Flying Medical Squad

I am home in Arusha alive and barf free from the flying medical squad. It was absolutely amazing. I met the team Monday at 7:45 at the airport and we loaded the plane with suitcases of medications and equipment and then we set out around 8:30. It was me, the pilot Jack - a polish guy who's lived here for 7 years now, and Trudy, a Swiss woman who is the secretary for a medical flight company there and is going to help organize the office here at some point. I got to ride in the co-pilot's seat for the first day, wearing the headset and hearing the air traffic controllers, etc. (But of course I didn't touch anything.) The plane seats 6, or 4 comfortably, with a small cargo area in the back and a small cargo area underneath. We flew about 25 minutes south to Emberet where we dropped off our overnight bags at a catholic mission and picked up the clinical officer that goes out with the team. We were flying at 5000-6000 feet which actually seems really close to the ground and you can still see a lot of detail. The runways are just mowed strips of dirt and grass. We had to fly over the runway once before landing to make sure that there weren't any major holes or animals in the way, and the tight turn going back around was always the hardest part of the flights for me from a nausea perspective. We did clinics in 3 tiny villages on Monday, flying between them - they were all within 25 minutes flight or less.

My job was pregnancy checks - I checked the blood pressure, looked at the eyelids for signs of anemia, checked for edema, and then measured the uterus for an estimation of age and identified the position of the baby if they were over 30 weeks. I then attempted to ask them if the baby moves and if I couldn't get that answered, I would just do a quick ultrasound for the heartbeat. The first day, I ultrasounded almost everyone but on Tuesday and Wednesday I was doing better with the phrase "Baby moves" in swahili and massai. I did between 5 and 20 ladies at each spot, except at the places were there was no bed or cot, in which case i just did the blood pressure, anemia check, and edema check. I found one baby at 36 weeks that was breach, and I asked the clinical officer what we should do, thinking at least we should warn her that it might be a rough labor etc, or that maybe she'd be advised to try to get to the hospital to deliver. His response was "Sometimes they turn around." so we did nothing, other than note on the pregnancy cards they all carry to follow the progress that it was breach. So I'm not sure what the point of checking is, but oh well. I wish I was able to take a picture of my 'office' in some of the towns - only one had an actual bed, the other were cots made of wood and twigs that were in various stages of coming un-made, or once 2 church benches side by side. Unfortunately, the Massai don't like having their pictures taken (and who can blame them - I'd be pissed if some foreigner came into the clinic while I was seeing my doctor and started taking photos) - so all the photos from this trip will be landscapes or from the air, no people. I generally try to avoid pregnant ladies at all costs, but the pregnancy checks weren't that bad and with no privacy or gloves, and no way to do anything with the results, I was in no danger of having to do a bajanginal exam.

Once I was done with all the pregnant ladies, I helped Jack and Trudy with immunizations or I helped the clinical officer, Moshi, with counting medications. Like in hospice, medications are dispensed from a large plastic bottle of pills into a small (1.5x3 inch) zip lock bag. The bottles of pills are kept in 2 rickety old hard backed suitcases, there is a third for liquid antibiotics for the children. Almost everyone gets an antibiotic if they have bothered to come see the clinical officer with a complaint - the favorites were Cotrim (bactrim) and doxycycline, though penicillin V and erythromyacin also did well and cloxacillin was popular with the children. The often also get 12 paracetamol (Tylenol) or 18 ibuprofen. The kids are all brought with their vaccination / growth charts - the mamas keep these - and weighed and then given any vaccines they are due for. We saw a lot of newborns - 6 months who were getting DPT and oral polio, but some measles and mumps were given and the pregnant mamas get at least 4 tetanus. Kids still die of tetanus here - Jack told us about a kid he flew to a hospital with tetanus - they had started vaccinating the previous year in that village but the mama didn't think he needed it. He died a couple days later in the hospital at Haidam. Frustrating.

So we did 3 clinics Monday, with a break between the second and third when we set up the folding table in the shade of the airplane wing and ate a lunch of bread and marmalade and coke. At the end of the day we returned to Emboret where we had a excellent dinner of rice and beans and greens and a beer and Jack played the guitar after dinner and we sang together. Tuesday, we set out at 8:30 and again did 3 clinics, the last in a brief thunderstorm - there was no bed here so I was helping Jack vaccinate babies and mamas under the wing of the plane while it was raining. Trudy got to sit in front Tuesday so the airsickness was worse, but I did manage not to barf. Tuesday night after dinner - rice and cooked greens from India (one of the priests brought some seeds and grows his favorite greens) and an eggplant dish and fries - we played Uno. Jose, the priest from Brazil, was terrible - he loved making up rules to give other people extra cards. Not priestly at all, but fun. Today we had one clinic, which was actually in a nice church at a town where people were less pushy (most of the time, they were crowding as close as possible to be next, which is fairly claustrophobic and pretty hazardous from a needle safety perspective while vaccinating. Then we flew back to Emboret and had lunch at about 12:30, and then home to Arusha. Lunch was Ugali - a corn meal dish kind of like pollenta but unflavored - at Trudy and my request - I hadn't gotten around to trying it yet. Most muzungus think it is terrible, but I actually enjoyed it quite a bit - it may be totally flavorless but it has a nice texture and consistency and you eat it with curry or sauce.

