Mbutuai stops by

I took Tuesday morning off to work on public health and orient a new internal medicine doc to the area. As I returned home in the morning Mbutuai and his brother Kimane stopped by! We had some chai and discussed Mbutuai looking for new employment. He was not being paid by the landlord when we were with him. They liked having pictures taken, so we can pass them along to their family- but I thought I would include them here as well. I'm sitting with Kimane, Bryant is with Mbutuai. If Byrant and I look crusty it is because the water is still out.

The good news is we worked out to visit their farm/home near the serengeti (~4 hr drive) in a few weekends and I finally got his number. It was good to see them again and I look forward to the day I can speak to them in Swahili- it is a real motivator to learn the language.

The new IM doc (Jose) was here last year for 5 weeks. He is originally from Argentina and I will be working with him this afternoon at the medicine clinic. Tomorrow we will be grilling out: Nitapika njema nyama (I will cook good meat)!

Peace,
Eric

Notes from a dusty rider

Just returned from a fantastic mountain bike ride with Mat and the new med student Dave (from New Zealand). We went up the hill quite a distance near a village called Il'Kidinga, and close to where I have done some home visits with hospice. Then we hit a lot of the streams/paths that I had been eyeing up for the past few weeks. There was a lot of incline/downhills and numerous obstacles- very fun. We passed through a weeks worth of touring the countryside in just a few short hours. Our bikes are not great, Dave and I did our best yesterday to tighten everything up. About half way through the ride Daves pedal crank began to make death threats- sounded like a dying cat. By nightfall it was hardly turning, we poured some water on the housing and sped home with haste. We passed many groups, kids chasing us, families coming out of their bomas to say hello, large church parties along the hillside. And a beautiful sunset. It was a great dusty adventure and I know it is something I will miss on my return home to Mn.

This past week at Selian was somewhat short for me, as Laura left Monday and I was at ALMC for clinic Tuesday. I spent the remainder of my time on the medicine wards. There have been quite a few deaths lately to deal with. I had some frustrations with a very old women who was going into shock. Most of my requests for care seemed to fall on deaf ears. I finally got a non-rebreather mask on her to help her breathing and they all wanted to take it off because patients don't find them comfortable! I unplugged from the team after we left her case, as I found myself teetering between apathy and cynicism over the care being provided. By Thursday I was doing well, but there have been several patients who have passed, and many more coming in for what appears to be paliative care. I have started going in on Saturday mornings now to spend extra time at the hospital. A man came in with a large tumor the size of a cantelope- where is the pre-hospital screening that should catch these things before they are deadly? No where to be found. I think primary care development here would save A LOT of lives. Many many different patients this week: an alcoholic (local Konyagi liquor here), TB meningitis, strokes, sepsis, malaria, AIDS, and many more. I plan to spend a week now with OB/GYN, and go from there. I have recently heard from another doctor that I will travel with in late April out into the rural areas, so I am excited to get out. The 2 hospital pics: one of Selian's low-tech ICU and the other is me with the hospice team.

Exempla house has decided to throw some challenges our way. We have been without water for about one week now. We are all getting fairly rank without access to showers and this warm dusty climate. We have a slow flow from the kitchen sink (cold water only). So we can fill our toilet tanks and take sponge baths. Before church today, Bryant and I went to ALMC early and showered for the first time in a long time, it was very cold! It seems they don't have hot water there yet... But it felt good. There is a fairly significant drought here as well, in contrast to the flooding in the midwest currently. It rains very infrequently and the dust is everywhere. The crops are dying and there doesn't appear to be relief in site. Kilimanjaro appears to be fairing even worse. Today at church they ended with an open mic to talk about what verses helped everyone "get through" the day or rough spots in life. It was great to hear the diversity of text being spoken and find what gives people strength.

Two new roommates came in the night Laura left. They are an ortho surgeon and ortho physicians assistant from Stillwater. They spend a great deal of time at ALMC, but we have spent the evenings going to dinner and getting out of the house. It has been great to see Arusha at night, even if only from a range rover window.


And a public proclomation that I miss my family! I don't like Laura and Charlie being away from me for this long! Charlie said his "goodbyes" to friends made at play group.



The simba (lion) was one of Charlie's toys here and keeps me company at night.





Also, just found out we received a nice amount from St Lukes church (our home church) as a donation! We really appreciate everyones support in our work and we will do our best to find an appropriate use for the greatest good.

