Our 11 year old is sick again. He has already missed 2 days of school, and it is only the second month since classes started. This time, he started crying and clutching his ears at 9 pm on a Sunday night. Naturally, I was sure this was a delay tactic to avoid getting ready for bed, until I looked in his ears with the otoscope. A bulging ear drum full of pus and blood stared back, one side only slightly better than the other.
Our medicine cabinet here in Moshi is impressive. It was impressive in Durham, but it has reached new heights of prevention. And thanks to a yard sale, all of our items are organized into Tupperware boxes. Since we were to be one of only a handful of faculty doctors on the compound, and not knowing what is available in Tanzania, we came prepared. We have antibiotics, anti-inflammatory, anti-viral medications, steroid creams, antifungal creams, antifungal tablets, tablets in german that were donated to our cabinet and that required a google search to identify.
However, we forgot ear drops. Luckily, there are many pharmacies in Moshi town, and I went to one of the biggest. They seemed to have all sorts of medications, prescription and non-prescription. However, the ear drops are a problem. I go through my list of choices: Auralgan- no. Cipro Otic- no. Cortisporin Otic- no. Let’s look at the generic names to see if anything sounds familiar. I mentally kick myself for not learning the Swahili term for “ear drops” or “antibiotic drops”. I have learned how to say “are you having contractions” “does your head hurt” and “is the baby moving”, which are only useful in a Labor Ward.
Finally, they emerge with a tiny little tube of some ear suspension medication I had never heard of, but it was sealed, and had a Pfizer label and tetracycline and steroid ingredients. I paid 11,500 shillings for those ear drops (about $10), and as I left the pharmacy, I did some mental math. It costs 15,000 shillings (about $13) to have a vaginal delivery at KCMC, and we are told that countless women could never afford to deliver there. I just spent almost that much to buy a 4 ml tube of symptom control for my son.
Barney update: Barney is still at the vet’s office. He is getting his final electrical stimulation, and he will return on Sunday. The vet says he is better- we’ll see what that means.
Friday, September 26, 2008
Saturday, September 13, 2008
Return on Investment
A pervasive challenge in Obstetrics is how best to monitor the fetus to ensure “fetal well being”. The ultimate goal is to end up with a healthy baby after delivery. One can listen with a stethoscope like device, a hand held doppler or with continuous electronic fetal monitoring. One can perform an ultrasound. The ability to do this well is a challenge in both low and high resource settings. In high resource settings, we over utilize fetal monitoring and this results in inconvenience and discomfort for the mother, a higher rate of cesarean deliveries and other unnecessary interventions. I have been tempted on occasion to hurl the fetal monitors from the heliport at Duke. In low resource settings, there is often no fetal monitoring. This is almost always due to resource limitations, training and personnel shortages. This paradoxically results in higher rates of cesarean deliveries because obstetric providers cannot reassure themselves that all is well and the smallest of things can prompt an “emergency cesarean”. In our first two months here, we reviewed at least a dozen fetal or neonatal deaths that might have been prevented with fetal monitoring. The loss of a pregnancy is hard on everyone: the patient, her family, the nurses and the doctors. The staff at KCMC were eager to prevent this from happening again and we had discussed some practical means of doing so on a few occasions. It might seem like an easy solution to simply monitor all women in labor or perform a cesarean delivery on all high risk patients. Not a simple task on a ward where there are two patients to a bed and a single nurse looks after 40 patients.
It is rare in medicine that you see teaching efforts bear fruit immediately. We taught the ObGyn residents how to perform and interpret continuous electronic fetal monitoring on Thursday morning of this week. We encouraged its selective use in only high risk patients because of significant resource limitations. That afternoon, a woman presented on referral from a local district hospital. She had experienced eclamptic seizures and had a dangerously high blood pressure prior to transfer. On arrival, she was quickly stabilized and magnesium sulfate was administered to prevent further seizures. A decision needed to be made about delivery: Attempt to induce her labor and deliver normally or expedite the process with a cesarean delivery. Already deemed a high risk patient, the residents performed what is called a non-stress test on the fetus with the single electronic fetal monitor system on the labor ward. They had never personally performed this test. The fetal heart tracing was ominous: Late decelerations with no variability followed by a few minutes of bradycardia (slow heart beat) A sign that the fetus was in trouble. This was the kind of tracing one might see in a textbook illustrating what a fetus looks like prior to intra-uterine death.
A cesarean delivery was performed. Dr. Tina Oneko from pediatrics was on hand to resuscitate a floppy looking baby. We have since visited this healthy looking child in the nursery. Her name is Grace.
