How do we "wrap up" our experience?

The big group has now been "home" for a few days. Home is relative as Minnesota is not home for everyone -  I think all but Ken have made it to the States though. We left Ilula on Tuesday and made it safely to Dar where some went on to vacation in Zanzibar and others spent the day in Dar at Slipway (a shopping center on the ocean) and the Bongoyo island. 

I have been thinking a lot about how to "wrap up" the trip in a blog post but it has been a challenge. This year was a quick trip to Ilula for me and it felt fast. I have been grappling with what this quick in and out trip meant to me, to the students/learners and to the Ilula staff and patients.

I asked the students to tell me how they would explain the trip in a few sentences and have one to share in particular: "With every adventure there is always it's ups and downs and we had many of both on this trip, especially emotionally. I, for one, am new to the healthcare world and was thoroughly unprepared for the sheer gravity of the helplessness I felt in many situations.  However, though we were surrounded by so much suffering and destitution while working in the hospital and traveling through the bush, the Tanzanian peoples never ceased to amaze me with their overwhelming hospitality and generosity. Though some of the practices in the hospital gave us pause, learning from the Tanzanians in regard to their attitudes is paramount and I hope to carry this completely selfless lifestyle into my practice back home."

I don't think I am off base when I say that each year a lot of American staff and learners feel helpless. It is a frustrating situation and a heartbreaking one at times. But I liked the hope in her message as well - the references to living our lives more like the Tanzanians. What a powerful hope to take away after being in Ilula for nearly 6 weeks. There is still lots to be done with our relationship in Ilula and the care they are able to give to their patients but also a lot we can take away from the experience into our own practices - Shoulder to shoulder. I came to the final conclusion that there is no way to "wrap up" our experience because these trips to Ilula are life changing and the process of digesting the information you learned, the things you saw and the things we witnessed, is life long. 

The Other Side of the Coin 5Feb2016

All those things I said in my last post were absolutely true.  Today’s experience has had a substantial mitigating effect for me.

Sravanti has been working with Anne since Randy left.  Anne has substantial experience with clinical research and, hence, the IRB.  IRB stands for Internal Review Board.  This board keeps our patients safe from our intrusive eyes.  And thus protects us from breaking HIPAA rules.  Believe me, this is a good thing.  And on our better days, we all acknowledge that.

How does this relate?  The CTC Clinic (Care and Treatment Clinic) was built in 2006 by the Clinton Foundation and in the last couple years, as the clinic has been up and running, USAID has been supplying medicines and testing.  When Randy was here working in the CTC for HIV positive patients, he began looking at the computerized data which go back to 2006 when the clinic was started.  He discovered some interesting things.  The rub is that the data have not been “scrubbed,” that is, the identifying data have not been deleted.  However, after Sravanti and Anne looked at the computer program they found some summary data that had no identifying data so they could collect some interesting information to evaluate.  This will help design a study that can pass the IRB scrutiny.  But this is not about the study.

It is about the relationship between Sravanti and Anne and the CTC staff who were so helpful in working with them with the day-to-day learning that they did.  Anne and Sravanti were so happy and appreciative that they invited the group for lunch at the guesthouse. They invited the five of them.  We were waiting after lunch wondering why they had not come.  About 2 pm or so they trickled in.  All ten came!  Pole sana!  Lunch was gone.  Still, it was a lovely visit, the wazungu expressing gratitude and Tanzanians sipping sodas.

There are other bright spots too.  There is a Hypertension and Diabetes Clinic weekly.  They are focusing on these diseases.  We do not well know the tropical diseases, but I promise you we are experts about hypertension and diabetes!

Randy told our Tanzanian colleagues that they should “count things,” the importance of which was reinforced for him by one of Atul Gwandes’ books. 

Dr. Kawono with the run chart

Of course, counting things is the first practice in making things better.  A couple of years ago, I suggested a run chart of sorts.  It was just a visual representation of the data reported at morning report: discharges, admissions, births, C-sections and so forth.  I got no traction.

