's hard for me to believe it's over. The physicians and nurses here are dedicated, caring and a pleasure to work with- I hope I have a chance to come back in the near future. While I have seen and heard about unbelievably sad events (most significantly, women and babies who died of preventable causes), working here has made me hopeful that changes can and will be made to improve this. Yesterday, we attended a maternal mortality conference where all of the maternal deaths from the past 3 months were presented. While several patients were late referrals from outlying areas, they reported 11 over this short time period. While the only discussed 5 cases, it was heartbreaking to hear about the 20 year old who had died of eclampsia after she spent 7 hours having seizures at another hospital, among others- all young women and some of which would leave orphaned children behind. Hassan, the resident who presented the cases left with a quote at the end from an OB/GYN who worked for many years in Egypt; "This will never get better unless we decide that these women are lives worth saving." I know that the people I've worked with here believe this, now we just have to work on the rest of Tanzania (and much of the rest of the world).

I've included some of my favorite pictures from the month, but I'm excited for my next adventure... safari and Kilimanjaro with Jon. I'll post on this later... I hope you all listen to this song while you look at pictures (link). Yes, I'm aware that I'm nerdy.

Cancer screening and preventable illness

   Sorry to follow up my upbeat post with something sad, but the hardest part of being here is witnessing preventable illness, and in some cases, death. One of the most glaring discrepancies between the US and here is the ability to provide preventative care. While I know that many Americans also have limited access to these services, it is not to the same extent. Although many people lack access to health insurance and don't have the benefit of having a primary care physician who sees them on a regular basis, many communities have free clinics or income based clinics that provide basic screening and care for patients without insurance. Here, this is much more rare, and in addition, many patients here are unable to miss a day of work without risking losing employment, which is much less common in the US. Others simply can't find reliable transportation to the few centers that may be able to provide them care until they are seriously ill.
    I hate to use the word perfect in relation to this topic at all, but cervical cancer is a perfect example. Since the introduction of the pap smear in 1946, there has been a dramatic decrease in the number of cervical cancer cases and deaths. For example, in Iceland, there has been a decrease in cancer deaths of 80% since introduction of pap screening guidelines. Decreases have been similar in the US and other developed countries, however, cervical cancer still remains a huge public health issue. According to WHO, in 2008, there were more than 530 000 new cases worldwide and 275,000 deaths from cervical cancer. And, as you might expect, the majority of these were in developing countries.
    While they have a reproductive health clinic at KCMC which offers breast and cervical cancer screening every Tuesday and Thursday, these are few and far between. In addition, because they do not have pathologists on site who are able to interpret pap smears. Instead they perform VIA exams, or visual inspection with acetic acid, which is essentially a colposcopy. They also perform breast exams and have the capability of doing cryotherapy or LEEP procedures if the exam is abnormal. Patients sign in the morning of the clinic, in a first come, first serve manner, sometimes waiting from 8 AM till 3 or 4 PM to have their screening exams. I often hear from patients that in the US that the wait is too long, or the parking is inconvenient, or even that they live too far away and it's inconvenient... so you can imagine how surprised I was to see a waiting room full of women, sometimes from towns that are hours away, who are spending their whole day waiting to be screened. (I didn't take a picture of the line, I felt like it was too much of an invasion of privacy).
    Despite limited resources, the clinic runs relatively smoothly. Cotton swabs used to apply acetic acid in the US are expensive, so one of the nurses who runs the clinic cuts dried grass and uses a large bale of cotton to wrap the swabs herself. Patients bring their own sheets (usually Kangas) to sit on to reduce laundry costs. They keep paper records of results and treatments in large books, but they also take pictures of the cervix to keep on file to compare on subsequent exams and plan for procedures, if necessary. Since they wouldn't be able to get biopsy results (at least in a timely fashion), they have to assess whether the lesion is concerning for cancer, and whether or not treatment is necessary, just by looking at it.

The Reproductive Health clinic exam room, complete with a patient's wrap placed
to sit on. (You can also see a cervix on the TV screen)

  While they're able to catch a lot of things, they often find cervical cancers which are advanced, as well as breast cancer (I found a large breast mass on one of my exams, and she already had palpable lymph nodes and symptoms of bone metastases). They're starting a study at KCMC soon to look at the utility of HPV testing as a screening method, which I think would be ideal. Cervical cancer (at least squamous type) and dysplasia are virtually impossible in patients who screen negative for HPV, and no pathologists are needed to complete the tests of interpret the results. It's unclear how this will change screening in developing countries in general, or if it will reduce cervical cancer mortality and morbidity, but I guess it at least makes me (and the physicians here), hopeful.

One of the residents, Timi and Jackie, a nurse practioner, update
the record book with screening results. 

