Karibu Zanzibar

For my last full weekend in Africa, Aparna and I went to Zanzibar, Tanzania for a long weekend. We went to Kisumu last Thursday, flew to Nairobi in the evening, went out to an Ethiopian restaurant for dinner and stayed overnight, and then caught an early flight to Zanzibar on Friday.

Friday we spent the day in Stone Town, the old part of Zanzibar City. We took a city tour with a man named Farid, who I read about on a travel blog online and was recommended by the blog author and a hotel in Stone Town. He was a character -- he spoke rapidly, knew a lot about the history of the city but rarely gave us information in a chronological order, and scurried us around the town without an obvious plan. He waxed poetically about the traditional dress and kitenge fabrics (worn as a sarong or head wrap) of the Portugese-Oman-Indian-African influenced people of Zanzibar (which included pointing at women in burqas and calling them 'ninjas') and showed us what felt like every single ornate door in the whole town. After 2 hours with Farid, we were hot and thirsty. He left us on the rooftop of the Emerson Hotel at a restaurant called the Tea House where we sat on pillows at low tables, drank beer and water, and had a great view of the Indian Ocean and the entirety of Stone Town. 

We wandered around town on our own after our hydration break, had lunch at Lukmaan restaurant, toured the Anglican Cathedral which is located at the site of the former slave market, and took in the sights and pungent smells of the Darajani Market. Then we caught a cab to the northernmost town on the island, Nungwi, where we stayed for the remainder of the weekend. It was a relaxing weekend -- we walked the white sand beach, watched locals wade in the shallow turquoise water to fish in the mornings and take out their dhows in the afternoons, swam in the pool, laid out in the sun, read novels, did yoga on the beach, frequented an ex-pat bar for afternoon drinks and chips (Beach Baby Lodge), and ate dinner while watching the sunset on the beach at Baraka Beach Restaurant two nights in a row (they had great pizza). 

Here is a selection of pictures from our Zanzibar holiday: 

View from the Tea House rooftop

Old Slave Market/Anglican Cathedral

Basement rooms where slaves were kept prior to being sold at market (this room would have housed 25-50 people at a time)

Memorial to Dr. David Livingstone 

Smiles Beach Hotel

Nungwi Beach

Dhows anchored in the water

Sunset Nungwi Beach

More Nungwi Beach

View of Mt. Kilimanjaro from the plane 

"Road Traffic Accident Emergency"

Well, the past week has been more eventful than usual!

