The Corkscrew Extraordinaire

Corkscrew Extraordinaire

Need I say more?

Miscellaneous

 2-06-2012

Just had a really nice warm shower.  Yes, warm!  The students (Laura B and Serena) ingeniously filled bottles with water and set them outside in the sun.  Nice holes in the cap served as a great showerhead (thanks to Carl).  We have been having intermittent water.  We assume that is due to the construction of the nursing dormitory, currently going at breakneck speed to finish in time for the nursing school to start.  Part of the time during the day, there is plenty of water pressure.  But by shower time in the morning, there is no pressure.  So nearly half the time, we have been dipping water to “shower” and flush.  Cold water.  Even when we have good water pressure, so you perhaps can imagine the luxury of a warm shower. 

Another invention was a corkscrew from a clothes hanger.  Someone borrowed and did not return our corkscrew and we were not successful in pumping in air with a syringe or grasping the partly protruding cork with my trusty Leatherman.  I managed to push it further down.  So Laura said, “If we only had a clothes hanger, we could make a corkscrew….”  Meg said, “I have a hanger!”  Carl manufactured a fantastic functional corkscrew.  And I enjoyed the wine.  Well, several of us enjoyed the wine.

Someone suggested Post It notes and masking tape for a schedule.  Water bottles have been used for exercise weights (not by me).  I used duct tape for my bed net. 

There are probably more innovations, but I cannot think of more.

My little Optoma projector has worked pretty well for a couple movies.  We were all depressed by “Ides of March,” but “Bridesmaids” the next night took care of that.  We intended to only watch half, but we couldn’t stop.  It’s hardly enough for daytime use.  It simply isn’t strong enough light and we cannot cover the windows adequately.  We will need to find a bigger projector to use next year, one that stays here.  It seems likely that the Nursing School will need one for teaching too.

And we continue to see interesting cases, of course.  Today, a child was admitted with “Renal failure” because of swelling.  I looked it up and in the US we would see 2 – 7 cases per 100,000 children annually.  The Clinical Officers here are often under pressure with a ton of patients.  On rounds a little later, we examined the child closely and found some telltale signs of malnutrition, including the swelling.  The MUAC (mid upper arm circumference) confirmed profound muscle wasting.  Her belly was distended and the ankles swollen.  Her hair was fine, like lanugo or baby hair, another sign of malnutrition.  We started the Plumpy’Nut.

But the Nutrition Project has been slow overall.  The Medical Director of the hospital was gone all last week and I have not gotten the chance to review the overall plan with him and things must be sanctioned.  It really is a formality, but necessary. Today I will speak to Mama Saga, Dr. Saga’s wife and the hospital Matron (or head nurse) about the project.  We will need heavy buy-in from the nurses to succeed.  We have Meg who is a grant writer helping at least informally for the funding grant we may try to get, but if anyone wants to do some grant work, PLEASE let me know.

We have had the benefit of our pharmacy students to help with drugs and bacterial coverage, which the Tanzanian doctors appreciate as well.  We have been seeing a number of pneumonias and other infections.  The students have been giving great talks after morning report.

Another interesting case today is a seven year-old, quite small, malnourished, but also with enlarged lymph nodes at the neck and many other places.  Is this extra-pulmonary TB, lymphoma or infection?  Almost certainly there is underlying HIV, but we will find out tomorrow, when the tests are back.  There has been an expansion of tests available, but still profoundly limited and we reamin unsure of what is actually available.

Hot water!

We have a couple mobile clinics to go on this week, then off to Ruaha for two days of R&R before we head home.

The students are all collecting great cases for their (mandatory) presentations at home.  They also have been stellar on their presentations here, generating many thoughtful questions.  They are a real credit to all of us!   they will be great doctors.

(They better be.  They will be caring for us in a few years!)

Isimila

2-4-2012

Another fine day.  We left for Iringa about 7:40 AM.  Unfortunately, the daladala we had intended to take to Mtua to catch the bigger bus had left at 7:30 AM.  We walked to Mtua to catch the bigger bus.  Unfortunately, that one left before we arrived too.  We got on a daladala to Iringa, along with a cast of thousands.

A daladala is generally a converted Toyota van with the top chopped off and replaced by a roof with a bit more headroom.  Of course the headroom was for beings as tall as Tanzanians, generally shorter than Wazungu.  With really narrow butts, too.  These vehicles are wide enough to seat three across, but they also put an aisle between the seats.  People cram into the SRO (standing room only) area.  There may be some rules about occupancy, since a few of the SROs ducked down as we passed some highway officers.

