Chapter 9 - The Mile High Home and Tanzania Hawk Down

Bill Stoeffer is an Infectious Disease doc from the University of Minnesota. He is here working for the CDC, writing the new guidelines for health screening of refugees entering the US (yeah...he's kind of a big deal). He spends some of his time in the Rwandan and Burundi refugee camps in western Tanzania, as well as monitoring for avian flu entering from Uganda. Pretty cool stuff.

On the side he volunteers his time at Selian a few days a week. Providing much needed expertise on both the medical and pediatric wards. He is sort of the quintessential ID doc. He is incredibly nice, friendly, and soft-spoken. But, when he is asked a question on any subject he sort of externalizes his internal monologue while explaining, in almost excruciating detail, the answer and to a lesser extent why other options are less than ideal. It's great for teaching, and I've learned a ton from him, but sometimes his audience is not as patient...especially if they are Kenyan (i.e. Dr. Morila - Selian's orthopod).

Dr. Stoeffer was kind enough to invite Rachel (a med-peds resident from the UofMN) and myself for an overnight at his house. He lives outside of Arusha on the outskirts of the village Lingojavi which means "windy." Being that his house is located on top of the largest hill in the surrounding area (over 6,000ft above sea level...higher than Denver) it is definitely an appropriate name.

As the three of us set out to his house driving towards Nairobi, Bill pointed at an immense "hill" (not really sure whether to call it a large hill or small mountain) adding, "That's where we're headed." Rachel and I looked at each other both equally impressed.

As we turned off the main road to Nairobi and on to a typical dirt side road Bill joked, "So this is my driveway...it's a real pain to snow blow." (This slightly geeky sense of humor I would also attribute to many internal medicine specialists).

As we slowly made our way up the rugged terrain up the side of the "hill" Bill rolled up all of the windows explaining, "There is a donkey that died a while ago coming up on the right." Sure enough the carcass came into site as the jackals who were up until then, enjoying their meal in peace, skirted off the road momentarily as we drove by. Rachel asked, "Did it get hit?" "No...thankfully, since Carol and I are the only ones to have cars up here. I found out that the Masaai actually carried the carcass to the road." "Why do they do that?" "I asked the same question of our housekeeper...she said, "It's just their way." Cryptic, non-helpful explanations are often common place here.

We continued up the winding path passing many Masaai bomas (homes) on the way. "So there are no other Mzungu (whites) up here?" "No...just us and a whole lot of Masaai."

As we passed "the gate" to their house I was shocked to see a broken chain lying on the ground. Either side was still hooked into the cement posts that sat across from each other. "That's the gate?" I asked astounded. "Yeah...what's left of it."

Normally, each Mzungu house is surrounded by a 8 foot fence with sharp, thorny bushes growing on either side of it. The gate is always thick and metal with sharp points on the top, or shards of broken glass glued on the top to dissuade any would be intruders. In addition, there is always an ascari (guard) who is usually armed with a ponga (a traditional spear).

"You've never had problems with break ins?" I asked thinking of several people I have met in my short time here who have been robbed in their homes.

"I thought the same thing at first. But, actually our house is so well hidden by the shape of the hill and the trees surrounding it that you'd never know it was there. Plus, even if it was common knowledge I doubt we'd have any problems. I asked our Masaai neighbors what would happen if someone broke in. They stated plainly, 'We would kill them.' Then, I asked a few Tanzanian friends what would happen if someone broke into our house. Every single one of them said without hesitation, 'The Masaai would kill them.' Then I asked what if the robbers had guns. Each one still said, 'The Masaai would kill them with their spears.' Being that Bill is literally surrounded by a large Masaai community, it doesn't matter if it is the truth or just the perception. If anything happened there would soon be a small army of Masaii charging at the intruders with their spears.

Keep in mind that while normally the Masaai are incredibly friendly and gentle, historically part of their right of passage was to kill a lion with a spear...which is pretty hardcore.

We finally arrived and were greeted by a large troupe of German Shepard puppies. Bill had recently adopted a Shepard from one of the local Tanzanite mines and brought her home to find that she was pregnant. "We're going to keep two of the pups. The others we'll sell off and then use the profits to continue some of the local community projects for the village." That's the kind of people Bill and his wife, Carol are. Salt of the Earth.

We were welcomed by a cup of hot tea and a short tour.

After visiting with the whole family, Jake (8 years old) and Max (6 years old) took Rachel and I out for a hike. I know a lot of people would say how difficult it is to travel with kids and to take them with you, but as these two boys literally had the run of the place pretending to be in the Lord of the Rings' Middle Earth as they ran down trails, through fences, and up big hills laughing without a care in the world, I realized they were just about the two luckiest kids on Earth.

After our short hike we set up shop in the front yard to watch the sunset. The kids got a soccer ball and shortly several Masaai joined them. They all laughed as they kicked the ball back and forth.

"We've really become close with our neighbors." Bill noted as he brought out some tea and the entire gang sipped and chatted as the sun went down.

Afterwards we went in for dinner. Somehow Bill had procured trout for dinner having connections to the only trout farm in Tanzania. It was definitely a taste of home with fried fish, au grotten potatoes, and brownies for dessert.

The rest of the night was spent helping the kids with their homework. Carol helped Max with his French (he is also learning Chinese and Swahili...again he is six), while Jake packed up for his overnight field trip to Tarangire National Park.

I read for a while then headed up to the guest house to sleep for the night. In the morning we set off for Selian. It was a good day as I rounded with one of my favorite counterparts. There were some interesting cases (more about those at a later date) and the day quickly sped by. Before I knew it, it was 3:00 and time to head home.

I was looking forward to a hot shower and a long nap as I had been wearing the same outfit for three days (including my trip to the bush clinic), had not taken a shower at Bill's (they had run out of rain water), and had not slept more than a few hours the last few nights.

I reflected on the fun and excitement of the past few days. Going out to the Bush clinic was one of the more interesting experiences of my time here thus far. As I was headed to climb Kilimanjaro the following Monday, I looked forward to a few days of what I thought would be some nice, quiet downtime. I was very wrong....

Sarah, the Australian occupational therapist, offered to give me a lift home as she was headed in the same direction. Five minutes after leaving Selian her phone began to ring.

"Hello....Ok....Ohh my God. Is everyone alive? Yeah, I have one with me right now....Yep we're on our way." In the middle of this exchange she took a sharp right turning on to the Coffee road.

I thought of the possibilities of our destination as the road we were on only led to two noteworthy locations. A) TGT - which is the plush country club out of town. It has its own gym, bar, restaurant, rugby pitch, cricket field, salon, and sushi bar, or B) The Arusha airport - and most likely to set off with Flying Medical Service. I doubted from her countenance that we were on our way to sip wine at TGT.

Immediately after hanging up she dived right into the story, "There was a helicopter crash near Lake Natron" (A Lake that lies along the Tanzanian/Kenyan border). She continued, "They don't know if anyone has survived or not, but they want to be ready just in case."

My adrenaline kicked in. Two minutes previously I had been on the verge of falling asleep. Not now. I envisioned arriving at a smoking pile of wreckage. Bodies strewn about. Victim's cries for help. My heart began to race. My mind going through all possible scenarios. The fact that we sped along the pot-filled dirt road at nearly twice the speed which a car would normally drive did not help calm me down.

As we neared the airport I made the conscious effort to slow my breathing. Closing my eyes I began thinking of all the supplies I would need to take with to make sure I was as prepared as possible for whatever I might find at the crash site.

The airport was busy. I pushed my way past Tanzanian businessmen and Mzungu travellers. I heard several scoffs as those in line were wondering who this shaggy looking, tall Mzungu thought he was. "Flight Medic for Flying medical service" I said breathlessly, pointing to myself as I reached the front of the security line.

The initial suspicious look of the security guards immediately changed as they pushed the last few people in line in front of me to the side allowing me to pass through the metal detector.

I ran onto the airstrip towards the FMS container. "Ok Michael, the amount of conflicting information we have received is staggering" Pat (the Catholic priest in charge of FMS) began immediately without any greeting.

"First we heard there were ten people on board. Then we heard there were six. Then we heard there were no survivors. Now we just got wind that there are two survivors." I nodded my head thinking how this information would change my game plan, if at all.

I headed over to the plane to see the familiar Mission Aviation Fellowship (MAF) red-striped Cessna 206. Ivan (actually spelled Eivand) came round the side hurriedly putting a stretcher into the back. We shook hands and greeted each other solemnly. "This is Jack. His son was in the helicopter."

A sixty something man sitting in the front of the plane turned towards me. His eyes were bloodshot, tears streaming down his face. "Nice to meet you...wait...no it's not" he was able to manage to get this sentence out in between sobs. Realizing the absurdity of niceties at a time like this he continued his morning, his body shaking with violent energy.

I hurried back to the FMS container. "Alright Pat, I need a Ambu bag, a C-collar, another stretcher, gloves, and wound care supplies, pain killers, splint materials...." I continued spouting off commands in a calm manner. Pat looked at me trying to process everything I was telling him.

"Do we have IV fluids?"

"Yeah" he pointed at the top shelf as he busily collected all of the other items I has requested. I grabbed as much Normal saline as I could carry making my way back to the plane.

"AHHHHHHHH......" Jack had collapsed to the ground on all fours and was now furiously sobbing, completely inconsolable. I dropped my cargo and rushed over to him fearing that he was having a heart attack. Eivand grabbed my arm, "No, he's alright. We just got word that his son didn't go out on the helicopter this morning."

Momentarily watching Jack and realizing that he actually was ok...well as ok as a father could be experiencing that range of emotions, I collected the bags of fluid and took them back to the plane.

Pat soon joined me, "Here is a blood pressure cuff, a pulse oximetery, and all the medications we have" lifting the tackle box he was carrying in his right hand. The three of us continued to load the plane with supplies.

The radio on Pat's belt began making, what was to me, inaudible noise. Pat listened carefully then shouted to Eivand and I, "Now the story is six passengers. All survived. Two serious."

My eyes widened. Looking at the plane and realizing that we would be able to transport two...maybe three people at the most. I took one last minute to check over all the supplies. Thinking furiously if there was anything I was missing. Continuing my internal monologue, "No. That's it. Let's go."