After a typical day at the hospital last week, I walked home around 4 pm with plans to read in the sun in the hammock or possibly fit in a quick workout before everyone else was home. Aparna had been in the operating room with a hysterectomy case that was pushing 5 hours, and she was starting to get sick, so I wasn't planning to wait for her to exercise. I changed into my running shorts and was sitting on the porch considering my next activity when Priyanka's phone rang. It was Aparna calling from the hospital. When Priyanka hung up the phone, she said there was a "road traffic accident emergency" in the Emergency Room. Not quite sure if that phone call was a request for help, I saw Priyanka starting to pull on her boots and realized that meant we were heading back to the hospital. I threw on my Chacos, waited for Molly to put her shoes on, and we started walking toward the hospital with Priyanka following behind. Her phone rang again and she ran up to hand it to me -- Aparna said that the RTA patient had an obvious head injury, his mouth was filled with blood, he wasn't breathing well, and asked what to do after they suctioned out the look. I suggested a jaw thrust, oral airway, and bagging if he wasn't protecting his airway. We picked up our pace, still at least 8-10 minutes from arriving at the hospital. About two minutes later, we saw the hospital's ambulance come careening down the dirt road toward us. The driver stopped in the middle of the road, let out two passengers and we loaded up into the van while the driver made a less than graceful 180 degree turn on the one lane road, taking advantage of a nearby yard. We tore down the dirt road with no regard to the ruts that plague the ground. I wasn't sure we were going to survive the drive without an RTA of our own. We pulled up to the ER entrance and ran into the resuscitation room to find Aparna and one of the COs at the head of the bed of a young man with a puddle of blood beneath his head, wearing a c-collar with a pelvic binder (i.e. a bed sheet tied around his hips) in place, and a splint (i.e. cardboard) applied to his deformed left femur. Sticking of the man's mouth was a laryngoscope and an endotracheal tube. His vitals flashed on the monitor at the bedside. -- heart rate 55, oxygen saturation 57%. Aparna attempted to intubate before we arrived but she was pretty sure she had the tube in the esophagus and had pulled it out. While trying to get some idea of what had already transpired, I grabbed a pair of gloves, squeezed between the head of the bed and the wall trying to avoid getting blood on my shorts or legs, and took a look with the laryngoscope. It wasn't the best view, but the airway was clear of blood, and I managed to get the endotracheal tube in place (which we could confirm only with listening to the chest and over the stomach). We tried to improve his oxygen saturation with bagging but the pulse oximeter continued to read low. I listened over his chest again and heard breath sounds with the bag assistance, but no heart sounds. We checked for a pulse, and came up empty. There was not any cardiac activity on ultrasound. Despite the efforts of the team, our patient was not going to survive. We debriefed for a few minutes after the trauma and identified many areas of improvement for trauma resuscitations here (especially following the ATLS algorithm beginning with "A" for airway). It was certainly a good lesson for the COs and nurses in how to work as a team and they astutely recognized areas for improvement and their need for practice/simulation with major traumas. Unfortunate outcome for the patient, but an important learning opportunity for the staff. 

Less adrenaline provoking, but a new experience for me was assisting one of the EM/FM residents with placing a suprapubic catheter in a older man with urinary retention. A normal Foley (urethral) catheter was attempted several times without success, so we decided to place a suprapubic catheter. This is not something I do regularly at work, but I decided to go check on the resident during the procedure to see if I could help. He had already attempted once when I arrived at the procedure room and was unsuccessful. I suggested using ultrasound guidance for his second attempt -- we could now see the needle enter the bladder, and also confirm the catheter was in the bladder after insertion. The catheter seemed to be functional initially but later urine started to leak around the insertion site. We considered taking him to the OR to open the incision site more and actually look at the bladder and see if there was a way to better secure the catheter...but I'm not a surgeon, and Aparna was going to have to be the surgeon in charge of overseeing the resident and she doesn't usually operate on bladders, or on men...so we referred him out to a urologist. I felt a little out of place trying to assist someone in a procedure that I am not comfortable with, especially when it is being done with a technique that I would expect in an OR and not in a procedure room in the ER, but it was fun to do some creative problem solving in an environment where there is flexibility to do such.  

Side note explanation for the random pictures below -- in honor of the upcoming Summer Olympics, we had our own "Sagam Olympics." Everyone chose an empire to represent (mine is the Ethiopian Empire) and an anthem (I chose "Roar" by Katy Perry) and we had an opening ceremony (which involved cooking Greek/Mediterranean food, slam poetry, and a parade of empires whilst carrying the "torch" -- an empty wine bottle with a candle sticking out of the top). Oh, and there were also glow sticks and glow in the dark face paint involved. Our first, and so far only event, in the Sagam Olympics was three on three tug of war. Aparna wore a shiny pink unitard straight out of an 80s jazzercise class. Enjoy!

Jeffrey, leading off the parade of empires

Molly, Aparna, Lance and Steve preparing the anthems for parade of empires (Lance chose "Pretty Fly for a White Guy", but the only version Aparna had was Weird Al's "Pretty Fly for a Rabbi"...we made it work)

Jennifer, representing Australian Empire

The infamous pink unitard

Gold Medal team on the left (me, Molly, Lance) and Silver Medal team on the right (Levi, Aparna, Karla)

Interesting Cases

Here is some medicine for those of you interested in the nitty gritty details...some of these cases are interesting because of the medicine, but many are here to illustrate the challenge of resource limitations. 

