Being thankful

Hi everyone!

Another new adventure happened yesterday.  Trish (my Irish doctor friend who started and grew this whole program) asked me to meet with Dr. Kisenge, who I guess is the Head of the Eductional Programs at Muhimbili University while I was here to discuss a few things.  So the ward administrator, Lillian, had been trying to arrange a meeting for about a week, but Dr. Kisenge had been busy because I believe there are exams or other coordination happening right now, so yesterday morning when we got to the hospital Lillian told me my meeting was in an hour.  Well, didn’t quite know what to expect but I think it all went well–at least Lillian said so, she walked me over and sat in the meeting so she could walk me back.  We discussed the current semester plan for the Master’s program, the goals for the students, some issues that one of the students has been having and how we can help with those, and then we discussed overall plans and commitment with regard to the next class of Master’s students in Pediatric Oncology.  I think there is commitment but like all good academic programs it comes down to guaranteeing funding.  Really, everyone has a goal of running 3-4 cycles of Master’s classes which will need visiting international lecturers to provide expertise and then after that enough local folks would be trained to carry the program forward sustainably.  It’s just getting there.  So everyone is working on that.

We have continued to work through topics that the doctors have requested more teaching/review of since their formal curriculum has finished.  Thus far, we’ve covered chemotherapy mechanisms, side effects and late effects (thank goodness that is my lecture for the fellow’s basic lecture series, I could just edit), Shelton has covered oncology emergencies and immunophenotyping for leukemias, today we did some cases with regard to fluids and electrolye management and tomorrow we take on palliative care (thank you Kathy Perko for some slides to get me inspired).  I’m interested to see how palliative care will go as culturally I think palliative care may be difficult for many people here.  So everyone wish us some good thoughts, cultural sensitivity and clarity as we venture into that topic.

Poor Suman, who comes next, I totally pulled a fast one and passed brain tumors on to him but in fairness I also gave him sarcomas which are in his wheelhouse!  Hopefully Kellie and Becca have provided him with some good outlines.

As you can see, this teaching thing takes a village, so thanks to everyone who has answered some sort of red exclamation point email that I’ve sent over the past week and a half.  Which brings me to my next topic for the night…..

Things I’m thankful for that we take for granted every day.

– Our wonderful team at Doernbecher/OHSU.  The team here is certainly becoming more cohesive but they lack a team of specially trained doctors and nurses and social workers, and physical therapists and nutrition people and consultants–and a PICU and pathology and radiology etc.  Just being able to walk down the hall and find a colleague who can provide insight or an ear to bounce an idea off of.

– A working flow cytometry machine and our wonderful hemepath fellows, a special shout out to Phil, who answer the call within hours of getting a sample.  The flow machine is still awaiting a technician from Nairobi so we have several children who are just sitting awaiting diagnosis.  Some who are not at all comfortable.  The ones who we feel mostly sure have ALL have started chemo.  The ones who we think have AML have not and are miserable.  Then there are a couple who we just have no idea what they have but need to rule out leukemia.  So we wait.

– A working CT scanner and the ability to get scans the same day (let alone within minutes to hours).  We have been getting exemptions done but the scanner broke.  Also, here’s the special shout out to to the radiologists again, because we take for granted the quickness with which we get reads.  Because the machine broke there seems to be an issue getting some reads.  We have one little very happy boy whom we are awaiting a CT read on to make sure he doesn’t have a brain tumor.  We are pretty sure he doesn’t and that he just had congenital rubella but we need to know so we can transfer him somewhere else.  But he is waiting almost a week now.

– Labs that result out relatively quickly, certainly thankful for the CBC machine in the clinic that spits out our CBCs on demand.  We get labs mostly back the next day here.  But sometimes the system has been down and that hasn’t worked well.  This one is a double edged sword, because the speed with which we get results really leads to our ordering labs frequently and we really don’t really need that.  Shelton has now seen how to manage tumor lysis with daily to not even daily labs.  We worked through cases today and used clinical symptoms to assess electrolytes, for example, which they do every day.  But I’m still thankful we can get labs quickly when we need them.

