Ilula Nursing School Dedication

Today was an eventful day at Ilula Lutheran Hospital, unlike any other day.  It was beautiful, like so many other day here.  Gary and I went walking in the fog.  He ran on as I walked back.  By the time I returned from the forty minutes total of out and back, the sun was up and the fog was burning off nicely.

Last night the troops watched a good movie, “The Last King of Scotland,” the story of a Scottish doctor who became the personal physician of Idi Amin, known to my generation, represented in this case by Gary and me, as the ruthless dictator of Uganda and the antihero of the “Raid at Entebbe.”  I think they were surprised that I grouped him with Hitler.

Everyone was a on alert because we were expecting guests by 8:30 AM.  The guesthouse was spiffed up and presentable by the time they arrived.  And kept arriving.  There were a lot of guests.  Anna fed them all and of course there was enough to go around, I think five loaves and fishes, metaphorically speaking.

Dr. Saga had made a detailed schedule.  Mwamoody sensed the ensuing need for more sodas and went for them and we were glad he did!  We would have been pronounced poor hosts had we run out.  The doings were supposed to begin at 9:00 AM.  Remarkably, Bishop Mdegella arrived on time, something he is not known for.  Even he was sensitive to our honored and charming guests, Andrea and Russell King, representing the Peter J. King Family Foundation the generous donors who have supported Ilula’s Medical Education Buildings and other buildings built specifically for the Ilula Nursing School.

Somewhere around 9:30 AM or after, we strolled to the area of the education building where the hospital had put up as many chairs as could be found and the Ilula Nursing School Dedication kicked off.  First came several numbers from the combined Ilula Lutheran Church choirs.  I only wish everyone reading this could hear them.  I will try to get one number from Radio Furaha, even if the recording is not ups to the finest quality.  After the choir, the sealing of the time capsule and the blessing and dedication of the Nursing School processed.  There were several speeches, mostly way too long, but of course my opinion might be tainted by the fact that I do not understand Swahili.  The hit of all the speeches was one of which I did not understand a word and in Kihehe, by my esteemed colleague Mwamoody.  He is nearly legendary here as the mzungu who speaks Kihehe.  People he does not know call him by name and he often has a conversation with them.  People laughed delightedly as he spoke to them.  Richard Lubawa could hardly contain his own laughter as he translated for us wazungu.

Russell and Andrea received gifts from community members and showed off the new shirt and Katanga (or whatever they are called).   The speeches eventually concluded and once again the choir sang.  It was one of the most beautiful songs I have ever heard, full of the loss and sadness and pain caused by HIV/AIDS.  To add emphasis, the women covered themselves and their heads and all sang sitting on the ground.  It was startlingly beautiful and mournful. 

Going on from this evocative song hardly seems fitting, but just as those of us left behind by HIV/AIDS and other ordinary losses, the dedication did go on.  I can only say how privileged and honored I felt to have been present for this wonderful dedication.

The last item on the dedication service schedule was a tour of the three buildings.  They are very fine, indeed.  Now to fill the dorm with students and teach them excellent nursing skills (then build a second dorm for the next class, of course)!

It’s funny how a long dedication service stimulates the appetite.  Anna and her crew did themselves proud.  The rabble ate by the administration building and the honored ate at the guesthouse.  I am sure I only got to eat at the guesthouse because I live here.  Actually, we did have two eating stations to accommodate the big crowd.  The food was excellent and there was plenty.  Anna should have a bonus!

But for me and Mwamoody, the rest of the wazungu crew took off for a jaunt in Iringa about noon.  Most will return tonight and we are off to Image (pronounced Ee-mah’-gee, not im’-ij) for dedication of the new library, also funded by the King Family Foundation.  I am looking forward to the students and faculty dancing for us, always a treat.

Now I sit looking out over one of my favorite views in the world, looking across the savannah at Mount Celebu, with a few birds nearby and cowbells off in the distance.  There are clouds rolling in and we have had a bit of rain but no drenching downpours.  It is peaceful and I feel reverent as I look out over this stark and beautiful land.  