This year, I presented the idea to the MOIC, Medical Officer in Charge, Dr. Sovelo and with a little background from hearing Dr. Randy talk about “counting things,” I found him very receptive.  Dr. Kawono was enthusiastic too. He and I discussed what we might track.  We got a big white board, taped it all up and made dates, days and categories for the staff to start “counting things.”  We invented some categories we thought might be of interest and left a few blanks for the staff – all the staff – to think of more categories. 

It's a start!

Chaplain Kikoti mentioned he had heard and wanted the staff to know that there is cholera in Iringa.  They will count cases of diarrhea to see if there is a spike suggesting cholera has hit Ilula too.  I hope a subtle spin-off might be a reminder of the importance of hand washing.  Whatever they choose to follow, I hope they will do so for a month or two for each new item.  Then if no value, think of a new category and replace the old one.  I hope their enthusiasm does not wane.  We are trying to model and instill a culture of learning. It would be wonderful if this began a culture of “counting things.”

A Poignant Plea for Palliative Care and Existential Questions 4Feb2016

Although we have struggled each year with the realities of Ilula, this year it seems especially acute. The backdrop of this experience with the learners and faculty is the extremely resource-poor hospital.  For example, medicines are not supplied by the government as they should be. Or other supplies like lab reagents, the lack of which idles essential machines and thus cannot provide the tests that could guide our care if we had them.  We can live with this and depend on our clinical acumen and our Tanzanian colleagues’ experience.  This accompanied by the helplessness we feel when our patients die, sometimes because we do not know the correct treatment and do not know the disease we are treating.  We name things as best we can and work from there.

We sometimes do differ in therapies from our colleagues too.  In Ob, our learners have made the diagnosis of pre-eclampsia a couple times and the doctors seem to be slow to respond.  This tries the physical capacities of the two patients, mother and baby.  The wazungu look on in pain, so aware of the differences in approaches to care.  We are used to being so much more aggressive.  The choice sometimes comes down to precious resources at a full (US) course of therapy or several partial courses.  Which approach helps more patients in this resource scarce environment?  We have only our biases to support our opinions on this.  It will stay this way until resources are adequate.  There are advances here including a significant drop in child and maternal mortality over the past half dozen years.

We have smart colleagues with local experience which certainly trumps our intellect, knowledge and experience nearly every time.  Well not every time.  We have some pretty smart cookies with us, faculty and learners.

But more disconcerting I think is a category of factors, like under-nutrition, which I refer to as “the disease hiding in plain sight.”  We see a tremendous disparity in things we think are controllable in any setting.  The Ob suite is always clean, despite a half-dozen or more deliveries per day.  I am a little reluctant to cast aspersions, since we know that the resources are so frustratingly low.  Some of the wards are dirty.  Yes, it is difficult to keep the chickens out of the open ward.  And some of the wards were painted last year.  This was a donation by visiting group.  Maybe the dirty stains need to be covered by new paint now.  Still, without cleaning, it will need more paint soon.  Does the lack of resources excuse the dirt?  Or perhaps the lack of resources saps the pride from the staff and this has become the “best we can do.”

And here we are.  All bright and shiny, here for a few weeks once a year.  Who are we to criticize?  We want to help and yet we must take great care not to judge.  So our existential question is this: how?

The above is capped off by the importunate speech we heard this morning.  It was mostly in Swahili, but several of us picked up on the words, “palliative care.”  We asked for a summary in English.

The palliative care team is usually a chaplain as leader, a nurse and a doctor.  They go out about once a week if everyone is available.  They dispense some medicines, write prescriptions and provide spiritual as well as medical care, a truly holistic endeavor.

They have no funding.  And they have 850 patients in need, and simply too few staff to provide the care.

Except as the charity of the staff can provide, that is.  They did have some fairly regular support from somewhere which has dwindled.  There is also the “poor patients’” fund, donations solicited from visitors.   I think it is a pittance.

I know the palliative care team could use cash, especially a regular stream.  They write prescriptions but often are thwarted when the patient cannot afford the medicine anyway.  Heart rending was the request for food and clothes and, of course, medicine.  Yes, all of those do translate to money.  And I suppose there is no end to the need.  It is the starfish story.  We will not likely save these humans but with a little cash, we can make them more comfortable.