Our understanding of daladalas was that they sped along, careening past other vehicles, putting lives in jeopardy.  No.  Not at the speed they travel.  No.  It took forever and a half to get into town.  Don Fultz and Gary Langness  picked us up and took us to Isimila.  It is a great place to hike around.  They now charge 20,000 Tsh and still worth it.  They also have a museum with interesting artifacts.  The artifacts and geology are truly remarkable.  If you are interested in seeing a marvelous site, call Birdie.  A group from St. James is going at the end of July.

We went to Sai Villa for lunch.  Fun and good food was had by all!It is a classy place.

Then back to Block A Apartment C, where Don, Eunice, Carol, Gary, Trish, Roger, Steve Clarke, Carl, Jake, Laura, Laura, Meg, Will and Serena sang “Happy Birthday” to me yet again.  I cannot remember a birthday where I have heard my name sung in that song so many times.  Marvelous chocolate cake with chocolate frosting and chocolate chip cookies and great fruit salad!  I have terrific friends!  And always willing to party.

Don took us back to the bus station.  We were just in time to get on the larger bus.  Half got on, but it was full.  Those got off.  We all ended up taking the daladala back to Ilula.   The engine apparently overheated, so we stopped for twenty minutes waiting while they refilled the radiator.  But it was only a minor breakdown and off we went again.  I was pretty glad to see Ilula.  So was my derriere.

Anna prepared a nice soup for us.  We drank a bottle of wine and talked about our favorite desserts, Saturday Night Live and other things that had us laughing.  But at 9:10 PM, we are all bushed and off to bed!

Carl, Will, Laura M, Jake, Serena, Meg

Will, Serena, Laura B, Laura M, Ken

Amani Orphanage and Mbigili Dispensary

2-3-2012

Fantastic day!  Meg, Serena and I went to the Amani (not Armani) Orphanage.  We originally made contact with them at their request when they wanted to know more about Plumpy’Nut.  The orphanage gets several children per year who are abandoned or whose parents simply cannot supply their needs.   Two such children appeared in the past week or two.  The Amani staff was directed by someone to get a protein shake supplement to help with the child’s nutritional needs.  Several problems.  One, it was 80,000 Tsh.  This is about $45 USD.  Second, although not harmful by any means, it is an adult formulation with inadequate amounts of everything for a malnourished child.  It would last a couple weeks, I guess, but for $60 USD, you could buy a full six-week course of Plumpy’Nut.  It takes only that long to reverse the severe malnutrition, then a child goes on a regular balanced diet.  I gave them a box to start treatment immediately.  We took the most recent admission, Harriet, to the Mbigili Dispensary, so that Dr. Singo could weigh and measure her

The orphanage is amazing.  It is supported by a German church, Lutheran, I think.  They have fifty kids.  They have a large garden, 8 acres of maize and some other veggies.  They have pigs, cows, rabbits, chickens and goats.  They collect the manure for biogas, raise some nuts for biodiesel and use some solar energy to heat water and some solar voltaic for electricity. 

They have a web site, but it is in German. Google will translate it for you.  Here is their site.   http://www.mbigili.de .

I hope we can work with them.

Meg Feigal and Friend

Serena, Alberto and Meg

Friendly future dinner for many

Tragedy and Pragmatism

First the mundane.   

It's my birthday.  I have gone from Daktari Ken to Daktari Babu in one day.  Babu is Swahili for  grandfather.  I am likely the oldest person on the campus, not a patient.  I had a great day with a little surprise party and fireowrks on a delicious banana cake.  Enough said!

There is a doctor’s strike in Tanzania.  Must be in Dar, since it certainly isn’t in Ilula.  However, the doctors here are aware of it.  The politicians are meeting with the striking docs.  The docs have been warned they must report to work.  Apparently not reporting for work is a serious offense.  So most are reporting for work, just not working very hard.  Or at least not very fast.  To add perspective, the politicians get 200,000 Tsh ($115 USD) per diem for being in Dodoma.  And they go out of the country for care!

Ilula is getting a “procurement specialist.”  This man knows how to work the system (in a good way, as far as I understand).  This could significantly help the supply chain.

Today, after lunch, I was chatting with Meg when Serena rushed in and said, “I need your help.  I don’t know what to do.  A set of twins was born.  One is not breathing.  They want me to certify death, but he has a heartbeat.” 

Before I arrived, Dr. Jen Tessmer-Tuck, Ob-Gyn and Laura Melcher, Jenna and dad  Dr. Dan Johnson, the ER doc, participated in a couple of failed resuscitations, which were very similar and both were twin pregnancies as well.

A few moments earlier, as Meg and I were sitting alone at lunch, we heard intermittent screaming.  We wondered if it was a woman in labor.  Generally, the Tanzanian women do not scream.  They tap, mutter, grimace, but they don’t scream.  Very stoical.  I don’t think we even noticed when the screaming stopped.  When Serena arrived, she told of how she had heard the screaming from the labor room and so went there.  She quickly related a nice summary of the events.

