Reflecting on Acute Malnutrition Management in Tanzania: Kristen Trickett

Expect the unexpected and keep an open mind" was the general advice that I received from various mentors, colleagues, and friends prior to departing for my international rotation in Arusha, Tanzania during the third year of my pediatrics residency. Little did I know, I would very quickly (almost immediately) learn the importance of heeding these wise words. It was my first medical mission trip abroad, and although I like to think that I did what I could to prepare, nothing can truly prepare you for the range of experiences and emotions packed into each and every day. During my first week in Africa, I felt as though I had been thrown into the metaphorical deep end. I was learning to practice medicine in an unfamiliar country where I didn't speak the language or have a complete understanding of the cultural context. The gravity of every decision I made as a physician had never been more apparent to me.

Initially, the census at Selian, the more rural hospital where I primarily worked, was relatively small as the rainy season had come late this year. Roads were completely washed out, preventing families from seeking medical care. A flood of patients came the following week, many of whom were very sick. One patient case that was particularly touching was a previously healthy five year-old boy whopresented overnight with a nail lodged in his skull after a fall. The nail was removed and a lumbar puncture was attempted, but unsuccessful. He was treated empirically for meningitis and admitted for observation while his family attempted to come up with money for his CT scan. Thankfully, he improved gradually throughout the course of his hospitalization and his village came together to pay for his imaging. I learned that this is a common practice in the Maasai villages. There is a real sense of community in every aspect of life. Even in our first few days walking through the village to work, we were consistently greeted as "brother" or "sister." Additionally, I should also include that we were most frequently greeted as "mzungu." I later learned that this translates to "someone who roams around aimlessly," which perfectly describes how I felt trying to navigate the village in those first few weeks.

In addition to time spent at Selian, I was also granted the opportunity to work at the more urban medical center in Arusha, Arusha Lutheran Medical Center (ALMC). Primarily my time was spent working in the NICU at this location, following babies I had transferred from Selian. In contrast to Selian, at ALMC the resource availability was much more robust. Patients would at times be transferred from Selian to ALMC if they were declining and would require more support, with the caveat that they were expected to do well after discharge. In discussing those decisions, the concept of resource allocation took a new face for me. In my experience in the NICU in the United States, all neonates, regardless of the expected outcome, received maximum support should that be the decision reached among the parents and doctors. However, in Tanzania, resources are much more scarce and life after discharge has very different implications. For example, discharging a neurologically devastated infant is challenging for families in any setting, let alone one which is stricken by poverty, a lack of education, and food insecurity. Additionally, there is no option for early intervention or the various therapies vital to the development of these children. Prior to this experience, I had never had to take these factors into account when making decisions about a hospital-to-hospital transfer.

Throughout my month abroad, Wednesdays were consistently my favorite day of the week. On Wednesdays, I traveled to work in the clinic at a place called the Plaster House, a place where therapies were available to children who would not otherwise be able to access them. The Plaster House, founded in 2008 by occupational therapists, is a low-cost surgical rehabilitation program for children with correctable disabilities. There are different dormitories in which patients can stay while they receive post-operative care for conditions including burns, chronic osteomyelitis, and various skeletal deformities. Providing general pediatric care in the clinic there was a highlight of my week. It was encouraging to see progress and learn stories of the healing taking place thanks to the altruism of the staff.

The patients I had the privilege of meeting and my mentors who taught and encouraged me have already impacted me more than they will ever know. I am beyond grateful for the lessons I have learned in compassion and the importance of human connection. These experiences continue to inspire me to be grateful for the resources and opportunities afforded to me back home. This experience also helped me elucidate what I value in caring for children, developing relationships and monitoring progress over time which will serve me well in my career as a general pediatrician. Additionally, I plan to continue my involvement with global health by giving back in any way that I can. For now, that means being involved in training the next generation of pediatricians. In the future, I hope to continue to make trips to Africa to aid in medical education and continue to learn myself.