Community Engagement

Tshepo means "hope"

Monday morning we began our week of community engagement at the Tshepo foundation. Meghan, Margo, Christina and I arrived at the foundation shortly after 9am. We were greeted by Peter and Petro Howe, the couple that began Tshepo in November 2000. Their aim is to uplift the community by focusing on the children in Bloemfontein. One hundred and seventy children are enrolled in their daycare program, but due to the holiday many children did not attend. Regularly, they attend classes, receive two meals a day and have a play time in the yard of their facility. Recently a wellness center has been initiated within Tshepo, and a local doctor voluntarily offers her services to the children and staff. The physician will refer the children and staff to hospitals in the area if she detects any health issues. We had the privilege of speaking with Dr. Rowan, Peter and Petro personally, and they explained in detail what they do. We were able to interact with the children and play with them for a period of time.

Pre-schoolers at Tshepo

We then were transported to Lebone Village, an orphanage in Bloemfontein for children with HIV. We arrived around at the time the children were being served lunch. We helped by spooning their meal into a bowl with milk. The children are very well mannered during their meal time, waiting for everyone to receive their bowl and reciting a prayer before eating. We were able to play with the children just before they took their nap. 

Playing games at REACH

On Tuesday we began our community engagement at REACH, an after school care program within a township in Bloemfontein. Normally the kids do not attend until after school, but because of the holiday many were present today. We played ice breaker games with the kids and sang along with their songs, such as "This little light of mine". The kids split into groups for a competition. The program is emphasizing drug awareness and prevention during the holiday week. Today the competition involved making a poster within their groups that shows the impact that drug use has in certain areas of their lives. 

Tshepo provides the children with jackets and hats 

We visited Tshepo for a second time, where we took at tour of the township in which the care facility is located. We visited a home that was built in the area by the government and also saw homes that were made from tin and blankets. Many of the children that attend Tshepo live in homes such as these. We returned from our walk to play with the children. They are so excited to have visitors and are very loving. 

Children playing at Tshepo. 

At noon, we visited an in home nursing facility in the township called New Horizons. A team of five nurses provide care to many people in the community by visiting homes. They have very limited supplies to work with, and struggle to see all the patients that need care in the community. The nurses walk to their destination to make house calls. We were able to visit patients with two of the nurses. The first patient I saw suffered a stroke. The single mother lives in a shanty house with her two young children. She is unable to walk or care for herself and depends on the nurses for aid. We also accompanied the nurses to the home of a woman who suffers from AIDS. They provide her with anti-retroviral drugs from the clinic and are also treating her for tuberculosis.

SURGERY

Our surgical rounds began with the observation of two gastroscopies at Universitas Hospital in Bloemfontein. The first gastroscopy we were able to watch on a computer screen, but the second was performed using an eye scope, so that only the physician could view the procedure. Later, we observed a hiatal hernia removal from the gallery above the theater. The lectures on Monday covered the biology of aging and anemia. Surgical rounds on Tuesday began in the pediatric burn unit of Pelanomi Hospital. Many of the patients suffered burns by hot water or stoves. One specific patient was in the burn ward as a result of a pedestrian-vehicular accident.  Hygiene is particularly important when entering the burn unit, because the patients are so susceptible to infection. Shoe covers are worn and hand sanitizer is used between every patient. We shadowed a doctor that led us around the ward, to ICU and then to the clinic. In the clinic we saw a 9 month  old and a 12 year old patient with umbilical hernias. The doctor informed us that these are very common in the black African population. We also witnessed a visit with a small child with a burn to the bottom of his right foot. The patient was in need of a skin graft. The doctor also had a follow up appointment with a patient with a facial burn. Most of the patients that the doctor saw in the clinic were HIV positive children.
The following day we learned how to properly scrub in for a surgery. I also watched a gal bladder removal from the gallery overlooking the theater. The surgery started endoscopically, but unfortunately due to complications the surgeons had to open the patient's abdomen. The next day we began with ward rounds. The medical students and I followed the head physician around to the patients room where reports were given on the patient's conditions. We were also able to see one patient in the clinic who had contracted an amoeba from a river. The amoeba was in his liver and was being drained using an ostomy since the condition was not treatable using medication. The morning was followed by afternoon lectures on optometry.

