Ilula - Minnesota International Conference Day 1 and new arrivals We met Ken, Sarah (nurse), Krista (nurse), and Nick (pharmacist) on the evening of 1/12. Unfortunately, Kristi, our remaining new arrival, had a flight that was delayed so we didn't meet her until 1/23. It definitely seems like a great new group! Though we'll be sad to see some people leave soon it's great to welcome new arrivals. We've already been to "downtown" Ilula as a group. Day 1 of the conference was a success, with attendants reaching the maximum that was anticipated! Driving up to the conference space there were already healthcare providers from all over Tanzania lining up for registration. John Kvasnicka had us stuff 100 folders for the conference a few days beforehand and we quickly ran out. The day was off to a quick start with lecture from Randy Hurley on Hematology in the Tropics. It came as no surprise that already after the first lecture we found a symptom similarity between the two countries, pica. We learned that healthcare providers in Tanzania also see pica (eating of ice and dirt) in patients with iron deficiency anemia, just as we do. We also learned about pain management, antibiotics in skin infections, and OB this morning. The afternoon consisted of lectures on hand hygiene and micronutrient deficiencies. We also participated in workshops ranging from suturing to obstetrical emergencies, it was a great opportunity for the two healthcare systems to interact and compare notes. The first day concluded with a lecture from Gary Moody on swahili songs, tanzanian geology, and Hehe proverbs. Those of us staying in Ilula arrived home at 8 pm and spent much of the night preparing for the next day of lectures! It'll be a busy two days but most of the group will be heading to Ruaha for safari this weekend! The worst part of the conference was seeing my Mom leave, it was an invaluable experience traveling and working with her in Ilulua and I anticipate us doing it again in the future. Rachel

A note from Randy

20Jan2015

A bouquet of roses, blossoming buds, and a thorn:

The bouquet:  that "difficult-to-name"feeling you get when, in this very resource poor environment, patients will seemingly miraculously get better despite our grim predictions and likely "despite" rather then "because of" the care we can provide.  Examples: a 15 yr old boy with osteomyelitis who we are concerned also has a septic hip joint is now walking with the aid of crutches;  a woman with possible molar pregnancy and what appears to be an acute abdomen.  We fear she will need a major surgical procedure that we can not provide, but after 24 hours of antibiotics is nearly back to normal;  an HIV positive woman with suspected PCP pneumonia who is incredibly sick with a respiratory rate of 40 and oxygen saturation of 79 percent who improves dramatically with a cocktail of drugs and is discharged. For these things,  I need a word that means "gratitude/awe/humility/ and utter innocence."

Lots of buds: the opportunity to work with my friends and this group and renew our longstanding relationships withTZ colleagues; the arrival of more friends including Ken tomorrow, the pending nursing school inspection, the upcoming medical conference followed by a visit to Tungamalenga and Ruaha

The thorn: despite many trips to TZ, this is still a trip best experienced with loved ones, yet Kari, Evan and Angela are at home. 

Randy Hurley

Bees, babies and sewing machines

A nice cool rain is falling this afternoon, so a good time to do a blog entry. Everyday is different here at ilula hospital, so one needs to be prepared for anything.  Today, two unconscious patients were brought in from the ilula orphanage project....they contracted carbon monoxide poisoning after working in a well. Both have recovered and are doing well.  Two days ago the hospital had a bee attack over many of the wards and outpatient department.  I was in the HIV clinic and we noticed all these people running about with their scarfs over their heads, trying to get away from the swarming bees. Apparently a huge bee nest had developed on top of the hospital water tower, and the bees decided it was time to go irritate the patients and their families.  Many of the inpatients just dropped their bug nets( which hang over most beds here) so it was the staff and outpatients and families that were most affected.  Never a boring moment here, for sure. Many of the patients and staff were laughing about it today....a good sense of humor always helps in unexpected situations. The bee nest no longer exist as it was smoked and burned out yesterday.

      We had a bit of a rough week last week as we lost 3 babies that probably would have survived in US hospitals.  One mother lost her second newborn of twins due to probable  prolapsed cord.  Another baby seemed healthy at discharge but returned the next day, very septic and expired about 6 hours later. The 3 rd baby lost was the "precious baby" patient that I referenced in a earlier blog entry.