We were immediately cleared for take off and Eivand and I were soon headed north-west to Lake Natron. The rush died down. I had 40 minutes to collect my thoughts and prepare myself for what lay ahead.

My phone rang notifying me that I had a text message. "Be sure to get the low down before you take off. S" Sarah's words of wisdom would prove impossible to follow as the story had changed every few minutes and no information about the nature of the injuries had been passed along...just that two were serious.

As we neared our destination we passed next to Aldonio Lingai (a very active volcano) on our left and the beautiful Lake Natron on our right. I swung my head in every direction looking for the plume of dark smoke.

"This is a though landing strip" Eivand began looking very serious. "It's really soft dirt, almost sand. It's gonna be bumpy." My jaw clenched. I nodded my head looking straight ahead. "It's gonna be fine. I just wanted to warn you." "Yeah...no worries."

I now began looking for the landing strip. I could see that we were almost directly over it looking at the GPS. Eivand took a hard left turn as we began descending.

Looking back and forth from the GPS to the ground I still could not see where we were supposed to land. My jaw clenched tighter. Suddenly, a white arrow appeared seemingly out of nowhere. I realized that it was a group of large stones which had been painted.

In front of the makeshift arrow there was a pair of white rocks thirty feet apart, spaced out every fifty feet.

I grasped the metal handles in front of me and to my right. My body completely rigid, preparing for the landing.

I was shocked at how smooth everything went. I could barely tell a difference between this landing and the others I had undergone with Eivand. "Nice" I attempted to shout over the roar of the engine as we came to a halt.

A group came out to meet us. Two were guides who had helped organize the helicopter outing.

"If we are going to take anyone to Nairobi we need to leave in exactly 50 minutes to make our last landing time. Otherwise we'll have to take everyone to Arusha. You know what Selian is capable of." Eivand tried to say this as an encouragement. It was not received that way. I knew that if there were any serious trauma victims they needed to go to Nairobi.

I set off with the guides screeching down the dirt road to the crash site after loading up as many materials as we could load quickly. Not five minutes after setting out we came across a caravan of three Land Cruisers slowly headed in the opposite direction. It was the victims.

After a brief exchange in Swahili between the drivers we turned around, passed the caravan arriving back at the airstrip. I waited anxiously as the line of cars slowly came into view. It seemed as if they were barely moving. Every minute seemed like an hour. I still had no idea what I was about to see.

Finally, the first car arrived. I ran to the driver's side. "My name is Michael. I'm the flight medic. Who's in the worst shape?" I have adopted the term "flight medic" because I feel uncomfortable saying "doctor" and "medical student" does not instill a whole lot of confidence in such situations.

"He is." The driver pointed with his thumb to the back of the truck. "Hi Michael. I'm Jeff." THANK GOD! The worst of the bunch was 100% conscious and oriented. He was even in good enough shape to be friendly.

Thoughts of people being cut by the helicopter blade, burned in a fire, and sustaining major head injuries vanished. My confidence rose as I slowly understood that I was not totally in over my head.

"I think I broke my hip." I looked at the 30-something. His left knee was propped up by pillows and blankets. He was shirtless and had multiple scrapes and cuts, but nothing serious.

A fifty something fellow safari member came around the side of the truck. "Hello. I'm a doctor. I happened to be on safari nearby when the crash happened." The man continued in some sort of European accent, "I believe he has a broken femur near his hip joint."

"Ok." I looked again and noticed the neat way the worst of his cuts had been dressed and the fact that he already had an IV line in with a bag of normal saline hanging, and couldn't help but be thankful and impressed.

"So he has normal sensation and pulses in his foot?" The doctor looked at me with the same look I have given so many times when I have forgotten to ask a crucial question while taking a history or forgot to look for an important physical exam finding by my attending.

Without saying a word I moved towards the foot of the stretcher. "Can you feel this Jeff?" I asked lightly touching various parts of his lower extremity.

"Yeah."

I felt for the dorsalis pedis pulse on top of his foot. "Good! You have a nice strong pulse here. Things are looking pretty good Jeff!"

I was relieved that the alleged fracture had not impaired blood flow nor severed any nerves to his lower leg. I was really hoping not to have to put traction on him there in the field.

I looked up and asked, "Who is the other serious patient?"

"The pilot." Several others said in unison.

"What does he have?"

"He has a gash on his neck and a blown out knee" The European doctor responded.

"Where is he?" Looking around not seeing any others that looked in bad shape.

"He's back in the village" A man answered who was shirtless and covered in scrapes, pointing in the direction from which the caravan had come.

"WHY IS HE NOT HERE?" I asked agitated that I would be unable to help him. I did not receive an answer.

After expressing my frustration with others who have more experience with medical evac's I was told that often whites are given the priority...even if a black Tanzanian is in more dire straights. A frustrating fact.

*** It should be noted that I recieved several emails from someone who was involved in the crash and from others who had first hand knowledge of the experience, alerting me that the reason the pilot was not brought was because he wasn't the worst off.

That the German Doctor made the decision to bring Jeff instead of the pilot solely due to the extent of injuries and not because of the color of his skin.

I absolutely agree that Jeff was most likely the worst off and in need of medical attention, but I have no idea why that excluded bringing the pilot as well. Especially, when there were three cars and space didn't appear to be a limiting factor.

Turns out that the pilot was in the Tanzanian Army and could not leave the country for medical attention.

Again, the decision to go to Nairobi had not been made and it was my decision to make...no one else's.

If the pilot was severe enough to need medical attention immediately we would have taken both to Arusha.

I understand that many of these decisions were made under incredibly stressful and emotional conditions. I am merely commenting on my frustrations that I was unable to even assess one of those involved who had severe injuries. ***

Eivand glancing nervously at his watch, "We have to get going if we're taking him to Nairobi."

"Load him up. We're just taking him."

Miraculously, everyone else on the helicopter had nothing more than cuts and bruises and would be flown back to Arusha the following day. After an injection of pethedine (a narcotic) we loaded Jeff up and took off for Nairobi.

Thankfully, he was completely ok the entire flight. He was able to drink and I pushed a liter of normal saline in him as several noted before take off that he was dehydrated. Vital signs were within normal range for the remainder of the trip.

Making small talk during the trip I asked about the crash. "We were filming a documentary about wildlife in Tanzania. I don't know how we crashed. One minute everything was fine, the next we were in the water. The heli caught fire and I just remember people dragging me out. Luckily, the water was only a few feet deep where we crashed. We were able to make it to shore and then waited for help to come."

"Jesus man...I know this sucks breaking your leg, but you are all so lucky to be alive."

"Yeah...I know" Jeff added seriously.

"And think of it...what a great story you got out of it." I could tell that Jeff was a laid back guy and hoped this attempt at lightning the mood would be recieved well.

"Yeah, I'll be the envy of every cocktail party for the rest of my life!" He added chuckling as he spoke.

After getting him squared away through customs (surprisingly easy...even without his passport) Eivand and I set out to stay the night at the Norwegian Mission complex yet again. I thought to myself, "2 for 2. Still at 100%" thankful that I had not had any deaths on my trips with medical evacuation...yet...knock on wood.

"THE DYNAMIC DUO RETURNS!" The head of the mission yelled as we approached the house for dinner. After another wonderful dinner I excused myself, got into my bed, and fell asleep instantly.

My adrenaline wearing off, my fatigue from the week's events had finally caught up with me.

Eivand and I returned to Arusha the next day without incident (I didn't fly this time mom :). As I got off the plane I was greeted by Pat. Expecting him to offer to buy me a cup of coffee and give me a ride home I welcomed his presence.

"Michael, I'm sorry, but I have another emergency." "Alllllrrrriiiiggghhhht..." I was really looking forward to some quiet time and a nice nap. But, those were luxuries that I would not be afforded.

"One of the staff at FMS has been having incredible abdominal pain and distention for the past five days. It's only been getting worse and this is a guy who never complains."

On that little information I immediately feared the worse.

"Fuck...this guy perforated his bowel" I thought to myself hoping that Murphy's Law would not prevail. (This is when a hole opens up in your intestines and stool gets into the abdominal cavity...which is normally a sterile environment). This is a bad scene even with incredibly wonderful healthcare providers and excellent facilities.

I didn't know what I was going to do for him...but I would do my best...whatever that entailed. After talking with Peter, who was a very gruff Belgian, and examing him I was overjoyed to see that he had absolutely no peritoneal signs (signs of fluid/irritation in the abdominal cavity).

The history was fairly non-specific and recommended that he come into Selian to get checked out. I made the trip with him and gave report to the head of medicine who would be seeing him later that day.

I made my way home hoping that I could lay down for a few quiet hours. The experiences of the past week swimming in my mind as I slowly drifted off and thinking of the adventure I would be undertaking in less than 48 hours... The trek of Kilimanjaro.

Chapter 8 - Bush Medicine

Since coming I have been on the "waiting" list to go along with the clinics the Flying Medical Service puts on in several of the surrounding villages around Arusha.

In late October I signed up for the next available date. December 3rd.

Becca, the pilot who would be leading the clinic, had just returned from her first visit to the states in three years.

"So Becca. I know you're jet lagged and have been in the country for all of two days, but are we flying out to do clinic tomorrow?"

"Funny story. There is a visiting mechanic who works with the FAA in the States. He comes every few years to do the checkups on the planes, and he actually declared our plane 'not air worthy.' Apparently, it needs a new engine."

Yeah...funny story.

It was unclear if the plane would be ready later in the week, or if there would be no clinic for the first time in FMS history.

As the saying goes, "the show must go on."

Instead of flying Becca came up with the last minute plan to drive to the closest village.

"Well, I know how to fly there. I guess it's about a two hour drive. I just got the directions from Jack (one of the other pilots). We take a left at the second gate in Kata (another village), and if we come to a school we've gone too far."

"Sweet. I'm up for an adventure."

It's a good thing too.

We left around 10 in the morning. Becca picked me up from Selian along with two of her friends she met in the peace corps who were visiting.

"I'm Marnie and this is Margie."

I thought to myself, "I can already tell this is gonna be a good day."

We piled into our little Suzuki Jimmy and were off. We became fast friends in the car as the two newcomers were very friendly and easy going.

Marnie and Margie continued to joke about how horrible the roads were as they bounced around in the back seat.

