Final Week Already!

5 September 2010 (Sunday) The ride home from Mikumi National Park was anticlimactic and fast. Joshua, my guide was anxious to get me back to home base so he could get back to Dar Es Salaam, his home so he take a shower in his own place, eat his own food and sleep in his own bed. Mmmm…that is the same thing I want to do but all the way back in the good ol’ USA, not just CCS home base. We drove one more time through Mikumi to sort of say good-bye to the animals that had given me such a fabulous experience the day before.

The watering hole where the elephants bathed that I inserted in the previous weeks post was totally dry. I guess between the heat of the day and all of the drinking, the water was gone. No more Hippo lounging in the water. Just empty and all the animals gone, kind of freaky.

I asked to stop at the lodge where we had eaten lunch the day before (inside the animal park) to see if the gift shop was open. My fellow volunteer, Claire and I have been looking for post cards to send her grandkids, everywhere! None. After all it’s not like the village of Bagamoyo is a hotbed for tourists. So I figured since all of game reservations are “tourist-type” places then maybe they would have postcards. Yeah! I scored. I bought 3 postcards for Claire and one for a souvenir for me. Of course I had to shop in the gift shop as well but it truly was just “touristy” stuff. I had seen many types of baskets at vendors alongside the road on our trip to the park. My friend Susan collects baskets from all over the USA and the world, so I did find one made in that region of Tanzania to give to her. As I mentioned, Joshua was in kind of rush to get home, so I was pretty sure I would not be able to get him to stop at one of the roadside vendors and then wait for me to haggle down the price in my broken Kiswahili so I made the purchase while I could.

 

As we exited on to the main road heading out of the park, 2 gorgeous giraffe crossed the road right in front of us, saying good-bye. It made my heart sing to see them so close. They had barely cleared the road then a speeding bus went barreling by, just missing the heels of the 2nd giraffe. Ahhh! Creeps!

We did stop for food about 2 hrs into our trip back to Bagamoyo. It kind of looked like a cross between a truck stop and tourist trap greasy spoon. The food was okay. I thought great, I can use the loo while we are in a structure that might have a toilet rather than pulling alongside the road to take a pee. I don’t know what I was thinking – a toilet! In the middle of a desert – Ha! Nope just a pit potty and me in pants! So I hitched my pant legs up to my knees to avoid cross contamination with previous visitors deposits and managed just fine. Yeah! I don’t mind using pit potties when I am in a skirt for obvious reasons but it is a challenge in long pants. Enough of my potty adventures.

Back on the road again. The time went by quickly. The last hour of the trip back to home base was on a “short cut” on questionable roads. Let’s say I would have preferred to have had a sports bra on for all of the jarring and assault from this road. It did make me glad to reach CCS home base!

 

6 September 2010 (Monday) Today’s course content was to review what was presented last week by myself as well the student presentations. Remember they learn best by repetition. At least this time all of my flip charts and lecture notes were already done, so all I had to do was review the content and then get to my favorite part asking challenging questions!

I had picked up the lecture notes turned in from the student presentations from the faculty office as the list of students for each group was on the lecture notes. Ah-Ha! Now I could call out the names for each group to know exactly who presented and which questions I could ask them and feel relatively confident that they could answer without losing face. Great!

Needless to say this was much easier on me but I think very stressful for the students. I did want them to be held accountable for the content they presented by being able to answer questions on the topic their group was responsible for. I wanted to make sure it was not just the speakers that knew or understood the content but their whole group. And in turn by repeating information known by the individual groups teaching the remainder of the class the content as well. So I had everyone in the first group stand up. Slowly and painfully I finally got all 8 members to stand. Then I started out asking questions, almost too easy of questions. No one was answering because they could not believe the questions were so easy – they thought I was tricking them. Not so! So I made the questions a little harder. One timid little hand at the back of the class room volunteered to answer the question. She got it right! Yeah! She got to sit down and be put out of her misery. Pheww! I asked 3 or 4 more questions of this group. With each answer they got a little more confident. So I allowed them to sit down. I moved on to the 2nd group. Now they were getting the hang of it – easy questions are asked first – if one answers a question one gets to sit down and hide in ones seat. So this time I had more ready volunteers to answer questions. But this time I didn’t stop with just 3 or 4 questions for the group, I made sure everyone had a question to answer. They did it! Yeah!

Group 3, had not listed their names on the presentation notes so I had the whole class stand up! Oh they hated that – being made to stand up. The classroom is 95°F, nearly 100% humidity, you would think they would beg to stand up and try to cool off. After much encouragement, they were all standing, listening intently for the question that would release them to the safety of their seat. I had a great amount of difficulty conveying the concept of diffusion of gases. I couldn’t decide if it was my English or the lack of their English or the way I was explaining it to them. So I kept trying different ways to demonstrate diffusion and then asking questions to check comprehension. I posed the question “What is the process of a gas in high concentration moving to an area of low concentration called?” Silence. I asked the question again. And just when I was starting to get a cramping pit in the middle of my stomach that no one was going to answer the question, 4 hands timidly were raised. I was smiling inside. One of the young men, Simoni, was first to raise his hand so I chose him to answer. In a very quiet voice he answered: “diffusion”? I just about did jumping jacks of joy! I told him to say it again, louder. He said it so loud I had to step back. I cheered and clapped. And said he could sit down. I looked around the room and saw that many others would have guessed correctly and said “if you had the same answer, you may sit down”. Nearly the whole class sat down! Good I think…

The rest of class session went much smoother with more questions and answers, building their confidence until it was time for tea break – time had just whizzed by!

