A Spikey Friend

 

“Some people talk to animals. Not many listen though. That's the problem.”
A.A. Milne, Winnie-the-Pooh  

As a few people already know, I went on Safari (a blog post to come) and had a chance to see some of the wondrous creatures living in Africa. However, one of my favourite animals that I've met on my African journey, lives a little closer to home. In fact right outside the front door of Family House 4, in Haydom.

Henry is an African Hedgehog, and an honorary member of Family House 4. He has been with me since I first arrived in Haydom over 5 weeks ago and has remained despite some challenges. Henry is not much of day-person and prefers to party at night; usually starting off with some fine-dining of bugs and plants around dusk. Although, friendly he largely likes to hang out by himself, and until recently he was very camera shy.

At the start of this week something happened that would turn Henry's whole world upside-down. One day whilst he was out (presumably at one of his other lodgings), a bunch of local human's decided they needed to demolish his careful crafted home to get access to a blocked drainage pipe. It was pure devastation, his home was annihilated in a matter of minutes by picks and shovels, never to be seen again. How does a hedgehog prepare for such wanton destruction.

Later that night Henry returned to what was once his home, staring across the barren red tanzanian dirt. Nothing was left, yet for him, there was now nothing left to lose. He did not run away, he did not hide, he continued on, because he had to.

It was on this night that we found Henry outside, alone, looking bare without the grass and scrub usually covering him. Amin (another medical student) scooped Henry up. Henry adopted his traditional ball defense position, leaving only a small part of his face exposed. For although we were already acquaintances, hedgehogs can never be too sure if you are friend or foe.

And this was how Henry had his first picture taken, barely fitting in Amin's hands. We merely captured a moment of this little hedgehog's life, yet it's a moment I will at least hold on to.

 
If you find hedgehogs interesting or want to find out more about Henry, you can look up Four-toed Hedgehog or Atelerix albiventris.

If you're coming to Haydom and stay in Family House 4 make sure you say hi to Henry.

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A Warm-up Climb: Mt Hanang

Keep close to Nature's heart... and break clear away, once in awhile, and climb a mountain or spend a week in the woods. Wash your spirit clean. John Muir 

 
Out of the many things to do whilst staying in Haydom, climbing Mt Hanang should be on ever visitor's to do list. The Mt Hanang trek is often used by many as a warm-up climb to Mt Kilimanjaro. However, Mt Hanang is not merely a warm-up trek, it readily offers up its' own unique scenery and experience.

A bit of information about Mt Hanang. Mt Hanang is the fourth highest mountain in Tanzania at 3,418m. It is located in the Manyara region, with the town of Katesh lying at it's base. Tours to Mt Hanang are currently organsied by Elisha (who nearly everyone meets on the first day) in Haydom.

Getting to Mt Hanang
Myself and four girls (two Danes and two Norwegians – and yes I'm a lucky man) left from Haydom on a friday afternoon at four to begin our journey to the town of Katesh. The drive takes roughly 2 hours, and is actually in my opinion, on one of the better roads in Tanzania. Our driver was Anom, who works as the information officer for the hospital. You'll find in Tanzania, everyone has a second business, a farm or something. In fact, the hospital's semi-retired radiologist Dr Naman even owns a bar, simply called Dr Namans. But I digress.

The Trek
The next day, the team consisting of myself, Thea, Anna-sofia, Christine, Anne-kine and Elisha (our guide) got up in the early hours of the morning (5:30am) in preparation for our climb. Traditionally, the car takes you from the town of Katesh to the start of the climb at 2000m above sea level. Unfortunately for us it had been raining the whole night before, which meant that the roads where largely impassable. So we started a bit lower, with an extra hour of walking time, before we even reached the starting point.

From there it was a day of progressively climbing up hill, with sunshine, rain, fog and everything in between. The fog was particularly beneficial in the morning, as it helped not being able to see how far we had to climb up. On the way up a few of the team members did suffer some mild symptoms of Altitude Sickness, so be warned. Roughly 6 hours after starting our walk, we finally reached the summit, and enjoyed the spectacular views that were given to us.

The trek is a mixture of climbing through forests, low lying scrub and rocky outcrops. There aren't many animals, but the scenery is always offering up something new. The difficulty of the climb can be quite variable, but is definitely made more challenging if there has been recent rain. No mountain trekking experience required, but you should be reasonable physically fit.