Becca and I looked at each other. "You do realize that the road is actually blacktop here? Just wait until we hit the dirt."

We had been driving about two hours when we finally arrived in Kata. Sure enough there was a second gate, and sure enough we hung left.

Becca, who has been a pilot for FMS for five years, continually had the same conversation with every passerby.

"Shikamoo Mzee" (I am at your feet)

Inevitably the reply was always the same, "Marihaba" (Delightful)

She would engage in the other three required greetings before actually asking the questions.

"Mbguini is in this direction?" Pointing generally to the Southwest.

"Yes keep going."

This reassurance every ten minutes kept all at ease. We continued to tell stories, joke, and laugh.

"SHIT!" Becca yelled seemingly out of nowhere. Our conversation unexpectedly cut off the three of us turned our heads immediately in the direction she was looking not knowing what to expect.

"The School." We said in unison in a rather defeated tone.

We turned around and started in the direction from which we had just come.

We soon happened upon three guys riding their bicycles.

As we waved them down and Becca reverted to the familiar conversation I suddenly realized that the youngest in the group was wearing a faded red winter coat. Considering that it was at least 90 degrees and that he was doing what could be considered vigorous exercising it was surprising to say the least.

"At least he didn't zip it up" I thought to myself.

The leader of the trio gave directions in a very excited manner pointing in various directions trying his best to drive home the point.

"Asante sana rafiki." (Thank you very much my friend)

We turned back around in the original direction feeling assured due to the confidence of our newest navigator.

After another 15 minutes we came round a bend only to find a HUGE sand pit with two immense dump trucks with many men hurriedly shovelling. Some appeared to be shovelling sand into the trucks while the others were shovelling sand out of the trucks into the pit. This sort of enigma seems to happen quite a bit here.

Becca made her way down to the pit and asked directions from a Masaai man who was wearing the traditional garb.

Margie, Marnie, and I remained at the car looking around and appreciating the beautiful day.

"The sky is SO blue today...and the clouds SO white. It's almost looks like the sky in The Simpson's."

I realized that Margie was totally right, and became upset with myself that someone else beat me to a Simpson's reference.

"OK, so we missed a turn 5 minutes back."

We re-entered the car and backtracked yet again, turning at the appropriate point this time.

A little ways after making the turn, the Suzuki began to act up. It would surge forward and then slow down nearly stopping. This oscillating pattern continued for some seconds as if the car could not decide whether to keep going or teak a break.

We all turned to look at each other, but went on in silence. As if the first word uttered would surely jinx us and the car would stop completely.

THUD

Evidently, the car didn't agree to this deal.

After several unsuccessful attempts to start the car we piled out. I took out my camera, taking advantage of the beautiful, yet barren scenery, while the ladies popped the hood and began to tinker.

I came down in time to hear Marnie's comment, "Well we have PLENTY of window washer fluid."

I thought to myself. "Ok Good. I'm not the only useless one here."

Becca tried to translate her knowledge of plane engines to the car and continued to dig fervently around...making only her rear end and elbows visible.

After ten minutes of contemplation and chin scratching Becca simply got back in the driver's seat and turned the key.

VROOOOOOMMMMMMM

HUZZAH!!!

We got back in, took off, and maintained our silence for a few minutes. We held our breath, waiting for an ominous noise or vibration.

It didn't come.

Winding our way through the last few hills we finally arrived at the airstrip (a long strip of smooth dirt) and a 20 x 8 ft mud hut which would serve as my clinic for the day.

We were all very excited and thankful to finally be at our destination. My thoughts immediately turned to the return trip realizing that our trip was really only half completed.

I cleared my mind of any worries about the return home.

I told myself, "One thing at a time" as I looked at the long line of pregnant women and children waiting to be seen.

"It's 2:15 (we had been driving just over four hours). Sunset will be around 6:30 and it will be dark by 7:00. So we should leave here no later then 4:30." Becca told us all the game plan as we unloaded the supplies and equipment from the SUV.

Looking at me she continued, "You'll be seeing all of the pregnant women and filling out their checkup cards."

She went through translating the Swahili on the card, "This line is for blood pressure. This line is to mark if there legs are swollen. This line is for fundal height."

"Ok, so the major aim is to screen for pre-eclampsia and that the child is growing appropriately?"

Rebecca nodded in affirmation.

"So, what do we do if one of the women are pre-eclamptic?"

Rebecca shrugged her shoulders and stated simply, "We'll take them into Selian, of course."

Let me clarify pre-eclampsia for you non medical folks. It is a condition that affects pregnant women usually during their first pregnancy. It is poorly understood. No one has proven what exactly causes the condition, but it seems that for whatever reason the permeability of capillaries increases (the smallest blood vessels in the body become leaky).

This can express itself multiple ways in the human body. But, the two manifestations that are common to all women with pre-eclampsia is high blood pressure and swelling in the legs.

This in itself is not dangerous, but if a woman begins seizing (thus changing from a pre-eclamptic to an eclamptic) then, if I remember correctly, she has a 50-50 chance of surviving.

The good news? It is very treatable with a safe, inexpensive drug. Magnesium Sulfate.

The bad news? During my two months at Selian two cases of eclampsia have been discussed during morning report. In both instances the question inevitably is asked, "Was Magnesium Sulfate started?" The answer both times, "No. The pharmacy is out."

One woman survived her bout with eclampsia. One did not.

My mind turned to the indifferent attitude of the pharmacist at morning report and I wondered if pharmacy had got around to restocking, or if my multiple examinations would be in vain.

Rebecca continued, "This one is for hemoglobin."

"Uhhhh Ok. How exactly do I check a Hgb out in the bush?"

"Oh right. We don't use numbers. Just look under their eyes. If it's red write 'good,' if it's pink 'ok,' and if it's pale 'poor.'"

Simple enough.

"If it's poor I just give them more iron tablets."

I thought of going into the finer points of iron absorption in the body, and trying to explain that no matter how much iron you give the body can only absorb so much. The rest just gets excreted. I decided against it as the line continued to grow with patients waiting to be seen.

After Rebbecca explained the last few lines she began to make her way out of the mud hut clinic. Before exiting she popped her head around the corner and added, "Ohhh and if anyone sick comes I'll come inside to translate for you."

I opened the suitcase of medications she had brought in and saw thirty some pill bottles in a jumbled mess. Each had a piece of masking tape over the cap with the name of the drug and the dose per pill.

After a quick scan I realize that I had six antibiotics to choose from, deworming pills, multivitamins, aspirin, Tylenol, ibuprofen, antimalarial regimens, cough syrups, epi-pens, various ointments and salves and even a few anti-convulsants.

I noticed that the folic acid pills were immediately next to the phenytoin bottle.

Again for my non medical friends the irony of this needs to be explained. Folic acid is given to pregnant women as a supplement to prevent neural tube defects (i.e. spina bifida). Phenytoin is a medication to prevent seizures and is not ideal in pregnancy because it has been shown to be a teratogen (causes birth defects), although sometimes the benefits of mom not seizing outweighs the risks to the developing fetus.

Note to self. DO NOT MIX THOSE TWO UP!!!

The first few Masaai women came in.

The assembly line began.

Check blood pressure. Check for edema. Check the color of the conjunctiva. "Lala" (Lay down). Check fundal height. Check position of the fetus. Ask about fetal movement - "Mtoto ana chezwa?" (Is the baby moving).

Thankfully A) None of the women had elevated blood pressures, nor did they have swollen legs. B) All of the fundal heights corresponded rather well with how far along they were in their pregnancies and all of the women answered "Ndiyo" (Yes) to the question if they felt fetal movement.

So far so good.

After seeing ten or fifteen 'Mama's' a woman came in holding her three year old daughter.

"Un momento." For whatever reason I subconsciously slip into Spanish when trying to get something across in Swahili when I have no idea how to say it...suffice it to say, it is a regular occurrence. Realizing that it didn't matter, (as she knows as much Spanish and she does English...that is to say none) I raised my pointer finger to try and tell her that I would be back shortly and went out to grab Becca.

The rest of the quartet was busy outside giving vaccinations to all of the kids and doling out vitamins and supplements to the pregnant women.

Becca recapped a needle and threw it in the makeshift "sharps" box. Expecting to see the familiar red plastic bin with an idiot proof top, she tossed it into a small cardboard box as the crinkled tape sticking up on the sides and swayed in the wind.

"So what are the kiddo's symptoms?"

My question was translated to Kiswahili by Becca, which was then translated to Kimasaai by the next women in line to the mother who patiently waited for words that she understood while holding her listless child's body.

The problem often arises at Selian that the Masaai do not speak Swahili, and that the providers do not speak Masaai. But, unlike Hennepin County, Selian cannot afford medical translators and usually relatives are counted upon for communication. Obviously, between that and the dormitory wards HIPPA (privacy) does not exist here.

Over the next few minutes the story slowly came into focus. The girl had been vomiting for the past month. She had been seen at several outreach clinics/hospitals. She had been given several different types of pills, syrups, and had needed IV rehydration as well. She had not been having fevers. She did not have abdominal pain. She had scant, watery diarrhea. She was not drinking much and eating even less.

"This is not good," I thought to myself as I tried to formulate a differential diagnosis.

I wasn't even sure where to begin...infectious? malabsorption? mechanical?

I felt every one's eyes on me. Looking for an answer that I was not prepared to give. I gazed over the suitcase full of medications. I poked and prodded through the various bottles as if the answer would simply appear somewhere.

It did...or actually the lack of possible therapies gave me my answer.

"Here's what I'm thinking...." I went on to explain to Becca that this kid did not took good (or toxic in medical jargon), and that sure I could give her some anti-biotics, deworm her, give her some nutritional supplements, but that there was no way in hell I was going to take a stab in the dark and tell her to come back to flying clinic to see how she was doing in two weeks.

"She needs to get to the hospital and get worked up for what is underlying cause of the problem. I can't just treat her empirically. I don't think she'd make it."

Becca nodded which gave me some sort of encouragement.

Similar cases came in...mostly children. Their were general complaints with non-specific symptoms. Coughing, diarrhea, abdominal pain, etc. I did my best to narrow down the most likely causes of the complaints and gave out medication accordingly, always explaining to keep the bottles or slips of paper to bring back to the clinic or hospital in case they did not improve. Thankfully, no one was even as close to being as sick as my first patient.