– The blood bank and a ready supply of blood products.  Really, the major part of the day for the interns is tracing blood.  Which means several times a day they go to the blood bank asking if there are blood and platelets available for any of the kids.  We have one little boy who we are pretty sure has new diagnosis ALL, who presented with symptoms of heart failure due to anemia who has gotten one blood transfusion but has been really in need of another for days now but we haven’t had blood.  Today we finally got blood and literally all did a cheer.  Then Erica doggedly followed nurses around until she got someone to hang it.  So we are feeling hopeful that he and this heart will feel better tomorrow.

– Which of course then makes me thankful for our blood donors–all you blood donors out there, you really cannot know how much you do for the people you donate for.

– Pharmacy, really the fact that we have pharmacists and they check and double check us.  There is no pharmacy oversight here.  We did have an incident here this week which the child has recovered from which I’m sure would never have happened if the unit had a pharmacist.  Everyone is doing the best they can but we all know that a pharmacist has special expertise that is vital to a pediatric oncology program running safely.  And I’m really sure that the nurses here would appreciate a pharmacist to mix the chemo rather than themselves.

– The HUCs.  The doctors and nurses spend a lot of time chasing things around here because that is the system but Shelton and I looked at each other this week and said, “They need a Misty.”  And again, I’m always so amazed by how far the program has come each time I’m here and just continue to wish them more efficiency so they have time to take care of their very high census.

Well, I’m sure I’m thankful for many more things but those just came to mind today and I thought I’d share.  We really are blessed to be able to practice where we do.

On that note, Happy Thursday!

Sue

Journal Club-Tanzanian style

Hi all,

Today was another interesting day at Muhimbili.  Shelton and Erica had a the opportunity to experience Journal Club.  Our resident, Imran, was presenting for journal club this week and his paper was a recent New England Journal paper about peanut allergy in infants.

Presentations such as Journal Club or Grand Rounds are an experience here.  Everywhere you go people have sort of “assigned seats,” we all just tend to sit in the same place when we attend certain events.  Well, at pediatric presentations it is official.  The room is organized such that the medical students sit in the back of the room, then the interns, then the residents, then the registrars and then there is a row of special seats in the front for the attendings/specialists.  Then when the presenation finishes the lead asks by section if there are any questions.  I haven’t been to a ton of these over time but it seems there are never questions from the medical students or the interns and rarely by the residents.  Occasional questions that are good from the registrars.  Then come the specialists.  They always make comments or ask questions and the learning style is quite diffferent than we are used to.  I’m not sure that the questions are so much geared at helping the group learn as they are at making the presenter feel moderately uncomfortable.  Per Imran, several interns have already cried this year during presentations.  Very different system.

So, it occurred to me today after Journal Club that our style of teaching involves a lot of asking questions to promote discussion, such as “What is your differential diagnosis?”  “What are you thinking when you are deciding to make that plan?”  “What do you think is going on with this patient?”  And it occurred to me that perhaps that might be intimidating to the docs here because of the system they train in.  That they might think I’m trying to trip them up.  So we discussed it and I clarified that when I ask questions I’m not specifically looking to point out something they are doing wrong, just to promote group learning.  They told me they had figured that out about us over the years but the resident and past-resident did say they wished their system of learning was more like ours.

After Journal Club, this woman who I have never met before announced that the medical students should come meet with her and then pointed at the 3 of us and said we were to come too.  I told her that we were not medical students but I was told we were to come at 10am to her office.  I was a bit taken back by that summons not knowing who she was or what the purpose of the meeting was in the middle of rounds.  Our Tanzanian Master’s Students apologized to us for her stating that was her personality and that she was the Head of Pediatrics.  Well, turns our she just wanted to know who we were and that all went fine after I clarified that I and our group had been coming for many years.  She is new from previous years so this was never a requirment in the past.  We’ll remember it for the future.

