Tanzanian EM and Lounging 101
What a whirlwind. Four weeks come and gone. Countless patients, great adventures, some work, lots of play, and another month in Addis in the books. It was by turns exciting, frustrating, beautiful, sad, and inspiring. One of the exciting things about spending a month in Addis is that you never quite know what each day will hold - it may be a day of morning lectures, critical care rounds, a relaxed lunch, a visit to another hospital in the afternoon and then dinner and drinks at night. Or it may be lecture followed by a crashing patient with no one else around, a walk between hospitals that takes you through a sketchy used car and farm fresh vegetable market, being followed/harassed by street children begging for money, a wedding with building-shaking music that lasts til midnight, and routing traffic jams while cars are stopped across the city for visiting African Union dignitaries. You just never know...
So let's hit on a few highlights and I'll try to keep it relatively nonmedical.
Dar Es Salaam, Tanzania - Wow! What a cool, weird few days it was. So the Emergency Medicine residency in Dar Es Salaam started ~8yrs ago, around the same time as the Ethiopia program (maybe 1 year earlier?). After meeting their awesome chief resident in October who was rotating at the pediatric hospital in Atlanta, we stayed in touch and I asked if I could jet down from Addis for a short visit. I spent four days working alongside Kilalo, going to their conference, and enjoying the city. I arrived on Wednesday afternoon, had dinner and promptly joined Kilalo at Muhimbili Hospital for the first half of her overnight shift. From 8P-12A, I watched in awe as Kilalo and her colleagues cared for three extremely sick patients. One, a child with malnutrition, was born 6+ weeks premature, was a month old, weighed less than 15 pounds, and had veins too small for any of their IVs. Another patient had severely infected diabetic foot ulcers, was confused and having trouble breathing. The doctors worked on her all night before she eventually succumbed to her illness. However, the residents appreciated the acuity of the patients' illness and worked hard (and quickly) to provide treatment. Unlike the ED at Black Lion, their emergency department has four spacious critical care rooms (although typically full with four patients crammed into each room), good crowd control with only 1-2 family members accompanying each patient, multiple nurses for each critical care room, and access to point-of-care testing where you can get basic lab results within 30 minutes. Although testing was more limited than what's available in the US and getting XRays or CT Scans remains a challenge, the ED functioned at a very high level overall. My excitement from my first shift was tempered by my last shift when I rounded with the residents on a patient who was having difficulty breathing, had a breathing tube inserted, but then couldn't get transferred to the ICU. They currently don't have any ventilators in the Emergency Department. None. So if there's someone who needs to be put on a breathing machine, the ED doctors have to call the ICU, make sure the ICU has ventilators available, get the ICU to accept the patient, and then either transfer the patient there before putting in the breathing tube or to place it in the ED and then quickly transfer the patient to the ICU. With this particular patient, there was a ventilator ready and waiting in the ICU, the ICU doctors were ready for her, and so the breathing tube was inserted, we got ready to transfer her, and then found out that there weren't enough nurses working in the ICU so they refused to take her. WHAT?!?!?! Seemingly a simple problem, this slowly devolved over the course of the next five hours while a rotating cadre of tireless medical students squeezed a breathing bag to keep pushing air into the patient's lungs. The supervising ED director was reasonably irate, made countless phone calls to hospital leadership, and yet, five hours later, the patient died in the ED. Unlike my first shift at Muhimbili, everyone else left the room shortly after the breathing tube was placed. Over the next five hours, I was the only senior resident consistently in the patient's room, directed her care. Similar to what I saw in Ethiopia and what I occasionally see in the US, it's disheartening to watch others give up on a patient when there's still a chance. This doesn't mean we should do absolutely everything we can come hell or high water without any regard for outcome - I'm usually in favor of ending resuscitations when it's clear that the patient would be brain dead if they survive at all - but these cases were far from clear cut.
Outside of the medicine, Dar Es Salaam has some really cool areas and is the gateway to Zanzibar and other cool surrounding islands. Unfortunately I didn't have time to get to Zanzibar, but I did spend an awesome afternoon at Bongoyo Island. Beer + Sand + Sunshine in December? I am not complaining. I had fresh grilled fish for almost every meal and alternated with the occasional BBQ chicken over an open fire - very South African style cuisine. I missed out on some of Tanzania's famed curry but it's good to leave things to do next time around. Beyond work and spending time along the waterfront in Oyster Bay and Masaki, there wasn't too much time for exploring the rest of the city. Overall, the city was pretty clean and modern (many ppl use Uber to get around), however crime is definitely a larger consideration than in Addis. For example, when I asked about walking the 1/2 mile between my AirBnB and the Hospital, I was told it would be much safer to Uber. Speaking with some peds residents who were staying in a nearby neighborhood, two of their members were held up at gunpoint and lost their wallets/cell phones in the late afternoon. I didn't see any crime but it was definitely a consideration there that my mind was blissfully insulated from while in Addis. Although I constantly felt in the way and slightly out of my comfort zone, it was an awesome break from Addis and invaluable exposure to an ED with strong hospital support in East Africa.