Eric

PS- Charlie started eating more veggies his last few days here: cucumbers, carrots and green beans. Well, not eat but chew and spit out. It's a start.

After the Match

A lot has happened over the past week or so, making it difficult to attend to a blog. I have been walking home from Selian a lot this past week, and have noticed I am on my last belt notch now- going to have to start eating more for dinner!


Selian: I have bounced around hospice care and medicine wards again last week. Beginning in March the hospital changed from private Lutheran to a government hospital (with no shift in the Lutheran function). The basic change is that children, pregnant women and the elderly are provided FREE care, with small bills for items such as linens, etc. There has been the anticipated increase in patient load, and this is likely to continue for some time. One disadvantage to the timing of this is that when ALMC (the new Lutheran hospital) opened, they took several of the most qualified team members with them- nursing, clerical, attending doctors. Selian has scrambled to rebuild, but it will take time. The hospice patient I described last week with HIV/Kaposis ended up having pulmonary TB as well. He died last Saturday afternoon, likely from the kaposis and TB disturbing his lung function. It was a very sad time in chapel when I heard about it during morning report. He presented so late in the disease course that there was not much we could do, and he was too sick to transfer to KCMC for the chemotherapy he needed. This past Tuesday I helped orient 2 new students from New Zealand. The pic posted here of Selian is from just outside the chapel- looking in the background you can see Mt Meru!

The Match: There has been a lot of excitement this past week leading up to Thursday evening (we found out at 8 PM). With Laura and Charlie leaving for home on Monday I took Wednesday afternoon through Monday off. Thursday morning we walked into town for some food and also bought a nice bottle of Jameson and Johnnie Walker whiskey to celebrate. They were nice to help calm the nerves during the final hours. We had several people over for dinner- Mat & Jane, David & Julian (new zealand med students), Mark & Linda. Bryant, Laura and I made some chicken masala and lentil indian dishes for dinner. After we found out we were very happy to find out we were going to stay in Minnesota at Regions Hospital in St Paul. Since then I have received several emails from the program welcoming me- very nice to feel wanted!

Public Health: I have lately been working on a project for my public health degree related to malaria. I am hoping that I can use it to complete my MPH degree. Right now I am basically looking through last years lab book and taking noted on all the patients who had malaria slides taken. Were they + or - for malaria, how many slides completed, etc. Then I start looking through their files to see if they were given anti-malarial medications, ever had a real temperature, etc. The reason for all this investigation is because I noticed that malaria was diagnosed here in almost every person, even if there was not a scientific reason for it. The hope would be to eventually create a study that would help them test malaria better or treat more appropriately.

Life: Last night we went to an outdoor bbq and movie night. Sarah hung a sheet in her back yard and we watched "The Gods Must Be Crazy", that is until the power went out at 9... Laura and Charlie left for home last night. We had a very fun morning together, and spent the last few days spending a lot of time together. I am noticing their absence though- not being woke up at 6:45 every morning to "Hi!" from Charlie in the crib right next to us for one thing.

2nd part! Best part!

We found out tonight that Eric matched at Regions in St. Paul. We are very happy and busy thinking about our next "move" as we have everything in storage right now! Thanks for all the support. We will see you all shortly!

The first part of the news!

Eric matched!! Yeah! This is a relief for Eric. I knew he would match...too smart and too good. Anyway, Eric just went to Selian and Charlie and I are kicking the soccer ball in the yard. "Boots" "kick!" "ball!" (that is what Charlie says.)

36 hours until Scramble Day

Monday at noon I will know IF I matched. No real news here, but an excuse to post a video of Charlie again:





Charlie tried waking up Laura with some passion fruit this morning! Didn't work!!







And some pics from the yard, flowers are blooming daily!






















































Hope all is well with everyone, things are going well here. A more detailed update tomorrow evening!!!
Eric

ps- the pics don't do justice to the beauty of this yard...