- Case 1: 6 yo M with sickle cell disease admitted with acute chest syndrome. He had multiple episodes of acute chest in the past. Febrile and hypoxic on presentation, he remained febrile after 7 days of antibiotics and was still hypoxic with attempts to wean his oxygen. He wasn't able to get a chest x-ray due to his low oxygen saturation. When we finally convinced the tech to due the XR, he had a large pleural effusion on the right side. He improved after the addition of gentamicin to his antibiotic regimen (ceftriaxone, azithromycin started initially). We attempted US guided thoracentesis, but without lidocaine and with a needle that was too short, so it was unsuccessful. He required multiple blood transfusions for a hemoglobin in the range of 3-4. We considered attempting an exchange transfusion if he was not improving and we were unable to wean his oxygen.

- Case 2: 10 yo M w recurrent seizures who previously had cerebral malaria and was treated, but now is in status epilepticus (multiple back-to-back seizures). We are limited here by the medications we have available to treat certain conditions. We have benzodiazepines (first line) to treat seizures, but our only second line option is phenobarbital, which can cause respiratory depression -- and we do not have the ability to provide ventilatory support for patients beyond an Ambu bag, making this a potentially risky choice. This is the second patient in status epilepticus we have had since I arrived. The first week I was here, we had another child in status who we transferred to the government hospital in Kisumu because his respiratory status was already poor (he tolerated the placement of an oral airway without gagging) and we did not have any other options for treatment here. He had multiple seizures en route to Kisumu and was intubated on arrival to the ICU. 

- Case 3: An older gentleman presented with hypertension and altered mental status, reportedly also with a fall from standing. His blood pressure was 200s/120s on arrival and he would not speak to staff or follow commands. His blood pressure was treated emergently in the ER with hydralazine and nifedipine with a resultant drop in his systolic blood pressure to 109 -- which is too much, too quickly! His mental status did not improve with the drop in blood pressure. We were concerned for possible ischemic stroke vs hemorrhagic stroke vs intracranial bleed related to the fall vs hypertensive encephalopathy given his presentation. He had a history of a prior stroke as well with unknown residual effects. We cannot use CT for stroke diagnosis without referral to outside facility, and usually patients with stroke do not present acutely anyway. His mental status improved after about a day, although he demonstrated some signs of dementia/delirium and it was unclear how much of his altered mental status preceded the elevated blood pressure or was a result of the hypertension. 

- Case 4: Another older gentleman presented with altered mental status and was found to be hypoxic on initial evaluation. His etiology of hypoxia and altered mental status was unclear (although it is very possible that he was altered because of the hypoxia, we did not know why his oxygen saturation was low), he had a negative urinalysis and unrevealing labs. He was started on empiric antibiotics with meningitis coverage and a CXR was ordered. He would not tolerate oxygen through the nasal cannula due to his altered mental status and kept pulling the cannula off his face. He was not on a cardiac monitor or continuous pulse oximetry. He could not get the CXR done due to his hypoxia. Overnight, his saturations dropped further and he became unresponsive and pulseless. After 3 rounds of epinephrine and chest compressions, he was pronounced. 

- Case 5: A young woman in her 20s presented with new renal failure of unknown etiology. She was evaluated at an outside facility and started on dialysis, but discharged from that hospital after a few days. She was not continued on dialysis as an outpatient. She presented here with altered mental status, likely related to uremia. Her GCS was 11 on arrival and precipitously dropped to a GCS of 3 within a few hours. We did not have the ability to do an EKG (out of EKG paper), nor did we have time to do labs and evaluate her potassium/BUN levels. Because of the acute mental status change and need for emergent dialysis, we arranged for transfer to a facility with the capacity to start her on  hemodialysis. She died on the ride to the outside hospital. 

