addendum: stonetown

OK, this is really the last post.

This morning we left Pongwe for Stone Town, the historical center of Zanzibar. En route, we stopped for a traditional 'spice tour,' in which a local guide takes you through a farm in which they grow fruits, vegetables, and yes, spices. Nothing like smelling fresh cinnamon bark or having your guide dig out turmeric root, but for nerds like Annie and me, two highlights were the iodine tree as well as the quinine tree, for obvious reasons.

We then reached Stone Town and checked into our lovely hotel, Africa House Hotel (with a room with air conditioning!!!!) After setting down our massive amounts of luggage, we headed out for a self-directed walking tour of the city. Two issues: first, the streets are winding and don't meet at right angles, but that's OK, because the streets are unnamed. Second, it was somewhere around 600 degrees outside. Nevertheless, we made our way through town, seeing such sights as

• destitute quarters in which slaves were held before they were traded in open market (as fascinating as it was horrifying)
• crazed, yet amazing local markets: one predominantly food-driven, the other, random gift-driven
• your standard array of palaces and old forts: cool and all, but not overwhelming.

More than anything, we just enjoyed getting lost in the narrow alleyways of the town. It was awesome. We then made our way back to the hotel, which is on the west coast of Zanzibar and offers an unparalleled view of the sunset (which we enjoyed while I started on Anna Karinena and Annie continued forging ahead with American Pastoral).

Once we had taken in our last sunset, we headed out for our final African meal. We decided to brave the street food market, held every night in a recently renovated park at the north end of Stone Town. Before heading in, we set a rule: don't eat anything that we might regret tomorrow. Surprisingly, we had plenty of options to choose from, including

• samosas and falafel
• a strange, yet delicious potato and coconut soup
• grilled plantains as well as grilled 'breadfruit' - a local fruit that tastes exactly how it sounds
• and, the piece de resistance, a "zanzibar pizza" which is basically a crepe. Our choice: nutella and mango.

By the end, we were stuffed to the teeth, and proud of our efforts.

And that's all she wrote! All that's left is three flights and one five hour layover in Dar (groan). Signing off for real this time, asante to all!

sink or swim

Greetings from Zanzibar!

This past Tuesday was our honorary ‘farewell dinner’ with the residents – we went out for local African cuisine and were joined by so many of the spectacular residents (all of whom are not only tremendously skilled medicine residents, but had all performed C-sections, exploratory laparotomies, and countless other procedures as part of their residency training), including Kilonzo, Gunda, Matungmbwate, Alex, Mopondo, and of course our all-time favorite, Meda. We are so proud to call them our friends and colleagues and are even more thrilled that, as part of the ongoing Cornell-Bugando exchange, we will be seeing many of them for a month at a time at Cornell this summer and fall! (I fully expect Annie to talk about her experience with the Assistant Medical Officers-in training in her post, because I contributed nothing to that amazing relationship.)

[Annie writing now, taking over mid-Santosh-blog-post]

The AMO’s are the Assistant Medical Officers. They are non-MD medical care providers, much like Physicians’ Assistants in the US; but unlike in the US where Pas are specialized in a given field, the AMOs are responsible for EVERYTHING, from pediatrics to adult medicine to ob-gyn to basic general surgery. This is because Tanzania has such a shortage of physicians that non-physicians are needed to serve the people who live in smaller communities, where resources are even sparser than what we’ve seen in Mwanza (the second largest city in the country). Whereas your average Tanzanian medical student or intern is in his or her early 20s, the AMOs are usually in their 30s-40s and have worked in the past often as pharmacists. And, unlike many of the medical student who unfortunately go into training to become a doctor because they are looking or a stable salary, I got the impression that the AMOs have decided to go into their training not because they need the salary – as they already had jobs before this training – but because they felt a calling to serve their country. In any event, every week I taught a group of about 12 AMOs; lectures ranged from rheumatic heart disease to portal hypertension to stroke, and we focused on the practical ‘how-do-I-diagnose-this/how-do-I-treat-this’ knowledge base that they so desperately wanted to establish before going out into the community. While I’ll be the first to admit that my teaching experience thus far has been limited, this has by far been the most gratifying part of the Tanzania trip for me. I felt truly honored to be working with such devoted men and women, and their genuine concern for others and enthusiasm about learning was inspirational. I’m convinced that they are the first step in filling the great shortage of medical care providers in this country. And, as though the teaching itself weren’t wonderful enough, on the last day of class they bought me a present – a traditional cloth that women wear. (And of course, they put me in it – can’t wait to share the picture with everyone.) Okay, back to Santosh.

