Those who matter most to me.

In the Dolomites, Jan 2007, Andrew (now age 12), Cody (now age 15), Jennifer (now age...uh, no comment)

Out of Africa

Male Ward

4-25-08; leaving Africa today. What an experience. It’s hard to consolidate everything that I have seen over the past three weeks.

Seventeen years ago I took a break from undergrad and went to South America for six months, Argentina to be exact. I had been planning on going into engineering, but after that experience I decided to go into healthcare. I wasn’t sure I was smart enough to get into medical school let alone finish. Some reading this blog would agree. I was one of those classic underachievers in high school, never really enjoying to study. However after that experience I started to apply myself with a newly found zeal for studying. I was studying for something/someone other than myself.

My essay application for medical school included the following line, “For me becoming a physician is not an end in itself, but a means to an end... to help others.” I truly believed that, but then life happened; distractions came, bills piled up, I made excuses for not returning overseas to serve. This past year though I was given an opportunity and encouraged by Dr Mike Tuggy to come to Kijabe Hospital in Kenya. That old flame that had almost burned out is now rekindled. Hopefully overseas service will be now an annual happening in my life.

The real people to respect here are those who have come here to serve long term. The Family Physicians, General Surgeons, Neurosurgeons, Internists, Pediatricians, Pediatric Surgeons, Obstetricians who have given up “having it all” to truly have it all. To serve in a place where they are crucially needed.

I came here to teach but have learned so much more than I have imparted. I have gained a wealth of knowledge both with respect to medicine as well as life in general. I now return to what matters most to me, my wife Jennifer, and my two sons Cody and Andrew. If any of you ever thought or planned or felt that you would like to serve overseas and then like me, “life happened”, or even if you never felt that this was something that you would like, let me challenge you to make a plan and go. It could be a life-changing experience…

Thanks for reading, and until next time…

Last sunset over Mount Longonot

Maasai delivery

4-23-08; A 15 year old female presented to labor and delivery. She is primiparous and comes from Maasai land. She has felt the urge to push since yesterday but is unable to get the baby out. So she travels 3 hours by foot and taxi to arrive at Kijabe. Fortunately the baby is still alive. She is completely dilated, +2 station, and her membranes are still intact. We rupture her membranes and encourage her to push. She delivers a male infant, weighing 3200gm, which is a good size for a Maasai baby. Maasai's are very thin and will eat very little during pregnancy so that they have smaller babies. When you deliver in the bush you can't risk a shoulder dystocia. As they say here when a Maasai comes to deliver at the hospital things are "thick" (i.e. there is trouble). The baby has a heart beat above 100 but is apneic, he had a tight nuchal cord, we bag him for about 5 minutes and I'm thinking about intubating him. Seeming to sense my thoughts he perks up and starts to cry. I'm relieved because we don't have any peds vents available and someone would have had to spend the night ventilating him by hand.

Registrars and Interns

Drs Joyce Mbula and Franklin Ikunda doing morning rounds; Nurse Gladys in the background.

Dr Emmanuel Wanjala explaining to Dr Kenneth Munge the finer points of Tuberculosis.

Medical training is slightly different here than in the US. You apply for med school right out of high school and it lasts 5-6 years. Everyone then completes a general training internship. After internship you usually go to a district hospital and work until you are accepted as a Registrar (Resident) in the specialty of your choice. At the district hospital, after your internship, you will be required to perform a high level of general medical and surgical care including cesarean sections, appendectomies and hernia repairs. Family Medicine is just getting started as a specialty here in Kenya.

A good night

4-22-08 (pm); return from IDP camp, I know I won’t be able to sleep after what I’ve seen and so I volunteer for OB call.

Jane, 28 years old multiparous female with a prior c/s is at term and is four centimeters dilated, she desires a repeat c/s.

I also hear there is a young Maasai lady, Joyce, who thinks she is 37 weeks pregnant and has been receiving prenatal care at a district clinic. Here BP’s over the prior month at that clinic have been in the 160-180’s/100-110. We perform PIH labs, urine protein is 3+, platelets are 94,000, Hb is 16, Creatinine is 1.12. She has severe preeclampsia. However she is only measuring 31 weeks. We give her steroids to promote maturation of the fetal lungs and hydralazine to bring down her BP. Plan to take her to rads to perform an US and then repeat her labs in 4 hours. (By the way the hospital still does not have any Mag Sulfate).

Off to the theatre to perform the c/s on Jane, lift up her gown, she has a prior verticle incision. Oh well, no time like the present to perform my first verticle incision. Fortunately it goes well.

