Saturday, July 20, 2013

The Internship

We’re a little more than halfway through our internship. In some ways it seems like it’s gone by fast while in others, not so much. Steph says the days are going really slowly but the weeks fly by, and I have to agree. At this point, I guess it’s way past time to talk about the hospital, which is why we’re actually here. Before I do, however, let me preface this by saying that my views in no way represent my school or anyone affiliated with it, nor are they in any way intended to reflect on the hospital or its staff. If anything, I would simply like to raise awareness of healthcare services in another part of the world that I have been fortunate enough to visit.

Stephanie and I are OT (occupational therapy) interns at a government-run hospital in Zanzibar. For my Kenyan friends, it’s basically the equivalent of a provincial hospital (if those still exist) or a smaller scale Kenyatta National Hospital-type. The closest I can liken it to a hospital in the states is Ben Taub in Houston (and perhaps Harbor View in Seattle) in that it offers free/low cost services, but is of course considerably smaller and has significantly fewer resources. Ours is one of two or three [other] hospitals in Zanzibar, and there are also several community clinics on the islands. That said, Stone Town being the capital, I suppose it’s is the largest hospital in the archipelago.

Where are we?
At the beginning, we had a bit of a difficult time figuring out where to go. A super friendly security guard traipsed all over the hospital grounds with us the Friday before our internship began (‘coz earnest students that we are, we wanted to make sure we didn’t waste time getting lost on our first day), trying to help us find the OT department and/or our contact (whom nobody we asked knew or seemed to have heard of…). Plus we had no idea what time to show up for work on Monday. You see, “excellent communication skills” is probably not a skill one would (or should) find on a resume around here. Anyway, after making a few stops in random buildings and knocking on a few locked office doors, we ended up outside the Orthotics/Prosthetics department…although we didn’t know this at the time because there was nobody there. The hospital seemed kinda deserted, with many offices/departments closed or seemingly staffed by just a couple of people. We chalked it up to it being Friday. Thankfully there were several helpful security guards around to help us.

Come Monday, we showed up bright and early and somebody directed us to hospital administration for paperwork, etc. Naturally they weren’t expecting us, and we had to explain who we were, where we were from, why we were there, what department we’d be working in, who our contact was (by this point we were wondering if this guy actually existed!), how long we’d be there…you know, all the stuff we’d included on the forms we filled out a year ago. After a couple hours of being shuttled from one room to another (sometimes to make room for other interns – mostly from Europe – who were also starting that day), and repeating the same information, there still didn’t seem to be any record of our internship, so we were asked to fill out the forms again. I really hope those passport photos we had to attach to our application forms way back when are not in some random person’s possession somewhere in Zanzibar…. We also eventually met our contact (he did/DOES exist!), and he took us over to the actual OT department (YAY!!) where we would work over the coming weeks.

The hospital
As you can probably surmise, the hospital is pretty typical for most developing countries, beset by limited funding and a lack of basic amenities, not to mention politics and policies that affect day-to-day operations. The wards, some of which we got to see when we were invited to observe rounds one morning, are pretty difficult to describe. Patients lie on threadbare mattresses, which are little more than thin pieces of foam, most without bedding (bed linens) to speak of. Most had kangas (a common East African fabric)…in lieu of sheets. A few did have sheets – or at least a single sheet – though from the mismatch of colors, I guessed they weren’t hospital issue. With the exception of a couple of screens that family members could pull around one’s bed as needed, patients pretty much have no privacy in the dormitory-style wards, most of which have a capacity of 25-30.

Speaking of family, they are an integral part of patient care. We learned that there are not nearly enough nurses on staff, so patients’ family members end up performing many nursing functions. A single nurse is typically assigned to cover two wards during a 7-hour shift (10 hours on overnights) with the help of two orderlies; i.e. probably 40+ patients, since the wards are almost always close to/at capacity. The patients we saw during rounds included people with orthopedic injuries, spinal cord injuries, burn victims, amputees (usually people with diabetes)…I could go on and on….

