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

My internal compass has lost direction momentarily

It has been quite a week. It feels like an understatement saying that.

After a long flight (which Charlie handled beautifully!) I was set to work early. 7:15am the next morning I was set on the road to Seliani Hospitali (Kiswahilli!) in a land rover with Joel, an infectious disease doc from California who has been coming here for some 30 yrs, Libby, a 2nd yr resident in internal medicine at U of Mn working with hospice, and Bryant, a public health administrations student from the U of Mn looking at a career in establishing hospitals in developing regions. The road up to Selian is an experience in itself. I will take some pics and talk about it more later.

With no set plan for what to do I have stuck with Joel on pediatrics this past week and will work with him until he leaves in 1 wk. So what am I doing?

I start the day in chapel. We sing and recite in Swahili and listening to a short sermon (actually I read my phrase book (Gina lako nani- "what's your name". Luckily Swahili is all phonetic) as the sermon is not in English. Then morning report on hospital news and off to the ICU (intensive care unit). This has been an eye opener as a traditional ICU has very advanced technology within a hospital. The most advanced equipment is a pulse oximeter to measure a persons oxygen level and heart rate. I have not taken too many pictures yet since I will be here a while and I don't want to appear the tourist yet. But I snapped one here from the ICU.

I might try for a better view, but this was prototypic Africa in my mind. The infant has severe malnutrition (marasmus in this case). The mother has not breastfed because she was told her testing for HIV came back positive. Testing the mother at Selian she was negative. The baby has been surviving on cows milk with sugar and tea leaves mixed in. She is hypothermic (cold) and wasted. Her face is that of an old woman and skin hangs off her limbs where fat and muscle should be. The skin on her chest is stretched taut around a fragile rib cage and she has a protruding abdomen. That light you see is like a 40 watt bulb, barely warming my hand from a few inches. That is their heating lamp. The sight is sad, but also enraging because this shouldn't happen!

The photo is also important because this is hopefully the "aha" moment for mom. She had been instructed how to feed her daughter properly but was not compliant. This is the second attempt at getting nutrition to the baby. She was taking down spoonfuls so very fast! I hope she will make it.

After the ICU we hit the peds ward- with slightly less sick children. I am seeing a lot of malaria, meningitis (brain infection), seropositive kids (+ for HIV), and malnutrition. I am also seeing several oddities, such as tetrology of fallot- a heart defect that needs transplant surgery. I am less active in care at this time since I am new and have not treated these diseases before. Mainly grabbing charts and doing the notes so I see what drugs are used for what and how management is handled. Notations are different, drug names are different and there are drugs used here that are not really happening in the US now- such as chloramphenicol. Interlaced to this are some trips to the micro lab, newborn exams and adult medicine wards. Several emotions happening each day: feeling ignorant/powerless around topics I have little exposure to, eyeballed as I walk home and get lost- the only white dude around, questioning my convictions when my wife is crashing (has God really called me to this?), and inadequate/foolish when I see such profuse poverty with the belief that I can create change. Fake it till you make it right?

After a quick lunch we drive down another route (just as treacherous) to the main hospital in Arusha- ALMC. This is the nice brand new hospital. There we hit another peds and newborn wards. Another sad case I wish I took some pics for. 10 yr old boy with AIDS, CD4 count of 7. Yours or mine is 500-1500. This is very low. He also has a myriad of opportunistic infections typical to AIDS patients: tuberculosis (TB), perianal ulcerations (HSV), oral ulcerations (CMV) and Kaposi's sarcoma. He's 10 years old and barely holding on. He was sitting in bed chewing on a cucumber with his mother beaming because he had survived the night. For this to happen in the US is a sad story, but here it appears commonplace. This is not only sad but a true problem in health care. I have been very frustrated by this case the last few days because I know we can do better by children like this. What sacrifices do we have to make in our own lives so that boys like him are not suffering? And he is suffering. Once Laura & Charlie sleep I hit the books. Malaria. Meningitis. Typhoid. Malnutrition. etc...

The staff here do good work, and the interns work their butts off. So far I am gaining the experience I set out to have. One final frustration for me that I hope to investigate while here: health care as a right vs commodity. In the curio & craft market today I met Barack. His brother needs a head CT. Selian has one but it will not work without $15,000. But the bigger issue for me is that a scan alone will cost Barrack 150,000 shillings. At his market stall he sells crafts for about 1000-10,000 shillings. Really only to tourists. And he has to eat. How can he afford that? The cost of care is prohibitive to all but "the rich" of Arusha. But the hospital needs to survive, they cannot do that without charging a fee at this time. Hopefully this gray issue will gain focus for me by May. I will try to share more about the feel of the hospitals in my next post.

As for our living situation it is quite different. We unpacked and turned on the sink- out poured about 50 ants! We drove in from kili airport to home at night. Once we left the main road up the hill into the shanty's I could sense Laura's apprehension. Linda Jacobson met us at our house with a wonderful care package, and the moment she left and the door closed there was a pivotal moment for Laura and me. Before I even looked at her, I knew what was going through her mind- "WTF!?!" How could I have dragged her out here to a dangerous corner of the world with our most cherished Charlie. It was a difficult night unpacking. Adding to the tension, I kept hitting my knee on the bed post and have since established a very large bruise. Fortunately for me, the culture shock isn't bad since I have walked in this poverty before & love the slow pace endemic to these regions. Unfortunately it appears life is going "tit for tat" and giving Laura a horrible experience for every uplifting time I have. Because of this my joy is incomplete, bittersweet. The house is nice, and our neighbors are friendly. The internet has helped. Linda has helped. I hope over this next week a calm balance will occur where we both transcend and figure this out.

Tonight was good though. Laura had a guided tour of Arusha (for free! in English!). Charlie began trusting strangers. We had a simple dinner with food bought from a neighbor. It felt so simple and good. At work I am at peace, at home we are searching for answers.

Eric


ps- Charlie is being pampered with chocolate bars and chocolate milk daily. We are wrapped around his finger tightly right now. Latest words: juice, choco, MINE!