Back to L&D to find Joyce is having repetitive decels, we need to take her to the theatre now. Perform her c/s, fortunately it’s her first. She oozes and oozes. They don’t use the bovie here for c/s’s, so I put about 20 figure-of eight sutures in her incision and pray. It works. Gary the pediatrician who I worked with over the weekend, comes in to receive the baby, I think he’ll be glad when I leave.

Back to L&D, Ruth, who is a primip at term, undergoing an induction, is having fetal tachycardia and is remote from delivery. Take her to the theatre where I lift up her gown to find an ex-lap scar, I ask where that came from and she said she had appendicitis. I’ve never seen an ex-lap done for an appy, she must have had a perforation. I perform a verticle skin incision to minimize the scar with some trepidation. We arrive in the peritoneum only to find bowel adhered to the anterior abdominal wall less than 0.5 cm from where I entered. I breath a sigh of relief, better to be lucky than good. Rest of the c/s is routine.

In bed at 4 am. Collapse from exhaustion. Sleep...

Diagnosis anyone? (#2)

Can anyone tell me what disease this nine years old girl has? Her name is Anna.

HIV...The man beside her is her caregiver. Her parents are dead. She lives in an IDP. No one can scrape enough money together to pay the three dollars to get her to the HIV clinic to get free anti-retrovirals.

I'll remember Anna the next time I think I'm having a bad day...

IDP clinic

Happy guy

Waiting to be seen.

Triage

IDP

Men at the Cafe

Children in the Rain

Most of the children loved to have their photos taken

IDP camp

"Clinic" at IDP camp, Hannah is on the Right

4-22-08; Where to begin. Today travelled to an Internally Displaced Persons (IDP) camp.

The other night I was at the nurses station minding my own business when Hannah (a Kenyan nurse) started to lecture me about the plight of the Kenyan IDP’s. There have been various times in Kenya’s history where tribal clashes have taken place. The most recent occurred this past December after the elections, in which many Luo’s felt, as do many in the international community that Kibaki’s win in the election was rigged. Kibaki is Kikuyu. The Kikuyu’s are business savy and have dispersed throughout Kenya, where they have lived contentedly among various other tribes. The frustration over the recent elections led to other tribes evicting them from their houses, killing the men and raping the women. There is an estimated 600,000 IDP’s in Kenya (total population in Kenya 35,000,000). These people have now lost their home and land and are afraid to return to their villages as there is very little that the Kenyan government can or has done to protect them. Many end up in IDP camps. The one I am going to, at Hannah’s insistance has been in existence since a previous tribal clash in 1992. She says there is a group of American physicians and nurses who will be holding a clinic there, I hope to go and help.

We travel by Matatu, small van that holds 14 people. White people very rarely travel by Matatu in Kenya, they usually have their own car or take a taxi. Therefore I got a lot of stares while on the bus, especially from children. After about 90 minutes of travel, and wishing I had taken something for motion sickness, we arrive at the trail to the IDP camp. After trudging through the mud for about a mile we arrive at the camp…

Words and pictures cannot express the site that I was met with...even as I type these words I am overcome with emotion at the helplessness and hopelessness that abounds. We have arrived before the medical team so we walk through the camp that is a series of connected huts that are covered in ragged plastic that has been salvaged from some dump. The camp is on a hillside that is cleared in the forest. Around the periphery are the outhouses which reek of human waste. Some of these outhouses are located at the top of the hill, above the camp, so that when it rains, human excrement is washed down through the camp. We encounter a gentlemen who has was operated on previously at Kijabe Hospital. He is grateful and wishes to buy us a cup of boiled milk. It would be insulting to decline. We walk into the café (what amounts to a fort I would have built as a child), with its split tree benches, dirt floor and tarpelin roof, filled with smoke from the open fire where the tea and milk are boiled. We are served a cup of boiled milk, fresh from the cows that mill about outside (Hannah tells me later that she had asked them to boil it a second time).

Men from the camp begin to enter to see this oddity who has come. They impart to us their tales of sorrow. I continually have to bite my lip to keep from breaking into tears. I ponder the randomness of life. Why did my soul alight into a body in a loving middle-class family in a wealthy nation when it could just as easily been deposited in a body that is birthed into this squallor?

The physicians have arrived. We go to the make-shift clinic of tents. I introduce myself and they are gracious enough to allow me to assist. I see a variety of complaints, almost all have lost a loved one in the conflict, many of the women have been raped. Many have various forms of psycho-somatic complaints related to the trauma that they have suffered (headache, chest pain, abdominal pain). We treat symptomatically, there is no cure…

The day ends and I am able to leave this place of despair. I go home and take a shower, one of the luxuries that we take for granted...