When the students returned from break I brought out another way to quiz them – flash cards. I so wish I had done this sooner because it was extremely successful. I had been listening to the volunteers who teach young children and how successful flash cards are. So I thought I will make my own medical terminology, respiratory system, clinical questions flash cards. They loved them, so much that they wanted to keep my cards to use during studying. I said they must be shared with the whole class not just the person that held the cards. They agreed.

An interesting note of our routine, after every lecture the class leader would come to the front of the class with a notebook for me to sign stating how many hours I taught. She would write in the hours, I would sign. What I found disturbing was she would only log hours where I was actually presenting a lecture not the time I was asking questions or writing on the board or reviewing vocabulary. Hmmpf! I felt like all of what I did was teaching and some of the best learning on their part was when I asked questions. Oh well, it’s not like I was getting paid by what was in the book but it still bothered me.

In the afternoon, I was planning to go pick up my skirt from the tailor, Pili. Sarah, one of the other volunteers said she would go with me but she forgot and went after her placement instead of coming back to home base to escort me back down the road. I had only been there once with Claire and was not sure which turns to make in Pili’s neighborhood to get to her house so I didn’t go. I get too tired in the heat and humidity to be wondering around in the wrong direction. I had wanted to wear my wrap-around skirt to the last day of classes the next day. Oh well, maybe I can wear it during clinical later in the week.

I think I was still quite tired from the busy weekend at Mikumi, and everyone else seemed tired too, so I laid down for a short nap. Ahhh…sleep…then all of sudden, doors slamming, building alarms gonging – what the heck! The alarm technicians had finally shown up from Dar Es Salaam to fix the short in the security system. Oh for Pete’s sake – I thought it was fixed! Nope, the guards just had not been turning on the alarm at night. Just locking us into the house after we went to bed and unlocking everything before we got up. Kind of scary, to be locked in and no fire department if we caught on fire. But oh well, I guess we could have pushed the mosquito screens out of windows to climb out if needed. So no nap!

I got out my little laptop and fixed up my lecture notes so I could finalize the files and store them on the CCS home base computers for future use if needed and to make hard copies to give to the school. I could print one copy at CCS but if I wanted more I needed to have them copied out in the community. The internet café near CCS did not have a working printer so I asked Sarah, where there was another Internet café. She told me near CCS Summer house. During the Summer when there are more volunteers than can fit into the home base house or home base and the annex across the street (where we were staying) then they open up Summer house down the street about 4 blocks. So Sarah walked me down to Churchill’s Internet Café for my printing needs. What a nice young man! He had a printer but it was not a copy machine. So each copy had to be printed one at a time, very tedious and right in keeping with TFT (Tanzania Flexible Time) – after all “this is Africa!” The electricity went out in the middle of my print job so we talked awhile to see if maybe the electricity would come back on. Churchill is originally from Kenya, hence why his English is better than most I had met so far in Bagamoyo. But he admitted his Kiswahili was not very good. He said in Kenya they tend to speak more slang and in Tanzania they speak “proper” Kiswahili, but he was learning. So we spent some time quizzing each other. The electricity returned and he resumed printing my materials, one page at a time.

By the time I was done it was nearly dinner time and the sun was setting. We (volunteers) are encouraged not walk alone nor walk at night. If it is dark we are to catch at Bajaj (a sort of a pedal cab) or an approved taxi to get back to home base. Well I had not brought my list of phone numbers with me and it was more light out than dark so I started walking back. It is considered rude to not say “hi” to people you meet along the street. As I walked back to home base I practiced my greetings: “Mambo”, “Hujambo”, “Harbari za jioni?”, “Mchana”, Most people responded with one word answers: “Poa”, “Jambo”, “Nzuri”, “Nzuri sana”, as they should. But there is always some young man who wants a longer conversation in partial English and partial Kiswahili that the ultimate goal in the conversation is to seek a relationship. Which just makes me walk faster. Hmmm, it’s the same all over the world, nothing new, it’s just tiring.

The remainder of my walk was uneventful. I watched children playing alongside the street and playing soccer in an open field of stones and dirt. The soccer ball was made out of cloth, left over remnants of kangas (a length of fabric used to wrap around the waist to form a sort of skirt) and such. How adaptable kids are! I finally made it back to home base for another great meal and relaxed.

7 September 2010 (Tuesday) My last day of classroom time with my 57 students. I was little sad, still wondering if I have made a difference in their lives. I know I feel different but have I in some way improved their lives, their education by my short interaction with them? I may never know but I hope so.

The faculty had requested I teach CPR with a particular focus on bag-mask ventilation for infants, children and adults. My tools offered were two baby dolls, 3 self-inflated ambu bags and 2 masks. Everything had been cleaned up for my use but the dolls were not CPR manikins so all I could do was demonstrate position and troubleshooting airway problems. I had them return demonstrate airway position, opening the airway, face mask position and reviewed normal respiratory rates. We talked about chest compressions but they could not imagine doing CPR on anyone in the hospital and definitely not out in the community. If someone was dead – you leave them dead and get on with life. Not mean just a fact of life. So the question “why teach them all this?” begs to be answered. After all I was trying to teach an 8 hr class in 3 hrs and struggling with this concept of “why do any of this?” So off I went to the faculty office (a room next to the classroom) and asked “when would they use this information?” I was told that children are often inadvertently over medicated with morphine so one may have to provide manual breaths until either a reversal agent can be found and given or until the medication wears off. Okay good to know! Another clinical situation would be during surgery, if a local anesthetic is used or surgery needs to be performed quickly, there is not always another physician to manage the airway so a nurse manages with manual breaths. Can you imagine doing a whole surgery with only bag-mask ventilation! Exhausting! And flashes of my early transport years before transport ventilators were available having to give manual breaths during the whole transport. Back into the classroom again to reinforce manual breaths and what situations they would use manual breaths.