Bwana asifiwe!  

 Amen.

Nursing perspective

A nursing perspective from Sarah Martin

Hello from Tanzania. We have each been encouraged to blog about our experience at least once (seems pretty reasonable until I remember that Internet can be a challenge here in Ilula... They have satellite to power their internet). I have been waiting for a day where I feel like I can actually contribute to the blog in a meaningful way and decided I should just note some of my impressions from my first couple days on the general ward in the hospital here. 

Maybe others have mentioned the differences between the hospital here and at home (they seem particularly stark for me coming from an academic medical center working as a nurse), but here are mine: 

when I think about nursing care, I think about the daily maintenance of each patient in my charge. I may do dressing changes, administer oral, subQ or IM and IV medications and education about each one, assist in personal cares, change and roll incontinent or bed bound patients, get vitals and watch trends, maintain drains, tubes, lines, etc. in addition to lots of other things. I work with my team and patients to take care of all their needs. Here the patient's families provide their own food for the patients and assist in the personal cares as necessary. There is one shared bathroom for the 50+ patients we saw and no private rooms, you are lucky if you get a room with only 3 or 4 other people in it. Infection prevention like we do in the states is non existent... MRSA precautions? Yea right... You are lucky if proper hand hygiene is done between patients. As a nurse, this is just such a simple part of my practice and Krista (another nurse who is with me on this journey - thank goodness) have been encouraged to continue to do education with staff here about washing hands and using hand sanitizer, etc. It was a major culture shock for me when such ingrained infection prevention techniques are not routinely followed. Some techniques such as IV set ups and other daily routines of the nurse seem actually pretty similar here minus a few infection prevention techniques we utilize in the States. The nurses here speak some English but not as well as the physicians. One nurse was able to tell me that they have 3-4 nurses on during the day for those 50 some kids, women and men on the general ward. For those that aren't familiar with nursing ratios, this is incredibly high. We have 3-5 patients in our care usually on a medicine floor where I work at home. The nurses here are not assigned to patients as far as I can understand, instead they work as a group to carry out the physicians orders and ordered medications. Daily vitals are only sometimes done to all of our consternation (no q4hr or q8 vitals). And I have yet to see a nurse do a head to toe assessment on a patient. They have very few drains, lines, Etc here. I have seen one NG tube and two Foleys total. One patient on oxygen. Such a difference from back home. 

It has been a true learning experience for me to see the difference in the role of the nurse here in Tanzania. There are certainly similarities in the roles such as the nurses give and document their medications (albeit with less technology than we do at home) but lots of differences too because the nurses do not take much initiative here and are not very independent. They get their orders from the physicians and that seems to be it. I have gained some perspective when it comes to my own practice and our complaints about feeling overworked, or feeling like I don't have the resources I need. Watching the nurses here has been eye opening and a good reminder that maybe our issues at home aren't as big a deal as I sometimes think they are (although that doesn't mean they don't matter of course). Our ability to just send lots of tests out to diagnosis a patient or our ability to call specialists is almost non existent here and such a gift. No ICU at the hospital here so the staff do the best that they can. The nurses seem to be constantly busy (although I would say most nurses at home are too) but yet they don't spend much time with their patients and don't seem to be taking note of issues or things that need to be addressed. Kinda frustrating for me as a nurse that thinks healthcare is a team sport to see a rather hierarchical structure and very little nurse initiative. 

The staff here have been very kind to us. The language barrier makes care from "mzungu" (white person) challenging; very few patients speak any English. The people here are pretty sick. Lots of malaria, injuries and diarrhea issues in addition to some other interesting cases. Learning lots and so happy to be a part of a group that is so fun, smart, kind and passionate about medicine. I continue to look forward to getting to know the nurses here and getting a better understanding of their role and how the nurse functions here. 

