"From the time we arrive on the planet
And, blinking, step into the sun
There's more to be seen than can ever be seen
More to do than can ever be done
There's far too much to take in here
More to find than can ever be found"
-The Lion King

Have I mentioned that Tanzania is absolutely breath-taking? Just riding in the car is an adventure. This weekend I travelled to Ngorogoro Crater. You may guess that I was with Norwegians but this weekend everyone was German; there is a German pediatrician volunteering here for the next 2 years (admirable, to be sure). She has several friends visiting and they, along with a German medical student, made up the group.

To get to Ngorogoro from Haydom you travel about4 hours in the Land Cruiser. We spent Saturday night in a town named Katesh and started the day early on Sunday. I was unprepared for the grandeur of the crater. You enter through the Ngorogoro Conservation gate where you are immediately greeted by baboons. Watch out! They like to help themselves to food in your car, per the guide. You travel through the conservation area for a while and pass through beautiful vegetation. Here we encountered our first elephants munching by the side if the road. We also saw some traditional, inhabited dwellings of the Masai tribe. The Masai have been granted permission to live within the conservation area. After driving for a little while you start your descent into the crater. It is incredible. I saw so many animals. Perhaps I'll let the pictures speak for themselves? Enjoy!

I think rainy season is upon Tanzania. Perhaps not officially but I don't know if there is a defined start date. Each afternoon it rains so hard that it is inevitable to get soaked if you are outside. From the entrance to the hospital (where reception is) I watch as Tanzanians run from all directions towards town, trying to make it home as quickly as possible. I brought laughter and smiles to some of the people as I sported my rain coat today. I don't know if they have ever seen a rain coat before... Umbrellas are nowhere to be seen.

This week is a little different because of the tropical medicine course taking place at Haydom. I am as likely to hear Norwegian as Swahili. In fact, I think I've learned more Norwegian than Swahili. I'm also pretty sure that I may return speaking as though English is my second language. The course is great- I'm getting to participate in lectures led by the Tanzanian and Norwegian physicians. The lectures include topics such as malaria, TB, HIV/AIDS, and other febrile illnesses.

I continue to work on the rapid malaria project. Today was a good day- 100% compliance of ordering rapid malaria tests in reception on all patients admitted with malaria yesterday. Elin and I have also finalized the goals for reception, list of equipment that should be in reception at all times, and triage classification. We've met with several of the Tanzanian nurses that asked us to work on this project and they seem to be excited about what we've developed. Next week we meet again to introduce and discuss with the staff nurses. I've been pretty emphatic about not presenting the changes but having the nurse officers bring it to the nurses so it doesn't seem like mizungos are coming in and telling the Tanzanians how to run the show. It's still their hospital and I am well aware of that fact.

I spent a lot of yesterday going through the supply room in ICU and equipment hunting. It is really frustrating; there is a lot of great equipment that was donated but is missing key components. For example, IV pumps were sent without the accompanying tubing. I found 5 different pulse oximeters but no probes.

I've spent more time in the child care unit this week. I'm happy to report that one of the babies went home with a family member yesterday. There are 2 new babies, though. I am learning about some of the Tanzanian traditions and superstitions. As it has been explained to me, if a mother dies in childbirth the child is blamed and considered unclean for 9 months. That is why the child care unit exists. After the 9 month period the child is accepted into the family. It's hard to imagine a world where those sweet faces are considered unclean but such a great thing that Haydom is meeting that need here.

*I should have mentioned previously that the physicians in Tanzania ended the strike pending negotiations shortly after the interns at Haydom joined.

Add to my repertoire of things I never thought that I would spend my afternoon doing: sewing up holes in my mosquito net. A group of Norwegian physicians arrived this weekend for a tropical medicine conference. Some of the volunteers are traveling for the week. I am staying with Phil and Iren who have graciously taken me in. Thus, I have a new room with a new bed and new mosquito netting which needed a little help to be effective.

This weekend I climbed Mount Harang with Phi, Iren, Erik, Asta, and Eli. Mount Harang is the fourth highest mountain in Tanzania. It is 3,420 meters (10,260 feet for the Americans who think in feet). We traveled approximately 2 hours from Haydom to Katesh where we spent the night at Summit Lodge. The hike took about 12 hours traveling at a leisurely pace. It was amazingly beautiful. There were parts of the hike that were quite steep and we did a bit of scrambling. I loved it. We climbed to 2 peaks with incredible views of the Great Rift Valley.

I'm an infectious disease dork at heart. My new project with measurable outcomes is related to malaria. There are a large number of patients that are admitted with the diagnosis of malaria. However, this seems to be a catch-all for every patient with a fever. The physicians are concerned that a large number of patients are given this diagnosis without any diagnostics. Translation: people are told they have malaria based on symptoms and no lab work. I'm told that the Ministry of Health provides rapid malaria tests for free so there is absolutely no reason that patients suspected to have malaria are not being tested. The infectious disease physician was informed that this test is being done on every patient admitted for malaria from reception (the emergency room). I've been there for 4 days now and can't even find the tests.

Solution: the physician and I are working with the medical director, chief nursing officer, nurse manager of reception, clinical officers, and nurses to ensure that patients are being tested. Today I developed teaching instructions and taught how to perform the test. I'm excited about the project and hope to see it work out well and improve patient care. There are some photos of the teaching I did today.