The last hour of class was spent on learning the Heimlich maneuver or abdominal thrusts to clear an obstructed air way. I had made a couple of posters reviewing CPR and the “Helping Babies Breath” program but ran out of flip chart pages to be able to draw choking and abdominal thrusts. But these young people have a fantastic memory so no worries. This was hilarious to teach as well as to watch! I think everyone was able to do it. While I was checking each student as I walked around the room, 4 creative students decided to get imaginative and create a Heimlich maneuver chain. One student was giving the next student an abdominal thrust while she was giving the same procedure to the next student. I wanted to take a picture because we were all laughing so hard watching the 4 of them all chained up doing the Heimlich on the next person. But they all seem to shy away from photos so no picture for ya – you just have to take my word it was hilarious! I was so proud of them for finally feeling comfortable enough with me to be silly and show off! Maybe I am making a difference…

We ended the class about a half hour early. We cleaned up and put the equipment away. I said good-bye to the class as a whole, a little sadly. But no one left, the students just sat there. I should have been suspicious. It was the last day of classroom time with all 57 students. I would have my 9 to 15 students in clinical but this was the last chance to see the group. I was a little sad that they weren’t a little more involved with saying good-bye. So I was feeling “poor pitiful me”, my students don’t even want to say good-bye to me. I went into the faculty office to give over my copies of lecture notes for their files, and have a mini exit interview. Again I should have been suspicious; all of the faculty were in the office including the principal (I never saw them all in one place before). I told them all the equipment is put away and was going to go stand outside for my ride back to CCS. They said wait. Okay….

Veneranda had gone to the classroom, still filled with students. She was speaking to them in Kiswahili so I didn’t know what she was saying but I heard “Kwa Heri” (good bye) and “Madame Krist” (for some reason many people would shorten my name since I was not Kristina and they didn’t understand it was Kristie and just shorten to Krist not pronounced Christ!). Then she came out closing the door behind her and I hear laughing inside. She pulls me back in the office and we chat with the principal. Mmmm…its chit chat, I think I am being kept here for a reason. Then we all head back into the classroom and the students start singing a good-bye song to me in English and Kiswahili! These quiet, docile students are rockin’ out for me! I loved it!

The class leader stood and said a formal good-bye in her very rehearsed English. Very sweet! Then another student had written a song to say good-bye and thank me for teaching about the respiratory system, CPR, Heimlich, positive pressure ventilation, vital signs, etc. Amazing! Then another rocking out song – they had voices like a choir – it gave me goose-bumps! Fantastic! And finally some parting words from the principal, my mentor faculty member, Veneranda and then I was encouraged to speak and say my good-byes. I gave them words of encouragement in their studies, their education and for their exams planned for next week. I hoped that they got something from this experience – I know I did. They stood and clapped for me! Very heart warming. And when I thought the good-byes were over – parting gifts were brought out! Oh boy! They gave me 3 meters of batik fabric in my colors of royal blue, purple and mint green (absolutely gorgeous!) and another length of fabric with zebras all over (great!). The wrapping was an empty page from the flip chart (uh-huh(!) the missing page I needed to draw the choking poster on!) *grin*

The best compliment I could give them for my gift, was I immediately and genuinely threw the batik fabric around my waist into a makeshift kanga (wrap skirt). They loved that I loved their gift! I was warm and fuzzy feeling all over! Sigh….

I shared my day with everyone at dinner that night. Everyone expressed their sadness about my pending departure but that was still 4 days away so don’t say good-bye yet. I am seriously thinking of coming back some day. It would be great if I could swing coming back while this particular group of students are still in their program. Veneranda shared with me she would like to retire within the next 3 years, so that is something to consider as well, as we got along so well. Maybe…some day…

8 September 2010 (Wednesday) Today was another day on the pediatric ward. I was excited to go as now I was feeling more comfortable with the staff, routine, and my students. I knew Madame Veneranda would be making a surprise visit to start assessing what the students had learned in their first month on the wards. I was nervous for them but I was sure they would do well if they stayed calm. The week after I leave will be their big exam covering the whole semester. The students started firing questions at me in their franticness to remember everything they think they will be tested on. Thank goodness I was able to answer everything – eek! After all its been many years since I attended my first nursing classes.

We only had one patient in the whole ward; A child quite ill with malaria and severe anemia who was just finishing a transfusion. Most of the kids from last week had been discharged home and some had died. So with only one patient and 9 students, it was decided to clean everything in the ward; curtains, bed stands, beds, mosquito netting, equipment carts. One by one each piece of equipment was carried out side on the covered walkway between wards, water hauled in and everything soaped up and rinsed off. Once dry, each piece was returned to ward after the floors had been cleaned. What a process but very thorough!

Since we had CPR the day before I decided to review the emergency equipment available on the ward. There is one corner room which is air conditioned where equipment is stored and where admission exams and procedures are performed. We pulled down the emergency box, sort of like our crash cart, but in a giant tackle box and began reviewing all of the contents and what the purpose was for each item. While we were in the exam/admit room, my thirsty students asked if I knew how to operate all of the equipment in the room. Yup! (thank goodness) So one by one we reviewed each piece of equipment, how to turn it on and off, what it was used for, how to clean it after patient use, where it was stored, what types of patients would need this type of equipment, etc. While I was reviewing all of this, 2 new interns from England who were going to meet Dr Paul (pediatrician) to begin their orientation to this area came in the room. Thank goodness they arrived because many of the meds in the tackle box were British, so even though I could guess at their names and uses, it was nice to have them confirm I was guessing correctly. The interns elected to stay and listen to the review of equipment and meds, knowing they may have to use this room some day when they start working. They thanked me for including them in our review. And my students respected me a little bit more for sharing our knowledge with strangers. At least that is how I interpreted their behavior.