The first twin was already delivered when she arrived and did make some respiratory effort.  The heart rate was 120 – a little slow, but not terrible.  Baby hearts almost always and readily recover if they can get oxygen.  She tried to assist.  No oxygen.  Technically, if the baby is breathing, additional oxygen is not absolutely necessary.  She tried to use the bag and mask to assist.  It was way too big.  These twins were probably only 32 to 34 weeks gestation.  She could have intubated the infant, but there were no endotracheal tubes.  She did her best.  She assisted with delivery of the second twin, which did well, initially.

We hustled our way to the L&D area.  The firstborn was completely covered with an orange and black kanga.  When I pulled back the cloth, I found the tiny tot Serena had been working so hard to resuscitate.  Indeed, he was not breathing.  His eyes were closed, mouth open.  His skin was translucent and pale and blue.  As I put my gigantic adult stethoscope to his chest, I could not be sure if I was hearing his or my own heart beating.  I used my index and long fingertips.  Yes, I could feel the heart beat and Serena could see his thin chest wall move.  The heart rate was 40 per minute.  For just a moment, I used the two fingertips for chest compressions.  The heart rate did not recover.

We expressed our sorrow to Mama who was holding the second twin, a girl, “Pole, pole sana.”  We are very, very sorry.

Serena and I left the room to commiserate about this sad situation: no oxygen, no properly-sized mask or E-T tube.  Also, no tiny IVs, no incubator type warmer.

The airlines now carry some rudimentary resuscitation equipment, but for many years they did not.  Having the equipment carries with it obligation to have knowledge in its use.  With that comes extensive training and cost.

As I think of the priorities at Ilula, I am wondering where this level of technology can fit.  The equipment I mentioned above is a whole layer of technology over what Ylula has, not simply a few thousands of dollars of equipment and training away.  Would this be the best place to start?  No, I don’t think so.  There are too many people who can benefit from much less costly, simpler interventions – like the Plumpy’Nut for malnutrition and HIV medicines.  All the more reason to work hard at these things!

Serena and I went back to see the baby.  The heart rate was down to a few beats a minute.  We cannot be sure precisely when the baby “died.”  This time it was, “Pole pole sana, mtoto na amefuka.” We are sorry, the baby has died.  Biologically, he died moments after his agonal breaths truly stopped.  We could not let go of the traditional heartbeat as our unfailing sign of death.

The second twin died too.

Laura Melcher and Carl Sherman giving a lecture to staff at IDH

Laura Brown, Serena Thompson and Jake Feigal

African Skies

Day of Grace - Randy Hurley, MD

“Sometimes I have difficulty walking up small mountains”

Health assessments as part of a “Day of Grace” health, wellness, stress and spirituality seminar for Lutheran Pastors in the Iringa Diocese of Southern Tanzania

“Sometimes I have difficulty walking up small mountains,” replied the 62 year old pastor when asked if he had any concerns about his health.  He was participating in one of 3 day-and-a-half seminars held in January 2012 in Iringa, Tanzania.  These seminars were planned and sponsored by the Iringa Diocese of the Evangelical Lutheran Church of Tanzania in conjunction with the St Paul Area Synod of the Evangelical Lutheran Church of America.  The seminars, entitled “Day of Grace” were conceived and organized in response to the perceived need for support of physical and emotional health and stress management for a group of 185 pastors in the Iringa Diocese.  The seminars included worship and fellowship time, small group discussion, and a lecture on stress management.  Participants were also offered the opportunity to undergo individual physical health assessments.

Data without personal identifying information was reviewed from 155 of 159 pastors (24 female and 131 male) that volunteered to participate in the physical health assessment component of the Day of Grace events.  All were offered screening for hypertension and diabetes and underwent assessment of visual acuity, height and weight.  A health questionnaire was devised with the help of Tanzanian leadership so that only culturally appropriate questions were asked.  Pastors completed the health questionnaire and physical exam with the aid of an interpreter when needed.  Female pastors were interviewed by female medical staff, counseled on breast self-exam and offered pelvic exams.  Volunteer medical staff included physicians, nurses and pharmacists from the Minneapolis-St Paul area and 4^th year medical students and pharmacy students from the University of Minnesota