There are no records or charts in bush medicine, and thus, no continuity of care.

A patient could easily come in and receive the same "trial therapy" many times before someone tried a different management.

Before I knew it Becca popped her head in to tell me we had to go after I was done seeing my current patient. I finished filling out the prenatal card and began packing up.

I checked the time. 4:50 pm. We had 90 minutes till sunset and just over two hours till dark. It's a general rule that you don't want to do too much travelling at night in developing countries. You certainly don't want to have a blown tire...or a breakdown. My thoughts turned to the episode earlier in the day.

We quickly packed up the rest of the supplies and began saying our goodbyes to the people who were still hanging around to see the Wazungu off.

The relatives of the little girl who had been vomiting began talking to Becca.

"They want us to bring her to Selian tonight."

The journey, which had begun cramped, suddenly became very uncomfortable. I was in the passenger seat with my knees nearly in my face. Margie sat in the middle in the back, her legs sprawled out into the front with one leg on either side of the gear box.

Now that we had our own personal navigator in the backseat Becca did not have to stop as often to ask for directions...or so we thought.

"Do we go left or right here?" Becca asked in Swahili as we came to the first of many fork in the roads.

"Right." The answer came quickly and confidently from the back.

"So where does the left road go?" Becca continued wanting to make sure our Tanzanian GPS did not get us lost at night.

"Over there." The old woman stated simply, waving her hand in a lazy manner wondering why we had asked such an obvious question.

We took the right.

Initially, we set out in good humor, noting several times that, "It's all part of the adventure."

But after the first hour, dispositions began to change somewhat and I found myself on the receiving end of multiple questions from the back trying to get at "Just how sick is this little girl?" Inferring, that perhaps it wouldn't have been so bad for her to wait until tomorrow to begin the trip to Selian.

Back seat driving is annoying. Back seat doctoring is worse. As least passengers have a driver's license and have driven before.

"This little three year old has been vomiting for a month. She's not eating. She's been "treated" several times and has not improved. You can't be three years old and survive all that for very long."

The questions ceased.

I added, "I've just seen too many kids die since I've been here to risk one more." Yes, it was dramatic, but that didn't make it any less true.

I had not expected this type of exchange from two women who had been empathetic enough to the plight of others to dedicate two years of their life in the peace corps.

I wanted to say, "Sorry that you're butt's are sore, but this little girl might die."

I was not convinced that I had made an appropriate decision though despite how confident/defensive I may have come across at that instant.

We made our way back through the landscape. Pointing out each and every landmark we recognized from the first half of the trip.

The anxiety would build as the minutes would pass away without such a recognition. However, we would instantly revert back to good humor as we passed each landmark followed by a slow building of nervous energy as we eagerly anticipated seeing the next.

The school! The roadblock! Ahh the same donkey carcass!

All were music to my ears.

As we passed through the Kata village we all relaxed. From here is was a straight shot to Arusha. I began noticing the beauty of the sunset and the range of colors it produced.

As so often happens, Murphy's Law (What can go wrong...will go wrong) brought us back to the reality that we were not out of the woods (or bush) quite yet.

THUD!!!

YOU HAVE GOT TO BE FRICKEN' KIDDING ME!

The same stop and go sensation followed by the same final lurch.

We had a good 30 minutes before night fully set in. I took advantage of the break to stretch my legs and snap a few photos.

As good fortune would have it, the car, after taking the same 10 minute break, started right back up again as if nothing had gone wrong in the first place.

We made it back to Arusha without further incident. The patient was dropped off at Selian and then we set off for pizza and beer at one of the finer establishments in town.

"Nauma Tusker tafadali" (I'd like a Tusker please).

Nothing feels quite so good as the first sip of cold beer after a long, hard day.

The next day at lunch Rachel, one of the pediatric residents visiting from the University of Minnesota, began, "Wow. That little girl you brought in from the bush is really sick."

Ok...now I relaxed a little bit realizing I had made the appropriate decision. Whether it would have a happy ending or not remains to be seen.

Chapter 7 - The Best of Times and the Worst of Times

As Ivan and I entered into the unfamiliar abode I was greeted by a large man with a huge chin-strap beard that could have easily been an extra for one of the Rohan warriors in the Lord of the Rings films.

"Ahhh...a new recruit!"

Before I knew it I was again in a crippling handshake. Ivan had taken us to the head office of the Norwegian Lutheran missionary office in East Africa.

"Karibu" (Swahili for welcome).

After introductions to Henrik, his wife and three young children we sat down to a hot home-made dinner.

Conversation was often in Norwegian most likely because the two countrymen had very few opportunities to discuss matters in their native-tongue. Norwegian sounds like a more poetic version of German...less throat clearing sounds, but still has the abrupt, staccato rhythm at its' core. I didn't mind a bit as I busied myself with the delicious food in front of me.

Inevitably, conversation turned toward the new-comer to the table.

"So you're from the States then? Whereabouts?"

"Minnesota...it's right in the middle of the country and borders Canada."

"Ohhh we know Minnesota...there are a LOT of Norwegians in Minnesota. Tell me...do you know what ludafisk is?"

My mind turned to some abstract idea of a pickled fish, "Ohhh yes, I know ludafisk." I immediately hoped that I would not be offered any of what imagined to be a less than desirable dish...

"That's great...no one in Norway eats that anymore!"

A wave of relief washed over me.

"So do you know Norwegian since you're from Minnesota?"

"Well you see you're either Scandinavian Protestant, or German Catholic if you're from Minnesota, and I'm of German heritage."

"Ahhh I see...."

The conversation again turned to the language which I did not understand so I busied myself with the plate in front of me once more. After taking a few more bites I suddenly realized that the conversation had stopped and that all eyes were looking in my direction.

"I'm sorry?"

"You don't speak German??"

"What?"

"Ohh...we just thought we'd speak in German for a bit for your sake."

"Ohhh...see most Americans can only speak English...yeah historically, it was seen as a bad thing to speak in your native tongue and not in English...so parents often did not teach their children whatever language they were raised in so that they could assimilate as quickly as possible." I was embarrassed that I was unable to partake in the conversation especially after realizing that everyone else at the table was fluent in at least 4 languages (Norwegian, Kiswahili, English, and German).

"It's kind of interesting because the same discussion is going on in America right now as some Americans insist that immigrants from Spanish-speaking countries are not "real" Americans until they can speak English." My thoughts went out to future generations of these current day immigrants...how they would most likely be put in a similar situation as I was currently in and how they would most likely feel shamed at their lack of knowledge of their heritage.

After dinner we sat in the living room as Henrik's wife brought out home-made apple crisp. JACKPOT! It was delicious to say the least.

After some more conversation and more food (I think I realize why Norwegians are large...they eat a LOT) we finally settled into the guest bedroom and turned in for the night.

The next morning we set off before sunrise so we could make good time back to Arusha.

I was amazed at how we were able to bypass any sort of security at all and go straight to our plane's hangar and begin loading up for the return trip to Tanzania.

Every time that Ivan had to head off to an office to clear customs or order gas he repeated the same command, "If anyone asks for identification just say that you are the flight medic...if they persist just tell them to wait for the Captain" Ivan knowing full well that I had no sort of identification on me whatsoever...and hoping that that would not be a problem.

Everything went smoothly and we took off shortly after arriving at the airport.

"We're going to have to clear customs at Kili before heading to Arusha."

"Sure...hamna shida." Kilimanjaro airport is 50 km from Arusha airport and as you can probably guess is immediately next to Mount Kilimanjaro.

I was excited at the eventuality of seeing Kili up close and personal for the first time.

We were less than 10 minutes into the flight when Ivan leaned over, "Look at that great view of Kili...and there's Meru just to the right." I squinted trying to adjust my eyes from seeing anything but the clouds in front of us and off in the distance saw two huge peaks towering above the cloud cover.

"Ohhh yeah...WOW!"

He continued to twist various knobs and turn dials. He leaned over to me and half smirking asked, "Would you like to fly?"

"Yeah sure...no big deal" I sarcastically answered almost elbowing him in an act of jest.

The expression on Ivan's face was not what I expected...instead of him laughing and grinning he just sat there and furrowed his brow not quite sure how to react to my response.

"Wait...you're serious?!?"

"Yeah...I have all this paperwork to fill out...all you have to do is watch the altimeter and keep it around this altitude and keep flying straight to the right of Kili."

I absolutely was scared out of my mind, but realizing that this would be the only such opportunity of my life and figuring that Ivan would let me fly for a few minutes at most I decided to take advantage. I slowly brought my hands to the controls and uttered the least assured "Sure thing" of my life.

"Slow movements." This was the only further instruction I received as Ivan busied himself filling out the many sheets of paperwork.

Five minutes turned into 10 minutes...then 15 minutes...then 30 minutes. All the while the immense Kilimanjaro became larger and larger as we drew closer to it.

For the most part we were above the cloud line, but there was a large column of cloud that was directly in front of our path. Not knowing the best plan of action I kept it on course refusing to alter either the altitude or flight path.

As we neared the wall of white it gave a sense of speed and I realized how fast we were really moving. It's interesting, but before going so near the clouds it just sort of felt as if we were floating in the air especially since the only landmarks were Kili and Meru and they were so far away. Increasing only imperceptibly in size from minute to minute.

As we slammed into the mass less cloud turbulence immediately turned, what had up to that point been a very smooth ride, into an uncomfortable experience. We were within the confines of the cloud for a mere 10 seconds or so, but that didn't keep it from seeming like an eternity.

As we finally escaped the cloud I was not reassured. In fact, I became alarmed as I realized we were no longer flying level, but at a 45 degree angle to the ground. I made the correction and looked over at Ivan who was laughing at the more than scared shitless expression plastered on my face. He pointed at the artificial horizon and merely said, "You want to keep an eye on that when you can't see where you're flying" as he continued to chuckle.

"Right...I'll keep that in mind."

We were now immediately next to Kilimanjaro.

"So we're just going to fly around Kili. KIA (the airport) is just on the southern side." He pointed to the GPS as the flight lines changed to a series of shorter lines connecting the dots around Kili.