I left my students to head to my pick-up stop for Elias, our driver to take me back to home base. On the way to my stop, the Matron of Nursing, stopped me to see if I could stop by the maternity ward the next day to “go over” the “Helping Babies Breath” program. Helping Babies Breath is a modified NRP course for third world countries with limited resources. Dr Douglas, one the OB physicians had asked if I would teach the program to the midwives, L&D nurses and staff but Dr Douglas had been called out of town. I kind of needed him to reinforce whatever I taught. I told the Matron I would certainly try. As soon as I returned to home base, I zipped over to the internet café to pull “Helping Babies Breath” info. Finally found some info on a British website including a little poster showing the algorithm. So I went to my back-up internet café to print the one page poster so I could make flip chart page poster for the next day. Thursday was to be my last clinical day as Friday was to be a holiday, Eid al Fitr (end of Ramadan). I was little sad I would be taking time away from my students to teach another group of people but I was in Africa to teach as many people as possible so decided I should go ahead with this project. I promised my students I would at least stop by the pediatric ward to say my final good-bye.



9 September 2010 (Thursday) My last day of work, tomorrow is a holiday. I presented myself to the Matron (Aeisha) who in turn escorted me to the maternity ward. The nurses were still in report for change of shift. It had been a busy night. They asked if I could wait an hour or so before I did the in-service on resuscitation. I left to return to my students on the pediatric ward. They were genuinely pleased to see me. I told the Matron I would continue working with my students until someone came to retrieve me to teach in the maternity ward. She said that would probably be the best use of my time.

3 patients had been admitted overnight. More malaria and another burned baby. Ouch! My students and I got to work, taking vital signs, preparing for a dressing change and talking about complications of the medications our patients were receiving. They are so much more relaxed with me now, comfortable asking questions and doing some tasks independently. We were busy so I did not even notice the maternity ward staff never came to get me. I walked back over to the maternity ward before I left and everyone was busy with lots of mothers in various stages of delivery. I reported to the Matron I was not able to teach a modified “Helping Babies Breath” program. She told me since I did not meet my objective – I would have to return some day to teach. Maybe I will…

An interesting note about ID of infant and mother. When a mother is admitted to deliver, she brings 2 or 3 kangas with her (the wrap skirt fabric, I have mentioned before). Each kanga has 2 halves that are identical. When the mother delivers she cuts the kanga in half, she wears half and the infant is swaddled in half. So at a glance one can match up a baby with their mother by the color and pattern of kanga. Great! This is done in the pediatric ward as well. The mother brings sets of kangas so if her child is sick, swaddled or covered with a kanga, the mother wears the same thing so everyone knows who belongs to who. Colorful and efficient!

In the evening, the Imams saw the moon which heralds the end of Ramadan. So Friday is now an official holiday. Eid al Fitr. No clinical. No placement. No work. Sad, as I would have preferred to work up until I left.

10 September 2010 (Friday): Got to sleep in a little. So conditioned now, really couldn’t sleep. And my stomach woke me on the dot for some of that good CCS breakfast.

Packed my bags. Sorted out clothes I would not need back home to leave with CCS to donate where they see fit. Donated my remaining teaching supplies to the CCS resource center (where the volunteers get supplies to teach or train at their placements. Checked in on the internet or tried to for my flight but because my final destination is USA, I was not allowed to check-in on line. What a pain.

Mama Thea our Program Manager for the country of Tanzania took all of the staff and volunteers out for Eid dinner. We went to a hotel restaurant along the beach. It was quite windy but it was great to eat close to the water. There were a couple of craft vendors on the beach. Of course I can not pass up one more opportunity to shop. Took a look but nothing that interested me – ho hum…

We finished our lovely meal and all piled back into the CCS van, kind of looking like one of the local daladalas (minivans that get backed to gills with passengers going short to medium distances. Sometimes with chickens, children, men, women, bags, fruit, etc until everyone is overflowing out the windows).

The daladala vehicles are saturated with countless people. I never saw an empty daladala. Seats would be filled and still more would be loaded into the aisles, windows, tops of van. Daladalas house an array of people, with children in their school uniforms sitting alongside of business people in more formal attire heading out to their jobs, alongside Muslim women heading to market. The driver never seems to interact with the passengers, yet there is a conductor of sorts that hangs out of the open door taking exit requests and fare money. At every stop along the way whether for traffic or a stop, hands would protrude from each window offering peanuts, fruit and scarves from the nearest marketplace.

Various daladalas traveled in front of our home base but I never saw the same one twice. Everyone seems to know where they are going and which one to catch. It seems pretty efficient but a lot of chaos!

I watched the busy-ness of Eid celebrants up and down the street and realize my time is almost done. I wonder if anyone will remember me. I hope I can keep all of my memories, feelings, values I have gained from this experience intact. This blog helps. I wonder if I have made a difference for my students, the hospital staff, the orphans I have played with, the women I have crafted with and the CCS staff that will remain long after I am gone. I have been honored by my students, the NTC faculty, the nurses and doctors at Bagamoyo District Hospital and even passers by in the streets. I don’t know if any of it is real but it all makes me feel like a better person for coming here and interacting with another culture. Maybe I have made a difference…



Adventures of my 2nd week in Tanzania

30 August 2010 (Monday) My first day to start teaching to the nursing students at Bagamoyo Nursing Training Center. They are at the end of the first semester of nursing school. Today we started the end of their anatomy and physiology class with the Respiratory System. It was a struggle to provide a college level course with flip charts, hand written notes and some computer generated notes. I realize how dependent I am on technology when I teach with Power Point presentations instead of back to the basic tools but I managed. It is very time consuming to write, draw and detail everything on flip charts. I was so worried I would not be ready in time for class as I had limited access to the Internet with electricity outages and server outages. I took my little laptop with me that has a basic word processing with me to Zanzibar so that did help me get a lot done. I was lucky enough to find an unsecured server on Zanzibar to be able to pull some clip art into my lecture notes. When I was done doing my 4 lecture classes, I made copies for the faculty to keep on file along with the flip charts. But just in case faculty change or the notes get lost, their is a digital copy on the CCS computers under my placement. I offered to make a hard copy on a CD but they really do not have a reliable computer to be able to access it so that was the best we could do for them was to give the paper copy.

