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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Happy Easter from Tanzania

The Bible tells us that Jesus Christ came to do three things. He came to have my past forgiven, you get a purpose for living and a home in Heaven - Rick Warren

Just a short one today, to say Happy Easter to everyone I know around the world.

I'm currently, relaxing in Meru House Inn in Arusha which I would recommend to all travelers. It has all the basics like hot water, a bed and wifi. Plus there is breakfast each morning.

We don't have any Easter Eggs for tomorrow, but somehow I think we will survive.

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The Odd One Out

We boil at different degrees - Ralph Waldo Emerson

Like this sunflower in a field of maize, being in Africa can make you feel like the odd one out. I would not characterize this as a bad thing, if anything it adds another dimension to your experience.

On my first day at Haydom, I met a large number of the other volunteers, medical students and guests at Haydom Lutheran Hospital (HLH). Unsurprisingly (at least to me), I was something of a novelty. Where as most of the volunteers are from Europe (especially Norway), here was this lone Australian. Not a single person knew where I was from without me telling them. First I was English, then American (someone even spread a story round that I came from a ranching family in Texas) and all sorts of places in between.

The Dongobesh Experience
As much as I was a novelty to the HLH community, as a foreigner (Kiswahili: Mzungu) you stand out in general in Africa. On my second day in Haydom, the Egenberg Family (Signe, Art and Lars) offered for me to go with them to visit some of their friends in Dongobesh. However, the car only had space for four and there were six of us going.

What were we going to do?

The answer was simple, two of us would ride in the tray-back/trailer of the truck. The two lucky volunteers for the first part were myself and Lars, as we were the youngest. So we set off for our two hours journey to Dongobesh, holding (or clinging) onto to the truck's rollcage.

As would come to no surprise too many, the roads were rough and full of holes. And so if you ever find yourself in the back of a truck, on dirt roads anywhere in the world, my advice would be stand up as much as you can. This saves you a lot of pain down the track. The downside is that you might get flipped off the back of a truck if you hit anything. So weigh up the pros and cons.

So here we were, a pair of Mzungu on the back of a truck; and quite possibly the oddest thing around. As we drove along the road, through towns and farmland, people would point, wave and look with almost a sense of shock. It's not uncommon for many Africans to ride on the back of a truck, but clearly Lars and I brought a different aspect to a common thing.

In Dongobesh, we met the Egenberg's friends, who are both highschool teachers (one teaching English, the other Kiswahili). It was at their house that I had my first family cooked meal in a Tanzanian household. And what can I say other than that the food was superb, and was all from produce (e.g. Icrops & animals) right in their very yard.

Whilst I was at their house, their kids inevitability caught a glimpse of my iPhone (I was using it to take photos). Being curious little critters, they wanted to look at it, which I happily obliged. The two boys loved it and were constantly battling over who's go it was to use it. The most amazing thing I saw was that, a four and a seven year old who had never seen a touch screen phone before, who couldn't speak or read english, pick an iPhone up and within the space of 30 minutes know who to navigate it. A win to Apple I guess for intuitive design. Somewhat to my angst, the only game I had on my iPhone Zombie Highway, which basically involves running over and shooting Zombies. I thought it was probably not a good lesson for young kids that the way to succeed is to see how many bodies you can run over. I'm sure others would argue however, that everyone, including man, woman and child, needs to be ready for a Zombie Apocalypse. 

Eventually we had to say our goodbyes and make our way back to Haydom. But, not before we took a walk through the fields outside of Dongobesh (where the above photo was taken). During this walk, we had the opportunity to see how things had been done for centuries, but also the progress being made towards a better future (the construction of a small dam for irrigation purposes).

The Lesson
Sometimes being the odd one out can be challenging, and leave you of unsure about where you fit in. The obvious truth however, is that we are all different. We each have different beliefs, personalities and perspectives.

