Last Day at Muhimbili!

Today is a national holiday in Tanzania (Labor Day). Therefore, much like we do at Doernbecher, we rounded with a smaller crew today and left the hospital a little early. I said “goodbye” to all the Watotos (children) as well as the moms and dads as best as I could. The interns were nice enough to translate for me a couple of times.

It has really been an interesting couple of weeks. I’ve seen some really good medicine during that time. It’s been challenging trying to make clinical decisions without ready access to labs, scans, or even other pediatric specialists. The team has cared for these patients with minimal lab tests and without a working CT scanner. The pediatric oncology Master’s students do their own ultrasound-guided biopsies, peripheral blood and marrow smears, and CSF cytospins.

It’s also been frustrating at times. There are children who had already been admitted to the hospital when I started last Monday and are still there without a diagnosis or treatment plan. When children have fevers, everything is empiric because the ability to get cultures is limited. And I often think these children may have all kinds of tropical infections that I would never recognize. We’ve had a few children with HIV and some type of malignancy. It’s disheartening that the children even have HIV.

But amazingly, despite the limited resources, I didn’t see a child die of infection or treatment-related toxicity in the two weeks I have been here. We sent a couple of kids with acute myeloid leukemia home without treatment as that intensity of treatment needed to cure AML is no possible here. Another child with AML who was only receiving supportive care died in the hospital.   Otherwise, all of the children with cancer are hanging in there (despite a few having tumors for which we don’t yet have diagnoses).

One day, I was casually speaking with team about the numbers and types of cancers that they see. We determined that at Mumhibili, they may only see about one-fifth to one-tenth of the pediatric cancer cases that likely occur in Tanzania. Muhimbili has the only real pediatric cancer treatment facility in the country. So, there are likely many more cases of childhood cancer that never get diagnosed.   It makes complete sense that Muhimbili sees a disproportionately high number of Wilms tumor cases, as those are the patients who are often OK even if it takes months to get to a facility where they can be treated.   The good news is that those are the patients who can often be successfully cured of their cancer. And from what I observed, they do a good job of treating those patients.   In the long run, much more infrastructure will be needed to be able to treat some of the more difficult types of cancers.

Like Sue, I’m leaving here with a new appreciation for all of the assets we have at Doernbecher that help us care for patients. I’m not sure how much benefit I provided (hopefully it was something—at least some teaching), but I can say that I certainly learned a lot. I come away from this experience with a little more confidence in my ability to assess patients and use clinical judgement rather than relying solely on tests. I expect this will make me a better pediatric oncologist when I get home.

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Following in Shelton’s and Erica’s footsteps

I realized today that all I’m doing here is basically picking up where Shelton and Erica left off. I’m not sure if I can live up to their legacy, but I’m trying.   There are the soccer games with Hilda’s son Dickson, the safari with Sanjay including the exact same itinerary, and the love for Africafe instant coffee, which was a wonderful surprise on my first morning here.   The coffee is amazingly good! And it’s instant! I went to the supermarket today and bought a couple of tins for myself as well as one each for Erica and Shelton.   A tin of that coffee has been at the apartment, so I’ve been drinking it since the first day I arrived. When I read Erica’s blog about the amazing coffee she had on the way to Mikumi National Park, I told Sanjay that we had to stop there. I thought if it’s better than Africafe, it must truly be amazing. I was expected some fancy coffee shop with an espresso machine and everything.  We stopped at some roadside restaurant, and when I ordered coffee, guess what they brought me!—a tin of Africafe and hot water. What’s up with that? Erica, did you not have Africafe the entire first week you were here? Imran, the resident, told me that Africafe is the “McDonald’s” of coffee here and that there are better brands. I’m still looking for the ones he suggested.

Something else that I share with Shelton is a total insentivity when greeting Muslim women. Imran rotated to the general wards this week, and I met our new resident Khadijah. And of course, despite reading Shelton’s blog, I didn’t learn anything, and I tried to shake her hand when I met her. You’re not supposed to do that!  I guess I can be a dumb American sometimes too! Like Imran before her, Khadijah is excellent! I’ve been very impressed with the knowledge base, work ethic, and general personability of the 2 residents with whom I’ve worked here. Khadijah presented the article for pediatric journal club today. It was a very interesting study done in Kenyan school children that showed the association between hookworm infections and pulmonary tuberculosis.   It was an excellent presentation. Apparently, kids with hookworm infections have 4-fold increased relative risk of having pulmonary tuberculosis. However, the most important things that I learned are 1) Don’t walk around barefoot in Africa, 2) There are an estimated 700 million people worldwide infected with hookworms (700 million!—that’s more than 1 out of 10 people), 3) pulmonary TB is 10 times more common than cancer in Tanzania.