 

- Case 6: We checked on a 80 year man in the morning on rounds during the CO's presentation it was noted that the patient was at the hospital for the complaint of dysphagia (difficulty swallowing). As a side note, he mentioned that the patient was also hypoxic despite placing him on 4 liters of oxygen by nasal cannula. Noting the continued low oxygen saturation, the CO increased the patient's oxygen to 5 liters per minute, but he never rechecked the oxygen saturation. When we were at bedside, the patient was altered (unclear baseline), had a gaze deviation to the right, and his oxygen saturation was 92% on 5 lpm oxygen. It seemed likely to us that his dysphagia, which was reported as the chief complaint, was actually due to a stroke and that the hypoxia was presumptively secondary to aspiration. Because his symptoms began more than 5 days prior to arrival to the hospital, and his poor overall prognosis given that he was dependent on oxygen (which he cannot go home with), he was discharged home with his family and referred to hospice care.  

No work, all play weekend

Aparna was asked to go to her Kisumu clinic on Saturday, so part of our group (six of us to be exact) travelled to Kisumu on Friday afternoon to spend the night and part of the day Saturday in the city. We again crammed into Freddy's car for the ride, with Lance sitting in the trunk with everyone's luggage, peeking over duffel bags like a gremlin. Fred's soundtrack for the ride was singable 80s/90s soft rock and sing we did. The road was crowded with kids walking home from school, drunk men stumbling across the street, tuktuks, and matutus (passenger vans that cost about 300 shillings for a round trip ride) with creative names printed on their windows -- "Haters Gonna Hate," "Sky's Da Limit." The streets in Kisumu were similarly bustling when we arrived, and Fred navigated through what felt like the entire city to get us to an Ethiopian restaurant where we planned to have dinner. It was getting dark when we reached the Ethiopian Habesha Restaurant and we were the only guests there. We were greeted by George, a Kenyan who previously lived in New Jersey, the owner of the restaurant which also serves as a bed & breakfast. George is very welcoming and accomadating. We had called in advance to place our food order because it takes multiple hours to prepare and he timed it perfectly for our arrival. George seated us at an outdoor table with a dark green tablecloth and comfortable chairs. We started our meal with Tusker (beer), washed our hands at table side with hot water and soap from our waitress, and then the food was ready! The tibs, wat, and lentils were fantastic; the injera had just the right amount of sourness, and we nearly ate every bite on our common plates. 

Beyond satisfied and nearly bursting, we piled into a taxi after dinner and headed for our hotel. As it turns out, there are two hotels with the name "Imperial" in Kisumu -- the original one, and the Imperial Express. We went to the wrong hotel on our fist attempt. Our taxi driver was gone so we asked the desk clerk if we could use the hotel's car to get to our intended destination. After negotiating a price, he agreed and asked us to sit in the lobby and wait. Which we did while eating a bunch of cookies from the desk. The van that took us to the Imperial Express was huge by comparison to everything else we've been riding in -- we each had our own seat, no one had to share. But the trip was only about 2 minutes long -- we enjoyed it while it lasted. The Imperial Express is more modern than the original Imperial and the clerk at the desk, Bellah, put up with our antics of attempting to check six people into three rooms with only three valid IDs amongst the entire group (I left my wallet/money/ID in Sagam -- oops). 

After Bellah showed us to our rooms, we met in the lobby to head out to a bar. We planned to go to a place called the Duke of Breeze, which is an ex-pat rooftop bar in the city that both Lance and Aparna have been to before. Our driver (the same taxi driver that we used at the Ethiopian restaurant) did not know where the bar was located, so he asked someone else on the street. A man on a motorbike said he knew the place and to follow him, which Robert (taxi driver) did. We turned down a dark, unpaved road and pulled to a stop outside of a lifeless building. Motorbike-man said the bar used to be in this building but the management changed and it was no longer open, possibly was undergoing renovations. He suggested a different bar and offered to show Robert the way. We drove in what turned out to be a circle, arrived in a parking lot for a large 4 story building with a rooftop bar that was located directly across from our hotel. Cost us 2 USD for a trip around the block. We climbed four flights of stairs, entered a dark wood paneled bar with loud music, sat a table near the windows and ordered more Tusker. The bar was pretty quiet when we arrived, but within about an hour the waitstaff cleared out some of the tables in front of the bar and everyone started dancing. We danced for a few hours as the bar filled up with both ex-pats and Kenyans. A couple of Kenyan guys danced with our group for most of the night. Our favorite was a tall lanky guy wearing a navy knit sweater, who silently slid into our circle and danced awkwardly but enthusiastically. 