Pastors in the Iringa Diocese have completed secondary education and theology training at the college level. The age range of pastors participating in the health assessments was 23 to 80 with a median age of 45 years.  Most pastors had never undergone a comprehensive physical exam although most had sough health care for treatment of malaria and a significant minority had been treated for typhoid.  Most pastors live on an income less then $2 per day but many supplement their income with subsistence farming.  Nearly all pastors were married.  The median number of children per married couple was 4 (range 0-10) and a median of 6 persons (range 1-15) lived in each household.  Female pastors had a median of 3 children per married female pastor.  Forty percent had a water source in the home however some pastors had to walk up to 30 minutes to obtain safe drinking water.  The majority of pastors used mosquito bed nets routinely and the prevalence of tobacco and alcohol use was nearly zero.  The most frequent complaints were dental-related and related to presbyopia.  Gastrointestinal/gastritis symptoms and musculoskeletal complaints were the next most frequent.  The musculoskeletal complaints were suggestive of degenerative arthritis or complications of prior accidents.  Few pastors had ever undergone surgery with orthopedic procedures following trauma being the most common.   It as very rare for pastors to be on medications on a daily basis

Visual acuity was strikingly normal with most pastors having distance vision of 20/20.  A significant number, however, were in need of corrective lenses for near vision and reading. Only 12% of the pastors examined had an elevation of blood pressure greater than 140/90 mm Hg however 30% of the pastors above the age of 42 had an elevated blood pressure.  Relatively few abnormal physical exam finding were identified and when present included issues such as soft tissue infections, hydroceles and hernias.  No abnormal breast or pelvic exam findings were noted.  Only 8 of the 155 pastors tested had an elevated fasting blood sugar above 110mg/dl.

For the medical examiners, the physical assessments were an opportunity to understand the health and lifestyle of a relatively homogenous group of Tanzanians.  Moreover, the standardized history and physical exam forms allowed for systematic evaluation of many of the social determinants of health of this population.  The presence of interpreters allowed examiners to enhance their own knowledge of Swahili medical terms

The medical examiners were perhaps surprised at the overall general good health of this cohort of pastors.  Pastors are a relatively highly educated group.  In developed countries, educational level and marital status are both associated with improved health outcomes.  In addition, “healthy worker effect bias” may help explain the relatively good health of this group.  This bias would suggest that those with underlying health problems and disability are unable to remain employed as pastors.  Therefore, only healthy workers remain as part of the cohort examined.

Overall, pastors were highly satisfied with the Day of Grace events and felt the physical assessments were the most important component of the health, wellness, stress and spirituality seminar.  Most indicated they would like to see the Day of Grace concept repeated with the opportunity extended to spouses to also undergo physical health assessments. 

This first attempt at a health, wellness, stress and spirituality retreat for pastors was, in some respects, also a feasibility study.  The co-leaders now have a better understanding of what can be accomplished in a day-and-a-half event.  Evaluation forms and a post-seminar debriefing have generated ideas for improvements and for future events.   Having an understanding of baseline health issues will allow closer tailoring of these assessments to better meet the needs of this underserved population.

Ilula Wednesday 2-1-2012

 This day was notable from some new connections we made at the Amani Orphanage.  I hope I get the name details correct.  Beata Mundt, a German nurse, social worker, family counselor at Amani and a colleague, William (Wilhelm), a pediatrician came to discuss Plumpy’Nut.  This came about after they had visited IDH and met Jill Strykowski at IDH and she referred them to me.    At the orphanage, they get many referrals and if they have room, they take them in.  These children may be true orphans or simply destitute.  They are often starving.  Bottom line is we have many similar interests.

I gave them a box of Plumpy’Nut to get some of the severely malnourished kids going.  They wouldn’t need a ton of it, but should have a couple cartons (150 sachets) on hand.  We also gave them the special measuring tapes to gauge the level of malnutrition.  The tapes measure Z-score, 2 standard deviations from the mean as measured at the MUAC (mid-upper arm circumference).  Serena Thompson taught them how to use the strips.

They also have a garden, but do not grow groundnuts, i.e. peanuts, or lentils (chakoro) or some of the other complimentary protein foods.  They do have milk and beef and goats on the farm, so they would not need the beans, except to teach the caregivers.  Meg Feigal is our garden guru and my hope is that somehow there could be some collaboration to add the beans.

Beata invited our group to Amani on Friday for a tour and lunch.  We will chat some more then. 

Dr. Saga stopped by this evening to say we may try to go to Idete tomorrow, to deliver medicines to the infirmary.  Idete is where Lutangilo Secondary School is, “our school,” where many of our Idunda students go.  Idunda is across the valley with bad roads, read “no roads.”  There are roads to Idete.  Compared with last year, there has been more rain.  Pole sana, I won’t be going to Idunda.

Tonight we are watching the first half of “Bridesmaids.”  No, we don’t have a movie for every night.  Last night we did watch “Ides of March.”  That is why we are watching at least some of “Bridesmaids.”  We need the comic relief.  And the students are already using my son’s mantra, “Don’t encourage him.”

I will try to upload Idete photos next post, or when we get them.