Another 48 hours

4-21-08; Whew… just finished 48 hours of call over the weekend covering ICU/Nursery (NICU)/L&D. Finally I’ve got some time to Blog. Now, where to begin?

Friday night had dinner with Dr Doug and Noel Walsh (he is a family Doc out here for 2-3 years, they have three boys) and Dr Robert and Ginger Nagy (he is an ENT, retired Navy, they have a daughter who is a nurse in the Navy). It was nice to share war and mission hospital stories.

Saturday morning took report from Dr Lean Finke (medicine side of a matrimonial Med-Peds team, husband Gary is a pediatrician) in regards to the ICU patients.

ICU – 4 patients:
#1- Zacharia, 40 years old male with tetanus, trach’d and stable on a vent (only adult vent available), utilizing magnesium sulfate for his muscle spasms (more on this later).
#2 – Helen, 24 years old male, organophosphate overdose (mode of choice in the developing world for suicide attempts). A few days ago when everyone thought she would die she had amazed everyone by coming a rudimentary pressure support adapter and commencing to breath on her own. She is now talking (though hallucinating, not sure if this is due to here anoxic brain injury, atropine or her baseline state, and may have been the cause of here suicide attempt) and eating.
#3 – James, 68 years old male remotely status-post hip surgery who subsequently experienced a bowel obstruction, underwent an ex lap and cecostomy placement. Stable for now.
#4 – Beth, 70 years old female with diabetes and hypertension who is 3 days out from AAA repair. Stable for now.

So, now over to the ward to round on my medicine patients:
Mohommed is a 68 years old male, from Somalia with hepatitis (probably hepatitis A), ascites and jaundiced. He has been sick now for almost two to three months and appears to be one of the rare ones who is having a hard time recovering (most recover completely from Hep A). He is developing hepatic encephalopathy and the hospital is now out of lactulose. I talk with the family about his prognosis.

The rest of my patients are fairly straightforward:
Aggrey, 38 years old male with TB meningitis, AIDS who surprisingly appears to be getting better. Having now had seven patients pass away in these two weeks, I don’t get my hopes up.
Zippy, 23 years old female with leokocytoclastic vasculitis and coalescing ulcers covering both lower extremities, rudimentary evaluation for precipitating cause is unrewarding.
Jane, 68 years old female with hypertension and diabetes now a week s/p Whipple for a pancreatic head mass.
A few more of this and a few more of that…and rounds are over.

Go home (50 yards away) to have a late lunch.

Pager goes off, Grace is here, term pregnancy, prior c/s, in labor desires repeat c/s…off to the theatre c/s performed.

Home again, trying to have late lunch…

Pager goes off, James is becoming hypotensive…back to ICU, bolus, bolus, bolus…still hypotensive. He needs pressors (MAP below 60mmhg), I place a central line and start dopamine, his pressures rebound and we've bought some time.

Home, now for dinner (still no lunch)…

Pager goes off, infant in nursery, born at 34 weeks, with h/o jejuna atresia, s/p reanastomosis has lost her IV access, no one has been able to replace PIV. Back to nursery, all extremities and scalp appear like a pin cushion, there are no peripheral sites to attempt, I place a PIV in her left femoral vein and hope it will last through the weekend.

Home, this time able to have dinner…

Pager goes off, Pauline a primip who is at term is experiencing fetal tachycardia and is remote from delivery. Back to the theatre primary c/s…

Home, it’s late, trying to get some sleep…

Pager goes off, ICU, Helen is starting to require more supplemental oxygen and having more labored breathing. Order a CXR and return to ICU to review. Appears as if ARDS (not uncommon in organophosphate OD). Attempt CPAP (no ventilator available) she does not tolerate it.

Back home to bed…alarm goes off 24 hours down 24 to go…

Having a cup of coffee…pager goes off…

Faith a 24 years old primip at 34 and 4/7 weeks, who has been admitted with mild preeclampsia is starting to have headaches, she is edematous, has 3+ urine protein and BP’s 180/110. She now has severe preeclampsia, fortunately LFT’s and platelets are normal. Give hydralazine IM to bring down her BP’s and bolus her with MagSO4. Fortunately she received steroids one week prior when she was first admitted. Cervix is long and closed; I receive word from pharmacy that the hospital is out of Magnesium (remember Zacharia in the ICU, he’s sucked up all the MagSO4), the option of attempting cervical ripening followed by induction of labor is out. I advise her that she will require a c/s. She accepts, she is in no condition to do otherwise. While back home at Swedish Hospital in Seattle these decisions are made without a second thought as we have outstanding NICU support, this decision weighs heavily on me as the hospital only has one dose of surfactant (to promote fetal lung compliance should the lungs not be prepared for this world) which would cost the family approximately $1,000 US (about twice the annual average income). I take Faith to the theatre and she undergoes a c/s, it’s a boy…my heart sinks a little…boys always struggle more than girls. Fortunately he is doing well as is mom, though I certainly would like to continue her on magnesium.