I have had 3 "counseling sessions" with Maria, the precious baby mom, and have gotten to know her quite well over the last week. She has given me permission to share her story and photo in this blog. I was expecting her to be in terrible grief over the loss of her 11 th pregnancy, but my talks with her have been quite different. She has been in an abusive relationship with her husband of 15 years.  She lives quite far from ilula, near Dar Es Salaam (Capital City), about  300 miles away.  She came to ilula hospital because she was originally from here and has family in the area. She did not want to get pregnant this time due to her past difficulties. After discovering she was pregnant, she asked her physician for an abortion and was denied - abortion is illegal in TZ.  Maria has adopted her 7 yo niece, after her sister passed away.  We have spent a lot of time talking about her next step once she leaves the hospital.  I think she will not return to her husband - he has not called or inquired as to how she has been doing over the last 10 days.  Maria says he is "fed up" with all her pregnancies.  Like many women in  the US who are financially dependent on their husbands, Maria is faced with some huge challenges to support her daughter and herself. She is now saying she does not want to return to her husband and wants to relocate with her daughter to the Ilula area. I have been very impressed with her strength and composure as she dealt with "expelling"  her 28 week old baby with no viable heartbeat.  We we're all hoping delivering the stillborn would go quickly but it did not.  All of the docs here, the ilula medical staff, Gary, Steve, Jenna and Theo , checked in on her, but no contractions. She was finally able to start contractions yesterday evening with an increase in medications, and she delivered at 7:30 am this morning, 5 days after she was told there was no fetal heartbeat. This avoided a potentially dangerous c section.

This has been a bit of emotional roller coaster for me. I was happy to get the news of her delivery, knowing that her recovery will be much quicker now.  But my excitement quickly turned to sadness, thinking of this tragic loss and it's impact on Maria and her family. Her fortitude through all these pregnancies (at least 60 months of being pregnant and no baby) is amazing. I have learned much from Maria about determination. I am optimistic she will forge a new life for herself as soon as she discharged.

After meeting with Maria and her cousin following her delivery, I went on hospice rounds and visited 4 patient in their homes. This was really enjoyable, as we got a good insight into the life in ilula.  All 4 patients and families  were very gracious and uplifting.....there is no quitting in these folks.  Particularly inspirational was a 52 man who contracted polio when he was 4 years old.  He has a severely disfigured body, can not walk, ambulates by shuffling on his hands and knees, and gets around town with a tricycle.  He is supporting a family of 6 by operating his own tailor shop. He showed us how he cuts material and operates a sewing machine, even with severe contractures in both hands.... Amazing! His wife is psychiatrically disabled and can not work. Despite all of these pressures, he is making a living and seems really happy.  I took a few videos of him and may use those the next time I have a patient that may need a boost.

We are off to Iringa tomorrow as we put on a 2 day conference for local doctors and nurses. We then head off to Ruaha national park for a 2 day safari and then head home on January 28. I will miss making the rounds and these patients. This has been a wonderful experience that I will always cherish.

Linda 1/18/2015 The Disease Hiding in Plain Sight

We have been here a bit over a week now.  I feel as though I am finding my way around and able to contribute to the health and well-being of the patients.

Last night, we had dinner with the hospital management team.  It was interesting to hear how the relationship with Ilula hospital developed.  Randy, Gary, John and Ken don't just "talk the talk" but also "walk the walk"  They work tirelessly to continue the relationships that are built here as well as improve patient care and provide sustainable economic development.

I have seen my first ever cases of Kwashiorkor (protein deficiency and Marasmus (protein and calorie deficiency).  It seems that many of these cases are overlooked.  Understandably, because there is little to treat the malnutrition and the concurrent diseases are first and foremost in the clinicians' mind.  Malaria, HIV, pneumonia, to name a few. 

We just received 50 cases of Plumpy'Nut, which is a high calorie, high protein paste that comes in a foil packet.  The supply of this supplement is not consistent, but now that we have it, we are using it!

The packets contain about 500 calories and 13 g of protein.  It also has some Vitamin A and Vitamin C.  The nursing staff and clinicians have been very supportive and the patients are receiving and consuming the correct dose. 

Many procedures are different here, not the least is the language.  As allied health professionals, Mark and I have been at a bit of a disadvantage, because we need to interview the patients to determine the correct treatment.  We often use the clinician as an interpreter, and that slows them down,

For example, this morning on rounds, I spoke with a newly delivered mom of a small weight for gestational age baby.  The baby was nursing well, the mom's diet contained sufficient protein and calories, therefore, no intervention needed.  Yippee! 

For another case, I had an interpreter.  The mom was HIV positive and looked malnourished.  The baby was small, and not feeding as well as we would like.  I prescribed 3 packets of Plumpy'Nut for the mom.  This way, she will have sufficient protein and calories to produce high quality breast milk in sufficient quantities.  It was a great experience to be able to counsel patients about their diet and feel like I wasn't rushed.  I felt like the patient received good info and I was able to assess their compliance. 

