Future Focus 2018: Cassandra Collyer

Cassandra Collyer, a medical student from University of Western Australia, was one of the five recipients of our FutureFocus grant for 2018. 

 

Our final FutureFocus 2018 recipient, Cassandra Collyer has returned from her placement at St Augustine’s Hospital in North Eastern Tanzania. 

As a medical student from the University of Western Australia, Cassandra found this unique experience to be both challenging and incredibly rewarding. Enduring the highs and lows of medicine in this remote and rural hospital, Cassandra was able to observe, assist and display initiative both within the hospital and during the home visits she attended with the palliative care team.

Below Cassandra reflects on her experience in greater detail.

 

Elective in Muheza

I spent five and a half weeks on my elective in Muheza, Tanzania, with two other medical students from the University of Western Australia. It was humid and hot, dusty and challenging – but an incredible experience that I would not hesitate to recommend to other medical students.

The hospital is located on the eastern side of Tanzania, approximately one hour from the coast and at the foot of the mountains. We flew in via Dar es Salaam, the largest city in Tanzania and also the prior capital. It was then a seven hour bus ride up to Muheza which is a small town on the road to Tanga.

Being in this location meant that the weather was hot and humid, without the elevation of the mountains or the breeze of the sea to cool us. However, being only a couple of hours away from each meant that we had some fantastic excursions on the weekends.

Just a casual stroll through town


Our mornings in the hospital usually started around 7:30am for the morning handover meeting where we would hear about overnight admissions. Despite being in a small town, the hospital was a district hospital that covered a wide area and was always busy with new admissions. It covered general medicine, surgery, obstetrics and gynaecology, paediatrics, and palliative care wards.

The hospital had open windows and long verandas to let the shade and breeze through – nonetheless this didn’t prevent ourselves and many students before us from fainting/almost fainting due to the heat inside. Unlike hospitals at home, there were no meal or washing services and patients had to bring in their own sheets and relied on family members to deliver meals (usually around 5am each morning before they started their own days’ work).

I particularly enjoyed the time spent outside of the hospital, both shopping in the local markets and getting our hair braided at the hairdressers. Tanzanian’s are wonderful, high-spirited people and it was a joy to live with them in their community. The outreach visits we attended were also a major highlight.

At the paediatric outreach clinics we weighed children using hooks from the roof (some loved this, others less so!). Children and parents were tested for HIV, given appropriate medications (e.g. worming tablets, vitamin A etc.) and vaccinated. Parents were also provided the opportunity to receive contraception. One hilarious day, right before Christmas, we drove through villages while men ran up at our car to collect condoms – it felt like Santa on his sleigh handing out gifts.

Weighing children in the paediatric clinic


The opportunity to visit patients in their own homes enabled us to see how they truly lived. Some houses were incredibly simple with mud walls, holes for windows and thatched roofs. We gained a glimpse into the enormous burden of care for family members who must both continue to attend to their farms and raising children, while also providing full time support to unwell parents or extended family members, such as those following stroke or HIV complications such as toxoplasmosis or Cryptococcus neoformans.

One woman we visited had an undiagnosed liver condition causing ascites (the accumulation of protein-containing fluid within the abdomen). The cause had never been determined and her case perplexed us as she didn’t have jaundice or any other signs of liver disease, just massive ascites and caput medusa making her look as though she was heavily pregnant. Every month, the team would visit her and she would have a paracentesis, draining the fluid from her abdomen into an old oil container. This relieved her back pain and allowed her to attain an improved quality of life.

A paracentesis with an audience

Treating the patient in her mud-hut home, the procedure was overlooked by two rather intrigued chickens who made themselves comfortable on the window-sill beside the patient’s bed – far removed from the sterile environment where a paracentesis would be performed in Australia. Her husband brought in oranges from the tree outside and cut them open for us to eat bedside her bed while we waited for the fluid to drain. This was a common occurrence and everywhere we went to visit patients we would come home with gifts of food, usually the delicious fruit that grows so well in that region such as mangoes, bananas, oranges and avocadoes.