That is a short summary of my Mt Hanang experience.

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Swahili 001 - The Essential Basics

To get the most out of your time at Haydom Lutheran Hospital (HLH), I would recommend learning some Swahili. I feel it's not only important to be polite, but also to embrace a key part of Tanzania culture. Not to mention as you progress it will help you on the wards.

For this lesson we will start off with some basic greetings, and phrases that any traveler to Tanzania should know. All the material I've either learnt during my stay in Haydom or picked up from various books. You might notice that what I have here occasionally differs to what you read elsewhere. This is because I'm largely just presenting the most simplest way of saying things. So this is basically a Crash Course in Swahili.

Ndiyo
Yes

Hapana
No

Greetings
Hello. (to one person);
Hujambo (response: Sijambo – I'm fine)

Hello. (to a group) :
Hamjambo (response: Hatujambo – We're fine)

Hello to an older person or authority figure.
Shikamoo (shee-kah-moh) (response: Marahaba).

Hello to people you know well and generally younger people
Mambo (response: Poa (cool), Poa kichizi kama ndizi (crazy cool like a banana) )

In more formal situations you should add titles when you are addressing people.

For examine saying hello to a male you can say;
Hujambo, bwana? (Bwana = sir, Mr, gentlemen)

For females you can use either;
Bibi or Mama. Mama tends to be more commonly used in Haydom.

Kwa heri
Goodbye

Asante
Thank you

Asante, sana
Thank you very much

Karibu
Welcome, come in, your welcome

Karibu sana
Your very welcome.

How are you?
There are a number of different ways to say how are you. Here I've listed the most common ones. Also note that you can often just say Habari, to ask how are you.

Habari Gani?
What news?

Habari ya asubuhi?
How are you this morning?

Habari ya mchana?
How are you this afternoon?

Habari ya jioni?
How are you this evening?

Nzuri, asante.
Fine, thank you.

And you?
Na wewe?

Tell them about you
Jina langu ni …...
My name is …....

Ninatoka …... (e.g. Australia)
I come from …..... (e.g. Australia)

Mimi ni Australian
I am Australian

And the questions they will ask to find out more about you.

Jina lako ni nani?
What is your name?

Unatoka wapi?
Where are you from?

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Evidence Based Medicine Coming to Haydom

Evidence based medicine is the cornerstone of how we are now taught medicine and it's coming back to Haydom.Yes, I was a little misleading with the title, but I'll explain why in a second.

At Haydom Lutheran Hospital (HLH), where possible interventions are based on guidelines, however due to the lack of resources and staff education levels and availability of doctors, evidence-based medicine is not always practiced. And I think the key to practicing evidence-based medicine is continuing education.

This is where a new exciting initiative comes in. As of tomorrow we are running education sessions every Thursday (typically lead by the expats) for all the local interns and doctors, as well as the foreign volunteers. This a great chance for information exchange to occur between people, who have come from all over the world. It also opens up the information (that we often take for granted) to the local doctors.

Systolic Heart Failure
So for the first session we are taking a look at Systolic Heart Failure.

The paper we are using as pre-reading is;
Systolic Heart Failure by Dr John McMurray in the NEJM (2010)

We are also using ProfessorEBM's module on Heart Failure to guide the discussion.

WHERE YOU COME IN
Considering my involvement with FOAM back home, I thought it would be interesting to see if we could get an asynchronous discussion happening every week on twitter as well. Bringing the collective wisdom of even more people to this hospital in remote Tanzania.

So for now I've come up with the hashtag #HaydomJC (e.g. Haydom Journal Club). If anyone comes up with a better one let me know.

Below I've provided an overview of some of the key points of the article and additional information concerning systolic heart failure for those who don't have time to read the article.