Round in the ICU, Beth’s abdomen is distended and painful (she is s/p AAA repair), vitals stable, pulses present. Order hemoglobin and abdominal films.

Go to male ward to visit Mohammed, he’s had a bad night, his creatinine is up, he is incoherent, long talk with the family, they understand there is nothing we can do he appears to be in hepatorenal syndrome. They desire to take him home where they would feel more comfortable practicing their Muslim customs. It is now that I find out that it is absolutely impossible to discharge on a Sunday. Explain to the family, they are gracious and understand he will have to spend one more night in the hospital.

Back to the ICU, hemoglobin stable, films show some air fluid levels but no dilated loops of bowel…back off on feeds.

I go home for a break…

Pager goes off… Esther is a term pregnancy with non-reassuring fetal status, back to the theatre for a c/s…

Back home for dinner…

Pager goes off… Helen is getting worse, I go to discuss her status with the family, I’m really tired of telling family members that there is nothing I can do…

Labor ward pages…Mary is a primip at 26 weeks who is in preterm labor… 4cm dilated… no Mag Sulfate for tocolysis, start her on steroids for fetal lung maturity, antibiotics for GBS prophylaxis (which were never given), Nifed and Ibuprofen for tocolysis.

Back home it’s late… can’t sleep…know the pager will go off any minute. Did I tell you that we also have a primip at 30 weeks gestation with a complete placenta previa and history of prior c/s. This greatly increases the likelihood of some form of placental invasion into the uterus and therefore drastically increases the risk of requiring large amounts of blood and subsequent hysterectomy.

Barely asleep and the pager goes off, 1230 am, 302 999 is the return page, this means don’t call, just run to the ICU. I arrive and the nurses are performing CPR on Helen, I don’t know why, there is no vent, I pronounce her and have a long talk with the family.

Back home… 2 am, pager goes off, Mary is delivering. Back to L&D, deliver what appears to be a 30 week infant (and yes, performed delayed cord clamping, even in Kijabe, Kenya). Kid is grunting but breathing on his own. Call in Gary Finke (pediatric half of med-peds duo), he is gracious to assist, infant Ballards out to approx 31 weeks and weighs 1400gm…he has a chance to make it. Youngest infant to survive here was born at 28 weeks.

0430 am back home and in bed…collapse, exhausted.

cultural differences

4-19-08; It’s always interesting to see the perspectives of various cultures. The other day we were performing a c/s on a lady. She requested a tubal ligation but before we could perform this we had to call her husband and request his permission… Half-joking I said, “What if a male wants a vasectomy, do you have to get the wife’s permission?”
Everyone looked at me cross-eyed, as if I was speaking a foreign language (and before you say I am speaking a foreign language in Kenya, I’m not, English is the official language, Swahili is the national language, with multiple ethnic languages also being spoken).

Dr Chege responds, “I’ve only seen three vasectomies in my career and two of them were on white guys.”

The nurse replies, “In Kenya family planning is the women’s responsibility, we don’t want our men running around without any trail as to where they’ve been.”

I remained quiet on this issue as I don’t think I will change any opinions.

Another interesting encounter was when I proceeded to try to discharge a patient on Sunday. You see here we don’t discharge patients on Sundays because the business office is closed. The business office being closed means that families/patients can’t pay the bill of their hospitalization. If you can’t pay the bill you can’t leave. You must remain in the hospital until someone liquidates your bill. Theoretically someone can be discharged on Sunday, but they must pay their bill on Saturday.

A bloody dilemma

View of Kijabe Hospital

4-18-08; Leah is a 83 years old female with a two year history of a draining sinus on her left hip as well as probable chronic osteomyelitis (infection of the bone) . She also has concomitant anemia, diabetes, hypertension and dementia. We consulted Ortho to evaluate her for debridement and possible graft however they were reluctant to do so because of her Hgb of 6.2.

Dr Temple, attending physician from America, to the team, “Why can’t we get any blood for her?”

