The Medical Apprentice

Before we made our way back to the US we had one last hurrah in Tanzania.  For some R&R on the last two days of our trip we had the opportunity to go on a safari.  The word safari means “journey” in Swahili, and the experience certainly lived up to its name.  On the flight into Tanzania I got to watch one of my favorite movies, Jurassic Park.  The trip definitely had the same adventurous feeling as the movie, up until that stormy scene when dinosaurs began eating people.   

Our trip began in the city of Arusha, a common departure point for safaris and excursions to Mount Kilimanjaro.  We loaded into our heavy duty Land Rovers and set out on the drive to our first destination: Ngorongoro Crater.  As our guides registered outside the park entrance we had a chance to get out and stretch our legs, allowing our first encounter with the local wildlife.  There were baboons everywhere, and they weren’t exactly afraid of humans.  I was admiring the scenery and all of a sudden heard a shriek from inside our vehicle.  Yours truly had left his window open, and a baboon was holding on to the frame, in the act of pulling itself inside.  Some frantic waving and shouting was able to scare it away, but other cars weren’t so lucky.  It was an impromptu security checkpoint.  Some baboons had managed to open bags strapped to the roof and were seen sitting on the curb eating packs of Skittles. 

Ngorongoro crater is a UNESCO world heritage site.  Over two million years ago it was a massive volcano.  The lava stopped flowing beneath it and the volcano collapsed on itself, forming a crater twelve miles wide and two thousand feet deep.  On one side stretches the Serengeti, meaning “endless plains.”  The area is also nicknamed the Cradle of Life, as close by is Olduvai Gorge.  This is the sight where the Leakey’s discovered the oldest known ancestors to humans, contributing a great deal to evolution research. 

Looking at the site from the crater rim, it was hard to grasp the enormous scale of what I was seeing.  We were at an elevation higher than Denver, and there was a chill in the air.  Looking down into the crater you could see a lake, groves of trees, and elephants reduced to tiny brown specks. 

As we drove around the rim of the crater we saw huts dotting the landscape.  These belonged to the Maasai, indigenous people who live in Tanzania and Kenya.  As we traveled we often saw men tending to small herds of cows or goats, carrying a single wood staff to defend their cattle from animal attacks.  The fabrics they wore were amazing blends of red and blue.   

We had the privilege of visiting a Maasai village.  We were greeted with a welcoming song, and upon entering the village we had the opportunity to go into a home.  The Maasai huts could be constructed in one week’s time, and are made with a wood frame covered in cow dung (and no, they do not smell).  It was cool to see that inside each hut was a special place for baby cows to sleep.  I enjoyed getting to learn about the traditions maintained for centuries, and day-to-day life in such a surreal location.

After we left the Maasai we started to head down into the crater.  We were on a narrow one-way switchback road, cautiously creeping down using four-wheel drive.  It was not for the faint of heart!  To make things more interesting we were attempting to eat our boxed lunches on the way down.  I had a triangular shaped pineapple juice box in one hand, an amazing samosa in the other, with the rest of my lunch precariously positioned on my lap.

As soon as we reached the bottom we turned to find a huge male elephant less than fifty yards from us.  Boxed lunches flew as we scrambled to open the top.  Our vehicle’s roof opened up on a hinge, allowing us to stand on our seats to get the best view out the top.  It was surreal to see a huge elephant with long tusks casually walking by.  The animals were used to having safari vehicles pass through.  There were strict rules against exiting the vehicle while down in the crater, so their interaction with humans was fairly limited. 

It seemed like we couldn’t drive for more than a minute without finding another group of animals.  We saw zebra and wildebeest herds intermingling, and hippos packed into a pond.  From warthogs to hyenas, I’m pretty sure we saw the entire cast of The Lion King. 

We were driving leisurely by a lake when all of a sudden our guide put it into high gear.  Kicking up a cloud of dust we sped down the dirt path.  Something was going on.  In the distance we saw a group of vehicles stopped.  A stopped vehicle means that they are looking at something, while a group of vehicles means they found something pretty amazing.  We pulled up to find two male lions in the grass.  They were enjoying one of my favorite hobbies, an after-lunch nap.  Looking out the other side we could see (and smell) what was left of lunch, a buffalo.  In the distance we saw hyenas and jackals on alert, waiting for their crack at the leftovers.  As we waited one of the lions woke up, yawned, and began walking around.  It was a thrill to be there at just the right time.    