Wednesday night was Annie and my last night in Mwanza, and to be sure, the evening was a bittersweet one. We’ve written about the many amazing things we’ve learned at Bugando hospital, but equal in importance has been the relationships we’ve formed here. This is really the first vacation we have ever taken where we have made true friends with the locals (and other visitors). We went out for dinner at our favorite local spot, Bugando Hill, and were joined by all of our co-visiting residents/students from Cornell as well as other visiting students from Ireland and England and Germany, but best of all, by the three people who made Mwanza home for us – Mussa (who teaches yoga, makes clothes, plays a mean Frisbee and an even meaner soccer), and the unmatchable duo that are Hezron and Emmanuel (our ‘taxi drivers’ who became so much more – local guides, protectors in sketchy areas, and most of all, friends). Nothing really makes an experience like being welcomed by the local residents, and with Hezron and Emmanuel around, we always felt that we belonged.

It was with a heavy heart that we set out on our final day of rounds on Thursday (featuring an exciting yet incredibly confusing respiratory arrest accompanied by complete loss of muscle tone and bilateral areflexia in a guy whom we had just pronounced stable for transfer to the floor). That afternoon, after showing the new medicine resident Amy the wonders of the local Mwanza market (which sells souvenirs and fabric as well as vegetables, live chicken, and other assorted goodies) as well as the wonders of the local ice cream shop (Mr. Cool Ice Cream Mwanza), we went to the apartment of our incredible attending physician, Dr. Peck, and enjoyed an afternoon soiree with him, his wife, and his four incredibly cute kids. (I’m proud to say that I built Lego castles, did ballet dances, played “airplane,” and gave piggyback rides while being bonked on the head with a toy soccer ball with all of them. Oh, and played hide-and-seek, a game at which I was surprised to discover, I stink.) As evening approached, we were taken to the airport by Hezron – this was the toughest goodbye of all, especially when he gave us a parting gift (a super cool traditional warrior fabric worn by the indigenous locals, the Ma’sai).

After a typical delay on Precision Air (their tagline should be “but not accurate, ha!”), we arrived at Dar Es Salaam, the nation’s capital, for a four hour siesta before heading out to Zanzibar. Let me summarize Dar: overpriced cab ride to decent hotel above an incredibly sketchy bar frequented by, um, people of questionable moral fiber, to another overpriced cab ride to waiting for our flight where we ate granola bars because the canteen had run out of veggie samosas and had no plans to make more. Yeah. Four hours in Dar is four too many.

Nevertheless, we arrived in Zanzibar yesterday morning and were met at the airport by Taxi Tembo, a lovable old Tanzanian man who is a tour guide/taxi driver (although now he, oddly, sits passenger while someone else drives), and he sports an incredible shirt designed like an American flag. He deposited us at Pongwe Beach resort.

So Pongwe is insanely awesome. First, it’s right on the beach, and it looks like what you picture when you think of the perfect tropical beach. Second of all, the staff is unbelievably nice (like everyone here). Third, the food is amazing, they have a pre-dinner cocktail hour where you can play Scrabble, and while you do so, they supply you with AWESOME snacks (hello, spicy popcorn, spicy roasted peanuts, and olives!). So what else have we been doing in Pongwe?

*Drum roll please*

Annie has been helping me with my (lack of) swimming technique! It helps that the pool water here is seawater, in which even a total idiot like me can float, but with some helpful tips on (and feel free to laugh here) floating, breathing properly, and kicking technique, I have actually been able to swim! Multiple different strokes! AND, we took snorkeling gear out into THE OCEAN, and snorkeled a bit! Someone needs to tell my mom.

