Mambo, (Wadi) No. 5

Day 5: April 8, 2014

Day five started out in a way that I wouldn't have expected or wanted had I been able to plan it.  I woke up at about 3 AM with a rumbly tumbly stomach, and for the next hour was alternating between sitting in the restroom and lying in bed wondering when I was goint to have to go sitting in the restroom again.  Finally a bit after 4, I fell back asleep and stayed asleep until 6:30 AM, when my alarm woke me and I snoozed it 3 times in a row.  At 7 I decided I couldn't put off the inevitable any longer, and though I was excited to get up for my first day at the BIPAI Tanzania Clinic, I wasn't quite as thrilled to make yet another morning trip to the restroom, even if it did have a view of bright red flowers and greenery just outside the window. 

Getting ready for the morning ended up taking quite a bit longer than usual.  A combination of trying to fit in morning prayer, my extra bathroom time, and getting all situated with my computer, charger, stethoscope, etc in my backpack, I found myself finally ready to leave at about 7:40.  I grabbed the bread I had thrown in the toaster, threw some pineapple jam on it, and walked out the door.  We took the long road to clinic, as we knew that we needn't be there until about 8:30 anyway.  We walked up the hill and around the bend back down toward the clinic, cutting through on an unpaved road over a creek that led past the Cathedral.  We walked onto the grounds of Mbeya Referral Hospital through a gate on side road.  As we crossed through the hospital grounds, I noted again that they appeared much like the hospital in Gaborone: multiple small, one story buildings that resembled American school buildings made primarily out of concrete and connected by covered cement walkways.  Finally we came upon the BIPAI Clinic and went in.  First off, Carmelle showed me to where our work area for the month would be, and as I sat down I marveled at the ability to connect to a wireless network and use the internet freely!

Shortly thereafter, I was met by Liane who gave me a bunch of study materials, forms, and other documents for the month.  She then introduced me to one of the other BIPAI docs, Michelle, who wisked me off for a tour of the clinic.  This of course included seeing the work areas, clinic rooms, lab, etc.  However, it also meant being introduced to about 30 different Tanzanians who worked at the clinic, none of whose names I had any chance of remembering as with every turn a new person with a name I'd never heard of appeared.  Everyone was very kind, and I heard the phrase, "Karibu, you are most welcome here" about 15 times or so. 

After the clinic tour, I had a few minutes to check and send some emails, and then it was time to start the day.  In actuality, this was not my first day working in the clinic seeing patients as Tuesday and Friday here are days on which one of the BIPAI doctors rounds on the kiddos in the Malnutrition Ward in the hospital.  I was very eager to have an inpatient component to the month, as this was a bit lacking four years ago in Gabs.  Jason was the doctor on service for the month of April, so he came to meet us at about 9 AM and we were off to the hospital.  As we walked into Wadi 5 (aka the Malnutrition Ward), it was clear how different this experience would be from rounding in America.  In the concrete building were four separate areas in a row, separated only by a 5-6 foot dividing wall.  In each area, which I estimated to be about 15 feet by 15 feet, 6 hospital beds covered with mosquito nettings were placed, 3 on either side, separated from each other on each side by about 2 feet and by about 3.5-4 ft across from each other.  Each area had a couple of windows that were left open in order to help cool the building, but as far as I could tell no air conditioning was to be found.  All told, there were 25 kiddos in the ward waiting for our team to round.  We were met by Rajeb, the new Tanzanian intern on the service, and began to round.

Now, rounding in this hospital was a far cry from that in the US.  There was no pre-rounding by the interns or by us. The entire team, attending, residents, intern, nursing, and pharmacy, started rounding at the same time, spoke to each patient/parent at the same time, and made a plan all together.  Then the attending would examine the patient while the intern wrote orders and the daily note. So picture, if you will, 1 attending, 2 residents, 1 intern, a nurse, a pharmacist, and a medical officer or 2...roughly 7-8 people, standing around a hospital bed separated from 5 others by just a couple feet staring at the patient and their parent while the attending (who is 6'4", mind you, bends down to examine the patient underneath a mosquito net that is about 5 feet or so off the ground.  It was, shall we say, rather cramped. 

The patients were, as you might imagine, unlike anything I'd ever seen in the U.S. Infants and children ranging from about 6 monts of age to 3 years of age with one or two outliers of about 7-9 years, all either previously or currently SEVERELY acutely malnourished due to either HIV, disseminated tuberculosis, or most sad of all, sheer lack of availabity of food with no other underlying medical problems precipitating their illness.  These were kiddos that we all would only recognize from those late-night commercials asking for your help of "just $1 a day". The muscle wasting and thin extremites on the sickest of the kiddos was astounding.  The stunted growth made it hard to believe that each child was actually the age their chart claimed them to be.  Needless to say, there were a number of patients with conditions that we all know only to exist in books and in theory.  These children were ADORABLE, but so incredibly sick. Just to recall a couple, the most memorable to me were:

- Winfrida, a young ~12 month old with malnutrition, due only to lack of food, so severe that she came in hypothermic, hypoglycemic, and swollen so terribly from protein deficiency that she could not open her eyelids, her skin shined due to how tense it was from the edema, her socks demonstrated the severity of her swelling as her lower legs bulged out once not confined by the elastic band (think wine glass shape), and the hair on her temples had a red tinge to it due to micronutrient deficiency.   