Ilula Conference view from John Kvasnicka

Monday January 26: 

We completed our second annual Ilula Minnesota International Medical Conference last week on Thursday and Friday.  We had almost 100 people in attendance.  Each of the 28 Southern Zone hospitals was invited to send one practicing physician, one nurse and one pharmacist.  We moved the location of the conference to Iringa this year to accommodate the larger audience. We are in the process of compiling the feedback from the evolutions, but the initial informal feedback has been overwhelmingly positive, both from attendees and presenters.

The design of our conference is based on several principles.  First is the importance of lifelong learning.  One of the central themes of the trip is the importance of learning and teaching, and the conference is one important part of that theme.  A second principle is interprofessional teamwork and learning.  We include pharmacy, nursing and physicians together for the vast majority of the conference, and discuss principles of interprofessional teamwork throughout.  A third principle is respect for our different cultures and medical practices.  We come together to learn from each other and teach each other the best practices from our respective practices.  The final principle is continuous improvement.  We include workshops in the content of the course where disciplines come together and develop specific plans to initiate improvement projects when they return home based on what they have learned at the conference.

I would like to thank several people and groups who made the conference possible.  First our generous sponsors: The King Family Foundation, Global Health Ministries, Norrie Thomas and the University of Minnesota College of Pharmacy, Dale and Patty Anderson, Arlene and Dave Tourville, and anonymous donors.  I would also like to thank fellow Course Directors Drs. Mfwimi Saga and Ken Olson, Shoulder to Shoulder founders Randy Hurley and Gary Moody, CME sponsor the HealthEast Care System, and all the presenters for all their hard work and critical contributions.

We believe that fostering leaning through the conference principles is one of the important ways we can improve the health of the population in and around Ilula. 

John Kvasnicka

Dr. Theo presenting, even though this was his day to have GI distress

Linda's interactive Nutrition talk

Grateful Farewell from Conference Participants

Saying Goodbye in Ilula

Linda and I made it home to Minnesota this afternoon, and surprised to see the lack of snow here.  We had a wonderful 2 day safari with most of the group at Ruaha National Park. The lodge we stayed at was outstanding with each tent/room having its unique view of the river, with Baboons and monkeys walking along.  We heard elephants and lion noises all night, so we knew not to wander too far.   We forced Randy Hurley to sit through an appreciation breakfast in his honor.  It was sad to say goodbye to everyone at lodge, but we look forward to seeing them at a reunion event soon.   Anne, Phil, Linda and I flew from the Ruaha "airstrip" to Dar  yesterday morning.  What an adventure that was - flying in a 12 seater plane, and seeing giraffes no more than 50 yards from the airstrip as we took off.
    Now that I am home and have better internet - here is the photo of Maria (Center), our precious baby patient with her cousin and Winnie,  the wonderful head maternity nurse.  A happy endign to long a ordeal for her.  And a few photos from our time in Ruaha.
Several clinicians will remain at Ilula for two more weeks -so we look forward to seeing their posts.
Asante sana to Randy, Ken, and Mwamoody for a great experience in Ilula!

Morning game drive stop

We watch this cheetah hunt a herd of impalas, but he was unsuccessful in his attempt

Appreciation breakfast for Randy

We are smiling here but a bit nervous during takeoff

Mark and Linda

Down to business at Ilula.

We are at Ilula tonight, we being Moody, Rachel Strykowski, Kristi Hembre and me.  The big group is suffering in some out of the way place away from civilization, among wild animals and such.  Mwagusi in Ruaha National Park, I believe.  I have heard there are lions and leopards and elephants, oh my!  The group is probably pretty scared by now, wishing they could be with us.  You may have guessed.  We sent them there as punishment.

Anna, our caterer cooked us some great soup and chapattis and sliced papaya and pineapple.  She will cook for Saga’s wedding too.  About 200 guests and 50 chickens to feed us all, not to mention sides and other courses.  It’s gonna be a hot time in the old town tonight, tonight being metaphor for the 7^th of February.