The next morning, Aparna left early for the clinic while the rest of us gradually woke up, had some breakfast at the hotel (they had great coffee), and took hot showers (finally!). We then split up in two tuktuks -- the boys went to the soccer stadium to buy Gor Mahia jerseys while Molly and I went to Java House for coffee frappes. The boys joined us shortly after and we ate lunch at Java before taking Steve to the airport to catch his flight home. We had a pretty lazy day in Kisumu waiting for Aparna, mostly we ate food (after Java, we had popcorn from the movie theater and Diet Cokes/Pringles from the grocery), shopped at Nakumatt, sat outside or in the car talking to pass the time. Aparna finished later than expected because, although she thought she was going to see patients in clinic in turned out what they asked her to come in for was to participate in a rally for International Women's Health Day. She marched, danced, listened to speeches, and did some cervical cancer screenings. She came back hungry and sunburned. We headed back to Sagam and made it in time for a dinner we had planned to celebrate Fred, Jeffrey, and Jennifer's birthdays at Debora's house (Debora is basically the COO of the hospital, her father is CEO/owner and also owns the property where we live). There was so much food and it was all amazing -- we had chicken nuggets, garlic pasta, chapatis, mashed potatoes, makote chips w guacamole, vegetable curry, and ribs made by Debora. For dessert, we had strawberry cupcakes with chocolate frosting (Jeffrey's favorite) and s'mores bars while watching the movie Shooter on TV. 

Sunday was eventful in a very different way. Aparna and I planned to run 7 miles (she is training for a half marathon) and we set out on back roads through the village. At the half way mark, we came to a big road that we thought was the same road that the hospital is on -- we were wrong. After running another 3.5 miles the wrong direction on the wrong road, we stopped and asked a couple of women how to get to Sagam. They pointed back in the direction we had come from and said, "Sagam - it is a long way." Yep, it was. In fact, it was 7 miles away. We walked back along the same route, without any shade most of the way. All I could think about was cold water for about the last 2 miles. Our planned 75 minute trip took a total of 3 hours. We were muddy, sunburned, thirsty, and exhausted when we made it back to the house. I chugged a liter of ice cold water (thankfully, I had put my water bottle in the freezer before we left) and lay on the porch while Aparna reclined on the cool kitchen floor. Then we shared a couple of beers with lime while we made breakfast tacos, including homemade tortillas. After a long shower and a nap in the hammock, I felt as good as new -- except for my very burned neck and face. 

Lance in the trunk of the car ("trunk gremlin")

Ethiopian Restaurant

A Day in the Life

Our days usually begin around 06:50 with breakfast in the old house (eggs or granola and a speedy cup of instant coffee if I'm lucky) followed by the muddy, humid, uphill trek to the hospital. Entering the hospital grounds through the red, white, and blue metal gate, we are greeted by the chirping of bright yellow male weaver birds building their elaborate nests and the scent of yellow guava fallen from the trees. We head straight to the ER for morning handoff at 07:30, when the night clinical officer (CO) discusses all of the patients he/she evaluated overnight with the morning staff. Then, it is upstairs to the library where the mud boots come off and we set up shop for the day to work on lectures, research, or other online activities (such as blogging...). By about 10:30, the COs are ready for rounds in both the ER and wards. 