- A two year old boy whose name escapes me at the time admitted for malnutrition but being worked up for suspected HIV infection and concern for abdominal tuberculosis.  His stomach bulged out with fluid so  much that it was difficult to see anything other than his belly while looking at him.  He had been started on treatment for presumptive TB but without any improvement after two weeks, and an abdominal ultrasound looking for abscesses, masses, or lymphadenopathy which came back with a straightforward read of "ascites (fluid in the abdomen)"...incredibly helpful, surely.  We contemplated how much longer we'd give him before trying to transfer him (ie put him on a bus to the country's capial with his caregiver to expedite the process as "ambulance" transport was extremely limited) as we had nearly exhausted the workup available at our hospital (which is limited when you consider the liver function test machine is down, no cultures are available, and one of the few radiologists in the area unexpectedly died about a week ago).

(No pictures here, sorry!  No allowed to post them publicly online!)

All told, it took us from about 9:30 until 2:15 to round on these 25 patients.  I found out after the first 12 patients that I was largely out of rounding shape...about 90 minutes in, my lower back started KILLING me...I tried to stretch, bend, etc with no relief.  There was nowhere to sit, and not anywhere that I really wanted to lean up against.  After finishing the second pod of patients I took a brief timeout to sit on a small bench in the narrow hallway that ran thru the ward.  It helped, but only for a few moments, and so I made it work for the remainder of rounds by squatting close to the floor intermittently and as we waited for the intern to finish the note on each patient.  Finally, we finished up with a young kiddo with Down Syndrome who actually was very well appearing comparatively, and rounds were finished.  It was quite the marathon, and I was happy to have a rest. 

My stomach was reminding me that I had not filled it since my toast and jelly at 7:30 AM.  Carmelle and I dropped our things off at the clinic and quickly walked down the road a ways to "Hope Sisters" restaurant. From the buffet style service line (ie a table with 10 or so large pots on it) we chose our food.  I had some seasoned brown rice with beans and chickpeas, passing on the available protein of fish as I preferred to not have to pick out bones, etc...I just wanted to eat.  After getting my heaping plateful of rice covered by the sides, we sat and I INHALED my food.  I went from amazingly hungry to incredibly full in almost no time.  We paid for our meal (mine costing just about 3500 TZS, or just under $2, with Pineapple Fanta), and headed back to clinic, where I met Simon, the procurement officer, for a trip to get a SIM card for my phone.

We traveled back into town down a side road, across a field with a path worn into it by regular pedestrians, onto a dirt road, and over a small creek spanned by a bridge that one need carefully walk over to avoid the spaces in between each plank.  We arrived at "Airtel", and after a couple minutes of conversing in Swahili, and a ten minute wait, I had my SIM card and was ready to go.  We retraced our path back to the clinc where I caught the end of a lecture on nutrition for infants of mother's with HIV.

After that, it was time to video call home FINALLY for the first time since Friday night.  Ali and the kiddos surely were a sight for sore eyes, but only made me miss home even more.  I felt guilty (justifiably) for leaving with so much going on at home, but was glad to hear that Ali had had some help over the weekend and on Monday.  Ali showed me all the rearranging of the house that had been done in preparation to get it on the market so we could move out to Katy, and it looked AWESOME.  I am greatly indebted to my father-in-law and sister-in-law for their help, and only moreso to the amazing wife who is currently handling three children under 5 at home for the next two and a half weeks.  I LOVE YOU!

About half an hour later, it was time to sign off for the night, and I said goodbye to everyone, hearing John-Paul crying again in the background as we hung up. 

A little while later, after doing a bit more work at the clinic, it was time to head home.  Navigating our way through the streets in the fading sunlight that was disappearing behind the mountains to our left, we decided to grab some dinner at pretty much the only available place within walking distance of the house: Mbeya hotel.  Our housemates were having a friend over for dinner as a farewell (she was moving back to Germany after 13 years of missionary work), so we made ourselves scarce for the evening. We walked down and grabbed a table, hoping to catch a waitresses attention as we had been warned about how long the staff could take to take your order regardless of how busy the place was. 

It took about 15 minutes, multiple attempts to waive down a waitress, and what I'm pretty sure was the result of the manager hearing us trying to flag someone down and chewing out the staff, to get our menus.  We perused the list that ranged from Indian to American to Chinese food, and I finally ordered the Szechuan beef...clearly I hadn't remembered my lack of intestinal fortitude, especially since I answered in the affirmative when the waitress asked "Very spicy??"  The food came rather quickly, and though rather very spicy, I liked it a lot and of course scarfed all of it down without so much as a thought of leftovers.  We settled our bill and headed back to the house, where the siblings and their friend were sitting on the veranda finishing dinner and talking.  We joined them, and to our surprise, Amelia asked, "Would you like your pudding now?"  I responded that I didn't know we had any pudding, but that I was certainly ready for some!  They brought Carmelle and I our own little german chocolate cakes topped with whipped cream and a cherry! They were delicious, and certainly hit the spot after my stomach had been subjected to such a spicy foray half an hour before.  Why it was called pudding, I had no clue, but I was not about to question something so yummy.

After finishing my pudding/cake, we sat and talked with everyone for about 30 minutes or so, covering topics that primarily dealt with dogs and snakes and then dangerous encounters in the jungle with black and green mambas, cobras, and the like.  We were assured that no such snakes were in Mbeya...but at that point it didn't much matter to me.  I was so sleepy that I welcomed the end our our chat, and after a quick shower there was not even an attempt at journaling as I was lucky to finish evening prayer without (permanently) nodding off to sleep.