Tanzania Part 2

Hello All!

the KCMC students packed up and ready to go home

I forgot to mention one aspect of the set-up here that is fairly important. In addition to the staff here, the hospital is currently hosting 10 Tanzanian students from Kilimanjaro Christian Medical University College. They arrived a few weeks before we got here, and will leave one week before we do. They are third year students, having their first clinical experiences. As part of their training, a resident comes from Kilimanjaro Christian Medical Center (KCMC) to teach them for a week in their specific discipline. They had OB/Gyn before we arrived, a pediatrics resident last week, and this week is a resident in internal medicine. I really like having the university-minded resident here – it allows me to see how the healthcare services provided are different even within this country because going on rounds with the resident is a different experience from rounds with the Gonja doctors. For example, he clarifies to the students that although the young woman likely does have somatization disorder, ideally we should check for organic causes of her behavior and the diagnosis of somatization disorder is one of exclusion. Another example is a type I diabetes mellitus patient that was admitted before Kendra and I arrived and is still here. The first day the resident saw him on rounds, he asked if they could do labs to check for end organ damage from the disease – how are his kidneys? His eyes? These things were not considered by the providers here – or at least not mentioned to me. Perhaps they didn’t mention it because they know they cannot carry it out. Which brings up the issue of resources.

One resource is doctors. When we talked on Tuesday, the resident described a familiar problem – doctors (especially specialists) finish their training and want to stay in the big cities. Even young adults who grew up in a rural area, once they go to a big city for training and get used to living there, do not want to return to the rural area they are from. Another resource is equipment, and I don’t think you will be surprised to hear that the hospital here lacks many diagnostic tools we take for granted at home. They have an x-ray and an ultrasound, but no CT. Also, I don’t think they have anyone here trained to use the ultrasound machine, which they need in order to really take advantage of what they can do with it. We went to the lab one day to learn what they can do here, and I still don’t think I know for sure. However, there are definitely blood tests that they cannot do here. As for treatment, we’ve had a number of patients that need one antibiotic, but can’t have it because it is out of stock. I am not sure they even stock other things, like dextrose solutions in higher concentrations than D5 (important for hypoglycemic patients), or small enough gauge IV’s for neonates. Of course, they do have medicines that I bet I couldn’t find in Clarion (mostly anti-retroviral medications for the HIV patients). Maybe it comes down to priorities and where they can spend money to benefit the most patients.

One last comment on resources; my friend and classmate had an experience with a patient in the hospital who had a terminal cancer and also a drug-resistant infection that was only susceptible to one antibiotic. When they ordered that antibiotic, it just so happened that they got a warning saying there is a (national?) shortage of the medicine. They went through the extra paperwork required and got the medicine for their patient. I heard about it because my friend brought up the ethics of using a limited resource for a patient that is going to die no matter what. In this case, the hospital/state/country is so big that the physicians treating the terminal patient will not actually feel the shortage or have to compromise care of another patient. At Gonja Lutheran Hospital, however, it is a different story. Choosing to treat an HIV patient with an opportunistic infection that they likely won’t be able to fight off might take antibiotics away from an infant later. Just a thought.

Probably I thought about this scenario because in our first week here there was a 5 day old baby boy who died of septic shock due to cord sepsis. The pediatrician from KCMC was here that week, and he had initially written for ampicillin and gentamicin to cover the possible organisms. The hospital didn’t have either of these, and instead they started injections of ceftriaxone. The baby got 1 or 2 days of antibiotics, but didn’t make it.

Just 2 days after that baby died, Kendra and I attended a delivery of a baby girl. She was born around 11:00 am and looked terrible. She didn’t cry and was blue and limp. I grabbed the bulb suction and tried to clear any secretions, but she still wasn’t breathing. Every once and awhile her mouth opened and closed in a way that reminded me of a fish out of water. There are many details to the resuscitation that I won’t describe because I’m not sure I can do it accurately. Mostly, the resuscitation was slow to be initiated and lacked many of the tools needed to do it correctly. Also, when it became clear she was having more prolonged trouble that stimulation and suctioning wouldn’t cure, Kendra and I had to really push to order diagnostic labs. Really, all we got was a glucometer that showed her to be hypoglycemic (this was about 2 hours after she was born). Although we were trying to get her to nurse at this point, mother and baby weren’t connecting. We ended up giving the baby 15ml’s of D5 solution (remember, D5 is the highest concentration they have) and we gave it orally because the smallest IV catheter they have is 24 gauge. Luckily, later that afternoon the baby started nursing. She stayed at the hospital for 5 days or so to receive antibiotics in case an infection was the cause of her hypoglycemia. There were a lot of things that could have gone differently, but maybe we wouldn’t have had to fight with her so much to start breathing if we had known we needed to correct her hypoglycemia and done that earlier.

Baby Girl (I can’t remember what they named her) has had the biggest impact on us so far. It plays right into Kendra’s project as well, as she was hoping to do some teaching about newborn resuscitation for her global health project.