Aside from that I helped with a couple of difficult bone marrows today, we rounded, Shelton took a field trip with Shakilu to radiology to get a couple of CT reads that we have been waiting on since last week, and we continue to hope that tomorrow the flow machine might be fixed so we can figure out what some of these leukemia patients have.  One repair person came from Nairobi last week and couldn’t fix it and another one was coming today.  So cross your fingers–only if you are in the US, because here it apparently means something rude.

That’s about all for me today.  Hope everyone is well at home!

Sue

Africans, Mikumi Mammals, and Morphine

So the car broke down on the way to the African Safari.  It could’ve been bad, but it wasn’t, and by that point I was so in awe of what I’d seen thus far that I felt like any situation would be a good one.  From Dar Es Salaam to the Mikumi National Park, we passed through many “towns.”  Back home these would be considered either gigantic expanses of homelessness or places where some sort of disaster relief from the government would be expected.  These are the “towns” where our patients arrive from and it really put our families in perspective to see these places.  All the hardship and chaos of these places aside, Africans by and large are very positively social people.  EVERYONE is outside all of the time, rain or shine.  I can’t even really tell what everyone is doing but they’re all out there and they’re all socializing.  Truth be told, each one of these towns looks like a big, disheveled party (kind of like some hot summertime music festivals I’ve been to) and everyone’s having a good time despite what it looks like from my perspective.  On the way through these parties, I bought some fresh cashews, had a coffee and some kind of meat pastry that was so good I got another one, and bought some hand-carved drink coasters made from ebony wood.  The Safari was everything Erica had to say about it and I agree that it was up there in the top 3 experiences I’ve ever had.  My favorite part, other than the hippoes, was when we became surrounded by a herd of Impala.  Hundreds of Impala and we turned the car off and just sat there while they hovered around us and then all sort of started to move at once.  Once they all started running it sounded like rain coming down.  Very peaceful.  Actually when these animals move in herds they’re kind of hard to see. They look like grass waving on a prairie or something like that.

Back to work today…more jaw-dropping cases and experiences.  I taught the team why people simultaneously lose fecal continence and have urinary retention with compressive spinal cord lesions….Some faint puff of smoke in my mind from med school years that came out very unexpectedly.  Fortunately some kids that were really sick last week looked a lot better when I walked in today…Smaller rhabdos and such.  Good to know they’ll need one less scoop from the common-use morphine jug!  Seriously though, there’s a common-use morphine jug that just sits on the desk for parents to come fill up when they need to.  Its the only pain med available here.

Til next time!

S

Watoto’s (children) and AMAZING safari!!

The last few days have been so full of new things I don’t even know where to start because even yesterday seems like so long ago! Thursday at the hospital I gave the nurses a quick overview of ALL treatment. Their protocols or “schema’s” are not very clear to them so they have a hard time answering parents when they ask what is going to happen yet. I realized fairly quickly when talking about this that they really weren’t sure what made up an FBC (full blood picture instead of CBC), why we worry so much about neutropenia, what the number values of hgb or plts mean to us, the timing of when blood counts are low. So my plan for the next day was to review all that. I also did spend some time discussing why their role is so important because I really don’t feel like they feel validated. We talked about how they are the people that are with the patient’s and the parents the most throughout the day and know them best and also that they are the one’s that carry out all the doctor’s orders and wouldn’t get done without them. I think this made them feel good but I’m not sure (I sometimes am not sure how much they understand me)- even one of the night nurses stayed to listen which I thought was awesome. I spent the morning with the nurse that rounded, a different one though. She was very interested in learning how to do more assessments so after the doc’s examined a patient that had a significant finding we would examine him/her after. Me and Shelton had agreed the night before that after rounds we would briefly talk about the sickest kiddos and me and her would go back and check on them later which I could tell she really enjoyed. We caught a few PRBC mistakes which I think made her feel a bit more confident that I just went and talked to Sue and the other doc’s because it seems like they don’t always feel comfortable confronting doc’s. It was a good and productive day and me and my “raffiki”(friend- I love that that’s right out of the Lion King) Henry played with his paper airplanes and threw them up into the fan a lot which he loved but we’ll have to make new ones soon.

