asante sana muhimbili

today was our last day at the hospital.  tomorrow we will shop, eat, and pack and then board our planes back home. 

i think i have a lot of thoughts about the trip, but i need a bit of time to reflect before posting.  it has been a really great trip - full of learning, teaching, laughing. 

today was a fairly typical day of clinic and rounding.  we did make it to the canteen one last time.  and, today, i braved chips my eye... the french fry omelette.  it was actually very delicious.  and, we said goodbye to our favorite canteen guy. 

they decided to do a little mini-fumigation of the wards today.  i think it more stunned the cockroaches rather than killed them.  they just seem to move a little slower.  i think a big fumigation is planned soon.  we bid farewell to the cockroaches as well.

during afternoon rounds, we told the families that tomorrow we go back to america.  it was hard to tell them we won't be there kesho (tomorrow), as it seems we have all grown accostumed to one another.  they all say hello and goodbye and we attempt the same words in swahili.  they see us run from the bugs and giggle and we watch them pay the bugs no attention.  they each said thank you and goodbye and wished for our safe travels.  we thanked them and said until next time to all the bright smiling faces.

only one more day at muhimbili...

it's thursday night.  tomorrow is our final day at the hospital.  we will give one more lecture this morning- we decided to end with fever and neutropenia instead of palliative care... it seemed better that way.  what's a better way to say goodbye than a little lecture on fever and neutropenia? 

we spent the morning in clinic and rounding (clinic included a fairly exciting spinal tap with wriggly little one... i was just the assistant, thank goodness).  then, this afternoon, we got to go see the hostel (the tanzania ronald mcdonald house equivalent sort of).  the parents and patients who live too far from the city stay here when they aren't inpatient.  there are nice rooms, toilets, classrooms, and a room where the mammas make jewelery and bags to sell to raise money.  it was nice to see the place that they are so eager to get to when they are on the inpatient ward.  and, we all picked up some great jewelery. 

we took a lot of pictures of the kids this afternoon- and, they love it!  they love to get a picture taken, look at the picture, get another picture, look at that one- over and over and over again.  i still can't quite get them posted but when i get home, i will put them up here...

we completed our lecture blitz yesterday- we talked to the pediatric residents about leukemia, lymphoma, wilm's tumor, rhabdomyosarcoma, osteosarcoma, ewing's sarcoma, neuroblastoma.  and, it was kind of entertaining- we got really stuck on the staging of hodgkins.  they all had out their textbook making sure we were saying the right stuff.  and, they had lots of great questions.  it was a little exhausting for all involved, but i think overall it was helpful.  between sue's lecture and ours, we have drummed up some business.  one of the residents has sent over 5 or so new patients...

i don't think i ever blogged about the fun island we went to last weekend... we took a little dinghy to a bigger boat which took us to an island off the coast of dar - bongoyo island.  there was a lovely beach and several little umbrella things to sit under.  we ordered fresh bbq'd prawns and sat in the shade.  we swam in the ocean and met someone from orcas island!  it was a great way to spend the afternoon.

tonight, we are waiting for the fundi to come back to see how our dresses are coming along... we'll see...

tomorrow, we will round and go to clinic, say goodbye to all the staff and kids.  i think it will be a little hard to say goodbye to all these wonderful little ones.  and, it will be hard not to know what will happen next for them. 

saturday, we plan to eat and shop until it's time to head home!  we have to fill up our suitcases that were filled with supplies on our way here- so shopping is a necessity! 

goodbye mr rat.

nameeta and i hadn't seen the rat that sue saw her first week here.  until today.  he unfortunately died and was swept up into a corner until he was disposed of... maybe he got into some chemo?  hopefully he was a he and didn't leave any little ones behind...

this morning, sue gave a kind of grand rounds- a lecture to the interns, residents, and some consultants (no medical students as they have been granted a "breather" for the next two weeks to study for exams).  she discussed what to do/what to think about when you are worried a patient has cancer.  soon after her lecture, two new patients were delivered from the general pediatric ward as her lecture set off alarm bells in the doctors head... we will see what they have. 

nameeta and i were charged this morning with preparing several lectures for the interns/residents to take place tomorrow afternoon... so, we are working on getting those together - in addition to our usual morning lecture.  hopefully we can find some previously created lectures in our stash that we brought with us. 