Dr Mbula, intern, responds, “ We’ve been trying for two weeks to get blood, but her family has not come to donate and we don’t have any of her blood type on hand.”

It is the usual practice in Kenya to have family members donate blood for patients, as there is not an extensive blood bank.

I reply, “Well what blood type is she?”

“O negative,” came the reply that I did not want to hear.

You see, this past nine months of fellowship and living in the dark, dampness of Seattle has been hard on the waistline of this physician. I attribute my weight gain to multiple etiologies; free meals in the cafeteria, late night morale-boosting milk shakes just to keep me going, Dr. Gamble enlightening me to the fact that I can get lattes with my meal card from the coffee stand. I also think that working for one year entirely with pregnant women, one cannot help but gain a healthy amount of weight. However of all the current fellows I am the one to put on the most pounds and that includes Dr. Parker who is now seven months pregnant!

So during this time of reprieve from the grind of fellowship as well as the cloudiness of Seattle I had set a goal of losing some weight while in Kenya. It is sunny and bright and despite my fear of leopards and baboons I have been running daily. Well, because we are at an altitude of six thousand feet, running places somewhat of a challenge to this out of shape Navy doc, it’s all I can do to get a half an hour in. I can’t imagine what it would be like now running at six thousand feet, down a pint of blood.

As this conversation and internal battle is going on in my mind I am brought back to the present conversation by Dr Mbula’s words, “Yes, without blood there is nothing else we can do.”

Before I can stop myself I say, “I’m O negative.”

Those of you who are O negative know too well the dilemma of having this blood type. For those who don’t know, while O neg is not the rarest of blood types it is the most coveted by blood banks as we can donate to all, however we can receive only our own type. Previously I have been a regular donor to the various blood banks, but over the past few years due to my travel, required military immunizations and living overseas I have not had the opportunity to donate. Now that I have been to an area where malaria is endemic, even the Red Cross won’t take my blood for six months.

No sooner had the words, “I’m O negative” crossed my lips and I was escorted down to the phlebotomist who withdrew one pint of my sea level adapted, only hope to survive this altitude and lose weight, blood. Gone were the double-blinded, super-secret questionnaires that delve into ones innermost secrets (i.e. Have you ever travelled to the Chang Rai triangle, eaten at Mamma Thai’s, utilizing a pink plate while the song “Beat It” played in the background?) I had been used to when previously donating blood.

Simply one question from the smiling phlebotomist, “What is your blood type?”

“Lie here, you’ll feel a poke, squeeze this, little more, hold this, thank you, free drink at the café.”

Well Leah’s post transfusion Hgb is 10.5, good enough for surgery, hopefully she’ll improve and no longer be bed-ridden.

As for me… I’m destined now to trudge through the jungles and up the hills of Kijabe, Kenya, not getting much exercise nor losing any weight... Well who am I kidding, through the years I’ve utilized most excuses known to mankind for being portly (I eat like a bird.. I don’t eat anything… Maybe it’s my thyroid…I’m big-boned). At least this is for a noble cause. Besides once I get TB I’m sure the weight will melt away…

Man knows not his time...

4-17-08; Rather interesting day today on rounds. I have this patient, Kenneth with TB meningitis and AIDS. I had inherited him from the physician who was previously on the service. Last week I thought he was getting better and had tried to discharge him. However his family was reluctant to take him home for fear he would die there. It is similar here as it is in the states, we want all our dying to be done in the neat and tidy environment of the hospital. While in the states it is likely due to the fact that we want someone else to clean up, here it is likely due to the fact that if someone dies in the home, unless everyone in the community is expecting it and ready for it, the immediate family may be blamed for not intervening. So it is sometimes easier to allow death in the hospital than explain to everyone in the community what is happening, especially with AIDS.

So back to rounds. I see Kenneth, he is not alert, this is no different than usual, he has meningitis. I listen to his heart, lub dub, lub dub, lub dub… I listen to his lungs, raspy breath sounds are present. I then go on to finish rounds on the rest of my patients.
Later in the morning the nurse calls me as the wife and sister have come to see Kenneth. I talk to them about Kenneth’s grave prognosis but give them hope that Kenneth may recover. They leave and seem happy that everything is being done.I then go to finish some notes.

Not ten minutes after I had the conversation with the family a nurse interrupts me, “Dr Temple, are you taking care of Kenneth?”

Not looking up from my notes, I respond, “Yes.”

“Can you come examine him with me, I think he has passed,” she says cautiously.