Thursday afternoon I played futbol with the boys. Dick picked me to be on his team against Shelton and two other boys (they also played the other day with him). I told Dick I wasn’t very good so he might want to make it 3 on our team but he kept saying “no no, you and me.” And I for sure was not very good but I did manage to make one goal on Shelton 🙂 There was an older, taller player that eventually joined me and Dick that was really good. The two of them were nice enough to keep including and passing to me and we actually did win!!

On Friday I spent some time in the chemo room with the chemo nurse…it’s a bit surreal in there..and very hot. For the kids in maintenance they bring in a water bottle (like a regular 16 oz one) and they get their 5 days of IV dex mixed in there that they then take by mouth. Their BSA is calculated purely based on their weight and a chart. I was told that the doses are rarely double checked by the nurse but they are supposed to so we went through them all at least while I was there. I played planes with Henry and he brought some of his friends Baraka and Ida…so cute!!! That night we went out for dinner with Dee and one of her friends and I had literally the BEST calamari ever!!

And then early yesterday morning me and Shelton left for safari!!! I feel like words can’t really describe it but I’m going to try my best. It was literally the most AMAZING thing I’ve done in my life so far! It was about a 5 hour drive out there which I thought was going to take forever but we had an awesome guide, Sanjay who told us so much about the park we were going to and Tanzania itself. He was so much fun! We stopped at a place to get coffee which was also….AMAZING coffee. About 30 minutes out from the park I saw a burst of steam coming from the hood. I couldn’t tell if Sanjay looked nervous or not when he got out and looked under the hood. I know it wasn’t a situation to be laughing at but I couldn’t help it…who does that happen to? I don’t think Shelton was worried either that I could tell. A truck with two guys stopped when Sanjay flagged- some seem to think it was just because they saw me but I don’t believe that though they did ask for pictures with me afterwards. Shelton tried to get in one of them and the guy just smiled this big grin and waved him to the side. I actually forget exactly what the problem was, the radiator overheated maybe?? Either way, it got fixed and we were back on the road within 30 minutes or so. Even before we entered the park I saw a “deer looking thing” that I learned was an impala (really working on my animals here), tons of baboons, and some elephants!! When we got to the park it was going to be time for lunch. There were tons of monkey’s just walking around; a blue monkey jumped into our jeep and stole the pear we had bought on the way out! We had chicken and beef curry for lunch which again was AMAZING! And something about having a beer while watching monkeys and very large elephant coming your way also makes that AMAZING! So yes this elephant just kept coming closer to us right up to the restaurant until it seemed like the staff was getting alarmed. It wasn’t hard to wave him off but how COOL is that?? We started the drive and saw so many elephants (several baby elephants that were adorable!- literally they look just like Dumbo and trip over their ears when they walk) and impalas right away. We saw a lot of giraffe which I have decided have become my new favorite. They would crack me up every time because they stand so tall and still as statues and just stare at you with this inquisitive facial expression; like seriously wondering what we are doing there. It’s just hilarious (at least to me) but I can’t explain it. The zebras are so pretty and have their quirks about them too; they typically stand facing in opposite directions with their butts next to each other. Sanjay said the idea is that they are both guarding a different side for predators but it looks like they are in an argument and just don’t want to look at each other. We did actually get to see one young male lion!!! I got a pretty good video that I’ll try to post another day but I was so excited to get to see one up close! He had absolutely no interest in us; he just looked up from his nap, looked at us, and went right back to sleep. The hippo pool was awesome too. I had never known how shy they were and they just poke their heads in and out of the water. I got some great pictures of Shelton’s reaction to them as apparently those are his favorite. We got a lesson on elephant poop from Sanjay- they only digest 60% of their food and poop out several pounds 8 times a day! EEEK! According to him if you are stuck out in a safari and there is no water you should eat elephant poop because it’s full of water and undigested grass : /  It was such an AMAZING experience though and we got to do it all again this morning though it was different because it had rained a LOT last night and…I finally got my thunderstorm last night which was also AMAZING! It went from clear sky to heat lightning which I hadn’t seen since Texas, then to full on downpour and thunder. So happy 🙂

This morning we were hoping to see two female lions with two cubs but no luck, it was overall though such an awesome experience. Definitely something I would love to do again. We will post pictures another day but they don’t even do it justice; neither do words. I should say though, Melinda, we are no competition to your photography skills. I accidentally put Sue’s camera on video at one point and didn’t notice for quite a while : / I haven’t looked through them yet but I’m pretty sure there are a lot of videos that don’t make sense.