I have updates on a couple of kids mentioned in a previous blog by Sue. Sweet little Joycee, with the tracheostomy and large rhabdomyosarcoma involving the entire left side of her face is doing well. Her tumor is shrinking with chemotherapy and she is able to eat pretty normally now, and she seems comfortable. I’ve had a couple of discussions with Shakilu about the long-term effects of trying to cure her. There is really no way to resect this tumor without it being completely disfiguring. And while local control with radiation can be achieved, it will definitely leave her with long-term residual effects, including lack of bone growth on that side of her face. No decisions have been made yet.

Henri, the boy with ALL and huge smile has moved to Tumaini (the unit for less sick kids). That’s bad for me because we working on a special complex 30-second handshake—you know, like when the starters get announced before basketball games. He’s still comes over to visit sometimes, so we’ll get it down before I leave. Hopefully, we can get some video of it too! (attached is photo of Henri dancing with 2 other children and the “clowns”)IMG_1227

Ugali and Safari!

IMG_1285IMG_1278IMG_1317After reading Shelton’s blog post, in which he stated that the safari to Mikumi National Park was one of the top 3 experiences of his life, I decided that I had to try it.  I booked the exact same safari that Shelton and Erica did 2 weeks ago–same company, same itinerary, same guide.  I have to say thanks to my guide, Sanjay, from whom I learned a lot about Tanzania along the way.  It was really nice and interesting to get out of the city and see the countryside.  I got a much better feel for the country and the people just from the drive out to Mikumi.  I also found out from Sanjay why there are so many Indians in Tanzania.  His grandparents came here from India when the British still ruled both countries.  People from India came to Tanzania to help build railroads.  In the India, trains are such an important part of the country.  But, unfortunately in Tanzania, while the Indians stayed, the railroads are mostly non-functional now.  I guess that may explain why there were so many trucks on the highway!  And since I doubt there are emissions standards, that sadly has something to do with why there is little snow left on Mt. Kilimanjaro! When we go into the park, we stopped the one restaurant there for lunch.  I’ve wanted to try one of the national staples of Tanzania called ugali.  I’ve heard it described as a tasteless, dough-like mass, but since it’s Tanzanian, I had to try it.  So, supposedly it’s best to eat ugali with some sort of curry.  You did the ugali in the curry (kind of like eating soup out of bread bowl).  I had the ugali with beef curry and really enjoyed it.  My guide told me that it’s actually made of corn meal, which makes it more like grits than bread dough.  Indian curry with southern grits–no wonder it appealed to me! I uploaded a photo of the ugali lunch and the safari.  Back to work tomorrow!

Reflections on My First Week

It’s hard to believe that I’ve already been here for a week. The days seem to go by really fast! I believe every day I’ve seen something that I had never seen before. But now that is starting to seem routine. I’m no longer surprised by the size of tumors that kids have.  Nor am I shocked by the malnourishment I sometimes see.

One challenge I’ve found is that the Master’s students, while very good doctors, are just learning how to treat some of these cancers. Therefore, they (probably appropriately) tend to follow protocols strictly. But since resources are so limited, sometimes one has to think outside of the box. For example, I finally convinced the doctors to give IT cytarabine in place of IT methotrexate for some of their ALL patients until they are able to get more methotrexate (which apparently may not be till late May). They had not previously realized that it was OK to substitute cytarabine (which is better than nothing).

In another example, we have a new 7yo girl with a pelvic mass. On the scan, it looks like the mass is arising from the bladder or uterus. Both ureters are obstructed and there’s bilateral hydronephrosis with renal insufficiency. I convinced them to begin treatment for rhabdomyosarcoma and not wait for biopsy results. If we wait for pathology, we’ll delay treatment for a week and who knows what will happen to her kidneys by then. Rhabdomyosarcoma is by far the most likely diagnosis for a tumor in this location for a patient this age. And if it’s something else, we probably can’t cure it anyway, so why not treat for the most likely thing. Also, because of her renal impairment, we can’t give Ifosfamide, which is standard per the European protocols they use. We looked at some dose modifications in COG protocols and decided to start with vincristine and actinomycin-D alone, and then add in cyclophosphamide at reduced doses when (and if) her renal function improves.   While the Master’s students are good doctors and are learning rapidly, they simply don’t have the experience to be break from protocol and to feel comfortable making up treatment plans. But in this place and with these resources, it’s often going to be necessary to think outside the box. However, it takes knowledge and experience to be able to do that.

Tumor Board!