Though we may be different, like the sunflower in a field of maize, we share the same soil, the same water, the same energy. We interact with and are molded by those around us. We may be separate in appearance, but connected by nature. For we each have something to add, and our individual oddity does not weaken us, but makes us stronger.

We become not a melting pot but a beautiful mosaic. Different people, different beliefs, different yearnings, different hopes, different dreams. - Jimmy Carter

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This is Africa

Traveling is a brutality. It forces you to trust strangers and to lose sight of all that familiar comfort of home and friends. You are constantly off balance. Nothing is yours except the essential things – air, sleep, dreams, the sea, the sky - Cesare Pavese

Finally the moment you've all been waiting for (I'm an optimist at heart), my first post ever from Haydom, and in fact from Africa.

As with many things in Africa, things happen at their own pace, a pace that can be very different to what you are used to. So after several days of no internet, we have finally got some resemblance of internet back in Tanzania, which has given me a brilliant opportunity to post.

The biggest challenge facing me right now, is how to condense all that has happened into a story, where you as the readers can comfortably reach the end. I hope that the stories I share will both be entertaining, but also impart some lessons I've learnt about traveling and working in Tanzania.

Arriving into Tanzania
Arriving into Dar es Salaam gave me my first lesson, into the pace at which Africa can operate. I waited nearly over an hour to get a visa at the airport (know doubt if any of my family are reading this they would be saying 'I told you so'). Consequently, my first point advice to any traveler to Tanzania is to try and get your visa in advance, it's not worth the wait at the other end.

With this delay in getting a visa and delays embarking the plane I actually ended up missing my booked flight from Dar es Salaam to Arusha with PrecisionAir. These flights were initially booked about a gap of about 2hrs.

Lesson 2: Book enough time between flights.

Of course you could argue that I'm largely to blame for not being better prepared.

However, because of this little mishap, I was more or less thrown straight into another aspect of Tanzanian culture; their friendliness and willing to help. I was helped by many different Tanzanians and eventually got a flight later that night to Arusha with FastJet. Sure there was money involved in this case, but just their approach was outwardly friendly and welcoming.

A quick comment on FastJet as I was supposed to originally fly Precision Air. FastJet provided a good flight to Arusha. The only discernible difference I could detect between FastJet and PrecisionAir is that more foreigners seemed to fly PrecisionAir.

I would like to provide a quick lesson on money in Tanzania, which I also learnt during this experience. They are both quite obvious, but I saw one American kick up a stink (Australian phrase to overally complain about something, where it's probably not necessary).

Lesson 3: If paying in $US expect to receive change in Tanzanian Shilling, often worse than official rates.

Lesson 4: In addition, to this if are going to use $US make sure you have small change (e.g. $1 bills) as many vendors won't accept larger notes. However, the larger notes do get better exchange rates.

Lesson 5: New $US bills get better exchange rates.

Getting to Haydom
Before I left Australia I had an initially planned to take the public landcruiser from Arusha to Haydom. Many of the visitors to Haydom do this and it is one of the most common transportation methods.

The down-side (as others have told me) is that it's a 5-6hr journey in a cramped bus, which has zero suspension and subsequently lots of sore buttocks.

I however, was very fortunate to score a last minute plane flight as a joiner (extra passenger on a chartered flight), with Mission Aviation Fellowship or MAF. The flight was an amazing experience and I got to truly see Africa for the first time during the day. One lake we flew over had so many flamingos all you could see from the sky was a mass of moving pink. That was alive both in movement and also colour.

Joiner Flights cost around $US35 a huge saving. Plus your supporting outreach flights.

On this flight, I met one of the nicest and generous families that I've ever encountered. And they are largely the inspiration for the opening quote, so they well and truly deserve a mention. The three team members of the Egenberg family that I met were Ark (Pallitive Care Doctor), Signe (Midwife turned researcher) and their son Lars (future army helicopter pilot). Signe is involved with setting up an initiative in Tanzania to improve maternal outcomes during labour.

And that's it from me for now with plenty more stories to come, especially featuring the Egenberg family.

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