Obs and Gynae

On Wednesday, Ros and I reported to Chris de Wet clinic once more to witness more follow up appointments. I learned more about the CD4 count, which is the result of a blood test performed on HIV positive patients. The test measures the amount of t-cells that are present in the body and are able to fight off infection. A pregnant woman with a CD4 count less than 350 will be placed on ARV drugs for the duration of her pregnancy in order to protect the fetus from contracting HIV. However, she will be taken off the ARV's after the pregnancy because her CD4 count already indicates she has developed AIDS. The same applies if a woman's CD4 count is much much greater than 350 will not remain on the ARV's after pregnancy, since the patient still has enough t-cells to fight off infection. A pregnant woman with a CD4 count greater than 350 will be placed on ARV's during pregnancy and will remain on the drugs for the rest of her life.
I also learned the three ways to determine the week of gestation of the pregnancy. The most accurate method is the date of the last menstruation. Using this date the nurse or doctor will add 7 days and 9 months to give the EDD, or estimated date of delivery. The second most accurate method used is the sonogram. Lastly, if the mother cannot remember the date of her last menstruation and she is unable to receive a sonogram a SF measurement will be taken. SF or symphyseal fundal height measurement is taken by measuring from the top of the mother's uterus (by feeling her abdomen) to the top of the pubic symphysis. The measurement in centimeters is an estimate of the gestation of the pregnancy.
Thursday we reported to MUCPP, Manguang University Community Partnership Program. Several nursing students were also there for clinical rotations and their lecturer explained a full body examination of a pregnant woman at 40 weeks gestation.
Thursday night was the second on call night of the week. Ros, Nelson and I were assigned to Pelanomi hospital, which is a secondary care hospital in Bloem. Upon arrival there was a cesarean section being performed in the theater (surgical room). The mother had been placed under spinal anesthesia for the surgery, but began to doubt her decision to be awake during the birth. The anesthesiologist put the patient under general anesthesia and a healthy baby girl was delivered shortly after. A NVD or natural vaginal delivery, occurred shortly after 10pm. It was an unusually quick delivery and a healthy baby boy was born. Another cesarean section occurred immediately after the NVD. A spinal anesthetic was used and the mother was awake during the surgery. No complications occurred during the c/s. All three deliveries that were witnessed were by HIV positive mothers.
Pelanomi hospital was much warmer, and more up to date than National hospital (where we were on call Monday night). Pelanomi is a more specialized hospital since they are a secondary hospital and National is a primary.

The 36 hour day.

My first two days of clinical internship were jam packed with lots of obstetrician/gynecology information and experiences. Monday began with a 7am meeting with the 3rd year medical students who are starting their two week rotation with obs and gynae, as they call it. After a meeting with their instructor we all split to attend our specific clinic or hospital ward rounds. Roswyn, the 3rd year medical student whom I will be shadowing this first week, was assigned to the Chris de Wet Clinic in Bloemfontein. We were assigned to observe Sister Pretorius as she completed follow up appointments with patients. I have noticed that everyone here, doctors and patients included have the utmost  respect for their nurses. It is also interesting to note that they refer to nurses as 'sisters'. From 8am to 11am we saw patients with various complications with their pregnancies. It is becoming more apparent to me how much of a problem that HIV is in South Africa. A very significant amount of patients that were seen by the sister were HIV positive. Others were seen for complications with high glucose levels, high blood pressure and tuberculosis. The Chris de Wet clinic (along with all public clinics in Bloem) is a free clinic, meaning that the patients do not have to have medical aid (or insurance) to receive treatment and medications. For this reason there was a large volume of people at the clinic that morning. Many of the pregnant women had arrived at 7am and were not seen until 11am, as Ros and I were leaving.
Following the first ward rounds we attended the 3rd year medical lectures on campus. The lecture hall is fairly new to the campus. The lecture hall we were attending was large, with two projector screens with a podium in the center of the screens. The first lecture focused on Myeloproliferative neoplasis. This professor used a microphone in class and also lectured using a powerpoint presentation.The second lecture was on pituitary function. Dr. M did not use a microphone but did utilize power point slides. However, the slides included a lot of words and few pictures were used. Lecturer number three presented presentations on aortic stenosis and aortic incompetence. This lecturer was very engaged with his students throughout the entire lecture. He asked questions, expecting answers and made students recall information from previous years education. He even went as far to ask students why they answered questions a specific way, requiring them to think critically about the question. He had very few slides, and even fewer words on the slides. It occurred to me that if you were not paying attention in class his slides would make little sense and would even cause misinterpretation of the information.
Day one didn't end there, as Ros and I were one of the first groups to be put on call in the OBGYN wards. We left lecture at 5pm and reported to National Hospital Labor Ward at 6pm. A woman was entering the last stages of labor as we arrived, so we were able to see our first natural delivery of the night right away. After the delivery a nurse explained to us the examination of the placenta. After delivery this is a very vital part of the process. If any part of the placenta is missing, and still attached to the mother she will experience internal bleeding. She showed us the two arteries in the umbilical cord and the vein which transports oxygen to the fetus. Several other patients were admitted throughout the night, one for a voluntary cesarean section and others who were in labor. Later in the night the patient that was admitted for the voluntary c-section began to experience labor and was transported to Pelanomi Hospital for an emergency c-section. National Hospital only preforms c/s when they are scheduled.
I found it very interesting that there were no doctors in the maternity ward throughout the night. The nurses delivered all babies and performed all tasks. The sisters were helpful, and taught us many things such as how to properly apply the fetal heart rate monitor to the mother's stomach while she is experiencing the early stages of labor.
Two more deliveries occurred during our shift at National. All three were natural deliveries with very healthy babies. One thing I noticed about the hospital is that it was not heated at all. The temperature dropped to -4 degrees Celsius throughout the night. I imagine it was a cold experience for mother and baby especially, since newborns do not maintain their body heat easily. No computer systems were used in the hospital, all information was taken manually. I also noticed that the sinks did not produce hot water, which I thought could be problematic if you wish to properly wash your hands. I also noticed that the  fetal heart rate monitors were not cleaned between patients.  I'm not quite sure what the standards are, or if they have any for hospitals in South Africa. It is something I may consider looking up though.
We left the hospital at 7am Tuesday morning and reported to Chris de Wet Clinic at 8am. Today was first time clinic appointments for expectant mothers. The standard procedure for first time visits are to take the mother's history and assess the pregnancy. The nurse writes down the patients name, South African ID number, address, age and marital status. The nurse also asks the patient for any information about previous pregnancies. This includes if they were normal vaginal deliveries, cesarean section deliveries, any abortions, or miscarriages. I learned that if it is the woman's first pregnancy that is called primigravida. If the woman has had more than one pregnancy it is called multigravida. Any problems the patient is having are also written down. A family history is taken, for example it is noted if there is an history of cancer,  high blood pressure, diabetes, epilepsy, twins or abnormal births in the family. Allergies and medications the patient is currently taking are also written down. The nurse then weighed the patient and measured her height. Usually the mother has been previously tested for HIV and the result is already listed on her chart. The nurse determines what anti-retro viral drugs the patient should be on and these are given to the patient to be taken during pregnancy. The patient is then tested (in the same room, by the same nurse) for sexually transmitted diseases, tuberculosis, hemoglobin levels and to determine their Rh factor. The Rh factor must be positive or without proper treatment it could cause complications with the pregnancy. A urine test is also performed in order to test for proteins, glucose levels and any abnormalities in the urine. I did not realize the extensive information and the complications that can arise during pregnancies. It was a very valuable learning experience to witness how this process takes place in Bloemfontein, South Africa.