Today was my third day at Muhimbili. After another busy and somewhat chaotic morning of rounding, we had tumor board today with the surgeons. A lot of things are done differently here, and there are many challenges, but I was impressed by tumor board. Both the oncology team and the surgeons had several patients to present for discussion. Not only did the various trainees and providers present the cases and show the x-rays/scans, but in some cases, they actually brought the patients! After the case was presented, patients were examined in the conference room! And after all of the cases were presented, both teams walked to the bedside of one little girl who was too ill to leave her bed, and we all examined her together. A lunch of some goat meat dish and rice was served after tumor board so we were all able to sit and chat with the surgeons while we ate.

 

Despite the pretty drastic lack of resources and lack of training, it’s incredible what these doctors are trying to do for these patients. There are certainly some chronic challenges:

  • results of labs that are drawn one day are back the following day.
  • Pathology (including marrows) takes a minimum of one week, and many things are sent to Ireland.
  • None of the patients have central lines
  • The availability of blood products is limited. A plan in the progess note stating “trace blood” literally means track down some packed red blood cells or platelets to secure for your severely anemic or thrombocytopenic.   So imagine this—we have a patient with ALL in induction. On rounds, we hear that the platelet count is 3k. Of course, that’s yesterdays count since it takes a day to get a CBC result. Then there is the difficulty of finding platelets for this patient, who has been sitting with platelet count of 3 or less for over a day!
  • There is no neupogen
  • There really are no blood cultures, so all antibiotics are empiric.

 

On top of the chronic lack of resources, we’ve had some acute challenges the past few days:

  • The one CT scanner for the hospital is broken
  • The flow cytometry machine is down
  • They ran out of morphine
  • There is currently no IT chemotherapy.

 

Despite all of that, we are still finding ways (sometimes very creative ways) of treating patients—both their cancers and their symptoms. I can’t say these kids will all be cured, and I can’t say that they don’t suffer more than kids with similar diseases in the US. But I do see kids who are more comfortable from day to day and there many who have a pretty good change of being cured. It’s a start!

Now I’m excited to see what Hilda made for dinner!

Day 2 (Day 1 at Muhimbili)

First, a little more information on Day 1:   I was able to, somewhat pitifully, extend the tradition established by Erica and Shelton by playing a soccer match with Hilda’s son, Dick.   However, unlike my predecessors who kept adding children to their matches, I had the opportunity to play an intense one-on-one match with Dick. I’m proud to say that I 1) survived the match and 2) only lost to him by one goal!

After arriving at Muhimbili by taxi this morning, Sue showed me around the Upendo and Tumaini units.   Walking into Upendo, we were immediately greeted by little 2yo Helen with acute leukemia, who within about 5 seconds stole my heart (I’m sure she does that to everyone!).

We started the morning with a teaching conference, which was Part 2 of Sue’s palliative care talk. I was pleased to see that this was much more of a discussion than a lecture. Palliative care is difficult topic anywhere, but due to some cultural differences, the discussion was even more interesting. Then, it was on to rounds. I was somewhat mentally prepared for what I saw on rounds—children extremely large tumors involving the abdomen, jaw, eyes, buttocks. I knew I would see extent of cancer burden that we don’t typically see in the US. But what I wasn’t completely prepared for and what really struck me is how many patients like this there actually were. We rounded on about 30 children with cancer on Upendo, many of whom had disease to an extent that we would not typically see in the US. In my career, I’ve seen tumors that have eroded through skin or become very large and ugly, but I’ve never seen 10 or 15 of them on the same day!   But of course, the kids here are tough as nails, so somehow, it didn’t seem to be as bad as it sounds. And the for the resources available, I think the team does a very good job of caring for these patients. I’m exciting to be part of this for the next 2 weeks. I’m sure that I’m going to learn a lot!

Kwa heri (“Goodbye”) Shelton and Erica; Mambo (“Hello”) Suman

I’m here! In Tanzania.  I arrived last night without any trouble at all.  The flights were on time, getting my visa at the airport was a breeze, and Tilly, the taxi driver sent to get me, was at the airport waiting with a sign.  I’m sorry that I missed Erica and Shelton.  We were actually at the airport at the same time–they were likely checking in as I was going through customs and immigration.  As soon as I walked out of the airport, the feel of the air and the smell (tropical air mixed with something burning and sweat) immediately brought back memories of India. As soon as I got to the apartment, Hilda (our housekeeper/cook/superwoman) was here to greet me.  The apartment is much nicer than I expected.  It’s actually really comfortable here.   And best of all, my first day in Tanzania was spent on the beach!  Since my first day here is a Sunday, we didn’t go into the hospital.  Rather, we spent the day on the beach at Mbudya island, eating grilled fish on the beach and swimming in the clear blue ocean.  To summarize, my introduction to Tanzania has been amazing!