3 days until match day

So I am a bit anxious to know THAT I matched (March 16, noon) and then WHERE I matched (March 19, noon). I don't usually dwell/wish for tomorrow but this week I actually do. Charlie is babbling away and trying to sing now! Very entertaining, enjoy:





Eric

The way of life in Arusha

The following is a typical day in Tanzania, read on: Last week, I made arrangements with Margaret, the gal that runs Step by Step for the handicapped kids, to come today for the whole morning without Charlie to work with the kids. I arranged the time with Eric so that he could look after Charlie and I was excited. This morning, I sent out my notes on the kids via email to Margaret and then had a taxi pick me up and take me there at 8:30am. I paid him 6000 schillings (about 5 dollars) and he dropped me off at Step by Step. It was closed, locked up, shades drawn. I waited for 30 minutes and finally texted Margaret, "did I get the start time wrong?" No, she replies, "I'm sorry. I forgot to tell you. It is a public holiday" end text. I then text my taxi driver to see if he can pick me up (he gave me the best deal) but to no avail...he is not answering. I walk about 6 blocks until I finally find a taxi. Since it is a public holiday (which I was not informed of), there are very few people working at all today. I find a taxi and they want to charge me 8000 schillings. I say, "no, 7000, and that is my final offer. Otherwise, I will take the dolla dolla," which is a joke because if my goal was to end my life I would take the dolla dolla. He finally agrees on 7000 schillings and I get a ride back to the house.

A little bit about the taxi ride: no seat belts, no shocks, car feels like it is falling apart. As we pass the patrol, the taxi driver half heartedly wraps his seatbelt around him (the only seat belt in the car) without buckling it until we pass and then swings it back to his side. The ride up to Il Boru is very bumpy and a car without shocks feels truly like it is going to fall apart. A few times up the hill I thought to myself, "I'll just walk from here. Pole, pole car..." I get to the gate and am finally home. "Karibu sana" the taxi driver says (you are very welcome) and I come inside. I am frustrated, have just spent about 11 dollars for nothing and did not help anyone today (except maybe the taxi driver). Then, I remind myself, it is just the way of life here...

Now, I am going to play with Charlie and Eric!

Hospice Week

A picture heavy entry here!

There is a lot that has happened over the last week both at Exempla house and the hospital. This week we spent time getting to know our yard. We made mixed fruit juices from passion fruit, guave and mangos. We also cut down our first bunch of green bananas. While looking for avacadoes we also came upon a great little lizard! On Saturday we had a scourge of biting ants march across our yard. I could not get a sufficient picture, but they were a menace. Eventually our gate keeper cleared the ants with kerosene.





































I started walking home from Selian this week as well. The ride is usually quite bumpy, but it is a very nice walk home taking about 1-1.5 hrs. It allows for a lot of time to think. The kids here seem to learn limited English- mainly "give me _____ (money/pencil/your water!)". It's quite rude I have noticed, but enough tourists have visited to make a decent payoff for them to continue. Other locals are much more pleasant to visit with. I was able to chat with some while they tried fixing the brakes on their bicycle today, and was invited to lunch at a local farm. You will often see women carrying something on their heads: water buckets, bags, firewood. And several herders with cows or goats. But the landscape alone would be worth the walk. The weather is pleasant and there is a view of Mt Meru as you go. Right now there is a deep layer of dust in some areas, reaching several inches.



Pole pole, so the saying goes here: slowly, slowly. Last Monday morning was all about slow. I sat through 3 hours on work duty hours in Swahili. I then took 40 minutes for tea as I waited for medicine to start rounding the wards. I stepped into the hospice office but received looks like I was interrupting more than tea time so I went back for more tea. By 1PM we had finally rounded on half the medicine ward.

The cachectic woman I previously mentioned had an ultrasound performed and a diagnosis of either cholangiocarcinoma (gall bladder) or pancreatic cancer. Either way she has been referred to surgery for possible paliative care, and to hospice services. From the perspective of public health it is an interesting case because there does not seem to be adequate pre-hospital care for these communities to catch advanced diseases. People are so secluded by geography that they rarely seek help until problems are too advanced for inconsequential actions.

I enjoy the hospice team home visits because I can get out into the community and am able to use my training well while outside the hospital, which I find fulfilling. There is a new patient that I met last week on a home visit who is now at Selian. Walking up to his home, we were met by several elder Masai women. Getting inside the small doorway it was very dark and difficult to see well. We were squeezed in, sitting around the bed of a 40 yo man. He was lying in bed, telling his story. After he sat up, it became obvious that he was going to need more than hospice could offer. His legs were covered in small Kaposi's sarcoma lesions, they were more swollen than anything I have ever seen, he was fatigued, had a cough and what sounded like a pleural friction rub in the lungs. This all added up to a likely (as yet) undiagnosed case of HIV/AIDS with associated Kaposi's sarcoma. Until he was in the hospital I thought he might have TB, common things being common, but the sarcoma had spread into his lymph nodes causing the leg swelling AND into his lungs. He is now being prepared for chemotherapy which should help decrease the sarcoma and start on ART for HIV. In the picture I am checking inguinal lymph nodes to show the hospice team the exam maneuvers and to determine the extent of the swelling.