Among the patients’ belongings on the floor next to and/or below their beds, we saw thermoses and other food containers…it turns out that the hospital only provides bread to patients in the morning but no other meals, so families pretty much have to bring in food daily. Although we knew, and had been warned before rounds began, not to expect the hospital to be like any of ours (in the U.S.), it was still hard to see. Yet, through the pain and discomfort, many patients smiled at us, joked with the doctors…one [a burn patient] was even asking for a smoke, or maybe weed, a.k.a. bhangi. The most I could decipher with my rusty Swahili was the doctor admonishing him to quit smoking the crap (I’m paraphrasing) that got him there in the first place. At the very least, I’m pretty sure we provided some entertainment by being the subject of discussion for some time after our visit(s). Hey, anything to help them get through the day! (Though I can’t lie…that’s not what I was thinking at the time:-/)

EARLY (okay, fine…7:30) on Thursday mornings, we attend an in-service presentation for hospital staff – mainly physicians, nurses, therapists, pharmacists, etc. Visiting interns in all these areas are welcome (encouraged) to attend, and I must say they have been quite interesting and informative. One Thursday, the guest presenter was a pharmaceutical rep promoting several drugs available from his company. It wasn’t the most riveting presentation – a typical sales pitch, and one more relevant to the doctors than anyone else. The room was unusually serene....even the annoying ring tone that could always be counted on to startle us all awake by going off at least 2-3 times during those meetings (it usually went on for a while before the phone’s owner answered it and carried on a conversation…right there…in the meeting…!!) was silent. Until…the drug rep started handing out free samples. Can you say STAMPEDE!?! I wanted to shield Stephanie from the rush (she’s so little – I was envisioning her possibly getting trampled), but we both kinda had our hands full with all the free swag. We had to take everything we could get our hands on or else we’d stand out even more, right?!? (Plus our department head, we think, gestured for us to take them.) But don’t worry – we turned all the contraband over to our supervisor.

I must say…the Thursday morning meetings since then have been pretty gosh darn dull.

Ahhh OT (…& more)!
The OT department is an outpatient pediatric clinic on hospital grounds. The clinic is on the second level of a two-story building overlooking the Indian Ocean, directly above the physical therapy (PT) clinic. The OT clinic is pretty well-equipped as far as clinics go - with a decent amount of therapeutic equipment, large floor mats for therapy, some toys, games, puzzles, exercise balls, etc. It is staffed by one full-time therapist and an administrative assistant/janitor. There is another occupational therapist at the hospital (our one-time “mystery” contact), but he has a dual role, including a job as head nurse (patron) of the hospital. His other responsibilities keep him pretty busy so he rarely comes to the OT department. So, unfortunately, the hospital’s staffing shortages are not limited to nursing. Downstairs, there are two PTs along with two or three aides/assistants. As you can well imagine, interns are a mostly welcome addition to any department.

The children who come to clinic pretty much all have one thing in common: They are PRECIOUS! Even when they are being bratty and crying – sometimes simply because the sight of a mzungu (Steph) is just too much for them…haha! J They have various diagnoses: Cerebral Palsy, Erb’s (Brachial Plexus) Palsy, Down Syndrome, Autism, developmental delay, fetal alcohol syndrome, and so on. Most are carried in by parents, grandparents, nannies, siblings...some walk with much difficulty, diligently keeping once or twice-monthly therapy appointments. Many of them have to take dala dalas to get to the hospital and/or walk long distances. All to be seen for 15-20 minutes. There simply isn’t nearly enough time to see everyone for the typical 45-50 minute sessions we’re accustomed to in the states, so sessions consist of lots of parent education on exercises they can do at home to help improve or maintain their child’s physical condition. We work nonstop from 8 a.m. until the last patient is seen – usually early afternoon. That may sound like a pretty short day, but the reality is, the therapist staff has doubled while we’re here (Steph and I work together/as a team), so try to think of how things are when there are no interns helping with patients…and just one therapist to see everyone. So many of us want to (and talk about) making a difference. She (the staff OT) does. Every day.

Twice a month, on Wednesdays, we go into the community – to health centers in either the north or southeastern (we alternate) parts of the island to provide therapy to those who cannot come to the hospital for whatever reason – distance, inability to carry children who have gotten too big and/or difficult to manage, finances (funds for transportation), etc. Guess what? The children there…?? All also PRECIOUS!!

On the Wednesdays we don’t go out in the community, we go to Orthotics/Prosthetics to observe a very talented orthotic technician do serial casting on children with club foot/feet. He is AMAZING!! Most of the children he works with are infants – it’s best to begin club foot correction at two weeks of age, but he also takes difficult cases (children who are 3, 4, etc.) His work is supported by an NGO and he too is making a life-changing difference in these children’s lives. And the babies, you ask…? Yep, you know it…ADORABLY PRECIOUS!!!