I look up from my paperwork and sure that she has the wrong patient and is mistaken I return, “Are you sure, I just examined him, and the family was in there with him, he was most certainly alive?”

“I am quite sure Doctor, please examine him with me.”

We go to the bedside and examine him, he is still warm, eyes are open with a glassy stare. Life has passed from him.

Man, and often physician knows not the time…

“Should we call the family and let them know to come back?” I ask.

“No. When they return, he will not be in the bed and they will know.”

I think to myself, “What a cold way to inform the family.”

However that is the way it is done here. Even with the pervasiveness of death, Kenyans are reluctant to talk about it and seemed surprised when told someone will die. Therefore patients and family members are often passively informed of the diagnosis and prognosis. Very different from our Western way of doing things where we want to know everything. Neither is wrong or right just different…

Diagnosis anyone?

First, what is the diagnosis in the x-ray above? Older physicians have a decided advantage as there are now only approx. 250 cases of this annually in the U.S. Younger physicians will know this if they have been reading. This was my first case of diagnosing and treating this entity. It's miliary TB, the patient has concommitant AIDS (approx 6.7% of the Kenyan population has HIV/AIDS, though this estimate is probably low. In addition there are 550,000 "AIDS orphans" and 78,000 children living with HIV/AIDS).

The photo below the x-ray is the "Respiratory Isolation" room where that patient is housed. Does anyone else see the problem with this picture, which I took from the common passage-way? Not only is there a gap above the door, but there is a vent which passes the air into the hall. I have a sneaking suspicion that nine months of INH is in my future.

L&D

To the left is the delivery room. Women are wheeled or more commonly walk to this room from the labor room pictured below. You can see two beds side by side in the photo, there are actually seven labor beds in this tiny room. I have a feeling Angelina didn't deliver in a hospital like this one when she came to Africa to give birth.

Hospital/Mortuary

On top is a view from above the hospital, which is in the foreground surrounded by trees. Beyond is the Rift Valley.
Below is the sign to the hospital. You know you're in trouble if the hospital you are going to gives directions to the Mortuary...

Home Away from Home

Viagra? Yes, even Viagra.

4-15-08; The 55 years old Somali gentlemen who I have been asked to evaluate by one of the CO’s (CO’s are clinical officers, similar to our PA’s) eyes me excitedly in the exam room of the outpatient clinic. “Why,” I wonder, waiting to see what story would unfold. This gentleman had travel three days to see a doctor. I don’t know how he ever heard of Kijabe Hospital. Word apparently gets out.

“When I’m sexy it burns,” Mohamed says.

I try to conceal my smile, thinking to myself that I often feel the same way when I’m sexy.

Controlling my emotions I ask, “When you say, 'I’m sexy,' what exactly do you mean?”

“When my wife and are together. You know… sexy,” he tells me as if I don’t know what sexy is.

I then ask, “When you say, 'it burns,' what exactly do you mean?”

Mohamed then points to what I expected, the source of all mans troubles, his groin. He says, “After 10 or 15 minutes of sexy, it really burns, like hot sauce.”

“What,” I think, “after 10 or 15 minutes of sexy. My goodness man, what are you complaining about? One should be so lucky.”

Never-the-less, I put aside my newly found resentment take his history, perform a physical and urinalysis and then I amaze myself by coming up with the pinpoint diagnosis of “urethritis” (hey it’s better than “syphi-gono-herpo-loma”)and subsequently prescribe him the appropriate medications.

I then open Pandoras box, if you will. I ask a question that all physicians cringe and hold their breath when asking, “Mohamed, is anything else I can help you with?”

Mohamed looks at the ground…looks at me…looks at the ground again and says, “When I’m sexy it’s weak. Like that.” He points to a limp flower stem.

Ah ha. Now I know what drives a man to travel three days to get treated.

Mohamed, “I don’t care what happens to the rest of my body, but this,” he points to his groin, “I care about.”

“Mohamed,” I think, “I understand. This is what brings all cultures, tribes and nations of men together.”

I prescribe to him what I never thought I would be prescribing on this trip… Viagra…They don’t teach this stuff in tropical medicine books.

Come to find out his daughter is married and lives in Columbus, Ohio. My home area. He and his wife are applying for a visa and will hopefully be moving there this summer. To the land of Viagra… and sexy…

Taking Account

4-13-08; adjacent is a photo of the "theatre." As you can see I have finally figured out how to publish the photos. I have added some photos to the older posts if you are interested.

Well, I've been here one week and feel like I have finally settled into the routine here. The only problem is there is no routine.