At the end of the day we made our way out of the crater and to the local village where we would be staying the night.  There was a small hotel there, but we were staying on the grounds outside, sleeping in tents.  The name of the village was Mtowambu, which translates to “river of the mosquito”.  We managed to rig up the mosquito net in our tent.  However, the next morning to my chagrin I awoke to find the net bunched up below my neck, with a fair number of fresh bites on my exposed hands and feet.  Luckily we were at a high enough elevation that we were out of the malaria zone, though it still wasn’t a pleasant wake-up call.

After a quick breakfast we were off to Lake Manyara.  We spent the day meandering through the forests and over the trickling streams leading to the lake.  The roads twisted a great deal, so it wasn’t unusual to come around a bend to find a group of impalas, a giraffe feeding from the tall branches, or a baby elephant and mom taking a drink.  One of the docs in my vehicle was an avid birdwatcher, and that day she was pleasantly surprised to see lovebirds, hornbills, flamingos and kingfishers.  Termite mounds were everywhere, shaped almost like sandcastles.  We even saw three mongooses raiding a mound, looking for a mid-morning snack. 

Before we left we visited a rathery popular watering hole in the park.  There was a group of hippos relaxing on the banks.  Flamingos, geese, and pelicans flew overhead.  There were zebras and a group of wildebeests crossing, with giraffes in the distance.  In the sky broad beams of sunlight cut through the clouds to shine on the red earth below.  It seriously seemed like a scene from the Lion King, and I was half expecting “Circle of Life” to start blaring from a speaker hidden in the bushes.  Instead we were serendaded by the sounds of two hippos mating in the foreground, pushing the whole Lion King concept to at least a PG-13 rating.

What struck me the most from our safari was how primal and ancient everything felt.  We passed by massive decaying baobab trees and earth littered with skulls and bones.  Everything functioned in balance and in nature’s rhythm.  I got an overwhelming impression that it was a place where life flourished for eons before humanity, and one that would sustain life long after we were gone.  Our team had spent the last week in a makeshift clinic in a neglected area that could greatly benefit from our attention and intervention.  The safari provided a stark contrast, as we were introduced to an ecosystem that in many ways depended on the lack of human intervention and meddling for its survival.  After all, as eloquently stated in Jurassic Park, “nature finds a way”.   

With the frantic sprint to finish logging my patients and procedures and study for the big test, I was looking forward to completing my surgery rotation.  After the exam the thousands of miles of travel getting to Tanzania certainly helped distance me.  However, it turned out I was in for one more eye-opening experience in surgery.

For this trip the medical team paired up with a surgical team led by Dr. Glenn Geelhoed from George Washington University.  During the first few days some minor procedures were performed at our clinic site, while patients needing operations at the hospital were selected to come back on the last two days for their surgery.  We were initially unsure of what diseases we would encounter and therefore what procedures would be performed.  In clinic we saw a fair number of patients with massive hydroceles (fluid collections in the scrotum), complications of filarial infections.  Other patients selected to go to the OR had unsightly lipomas, fibroadenomas, and scars. 

The surgeries were performed at the Korogwe district hospital, a few miles from our clinic site.  The hospital’s two operating rooms were in a relatively new building that was sealed with glass windows.  In order to keep things clean, everyone removed their shoes upon entering the building and slipped on a pair of communal flip flops. 

The operating room was bright white and fairly spacious.  Or rather, it lacked the crowded array of monitors and trays of equipment that I was accustomed to back home.  Each room had a single surgical light.  However the electricity went out quite frequently, so the building was designed with large windows to keep things well lit.

The OR attire consisted of scrubs, a white plastic gown, and matching white rubber boots.  The surgical caps and masks were cloth, so they could be washed and reused.  The process of scrubbing in for surgery became complicated by the hospital’s lack of running water during the day.  Therefore at the foot of the scrub sink there was bucket of clean water, which the nurse would carefully pour with a cup over the hands of those scrubbing in.     

Having a successful day in clinic depended on flexibility and a little ingenuity, and a day in the OR required the same.  Surgical supplies and equipment were limited and carefully rationed.  Even though needle drivers were not in every surgical set, sutures still had to be placed.  It was quite a departure from the cornucopia of instruments seen on trays in the United States.  Despite some surgeries starting with seemingly two strikes against them, at the end of the day things turned out well.

I was surprised to hear that for some hospitals in Tanzania surgery could not be performed during the rainy season.  Surgical towels and cloths were washed and left outside to dry, since many hospitals could not afford a dryer (or did not have the electricty to run one).  Only after completely drying could the fabric be placed in the sterilizer.  Therefore in seasons when the fabric could not dry, sterile surgical sets could not be assembled.