AETIOLOGY

• Coronary Artery Disease (cause of 2/3)

PATHOGENESIS

1. ↑Afterload – due to ↑pulmonary / systemic resistance + ↑volume
2. ↑Contractility - due to SNS stimulation
3. NaCl & H2O retention – due to SNS and RAAS
4. LV remodelling – hypertrophy, dilation, fibrosis

INVESTIGATIONS

• Blood tests – FBC, LFT, urea, electrolytes, cardiac markers, thyroid
• ECG & CXR: Largely insensitive, but can provide useful findings
• Echo: allows confirmation of diagnosis and information about the heart
• Cardiac MRI: useful in difficult cases

TREATMENT
Lifestyle

• Exercise
• improved functional capacity and quality of life in patients
• Salt Restriction
• often recommended
• little evidence

 

Pharmacological

• Diuretics
• For relief of symptoms
• Loop diuretics should be given to patients with fluid overload
• ACEi
• Enalapril, Captopril, Perindopril, Lisinopril
• reduce ventricular size, increase the ejection fraction modestly, and reduce symptoms.
• Angiotensin-Receptor Blockers (ARBs)
• Irbesartan, Losartan, Candesartan
• similar effectiveness to ACEi, but more expensive
• Beta-Blockers
• Non-selective: Propanolol
• β1-selective: Atenolol, Metoprolol
• Aldosterone Antagonists
• The addition of an aldosterone antagonist should be considered for any patient who remains in NYHA class III or IV despite treatment with a diuretic, an ACE inhibitor (or ARB), and a beta-blocker.
• Hydralazine and Isosorbide Dinitrate
• Studies indicate that those of African descent respond more effectively to hydralazine–isosorbide dinitrate than Caucasian patients.
• Pneumococcal and influenza vaccinations are recommended.

Surgical

• Implantable Cardioverter–Defibrillator
• reduces the risk of sudden death in patents with left ventricular systolic dysfunction
• indicated for secondary prevention
• Coronary revascularisation
• Valve replacement / repair
• Cardiac Transplantation

Image Reference: Heart by Guga85

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An African Sting

There is a thin line that separates laughter and pain, comedy and tragedy, humor and hurt.
Erma Bombeck 

I know some of you may be wondering if I actually do any medicine at Haydom Lutheran Hospital (HLH), but don't worry I do. Up in till now I've largely steered away from telling cases from the hospital, and I'm not about to start. Instead I have a little story to tell from yesterday, with some added education.

If we start right back at the beginning, yesterday felt like the first actual normal day for me in Africa. I started the normal routine of practicing medicine at HLH, with the minor change that I had moved from General Surgery to ICU. But alas, you can not have any normal days in Africa.

In the afternoon, a group of us consisting of myself, Amin (Medical Student from the Netherlands), Tea and Anna-sofia (two Danish Medical Students), thought it would be nice to go for a walk around the sunny hillside of Haydom. Having run the route several times by myself, it was nice to finish off the day with a relaxing walk with a few of the others. On the way through the town we met some local kids, who as always seem to have great fun checking out the Mzungu. There was even a little girl who ran up to each of us, just to touch us like we where some sort of good luck charm. Two of the kids followed us on our walk past the airport, until even they sped off on their bikes.

It was then that something strange happen. The kids quickly semi-crashed/jumped off their bikes and started doing what looked like to us weird dances and running all over the road. Having just talked to them a little, we thought this was odd, but couldn't help laughing, thinking that they must be doing some funny local dance thing.

So at this point just imagine a few happy Mzungu going for a walk and seeing some kids do a funny dance. We were in ignorant bliss. We were ill prepared for what was about to happen, and in retrospect we should of gotten right out of there.

But we didn't turn back. No, for we thought everything was fine until we started to hear this buzzing sound. Our ears pricked, we turned to look at each other, and a sudden realization of what we had stepped in to and what the kids had been doing only a minute before.

 An African Bee Swarm

 

African Bee via Wikipedia

Now for those who know little about African Bees, let just say they are very similar to European Bees, just add an extra dose of aggression and about 50 more of them. They are quick to perceive a potential threat, send out more bees to any one threat, and follow victims for a much greater distance. For victims is what we were about to become. Just like the kids we had seen earlier, we ran all over the road, sprinting like most of us had never done before, just to try and shake these bees. Being persistent little Bees (not to mention venomous) a collection of them followed us a distance well over 500 metres. And whether we liked it or not, the outcome was fixed the moment we didn't decide to turn back when we saw the kids acting strangely.

Fortunately, for us we suffered only a total of 6 stings being the four of us. Somehow I don't think the kids were so lucky, and I can only hope they didn't get swarmed to death.