Searching for Woman Stores... and Friends

   I've talked mostly about work so far, but I can't say that I've spent the whole time working. Last weekend, Veronica and I went to Arusha to do some shopping, specifically for gifts for family and friends. Although we had a really fun day, I have to say, it was a little overwhelming. While I had previously made comments about the terrible driving, this was a completely different ballgame. Really, a different sport. All of the roads are packed with cars, and traffic flow is a complete free-for-all. To put things in perspective- it's about the size of Raleigh, but there are no large roads (they all have a single lane in each direction)... and only three stoplights... yes, three. And to be clear, when I say this, I should also mention that they do not have any other type of road signs to direct traffic either, including stop, yield, or any other right of way directions. The person who gets the right of way is the person who is able to push ahead without getting in an accident. In hindsight, I should've taken some traffic pictures, but I was too busy wondering if I was going to die.
   The first place we went to in Arusha is The Shanga Riverhouse. It's a small artisan workshop that employs Tanzanians with physical disabilities (many are deaf or mute). It's set in a little garden next to a large coffee plantation and it has a little restaurant and shop on the property. They had someone giving tours the day that we went, and we were able to watch them blow glass, weave, do beadwork, etc. They even offered to let us try glassblowing, but we were both a little worried that we would a) screw up something nice or b) burn the crap out of ourselves or someone else. While I recognize that this is clearly a destination intended for tourists, and the items they sell are more expensive than souvenirs we'd find elsewhere, I still enjoyed going. It's a really relaxed and picturesque, and frankly, I feel a little guilty sometimes haggling over a few dollars for souvenirs on the street, even though I know this is the custom and they quote me inflated prices. We had planned to have brunch there, but they didn't open till 11 or 12, and we were too hungry to wait around. She had heard the food was good, but it's also $22/ person, which is pretty pricey for Tanzania.

(From top to bottom) The entrance and courtyard near the workshop, an artisan blowing glass and the store.

   After we left Shanga, we went to a craft market, which was a little crazy. For whatever reason, it wasn't very crowded when we went, and since we were clearly foreigners, every person we passed tried to convince us to look at their shop. I was interested in looking around a little more to see what was there, but we didn't end up spending a lot of time there, because Veronica was feeling a little overwhelmed. I don't know the exact address, but it's on School Rd and it hard to miss. I didn't take any pictures, but I found some on this site. After that, we went in search for woman stores.
   For those of you who aren't familiar with this term, this is what my boyfriend, Jon, calls stores that sell crafty items, pickled vegetables, cookbooks- you know the kind I'm referring to. Often they serve brunch? If you live in Durham, Parker and Otis is the quintessential woman store. In fact, I think that's where he coined the term. Ann Arborites, basically think of any store in Kerrytown. While, they have literally taken the US by storm, I wasn't expecting to find any in Tanzania. Well, I was wrong, savvy business owners here have figured out what tourists want, and they're cropping up here, too. We went to a new complex outside the city called the Sable Square Shopping Village. It had a variety of shops, but it's so new that most of the shops were still empty and some were even under construction. The first shop we went to was Tanzania Maasai Women Art, which is a company that decided to combine traditional Maasai beadwork with more modern designs. They work with an Italian designer who helps develop jewelry that's a bit more stylish and wearable than the traditional designs. There were several other shops in the plaza, including ones that sold art supplies, Tanzanite, books, and souvenirs of all types. They also had a couple cafe/ restaurants. Again, clearly a tourist destination, but we had some good finds.

The Green Room, the ultimate woman store

   Veronica left a couple days ago, and Peyton left last week so I'm now on my own when it comes to meeting new people and entertaining myself. While I'm generally pretty easily entertained and like having some alone time, it has been a little lonely. On the up-side, the residents and faculty in the department have been very friendly and welcoming. Last night, a couple of them actually invited out for a couple drinks last night. We went to a bar called the "Biker Bar," which I'm pretty sure is mostly locals- I seemed to be the only foreigner there last night. The place itself is a little looks like a snack shack at a resort, and all of the seating is out on the patio or under open air but covered. Throughout the bar, there are bike parts re purposed as railings, tables, etc. The group I went with were clearly regulars, and their pictures were even on the bar website. They had planned to go to a bar called Glacier to go dancing, but I ended calling it a night a little early to recover some from the week. But, we all had a good time till then.