As we made our way around the mountain Ivan took out his camera and took a few pictures noting, "Kili is NEVER this clear at this time of day...this is amazing."

I continued to glance over at the majestic mountain every few seconds trying to burn the image into my mind. The entire range was in few with the cloud cover remaining quite low on the mountain. It was indescribable.

My sightseeing was limited however as Ivan alerted me, "So we need to start our descent now."

"Right." I nodded at him giving him the "go ahead" to take over control of the plane once again.

He was having none of it.

"So what you want to do is very gently push forward. This is the instrument you want to keep an eye on. Try and keep the descent at 500 feet per minute" as he pointed with his pen.

"Alllllrrrrriiiiigggghhhhttttt."

Initially, I made corrections too quickly and was bouncing around from -1000 feet/min to keeping the plane level. I soon got the feel for how little I needed to push on the controls and the majority of the descent went very smoothly.

"There's the airstrip" Ivan noted pointing straight in front of us. "The thing is it's perpendicular to us right now...so we need to sweep way off to the right and then turn towards it for the approach."

He made no move to take the controls, but simply continued to point in the direction he wished to head.

"Ok now hang a hard left."

I did as I was told.

We were now very low to the point where I could make out the various animals on the farms below.

"Mind if I take over now?"

I could see that Ivan was very serious in his question. As if he did not want to offend me by taking over.

I briefly considered what his reaction would be if I had said, "Nah...I got this one." This scenario was fleeting as I looked at the airstrip looming.

"Yeah man...go for it."

After a smooth landing I broke out into a huge grin. It slowly began to hit me. Wow...I just flew a plane around Kili...WHAT? As I reflected on the amazing experience I began comparing it to the other highlights of my life.

Hmmm...top three experiences of my life? I realized that the day's events had just shot into first place. Delivering my first baby, which had just occurred two months previously, while on my OB/GYN rotation had slipped into second, and scuba diving with the Ragged-Toothed species of sharks in South Africa was now third.

As we made our way back to Arusha the Cheshire-esque grin remained stuck on my face well into the next morning.

As I arrived at Selian I was asked numerous times "How did the med evac go?"

I retold my story over and over as the visiting docs from Colorado either expressed a look of jealousy or fear over my experience.

Kent gave me a knowing smirk. "Africa's not so bad is it?"

"Nope...it sure isn't."

My honeymoon would come to an abrupt end that very morning.

Dr. Kisanga, the hospital's general surgeon, began morning report.

"Yesterday we began with 87 patients. We had 12 admissions, one transfer, and 5 deaths."

Let me clarify something for those of you who do not work in the health care setting...having 5 people die in such a small hospital (120 beds or so) is UNHEARD of in the States. In my third year working on the wards I had only one patient pass away while under my team's care. It was while working in the ICU at HCMC. He had 5 different terminal illnesses and had already been on hospice care for a few months before his final admission to the hospital.

Sadly, hearing of multiple deaths is not even unusual during morning report at Selian.

Dr. Kisanga continued to discuss those patients who had died. "And the last patient who died last night was Vincent K."

My jaw dropped to the floor.

Vincent was my favorite patient to date at Selian. He was a very kind and grateful man in his late 40's who had had several recent admissions due to tuberculosis and long standing HIV infection. He also spoke some English...which is probably why I came to enjoy treating him so much.

One of the most frustrating aspects of working here is the language barrier. Being unable to make small chat with my patients or providing comforting words in difficult situations alienates me from my patients. This may sound horrible, but sometimes is feels as if I'm not treating a person, but rather a thing. I don't know quite how to put it, but at home each patient becomes so personal to me. I get to know their personalities and intricacies and I enjoy the personal relationship to my patients as much, perhaps even more, then thinking through their management. That doesn't happen here...and I'm beginning to realize how integral that aspect of medicine is to me.

"Was this an expected death or not?" Kisanga put forth the question to the medical team.

The AMO stood up, "The working diagnosis was PCP (a horrible pneumonia that only afflicts the immunocompromised). So this was an expected death."

Bullshit.

"He became acutely dyspneic during the night and died shortly afterwards."

When I had seen Vincent two days previously he was sitting up in bed, breathing comfortably. His chest x-ray was relatively clear, and his oxygen saturation in his blood was close to 100%. He had come in due to an episode of shortness of breath and chest pain the night before.

He was compliant with his ART meds as well as his anti-TB regimen. While interviewing him he noted that his left calf had been hurting him and that he had come into the hospital several times previously due to similar episodes over the last few years.

Knowing full well that he had been relatively immobile recently due to his long stays in the hospital I immediately began to worry about pulmonary emboli.

PE's (for short) occur when blood clots in the legs break loose and go to the lungs. They cause the exact picture of what Vincent was experiencing and describing. If they are small the episode passes, but if they are large they can kill the patient incredibly quickly.

The AMO was less than convinced when I shared my concern as she was leaning more towards the diagnosis of PCP (which a CO, with two years of formal training, had come up with). I recommended that he get a Doppler exam on his legs to look for clots immediately.

"Let's start with these investigations for today. We can always do a Doppler tomorrow" she replied.

She was wrong.

I was able to convince her to start high doses of aspirin regardless. Again, you medical folks out there will no doubt be saying to yourself "No...you use thrombolytics or heparin for immediate treatment of DVT's (blood clots), or at the very least begin on warfarin."

The pharmacy does not carry thrombolytics. It had been out of heparin for several weeks, and Selian does not use warfarin as they are unable to perform INR tests (done to ensure that the patient's blood is not too thin).

I took some solace in knowing that even if we had known for sure he had DVT's, the outcome would have been the same as we were already covering for that possibility as best as we are able.

After morning report I made my way to the medical wards with the rest of the team.

The nurses were busy getting the charts ready for the rounds and I stood around with the rest of the team discussing Vincent's case.

We had only been in the wards for a few minutes when suddenly a commotion began on the male ward.

A man in his 60's who came in with heart failure several days prior, had literally jumped out of his bed with the sort of swift movement you would associate with someone a fraction of his age.

His son had caught him to prevent him from falling over and slowly helped him back into bed. Anna and Janet (the other team members) sauntered over to the bed as I followed behind him. Everyone in the vicinity was discussing the situation in Swahili and my thoughts drifted back towards Vincent.

Everyone's speech became more and more excited. I regained some focus and lazily looked at the patient. Anna and Janet were taking turns listening to his heart and lungs with their stethoscopes and feeling his pulse.

My eyes bulged as I suddenly realized that the patient's chest was not moving. I forced my way through the crowd and pushed Janet out of the way without meaning to as I looked for chest movement and felt his carotid.

Nothing.

"HE'S NOT BREATHING! HE DOESN'T HAVE A PULSE!" I said it more to myself than anyone in particular.

Anna and Janet merely looked at each other with a deer caught in the head lights expression.

"ARE WE GONNA DO CPR OR WHAT???"

Anna looked at me and nodded in the affirmative.

She quickly made her way to the nurse's station and grabbed a mask and bag to begin delivering oxygen. Returning to the bed she gave a few breaths to the patient.

The mask was a pediatric one making it much to small for the patient. The patient's head was also propped up at 45 degrees because of his heart failure...making it unlikely that his airway was even open. She gave a few breaths and I could hear the air escape over his cheeks as there was no sort of seal between the mask and the patient.

I rushed down to the foot of the bed grabbing the patient's legs and dragging him lower on the bed so that his head was laying flat. I then took over the airway performing the "head tilt/chin lift" maneuver which up to that point I had only practiced on plastic dummies. I tried my best to make the plastic fit over both the patient's nose and mouth while keeping a tight seal as I delivered a two breaths.

"Anna...you do the chest compressions."

I watched as Anna performed what could only be described as a massage rather than compressions.

"Lock your arms and get directly over him."

She repositioned and we performed CPR for several minutes.

The patient did not make it.

We stopped CPR and I just dejectedly hung my head. I then slowly turned my head toward the son.

A word was not spoken.

The son began to wail in his intense grief...he grabbed his father's arm and sunk to the floor. A minute later he was running to the courtyard sobbing and yelling.

Anna and Janet made their way back to the nurses' station and prepared to begin rounds.

I gazed at the now lifeless body.

His eyes open and staring at the ceiling and his mouth agape.

I gently slid his body back on the bed so that his legs were no longer hanging off the edge and slowly covered him with the sheet.

The nurse brought over and set up the green partition which is normally reserved to give patients some sort of privacy during invasive examinations/procedures in the dormitory style ward.

We began rounds on the other five patients in that very room without moving the body.

As we made our way from patient to patient I remained in a zombie-like state. The rest of the team appeared unaffected. I did not find this surprising as I knew full well that each had undergone numerous similar experiences.

My head swimming with the extremes of the past 24 hours I said to myself over and over "T.I.A."

This Is Africa.

Chapter 6 - Up, Up and Away

The day began just like every other.

The alarm on my cell goes off. "It's time to wake up, the time is 6:30." This repeats several times in the familiar female British accent I've learned to loathe.

Right, quick shower before the hot water runs out.

And a quick bit of oatmeal before taking the Moshi-Nairobi Road to Ngorumtoni and Selian Hospital.

After morning sala (service), morning report began.

"With us we have the visiting group from Exempla." Dr. Jacobson announces the visiting physician group from Colorado who are helping to facilitate the upcoming move to the new hospital in downtown Arusha. While being introduced during morning report you could see in their faces a mixture of jet lag, excitement, and apprehension of not quite knowing what they were getting themselves into.

Following morning report we have our daily radiology rounds. I start to chuckle as the pulmonologist/intensivist (Lung/ICU doc) expresses a worrisome look as Dr. Mollel, the AMO who poses as Selian's resident radiologist, breezes through chest xray after chest xray.

"Yes, yes...normal lung here. I don't see any signs of tuberculosis." He looked at the CXR for all of 5 seconds before moving on to the next one. This continues for several minutes as I try to catch the eye of the visiting physician. Giving a quick nod towards the front after doing so as if to say, "Feel free to chime in."

He didn't.

Rounds were greatly delayed as Dr. Temu and I worked our way interviewing four new admissions in the ICU and Private wards from the weekend. After some lengthy discussions with the patients and their relatives we finally reach the medicine wards.

Let's see...it's 12:15 right now...there are 15 patients to see, four of which are new admissions.