Bee Stings 
So to make the most out of this experience, I thought I should at least impart some medical knowledge about bee stings. For anyone who seen my Medicine in Small Doses series over at IVLine.info, I'm going to use a similar format here.

The most important thing to remember with bee stings, is that you can have different reactions each time (from mild swelling to anaphylaxis), and more stings (i.e. more venom) can lead to worse symptoms.

Clinical Features: 

• Nausea, vomiting or diarrhea 
• Headache 
• Vertigo 
• Feeling faint or fainting 
• Convulsions 
• Fever 

Management: 
In general, management can be reasonable conservative for the vast majority of bee stings.
The following is reccommended;

• Remove the stinger 
• Wash the area with soap and cool water 
• Apply hydrocortisone cream or calamine to the site
• Take an oral antihistamine
• Elevate the extremity if swelling is increasing.

 Lessons Learnt

1. No such thing as a normal day in Africa, each day is full of surprises. Arguable there is no such thing as a normal day back home, we just forget to appreciate the little things that happen around us.
2. Bee stings hurt.
3. There can sometimes be a thin line between laughter and pain, and it's important to remember that each of us draws the line at different places.

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Taking a Step Back in Time

Yesterday is gone. Tomorrow has not yet come.
We have only today. Let us begin. ― Mother Teresa

At Haydom Lutheran Hospital (HLH), there is a set routine to things. You get up in the morning, go have breakfast, then go to the doctors meeting at 7:30am, followed by Sala (which is a morning prayer and general announcement session attended by all in the hospital), then the radiology meeting and finally clinical duties (which typically starts off with ward rounds).

At Sala newcomers and guests to HLH introduce themselves. I did this last Monday and I basically just said who I was, where I was from, how long I was staying and what department I was going to be working in. If you're really organised or already know a lot Kiswahili, it makes a really good impression if you say it in both English and Kiswahili.

While there is a large overarching routine to things, a lot of this falls away at the immediate practice of medicine. Having done several ward rounds now I can honestly say they have been of variable experience. One the fundamental issues is a lack of organisation at times, which seems to make ward rounds last a century. Secondly, rather than a single nurse in charge of a patient there are multiple. This might sound like a good thing, but the problem is each nurse only does one task (e.g. insert a line, be at the ward round, send for x-ray), and they don't always communicate with each other or the doctors. But for now I play the foreign medical student role and see how things play out. No one likes being told what to do, and if it works for them who am I to say otherwise.

In my first observed operation at HLH, I was able to get a reasonable picture of how all operations are done at HLH. We were very fortunate to be in the lucky theatre with a pulse oximeter (other vitals were just done at the beginning). I couldn't help remembering from SMACC whilst I watched, that the pulse oximeter is the world's first time machine, taking you a step back in time.

Some quick facts of life with Surgery at HLH;

• Typically no vitals. BP cuffs work on a hit and miss basis.
• Nearly everything that can be reused will be reused (e.g. ET tubes).
• Saline is produced on site.
• Anaethetists are not Doctors, but trained technicians. They are still very good at the job, considering they often have to deliver drugs and manually ventilate at the same time.

Our time machine came into play later in that first operation. In HLH oxygen is provided to patients during surgery, however since there is only one machine that makes oxygen, up to four patients can be plugged into the same box simultaneously. During our operation the patient started desaturating (/was already desaturated), and we had to problem solve. Ventilation was all good, patient was not losing any blood, and probe was correctly attached. So next step was for the newbie medical student aka me to do, go clamp off the oxygen lines to the other patients so that ours could get more. Our patient steadily recovered and it was then my task to go tell all the other surgeons that we had cut oxygen off to their patients (as far as know no once suffered an adverse consequences).

I expected that my time Haydom would take me into a different world of medicine and clinical practice. As often is the case though your preconceptions, can differ from reality. There were aspects, I could not anticipate, and scenarios that I thought would exist, that have not yet materialised (and I doubt will). I thought working at Haydom would be like taking a step back in time. However, I now think it's something rather different, it's about going back to the basics. Sometimes doing things there in the moment, not knowing how it's going to play out further down the track. Many people doing the best they can, with the limited resources available, to make a small difference.

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