Well it’s back to work tomorrow with the watoto’s so I’m off to bed. Good night!

Pole sana Erica and the Paper Airplane Obsession Continues

Hi all

Well, one of Erica’s big goals on this trip was to see a big thunder/lightning storm and she is missing it!  I just got back from Sunday rounds where it was so hot it was like a sauna and sat down at home for a couple of minutes and the skies literally opened up and buckets of water started falling.  Then the thunder and lightning came.  That went on for about 10 minutes and now it’s just raining hard again but not buckets.

Pretty soon the sun will probably come out again and all of this rain will make a nice outdoor sauna of drenching heat!  This morning a little drizzle of rain created a sauna so I can only imagine what will happen after this!  Maybe the rain will just continue.

Maybe it’s raining on the safari too, but I hope not, the animals don’t like to come out in the rain.

Anyway, I went in to round with Dr. Laiti this morning and do some teaching if the occasion arose.  I got totally ripped off by the bajaji driver but it was Sunday so there weren’t choices and I didn’t really want to walk through the hot sun.  Things were pretty calm.

We have just a ton of kids with ALL on the ward and then a bunch of kids with suspected leukemia who are in a holding pattern.  The local machine for flow cytometry is broken or not working so we can’t get any preliminary report while waiting on the Ireland back-up so we are just waiting.  We are also waiting on exemptions so hematology can write official reports on peripheral smears but we don’t base treatment off of those.  All of the kids on oncology get cost waived for labs, imaging and other testing but rather than just putting one global exemption on the chart, every order needs to go for approval and no one approves on the weekend.  We are also waiting on CT reads for a few kids and although they print out a couple of cuts for us they usually aren’t all the cuts I would need to make any real impression so we are waiting for Monday for those as well.

The paper airplane squadron commanded by Henry continues to grow.  His airplanes were soggy again so he bummed paper off of me to make a new one and then more for “rafiki mbili” (his 2 friends).  After rounds we did an improptu Swahili/English lesson with all of the paintings on the ward.  I did pretty well except I’m not at all sure what bird actually is.  Some birds were denga, some were tenga and some were mdodo.  It seems the denga/tenga word means flying bird but I’m not totally sure, we were doing a lot of miming and signing.  The parents were laughing at me so I’m not sure what he had me saying.

I was completely unsuccessful at getting pictures off of my phone and onto the computer with the cable so hope to have some pics for you once Shelton and Erica are back from safari and can help me.

The rain is stopping, the sky is clearing again, let the sauna begin!

Sue

Oh, ps. I think we may have a guest blogger this week.  I think Dee may write in and give you her impression of all of  us Portland doctors.  All of you fellows out there, Dee says Hi!

Warming up to the mzungus

Hi again!

Shelton and Erica left this morning for a safari and will be back tomorrow so I’ll try to keep everyone in the loop until they return and can update you on their adventures the last couple of days.

It’s always an interesting day when the kids really decide to start warming up to us.  Initially they start out sitting on their beds very polite with us and then there comes a point when they are running at us in the morning and following us around in the afternoon–and then they get a hold of our Iphones and the relationship is cemented!

There is one boy, Henri, who has been the fastest to become our friend.  He made a paper airplane on Thursday (I’m not sure where) and he and Erica were flying it around–I’m told at the fans to see if they could really make it fly.  He loved that paper airplane!  And you can imagine what happens to paper airplanes at the hot, damp equator–on Friday morning he came running up to us with his very limp paper airplane showing me how floppy the wings were and demonstrating that when you tried to fly it, it just fell on the floor.  So he wanted more paper–never fear a new airplane was flying later in the day!