Also, we kayaked. We set a course for a peninsula that seemed very attainable, but after an hour, it was clearly not. On the way back, I inexplicably began to struggle as my kayak would continuously drift to the left. By the time I exhaustedly got back to Pongwe, I had concluded that (as usual) water causes me to be a complete tool. But I was vindicated: it turns out that the kayak had a giant leak on the left side that had caused THE ENTIRE KAYAK TO FILL WITH WATER. As I said to Annie, “I just kayaked a friggin’ anchor back home.”

What else have we been doing here? What we always do: lounging around on either beach chairs or hammocks and reading. Annie and I are absolutely transfixed by our current books: she by Philip Roth’s American Pastoral, myself by Dostoyefsky’s Crime and Punishment (thankfully on the Kindle). Oh, and we’ve been drinking lots of Fanta – oh man, how have I not mentioned this? There are CRAZY FANTA FLAVORS HERE, and they are all way better than orange – passion fruit, pineapple, and black currant are all ridiculously good. Oh yeah, and because Pongwe is on Zanzibar’s east coast, we got up at 6am and watched a glorious sunrise on the beach.

Tomorrow we leave Pongwe and head for Stonetown (the historical center of Zanzibar), where we hope to a) learn some Zanzibarian history, b) do some shopping, and c) watch a nice sunset (Stonetown is on Zanzibar’s west coast). Then it’s off the next morning to the airport for 36 hours of flights back home! Hoorah!

Well, this may have been my most long-winded post, and I’m not sure there will be another one. Our friend Nick coined a phrase, “TIA” while we were at Bugando. It stands for “This Is Africa,” and it was what we said to each other in the hospital whenever a lab test wasn’t available or a medication didn’t get given, to not only be able to overcome our frustration, but to remind ourselves to withhold our judgment. Well, these last six weeks were our Africa, and we loved every second. To everyone who made our experience unforgettable, asante sana!

Weeks 4 and 5

Hi all! So Annie and I are in the last few days of our time at Bugando hospital. There are so many unforgettable parts of the experience, both inside the hospital and out. We had one such interesting experience this past Friday night. After morning report on Friday, one of the awesome Tanzanian residents, Matungmbwate, came up to Annie and said, simply, “Disco?” We correctly took this to mean “Let’s all go out tonight!” So we all gathered at one of Mwanza’s new nightclubs, Club Lips. There are many notable aspects of this experience:

1. When we arrived, there was no one else there. Creepy, but allowed us to sit at a table in the back like we were VIPs or something.
   
2. At midnight, when it turned April 2nd, my oldest sister’s birthday, 2 consecutive songs that I a) know she loves and b) don’t expect to hear in a club came on: ‘Big in Japan’ by Alphaville, and ‘La Isla Bonita’ by Madonna.
   
3. The club basically played 2 types of music. For most of the night, there was African music, which is kind of a chill beat to which you sway back and forth (Nate, one of the Tanzanian Pediatrics resident, exemplifies this version of dancing. He throws in rubbing his belly as he does it, which Raja refers to as “the Teletubby dance”). Then, as we were getting ready to leave, the DJ inexplicably switched to a string of mid-90s techno music (aka “Tonight is the Night,” “Be my Lover,” and the one that made EVERYONE go crazy, “Barbie Girl.”)

Needless to say, it was a pretty unforgettable night.

As far as the hospital is concerned, we’ve obviously still had our ups and downs, but I think we experienced one of our first unequivocal successes this Monday, when we saw a patient with severe tetanus whom we had met in the ICU on our first day walking around on the main floors. Even better, he recognized us and gave us a big wave. I was so excited I wanted to bear hug him; unfortunately this probably would have knocked him over.

Oh, one whomp; the soccer match we were going to go to was pre-empted by a 2-day gospel concert. Even worse, Young Africans FC are playing Toto Africans FC this Sunday, when we'll be in Zanzibar! OK, Zanzibar is cool too, but still. Boo.

Till next time, quaheri!

one muddy brown step forward

Let me tell you; the times are few and far between when we’ve done something actually useful, but today was one of those times.