Gloria looks at me and says in a low voice, "These are going to be some quick rounds." I nod my head in agreement knowing full well that she won't be 100% satisfied until she talks to and thou roughly examines each patient. As well as carefully considering the best plan for management.

I grab the first patient file and begin giving her report when I feel a hand on my shoulder. Turning around I see Kent, my housemate, and half of the visiting group. His face beaming with a large smile as he introduces Gloria as "the brilliant young physician." He continues pouring on the compliments as Gloria begins to blush.

I look at my environment and suddenly I am very aware that the medicine ward has suddenly turned into a zoo. A group of 10 Mzungu (white) visitors peering around with their necks stretched as far as they can go as if there was a glass barrier barring them from simply walking up to a few of the patients and saying hello.

The visiting anesthesiologist has his camera, fully equipped with a tele-photo lens, up to his face taking pictures of Gloria and I standing over a wasted, jaundiced man who is constantly itching himself (due to his high levels of bilirubin) and will almost assuredly die before the end of the year due to his advanced pancreatic cancer.

I think to myself sarcastically, "What a safari!!!"

Kent continues to sing the praises of Gloria (very deserved) and gesture around the wards energetically as the 15 men lay in their beds peering hesitantly at the new arrivals wondering why they are here.

I think to myself what I would think if I were laying in one of these beds...having just learned that I was HIV+ (as many of our patients have) and having a group of foreigners walk through smiling and talking in some language that I can only catch a few words of.

I doubt I would be amused.

"And this is Michael Lawson he is a medical student from the University of Minnesota who has dedicated a good chunk of time to work here at Selian."

"Hi." I kept my response short and slightly frigid trying not to invite any questions or comments as I think both of the time crunch to see all the patients, but more because of how incredibly awkward I perceived the situation to be.

"So how do you know when the patients are ready to be discharged?" asked one of the visiting physicians. As if to say to Gloria, "So do you know what you're doing? Are you able to do anything at all for these patients?"

What the hell kind of question is that? It's an asinine question is what it is. How do you know when do discharge someone?

WHEN THEY GET BETTER!!! It doesn't take a rocket scientist (or even a medical student) to look at a patient and know if they are feeling well or not. If their disease has been managed with a plan to follow up and are feeling well enough to go home...you send them home.

Three hectic hours later I begin walking to the hospital staff bus to take the hour long ride back to the bottom of Ilboru Road. I had just sat down in the seat directly behind the driver (so I have a *bit* more leg room) when my phone began to ring.

"Hello Michael? This is Pat." Pat, a sixty something Catholic priest from Detroit who has lived in East Africa for several decades, is the head of Flying Medical Services.

"Would you be interested in going out on a medical evacuation to Nairobi this evening." His soft, calm voice helped me to keep my composure as my heart began to race.

"Yes. Definitely. Anyway I can help, Pat." I tried to display my enthusiasm yet remain cool and collected, if only in appearance.

"Wonderful. Just take a taxi over to the Arusha airport. The doctors think that the woman being evacuated is having a heart attack."

I quickly, and not gracefully, made my way off the bus as the wave of workers, done with another day's labor, slowly began milling on to it.

I ran out the front gates pointing to a car parked in front of the gates with wild eyes, "TAXI???" The driver nodded and asked where I wanted to go. "Arusha airporte!" Kiswahili has that interesting aspect of language where you can sometimes get away with adding an "E" at the end of the English word and it will work (sort of like adding an "O" to some words to get the point across in Spanish)...as long as the word is a "new word" meaning only being in existence for the past fifty years or so.

"25,000 Schillings."

"WHAT???"

The driver broke into a grin knowing that I had caught him trying to rip me off. That's right, this Mzungu knows the value of a schilling.

After settling on a price I quickly texted friends who I was suppose to meet to play basketball, as well as my roommate to let him know I wouldn't be around for dinner.

"Med evac to Nairobi, pole."

That being done I suddenly realized with horror that I didn't have my passport. After a quick call Pat assured me that I would be listed as crew and therefore would not need to have any documentation whatsoever...sometimes loose regulations are a good thing.

SHIT! I don't have my stethoscope...I don't have my pharmacopoeia manual...why didn't I grab my white coat before leaving Selian?

OK...composure kicking in. How would a stethoscope help keep the patient alive? It wouldn't. And honestly...do you think the plane is going to be equipped with any of the meds you would have to look up for dosing? Probably not.

I arrive to the airport and bustle through the departure lounge to a gait leading to the airstrip...I head out of the gait and start looking for the plane when I hear some Swahili being yelled at me from the security checkpoint.

"Flying medical service doctor" pointing to myself emphatically. As impressive as that may sound I soon found that it's not impressive enough to skip the security checkpoint.

I found the plane with the pilot furiously doing the last few spot checks preparing for takeoff. The plane was a 6 seater red and white single prop engine. I would imagine it was some type of Cessna, but I could be wrong. Ivan, who I had met previously, is a tall, lean Norwegian pilot that has been flying in East Africa for the last few years.

Ivan is actually a pilot for Medical Aviation Fellowship, but had been helping to fill in for Flying Medical Services as they had recently lost one of their airplanes (Pat had a crash a few months earlier...he walked away from the crash with several broken bones...including a few vertebrae in his back...the plane was not so lucky).

Ivan is 30 with shaggy sandy blond hair, and a full beard. He whizzed around the plane making various measurements and examining various parts. His oil stained baseball cap, tinted aviator sunglasses, worn blue jeans, and sweaty brown pilot shirt seemed to scream "bush pilot."

"Hello again." He broke out into a big smile and he took my hand with a grip that would have given Beowulf a run for his money...yes...that's right...I just made a Beowulf reference.

"We're just waiting for the patient. But I believe everything is ready. I have the oxygen tank ready with both a face mask and a nasal cannula."

"Great. Do we have any Beta-blockers?" A blank stare.

"Atenolol?" The blank stare continued.

"Morphine?"

"Nitroglycerin?"

Exasperated I held out hope against a shutout.

"We must have aspirin...right?"

He pointed towards a nearby shed, "I'm not sure mate...check in there."

I ran and furiously searched through all of the labeled bins imagining that a car carrying the patient would be screeching towards us any second. I soon realized that 90% of the bins were spare parts or plane related materials. I found two small drawers one labeled "First aid" the other "Medications."

I yanked open the meds drawer and found a zip-lock bag with 30 tiny white pills in it. "300mg Aspirin" JACKPOT. I continued to search hoping to find any of the aforementioned materials. None. All right...ASA and oxygen...I can live with that...but can the patient?

I made my way to the plane and set up the oxygen mask. I looked around the plane...well I don't have to worry about EKG or a defibrillator seeing as there are none. I began going over the steps of CPR in my head...Ok 30 compressions then 2 rescue breaths...

Ivan continually gave nervous glances at his wristwatch every few seconds. "I'm either going to have to skip landing at Kilimanjaro airport (to clear customs) or miss my last landing time in Nairobi." After a few minutes of consideration he continued, "I think I'm going to just fly direct to Nairobi and to hell with the consequences. I don't want to have to mess around with missing my landing time and flying into bad weather...especially since it's the short rains season."

"Yeah man, whatever you want to do...you're the expert."

A few moments later a few cars pulled up and 12 more people were soon surrounding the plane.

The entire family was coming out to see the patient off.

"Hello. I am Rasheem. I am the eldest brother." The Indian man greeted me warmly.

"Ohh Ok...where's the patient?" Rasheem nodded over his left shoulder and I could see a large woman in her 50's sitting in the car looking rather comfortable.

"So when did all of this start today?" Rasheem pulled me in very closely as he had not let go of our introductory handshake.

"She does not know that she has a heart problem. So if you could ask her as few questions as possible that would be preferable."

What the %#$@???

"Oooook. So when did all of this start? What were her symptoms?"

"Ohh she was having trouble breathing, feeling tight in her chest, sweating a lot, and feeling nauseated."

Yes...this definitely sounded like a heart attack, but the patient was remarkably calm and comfortable considering this.

The patient struggled to get up and with some assistance began making her way to the plane. They spoke in Hindi.

Rasheem began, "She would prefer not to lay down, but to sit."

I looked at Ivan to see what he thought, "Yeah OK I'll go get the seats and put them back in."

We slowly got situated and prepared for takeoff. I took the pulse rate of the patient and monitored her respiratory rate. I thought to myself, "OK high 90's, but she has a strong pulse...22 breaths, not bad she seems to be stable."

After giving her an aspirin I began to put the oxygen mask on her.

"Not too much, or it will make my nose burn."

Jesus...this is the most high maintenance heart attack patient I've ever seen.

"Ok, I want to give you at least 4 Liters/minute. You can breath through your mouth too."

Ivan turned around, "Yeah I don't think you should go any higher than that...otherwise we'll just run out." He was right.

Immediately after take off it struck me. "SHIT! If this lady codes on me how the HELL am I gonna do CPR with her sitting???" I looked around the plane. There was no room to move whatsoever, let alone maneuver. I immediately began a string of curse words in my head that would have made my mother blush. I couldn't believe I could be so stupid and continued to curse myself out for my lack of foresight.

We flew past Mount Meru and Kilimanjaro...I knew Aldonio Lingai (a huge active volcano) was nearby somewhere and was praying that it wouldn't go off as we flew over.

As we flew I continued to ask the patient how she was feeling while taking her vitals every few minutes.

"So how did all this start this morning?"

The sister in the back instantly grabbed my shoulder and shook her head as if to say that is enough...no more questions.

I thought angrily to myself, "Ohhh I am sorry for your cultural taboos...I'm just trying to made sure your loved one doesn't die."

Everything was going smoothly as we flew into Nairobi. Then, as the interns at Selian would say, the patient's status changed.

As we started our approach she began breathing much more rapidly, and dry heaving in her mask. I yelled up to Ivan for a sick bag who nimbly snagged it and threw it back to me without taking his eyes off the runway.

I held it up to her mouth and took the oxygen mask off as she began throwing up. Sweat was dripping from her forehead.

DAMMIT!!! And we were so close...Ivan quickly glanced back at me with a face that let me know he was thinking the exact same thing.