Henri also fancies himself an amateur photographer and videographer.  Maybe because he has the biggest smile I think I’ve ever seen.  He had Erica’s phone on Thursday and wanted to take videos but he takes videos that are very short like pictures–but he doesn’t want to take pictures.  Friday he had my phone and I now have a series of Henri selfie videos on my phone.  He is actually very good with an Iphone, he knows how to go between apps and can zoom in and zoom out and all.  We were talking for a couple of minutes not paying attention to them and suddenly heard loud music coming from my phone–which I couldn’t figure out until we realized that they had found the Remission 2 game that I have on my phone from when we were trying the game out.  So then there was a whole herd of little boys around the phone.  Well, I guess we are taking a multi-faceted approach to curing cancer and I guess all little boys like video games.

There is a super cute little girl named, Helen, who is about 3 years old who I think has a crush on Shelton and that may go both ways.  She likes to find him and follow him around.

The kids were relatively stable on a medical front yesterday.  There is a child who is 2 years old that we met Tuesday with ortital and jaw masses that were obstructing his airway that I advised just starting Burkitt’s treatment on becuase the tumors were literally growing before our eyes–so what else could it be?  He got chemo on Wednesday night and yesterday things were visibly better.  We would worry a lot about tumor lysis and do lots of labs in the US–by omission he didn’t get IV fluids after chemo Wednesday but seems to be urinating just fine.  I think his Thursday chemistries didn’t result yesterday.   So we will see what the next couple of days brings.

As a side note for all you oncologists out there, we asked and they don’t see a lot of later increases in phosphorus.  They are not necesarily looking for it either but we seem to see that more often.

Joycee, my little one from the last post was doing great on Friday.  Her tumor is also visibly getting smaller and her Dad reported that she was able to eat some solid foods too.  So we’ll see how she does over the next couple of days as well.

Shelton, went on his first consult mission to one of the other wards outside of Jengo La Watoto yesterday too and really got a picture of how wonderful the oncology ward is compared to the other conditions.  They brought that consult child back and we suspect metastatic neuroblastoma presenting with a large orbital mass.  It’s unclear to me so far whether the abdomen has been imaged yet because the child came later in the day but the mama had the head CT done in Arusha in February and the orbital mass seems to be arising from the bone with other skull based mets.  We will continue to work with them on this one.

That’s it for now, when my phone is charged again after its run with the children I’ll try to post some of the Tinga Tinga art I talked about previously.

Sue

Day 2

Hi all!

Well, I think I get the post tonight, so you get the wordy writer today!

More things I’ve learned on this trip….I think I have finally figured out the medical doctor training system here so I will share and then tell you who is on the team this time around.

Children start primary school at age 7 years here and go to primary school for 7 years, so they finish around age 14 year.

Children then go to secondary school and this goes on for 5-6 more years, to age 19-20 years

Then they go to medical school which is 5 years, so we are to age 25 years.

Then they are an intern for 1 year and it seems like they rotate around whatever hospital they are at as an intern.  At Muhimbili it seems like they are only in one place for 1 maybe 2 weeks at a time.

Then it all becomes a bit free form.  You can choose to be registrar which is sort of an employed doctor for any period of time you want before you try to get a residency.  People don’t necessarily do registrar in the specialty they want to go into.  They may choose to be a registrar because of personal reasons such as wanting to have a baby or it may be out of necessity, because they need to be sponsored in order to become a resident (ie have someone to pay for them).

So when you decide to become a resident then residency is another period of time, for pediatrics it’s 3 years.

So there you have it, but it seems you can also pretty much never decide to go back to residency and still practice.

That all being said the doctor team is a lot of very familiar faces:

Dr. Shakilu and Dr. Laiti are the Master’s students

Dr. Living, Regina, Mwanaidi, Lulu are the faculty pediatricians

Dr. Edith is a faculty pediatrician but also has oncology training in adults and children in China-not entirely sure what that was exactly, a fellowship?

Dr. Beatrice, Aika are registrars.  Beatrice wants to do adult cardiology and Aika pediatrics.