It is rare in medicine that you see teaching efforts bear fruit immediately. We taught the ObGyn residents how to perform and interpret continuous electronic fetal monitoring on Thursday morning of this week. We encouraged its selective use in only high risk patients because of significant resource limitations. That afternoon, a woman presented on referral from a local district hospital. She had experienced eclamptic seizures and had a dangerously high blood pressure prior to transfer. On arrival, she was quickly stabilized and magnesium sulfate was administered to prevent further seizures. A decision needed to be made about delivery: Attempt to induce her labor and deliver normally or expedite the process with a cesarean delivery. Already deemed a high risk patient, the residents performed what is called a non-stress test on the fetus with the single electronic fetal monitor system on the labor ward. They had never personally performed this test. The fetal heart tracing was ominous: Late decelerations with no variability followed by a few minutes of bradycardia (slow heart beat) A sign that the fetus was in trouble. This was the kind of tracing one might see in a textbook illustrating what a fetus looks like prior to intra-uterine death.
A cesarean delivery was performed. Dr. Tina Oneko from pediatrics was on hand to resuscitate a floppy looking baby. We have since visited this healthy looking child in the nursery. Her name is Grace.
Thursday, September 11, 2008
Barney
We adopted a dog in Moshi. His name is Barney. Barney is a mix of a Rhodesian Ridgeback and a Boxer. He’s gentle and fun and BIG. A good dog to have around the house at night. His original owners just returned home to Australia after a 6 year stay in Moshi. A few days after they left, Barney began to look ill. I thought he might be depressed, missing his real parents. He stopped eating and appeared listless. He usually eats anything and is full of life. The local veterinarian made a house call and after a few injections, I was hoping that Barney would be on the mend. He was not eating his usual rice and dried fish dinners so I made a stop at the store to see if I could get him a special treat to perk him up a bit. Looking through the aisles at the store, I noted a host of options for the discerning pet owner. A small store in Moshi, which clearly caters to the expatriot community, had at least 6 forms of dog food. A single can of food was about $2.25. A two weeks’ size bag of dried food cost about $22.00. The average family of four in Tanzania eats for a week for under $10. In the USA, $33,000,000,000 (billion) is spent annually on pet care products, including $14.2 billion on dog food alone. The GDP of Tanzania was about 49 Billion in 2007. The health expenditure per capita in Tanzania is about $50. I spent more on one veterinarian visit and some pet food than the average Tanzanian spends on health care in a full year.
Barney started to look more ill last night. He was panting and could not stand on his own. We lifted him in to the car and drove him to a German veterinarian who lives 17 kilometers away in Machame. The sun was beginning to set as we left Moshi behind. I had promised myself not to stray far from Moshi at night: No street lights, uneven, unmarked pavement, a host of pedestrians and animals on the shoulder and huge trucks with variable safety features. After a ride part way up the foothills of Kilimanjaro, we arrived at the vet’s home and coaxed Barney from the vehicle. He was able to walk to a small clinic down the hill from the doctor’s home. The lab was well equipped with a microscope, hematology and chemistry analyzers and a decent operating table and lights: The envy of many hospitals and health centers in the region. The doctor was efficient and courteous. Not once did he ask how I would pay. It was assumed that I could pay and that I would pay. I thought of the countless patients in hospitals throughout Africa that night who were deprived of testing and treatment because they could not afford to pay. My newly adopted dog was receiving better care than many if not most human patients can get. Was it right to expect treatment for my dog when my patient could not receive the same? Should I allow Barney to languish ill and go pay the hospital bill for the patient in room 25? Would there be some perverse justice in that? This is not a moral dilemma unique to Africa. The 50 million uninsured people in the US can attest to the difficult decisions surrounding healthcare in the richest country in the world. The relative scale of the moral dilemma in Africa, however, is, simply put: HUGE
Barney started to look more ill last night. He was panting and could not stand on his own. We lifted him in to the car and drove him to a German veterinarian who lives 17 kilometers away in Machame. The sun was beginning to set as we left Moshi behind. I had promised myself not to stray far from Moshi at night: No street lights, uneven, unmarked pavement, a host of pedestrians and animals on the shoulder and huge trucks with variable safety features. After a ride part way up the foothills of Kilimanjaro, we arrived at the vet’s home and coaxed Barney from the vehicle. He was able to walk to a small clinic down the hill from the doctor’s home. The lab was well equipped with a microscope, hematology and chemistry analyzers and a decent operating table and lights: The envy of many hospitals and health centers in the region. The doctor was efficient and courteous. Not once did he ask how I would pay. It was assumed that I could pay and that I would pay. I thought of the countless patients in hospitals throughout Africa that night who were deprived of testing and treatment because they could not afford to pay. My newly adopted dog was receiving better care than many if not most human patients can get. Was it right to expect treatment for my dog when my patient could not receive the same? Should I allow Barney to languish ill and go pay the hospital bill for the patient in room 25? Would there be some perverse justice in that? This is not a moral dilemma unique to Africa. The 50 million uninsured people in the US can attest to the difficult decisions surrounding healthcare in the richest country in the world. The relative scale of the moral dilemma in Africa, however, is, simply put: HUGE
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