She reached to her left to attempt to open the window. I quickly grabbed her hands saying, "No no no no no." Worrying about the worst possible outcome of some huge distraction just as we were landing. I put the oxygen mask back on and in the most reassuring manner I could muster at that moment said, "Calm down. Just breath deeply...that's right. In and out. Good."

To my surprise she followed my commands. She began to settle down and we landed safe and sound. Ivan taxied over to the hangar where the ambulance was already waiting for us.

I helped her walk over to the ambulance.

"I don't want to lay down in the stretcher."

The EMT was there and I gave report to him, "This is a 50 yo female who began having chest tightness, nausea, sweating, and shortness of breath earlier today around 3:00pm. She did well for the majority of the flight but began having relapsing symptoms as we landed. Her vitals were stable throughout the flight with her heart rate being borderline tachycardic at high 90's-low 100's. Her respiratory rate was fast as well but stable at around 22 breaths per minute. She's already received 300mg aspirin and was on 4 Liters of oxygen throughout the flight. She has not received any beta blockers, nitro, or pain meds."

He stared at me with a look of concentration.

"Do you have any questions?"

"So...she has oxeeegen?"

"Yeah."

"How mooooch?"

Shiiiiit. "Four liters" holding four fingers up. I felt slightly deflated as my report was worthless.

Rasheem came over, "I have this letter from the doctor in Arusha."

True to stereotype I could barely read a single word on it...but the bit I could make out was that she had a pacemaker placed several years previously.

ARE YOU FRICKEN' KIDDING ME? This lady doesn't know she has a heart condition but she underwent surgery less than 5 years ago? What...did they tell her that she was having her appendix out?

I simply maintained the poker face which I have become so accustomed holding with my experiences in medicine thus far.

"Great Rasheem, just make sure the Doc gets this. Let him know that she already got an aspirin, but nothing else for medications."

We wished them well as they took off in the ambulance.

Ivan looked at me as we began walking off the airstrip, "So I have friends that run a mission nearby. Karibu."

"Ahhh so we're staying overnight?"

"Yeah, Arusha's airport doesn't have lights on the runway and it's against MAF guidelines to fly at night."

We entered the Norwegian mission grounds which was actually a huge compound. We strolled through the darkness to a small house. Ivan walked in and said a few words in Norwegian.

I heard a voice reply, "Medical evacuation I presume?"

TO BE CONTINUED...

Chapter 5 - Mr. Lonely on the Wards

I've been working in the medicine inpatient wards for a couple of weeks now. For non-medical people all that means is sick people who are admitted to the hospital who don't need surgery.

Before coming to Selian I knew that it was considered one of the best hospitals in Tanzania and definitely the best hospital in Arusha (population in the area between 1-2 million people).

I'm not sure what I was expecting to find...but I can honestly say that nothing in my experience thus far could have completely prepared me for what it would really be like.

Up to this point I have avoided writing extensively about work. I did this because I figured that the first week or so would be so completely different from what I have known that it would be an unfair and most likely an inflammatory comparison if I began spouting off about my frustration right off the bat.

Now that I have had some time to get "comfortable" in my routine, with the staff, the patient population, and everything in general I believe that I have gained a little perspective and can be a bit more objective in my thoughts. That being said I do often find myself becoming quite frustrated with the quality of healthcare here (as you will soon find out why).

I also apologize as some of the stories may not make total sense without some medical background, but I'll do my best to keep the jargon out as much as possible and explain some rationale (or lack thereof) as I go along...

All of the following took place on Wednesday, October 24th (believe it or not).

"The first patient is a 68 year old male who presents with inability to pass urine."

The man who is of Indian descent is laying in the fetal position seemingly hiding underneath his blanket. His head popping out the top of the covers displaying a ring of silver white hair surrounding a large bald spot. He emits a high pitched, constant moan from underneath only to be interrupted for brief moments as he quickly inhales before continuing his distressing call. It has a pathetic quality to it. Initially, it seems to be the quietest of whimpers and yet somehow echoes throughout the dormitory style ward so that during the exams of each subsequent patient it continues to pierce the air.

I lifted up his shirt to examine his abdomen.

The moan changes abruptly to an even staccato tempo as if he were a horrible sounding metronome.

"Ohhh Ohhh Ohhh Ohhh Ohhh."

I answered as gingerly as possible, "Pole, pole" (Kiswahili's more dynamic version of "sorry").

I palpate his lower abdomen to find that his bladder is distended to his belly button.

"Well, his UA was not sent." (UA being an urine analysis). Perfect! Here is a guy who is very sick looking, who isn't spiking fevers (a usual sign of infection) , but the elderly do not always repsond to infection as well as they should. Also, he could very well be HIV + and therefore his immune system is unable to mount an appropriate response to any infections he may have. The UA would have told us if he had a urinary tract infection or if he was just uncomfortable due to his very large bladder.

"The ultrasound of his kidneys, ureters, bladder, and prostate came back though." A sense of relief swept through me as at least this imaging study could provide us with good information that would guide our management of the patient.

I read the results line, "He has a large four chamber heart with an ejection fraction of 42%."

My heart sank. Ohhh Shit. Are you kidding me? The "radiologist" (who is actually an AMO which consists of two years of training...not the six years that physicians get in Tanzania) had done an echo of the man's heart. His urinary tract was ignored.

I angrily snatched another form from the nurses trolley and wrote down for the ultrasound to be performed again. I added in the margin that the man had already paid the 10,000 schillings ($8) for the study and would not be paying again.

We inserted a supra pubic catheter as a temporary measure until we were able to figure out why he was unable to pass urine.

The next patient is a 80 yo (year old) male with confusion.

I take a quick look through his vital signs and am glad to see that he has been afebrile (no fevers) since his admission 3 days prior. I then scan down to see his heart rate and notice that is was 84 beats per minute every single day.

God dammit.

It is physiologically impossible for someone to have the exact same heart rate four days in a row. The explanation was the nurse who had been recording his vitals was most likely making them up. In her mind the fact that the patient had exactly the same heart rate being a good thing and showing that the patient was stable. I then noticed that there was nearly no variation in his temperature and blood pressure recordings.

"Ok, well we can't trust the blood pressure readings, and we certainly can't trust the temperature readings. I'll go get the BP cuff (there is only one for all of male, female, and pediatric wards) and a thermometer."

"Excuse me...Doctor? Can you fill this deescharge form?" The nurse handed me one of the green discharge order forms and I gladly accepted it. I began looking over the file and realized that it was a surgical patient, but because of space limitations he had been transferred to the medicine ward.

"Ohh, he's a surgical patient. Dr. Kisanga, or one of the interns on the surgery service will need to fill this out."

"But, he forget to do. Can you fill this form please?"

"Ohh, sure." Let's see name, registration number, date of admission, date of discharge, admission diagnosis, discharge diagnosis...I flipped through the patient's chart and copied all of the necessary items to the discharge form.

Until I came to discharge plan/medications. I looked through the notes trying to decipher what the patient should be sent home on and when he should return for follow up as well as any specific instructions for him to follow. I couldn't find it.

I handed it back to the nurse, "I'm sorry, but I can't fill this out." She returned a quizzical look. "Well, you see, I've never seen this patient before. I don't know what medications he needs from the pharmacy, or when Dr. Kisanga wants to see him in clinic." The look continued. "It's not safe for the patient for me to fill this out."

Anna, one of the clinical officers (more training than an AMO, but less than a MD), took the chart out of my hand and finished the discharge form in short order without even looking at any of the surgeon's notes. The nurse was finally satisfied as she could empty another bed before her shift was over.

I dropped my head and slowly shook it as if that would change what I had just witnessed.

The next patient is a 40 yo male who presents with three month history of left sided weakness.

After spending a good twenty minutes trying to obtain the history of the patient's illness I began the neurological exam. To test his strength of his left hand I asked him, through the nurse interpreting, to squeeze my fingers with each of his hands.

As the nurse finished the man took his left arm, and with concerted effort, began repeatedly lifting his arm into the air. I patted his shoulder as if to tell him to relax and put my fingers into his palms. I then repeated the directions to the nurse who relayed it to the patient. Again the man went back to work as if he was lifting an incredibly heavy, invisible dumbell.

I then attempted to demonstrate on him, squeezing his fingers with my hands...then gestured with an open palm as if to say "Now it is your turn." The man looked at me for a brief few seconds and went back to his workout routine.

I slowly wiped my face with my hand and rubbed my eyes trying to refrain from anger. It suddenly reminded me of a African version of the Abbott and Costello routine "Who's on First." I took a deep breath, grinned slightly, and proceeded to demonstrate with the nurse.

After a few more tries I succesffuly finished the neuro exam.

Next patient is a 16 yo male who presents with general malaise, night sweats, intermittent fevers, and extensive lymphadenopathy (big, hard lymph nodes).

Anna looked briefly in his chart, scribbled a few notes down while having a brief exchange in Kiswahili. Then, closed the chart and sauntered towards the next patient.

"That's it?" I was very confused as it takes at least 10 minutes to complete round on even the most straight forward of patients. She glanced over her shoulder, "We think he has lymphoma, but he can't pay to have the histology done of his biopsy" as she waved a dismissive hand in the general direction of the patient.

I stood frozen looking back at the teenager as he buried his head in his pillow not exposing his face, but showing the edge of the bandage from where his biopsy was taken.

"Wait...so he's already had the biopsy...and the lab has the results...but they won't release them until he pays???"

Anna shrugged her shoulders as she tilted her head and raised her eyebrows as if to say "What are ya gonna do?"

I thought to myself, "How about start with telling him his GOD DAMN RESULTS!"

I was still fuming as the nurses' cell phone rang. She immediately stopped copying down the orders for the previous patient and walked outside and began conversing with the person on the other line.

Anna excused herself to go "check on something."

I was flabbergasted. Coming from a place where people turn off their cell phones during movies...I just couldn't comprehend why it is acceptable to take a personal call when lives are literally on the line.

I looked around blankly. Helpless to do any work without someone to translate for me I simply sat down roughly on a wooden stool which was less than two feet high.

I closed my eyes and tried to calm myself. I could feel the anger, helplessness, and frustration culminating in a storm inside my head. I took a few deep breaths trying to concentrate on anything else. The fog of anger lifted and I began to hear the man to my right with tuberculosis coughing horribly and spitting into a cup, the man with the distended bladder continuing his pathetic whimper, a horrible scream from the pediatric ward, the nurse at the front desk laughing hysterically at a co-workers joke.