On average, we round on about 25-30 patients. We begin with the "high dependency unit" and pediatric patients in the ER, then move onto the private ward upstairs, followed by maternity, female ward, pediatric ward, and male ward. This takes until nearly 12:00-13:00. Then we lunch in the canteen!  The post-lunch routine is variable -- sometimes we give lectures for medical students/COs, the fellows have meetings, or we continue to work in the library as in the morning. We end our work day around 16:00 and walk back to the "compound."  Shoes get kicked off on the shoe porch, sandals go on, and then it is leisure time. Usually for me this means exercise (running, yoga, Nike Training Club), reading, and playing games. We take turns cooking dinner each night for the "family" and plan out our meals in advance. Last week, Aparna and I made a "tamale pie" although I did not have cornmeal to make the topping so I made up a mixture of corn, breadcrumbs, spices, baking powder, chapati flour, and milk and created my own cornbread. Lance makes some sort of bread it seems almost daily, and he makes his recipe "by feel" which is impressive -- my favorite bread variations so far are the caramel rolls and pizza that we made over the weekend. Cooking together is a nice way to wind down after the day and it is fun to creatively plan meals with the foods we have available. After dinner, we all sit down in the living room to watch pirated movies (Jeffery buys movies from someone in Kisumu, who will put movies on a flash drive for between 0.30-0.50 USD) or play card games (I taught people to play "Chinese Bridge" and learned how to play "Euchre") before bed.  

Weekends are less structured and the fellows are only responsible for rounds. The cool weather in the early mornings is perfect for running, so Aparna and I set out for a 6 mile run Saturday morning. Our route was challenging but beautiful -- the rocky, uneven, dirt roads are lined with blooming bushes with multicolored flowers, quiet farms, and little kids in oversized mud boots. During runs or walks, we are frequently greeted by passerby most often in English ("How are you?, "Fine"), especially the kids, who also love to give high-fives. This area of Kenya is punctuated by rolling hills, making our run particularly exhausting. I spent the remainder of the day recovering in the hammock with a book. 

Saturday evening we went out to celebrate Fred's 30th birthday. All seven of us, plus Fred (who was as usual driving), and three more friends from the hospital packed into a 5 passenger SUV and made the mercifully short trek to Luanda, about 6 km away. We pulled up to a pink building, home to a restaurant/bar called Oasis. Climbing at least 4 flights of stairs, we passed rooms filled with people eating and drinking at each level, to reach the top floor overlooking the tiny main street in Luanda where there was a pool table, TVs broadcasting the Manchester United game, and people sitting at plastic tables eating fried fish, chips, and drinking Tusker beer. We pushed three tables together and ordered food and drinks -- including an entire bottle of Jameson for Fred, which he shared with some of the guys. As a result, after dinner Fred started dancing and convinced everyone to join him. Somehow we managed to get our entire raucous group back into the car and home without any problems. Poa kichizi kama ndizi!

Weaver bird nests

Library Work Room

Canteen

"The Container" (meeting space)

Wards

Emergency Room

Entrance 

Return to Africa - The First Week

A year and a half after my last trip to Africa, I am back. My trip to Ethiopia with Auna was a much needed reprieve from the frustrations and pace of American medicine. It felt like a reset. I left Ethiopia with a new found confidence in my ability to practice medicine independently and an appreciation both for the conveniences of life at home as well as the simplicity of a life without constant electronic stimulation, where there was ample time to enjoy the outdoors, exercise, sleep, and read. Here's hoping for similar results from this trip. 

As before, I connected through Dubai but only had a 4 hour layover in the airport, enough time to grab a Coke Light and a quick nap under the desert sun pouring in through the windows. I arrived in Nairoi around 8 PM local time, stayed overnight in a small apartment owned by the MGH program to house visitors connecting through Nairobi, and left for Kisumu early the next morning. It was still dark when I went to the airport and the driver, Jeffrey, pulled up to a checkpoint to enter the airport grounds where we were met with a traffic jam. Many people were getting out of their cars and walking to a sidewalk on the right had side of the road. I didn't understand what was happening at first. Then Jeffrey said, "When we get closer to the gate, you get out and walk with those people to the small building there and go through security. You don't need to take anything." I thought he was joking at first. I have no idea what the purpose of this exercise is -- from what I can tell, passengers disembark and walk through a metal detector housed in a building off to the side while the drivers stop at the security checkpoint and the cars are searched. Then all the passengers wait on the other side of the checkpoint to get back in the car. Given that you have to go through security twice more before actually boarding a flight in the airport, this seems like a meaningless exercise. Despite the delay, I made it to my gate on time for my Kisumu flight. I even had a chance to use 15 min of free internet in the airport -- long enough to find out that oral board scores were posted and that I passed! That was a relief. 