I am now covering both the Green and Blue team. Dr Paul Jaster from Kansas is on vacation this week before his children start back to school, so I am covering the Green team for him. Overall I have about 14 inpatients on the medicine ward. Three of my patients nave passed away this week. I can't think of any other time in my career that I have lost three patients in one week. Unfortunately, these will not be the only ones I will lose. Death is common here...

Most interesting patients I currently have are related to illnesses that I hardly ever see, HIV/AIDS, TB, malaria. One young lady has Scrofula (tuberculous cervical lymphadenitis) you don't see that often in the US. I have a couple of Somali women who have old femur fractures (2-3 years old) with non-union. I can't imagine how much pain they must have been in until arrival here. I have three patients with TB meningitis/AIDS, they will not make it out alive.

I continue to be amazed at how so much is done with so little. Last night was called to consult on multiple cases in L&D. Lady with severe HTN (BP of 170/110 and normal labs/urine protein); another with twins and a cerclage at 22 weeks who is trying to labor; another who is bleeding at 18 weeks and will likely lose this pregnancy. We have women who are attempting a trial of labor after cesarean. We don't have intruterine pressure catheters, fetal scalp electrodes; there are only two electronic fetal monitors and they only record the fetal heart rate tracing not the toco. We can't print out more than 5-10 minutes of a tracing due to lack of paper. Therefore many of the residents and interns don't know how to recognize fetal distress.

Today is my first night off Labor call in a week. Nice to be able to relax a little. Went to Mama Chiku's for dinner: beef stew, chapatis (tortillas), samosas (beef filled, fried croissants), and Chai (tea). Food was cooked over an open fire. Walked home in a light rain and darkness.

View out my front door

Local House/Farm

This is a local house/farm. For 80% of Kenya's population agriculture is their source of income. 50% of Kenya's population lives below the poverty level.

Mama Chiku's

This is Mama Chiku's Hotel/Restaurant. Where many a good meal can be had.

Fear and Trepidation

4-12-08 Went on a Safari to Lake Nukuru today with a couple from Atlanta. He is finishing medical school at Emory and is starting residency in ansthesia this summer at Mayo Clinic in Rochester, MN. Both Mike and Cory graduated from Anderson University. I spent my first year of undergrad there. Small world. Kennedy was our guide. We saw a variety of classic African species. Hopefully will be able to download more of the pictures.
Had dinner with Ted and Colleen Sugimoto and three medical students from Hong Kong who have also just finished medical school and are starting internship there this summer. Ted is a general surgeon who has been intermittently serving at various places in Africa for the past 25+ years. Ted works in Michigan (can you believe it, even over here in Kenya I’m running into people from Meechicken). Furtunately he is not much of a football fan. Colleen is an RN and a great cook, the best meal I’ve had since leaving home. One of their sons is getting his PhD at University of Washington, another is an electrical engineer and their daughter is in general surgery residency up in Saginaw, Michigan.
During the dinner conversation as we were talking about the animals I had seen on the Safari and my disappointment at not seeing any big cats Ted mentions that he had previously seen a leopard not too far from the hospital. All of a sudden I’m paying very close attention.
“Where exactly did you see the leopard,” I ask.
Ted, nonchallantly answers, “On the lower road.”
Thinking I know where the lower road is, but wanting to pinpoint where precisely, I ask, “Where is the lower road?”
Ted begins to explain but being “geographically challenged” his wife interrupts to tell me the location of the lower road. You may ask why is all this important? Well, in an effort to get in shape, and more importantly pass my upcoming Navy physical readiness test, I have started running again. One of my routes I have just found out is on this “lower road”.
“Don’t worry,” Ted and Colleen tell me. “If anyone sees a leopard they will kill it.”
“What happens if the person who sees it doesn’t survive to tell anyone,” I think.
Ted goes on to tell me that two baboons can kill an adult leopard so leopards won’t attack a group of people. Now I have to worry about the every present baboons in the jungle. Have you ever seen a baboon, they are evil appearing with their long fangs and loud screech. All of a sudden getting inshape and passing the PRT have become less important to me. I think I’ll just stick to helping at the hospital. That’s what I’m here for anyway…