So we’ve already blogged a couple of times about the mid-30s woman who became septic following an incomplete abortion and went into complete renal failure, making her the second patient ever at Bugando hospital to receive peritoneal dialysis. Well, it had been nearly a week now, and her urine output has started to pick up. We were hopeful that this was indicative of the second stage of an acute, and reversible, form of kidney injury called acute tubular necrosis (ATN). In the first phase, the cells lining the tubules of the kidney die from a lack of oxygen, clump together, and obstruct the tubules, causing the patient to have markedly decreased urine output. In the second phase, the clumped, dead cells begin to clear from the kidney, but the new tubule cells don’t work yet (and their main job is to reabsorb salt and water), so the patient goes from making almost no urine to making a ton of urine. In the third phase, the patient’s kidney function recovers (typically to baseline).

Diagnosis of ATN is often clinical, but can be confirmed by one particular finding, and today, we found it. We discovered that within the ICU there is a centrifuge and a microscope that could be used to look at urine sediment. We then scrounged up some glass slides and cover slips from the lab, put the slide under the microscope, and there it was: a muddy brown cast (when the tubular cells die and clump together, they become very densely packed – thus the muddy brown – but deform to fit the shape of the hollow tube – thus the cast). Clear as day. We showed our finding to Mubarak (an absolutely brilliant resident who is essentially the one man peritoneal dialysis team at Bugando). Unbelievably, we may have managed to use a limited resource in the exact appropriate setting – to temporarily stabilize a patient with a reversible condition. She’s still very sick, and we don’t know if too much damage has been done, but we hope. We hope.

(In other news, we went to an awesome pizza place yesterday, and absolutely gorged ourselves on pizza with a variety of exciting toppings, including: pineapple, spinach, avocado, eggplant. It was sweet.)

code leader?

(First of all, Portishead’s Only You is playing in the ex-pat bar from where I am currently blogging – awesome.)

I asked Annie what today’s subject should be, and she said, “Code dynamics.”

By Code, she means the standardized sequence of events that is classically followed when a patient loses circulation (otherwise known as Advanced Cardiac Life Support, or ACLS). In the US, the success of ACLS is achieved in large part due to implentation of a highly systematic process in which everyone’s role is clearly delineated. A “code leader” stands at the foot of the bed and gives instructions, while nurses and other residents are performing chest compressions, performing bag-mask ventilation, drawing blood, achieving intravenous access, or securing an airway via endotracheal intubation.

So, things run a little differently in Bugando. First of all, the ICU is not consistently staffed by residents. The residents round once in the morning and once in the evening; the remainder of the day, the patients are monitored by the nursing staff. Based simply on who is usually present, the nursing staff classically initiates what they call “resuscitation” when a patient loses a pulse, including fluid administration, cardiac resuscitation, and intubation. But this becomes a problem when a code occurs while residents are present. The reason this is a problem is because (and there’s no other way to really say this) the nurses code patients in a manner that is largely incompatible with any positive outcomes. Resuscitation is often not even begun until the patient has been without a pulse for minutes, and the sequence of events occurs at a painfully slow pace.

So. Situations often occur like this morning, in which a lovely, middle aged woman who was transferred to the ICU in relatively stable condition yesterday was found this morning by a humble visiting medical student to be hypotensive and largely unresponsive, and after recruiting his resident/wife, the patient took 2 agonal breaths and abruptly lost her pulse. Our natural reaction was to begin chest compressions; yet, it was critical for us to successfully attract the attention of a nurse in order to get permission to begin participating in a code situation. Throughout the code, we struggled against the slow pace at which resuscitative efforts were happening (you should all be proud of the multiple ways in which Annie politely asked for a defibrillator without losing her cool), all the while realizing that at this pace, nothing we were doing would be of any benefit, yet we were limited by the culturally established hierarchy on whose totem pole we were woefully low.

Ultimately, our success in this situation, like in a recent situation, came when we were able to partner with the in-house resident when he arrived to prevent a lifeless body from being intubated. However, our attempt to gain permission for an autopsy (the only way that we would ever find out if and how the management of this patient had been misdirected) was unsuccessful, leaving us to wonder if we had made any positive impact at all. Today was the second consecutive day that a patient we hoped would pull through literally took her last breaths in front of us, as we struggled against 2 very different, but equally frustrating limitations: first by the hospital resources, second by our lack of authority.