While rounding today I diagnosed my first heart block and was able to talk the interns through what it was, what it sounded like and what would be best for the patient. Unfortunately she likely needs a pace maker, and this is not something commonly accomplished in Tanzania...













Today I came home to a very tired Laura who had taken Charlie all over Arusha. He was a ball of energy and all over the yard/house/floor today. He apparently seized the day and throttled it!!!











Laura is enjoying herself and seems very happy these days. She is relishing her last 2 weeks here. Tomorrow she is going to Step by Step while I spend time with Charlie. She is going to help coordinate peds activities, but I will let her tell you all about it tomorrow!

I will add more to this tomorrow, because it is late here!
Eric

Settling in

Charlie and I are settling in quite nicely. The days are slow, routine and filled with enough time to enjoy every moment and take up a few hobbies. Since being here, I have actually cooked on a regular basis (not sure what I was doing at home when I think about it but cooking has never been my forte). I have also taken up knitting. I am definitely not an expert but at least now I can make something like a potholder or scarf and not get so frustrated that my weave is too tight. It flows easier. The only way I can explain how life is here is like a river that is meandering its way downstream. Back home (in Minnesota) life was more like a hurricane... I am not very good at metaphors but that is the best way I can describe it.

Life here has offered a new perspective. Like any drastic change, it sucks at first but you realize somewhere down the road that it has actually taught you something, enhanced life, helped you to understand more about yourself (as a wife, mother, individual). I think it is going to be hard to go back to the pace of life back home but, luckily, I think I have figured out how to ease back into it...we'll see...

A bit about Charlie: Every time I look at him I think, "what a blessing" or "you are soooo amazing!" I feel so humbled by him and love him so much. He is sooooo much fun! Right now he is eating crackers next to me, which he calls "COOOkie" and as he is about to take a bite he says, "Yum!" This morning he woke up at about 6:40am. He stands up in his crib and says, "out!" and then tells me to take his "night night" which is his blanky. I then lift him up out of his crib and bring him to daddy while I make up his breakfast. Lately, all he has wanted to eat is bananas so even though I prepared cereal, he wants a banana. He eats his banana double fisted (banana cut in half) and then, once finished, asks to get down by pointing and the morning routine of changing his diaper, clothes, putting on deet and sunscreen commence.

Then, we play soccer outside together after he insists on putting on his galoshes (boots) because the ants bite and after he has placed my sandals by my feet to get me going. We play for about 30 minutes, kicking the soccer ball around and then make are way around the yard looking for the turtles. We couldn't find them today and since the ants were killer this morning, I retreated us back to the front lawn (where the ants are not) and fill the basin full of water. We pretend to make soup, stirring it with sticks we found in the yard and placing grass, leaves, flowers, toys into the "soup" and say "yum!" He wants to do this FOREVER, so I ablige for about 1-1.5 hours and then take us in to do dishes. He helps me, standing on a chair. His job is to put all the dishes on the right side, on the left side into the basin filled with soapy water while I wash. He insists that I run the water so that he can fill up a cup and unfill it in the meantime and I ablige him because, frankly, it is easier than fighting him on such a small thing. We get done with the dishes and I start on lunch at about 10:45am. Today, I heated up the leftover pasta I made yesterday, cut up some cucumbers and cooked a hot dog for him. He ate the hot dog and cucumbers and drank some water. He knows the routine, so when he says "all done" by saying it and waving his hands back in forth (signing), I take him to bed, change his diaper and read him a few books. Then, I put him in his crib and say "good night" and he slowly falls to sleep.

Charlie has always been really good at nap time so he makes it easy on me. He sleeps while I read my book ( I am hooked! It is called "my sister's keeper" and is very touching which is maybe why I am a bit sappy right now....no, Meagan, I am not PMS'ing). Charlie wakes up enough to see me reading by his crib and stands up. I pick him up and he lies back down on my chest and falls asleep. I pick up where I ended in my book and continue reading. After about an hour (total 2.5 hour nap), he wakes up and we make our way to the kitchen where Christina (our maid who works 3 days/week for 20 dollars a week) is making homemade passion fruit juice from the passion fruit trees outside in our yard and homemade bread is in the oven. This is the life! She makes Charlie some juice and I give him some crackers and...that is where we are right now. Later, I may have a play date with Natasha and her 2 kids, Henry and Elijah..or, I may not. That is the beauty about living here, there are no appointments, no major expectations, just learning to live in the moment...