I am really glad I got to go out with the flying medical squad. Aside from the landings, the flying was actually surprisingly pleasant and fun for someone with fairly severe motion sickness, and I feel like we actually helped a lot of people (at least with the vaccinations) and I got to see some beautiful places. So often it feels like we're not really doing much for our patients here - maybe making them feel better in that they have received care but rarely fixing big problems in the hospital. (To be fair, many of them are problems that just can't be fixed given the resources they have here) It was nice to do something that is tangibly useful like vaccinating - even if you don't need to be a doctor (or even a nurse) to do it, you can do it and it will prevent childhood deaths.

To clarify for anyone reading the blog that doesn't know me well - the Marmalade listed at number one on my things I miss list is my cat, Marmalade, not the jam product made of oranges. :)

Top ten things I miss / will be happy to come home to

So I've been trying not to write this post, in part because it's kind of negative and partly because I knew writing it would make me more homesick. But in a week I'll be home, so I guess now is the time. So here are the top ten things I've missed while here in Africa:

1) Marmalade
2) Bacon
3) Martinis. They have gin here but no olives or vermouth.
4) Paved roads. The roads here are for the most part insanely bumpy and just keeping upright and in your seat is a full time job for a passenger.
5) Being able to easily talk with family and friends (sorry guys, you only make 5 cause I can still e-mail you and call if necessary.)
6) Not having to great everyone I see. Usually 3 times. Sometimes impersonal interactions are nice.
7) Being able to go out to dinner. (Here, we have to be home by dark or take a taxi home because white people aren't safe after dark on foot. It just makes eating out too much of a hastle)
8) Things getting done in a reasonable period of time. (African Time!) As an example, Thursday morning they admitted a guy to the medicine ward who had newly diagnosed HIV, kaposi's sarcoma with extensive lymph node involvement causing severe leg edema, and an oxygen saturation of 63 (Normal for my non-medical readers is >90. 63 will get you on a ventilator in America, or on 3 litres of O2 by nasal cannula in Africa) with a pleural rub. Our working diagnoses were pulmonary kaposis or TB. The chest x-ray we ordered? Not done yet Friday at noon. I have a bet with Eric that it still won't be done when he rounds with the medicine team Monday, based on my past experiences here. That's high quality medical care!
9) Washer and Dryers - don't get me wrong, we're spoiled in that our housekeeper does all our laundry, but my jeans just don't fit right.
10) This is a tie between Bacon and Whiskey. I really miss bacon a lot, possibly enough to be on the list twice, but I also miss manhattans.

You'll notice some notable exclusions from this list: My computer, reliable internet access, snow, the TV and radio / any media source, the 70 hour work week, (that's one thing that's nice about no one feeling personal responsibility for their job or patients - much shorter work week), driving. I miss being independent, but I haven't really missed driving while here - I haven't been behind the wheel since January 13th. Minnesotans would be wise to watch out for red geo prisms doing crazy stuff on the road starting March 14th. :) I suppose I'll happily adjust back when I get home, though I'm sure I will miss the more relaxed lifestyle / timeline here once I'm home.

Winding down

As my time here in Africa comes to a close I've been trying to get some things done that I've been intending to do but hadn't gotten around too. (I blame African Time). This week I completed my review of oral morphine prescribing by the hospice team. The number of patients receiving repeat prescriptions during 2008 could be counted on 2 hands, and even the repeat scripts were not frequent enough to achieve adequate ongoing pain control, at least by American standards. And of course we still don't have any morphine - when I got here in January I was told we should be getting some soon, but that doesn't seem to have materialized. I will leave the data I copied (by hand) for Dr. Hartwig and perhaps he can get something more useful or encouraging out of it. I am scheduled to give a talk on pain and symptom management to the doctors and nurses at Selian next Thursday. I am having a pizza party for the hospice team on Thursday evening. And of course there's the Flying Medical squad Monday-Wednesday.