For all these services (therapy, casting, etc.), the parents/caregivers pay what they can afford…and the rest is funded by the hospital and donations. Most everyone seemingly scrapes together even a few coins to bring. We have this one patient that comes every two weeks – her grandmother brings her. Except…we recently found out that this lady isn’t actually her biological grandmother. She is someone who saw a special child in need of love and care, and took her in. They are often late for therapy because public transport from their home is overcrowded and unreliable. When she gets to the hospital, she has to have someone to carry the child up the stairs to the OT department, because she cannot physically manage it. I have no words. The least I/we can do is provide the best care we possibly can to the child, and carry her downstairs for her even more special grandmother to make the journey back home.

Our adult patient
One day, about a week and a half into our internship, one of the physical therapists asked us if we’d like to work on a spinal cord injury case with him. Sure…we were open to learning any/everything! The patient was a 24-year old who broke his back when he fell out of a tree while harvesting cloves on a spice farm, apparently a common injury on Zanzibar and Pemba. He had been in the hospital for at least six months! He was understandably tired of being there and ready to go home, having gone through many ups and downs – with significantly more lows than highs – during that time.

When we first saw him, we were overwhelmed at the thought of being able to work with him with very few, if any, of the items that would typically be at our disposal at a better-equipped facility elsewhere.  Furthermore, he did not have a wheelchair…nor would he have one at discharge. He, like many other spinal cord injury (SCI) patients in Zanzibar would likely have to depend on people to help him perform most, if not all, day-to-day activities for the rest of his life. A life that was likely significantly shortened due to his injury. (Many SCI patients here succumb to severe infections from bed sores or catheters a few months or years after their injury.)

So here we are with this young man who can’t walk…a fact which hasn’t really sunk in for him yet. No wheelchair. No supplies of any kind. No nothing, as my mother would say. :(

But occupational therapists are creative…we make stuff from nothing! (*vigorous chest thumping*) Steph came up with the brilliant idea to make him a rope ladder (to help him pull himself up to sitting from a supine position {laying on his back} in bed)…YEAH!! So what it took us a few days to find rope of any kind (let alone appropriate-ish rope) in Stone Town!?! Still…WE MAKE ROPE LADDER!!! (**more chest thumping**)

First, back to our initial visit after rounds. My first question to him was had he been out of the ward since his injury and subsequent surgeries, and I was shocked (but not really) when he said no…not once in six months!! I can’t even imagine! We commandeered a wheelchair that was in the ward for patient use and brought it over to his bed. It took 3-4 men to lift him out of bed and place him in the wheelchair. His brother pushed him outside, onto a balcony on the same floor…just a few (15-20) feet away. Our guy got to breathe fresh air and see the ocean for the first time in six months. I’d like to say that I’ll never forget the smile on his face…but truth be told, I was sooooo very nervous about everything else, Steph’s the one who told me about the smile. (I know – she’s an AWESOME friend!!) The important thing is…he smiled.

We have since worked with this young man and his family/caregiver(s) teaching them some basic skills to help him be more independent once he went home. Upon learning that we were working with him, our OT supervisor offered to give him a [bariatric] wheelchair that had been donated to the OT clinic. “Naturally,” we threw our wheelchair fitting training out the window and jumped at the offer! After all, any W/C was better than none.

I can’t lie…there have been moments of frustration – many of them – due to language issues and, I guess, cultural differences, some of which affected what we want to do to help him. Through it all, sweet Steph keeps reminding me that we have to “Meet the patient where they’re at…” so true.

I teared up when he was discharged. This young man may not have been my first patient, per se, but I will definitely always remember him and soooooo wish him well.

Friday, July 19, 2013

Zanzibar International Film Festival

Anyone who knows me knows I’m a ‘lil bit of a TV junkie…and seeing as there is no TV to be had on this lovely island, imagine my excitement at an INTERNATIONAL Film Festival!! (After all, it’s not a huge leap from TV to film…ya? ;) I figured I’d make believe I was at Cannes, or at least Sundance, or, barring that, Telluride…and surely I’d rub shoulders (or share breathing room) with at least one celeb…right?!?! At the very least, we’d see a few movies, before most of the rest of the world got to see them. So we excitedly Googled everything we could about ZIFF and planned to stay in Stone Town the two weekends of the festival to ensure we didn’t miss any of the fun…Woop!! We pored excitedly over the program – @500 Tanzanian shillings/~USD$0.31, splurged for two (gotta think about scrap-booking…), and mentally noted which films we [thought we] wanted to see. As it happened, one of Stephanie’s and my professors was visiting – partly to make sure that we were actually working at the hospital, and not just living it up in Stone Town – so we got to share part of this exciting experience with her and her daughter.