Oh, and Eric just walked in. It is 3:30 pm...I LOVE IT!

Weekend update

This weekend we moved down to exempla house. It is a great location with a lot more exploring to do in the yard for Charlie and more comfortable surroundings. We have passion fruit, bananas and avacado trees around the yard that are producing right now. Our housekeeper also brought a ton of mangoes in today!

These first pics are from Saturday afternoon. It is Charlie's first shin scrape! He was playing soccer in his rubber golloshes the gravel driveway and fell down. He barely cried though, and went on playing. The reason for the boots is the army of biting ants currently moving through our yard. He got bit a few times in his sandals and refused to go out without his boots. The reason for playing in the gravel driveway is he was scared of the biting ants. He's fallen a few more times but the ants have migrated to more peripheral areas, so he roams the grass more confidently now.

Since the migration, Charlie has ventured around the yard and found the two long term residents of exempla house: turtles! He loves following them and watching them walk/eat grass/retract into their shells. He currently calls them "doggie", but we hope to have him to turtle before he leaves...

He spent Sunday morning before church getting very muddy in the small stream that runs through the yard. He threw rocks into the mud for about an hour and then sat right down and smeared it all over for a finale. Tonight we forgot to give him malarone (anti-malaria meds), so we woke him up with the standard crushed malarone in Nutella- he successfully took down the chocolate easily while remaining asleep.

Today I moved from pediatrics to hospice/adult medicine. Hospice seems to move with spurts of activity so I anticipate a good mix of both. Until noon I basically rounded with the team on the female ward. More frustrations with the health system here as many of the basics are lacking: we had a patient with an acute abdomen who could have a stomach ulcer, or possibly pancreatitis. But they don't do the labs that could diagnose pancreatitis so it is a guessing game. There is also the woman who ingested the unknown pills. Apparently they were Flagyl (a fairly harmless med) and 8 other unknown pills. The problem here is she has depression, but there is no Prozac to give her. That is a safe and cheap antidepressant. There is an alternative, but it has side effects we like to avoid and some dangerous elements for a person who attempts suicide by pills.

On the flip side, this hospital is one of THE best in the country. For all my frustrations with it, it remains one of the best options for care here. So please don't misconstrue my frustrations as directed at the hospital itself, just the situation the health care system is in! It is a sad fact that a great deal better care is possible, as our system and many others have proven, but these people do not have access to it.

One patient that stuck with me today was a 68 year old woman who appears well into her 80's by first look. She is extremely cachectic (emaciated/thin), to the point that I can easily make out the bony landmarks of her skull and skeleton. On abdominal exam there is a large right sided mass about the size of a tennis ball, and it is tender. We are waiting for a diagnosis, but it is likely an intestinal tumor. Why did she wait so long for care? How could she have gotten so far along before seeking medical help? To end today on a positive note I correctly differentiated a fixed vs physiologic splitting of heart sounds! A fixed split is not a good thing, means you have a hole in your heart where there shouldn't be one. A physiologic split is just a ramification on your heart beat when you take a deep breath, which everyone has. A good difference to distinguish and it made me very happy.

To end the day, Mat and I had a very nice mountain biking experience. I would have had a picture too, but the watotos (kids) who asked for a picture ran away screaming when I U-Turned to oblige them! We hit some fairly steep grades and crossed some awesome streams. We left the main "road" for walking paths that are perfect for biking. There appear to be 3-4 road types: one a car could take, one for push carts, one for walking, and the dangerous small ones that get us lost! My bike is not exactly perfect- poor gear shifting and soft breaking which I can easily fix myself. But with that and no helmet it was an experience today. The brakes squeak horribly, so it was funny to come barreling down a hill into somebodies backyard that dead ends into their field. They would come out to see the cause of the noise and find two sweating Wazungus (white people)! We would be chased by several kids and met a lot of friendly people. The great aspect is you leave the population used to seeing wazungu and enter a region where our presence is a novelty and not one where we are constantly asked for money or some such silliness. It was a beautiful countryside and nice to know I can easily get away from the hectic streets into the countryside. As it approached dark on our return, we passed a church holding choir practice, and it was a peaceful moment to hear the songs reverberate as we went by.

The nightly neighborhood dog fight has begun, which means it is time for bed.

Cheers!
Eric