Medical Errors in Modern Medicine

   Sometimes, at home, I have thought that the safety checks we do in the hospital are unnecessary. For example, we do a "time-out" prior to a vaginal delivery, where the nurse states the patient's name and a couple other key details. While I am normally very pro-safety, I have, on occasion, thought: "Who cares what her birthdate is? There's a baby coming out, RIGHT NOW, and I'm going to deliver her regardless of what you tell me." In Tanzania, and many other countries, I would imagine, time-outs are not regularly (or sometimes, ever) performed. This is true even before major surgery, which is unbelievable to anyone who has practiced medicine in a developed country. This, compounded with the fact that all records are paper, which can be easily misplaced, switched or damaged, and patients in the hospital don't have the standard "armband" to identify then sets up an ideal environment for medical errors.
    Since coming here, I've heard of several such errors, most of which have been surgical issues, but medical errors could be made just as easily. For instance, one resident told me that a patient had gotten a craniotomy instead of a pin placed for a broken leg in a hospital in Dar es Salaam when his chart was inadvertently switched with another patient's chart. He ended up dying shortly after the surgery. In another case, a patient with endometrial cancer, who was scheduled for an abdominal hysterectomy (TAH) had an exam under anesthesia and another, young, patient who had a presumed fistula, had a TAH instead of an exam to identify where her fistula was.
   I guess, my point is, even though we may have to do thousands of seemingly extraneous safety checks to prevent one outcome, it's worth it. I would hope that if myself or anyone I love needs surgery in the future, the surgical and anesthesia teams would take the time to make sure things go safely. Sorry, Duke Birthing Center, I'll stop grumbling about time-outs.

Sunset Run

So, this is just because I wanted to post some pictures, there's nothing work related. I went for a run just around sunset last night-really just around the compound, but it was so beautiful (and I'm so unused to running), I decided to stop and take a few pictures. It made me wish that I could share it with someone special (I'm talking about you, Jon). Enjoy, happy Sunday!

The Labor Ward

   I've spent a few days now on labor and delivery, or the "labor ward," and being there reinforces that there are some things about obstetric care that are truly universal. A G0 (a woman who has not had any prior deliveries) who presents for her first labor evaluation, 9 times out of 10, is less than 1 cm dilated; on any given day, there's a decent chance that someone will deliver in the hall, or their car, or (gross) someone else's car; and things can go from boring to crazy in literally no time at all. Although, I have to say, the atmosphere is different here in a lot of ways. For one, crazy has a totally different meaning here than it does in the states.
    Earlier this week, while I was passing through on my way to the OR, they wheeled in a lady who had attempted to make it to L&D, but ended delivering in the hall on the way there, standing up. She simply wrapped her baby up, umbilical cord still attached and continued to make her way to the unit. I stopped and talked with her very briefly until one of the KCMC interns came to interview her. She told me that she was a pastry chef and wanted to make a cake for us because we were taking care of her. It seemed completely commonplace to her that she just delivered a few minutes ago, or that it seemed a relevant topic of conversation. It's common for women to deliver essentially out in the open here- the labor ward itself is a single room with 4 beds that are essentially separated by a half wall. While the volume isn't as high as it is at Duke, it's common to have multiple patients laboring side-by-side, with even a few in the hallways on busy days. It makes me smile a little bit thinking of patients at home, who complain about their small post-partum room, all of which are private and have an attached bathroom.

This cutie was delivered to a 19 year old girl earlier this week.
The mothers bring cloth from home to match their own outfits
so there are no mix-ups.

   Aside from spinals for c-sections, there also isn't any anesthesia. After the first delivery I saw on labor and delivery, they gave an IM injection, which I thought might be for analgesia (they use IM pethidine here frequently)... but no. It was pitocin. In fact, it is essentially considered shameful to cry out in pain during labor- patients are expected to be stoic in the face of significant pain. Labor is expected to be painful, and women are expected to grim and bear it. For this reason, the ward can be eerily quiet, with occasional muffled cries and rarely anything more than that. It's a start contrast from home as well, where patients frequently scream, lash out and yell at their partners (sometimes even with an epidural). I remember last year, I had a patient who progressed very quickly while waiting for an epidural (the anesthesia team was in the OR), and while she was pushing, began to scream for the anesthesiologist: "where's the guy, I want the guy!!" When it comes to women who aren't able to keep their cool, the nurses and midwives on the floor are considerably less nice and patient than in the US. If they do fight and cry out during labor, the widwives smack their legs and yell at them. To be fair, I can't speak Swahili, so I'm only able to pick out a little of what they're saying- they could be saying words of encouragement and praising them... but that would be incongruent with their tone. Partners also rarely attend deliveries, or are seem to be present at the deliveries, but more on that later.

One lucky woman gets a spinal... after 24 hours of labor, shortly
prior to her c-section.