Around the classroom they have commercial posters of the various systems they have learned about during the semester. The nervous system, the gastrointestinal system, the musculoskeletal system, etc. A poster for almost every part of the anatomy except the respiratory system. So I got approval to send back a wall posters with the parts of the anatomy they do not have yet. Before I return to work I will shop the University of Utah medical book store and get those sent off so the students so the posters should arrive by the time they start their 2nd semester. I have approval from CCS and the principal of the training centre.

I admitted at the beginning of class that it was going to be a challenge for them to understand my English with an American accent. They agreed! And since the students are from all over Tanzania I would also have to take my time to train my ear to listen to their English with the various accents their tribal languages lend to their speech and pronunciation.  Working together we would hopefully both learn together. I encouraged them to ask questions whether it was related to the lecture topic, nursing or not. After all we are to be sharing our cultures with each other. They are so shy with me, quite fragile. I am a little nervous about pushing them with questions as I don't want them to lose face but I also want them to be interactive.

57 nursing students in one hot classroom!

Apparently the style of learning from Primary school on is rote memorization and learning info in particular order. Students have a great deal of difficulty answering questions out from the order of how the content is presented. The other volunteers who teach the younger students said the same thing about teaching the ABCs and 123s, etc. They can say what something is in English if you ask them in order but ask a question about the alphabet out of sequence and there is a problem. So at college level I was having the same problem. So after each lecture we would have a verbal quiz to help the students stretch their minds and check and see if they truly understood their readings and my lecture. At first verbal questions surprised them and stressed them but by the end of my time with them they were getting the hang of it - it became quite fun! The best help in this style of reinforcing learning worked best when I introduced flash cards. That way the students could read what I was asking and not have to deal with my accent - perfect! I finally got the students to be competitive wanting a turn at answering questions!

After placement, we (the volunteers) were taken to the art center. Dickinson trained us on making our own swatch of batik fabric, drumming and making our own woven bracelet. Great fun! The time went by fast. I met woman sewing a dress together for one of the kids without a pattern on a manual sewing machine. I had one of the artists speak to her for me about I sew as well. She just beamed a smile at me. So I asked if I could take her picture while she was sewing. Yes! At this artist compound there was the usual array of wandering chickens but these were blue! I thought well they do belong to artists that is probably why. But no, they died them so that predator birds do not recognize them as food! How smart is that!

                  

    

Hot all day long, wears one down and builds quite an appetite. Headed back to CCS for another fabulous dinner!

31 August 2010 (Tuesday) Today the students were responsible for presenting the details of the respiratory system. Monday I have presented an overview. The 57 students were broken up into 7 groups with me finishing up with the nervous system control of the respiratory system. Each group of students had 8 to 9 students. Most designated one speaker which was too bad because I thought I would hear from everyone. The remainder of the students must have contributed to drawing the illustrations to accompany the spoken part of their presentation. The drawings were phenomenal! Granted they were copying the illustrations from their text book but they were making them poster size - no easy task! Wish I had thought to take some pictures of some of their work but I think that would have embarrassed them.

I ended the class with more spontaneous questions about what they had just presented. It was still kind of a painful process but at least I was starting to get volunteers to answer! Yeah!

In the afternoon our cultural experience was to visit a traditional healers house / office. I was excited about this as I am always interested how the past health care influences the present. I thought it was quite interesting! So interesting I forgot to take a picture of the Dr Id. He is 74 years old and still a very active practitioner. Most of the younger volunteers thought of him as a little loco but one has to look past the verbiage used like "being made ill with a bad genie" is really the same as mental health can influence your physical health and wellbeing. So he not only treats the physical symptoms but is a counselor for the behavior or mental health issues that are contributing to their illness. I think he is just like conventional medicine just goes about it in a different way with age proved "herbs and medicines" instead of our scientific proved methods. He gets the same results, sometimes better!

Mama Christina our Kiswahili teacher

We have Kiswahili lessons for an hour 3 times a week for the first 2 weeks. I love languages especially when they make sense. I do not like learning the grammar though, I just want to be able to speak and get around and not be so dependent on others speaking English. We learned this week about time, numbers, etc but I think I explained that in an earlier post. Kind of confusing but at least that explains why there is sometimes confusion about what time we are supposed to be someplace.

Dr Ponza, pediatrician

1 September 2010 (Wednesday) I was dropped off at the Matron of nursing's office for her to take me to the pediatric ward to meet the staff and make sure I could find my way. Matron Aisha is quite a personable person. She is friendly and supportive but she can also be stern and directive when the situation demands. Her presence demands respect and everyone leaps to their feet when she enters the room. It was like I was in the military all over again!