Bloemfontein, between somewhere and no where...

Women's Memorial at The Boer War Museum

Emily Hobhouse

Today we took a tour of Bloemfontein. Our first stop was at the Anglo Boer War Museum. The site recognizes all the women and children that perished in concentration camps in the war that lasted from 1899 to 1902. There was a statue commemorating Emily Hobhouse, an English woman who worked to change the deprived conditions of the concentration camps in the war. The residence hall we are living in is also named after her. We also watched a film that explained the significance of both white and black soldiers in the war and how the museum commemorates all the soldiers that fought for their country. On our tour we also saw Bloemfontein's first hospital in passing. We also visited an art museum on the tour, which used to be the South African President's residence. We drove through many townships in Bloem, where many people still do not have electricity and running water and they reside in shacks. In 1947, the British King set up RDP  homes for the South Africans that lived in these town ships. Many of these houses are still lived in today. We also made a quick stop at the Lebone (meaning 'light' in Lesotho) Village, an orphanage for children living with HIV/AIDS. We were unable to see any of the children because they were attending school, but we took a tour of their premises and learned about their self sustainability. They grow their own food, have a bakery, a wood working shop, and a shop to make clothing. Many of the people that work the fields at Lebone are unemployed volunteers, who work for two meals a day and food to take home to their families. Our last stop was at Naval Hill, a small nature reserve that overlooks the city. There were many hiking trails, and once we reached the top we saw ostriches, a wildebeest, several zebras and a giraffe.

Greetings from Bloemfontein!

I have arrived safely in Bloemfontein, South Africa! After 27 hours of travel time I am grateful to have my feet on the ground! All three flights went smoothly. The worst part of the trip was our seven hour wait at the airport in Johannesburg for the plane to our final destination, but even that was bearable. The flight in to Bloemfontein was beautiful and I had a great view of the country side from the plane.  I am fighting the jet lag and attempting to stay awake until a reasonable time to go to bed tonight. Hopefully the six hour difference won't take too much of a toll on me. I felt extremely welcomed by our host Louise,who greeted us at a residence all at the University of the Free State. She settled Tina and I into our 'hostel' or as we would call it, our dorm. She was extremely generous and stocked our refrigerator with lots of goodies and provided us with brand new sheets, blankets and towels.
The residence hall is much like one at Appalachian, with a common bathroom, laundry room and kitchen. One difference I did note is that the bathroom has stalls with bathtubs as well as showers, which is a interesting change. The other girls that attend UFS and live in the dorm are very friendly, and everyone greets one another in the hall way. I am looking forward to getting to know them better.
So much is in store for our group this week! I am excited about Margo and Meghan's arrival tomorrow and the barbeque that we will be attending tomorrow evening with the UFS medical students! I will have much more to update on in the weeks to come!