My flight landed in Kisumu just a bit after sunrise and I exited the plane, walked across the Tarmac in the cool morning air to the terminal to collect my bag and find Jeffrey, one of the post-undergrad research coordinators here. I spent the morning in Kisumu with Jeffrey and Fred, our driver, whose birthday happened to be the same day. Jeffrey and I had breakfast at Java House (good food, coffee, and reliable wifi; Jeffrey also bought Fred a piece of cake while we were at the cafe), went grocery shopping at the Nakumatt (impressively well stocked), and then returned to the airport to pick up a pharmacy resident who is also visiting the hospital for a couple of weeks. We then set out for Sagam where the hospital is located, about a 45 minute drive from Kisumu. Thankfully, this drive was significantly less eventful than our cow-dodging trek in Ethiopia. Fred entertained us with his eclectic collection of music, ranging from Dolly Parton to R Kelly. It is the rainy season here, so the countryside along the drive was lush and verdant, dotted with banana trees, hibiscus, and bougainvillea with purple mountains visible in the distance. The road we traveled was apparently once partially unpaved, but was finished recently in preparation for President Obama's visit to Kenya. His family is from Western Kenya near Sagam and there was a possibility that he would travel to this area to see them -- thus, the push to finish the road (the President ended up just staying in Nairobi, however). 

Once we made it to Sagam, we dropped our bags off at the house where I am staying during my visit. I am living with six other people at the moment, although this number will fluctuate during my month here. Currently, there are two Global Health fellows (my friend Aparna and Priyanka, a family medicine doctor), a pharmacy resident (Steven) and three research coordinators (Molly, Lance, Jeffrey -- they are all med school bound in the fall). Just before Steven and I arrived, the group had partially moved into a new house. Both houses are located on the same property, the new space is just up a small grassy hill from the original house, but we are splitting our activities between the two because of some finishing touches (hot water, window screens, etc) missing in the new house. Essentially, we only sleep in the new house and socialize, shower (if you prefer warm water), watch movies, and cook meals in the old house. 

The property on which the houses are situated is secluded and peaceful. It is about a 15-20 minute walk down rocky dirt roads from the hospital to the property, which is tucked back away from the road and surrounded by tall shade trees. The grounds are well kept with garden beds at the bases of the trees, pink roses blooming in the yard, and monkeys, chickens, and one small tri-colored dog roaming the area. The new house is two stories and is spacious -- with 10 bedrooms, 4 bathrooms, a kitchen, and two living areas (one upstairs and one downstairs). The old house is a single story bungalow with a  long front porch that is truly multipurpose -- there are table and chairs where we sometimes eat, play games, or just hang out and relax; a hammock, which is the best reading nook; work out equipment consisting of two yoga mats, an exercise ball, and two sets of hand weights; and a diverse, plentiful collection of footwear ranging from mud boots to running shoes to flip flops. In fact, about a fifth of the porch serves as the shoe holding area. The inside of the old house has a small kitchen with a stocked pantry, a projector for watching movies, two old comfortable couches, and most importantly flushing toilets and hot water. 