I am looking forward to being on rounds tomorrow.  That's the "getting down to business" part.  What is so familiar to our Tanzanian colleagues is unfamiliar and alarming to us on so many levels. Who knows what we'll see?  Some predicable, some not.  What can we help with?  What should we simple accept  - for now?  What do our colleagues most want our help with?  We want to challenge them, not overwhelm them.  I need to personally not respond to my own sense of being overwhelmed by trying to force unwelcome change.  Patience, Dr. Babu!  

There are four Swedish nursing students here for a bit longer than we are.  By our standards they do not have supervision or guidance – sort of a sink or swim deal.  We invited them to the conference, which was a highlight for them.  They said they learned a lot, especially about HIV/AIDS and TB.  I invited them to go on rounds with us tomorrow.  Although they are tired of shadowing, I think this will be an improved experience for them.  On Tuesday, they will make a foray into Iringa and try to arrange a safari that will fit into their budget.  Although it is perhaps a choice, since they will be staying in Zanzibar for two weeks.  “TWO WEEKS!” I exclaimed, a little jealous because I found our two nights there in 2008 at least a night too short to see and do all I had hoped.

Before going to Mama Iringa’s for late lunch of pizza, all of us went to church at the Cathedral.  At different services.  Why?  I went with Trish and Roger to the 7 AM service, determined to be the most likely service to let out at the prescribed time. It was done a few minutes to 9 AM.  Next, the 9 AM service was next most likely get out on time and had the feature of the Gustavus students singing.  That was a harder choice to make.  The featured highlight of the 11 AM service was the installation of a pastor.  It lasted until 2:30.  Whew!  I was glad I missed that one. 

The four of us visited with Anna and Esther after the excellent dinner they had served us, a real rarity.  Invited often, they almost always refuse, perhaps intimidated by the big Wazungu group.   Dr. Saga stopped by to greet us and talk briefly to Anna about the wedding.  The Swedish girls came by to collect some info on safaris.    Now it is quiet and I am off to bed.

But here I am again at 4 AM, tired of tossing and turning for the last hour.  Dropped off to sleep immediately, but awoke with a million things on my mind.  And hungry too.  I can wait a couple hours to eat, although the Lindt Dark-Orange-Almond candy bar staring at me from the table in front of me is tempting.  Oh, I’ll just have a little tiny piece….  If I remember correctly, it is Anne that is the chocolate fiend (as I am).

After a little pressure from me, prompted by a price hike for our lodging, the hospital has spiffed up our places.  Most of the toilets work better than they have since I have been coming here.  Snazzy new curtains adorn the windows deodorizer cakes hung in the bathrooms, and the kitchens are all cleaned up too.  And last, but not least, the water works!  I will make a careful inspection later, but only for glaring defects.

That’s the news from Mount Selebu.  Assuming the safari group returns unscathed, I am guessing they will have tales to tell, with tails.

- Ken

Anne - January 20, 2015

Ed. Note:  We had trouble posting for a variety of reasons, but failed not for lack of trying!  All fixed now and nearly up to date. kpo

This blog entry is a little late – pole! (sorry!)

We have had an exciting day on the medical end at the hospital.  The
Outpatient Department has been filled with interesting cases from
infants to the elderly.  Congenital urogenital malformation, cataracts
causing near complete blindness (that will be fixed) and an array of
tropical infectious skin diseases that we try to sort out as a group.
A dermatology atlas of skin conditions common to this region, with
LOTS of pictures, would be great. Today we had two workmen come in
emergently with carbon monoxide poisoning from running a gas-powered
engine in the bottom of a water-holding tank, where they passed out.
Luckily a couple of people were there and pulled them out but they are
still in the throes of a several hour resuscitation.  They should
recover completely.

We have a super team here.  There are at least two excellent
clinicians from the hospital patiently working with us.  Our American
team sits down every afternoon to generate differential diagnoses on
the mystery cases, which is a stimulating exercise.  We try to rank
most likely to least likely but admit to significant data gaps that
make it difficult to lock in on a diagnosis most of the time.
Sometimes we indulge in thinking about  lab or imaging studies we
would order at home, but not too much.

