Some quick notes from last week- July 2-4, 2012

July 2, 2012

Today, we arrived at Ingira Kammed Clinic to find Dr. Lewis heading to the Bondeni Clinic, which is the second of Dr. Mhando’s clinics, located just outside the main market in the centre of Arusha. It was a busy day of patient exams and visits. Patients here treat visiting the clinic as a whole day event. They come and see the doctor, who orders a series of tests, and then they proceed down the hall to receive the ordered investigations. Then they wait to see the doctor again with the results- all in the same day! I wish we had that kind of service in our walk in clinics in Canada. The down side is the lack of investigations that are possible (we’re talking the basics here- CBC, electrolytes, EKGs, tests for HIV or H. pylori, blood glucose etc. Somewhat disturbingly, they also try interpret findings off a single lead EKG…), as well as the costs of the tests to the patient. Nonetheless, it is helpful to suspect an infection and have the patient come back in a few hours with lab results confirming the diagnosis before you prescribe antibiotics based on history, as we sometimes do in Canada.

After a full day at the clinic, the rest of the evening was quite relaxing. Julia and I cooked up a vegetable soup for the group (mmmm so many veggies I’d been missing!!!) and then Jocelyn and Loiq joined us for a moviel. It was nice to all snuggle in, eat some stale pop corn (omg, so delicious and it gets better the longer I’m here. Those small tastes of home…) and enjoy a comedy. Good night!

July 3, 2012

Bit of a slow day in the clinic today. Only 3 patients admitted on the wards so rounds were quick. Julia and I ended up spending the morning helping “computerize” the clinic. We transferred old echocardiogram reports that were in a notebook onto a computer file and tried to teach the nurses how to continue doing so themselves.

In the afternoon, we worked with Dr. Mhando, who had an afternoon of echocardiogram appointments. A slow morning was worth it to see some of the findings we saw later in the day! One of our patients had actual clubbing (something we are always told to check for and I have never actually seen) and many of our patients had murmurs and thrills. Really think I’m starting to pick up on the cardio findings!

Afterwards, Julia and I headed to the market to hunt for some local clothing. Julia picked up a pair of pants and a dress but I’m still on the fence. Unfortunately at the market, there are no sizes, no dressing rooms and only very small mirrors. Julia and I hold up things for one another to try to assess if we like them or not, or attempt to move the mirror around so you can see different corners of what you’re trying on. I did pick up some earrings though, so many in all the shops!

In the evening (meaning about 5:30 because the sun sets around 7 pm here) we went for a run and even convinced Jocelyn to come along! Next came an absolutely mind numbingly slow dinner at Pepe’s. Omg, it took about 2 hours to get our food. Dilan and Loiq have started placing bets on how long dinner will take. All I can say is, TITS. By the time we got our food, our group looked like wilted plants. No one was even talking anymore, some people had their heads on the table, and when food came, we remained silent as everyone shoveled food into their mouths, haha. Finally fed, we polished the evening off by finishing our movie from last night. And BED! Ahh! 🙂

July 4, 2012

What a difference today. Julia, Dilan and I were all together at Bondeni Clinic today with Dr. Baraka. Holy cow, it was busy and long, compared to the slowness of yesterday.

Some interesting stories today… we saw a little boy who had been complaining of a three year history of abdominal pain. He had already been treated for malaria, hookworm, typhoid (i.e. the classic diagnoses here) with no improvement. He also complained of eye pain and knee joint aches… and upon further questioning, had not been gaining weight and had a family history of similar abdominal problems. Another classic diagnosis here is peptic ulcer disease. But with his constellation of symptoms, I wondered if inflammatory bowel disease (i.e. Crohn’s or colitis) should be ruled out. Dr. Baraka had actually never heard of that condition. With the limited resources and range of tests they have here, they don’t scope people and therefore, never diagnose those conditions. The most patients will get is an abdominal ultrasound, they’ll find an abdominal obstruction and call that the final diagnosis. Anyways, we started with a few simple tests this patient could afford, like a CBC and an H. pylori test… and an HIV test. However, we didn’t tell the patient he was having an HIV test. Apparently, if patients were told that an HIV test was being ordered they would refuse it. Furthermore, each clinic uses a code acronym for “HIV test” so even on the test requisition slip, the patient would not be able to figure out what was being ordered. Dr. Baraka did admit that it’s not entirely appropriate, but that in this area, it has to be done and the benefits of diagnosing HIV outweigh any harm done to the patient’s autonomy. Interesting lesson in Tanzanian medical ethics.

Interestingly with this patient, his CBC showed what would in Canada be diagnosed as anemia… however, the acceptable ranges for Hemoglobin concentration are wider here and he still fit into that “normal” range. In fact, they won’t even transfuse patients til the hemoglobin is below 40. In Canada, the limit is 70. Another challenge, as in Canada, we may have interpreted the anemia as a possible sign of his abdominal condition and ordered further investigations; here, that was sufficient to rule out IBD. It’s a dilemma though- even if we made the correct diagnosis, what could be done about it? Does it make sense to ask the patient to pay for expensive tests if the management won’t actually change? I don’t know.

Later, we saw a patient in pretty bad shape. His heart rate and BP were through the roof, and he was having a lot of difficulty breathing. In fact, his heart was beating so fast and forcefully, his cell phone in his front shirt pocket was vibrating with the beats. We sent him for an EKG, and were then told the EKG machine had broken because his EKG reading was so wild. Upon glancing it, Dilan and I realized it wasn’t any problem with the machine- his EKG just looked that bad because it had the signs of an anterior heart attack. Unfortunately though, no one at the time was that adept in reading EKGS and thus, didn’t seem to understand the seriousness of the situation. It was such a frustrating situation. I was pretty concerned that this man was going to pass out any second, and Dilan kept asking if an ambulance could take him to a hospital, get some heparin in him, anything. We finally at least got him to chew some aspirin. Dr. Baraka agreed to admit him and have him assessed by Dr. Mhando- tomorrow. It’s hard to say- I don’t know if I was just really naïve or incorrect or being a panicked 2nd year med student who doesn’t know better, but we seemed feel so much more urgent about the situation than anyone else. We’ll see how he’s doing tomorrow, I  suppose…

We also met Dr. Baraka’s Mom today. Cutest ever, he called her Mommy. What a kind man! hehe 🙂

After clinic, we helped out the dents do some porch dental screenings on the CCF Arusha boys, and then took them out to dinner at a local restaurant. Pretty much the only thing on the menu was masala chicken. Julia and I discovered this when we tried to order a “lemon chicken” and instead got masala chicken with lemon juice squeezed on it. HAHA. Amazing. Oh well! Good times.

Much love to everyone,

Alina

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