Muheza: Week 2

Made it back to Muheza on Monday evening after an equally confusing day of travel from Mombasa (at least we were expecting all the bus changes etc this time). This week has been a very interesting week at the hospital. I spent the majority of my time on the inpatient medicine wards, mostly on the female ward, but also on the men’s ward, and the “infectious” ward. I worked with a very nice female doctor, Dr. Hadija, and we saw a lot of advanced disease- peptic ulcers, TB, HIV/AIDS, heart failure, stroke… and also a questionable “rat bite.” The amount of HIV/AIDs here is astounding. In the Muheza area, the prevalence of HIV is quoted at 8% (ranges in various areas of Tanzania from 2%-15%), but in the wards at least the prevalence is much higher. Today, Dr. Hadija and I counted that 50% of the female patients were HIV positive and admitted either as a new diagnosis or for some complication of the disease. She thinks that the true prevalence in Muheza is higher than the published 8%. It is interesting and sad to see the full spectrum of the disease process here, from people who are fully healthy and just with the “sero-positive” label, to patients wasted and suffering from active tuberculosis, to those blind with CMV infection and with herpes zoster and Kaposi sarcoma covering their skin. Dr. Hadija commonly laments on rounds about this horrible disease afflicting so many people, she wonders where it has come from and what they can do. She told me that even she is afraid to get married because that too can bring the problem of HIV and really no one is safe. Once again, treatments are limited, with ARV therapy started when CD4 count drops below 100 or when patients begin to experience opportunistic infection. There are many patients admitted for IV antibiotics or antifungals. There is also a palliative care team here, and they usually take over when patients are in the end stages of the disease.

The “infectious ward” is interesting, because the idea behind it is to segregate any possibly contagious patient away from the rest of the patients. There is a barrier room that maybe is for segregating active TB patients, although for the most part they are just in the regular infectious ward or even the regular medical wards. No one wears barrier masks around the TB patients, and the wards are open anyways so it probably wouldn’t make a huge difference. Some of the doctors and nurses have unfortunately contracted TB in the past. Also, all the diarrhea patients are admitted to the infectious ward which is probably good, although not if they also contract TB in the process.

Although there isn’t much sit down didactics during the day or during rounds, I still feel like I am learning a lot about medicine that will serve me well in the future. I am definitely honing my ability to tell “sick” from “not sick” just at first glance, and also to begin to formulate a diagnosis based on observation alone. It is really interesting here that there is not very much in the way of physical exam of the patients (besides observing them and maybe listening to the chest). I had expected that there would be a lot more reliance on the physical exam here because there isn’t much in the way of diagnostic studies. I guess a lot of diagnoses are so common that history and observation is all that it takes for the most part. I think that they are much more crude diagnoses than they would be at home, but then again, there isn’t much that can be done in a lot of cases so sometimes honing the diagnosis is just not accurate or feasible. In addition, the doctors and nurses don’t have a lot of time to spend with each of the patients- there is one doctor and maybe 2 nurses per 40ish-bed ward, and sometimes doctors are caring for multiple wards at a time. This doesn’t leave a lot of time or brain-space to really get to know patients or to mull over diagnoses. As well, it is often the family members who are providing most of the care to the patients (feeding, changing, washing, keeping away the flies etc), while nurses are more present to administer medications and follow-up on test results. It is also the job of the nurses to inform patients of lab results (ie- HIV diagnosis). This is interesting because it is something that is so casually done and dealt with, with the doctor providing a very cursory role. Back in the US, the delivery of an HIV diagnosis would be something discussed and planned for by multiple members of the care team. It is just very interesting to see how medical care differs in response to different needs and resources.

I was also able to spend a few hours at “Kids Club” which is a playgroup for kids with HIV. They were normal, healthy-looking cute kids who got together to play with stuffed animals and on a swing set, and also to sing songs etc. They all seemed to enjoy it immensely. This group is also part of the palliative care department, which is expansive and very well run.

Kevin, Cordelie, and I went for a day to Tanga to visit the “Youth with Disabilities Community Programme” (YDCP). It was a super interesting visit. The program, whose motto is “all different, all equal,” provides assessment, outreach, medical/physical therapy services, and assist-devices to children with disabilities. Funding comes from the European Union and Fida International, as well as a church. We toured their facilities, and were able to watch the artisans in the wheelchair/prosthetics shop make custom prostheses and orthotics for their clients. They make everything there (including custom wheelchairs) with money and supplies donated by the Red Cross. There were even a few prosthesis students who had come from all over the world to study at KCMC in Moshi and do rotations at YDCP. We also met with some of their physical therapists and community outreach personnel, and spent a few hours going to villages to visit children in their homes. Most of the children we saw were suffering from cerebral palsy, with varying levels of functionality. The community outreach provider was so good with the children, and would work on some physical therapy movements with them. They also assessed for improvement and for the need for wheelchairs or orthotics. We were told that a lot of children were being raised by family members or neighbors because their mothers could not/did not want to care for them anymore. But, the children were really happy to see the YDCP people, and seemed to have a great relationship with them. Overall, the program seems to be very well run and well supplied, and we were extremely impressed by the facilities and the overall program.

Friday we had a going away party of sorts for Cordelie and Kevin, who are continuing on to safari/Kili climb, and of course the party was complete with local beer and chipsi-mayai. I have a weekend on my own, which I’m spending at a beach resort south of Tanga, and then am expecting two fresh new UK med students on Monday. I can’t believe that I already halfway done with the rotation, time definitely flies!