Things otherwise are going well. I'm building relationships with the nursing staff. It continues to be frustrating at times. I have gone in later the past 2 days so I could work with am and pm shifts. This also allowed me to go play with the babies yesterday. I've included a couple of those pictures. The weather is beautiful and there are always people around to enjoy the leisure time with me. Several of the Norwegians are leaving today and tomorrow so we had a small going-away party last night.

The last pictures that I've included for your information and visualization of where I am are of the reception area (emergency room). The purple stuff in the bottle is the mystery solution they use for sanitizing everything- your hands, the table, before starting an IV...I have no idea what it actually is.

Chaos. That is how I would describe my day. There is a certain type of organized chaos that exists in any emergency room but what I observed today goes beyond what I've experienced. Today was designated as an observation day. I need to spend time with the nurses, providers, and process before I can best formulate how to integrate change, right?

I am quite certain that there is a system for handling patients in the "reception" area. I just don't understand at this point. I was bewildered for most of my time observing today. I have no idea how the nurse (yes, nurse in the singular tense) has a grasp of when patients come and go, see the provider, have orders, etc. I actually miss patient armbands. There are charts and papers everywhere. The Tanzanian nursing students are wandering aimlessly and directionless around the room, adding to the craziness.

The disorganization, I think, I could handle if I felt as though the staff agreed that there could be a more efficient way to run reception. I went to lunch feeling completely discouraged that I will be able to help improve anything with the cooperation of the nurses. Things improved after lunch. I can't quite put my finger on what directly made the improvement but things seemed to run more smoothly. The afternoon nurse seemed more receptive to us (I've been working with one of the Norwegian nurses). This helped me end the afternoon on a high note. Tomorrow I will go to work a little later and stay later to be able to work with both am and pm shifts. The challenge is to work with the nurses. I'm on their side and want to help them and their patients as best as I can.

You've seen the commercials for Insanity workouts? Bet you didn't think Insanity would make its way to Tanzania. Me either. Yet, 4pm found me working out to Insanity with Norwegians and Tanzanians. There are moments in life where the randomness of the situation just makes me laugh. A couple of us followed the workout with a walk around Haydom Mountain. Dinner consisted of beans, rice, and mango. I played cards for a bit after dinner. The Norwegians are eager to teach me new games and their language. Of course, all of the words I'm learning are really useful- "t-shirt tan," "flower," "cake," etc. It's pretty fun.

End of the day as seen from Haydom Mountain:

It is a lazy, rainy Sunday afternoon in Haydom. I've had the weekend off so there have been opportunities to explore and enjoy the area. I started yesterday morning with a run. I spent some time in the child care unit playing with the babies. Then, I hiked Haydom Mountain with a couple of the Norwegian nursing students.

This morning we hiked Mount Harare. Here are some pictures from the weekend. I've also included one of my room and bathroom.

"Quit fooling around
Give love to the ones who can't love at all
Give hope to the ones who have no hope at all
Stand up for the ones who can't stand at all"
- Jon Foreman, "Instead of a Show"

My first week of work is complete; time goes quickly. I've learned and been challenged. There is so much sickness and death. The frequency appears to make the local healthcare providers not address emergencies; it is as though they are defeated already. I've not seen a local nurse or doctor seem concerned about any deteriorating patients (again, I've only been here a week) while the American and Norwegian providers rush to the bedside. I'm talking about sick patients here; I've assisted with CPR on the same infant twice while moments later a 14 year old died. I would like to light a fire under their butts.

On a positive note, there have been wonderful opportunities for teaching. Some of the nurses and nursing students are excited to learn and show signs of putting the pieces together. We talked a lot about preventing complications today and I watched as the nurse put those ideas into practice- yay!

I toured "casualty" today. Casualty is basically the receiving area of the hospital. To call it an emergency room is really giving it too much credit so I refuse. There is no triage system so patients are seen in the order in which they arrive, somewhat regardless of acuity. The chief nurse of Haydom requested my help in establishing a triage system and making sure the right equipment is available. I spent the afternoon researching and found that the lack of emergency care is a big problem in developing countries. One study found that people in Nepal are far more likely to present to primary care centers for emergency care and that this is a big obstacle in promoting good outcomes. Interesting contrast since many Americans use the emergency department for primary care. I found some really good resources and will work with the Tanzanian nurses to help implement some changes that hopefully are sustainable. If you are thinking that I'm under-qualified, you are correct. Thankfully this week Karen has been here with me and she is a wonderful resource.

Yesterday we visited the primary school and took some supplies. Children love to touch the "mizungos." They are fascinated by our white skin. The children are so joyful and trusting. Karen and I took a walk around Haydom Mountain yesterday and I had 2 small girls grab my hands and just walk with us for a while. After our walk we had dinner at a local cafe. It is a dish called "chips miyaya"- french fries cooked into egg. Weird concept but delicious. You may be wondering what exotic cuisine I have been eating here inTanzania. They serve a lot of potatoes, rice, and bread. I miss fresh fruits and veggies! We do eat mangoes and oranges- delicious. The locals eat a lot of beans and ugali (some type of dish made with corn) but they do not make those dishes for us.

Top 10 diseases treated at Haydom:
Malaria
Pneumonia/stroke
Amebiasis
Gastroenteritis
HIV/AIDS
CHF
Typhoid
Cirrhosis
Psychosis
Peptic ulcer disease