I was especially proud of two Kenyan films (and they even won awards…yay!) – Nairobi Half Life & Ni Sisi – both a realistic depiction of lives one may live in Nairobi/Kenya. Sadly, we didn’t get to see quite as many films as I/we envisioned, but Maggie, Steph, and I did get to see one awesomely bad film…which we will never ever EVER forget. It’s been a few weeks, but we still talk/wonder about it occasionally…usually when some aspect of life in Stone Town is so puzzling, that the only thing we can relate it to is the film. I guess, in the big scheme of things, it was worth every bit of our time and free entry in that it still entertains every once in a while as we try to decipher the (or any) point of the story. Maybe it will be available on NetFlix someday, so y’all can watch it too!

ZIFF verdict: I’m glad I got to experience an actual film festival, but I still wanna go to Cannes…or Sundance…or Telluride…or a movie theater…. Heck…I’d settle for a teensy, tiny, handheld, battery-operated TV at this point – even one that only worked at the beach. Or, just a radio. Even if it just had baseball…. :-/

Sunday, June 30, 2013

Nobody told us about the cats!

Speaking of cats…Zanzibar is teeming with them, in varying sizes and levels of fierceness; most of the ones we’ve seen hang out at Forodhani. (Except at night, of course, when they hold “Cat Fight Club” outside our windows.) I can’t say I blame them. Lie around in the sun all day; eat scraps from the daily food fest/barbecue all evening; then work out (a.k.a. fight) – seems like a pretty good life!

Seriously, though…is the cat Zanzibar’s official animal?? They are more annoying than the spiders, ants…even the flies, and if you know me/my aversion to bugs, that’s saying a lot!

But first, let me digress for a minute and talk about the bugs. There are many. Spiders, ants (none that seem to bite…yet), cockroaches (ugh…but not surprising given how close together apartments in Stone Town are). We won’t talk about the bugs from last weekend when we went up north to a small, quieter beach town called Kendwa. One of the first things I made sure we bought as soon as we arrived was bug spray for our apartment. Turns out, we didn’t need it. Our sweet, tiny little Stephanie is a fierce bug killer. Maggie and I usually scream, and sometimes run – AWAY from the bug(s), of course…while Steph mercilessly squishes them with a shoe, napkin, or whatever’s close at hand. Maggie and I have learned to cover our ears if we don’t want to hear the “crunch” or “squish” as the creepy crawlie loses its guts. Stephanie says we should thank her brothers for this side of her, so THANK YOU Michael and David!!! The other day, we were sitting at a table at an outdoor cafĂ©, about to order food, and Maggie smacked her hand on the table, smashing an ant, barely looking up from her menu. Naturally we were (okay…I was) in awe of her; she shrugs and says, “Just wait till you’ve been here 6 weeks…you’ll do that too.” Poor, harmless ant…I’m still at the point of trying to blow them away from me…but they’re island ants, i.e. persistent and aggressive. It doesn’t work.

Back to the cats. They are our constant, if uninvited, dinner companions when we eat at Forodhani; they stroll around like they own the place, yawning and stretching lazily at the start of the dinner rush, ready for the evening entertainment. They sit at our feet in packs of at least 3-4, watching intently as people eat, licking their lips and inching closer with every bite. Forget having any semblance of human-cat personal space on the days you happen to get fish…you’ll be lucky to finish half of your dinner before you’re silently goaded into tossing what’s left into the trash where they half-heartedly fight for the scraps, move on to the next victim of their stare-downs. And you should see the battle scars on some of these cats – it’s no wonder people give in to them! We can usually tell from a distance when an especially bad-a** cat is en route, even before we can see the scars or scabbed-over wounds; the other kitties yowl and jump out of the way, as he/she walks majestically to his/her next target. **Shudder**