            

Grace, Monica and Sara

My first clinical day with my students on the Pediatric ward. I am dreading this as well as looking forward to it. The hospital is very bare and basic but still have to deal with life and death issues. Its a good thing I have been in the military and have had to "make do" with minimal resources before and that I have a head for "figuring" things out. I figured there would be 3 or 4 students assigned to the Pediatric ward but no their were 9! There was more staff and students than there were patients! There was one patient recovering from pneumonia, another being admitted with pneumonia, 2 with slowly recovering from malaria, 2 with acute symptoms of malaria in the isolation area (due to diarrhea). Both the patients in isolation were severely dehydrated and nearly unconscious, very sad. The last patient was a little 2 year old with healing burns. Most family meals are prepared over an open fire with children playing near by. Very scary! One of the older children was pouring porridge from the boiling hot pot into her bowel when she lost control of the post and the whole pot of porridge poured down the front of this child. How painful! She had to go through painful dressing changes every day with only a little oral morphine to take edge off the pain. Apparently there is too many problems with respiratory depression if too big of dose is given so they tend to under dose. Sad!

I was a little overwhelmed with severity of the patients and how basic the conditions but they all seemed to take it in stride. My job with the students was to help them apply what they had learned in class to their clinical setting. So we got to work with practicing taking vital signs on each other, listening to normal then obtaining vital signs on the patients. Vital signs need to be recorded before the physician starts rounds. The physician mostly does sit-down rounds and has the mother bring the child to the desk. Yup with IV fluid, dressings and all. No poles for the IV fluid either. These are truly multitasking moms. They just sling the child up on their front or back and carry what ever is connected to them and sit down in front of the doctor. The doctor asked the mother if there is any improvement or concerns not the nursing staff! I kind of think it should be both! The doc will write orders in his or her notes and then one of the nurses transcibes the orders into a log book so everyone knows what needs to be done for the patients. That first day there was a lot to do for me and my students. We started an IV, drew lab work and helped admit new patients. One patient got to go home, which was exciting!

All of this done with a minimal amount of sleep for we had been woken up with the building security alarm sounding "whoop-whoop-wa-wa-wa-whoop-whoop!" At first security thought it was a cat or something on the fence but it ended up being a short in the system but that was determined after trying to reset it several times hence the little sleep! Another adventure in Tanzania...

2 to 3 September 2010 (Thursday and Friday): More time on the wards with my students. I thought I would have the same students but no some students rotated to afternoon shift and some rotated from afternoon to day shift. I thought how am I going to learn anyone's name if they keep changing who I am working with so I decided to take pictures of 2 to 3 students at a time and list their names so I could start learning their names. I did pretty good with this method which in turn helped me know at least a few of them by name in class. The students that I would remember their names would just beam at me. The men were the easiest to remember as there are only 9 men out the 57 students.

Sania, James, and Hadija

The little burn patient had to go through another dressing change and I was asked if I had any ideas on how to make it more comfortable for her - you bet! Its so much nicer to be asked than to barrel ones way into a situation dictating what needs to be done. After all who am I to say do this different when this is the way that has worked for them for so long. So I demonstrated how to soak the dressings off more thoroughly by squirting with a saline bottle than just splashing bath water up on her dressings and then I demonstrated how to layer the new dressing without lumps and to secure with ties instead of copious amounts of tape that made it eventually more difficult to remove the dressing (having the layers of tape not the way I showed them how to dress the burn). The mother could see right away that this was going to be easier on her daughter and she bowed to me and called me little mother in Kiswahili! I almost cried. The charge nurse I think respected me better as well because so far I had not shirked any task she had tossed my way. I felt very good about how the week was ending.

I do have to interject in my jubilation that there was also some great sadness. Every day there would be at least one child who died. So sad because it was often so unpredictable. It was not always the most ill child. I think the random death was one of the hardest things to deal with and sometimes interfered with my concentration on what I should be doing with my students. Extremely sad. The illness and death rate for children under 5 years of age is extremely high and unfortunately I got to witness this fact daily. The  mothers are fractured by the death. The staff seam to leave the mother to her grief rather than do any consoling. I don't know if this is their culture or is it because the nurses are pediatric nurses and do not know much about taking care of adults and adult grief. But it is my culture to give my condolences so on one child who had died just before I arrived for the day, I went to the mother and hugged her and said how truly sorry (pole sana) I was for her loss. She knew I was genuine and hugged my hand in response. I can still feel the wetness of her tears on my hand - so very sad...

Thursday afternoon we got to cook with our chef Chiku and her assistant Edna. We were allowed to pick a couple recipes we wanted to learn. I was tempted to decline and offer to teach some Mexican food but I really wanted to learn how to make Chipati (Indian flat bread but made the Tanzanian way). So I requested the Chipati recipe and experience and one of the bean dishes. Claire and Michael requested to learn one of the veggie salad type of recipe. We all worked together while learning. It was great fun! Just what I needed after a stressful day at the hospital.

Chiku, one of our fabulous Chefs



Michael (fellow volunteer) following the recipe



Yes they let me use sharp objects! Amazingly trusting!



Joshua, my personal safari guide





3 to 5 September 2010 (Friday afternoon to Sunday afternoon): Mikumi National Park Safari! I almost did not book this trip because I was exhausted emotionally and physically! But I called our travel contact Kennedy to see if he could book be a short notice safari. Yes! He came through for me! Since I was the only one going and only going for a short safari we had haggle over the price but finally came to a compromise. He would provide a guide and driver all in one and we would use his own car a 4 wheel drive Toyota. Worked out great! Joshua was my guide/driver. A very nice 34 year old young man. Being the only two together all weekend and on the long drive we talked about everything. Work, school, family, travel, languages, opinions, etc. I had a great time.

Smile Twiga!

When we reached the entrance to the park on the way to the lodgings, we saw all of the animals I wanted to see, giraffes, elephants, zebras, impalas, snakes (well I didn't really want to see that but we did), warthogs, and baboons! Amazing! I thought if I see all of this so close to the road right away what was I going to see the next day on entry into the park? Well it was even more amazing!! I saw lions, more baboons and tons of giraffes and zebras. But probably the very best was sitting at the watering hole watching the hippo and then the elephants come in to have a drink and a bath. Fantastic! They were so close I could smell them, hear them probably could have touched them if it had been permitted. I will try to put the video in of their bath. The elephant bath ended when the bull elephant decided we were too close and postured for us to leave by stomping feet and flapping his ears. So needless to say we booked on out of there! Thrilled with the experience!