    Lastly, the labor ward is full of heartbreaking stories. While KCMC is an advanced hospital considering their resources, they get complicated (and ill) referrals from all over the region. Also, while they have some advanced technology (for example, they have an US machine on the ward), they don't have electronic fetal monitoring (EFM), and still use a fetoscope to monitor fetal heart tones every 15-30 minutes. Over the last week, there were 2 fetuses that died during labor (IUFDs), and birth asphyxia is very common, because they are often unable to detect a problem without EFM until it is too late. In addition, patients present less for prenatal care, and preeclampsia is quite common as well. This week, a patient in her 20s was transferred for eclampsia (preeclampsia with seizures). On arrival to KCMC, her blood pressure was 220/140, and her fetus was noted to have died during her transit. While they were able to stabilize her blood pressure in the ICU, she was essentially unresponsive after several days of ICU care and was thought to have had a stroke and brain death. Even though she was unconscious when I met her on the ward, even hearing about how she was doing at morning rounds seemed overwhelming to me. I couldn't imagine how devastated I would be if something like this had happened to my mother, little sister or a friend. 

    Here, the doctors and nurses have to be a little callous to survive in the medical profession, but these events affect them as well. Many of the residents I've worked with are passionate about learning all they can in training any many of them have big plans to change healthcare in their home country for the better- whether they are staying in Tanzania or returning home to the Congo or Rwanda after they finish training. For instance, one senior resident is doing a fellowship in fistula repair before returning to the DRC to become the only fistula surgeon in the country, while a couple others plan to stay at KCMC to teach and continue clinical advances at the place they trained. It just reinforces to me that enormous advances and improvement in clinical care can be made with education alone, even in placed where advanced technology in unavailable. 

One of the senior residents performing a GYN ultrasound

World's Largest Salvation Army and Other Adventures

   I started my first weekend here with rounds in OG2, the GYN and antepartum unit. On any given day, there may be 30+ patients that are there for a pretty wide variety of reasons (and not the things we're used to seeing in the US). For example, this weekend, we had 2 patients with advanced cervical cancer (one of which was awaiting transfer to Dar es Salam, where they have a cancer center capable of providing chemo/radiation), an OB patient at 24 weeks, who is HIV positive, and came in with seizures of unknown cause. She was thought to have either bacterial or cryptococcal meningitis, and had begun to improve on antibiotics by the time I saw her on Saturday. Like in Durham, there were also an occasional social admission, for instance, the pregnant, orphaned, 16 year old who had been HIV positive since birth and had lost her entire family to the disease. She had been taken in by someone in her village, but was thrown out when they found out she was pregnant and had no where else to go.
   Rounds were also a little different than home- instead of patients having private rooms, there are up to 12 patients in a large room, each in a bed surrounded by curtains, which are usually all pulled back unless we were examining the patient. They all sit in bed and watch us as we make our way around the room. The intern gives a brief description of the patient to the senior resident who listens and then barks out orders, while the intern scribbles... "Discharge." "Continue management plan." "Obtain lumbar puncture." And then we move on. While the patients have no privacy at all, none of them seem to mind. One by one, they greet us and thank us for caring for them as we walk through. I wish I had some pictures of the wards, but I didn't have my camera with me on rounds... I'll post some later

   Aside from rounding on Saturday morning, I had this weekend free to explore the area a bit. I ended up going to the Union Cafe, which is sort of an expat hangout in Moshi. They have good coffee (apparently) and the fresh-squeezed mango-passionfruit juice was fantastic. There's a large, almost plantation-style porch you can sit at and enjoy your drinks/meal.

 

   After lunch, we went to a clothing and shoes market, which I can only describe as the largest Salvation Army I've ever seen.... I don't mean that figuratively, either, it literally is. Bales of clothing from donation sites all over (such as Goodwill and Salvation Army) arrive every Tuesday and Friday, are unpacked, and the contents sold for bargain prices to locals and slightly less bargain prices to foreigners. Apparently the best items go quickly after the bales arrived, and things were a little picked over by Saturday afternoon. I have thought about going back on one of the delivery days, but I think I may rather buy some fabric here and have a local tailor make something for me with it- my roommate here has done that several times and the patterned fabric here is so beautiful.

   Today, I went to a golf club with Veronica, which is clearly geared towards tourists, but was still picturesque. It's outside of Moshi, near a sugarcane plantation. It's called TPC Club and in addition to golf, they also have tennis courts, a swimming pool and a restaurant (with all outdoor seating). We went just for brunch, which was quite a meal. There were at least 6 courses, including fruit/ granola, a strawberry parfait (seen below), an omelette with sausage and bacon, steak with caramelized onions, potato pancakes with soft cheese and salmon and practically a whole loaf of bread. I could barely eat half the omelette, and there was no hope for the last 2 courses. We wandered around a bit, checked out the pool, etc. The food was good, and we had the added bonus of 1) getting to sit out in the sun and 2) we had a great view of a 7 year old flail around in the sandpit for a good half an hour before she eventually gave up. 

    The rest of the day I just spend catching up and it cleared up enough to see Kilimanjaro from the road in front of the house. How could it get any more perfect?