The other day, Maggie’s dinner (at Forodhani) was cut short by a particularly aggressive cat that did not so much as bat an eyelid when shooed away, or react at a half-hearted attempt from a skewer-wielding me to scare it into submission...or at least keep it at bay long enough for us to finish eating. (Relax, my animal-loving friends; the skewer in question is pretty much a long flimsy toothpick, and it’s all I/we had at our disposal at the time.) He decided enough was enough, hopped onto the bench we were sitting on, and proceeded to chow down on Maggie’s food (chili & all) as she dropped her plate onto the bench and jumped away. I don’t blame her…that kitty looked MEAN!! I’m pretty sure he had won the previous night’s bout. Even the other cats give him a wide berth. Needless to say, we provided some fun entertainment for our local friends that evening. Later that evening, the same cat scared Maggie into dropping her mango. Not a good night for dinner at Foro, I guess. Spice Girls: 0; Scary Kitty: 1. Oh, who am I kidding!?! Scary Kitty wins every time!

Stone Town…where everybody knows your business

I’m starting to think I should walk around with a sign: “You look, you pay…” Even if we just charged one hundred Tanzanian shillings (~0.06 cents, USD) for every stare, I’m pretty sure all three of us could pay off our student loans with the money we’d make while here; okay…maybe just one of us, but still…. It’s very unnerving. We’ve tried staring back just as intently, but trust me…these people are experts! Also, we can’t ever walk around alone or in a pair without someone – usually many someone(s) – asking about our friend(s)…or where we’re going…or anything else they might want to know about you at that particular moment on that particular day. It’s really fun on the days we go back and forth – running errands, or if we happen to finish work early and go back to the apartment before leaving again. I’m perfecting the art of the “appropriately-island slow albeit with a purpose while constantly responding to people’s [multiple] greetings but avoiding making eye contact with anyone and never stopping” walk.

I forgot to mention something about Stone Town. While it’s largely residential, it is also filled with touristy curio-type stores, strategically located along every street/alley/path. So pretty much every person you walk past welcomes you into their shop, “just to see…” I quickly learned not to respond with, Kesho (tomorrow) or Baadaye (later), ‘coz guess what? They ALL reminded me when it was tomorrow…or later! Lately, instead of every single person we pass saying hi and trying to get us to come into their store, it’s more like every second person says hi and every third also welcomes us in. Ahhh…progress! But now that we’re “locals,” the greetings are no longer the tourist staples of Jambo or Mambo; now, it’s more like a conversation…composed entirely of [repeated] greetings, many directed at our backs…’coz remember, we do not stop!! (Only tourists do that, haha!)

To further complicate matters, Stone Town’s very narrow streets (if you can call them that) are not only used by pedestrians, but also cyclists – on bicycles, Vespas, motorbikes, and many other two-wheeled vehicles that constantly fly by and around sharp corners at breakneck speeds. Thankfully, the riders usually warn us they are coming up behind us, towards us, or are around a corner. The motorbikes and Vespa drivers honk, while the bicyclists ring their bells; for those without bells, a squeeze of very squeaky breaks suffices to alert folks to hop to; and, my favorite…a kissing sound made by the rider also means, “beware, bicycle about to run you over if you don’t get out the way!” Let’s not go into my reaction the first time I heard that! Occasionally, we also have to make way for hand carts, known as Mikokoteni…but at least those move slowly enough that we have plenty of time to make room…usually. Unless they’re going downhill. Then good luck. We’re in the habit of walking single file, especially when all three of us are together. At least that way if one of us got run over, we’re all going out together!

Vespas/motorbikes zooming & honking, bicycles trilling, kissing sounds, and endless greetings are not the only sounds we hear in Stone Town. There are also the cats that fight every night, usually around 3 or 4 a.m., so I guess technically morning. The first time I heard it, I thought our next door neighbor was shooting a bad slasher flick to screen at the upcoming Zanzibar International Film Festival! Nope, just a couple of cats going at it like there’s no tomorrow. Honestly, from the sounds they’re making, it’s no wonder the streets are dead silent. I certainly wouldn’t want to get caught in the middle of any of those cat fights, let alone try to break them up! Yep, Stone Town in the wee hours belongs to yowling cats. Many of them…or it could be just two. I’m too scared to even peek out a window to get a look. The locals are obviously smart enough to steer clear, and I plan to do the same.

I have no idea how I’ll ever again be able to fall asleep without the sounds of Stone Town once I leave this place.