last evening, a fundi (a worker of any sort- this one happened to be a tailor) came to the apartment to make dresses out of the materials we bought while on our bike tour (did i already write about this?  i am having deja vu).   anyway, we giggled our way through the measurements.  he is going to bring the dresses by on thursday for a fitting and they will be done by the time we leave on saturday! 

nameeta and i spent the afternoon today gathering together the information we have collected in our mini chart review- hoping to give the doctors here some information on their patients and areas of successes and areas of challenges.  it has been interesting to read through the charts and see how children present to medical care and the challenges surrounding that.

ok i must go... lectures are not preparing themselves.

muzungu sana and muzungu kidogo hit the big city on two wheels!

i'm sorry for the delay in posting, we have had a very busy few days... so, get ready for some updates.

Saturday:
nameeta and i got up and caught a taxi to a building not far from here.  Nameeta's in charge of getting taxis and negotiating the price.  we decided that i should hide in the bushes while she negotiates since they think she's a local and won't charge her a muzungu price.  we hopped in and off we sped...going way too fast down the chicken lane.  i almost asked him to slow down but decided to just close my eyes and hope for the best.  we arrived safely and located our bicycle tour guide and the bicycles.  the bikes were in pretty ok shape.  the guide took the one with the fringe on the back of the seat that i'm pretty sure nameeta was eyeing.  we strapped on our helmets and off we went.  we started at 8:30 am...
the first stop was at a few of the second hand shops.  the shop owners go to the bigger, more chaotic second hand market, purchase items inexpensively, and then bring them back to their stores to clean them and mark up the prices to sell to people who don't want to go the chaos of the second hand market.  there were some pretty awesome shoes... very tall and very brightly colored. 

the second stop was at a...coffee shop of sorts.  men were grinding coffee beans and making fresh, strong coffee.  they make the coffee and then carry it in the pot around the city selling it to people passing by.  rather than having sugar to put in the coffee, they make fresh peanut brittle and sell that as a sweet.  we watched them make both things, and then we tasted it... i didn't care much for the coffee but nameeta loved it!   but, i did really like the peanut brittle.  it was perfect - just enough sweet... there were several kids there that were running around and playing, and checking out the visitors.  the chickens and roosters were up to the same thing...

the third stop was at the chapati/chai container...literally, there was a container (like off of a ship), where windows were cut out and a woman was making chapati and chai.  the chai was perfectly spicey, and the chapati was fresh and hot.  the woman making them had a bright face with a nice smile and big hoop earrings. 

hmmm, somwhere in there, we went through the ghost market - an open market that the government built but then the taxes were too high so no one used it - hence the name ghost... but then the taxes were lowered, so people are starting to use it.

as we were riding our bikes on very bumpy roads, children would come running out of the houses chanting mu-zun-gu, mu-zun-gu, mu-zun-gu, and then they would run up to us and give us "knuckles" on our bikes, and then run after us until it was too far.  i wish i had a picture of us being chased by children chanting muzungu, but the one in my brain is pretty bright.

ok, next stop... a traditional house- a 6 room house, each room contains one family - maybe up to 6 or so people, then a veranda where everyone sits for food or entertainment, and then one washroom.  we went inside and saw how cramped the space is... and, we were told about the soap opera like drama that can develop in these tight living quarters... we ran into several little children here- all saying, take my picture.  so cute. 

then, on to the herbalist/midwife/doormat maker whose friend also makes paper mache roosters... very normal.  we learned about different plants for fever, seizures, constipation, malaria.  and, we learned how to make paper mache animals.... all very handy lessons, i think.

we next met the man selling herbs and such at the witch doctor store (his brother is the witch doctor but he was out).  we smelled a few different items, but we were trying to get him to give us some love potion...it seemed kind of like an interesting pursuit. but, only the witch doctor can give that out apparently.

this was followed by a trip to the kanga shop where we picked out several fabrics.  our guide, a very nice young man patiently translated each saying on the fabric as we held them out.  and, he thoughtfully helped us decide which one was best for each of us.  he said we spent a very long time in the shop... but, we left with several kangas and tonight, a man came to the apartment and is making clothing for us tonight.