I sat with my head buried in my hands massaging my temples trying to make sense of what I was seeing, hearing, and doing. When suddenly another cell phone began to ring. The ring tone was the vaguely familiar Mr. Lonely...

"Lonely, I'm Mr. Lonely,
I have nobody for my own.
I'm so lonely, I'm Mr. Lonely,
wish I had someone to call on the phone."

The absurdity of the day had finally won out. I surrendered to it and immediately threw my head back and began to laugh a loud, hard, long laugh...it was either that , cry or punch a hole in the wall. I think I chose the most effective means of relieving my frustration.

Although punching the wall would have been very satisfying as well.

Chapter 4 - To Zanzibar by Motorcar, Boat, and Dala-Dala

Two German med students were ending their time at Selian and were going to spend a week at Zanzibar which is nicknamed "Spice Island." When they invited me to tag along I was a little hesitant at first seeing as I had only spent a total of eight days at Selian thus far, but as they were the only other scheduled students until December, I decided I should take advantage of their company and do a little travelling earlier than I had expected.

We set off on the Dar Express "Luxury" Bus early Saturday morning. The trip was mostly uneventful, although we did pass two horrible accidents on the eight hour drive to Dar Es Salaam.

FYI if you ever find yourself in a horrible car accident in Tanzania you need to flag down a taxi to take you to the nearest hospital...there is no central functioning emergency services in the entire country. This poses problems for two main reasons...First, the likelihood of your accident taking place in the vast countryside is very high and thus, no taxis...and second, even if by some miracle you are able to find transport to a hospital it would be useless unless it's one of the five or so hospitals in the country that is able to help said victims.

We arrived in Dar unscathed and took a taxi to the YWCA for the cheapest room available. After a quick shower we set out to meet up with two Tanzanian med students the Germans had met before I arrived.

We ate at The Breakpoint which is a local hotspot among Tanzanians. Meaning that A) we were the only white people out of the hundred or so patrons and B) the food was good and cheap!

We sat down underneath an enormous tree and began drinking a few beers. I felt something drop on my leg shortly after sitting down and unconsciously attempted to wipe it off. I then had the unpleasant sensation that what ever it was...it was wet. I looked down and saw the unmistakeable appearance of bird poop. I slyly wiped it on the grass and began looking for the bathrooms so I would be able to wash my hands before eating when I noticed Merle (one of the Germans) with a confused expression attempting to pull something out of her hair.

"Yep...that's bird poop. I already got hit."

The entire table looked up and realized that what we thought were flowers in the darkness were actually neatly lined row of bird behinds perched on the branches above us. We all had a good laugh and decided that it must be a good omen since we were being shitted on (literaly) early on in our trip that our expereiences could only get better from here on out.

We continued to be "blessed" throughout the meal and needless to say ate our dinner quickly attempting to cover it as best we could.

We took the 2.5 hour ferry ride to Zanzibar the next day. Being the last ones on the ferry we had to forego a seat in the air conditioned cabin and decided to sit in the front of the boat.

It was a beautiful day. The sun was shining without a cloud in the sky and the water was a color blue that I had previously thought only existed in movies and postcards. Closing my eyes I concentrated on all of the different languages which were in hurried conversations all around me...a couple in front of me speaking Kiswahili, the Germans to my right speaking in their native tounge, a family of five speaking French behind me, and to my left an English couple in a heated debate over the Rugby World Cup with some packpackers from New Zealand.

After arriving in Stonetown we quickly got a taxi to head to our lodging for the next week. Our driver was Ali a twenty something Zanzibari. He was very friendly and offered us advice of what we should do with out week on the island.

He was also dressed from head to toe in traditional Muslim garb as nearly the entire island is Muslim because Zanzibar had been a popular stop on the Arab trading routes. Merle asked where they sold Mulim clothing because she liked what the men wear. He told us the exact marketplace where they were sold. Merle then offered that she would like to buy one for herself because they looked so comfortable...

"Ohhh, well these are made especially for men, but they also sell the women's traditional clothing as well."

Merle answered in her almost British English that only gave away her German birth due to her stacatto tempo with which she spoke, "Right, but they would also be useful for women's pajamas. You know? To wear while sleeping."

My blood ran cold. Here we were in the middle of nowhere 20kms out of Stonetown and another 20kms from where we were going and Merle had just said something that could be taken as heretical...if he decided to kick us out of the cab we would be stuck. Luckily, Zanzibari's also have one of the qualities which seems common to all island dwellers...being extremely laid back.

Ali simply shrugged his shoulders as if conceding the point and Nina (the other German) and I both gave Merle the stink eye and Nina said something very quietly in German which I can only assume was the English equivalent to "Shut your pie hole."

We arrived at Robinson's place shortly thereafter. Eddie (the Zanzibari owner) came to meet us and show us our rooms/tree forts. Eddie is the quintessential laid back islander. He always has a smile on his face showing the gap where two teeth used to be, long dread locks with thinning hair in the middle, and a quiet and warm demeanor. The phrases Karibu (welcome), hamna shida or hakuna matata (no worries), and asante sana (thank you very much) make up 90% of his vocabulary. Not because he isn't fluent in English, but because he rarely feels the need to express more than that.

Every morning Eddie and his other staff member would whip up an excellent breakfast for the 5-10 people staying there complete with fresh papaya, passion fruit, bananas, assorted citruis fruit, chai tea, coffee, and toast with jam. Every evening they would hand out kerosene lanterns and he would cook an immense dinner which varied every night from pumpkin soup, fresh fish, pilou and vegetables(a spiced rice dish). It was fantastic.

The first thing we did after arriving in Bwejuu (the village where Robinson's Place is located) was go for a swim. I jumped in first expecting to get the shock of cold out of my system as soon as possible. The water, however, was incredibly warm. Warmer, in fact, than some of the "hot" showers I had taken in my time in Africa thus far. We got up early the next morning for another dip in the tropical waters...I was greatly disappointed to find that the water more than cooled down during the night.

We made sure to have our swims in the afternoons from there on out.

After bumming on the beach for a day and a half we decided to take the dala-dala into Stonetown. I think every developing nation has their version of cheap public transport...chicken buses in Guatemala, or Kombi's in South Africa...it's really just different versions of the same thing. Crowded, hot, fast, and cheap. All of the trucks/minivans have religious themed slogans (Glory to Allah, God is Great etc etc.) They do this because driving is inherently unsafe. Perhaps if the 11th commandment would have been, "Thou shall not pass on a blind corner," or "Thou shall not drive like a bat out of hell" there would be fewer accidents.

Stone Town is what I would imagine Morroco to be. Busy, dirty, narrow streets, but also quite beautiful in it's own way. Ornate, hand carved doors everywhere you go often painted in vibrant colors contrasting nicely with the neutral color of the buildings. The buildings themselves were invariably old and run down (bordering on dilapitated), but still very aesthetically pleasing to the eye. The streets criss-crossed every which way, but the city is small enough that no matter where you walk you will run into one of the major roads in a matter of minutes. It was very satisfying to turn off one of the noisy/busy main roads to a quiet side street and find a group of kids playing soccer or group of men laughing. Even though it is a large tourist attraction heading down any number of side streets you would think you were the only Mzungu for a hundred miles.

We finished the day at the "open market" also known as the Foridani Gardens. It is sort of the public square of Stone Town. Here local artists/traders gather to sell souvenirs to the Mzungus as well as normal goods to the Zanzibari's. Ramadan had just finished a few days prior (the month where Muslims fast from sunrise to sunset) and the atmosphere could be likened to Fat Tuesday in Mardi Gras...except with less flashing. It seemed as if everyone in Stone Town had come to enjoy food, music, and dancing.

We strolled up to one of the shops where you could pick which fish you wanted to eat. Merle picked a kingfish, Nina a tuna steak, while I opted for the lamb kabobs (my stomach was still recovering from Calamari Thai from the day before). We sat at a table outside while the sun was setting, the Tarab music blaring, and ate our meal smiling all the while.

While exploring the local culture, the spice tour, Stone Town and beaches was incredible, it was just as fascinating talking with Merle and Nina and having our own cultural exchanges. We discussed at great lengths the differences and similarities of our nations and cultures. I always enjoy listening to people's ideas of what they imagine America is like, just as much as I enjoy how things are done or viewed in other parts of the world.

Our conversations were not always deep and serious (anyone who knows me could figure that out on their own). For instance, I learned that in Germany if you are cursing at someone it is very common to tell them to...how shall I put this...do something explicit to their knee (I found that very entertaining). It went both ways however, as I tried to explain to them the joke where if someone says something that could, out of context, be taken as sexual inuendo often someone else would chime in "That's what she said" (Any "The Office" Fans???). I felt like my explanation was lost on them as they sort of returned my description with blank stares.

Turned out I was wrong.

The next day I came out out of my room to find them laughing hysterically. They explained that Nina had come up with the idea of calling me "Grausse" (sp?) which translates to "The Big One." She had wondered out loud whether I would mind being referred to as "Grausse" when Merle had commented that she doubt I would mind at I had problably been called something similar many times. Something instantly clicked for both of them, and turning to each other they said in unison "That's what she said."

Steve Carrell would be proud.

My trip home was uneventful. I made it to the aiport with hours to spare and although my flight from Dar Es Salaam was delayed 35 minutes for no apparent reason it went quite smoothly. One German couple on my trip did get quite upset and agitated that we were not boarding one time. They expressed their frustration in broken English pointing to their watches to drive home the point. The ticket takers would simply shrug their shoulders, point to a chair, and say "Soon, hakuna matata."

German efficiency and "Africa Time" are not a good mix.

Nina and Merle left the day after I did. They arrived to the Zanzibar airport to find that the flight to Dar Es Salaam was double booked. They were not in the half to make it on the plane.

While this might seem like a minor inconvenience it was not. The small companies that fly the domestic routes in Tanzania do not provide assistance for connecting flights. Merle was scheduled to fly back to Frankfurt and then the next day, fly to Jerusalem for another two month rotation. She called to let me know that she figured she was out around two thousand euros...

Her response?

"That's Africa."