Not all is depressing, however. In fact, I’m very proud of the fact that our current team, led in tandem by Annie and Meda (our brilliant Tanzanian resident) and supported by Judith (who is headed to MGH for medicine) and myself have been able to promote a systematic approach to daily rounds in the ICU. I think we’ve helped show one of the best senior residents here that a systematic, evidence-based approach can be effective even when optimal resources are unavailable. It’s the refrain that we all repeat to ourselves: that the benefit we are providing is (hopefully) systemic.

In other news, I played soccer over the weekend with a bunch of local Tanzanians and Indians. News flash: people who play soccer often are awesome at soccer. My big success was that I managed to play for a half hour without attempting to strike the ball and completely missing, or committing any abhorrent turnovers. Of course, once I left the field, I had to pretty much go into suspended animation for the next 12 hours to recover enough strength to even eat dinner. Still, it was awesome, and made me even more excited to go see a soccer match (featuring Simba FC, who stand atop the Tanzanian Premier League) this Saturday!

Till next time!

Food

Since Santosh has taken on the responsibility of updating the blog with important things like our medical experiences, etc., I figured I'll take it upon myself to write about something no one really cares about except for me: food.

Things we eat a lot and like:
- mango and pineapple -- WOW is this stuff ever better than what we buy off the street in New York
- rice and beans -- simple, yes; protein, yes; cheap, wowee yes
- carrot and cabbage pizza -- this requires a bit of explanation; at the house where the visiting residents / students live there are three House Ladies who cook lunch and dinner every day; they are very sweet and have decided that we miss Foods of Home, which apparently means Bizarro Italian Food; lots of lasagna (good), pasta (good), but best of all, pizza; they toil over this home-made crust all day (or so we've told ourselves) and top it with the strangest and most available veggies imaginable: carrot and cabbage; the other day we found some lone strands of eggplant; bon appetit!
- peanut butter and bananas on toast -- breakfast of champions, especially when the milk is poison
- stoney tangawese -- ginger beer, and my drink of choice
- passion-fruit flavored fanta -- Santosh's drink of choice
- chili sauce -- this is my favorite thing here; mild-moderate spicy, but more important, has a smokey flavor to it; goes well on rice, pasta, avocado, bread, a spoon... I plan on bringing many bottles home with me in my checked luggage; Santosh only will let me do this if I promise none of his belongings is in the bag I use to transport the chili sauce, since he doesn't trust bottle caps
- TONS of Indian food, everywhere; major Indian influence in the country because of the ancient spice industry on the coast / Zanzibar

Things we try to avoid eating despite the availability:
- ugali -- this is a ball of corn meal that has zero taste; the plan is you dip it in whatever you're eating; but in the end, it is dense and flavorless and definitely has no fiber for those of us concerned (ahem: me); greatly improved with chili sauce (see above)
- mayo -- on many, many dishes; and unlike in Japan, where mayo is abundant and refrigerated, the climate here is quite warm...
- kilimanjaro instant coffee -- BLECH

Things we miss:
- real coffee
- sushi
- non-poisonous milk
- green vegetables

Am looking forward to our first meal home of sushi, spinach, and coffee-flavored ice cream.

Mood swings

Oof. This morning was a challenge. It was yet another reminder (as if we needed one) that the limits on providing care at Bugando extend far beyond lack of laboratory tests, diagnostic tools, or therapeutic interventions. Let’s revisit the last 24 hours!

Yesterday morning, ICU rounds
Patient 1: 43 year old male, recently underwent an exploratory laparotomy for a surgical abdomen (which, incidentally, revealed a liter and a half of fluid that had accumulated for no apparent reason, and of course, did not get sent for analysis), with post-operative severe hypertension.
What we would do in the US: use any number of IV anti-hypertensives at our disposal
What we were doing: using hydralazine, the only IV med we had, while hoping that he would be able to take oral medications before he had a stroke
What happened yesterday: He passed gas! Hooray! We started him on 2 oral anti-hypertensives. By the afternoon he had achieved target BP reduction.

Patient 2: 41 year old male, in the ICU for 3 weeks with severe tetanus.
What we would do in the US: probably run frantically to Up To Date because we have no idea how to manage tetanus
What we were doing: effectively controlling his spasms with a combination of sedating medications. He was past the worst and was getting better every day; the only problem is that he hadn’t had a bowel movement since coming in, and was now starting to eat. We had tried a lot of stool softeners and they weren’t working. This day he had started hiccupping (a sure sign that the gas he was making was coming out the top instead of the bottom), so we asked the nurses to do an enema.
What happened yesterday: he had started vomiting bile, and (understandably) refusing to eat food. We asked the nurses, again, to do an enema.