During the day there was an accident outside of town involving two busses.  There were over thirty injured, with four fatalities at the scene.  About a dozen were admitted to the Korogwe district hospital.  A local doctor was operating on one of the patients in the room next door.  She was nine years old with severe injuries to both her legs (bilateral compond tib-fib fractures).  The initial plan was to externally fixate the broken bones and send the patient to a larger hospital, five hours away.  At the time it was uncertain if this child would ever walk again.  Her case was one of so many that frustrated me that week, as I knew the outcome for many of those patients would have better if the accident had occurred back in the states.  Yet we were far from home, and all that anyone could do was simply the best with what was available. 

For Dr. Geelhoed, teaching is an important part of his medical mission work.  He teaches new surgical techniques and procedures to local medical personnel.  Performing surgery for a week is beneficial, but teaching others the surgeries that can be done the other 51 weeks can make a huge difference.  In this same way the medical team offered guidance to the nursing students who were helping us that week, since they will be continuing the patient care where we left off.  At the end of the week the remainder of our twenty duffels of medications and supplies were donated to the hospital.

To say the least it was eye-opening to be inside an operating room thousands of miles away.  It was strange to be in a situation that seemed both familiar and alien all at once.   

Here are some more random pictures and stories from clinic and our travels out and about in Tanzania.  For larger versions of any photo just click on the picture, then click “all sizes” with the magnifying glass icon.  Here is Mount Kilimanjaro.

Korogwe district hospital was a few miles away from our daily clinic site.  It is all on the ground level, and has 150 beds in pavilions that are connected by open, covered walkways.  The setup is very functional.  No elevators are required, which is good given that electricity to the compound is somewhat unreliable.  In times of disease outbreaks buildings can easily be converted to isolation units to protect the rest of the patients in the hospital.    

Here is the pediatric ward.  Notice the brightly colored mosquito nets at each bed. 

Here is a list of the top 10 diagnoses from the pediatrics ward. 

Each day at our clinic site there was always a swarm of curious kids.  They would run behind our vehicles as we came and left.  We’d always play with them in our down time, and it was a blast.  We knew very little Swahili, and they little English, so it made things quite interesting.  They called us “Mzungu,” meaning white person.  The word isn’t meant to carry racist connotations.  Rather it’s more like calling things as you see them, and my pale Irish skin certainly stuck out like a sore thumb!   

On our first day the kids found a turtle outside.  (Another one of the first Swahili words I learned, turtle = kobe).  The group picked up the poor little guy and carried it with them to various mzungu-watching activities throughout the day.  Therefore it ended up in a fair number of photos.  At the end of the day the game changed to trying to sell the turtle to the mzungus for the bargain price of 10,000 shillings (about $7.70) 

There were always a fair number of animals around our site.  Sometimes a wayward group of goats would wander through. 

I’ve written before about the interesting medical student jobs that exist, and on this trip I found a new one.  Medical student job #874: capture and remove chickens from triage. 

Traveling was always an adventure in Tanzania.  Here is the bus that we used for our longer trips between cities.  We crammed 25 in for our 4-10 hour rides.  While it might not have looked like much, our driver used it like a sports car.  He would pass on hills and blind curves, and we had more near-misses than I would like to remember.  One day we got pulled over for going 82 mph! 

Multiple trips were needed for the brief rides to clinic each day, as our team normally only had one vehicle to use.  To help expedite things a bit, the more adventurous of us (or less smart, depending on how you look at it) would ride on the luggage rack.  It was a pretty fun way to travel, giving great views of the town.  The only bad part was having to watch out for low-lying tree branches, which weren’t always visible when coming back in the evening!

The interesting part about these trips was that you never quite knew what to expect next.  If you could maintain a sense of adventure and flexibility (and the ability to block out traumatic near-misses on the bus), these little moments quickly became favorite memories.  

First off, I have so many stories and pictures I wish to share from my trip.  In an effort to not crash the website (or my own brain), I’ll be dividing my thoughts into a number of entries over the next week or so.  For now, here’s a taste of a typical day in clinic.

Our days would begin with an early breakfast of an egg, toast, and hot dog, along with some pretty tasty instant coffee and tea.  We ate in an open-air pavilion listening to the calls of exotic birds while feeling the brush of a stray cat as it sneaked beneath our chairs.   

Our team loaded our duffel bags and crammed into every nook and cranny of our vehicles for the short ride through town to our clinic site.  We were in Korogwe, Tanzania, about an hour’s drive from Tanga.  Our fearless leader was Dr. Richard Paat, an internist at St. Luke’s hospital.  Bill Schnackel and I made up the small but mighty UT med student contingent.  For the week we also joined a surgical team from George Washington University, but more on that later.      