Jeffrey took us on a tour of the hospital next. Sagam Community Hospital is much bigger than I expected. It consists of a clinic/OPD building, a female ward, male ward, pediatric ward, maternity ward, a new ward with private rooms (mostly empty the majority of the time), radiology department, pharmacy, operating room, and a large ER that has a separate section for pediatrics (3 beds) and a high dependency unit (basically the ICU equivalent), a library where the fellows/coordinators work during the day, "the container" which is a trailer that serves as a meeting space, and the canteen.  We ended our tour in the canteen where we met the rest of the group while they were lunching. The canteen is also a tiny trailer-like structure with white plastic tables and chairs, an abundance of flies, ice cold orange Fanta and water in the fridge, and menus scattered about with a food list that vaguely resembles what is actually available. But the food is so good! You order at the window/Dutch door to the kitchen, then write your order in a notebook under your name so you can pay later. Lunches here take about an hour to finish, the food is far from fast, but it is refreshing to take the time to sit and relax after the morning of work. My favorite foods so far are chapati (a flat bread similar to naan), a dish we call "Rolex" (although I'm pretty sure it is actually "roll egg") which is fried egg rolled up in chapati. Other popular dishes are warm cabbage salad, sukuma (kale/collard green-like veggie), beef stew, and mandazi (Kenyan version of doughnuts). The Kenyan favorite is ugali, which is basically a bland dense cornmeal paste brick. 

After a week, I am now settled into the routine of life in Sagam...stay tuned!

View of the hospital

A visitor outside the kitchen window

Roads between the house and hospital

The new house and the yard

Shoe porch

Dog friend

Reading hangout

Last Things

Our trip has nearly come to an end.  We could not have asked for a better experience.  We saw so much in a short period of time, patients that presented as textbook perfect cases of diseases, some of which we have only read about.  We also developed some basic McGuyver skills, creatively fashioning solutions out of next to nothing.  We learned to be conservative in how we practice medicine, not by ordering a battery of tests to protect ourselves, but by using only what is necessary for diagnosis and treatment and nothing more.  We had to think more about our resource utilization, which made us think more about our physical exam, bedside ultrasound, and our differential diagnosis before we planned our work up and disposition.  We are better doctors because we had this opportunity.

While the medical experience was extremely rewarding, our experience would not have been the same without the people who helped us each and every day.  Our Ethiopian nursing staff in the ER made each shift a joy.  They tirelessly translated for us 'ferengis', proficiently navigating some difficult cultural and ethical situations and kindly but firmly redirecting patients who strayed from the questions we asked.  Sometimes we asked them to do something differently than they are accustomed to, or we wanted to do something that was brand new for them in the ER, and each time they were eager to learn and happy to help.  The GPs that we worked alongside were also invaluable resources -- we taught them a few things about airway management, central lines, ultrasound, and chronic diseases like AMI and stroke, but we learned so much from them in return-- they are experts in tropical diseases, they helped us broaden our differentials to take into consideration the disease processes that are common to this particular area, and they showed us daily how to make the best use of the system we had available.  They work extremely hard and they do not complain.  They were thankful for our help in the ER, but we were equally thankful for everything they did for us and for the work they do each and every day for these patients.

Finally, the Gabrysch family and all of the other missionaries at SCH were wonderful hosts.  Everyone was welcoming and generous, and it was nice to both live and work among them as part of their community for short time.  Jeremy especially was instrumental in making this a successful and rewarding trip.  He helped us immensely in the ER, we learned together as a team on some complicated cases, and more often than not if we called him to ask a question he dropped whatever else he was doing to come see the patient alongside us.  He even let us babysit his amazing kids for a few hours, but after keeping them up way past their bedtime playing games, I'm not sure we'll be invited to do that again!  Christina and Jeremy also let us crash their short vacation to Lake Langamo on the way to Addis before we all leave for the United States, which was relaxing and fun.  Plus, we got to spend some more time with the kids, both of whom are full of energy, very entertaining, and a joy to be around!

We will miss this place.  It will be quite a shock to be back at county in just a few days compared to our lives for the past month, but this was a welcome and refreshing interlude before the home stretch in our final year of residency.  Thank you again to everyone at home who made this possible for us, we love you all and we will see you soon!

New Airway Cart in the ER.  We finally completed this during our last shift!

Relaxing on the beach!

Fun in the car and kid-sitting shenanigans!