Tomorrow I will give a short inservice to the medical staff on how and when to prescribe Plumpy'Nut.  I know the staff were stunned when I prescribed Plumpy'Nut for a mom, and not the baby! 

Just a few more days before we leave the hospital and go on another safari.

Then back to the US for Mark and I on the 29th.

Monday, January 13th - Sarah

This day was a national holiday. I believe it is to remember the day Tanzania acquired Zanzibar.  The HIV clinic here was supposed to be closed due to the holiday, but the patients were not aware and so they showed up anyway and the physicians staffed the clinic anyway.

Many patients have to travel very far to get their medications and so it was nice of the physicians to be open anyway. I don't think this would ever happen in the U.S. The HIV clinic is referred to here as the CTC clinic here in order to decrease the stigma. It stands for center for treatment and care. Many acronyms related to HIV are changed to decrease stigma. I was in the part of the clinic where the medications were given out. The patients would come in to our room one by one after seeing the physician and present their file and a medication card. The card had columns for the date, the date they were to return for another check-up and more medication, the medication they were to receive and the quantity. Most patients received one month's supply, but if they traveled from far away, they were often prescribed two months worth. The pharmacist would then sign the card, document the medication to be dispensed in a log book, and then dispense the log book.

We saw two patients in this setting who presented with serious skin conditions and we sent them back to the physicians to determine treatment. I'm not sure whether these patients had bypassed the physicians their first time through the clinic or if the physicians had made a clinical decision not to prescribe further treatment for these patients. Upon examination the Tanzanian physicians determined that one of the patients had leprosy and the other had a horrible case of shingles that left a deep wound that had gotten infected. The appropriate treatments were investigated, but I wonder if the patients will be able to obtain them. Drug cost and supply are difficult issues here.

In the afternoon, we visited the Ilula Orphan program where we were greeted by a group of singing girls. They sang "Karibu" meaning "welcome." We then signed the guest book and spoke with Berit, the Norwegian woman who started the program. After a concert by the girls which included everyone being pulled up to dance, we learned about all the additions that had been made to the program to improve the lives of people in the area. They grew crops and raised animals including pigs, goats, cattle, and chickens. There were areas for making shoes, sewing, welding, and carpentry. Recently a library was opened with lots of financial assistance from the people of Norway. The high school was very impressive with its comparatively well equipped chemistry lab and also appeared to be well respected. We saw a Lexus from Dar arrive to drop off a few children after the long holiday weekend.

Samantha - What a week it's been!

I'm a senior at Gustavus Adolphus College and will beginning medical school in the fall. I've been enjoying my time following the other members of our group and learning so much from them all. 

On Thursday we had a group of kids visit from Gustavus. They toured the hospital and and we had an interesting conversation about healthcare in Tanzania. 

Today I joined Emily and Laura K at the Ilula Orphan Program. We started out varnishing and sanding down the doors with the high school students and ended by playing games with the young girls. I delivered photos and letters written by fifth and sixth graders at the Church of St. Peter in Minnesota for the girls at IOP. They seemed very excited to learn about what life was like for other kids their age. The girls are working on a letter to reply to the children in Minnesota. 

When I returned to the hospital campus, we had dinner and sat around having discussions with the group while listening to Dr. Hurley and Dr. Moody sing along to Johnny Cash. I am looking forward to see what other adventures this trip has in store!

Samantha 

Theo Edwards - 1 week down:

Sitting here in Iringa at an internet cafe, finally getting a chance to write a few things for our blog. I think the best way to summarize this adventure so far is to reiterate our debrief today. We were asked what has been our biggest challenge, what has amazed us, and what we are looking forward too. So I will start with my thorn (biggest challenge). This has been just trying to make sense of the chaos that goes on in the hospital. Communication has obviously proved to be a major obstacle, and we do the best with what we have. Now I could go on about this, but I will just leave it at that. My rose (that which has amazed me), is a number of things, but I will only name a few. 1) I am amazed at what a significant impact Randy, Gary, Ken, and all the others have made through the years, and they are very humble about it. So Bravo!!!! 2) I feel incredibly lucky to be working along side such an amazing group of people. Everyone has their own unique talents (from nutrition, to pharmacy, to psychology), and I see this paying dividends in the lives of our patients each day. Lastly, I should mention what I am looking forward to in the coming days. Yes, spending 3 days on safari next week will be a magical experience, but moreso, I am excited to what surprises are in store each day. A quote I heard when we arrived has kinda stuck with me. "you come to africa trying to change africa, and you realizes that it is africa that changes you". Asante Sana!!

Theo