Dr. Imran is the pediatric resident

There are 2 interns and scattered medical students.

Whew! I think that’s everyone.  Most faces are folks I know from the past which is great because that means some good continuity in the program.  Many of the nurses are the same too.

Then there are some exciting things on the ward:

The Upendo ward has been painted and it’s amazing!  Mr. Chongo, a local artisan, painted the whole thing and it puts our ward to shame!  It’s covered in an art called Tinga Tinga art and it’s all sort of animals and color and beauty!  I told someone we needed to bring Mr Chonga back with us and they astutely said we should take pictures and project them, sort of like paint by number.  It’s a good thought.

Another exciting thing is they have a water filter installed on the ward.  This was more exciting when we thought it worked more consistently, but when there is no water in the hospital to filter there is no filtered water.  Well, it’s still a significant improvement.

New outpatient infusion unit where the very unsafe outdoor patio was.  A donor gave money and they decided to enclose an outdoor patio area to become an outpatient infusion room.  The outdoor patio is off the waiting room and was always a great idea for the children to get fresh air but they were never able to get the wall high enough to feel safe so this is much better.  They are just putting the finishing touches on it and it will be open for business.

A chemo hood!  The nurses currently draw up chemo in the basement with no hood and Dee was able to get a used hood and new refrigerator.  So the plan is to renovate several rooms in the old Tumaini ward and one of those will become the chemo prep room.  The hood is in the room but not hooked up yet.  They need to get more plumbing, electricity, work tables and air conditioning in there so many fundis are being sought.  Fundi is a word for worker and you can be a fundi for just about anything.

That is all the new and exciting I think but that is some amazing stuff.

Rounds are going well.  The census on Upendo is a moving target but somewhere between 30 and 40.  I’m not sure about Tumaini because they keep saying not many are over there but some seem to transfer in and out of there each day.  The improvement in knowledge among the doctors is evident.  Things that were still getting missed last year are not getting missed this year.  That is great.  I think the continuity of doctors has a lot to do with it.

The children continue to be really sick and the extent of disease they have at presentation continues to amaze.  Their resilience also continues to amaze me.  I will tell you one story–warning, somewhat graphic  content for you non-medical types out there.  Skip to the next paragraph if you have a queasy stomach.  Lovely little 3 yo girl, Joycee, who has a rhabdomyosarcoma of the face with tumor protruding out of her eye and into her mouth disfiguring her left side of the face.  She just started chemo.  She has a trach because her airway is compromised because of tumor.  It is also hard for her to swallow anything solid because of the tumor.  But she is determined to eat–or try.  Yesterday in the morning she was eating porridge and she would take a bite, chew it up and spit it out.  In the afternoon she was having a great time eating watermelon where she would take a bite, chew to get the juice out and then spit the pulp back.  This morning the nurses called us over at the start of rounds because Joycee was bleeding from her nose, mouth and trach and coughing and coughing and her daddy was patiently wiping it away.  Can’t get platelets so a little transexamic acid and the bleeding stopped.  This afternoon she had  a cup of milk on her bed to drink but she was hugging a 1.5 L water bottle full of milk and giving her daddy an earful about how she needed all of that milk to drink because she was hungry.  And the lecture continued for quite some time.  And her daddy is so patient and was just chuckling at her with us.  If that isn’t resilience I don’t know what is!

I’m really excited about how things are going with the nurses too.  They are relating to Erica as a nurse in ways they would not to someone else.  She has already started formal teaching in addition to working with them and they are asking for more topics!  I think this could be the start of a great opportunity for a nursing teaching collaboration.

The internet is uploading slowly and I keep getting ahead so not much more but a few other fun things…

Shelton ventured out to the Serena Hotel today to change money and scored a back gate taxi driver named Mr Brighton who we have enlisted to bring  us home each day.  He used to work in the prison system for  35 years so when the  police pulled him over for no good reason he whipped out his prison police papers and away we went.