Patient 3: 37 year old female with a recent self-induced partial abortion, who had developed endometritis, likely sepsis, and complete anuric renal failure with encephalopathy.
What we would do in the US: urgent hemodialysis, imaging, and probable hysteroscopy to rule out retained products of conception.
What we were doing: first, trying massive doses of lasix to try to generate urine output (unsuccessful), then attempting to convince the surgeons to place a peritoneal dialysis cathether so we could perform intermittent PD in the ICU. Oh, all this without any way to objectively measure her renal function.
What happened yesterday: The surgeons took her to the OR! Hooray! We planned for PD overnight.

Patient 4: 39 year old female, known diabetic, who recently went to a healer in Arusha who has been telling people that he can cure 5 common diseases (AIDS, TB, asthma, diabetes, and epilepsy), with a plant boiled for 10 minutes. She had stopped her insulin and presented in diabetic ketoacidosis, as well as neck stiffness, fever, and altered mental status.
What we would do in the US: DKA protocol, head CT, LP
What we were doing: actually pretty close. No imaging, but we started the DKA protocol and did the LP
What happened yesterday: CSF was in the lab for analysis, and her blood glucose was improving. We planned to transition her to an outpatient insulin regimen.

Annie, Judith, and I left triumphant. We had made some big steps forward.

This morning (Saturday), ICU: We walk in to a disaster.
Patient 1 (hypertensive emergency): after stopping the hydralazine drip and starting PO medications, the nurses saw that his BP had rebounded somewhat. Instead of giving him a PRN medication to keep him off the drip, they restarted the drip and skipped his AM medications.

Aftermath: This one isn’t so bad: we stopped the drip, added on more oral medications, and left detailed instructions for the nurses).

Patient 2 (tetanus): continued to vomit bile, refused all oral intake, no bowel movements. No enema done.

Aftermath: Even this one is OK: Annie hovered over a nurse until she did the enema. And he had a bowel movement! Yay! Poop!

Patient 3 (complete renal failure): Mubarak (an amazing resident here at Bugando and the man in charge of peritoneal dialysis) shows up at 11pm to start dialysis and finds the patient in a pool of her own blood (hemorrhaging from her cathether site). He orders an urgent blood transfusion, holds pressure for 2 hours before she stabilizes. Labs from 3 days ago return showing that she is in DIC. This morning, she is stable, but unarousable.

Aftermath: peritoneal dialysis is finally started, but she has lost alot of blood, and being in DIC isn't going to help things.

Patient 4 (DKA +/- meningitis): We show up to find her intubated. The flow sheets show that she became hypoglycemic in the evening, but the insulin drip wasn’t stopped. Then at some point, the drip was stopped. In the middle of the night, she inexplicably became hypoxic and was intubated. This morning, she was back in DKA. Oh yeah. They never sent the CSF.

Aftermath: We took the CSF down to the lab ourselves, and re-started the DKA protocol. Unfortunately, patients who get intubated at Bugando have essentially a 100% mortality.

So. It was rough. Now, as usual, onto some happier items!

1) The boat ride happened!!! It was amazing actually; you can sit on top of the boat and have a completely unobstructed view of Lake Victoria and Mwanza. One of the coolest things we’ve done here.
2) Thursday, we went to yoga, then came back to have dinner at a local restaurant that we all like to say goodbye to Jenny, one of the OB residents who was leaving. It was a blast, until a crazy thunderstorm started and the power went out in the city all within about 3 minutes.
3) Friday, we went back up to Dancing Rock and had a picnic for our friends Sonabel and Nora, Cornell med students from Qatar who left today. Then Annie and I came home and watched West Wing, and I started on The Plague (loving it so far).

This weekend’s big plan: possibly a trip to Capri point (apparently the neighborhood where the wealthy Tanzanians live, with lots of scenic viewpoints).

Oh yeah. Annie and I bought some chocolates for the village kids behind one of the houses, and I got to give them out. I felt like Santa. It was AWESOME.

Till next time!