We drove up narrow dirt road, kicking up a cloud of dust behind us.  The soil had a red-orange tint to it, and it felt like the everything was covered in a thin layer of dust.  By the end of the day you could feel it on your skin, drying out your eyes, and producing never-before-seen colors when blowing your nose. 

Our clinic for the week was set up in a school, since classes were out for summer.  We commandeered four buildings, and rearranged the desks and tables.  There was no electricity or running water.  The only light came from large windows with chain-link screens. 

We were lucky enough to have a great crew of interpreters.  They were nursing students at the local school who volunteered during their vacation to help us.  While many of us picked up quite a few phrases of Swahili by the end of the week, we would have been sunk without them!  I could say “Habari, za asubuhi” (hello, good morning) and “Jina langu ni Patrick” (my name is Patrick), but outside of that I suffered a linguistic meltdown fairly quickly. 

Our patients would often be in a long line waiting when we arrived each morning.  The crowds increased each day as word spread about us.  The first building that patients would enter was triage.  Here our team started a patient encounter form, taking down demographic information (age, number of children) as well as a basic medical and social history (tuberculosis, HIV/AIDS, cigarette and alcohol use).  Then the patients would briefly explain what brought them to clinic that day.  Next they would have their vitals checked.  Children were measured and weighed so we could give weight-based doses of medications, and later construct growth curves. 

After passing through triage the patients would then go to our next two buildings that had our clinical stations.  Each station would be a group of desks shoved together, covered in stacks of stickers, prescription sheets, various scopes, and bottles of hand sanitizer.  A physician/PA/NP would be paired up with a med student and an interpreter.  We would group by the windows for light, though careful not to leave our supplies within reach of the swarm of curious kids always peering in with wide eyes.  The few tables of the room were packed with various supplies such as glucometers, specimen cups, gauze and gloves.  In the corner was an examination table which we made private with the help of rope, surgical draping, and a little duct tape. 

I saw patients with a number of diseases rarely seen in this country, such as malaria, filariasis, and intestinal parasites.  At the same time we also encountered conditions quite common in the states, such as asthma, arthritis, and hypertension.  Part of the fun of clinic was having to improvise at times.  Spacers for albuterol inhalers were made from wrapping tape around a paper tubes.  Sometimes you had to carry the baby outside into the sun to get a good look at a rash.  Breathing treatments were given using a nebulizer powered by the cigarette lighter on a truck. 

Almost all patients we saw were prescribed some type of medicine, if nothing else vitamins or Tylenol.  The prescription sheets were written in English and Swahili, and we circled statements describing how to take the medicines. 

After seeing the medical team, the patients would then proceed to the pharmacy to pick up their medicines.  Some medicines were already counted into convenient amounts (such as ibuprofen in packs of 30) to help ease dispensing.  Before sending patients on their way with their meds in small plastic bags, the local nursing students would talk to the patient and ensure they knew how to take each medicine they were receiving.   

As the sun began to set, triage would stop seeing new patients.  As there was no electricity in the buildings or street lights outside, daylight was our limiting factor.  Our clinic days usually ended with many of us crowded into the pharmacy, flashlights in hand, fumbling in the dark to help fill prescriptions.  While our days could best be described as organized chaos, the pharmacy at dusk usually leaned towards the latter! 

Once the last prescriptions were filled we quickly packed up our supplies and headed out.  The fatigue from the long day wouldn’t actually hit us until we had a chance to clean up and sit down for a while.  After a hearty dinner the students presented on various topics they researched, and the group would talk about interesting cases they saw that day.  If there was time we would relax and sample a Tanzanian lager before heading to bed to get ready to repeat the process the next day. 

We ran our clinic at the school for 5 days, treating over 1500 patients.  I feel honored to have been able to share the experience with such a great team.  We met some amazing people in Tanzania I won’t soon forget.  More stories and pictures soon!

We left our hotel in Dar es Salaam to head for the airport around 5 AM, and a little over 30 hours later we were finally back in Toledo.  Everyone returned safe and sound.  The medical mission was a success and the Toledo International Youth Orchestra was warmly welcomed.  I have plenty of stories and pictures to share in the coming week or so. 

For now, a bits-and-pieces tour of our clinic site (due to technical difficulties half of the clips from the tour didn’t quite make it).  We were in Korogwe, located about an hour away from Tanga, Tanzania.  We took over a school for the week to set up shop.  Sorry for the “Blair Witch” style video.  Many more stories coming soon!