Game 2 of the football series Team Dick vs Team Shelton took place this evening.  AND with another  massive come from behind victory Team Dick takes a second victory!  Dick is a master of strategy and always seems to start with the “weaker” team and bring in the ringers once he is behind.  Tonight it was Dick and Erica vs Shelton and 2 other boys from Game 1, then once  down he  got a massively talented older  teen to join and it was all over.  Shelton even  tried playing  without shoes which  Hilda thought was hilarious.  Dick has assigned me to cheer from our 3rd floor balcony–I think he wants the stadium feel.

Ok, gotta stop, internet bad..

Sue

First full day!

So my first full day with the nurses here was definitely interesting. I have to say though I’m impressed that because there is no pharmacy to calculate concentrations of anything and they draw up all the antibiotics, chemo, pretty much anything that is given IV. They calculate drips too which I’m going to get a crash course in tomorrow because I can’t say that I’ve done that since nursing school! It’s very different in that each nurse doesn’t have their own patients, they have different roles for all the patients. So the first nurse I spent part of the morning with had the role of being the rounding nurse. He went around with a rounding book that he took notes in about the plan for the patient. He unfortunately though kept getting called away to do other things so it made following along with rounds hard. I can remember now why we have reverted to a computer system! All the papers on different patients that didn’t seem to have an order that I at least understood yet were giving me a little anxiety. The next nurse I spent time with was the medication nurse, mostly antibiotics. She would draw up all the antibiotics and start going around to rooms, sometimes the patients weren’t in there and were out roaming around so we went on missions to find them. Around 3 pm her shift ended and another came on who was the afternoon rounding nurse who’s role was similar to the AM nurse but a lot less papers! It was mostly for her to know any new orders to get done, things that were maybe missed from the morning, and if there were new patients. She took me down to the basement where all the chemo is stored (I also found the cockroach graveyard) and we even took the elevator which is something Sue has suggested against doing as they get stuck a lot : /

We had some down time in the early afternoon that we chatted about some things they would be interested in learning more about- there was a lot of questions about ALL protocols and chemotherapy safety/side effects so those were things I was definitely going work on teaching. At least one also seemed interested in learning how to better do a physical assessment so that would be good too. I didn’t get to spend time with the cannulation nurse (places all the IV’s) or the chemo nurse at least today and there’s also a vitals nurse but I’m not sure exactly what that entails yet since the momma’s take the temperatures on the kids but I’ll probably find out more tomorrow. It was nice to still be able to spend some time with Shelton and Sue during rounds too!

On a total side note, Hilda, the wonderful housekeeper definitely laughed hard this morning when I asked her when it was going to rain. She asked me if it doesn’t rain where I live very much and I told her it actually rained a lot I just wanted to hear a thunderstorm at some point 🙂 She felt pretty certain I would before we left.

Good night everyone!

Day 1

First day of official rounds/work today…A couple factoids about this place to get a feel for it.

There’s 1 ventilator…in ALL of Tanzania.

Theres no microbiology…no blood cultures.  Yes you read that right

Sometimes there’s just no water….in the whole hospital.

Theres 500 pediatric cancer diagnoses per year here, at least, with zero, zero pediatric oncologists.  For perspective on that for people who aren’t in our field, a robust program in the US sees about 150 new diagnoses per year, with about 8 trained oncologists on staff, and countless support staff.

These kids are tough kids.  They are really, really, really sick.  They have tumors eroding out of limbs and facial structures.  They have belly masses so big that they tip over when they try to stand up.  They have leukemia that’s invaded their eyes and blinded them.  It’s at least 80 degrees in the ward.  And still they smile at me and their parents are lovely.  Its pretty awesome to see.  The rounding team consists of multiple residents, a few general pediatricians, and two Muslim female interns who I accidentally tried to shake hands with (not kosher).  And there’s Sue and I.  I think I’m going to be giving some lectures to the pediatric residents over the time here; there’s 12-15 pediatric residents here at Muhimbili.

We had fried Tilapia fresh out of Lake Victoria for lunch today. Bony, but pretty good.

Erica has been a rockstar with the nurses.  But I’ll let her comment on that part.  Hope all is well back home!