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Dr. John Ross reports from Tanzania

PRAXES Physician Dr John Ross reports from Tanzania on local markets, food and oh yes, the hospital in Dar es Salaam!

Nov. 16, 2013

I am sitting in the living room of the Abbott House, sitting by an open (screened) window, ceiling fan spinning, listening to birds (hey! there are some), watching numerous butterflies on the bush outside the window, and experiencing a mix of olefactory stimuli ranging from lush tropical greenery to the unattended male/female toilets on the hospital grounds just outside our property gate.

Out the opposite window is the Abbott Fund gardener, a wonderful guy who used to be the guard here. He sold his bicycle earlier this year to pay for his kid’s school fees, so he and I went to the CRAZY Dar market in Kariakoo last Sat and bought two old bikes – one for him, one for me.

The market

Karikoo market–  Hot, humid, sweating, sticky, continuous car and truck horns, people talking/yelling, dogs barking, no discernible traffic flow, motor bikes careening through the crowds assuming people will get out of the way at the last minute (most do – those that don’t visit my shop), grossly overloaded delivery trucks crowded into streets that should not allow them to pass, but do, buses, hand carts, all devoid of North Americans’ risk aversion or worry about the future.

There are few rules apparent but probably many in operation; everything under the sun for sale. Vendors with wares on carpets and towels in front of the stalls including an endless supply of used footwear that ends up here from such suppliers as Goodwill and the Salvation Army. Billions of random telephone parts, cords, copied DVDs, generators (constant local power outages), plumbing fixtures, cheap clothing, huge, fantastic vegetable, fish, spice, meat market – I mean, it is INCREDIBLE.

The food

Food is very good Indian and local chicken, rice, and a flour/maize mix called ugali that is a thick paste ball you eat with your hand, soak up sauces, and use to feel full I guess. We have gone to the Mix Restaurant for dinner a few times recently – about a 1.5 – 2 k walk along somewhat dangerous broken sidewalk, dusty road sides with random gaping holes and missing sewer grates. The Mix is operated by an old Indian gentleman and his family. His wife developed the recipe 20 years ago – she died 12 years ago and he has kept the tradition going ever since. Deep fried potato balls, cooked vegetable balls, spices, teeny bits of beef on skewers (10 skewers for about $1.10), wonderful mystery spiced soup/sauce, crunchy bits, chillies all ‘mixed’ together in a bowl + small veggie samosas for about $3.00. Add a Safari beer ($1.00) from the discreet booze-and-everything-else-you-could-need-in-a-microscopic-space shop next door, and you have a fine meal.

When I get here I refresh my memory for all the Swahili greeting words – there are many and one gets tested every day by many people to ensure one knows the routine. “Mambo – How’s it going?” “Poa – cool. Vipi – Everything good?” “Safi – smooth. Hujambo – all good with you?” “Sijambo – all great…” and so on. Next I remember how to count. That is critical when negotiating basically every deal – taxis, shops, meals – everything. You never agree to any exchange until the price is worked out first. This is where the foreigner rate comes out. The taxi guys are the most entertaining. Locals mostly take the dala dalas – massively crowded, mechanically sketchy (often see a few dala dalas at the sides of the road with several legs sticking out from the front (moving thankfully – but yes, sometimes not moving) trying to effect yet another temporizing repair).

“Special muzungu (white person) rate?” This is usually where the audience broadly smiles at me, has a good chuckle and it is repeated several times. All eyes back on the potential driver. “What you will pay?” “Elfu nne – 4000.” I am now using Swahili numbers. Shock, horror. “Cannot.” “sawa, asante” – right, thank you – and I start walking away. “Elfu saba?” – 7000? “Elfu sita.” – 6000. Big sigh, looks like I just took his life savings – door opens, and off we go. Big smiles from the other drivers, still laughing about the ‘special muzungu rate.’

The hospital!

The medical work in the EMD is variably interesting, at times ++ frustrating, at times totally confusing – a wide variety of relatively minor to super sick people – mostly seen by interns who have little idea what they are doing. Sigh. I also get asked for help, or I try to divine when there is an issue, or I frequently ask for summaries and try to compare my suspicions with what I am hearing in the summary. After being here for a while, it is amazing how my eyes, ears, smell, spidey sense all combine to get a very rapid sense of what is going on.

Some days, all 12 hour shifts, there is a constant crush of super sick people arriving. Most are being sent from district hospitals with REALLY limited resources (pieces of cardboard ‘splinting’ their fractured femurs or holding their mostly severed foot on – for now.) They have limited diagnostics, everything takes near forever, many forms to complete, constant interruptions, limited pharmaceuticals (what was in stock yesterday is gone today.)

The day started yesterday by being called into the Peds room (my least favorite but admittedly most challenging and possibly most useful in terms of life years affected place to intervene) by the good-insight Chief Resident who said she needed help. A 2 year old (more like 1 year old size in our world) had just arrived and was having severe respiratory distress – rapid breathing, sternum was being sucked in against his back bone, head tilted back, revealing a bilateral huge lumpy neck swelling and a dirty bandage around his neck. Eyes were still looking around and all 4 limbs were moving – that’s good – we’ve got a few moments then. At birth he was diagnosed with a cystic hygroma, a series of lumps formed by dilated lymph veins – serum containing cysts. This kid’s hygroma was big and tight enough that he had somehow had a tracheostomy done 2 weeks ago.  A trach is the placement of a tiny (in his case) metal curved breathing tube through the neck into the trachea. Guess what came out 2.5 hours ago?

Ensured everything was working. Ketamine to sedate but keep breathing. O2 saturations 100%. The resident was not keen on trying – wanted to see the expert. Sigh. After a few gentle pokes, the use of a small stylet as a airway tract direction finding device,  the small metal trach tube was back in place, and the oxygen saturation was at 100%.

Every day has got a few or a lot of these. One realizes that despite the lack of experience with such things, we have the gift of excellent medical training, critical thinking, methodical planning, anticipating and preparing for complications, and acknowledging that if you don’t do it, no one else will.

Heart attacks are a disease of relatively well-off, over-fed people. What about the millions of have-nots who are crashing their cheap motorcycles; toddlers pulling boiling water onto themselves or falling into open fires (many we see per day); rampant malaria; terrifying driving and carnage on the roads? They need a major Public Health focus first and a reactive disease/injury system second. But the money and sexiness is in the latter, not the former.

Ok, I’ve got numb finger tips.

Tutaonana – good bye!

JR

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