So let's hit on a few highlights and I'll try to keep it relatively nonmedical.
Dar Es Salaam, Tanzania - Wow! What a cool, weird few days it was. So the Emergency Medicine residency in Dar Es Salaam started ~8yrs ago, around the same time as the Ethiopia program (maybe 1 year earlier?). After meeting their awesome chief resident in October who was rotating at the pediatric hospital in Atlanta, we stayed in touch and I asked if I could jet down from Addis for a short visit. I spent four days working alongside Kilalo, going to their conference, and enjoying the city. I arrived on Wednesday afternoon, had dinner and promptly joined Kilalo at Muhimbili Hospital for the first half of her overnight shift. From 8P-12A, I watched in awe as Kilalo and her colleagues cared for three extremely sick patients. One, a child with malnutrition, was born 6+ weeks premature, was a month old, weighed less than 15 pounds, and had veins too small for any of their IVs. Another patient had severely infected diabetic foot ulcers, was confused and having trouble breathing. The doctors worked on her all night before she eventually succumbed to her illness. However, the residents appreciated the acuity of the patients' illness and worked hard (and quickly) to provide treatment. Unlike the ED at Black Lion, their emergency department has four spacious critical care rooms (although typically full with four patients crammed into each room), good crowd control with only 1-2 family members accompanying each patient, multiple nurses for each critical care room, and access to point-of-care testing where you can get basic lab results within 30 minutes. Although testing was more limited than what's available in the US and getting XRays or CT Scans remains a challenge, the ED functioned at a very high level overall. My excitement from my first shift was tempered by my last shift when I rounded with the residents on a patient who was having difficulty breathing, had a breathing tube inserted, but then couldn't get transferred to the ICU. They currently don't have any ventilators in the Emergency Department. None. So if there's someone who needs to be put on a breathing machine, the ED doctors have to call the ICU, make sure the ICU has ventilators available, get the ICU to accept the patient, and then either transfer the patient there before putting in the breathing tube or to place it in the ED and then quickly transfer the patient to the ICU. With this particular patient, there was a ventilator ready and waiting in the ICU, the ICU doctors were ready for her, and so the breathing tube was inserted, we got ready to transfer her, and then found out that there weren't enough nurses working in the ICU so they refused to take her. WHAT?!?!?! Seemingly a simple problem, this slowly devolved over the course of the next five hours while a rotating cadre of tireless medical students squeezed a breathing bag to keep pushing air into the patient's lungs. The supervising ED director was reasonably irate, made countless phone calls to hospital leadership, and yet, five hours later, the patient died in the ED. Unlike my first shift at Muhimbili, everyone else left the room shortly after the breathing tube was placed. Over the next five hours, I was the only senior resident consistently in the patient's room, directed her care. Similar to what I saw in Ethiopia and what I occasionally see in the US, it's disheartening to watch others give up on a patient when there's still a chance. This doesn't mean we should do absolutely everything we can come hell or high water without any regard for outcome - I'm usually in favor of ending resuscitations when it's clear that the patient would be brain dead if they survive at all - but these cases were far from clear cut.
Outside of the medicine, Dar Es Salaam has some really cool areas and is the gateway to Zanzibar and other cool surrounding islands. Unfortunately I didn't have time to get to Zanzibar, but I did spend an awesome afternoon at Bongoyo Island. Beer + Sand + Sunshine in December? I am not complaining. I had fresh grilled fish for almost every meal and alternated with the occasional BBQ chicken over an open fire - very South African style cuisine. I missed out on some of Tanzania's famed curry but it's good to leave things to do next time around. Beyond work and spending time along the waterfront in Oyster Bay and Masaki, there wasn't too much time for exploring the rest of the city. Overall, the city was pretty clean and modern (many ppl use Uber to get around), however crime is definitely a larger consideration than in Addis. For example, when I asked about walking the 1/2 mile between my AirBnB and the Hospital, I was told it would be much safer to Uber. Speaking with some peds residents who were staying in a nearby neighborhood, two of their members were held up at gunpoint and lost their wallets/cell phones in the late afternoon. I didn't see any crime but it was definitely a consideration there that my mind was blissfully insulated from while in Addis. Although I constantly felt in the way and slightly out of my comfort zone, it was an awesome break from Addis and invaluable exposure to an ED with strong hospital support in East Africa.
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