I spent this morning doing some final shopping and ordering the last of 3 outfits I am having made - the first, a skirt and shirt made by Mama Makule's tailor (who also made my traditional Tanzanian dress) turned out wonderfully, so I am having a dress made there. There is a tailor in town who caters to Muzungu (foreigners) though, and she also runs a non-profit home for developmentally disabled children, so this morning I went to order a dress from her as well. It will be 10 dollars more than the other tailor, bringing the total cost to 25 dollars, but it benefits a good cause. Plus, it's still amazing to have something custom made for 25 dollars (plus the 6 dollars I spent on the fabric - but that includes lining, zipper, all other notions, and the sewing itself.) After the market, where I bought the fabric, and the tailor, I hit Shop Rite for some milk and the coffee store for some coffee beans to bring home. I'm fairly certain it's not illegal to import coffee because it's roasted. Then I headed back up hill (Shop Rite is at the bottom corner of the town) and across town past the little grocer that sells tomato sauce cheaper - 1.50 for a large can vs 1.30 at shop rite for a tiny one. I made it to the Meat King just before they closed at 1 and was able to get the mozzarella and chicken for the pizza party. We won't put pork on the pizzas because almost none of the locals eat it. Laden with my purchases, and now on the opposite side of town (but at least not as far down hill) I headed home. At the foot of Il Buro road (the road we live on - it's about a 15 minute walk from the base to our house) I twisted my ankle. The locals seemed genuinely concerned, and surprisingly none of the taxi drivers that park there tried to take advantage of the opportunity to get an extra fare. I managed to hobble to one of the many pharmacies on the way home and buy and ace wrap and Bryant and Eric kindly came down the hill to meet me and help me home. I'm fairly certain nothings broken, but it's definitely sprained which is going to be a pain in the ass. Today I am icing and elevating and I'm considering skipping church tomorrow for more of the same, particularly since I am committed to working Monday through Wednesday.

Which brings me to the flying medical squad. Apparently, the flying medical squad does mostly well baby checks, vaccinations, and pre-natal care. None of which I am specifically trained for, and all of which I have decided not to do as a practicing doctor in America. We will fly out Monday morning to somewhere in the bush (they told me the name but i forgot to write it down so I've forgotten it.) We'll spend all day with the patients - I will probably be in charge of blood pressure checks and fundal heights, while the pilot (who is not medically trained) will take care of vaccinations. We'll spend the night in a mission settlement nearby and repeat the clinic Tuesday and Wednesday. Eric is kindly allowing me to borrow his tape measure and obstetric emergencies cheat sheets, though it's unlike we'll have any of the drugs or equipment we'd need in an obstetric emergency. Apparently, when they don't have any volunteers to go along, the pilots do everything. The pilots get their medical training from a catholic priest who also has no formal medical training. So I'm trying not to feel woefully unprepared for the patient care I'll be doing, but not entirely succeeding. At least Jane gave me some anti-nausea medications - she went on one flying medical squad flight and barfed the entire time. So I have lots of exciting things to keep me busy till it's time to come home, and while my time is winding down, my list of stuff to do seems to be ramping up. :)

African Time

In Africa, like much of the rest of the world outside the US, things happen slower. On my days with hospice, we often spend 2-3 hours in the morning getting ready for the day - getting the medications we are going to take in order, having tea, buying any other supplies, etc. This is all done at a leisurely pace and we rarely do any actual patient care before noon. Rounding on the Medicine wards is similar - if someone wants morning tea, we have it before we go see the patients. The change has been both pleasant and incredibly frustrating to someone who is used to the American medical system where practically every moment spent at work is spent working unless you are actually forced to wait for something and there's nothing else that can be done during that time. The westerners here roll our eyes and wink at each other and refer to 'African Time' when we think something is taking too long or not being prioritized appropriately. However, we've also gotten used to this system. As my departure date approaches (I leave next Friday, the 13th) I feel like my time is accelerating back to American time and I have a lot of things on my list of stuff I was planning to get done eventually while I was here that now needs to get done soon. For example, I was planning to give a CME (continuing medical education) talk on pain and symptom management on my last Tuesday here. Unfortunately, yesterday I ran into Sarah, who coordinates with the flying medical squad and had arranged for me to go out with them next Monday through Wednesday. She forgot to tell me that she had arranged this and I had assumed she had forgotten I was interested and I wouldn't get to go. So now I will be in the bush somewhere doing basic medical care on Tuesday morning. Hopefully Dr. Kipuyo, the selian hospital director, will let me give the presentation Thursday. I kind of miss African time already, and I've not even left yet.