The hospital vehicle (a Toyota Land Cruiser)


Sometimes the placement would be confronting and we would have days that were more difficult and we would come home and debrief amongst ourselves about the limited facilities and resources. For example, there is no CT machine and open laparotomies are sometimes the only diagnostic tool, and a simple and cheap drug such as lactulose is not available which is incredibly effective in preventing and treating hepatic encephalopathy. Infant and maternal mortality are much higher than developed countries, and it is not difficult to understand why when you see the limited facilities and parental education.

Amongst the hard days however, there were positive experiences, such as assisting in the birth of babies. Again, the processes surrounding birth are entirely different. There are no birth plans, or even midwives for that matter, and families must bring in all of their own cloth material for the birth (including material used to clean up faeces, vomit, blood etc.). Despite the language barrier, I was able to stay with a young woman giving birth alone to support and encourage her. Nursing staff were largely only present toward the very end, when it was evident an episiotomy was required. The baby was moved into the next room while they sutured her perineum and I decided to perform a neonatal check on him during this time. This is a good example of the experience of a medical student in another country where you often need to take initiative and get involved if you want to gain anything from the experience. Overall, I found everyone was willing to let us be as involved as we were willing, as long as we expressed this to them. Tasks we performed included scrubbing in as a second assist for surgery, performing with chest compressions on a neonate, taking histories and performing examinations (despite the language barrier), performing cervical screening tests and many other procedural tasks.

Use of Funds

The money granted by this scholarship was used to help children who attend the monthly HIV Kid’s Club. The Club is an incredible opportunity to improve medication compliance for children on antiretroviral treatment as they are given their medication free of charge on attendance (a 30-day supply to last until the next Club). The Kid’s Club is held on a weekend so that children do not miss school, however doctors are still in attendance and this is an opportunity for patient consults as required.

One big draw card of the Kid’s Club was the meal provided at lunch time. The children took plates laden with beans, rice, vegetables and some meat. The provision of lunch not only provides possibly their only meal for the day, but is an enormous incentive for attendance – consequently improving medication compliance. Without the clinic, their medication compliance would be much poorer, and without this medication, there would be a much higher risk of potentially fatal opportunistic infections and cancers.

Unfortunately, the funding to provide meals at the Kids Club had ceased the month before our visit, however this proved a timely opportunity to donate funds in order to keep this service running, while the program coordinator sourced alternative long term funding.

It was a privilege to be able to contribute to this amazing program in a small way and to have the opportunity to spend time with these children and see the benefits of this program in action. From my public health background, I understand how important early life measures such as education are on lifelong outcomes for individuals. Nurturing the early years of a child’s life with access to healthcare, nutrition and education is so crucial to promote a positive trajectory for the rest of their lives.

Activities around Muheza

On weekends, we took the opportunity to step away from the hospital to explore the beautiful countryside that Tanzania has to offer.  We camped on the beach in Peponi (the Swahili translation is paradise) where we took a dhow (traditional sailing vessel) out to an island and went snorkelling. We also enjoyed hiking up the mountains of Lushoto to glorious lookout spots and spectacular waterfalls. After concluding our time working in the hospital, we couldn’t pass up the opportunity to travel to Arusha (7 hours away) for a three day safari where we saw so many amazing wild African animals.

A view from the top

Summary

There were practical and emotional challenges during this elective. Amongst the challenges however, we saw incredible joy and happiness such as a patient receiving appropriate and effective treatment, healthy babies being welcomed into the world and the wonder of the Tanzanian landscape.

The main reason I highly recommend Muheza Designated District Hospital for a medical elective would have to be the exceptional staff.  We were very well looked after in terms of our learning opportunities and interaction with patients. I can certainly walk away saying that I have learned so much about conditions I was previously ignorant to - malaria, sickle cell disease and cryptococcal meningitis, as well as conditions I see regularly in Australia such as liver disease, diabetes and heart failure.

The experience has helped me develop the skills to negotiate cultural and language barriers and has given me a true appreciation for the value of other cultures.

If you would like some deeper insight into the culture and workings of a rural hospital, visit Cassandra’s daily blog from her time in Tanzania: https://cassintanzania.home.blog/

 

“Travel makes one modest. You see what a tiny place you occupy in the world.” – Gustav Flaubert.

 

Developed exclusively for medical and dental students, each year the BOQ Specialist FutureFocus grants enable five students the opportunity to undertake an overseas placement so that their commitment to helping others can be realised. You can also access funds to help undertake an overseas placement, with our Student Banking Package.

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