Our medical team includes 5 generalists (3 family medicine, 1
emergency medicine, 1 family medicine) and 2 heme-onc specialists
(although Randy is an honorary generalist after tropical medicine
training and many years coming to Ilula).  I hope the 2 medical
students (1 headed for internal medicine, 1 for gyn) realize clinic
won’t be quite so exciting when they get home.  My rough calculation
(based on ~9 days of inpatient rounds) is that ~50% of patients would
be in the ICU in MN.  I think it’s Medical Camp for Adults.  It’s hard
to imagine a more fun way to learn.

Has anyone written about the food on the blog yet??  Today’s breakfast
was special – samosas!  Also fried bread with a trace of egg!
Africafe!  Nutella! Peanut butter! Nutella! Nutella! Africafe!  Usual
breakfast is fried bread (in various shapes), hard-boiled egg.  Lunch
and dinner are quite similar to each other, and quite similar day to
day (a polite understatement). Common elements: rice, (pinto?) beans,
potatoes (mostly fried), ugali (sometimes), meat (beef/pork/goat),
shredded cabbage (cooked), and spinach (I think).  Sweet pineapple and
mango are intermittent treats.

The countryside is beautiful for walks, especially the farther you get
from Ilula.  The farmers and kids we meet on the dirt paths are all
friendly and tolerant of our laughable Swahili and Hehe.  We feel very
comfortable and welcome.

There are at least 20 times each day I see something I desperately
want to show to my colleagues at home in the Primary Care Center, and
perhaps just as many times a day I miss showing my 3 beautiful
children, Alice, Pavel and Claire, something extraordinary.  We’ll be
home before you know it, full of pictures.

Love to all, Anne

Phil McGlave - January 19, 2015

Ed. Note: Apologies to readers and authors.  We have had some difficulty getting into the blog - all fixed now! kpo


Hard to believe that we've already been in Ilula for 10 days.  Here's how the day went.

We didn't have running water yesterday, but someone fixed the pump overnight.  We awoke to the very pleasant surprise of water in the pipes!  It's Sunday, so we looked forward to church services. However we did have inpatient rounds to complete first. 

We were gratified to see that a young man with osteomyelitis of the leg and a frozen hip seemed to be responding to IV antibiotics.  Our concern is that he'll need months of physical therapy to get back the strength and mobility in those wasted legs.

We also saw a woman with an acute abdomen and probable molar pregnancy.  She's a little better on antibiotics, but hardly out of the woods.  We could fill pages and pages with tough cases we've seen.  We give a lot of credit to the doctors, nurses and health care workers who work with these patients throughout the year.

Church was wonderful.  This coming from someone who's not exactly a regular attendee,  We've been treated to music throughout the services, so we thought It was our turn.  We sang "This Little Light of Mine", then followed up with "The Hokey Pokey" with body parts sung in Swahili...we brought down the house when we put our "taco" in and "shook it all about".  you may want to look that one up!

Mark, Linda, Theo, Anne and I took a long hike through the fields which stretch to the north of the hospital grounds. Everyone we met was friendly and, I suspect a little curious about the white folks wandering around this rural area. Our language skills didn't hel p much with direct communication, but invariably provoked lots of laughs.  Sometimes I wonder what we're really saying!

 After our walk we were treated to a comprehensive review of Hiv treatment as practiced in Ilula.  This was prepared and presented by Astrid and Sarah with, I suspect, a little help from Jill.

The day was far from over.  We spent the next few hours meeting with Ilula Hospital leadership.  Randy Hurley provided a brief history of his 13 year interaction with Dr. Saga and his colleagues.  We left with the sense that this has been a meaningful and durable partnership.

Anna and her staff prepared a delicious chicken dinner.  Some of us were just a little sad because  only yesterday we had ridden back from Iringa with there of the chickens, but they sure tasted good!

Whew!!!

Phil McGlave