Bull Elephant ready to charge!



Starting work and having fun!

I know this seems kind of backwards hearing about my first week of activities a few days before I leave but my time has been packed with cultural experiences, work at my volunteer placement and more. So this week I have a little free time an am trying to catch on my posting before I forget the freshness of the experience and before I can't read what I wrote in my journal! I hope you enjoy the postings. There will be more over the next couple of days as I prepare to return to the USA.

During the first week we attended different cultural experiences. One was visit to the Zawose family compound. They are a very musically talented family all from the same tribe and have traveled all over the world to show a taste of Tanzanian culture. I could not resist these young girls mimmicing their older counterparts. Way cute! Way talented! (Still working on uploading the video, some day)

22Aug2010 The first full day in Bagamoyo at CCS (Cross Cultural Solutions) Home Base mostly was spent recovering from our long journey the day before. We (the new volunteers) filled out our temporary resident permits that we basically use for ID instead of our passport. I have put my passport in the safe in my room for safe-keeping. With our resident permit we are considered residents of this country, we get discounts for being residents and do not have to go through the same immigration, customs hassles at train, bus and boat transportation as “visitors”. The cost for the permit was 120 USD. Money well spent for the benefits of being able to move around the country as a resident. The paperwork was returned to us all approved about 2 days later. Pretty efficient for something to do with the government in any country. But not everything here runs so smoothly or efficiently. We are slowly learning to adopt TFT (Tanzania Flexible Time) or it will drive you nuts.

Tanzania Flexible Time means you better be on time but for the local residents it can be ½ hour before the agreed upon time or up to an hour after the agreed time. So one must not schedule too many activities too close together or you will miss one. So I have relaxed, it is much easier to go with the flow than get all tied up in knots about the clock.

Oh, yeah that brings me to another adjustment the Tanzanian time is 6 hours off from the rest of the world and they only measure by 12 hour blocks. An example is the day starts with 0600 AM but that is not what it is called it is 12:00 in the morning, 0700 AM would be 1:00 in the morning and so on but we have to say a whole sentence to just to say the time but everyone seems to know what the time in the rest of world so they may say meet at 10:00 in the morning. In Tanzanian time there is no such thing as 10:00 in the morning so one would have to 4:00 in the morning if one meant 10:00 AM or if you talking about 10:00 o-clock Tanzanian, it would be either 10:00 at night (0400 AM) or 10:00 in the afternoon (4:00 PM). And of course this is all in Swahili so needless to say I learned my numbers in Swahili rather quickly if I wanted to know where I was going when!

23 to 27 Aug 2010 (Monday to Friday)
We started out the day with meetings. Learning a little more about our placements. Who our contact person would be and how we get to work. All of our placement contacts joined us for lunch so we could talk a little and make plans about how we could best serve our placement. I have been assigned to the Bagamoyo Nursing Training Center. The students I would be teaching are at the end of their first semester. As I will only be at my placement for 3 hours a day in the morning  I would focus on teaching Anatomy and Physiology. Oh boy did I have to reach back in my memory on what to teach something so basic. And teach with no computer, no power point and where all of the students English is a second language. I felt handicapped. I was allowed to borrow a text book on anatomy and physiology, given a large flip chart write notes, and draw illustrations. This type of media reminded me of teaching Sunday School or Vacation Bible School. All I needed was some felt figures to stick up on the wall and I would have been set!

At first my mentor of the faculty from NTC, wanted me to teach First Aid and Triage. Something the students will be covering next semester. It seemed a little odd to teach content our of order from what was scheduled in their program. The next day I met the principal. He did not seem pleased with the idea that I would be disrupting this semester and the next by teaching content in the wrong order. I asked if I was not here what would be the content / subject material that would have been taught. What was already in their curriculum? Both my faculty mentor and the principal said they would finish their anatomy and physiology with the Respiratory System! Well perfect! Since I usually teach my graduate students ventilator management and I do know the respiratory system - I thought this was a much better topic to teach. Now to just tone it down to beginners with a language barrier without talking down to them and I was set. What a challenge.


The other challenge was the students had just started their first clinical assignment in the hospital and clinics on Aug 2nd, so they would not be in class every day. They would only sit for lectures on Monday and Tuesday and be at their clinical assignments on Wednesday, Thursday and Friday. So it was decided I would “help” mentor the students that were assigned to the pediatric ward & maybe the maternity ward. Helping them apply what they have learned in class to the clinical arena. I was a little hesitant about this because after our tour of the hospital and saw its lack of resources and technology I was not sure what I could teach them, mentor them about. But it has been great fun, teaching them how to take vital signs and the challenges of taking vital signs on children. I have started IV s and drawn labs, assisted with a LP and changed burn dressings. Demonstrated a more comfortable method for dressing the burns rather than taping all over the place. And unfortunately, I have witnessed the loss of children to malaria, AIDs and pneumonia. So very sad.

Health care, immunizations, health exams and illness treatment are free for children under 5 years old. Children from 6 to about 12 years can receive care with some sort of sliding scale payment system that I do not understand. But it looks like and sounds like many children do not get treated due to lack of funds or access to health care.

Price lists for a type of copay system. 1500 TSH = $1



Teeth brushing directions in Kiswahili



Part of what I am training the nursing students for is to be able to staff outlying villages with a dispensary. They will be the first line of health care, triage and treatment. A very grandiose idea - I hope it works. The students are enrolled in a government program so everything is paid for but I am sure they have to promise to work where assigned for a certain amount of time in exchange for their education.