then, we went to the cinema.  not really a 12 screen or 10 screen or 8 screen cinema... more like benches and a 24 inch TV with a make shift stereo system playing a bollywood movie with swahili translation very loudly.  it was hot and sweaty in there, but we took this opportunity out of the sun to re-apply our sunscreen.  i lathered on my lotion and nameeta used her spray container.  the locals were quite confused at our sunscreen and thought nameeta's was perfume.  one woman looked accusingly at her husband asking why she couldn't have sunscreen.  i explained to them how i was going to get skin cancer if i got a sunburn... and, then they looked at nameeta and said she wasn't all that muzungu... and thus we were named muzungu sana - very white and muzungu kidogo - just a little white.

ok, next... oh the other market where there was so much fruit and beans and rice and corn and peppers and people.  people everywhere wanting to get their pictures with us.  one particular man, yelled out in swahili that he wanted me to come sit with him as i could be his ticket to america!!  there was extensive talking involved which ultimately led to me sitting on a pile of oranges with him posing for a picture... i hope that doesn't mean we are somehow married.  

we then went to the secondhand market where they were selling all the stuff they sell in the first place we visited.  i have never seen so many bras and underwear... and i was worried about having enough!!

i think our last stop was to get a soda and chat with our guide.  he was really a great guy and full of information and made sure we were always safe.  our tour lasted until 1:30, and we left feeling like we had gotten a great experience of the city and people.

then, we went to the golden tulip to swim in their infinity pool, surrounded by people in questionable bathing attire.

sunday, after rounding, we went to an island!  an uninhabited island!  so great...

more about this later...dinner is ready!

Saturday at Muhimbili

Hi all!

Nameeta and Kristina are off at Muhimbili today (it's Sunday morning) and I'm home getting ready to do some paperwork stuff (an organizational plan for the ward after we leave and a presentation for Grand Rounds--yes I now get a crack at the infamous grand rounds of the earlier post) so I thought I'd fill you in on Saturday at Muhimbili (because, yes, I'm procrastinating on the other tasks)!

So, pole sana (very sorry), Edwin didn't show up to get me on Saturday morning.  I'm not sure what happened, maybe the bajaji is still broken, but he usually sends someone else then.  Anways, at 8:45 I decided I better get walking or finding a taxi on the road.  No taxis to be found and it wasn't that hot and no rain so walking it was!  I did walk mzungu-style because I was late.  We've figured out why the locals all walk slow, they don't get hot--and mzungu-style fast walking makes you sweat a lot.  So we try not to walk Mzungu-style but no choice today!

The best thing was that the patient Kristina wrote about with likely T-cell ALL and a mediastinal mass who had been febrile and looking terrible for a couple of days looked wonderful on my arrival (after a rather large desperation dose of IV Dexamethasone the night before).  Mom reports no more fevers and greatly reduced pain and her breathing is much better.  Now, for those oncologists out there, her labs were not yet back in the evening so hopefully the kidneys did ok, I guess Kristina and Nameeta will find out today.  Our other new AYA leukemia patient also was feeling much better after his first appropriate dose of dexamethasone, so a good start to Saturday.

Rounding was uneventful--pretty much anyway.  And then when we finish on Upendo(the "sick" ward) then we go to the nurses office and the Tumaini (the more well ward) parents come find us if there are issues.  So there were a few issues.  An outpatient waiting on chemo came with a new CBC which wasn't good enough so there was an extensive conversation.  Then another outpatient, a little girl only a month or so into Wilm's tumor treatment came with her mother and mom reported that they were going to discontinue treatment to go home to pray for healing.  We tried to discuss but mom's mind seemed made up.  Very sad because she was doing well.

Then I had a brief break and a couple of kids decided to hold my hand and walk me around the unit.  One was our very sick Hodgkin's patient from when I started who looked VERY bad and now looks great!  Yeah chemo!  We were walking and then the food trolley came along which means they are getting close to handing out lunch.  She dragged me back to her room and woke her mama from a dead sleep shouting in Swahili what I can only assume meant it's lunch time!  The mamas came running to get in line but they weren't quite ready to hand out lunch so they all laughed at the little girl.  I think it's been quite some time since she has had a good appetite so it's nice to see and all of her swelling has gone done and she now wears all her pretty dresses again!

