Finding a place at the hospital.

Hey everyone,

It was so wonderful to talk to both sets of parents this weekend. Sorry, mom and dad Casanova I was still asleep from a late night out!

In any case the week has been exciting. I have a level of independence here at the hospital that is exciting and very challenging. I was called into an emergency surgery on Wednesday night. A women had a ruptured ectopic pregnancy. I'd seen the surgery done twice in the US, but both times the pregnancy had been detected before it ruptured. The doctors here helped me immensely and the surgery went very well.

The day before, however, I found myself in a cesarean section running into problem after problem. The suture string here is not attached to the needle so as I was trying to sew up the uterus, the needle kept on coming off my suture. In addition, of course, my suction was not working so it was impossible to see what I was doing. I felt terrible because it was nearly impossible to tell if I had stopped all the bleeding. We finished the surgery, but I had a guilty feeling that the surgery may not have gone well. I was comforted to see the women the next morning breast feeding a beautiful baby and her surgery seemed to have had no complications.

I think rounding on the children's ward is the most challenging job I have taken on. There is no designation of an ICU and there is only one nurse for all the patients, with the help of 1-2 nursing students. The most we have had is 20 children. Rounds in general involves asking some basic questions, mostly whether or not the mother thinks her baby has improved. There are very few laboratory tests to confirm what may be cancer or sepsis, you have to go entirely on the clinical picture. Since I'm so used to micromanaging sick children in the US, I find it very difficult to change my expectations of what I should be doing. As a result every morning I come to the hospital to find that one child, sometimes expected, sometimes not, has passed away.

The staff at the hospital has been so amazing. They love to learn and love to soak up knowledge. They also are generous in sharing information and teaching me about tropical disease, local feeding patterns, traditional medicine and various techniques of doing procedures.

In any case, I am finding that the challenges to health care in a rural community in Tanzania are only amplified in the hospital. Most of what I see is complications of preventable disease, Malaria, Pneumonia, Meningitis, some of which we have vaccines for in the U.S. But also, the number of patients showing up after watching a wound fester into gangrene or seeing HIV go to the level of wasting is tragic.

Finally, I've spent time with the well funded HIV clinic. They are able to give medicines for free. The number of people on antiretroviral medicines is about 800, with 1200 HIV positive people visiting the clinic monthly. The have an outreach worker who finds patients who miss appointments and they have 5-10 people coming to be tested every day. People are amazing at tacking their medicines. Almost no one misses a dose, and it seems inconceivable that so many people still lack treatment because of stigma, cost of care or lack of infrastructure.

In any case, I think I'm realizing that for all the procedures and surgical training I have, there is nothing that replaces a local health care provider in your community, that you can get to any time, and that will treat your problems early, with thoughtfulness and respect. I'm so glad I'm a family doctor.