Not everyone delivers their babies in hospitals though that is a goal particularly for first time mothers or mothers with health concerns. Another way to help improve infant mortality is to train birth attendants on newborn resuscitation. Many African countries do not have the technology Western healthcare has so the W.H.O. and AAP along with other organizations have taken our Neonatal Resuscitation Program and created a trimmed version for countries with reduced resources. The program is called "Helping Babies Breath".  I talk about this a little more on my final week post. I mention this here to show the slide below on infant resuscitation capabilities in various African countries. It is amazing that there is such a disparity between "Western" healthcare and healthcare available in Africa - amazing that both can co-exist on the same planet for the same species. Maybe someday this disparity will dissolve as we humans evolve.

The unfortunate thing about my first week here was I was not able to start working with the students on the pediatric ward until my 2nd week due to some political who-ha having to get permission from the hospital administrator to work with students in the hospital. Same all over the world, got to get the head honcho’s permission before you can play in their yard. So my first week was spent preparing my lecture material (tons of flip charts). I am so glad I brought my little laptop with me to type out my notes and then go to the Internet café to print them or I would have spent a fortune at the Internet café using their computers!


My permission to work at the hospital finally was approved on August 25th. Too late to get started with the students so I was introduced to the Matron of the hospital and some of the doctors, given a lengthy, detailed tour and met a ton of people. Ahhh - so many names to try to remember. I tried to remember at least the names of the nurses on the pediatric ward as I would be working with them the most. I succeeded! The rest of the day on Friday the 25th, I spent observing in the maternal child clinic, well child and sick child visits, immunizations and weighing the children, plotting their growth on their growth chart. Interesting process. What seems like bedlam was quite organized and flowing. I wish I could have taken a picture of the whole process but I could not figure a way to respectfully take a picture so I didn’t.

27 to 29 August 2010 (Friday to Sunday)
My first weekend off! Of course I could not sit around and flake. I am half way around the world, of course I had to get out and see the sights and play! No matter how tired I am or was. So a booked a trip to Zanzibar, the major island off the coast of Bagamoyo. But no you can not leave from Bagamoyo one has to travel back to Dar Es Salaam to catch the passenger ferry to Stone Towne on Zanzibar. I was lucky that previous volunteers had already developed a relationship with a sort of an agent. So I called him. He booked a car and one of his employees to pick me up at the CCS home base Friday after work. So I scarffed a quick lunch and off we went. Anna, Kennedy's employee guided me through the port authority, bought my ticket and return, selected a legal porter to escort me through the ticketing and boarding. I was booked in first class (yeah!) which has air conditioning, just lovely! Movies and video clips were played on the 2 hour ride over to Zanzibar. If you have any tendency towards sea sickness be sure to bring Dramamine or your drug of choice. The ride over was not too bad because the boat was so big but the ride back to Dar Es Salaam was horrible due to the turbulence. I even got a little queasy on the ride back and the person behind me barfed (at least it was in the bag) – gross!



Juma, my Zanzibar guide



I was met at the dock by another of Kennedy's employees or partners, Juma and his driver Malik. Very nice young men. Picked me up and whisked me away to the village of Kwenda where I was booked at Sun Set Bungalos. The whitest, softest sand I have ever seen. Unlike many other areas I have traveled recently remarkably clean! And the very best a hot shower!!!! What a glorious feeling!

I brought school work with me to work on as I had to teach on Monday. But on Saturday I gave myself permission to play for a little bit. While reading and writing in my journal a man approached me named Wiseman who runs a boat service for snorkeling, scuba diving and sight seeing. I told him if it could be short trip I would like to go snorkeling. So off I went with his partners, Mubarik and Ali and 4 other tourists. 2 tourists were from the UK and 2 from Germany. Visibility was iffy in some places but amazing in others. So 15 USD it was a good little adventure.

The restaurant on the beach was okay but I am now spoiled with how good our food is at CCS. My waiter's name was Karim and his supervisor was Dude (I kid you not!). Very nice and attentive. I am sorry to say the Mzungu (white people) were not so nice, almost mean. They were mostly European but that is not excuse to treat people like dirt just because of their ethnicity or employed status. Most of the wait staff would greet me with “Shikamoo” (a greating of respect for those older or more revered) because I was so different than the others they were serving. So I was honored that they greeted me in this fashion. The response for such a greeting is equally respectful: “Marahaba”.

On Sunday morning before my departure Juma and Malik picked me up from Sun Set and took me to the Spice Farm for one of the famous Spice Farm Tour. Our farmer's name was Abeid, his sister who cooked my lunch was Majuma. The tour was great and learned so much! I bought fresh spices for some of my friends who cook. The food they made fresh for me while I was on the tour was fantastic. Unfortunately, my guide and the farmer were Muslim and could not eat with me, as it was the middle of Ramadan when they fast during the day. But the food was fantastic none the less.



Spice Farmer Mr. Abeid


The chicken eat a lot of the fruits on the farm. Mr Abeid called them fruit chickens. When the chickens are cooked up they taste more like the fruit they have eaten than grain or even like chicken. Kind of an odd but true.

After the spice farm tour, we had a quick tour of Stone Towne where the slave trade was centered back in the day. It was a race to get me to the dock in time for my ferry. The ferry's leave early during Ramadan in order have everyone where they are supposed to be once the sun goes down and they can break their fast. I made the boat. Kennedy was there and waiting for me. He tried to find an ATM with money for me so I could send a tip back to Juma and Malik but no machines had money on a Sunday. Oh well...

I will have to add pictures later, I am out of internet time. Badaaye (See you later!)

Kristie