Then we moved on to chemo in the spinal fluid--these were left over from Friday.  I can only say that I've not seen anything quite like it.  The chemo was not really labelled and we had to deduce the doses.  We didn't have the right doses for sme kids (so no-go) and we had more chemo than charts but we managed to give IT (intrathecal chemo) to about 5-6 kids including our new 18 year old with leukemia.  Thankfully another teen had just gotten one because the new patient had no idea what we were talking about (and the Tanzanian attending had explained it) so he felt better seeing that other teen.

Oh, I forgot before ITs 2 new patients with very large abdomens showed up in on the ward with no warning.  One seems to have the largest Wilm's tumor we've seen and not sure about the other one.  So we got that organized-sort of.

Then during ITs someone with fever came in from outpatient and didn't look so good and we spent the better part of the next 2 hours trying unsuccessfully to get an IV in.  I tried (now that's not saying much), Lulu, the Tanzanian attending tried a lot, and then the Tanzanian resident tried.  Finally, we sent him to the emergency department to plead for help.  We left then, I hope he got a line, we sent the antibiotics with him so he'd get them ASAP (well not so ASAP from the fever but when the line was in).

Lulu brought me home and then I managed to find my way to meet the girls for dinner after their lovely day experiencing Dar!  Wait until you see the pics!

day off = awesome...

we will post more soon, but right now we must go to bed as the sun zapped all of our energy during our amazing day off!! 

the bike tour was so great- we saw a lot of the city and were chased by children chanting muzungu muzungu muzungu take my picture... so, maybe tomorrow i'll get some pictures up if i can make it happen.

we spent the afternoon at the golden tulip hotel at their pool.  so nice.  and then, we had a lovely dinner watching the sun set!  so great!! 

off to bed now and then rounding tomorrow.  and, hopefully we'll get back to the golden tulip tomorrow afternoon for another dip in the pool!

chitty chitty bang bang goes boom boom

Our Friday got off to a rough start to say the least. Edwin promptly arrived and off we flew! We made the traffic light right turn at the busy road which takes us to Muhimbili and we all cheered...but as fast as we were zooming little did we know trouble lied ahead.

All of a sudden as the breeze was cooling our faces, we heard a hiss sound from the Bajaji.  Ohhh no! Edwin turned around to look at the right tire and sadly we had a flat tire.  The bajaji was tilting toward the side I was sitting on and Kristina had to keep holding me in on all the turns!  We were just pulling into Muhumbili hospital and Edwin insisted on driving us to the drop off round-about at Jengo lawatoto (Home of the Children)...such a nice man.  We arrived safely and soundly...Hopefully Edwin was able to fix the flat tire and had lots of good business today. 

Today we went to Grand Rounds, Tanzania style.  One of the 3rd year pediatric residents presented a case of a young girl with a mediastinal mass and impressive cervical lymphadenopathy.  The room was packed with medical students, interns, residents, consultants (general pediatricians), and specialists.  When we introduced ourselves everyone giggled and laughed....were they laughing at the muzungus??? Nope. Apparently we just sat in the intern section!  The grand rounds was a clinical presentation of our patient who had Hodgkin's lymphoma and the resident was heavily critiqued on everything from her sentence structure to her physicial exam skills.  It was intense!

After grand rounds, we returned to the ward to check on a sick patient in respiratory distress.  When we returned, we saw him take his last breath. We removed his 02, closed his eyes,  and said goodbye.  Just his aunt was with him and she had to call his parents who live 10 hours away.  It was very sad. We still don't know what he had and may never know.

I spent the day in the outpatient clinic and it was very busy.  Patients quietly wait in the lobby outside and all have numbers.  One comes in and we signal for the second patient to come in at the same time.  So basically you are seeing two patients at once....HIPAA does not exist. The highlight of the clinic was when a child who was 2 years off therapy for Wilm's tumor showed up with his file (chart) and large lumps around his jaw...MUMPS!!! yikes! We ushered him to the now empty lobby and got him taken care of without further exposure to the immunocompromised children. 

Tomorrow Kristina and I are off on a bike tour through local parts of Dar-es-Salaam then relaxing by a beautiful beach in the afternoon!