Sawa Sawa

4-11-08, 2am; like it has done hundreds af times since starting clinical rotations in medical school the beep of the pager awakens me from shallow slumber. I gather my thoughts, take a deep breath, fumble for the phone and call the number displayed, #450, L&D. Dr Chite, the intern, immediately starts to present the patients to me. She begins to relay to me the presentation of Faith, a 27 yo female with PV (PV means vaginal) bleeding, with last menses in December 2007. The patient was initially hypotensive but had normalized her blood pressure with fluid resucitation. As I clear the cobwebs from my head and try to come up with some semblance of a comprehensible plan I think, “Good, this is an easy one, a simple problem with an easy diagnosis and plan.”
I say, “Get an ultrasound and if the fetus is not living we’ll take her to the theatre to perform a D&C for a spontaneous miscarriage.”
Dr Chite responds, “Radiology will not perform an ultrasound unless the patient has a full bladder. We just emptied her bladder to get a pregnancy test to confirm that she is in fact pregnant.”
Sawa, sawa (OK in Swahili), what would I do in the states? I would get one of the everpresent ultrasound machines that we have in every clinic and crawl space and perform the ultrasound on her myself.
So I say, “Am I allowed to use the ultrasound machine in the Radiology department?”
Dr Chite, “Do you know how do perform an ultrasound?”
Dr Temple thinks, do you know who your talking too? Of course I know how to do an ultrasound. But he answers, “I think I can figure it out.”
So I trudge up the hill to the Hospital, unlock the back door so I don’t have to walk all the way around the hospital and meet the patient and Dr Chite in the Radiology department where I am met by the prototype of ultrasound machines. It took me 10 minutes just to figure out how to turn the darn thing on. I had never worked with anything this antiquated before. So after wasting 20 minutes learning how the thing works, all the while loosing credibility with the patient and Dr Chite, I was finally able to confirm that the patient indeed was miscarrying.
Most women in the US are tearful when met with the news of a miscarriage, especially this late in gestation (approx 16 weeks). Faith however, was nonplussed by the news. Death is common here. The infant mortality rate was 61 per 1,000 live births in 2005. The way Interns or midwives present patients is in the following manner: Gravida 4, Para 2+1, the +1 signifies that she has had one child that died after birth, +2 would have been 2 children that died after birth and so on. I have seen very few women who have a 0 after the + sign.
We took Faith to the theatre and performed her D&C. Hopefully she will have more success next time.
Did I mention that last night in the middle of a c/s the power went out. Lights and all for about a minute. No big deal, apparently it happens here all the time. Fortunately the infant was out and the uterus was already closed. I am thinking about what could have happened at various other stages of the c/s…
The photo is down onto the Kijabe Hospital Campus.

Children who I met on the roads near Kijabe.
"How are you," they asked.
"Fine," they would answer.

lifes little adventures

4-10-08 warning!… medically explicit material. So let me just tell you how the small insignificant things in life sometimes become larger things when you least expect them to. For those who don’t know we have a puppy. Aldo’s favorite thing to do is chew on my arms. She doesn’t do this to anyone else in the family, just me. I like her so I oblige the mutt, thinking that she will grow out of it and we all like attention even if it’s negative. Harmless, right. Well the result of this playfulness is multiple excoriations on both of my forearms. Those of you who are reading this are asking about now; what does this have to do with his trip to Kenya? Well I’ll explain. So tonight I’m hanging out at labor and delivery and I am summoned to the delivery room where the midwife (we act as consultants to the midwives and interns) has just delivered a patient precipitously (fast) and she now is hemorrhaging. Right about then is where I wish I had one of those Bakri devices that Dr Gamble talked to us about at the conference. So I put on a pair of gloves to explore the lower uterine segment and start to remove a large amount of clots as well as some retained fragments of placenta. I am basically up to my elbow. I look down at my arm only to see that it is covered in blood. Now you know where I am going with this. Those cute little puppy bites which have not completely healed are covered in blood. I then get the bright idea and ask the midwife about HIV status of the patient. "Don’t worry "she says with a big smile, "she is negative", then she seems to casually mention that the husband is positive..…. remain calm…..clarify the question, maybe there was a miscommunication…..no the husband is positive... "well how do you know the patient is negative," I ask will trying to control my anxiety. "She was tested at the beginning of her pregnancy," says the nurse still grinning. I wish she would stop grinning. So here I sit, midnight, waiting for her rapid HIV test. And don’t worry, I’ve already reviewed the post-exposure prophylaxis in Sanford. I’m so glad I thought to bring that little book.
While I’m waiting for report on that patients HIV status I’ll also tell you my first cesarean section experience here in the developing world. The victim, I mean patient, is 27 years old primiparous female who arrests at 9cm dilated. She is taken to the “theater”, that is what they call the O.R. here in this former British colony. Spinal anesthesia is administered. I then scrub, with soap and water, no scrub brush, just soap and water. I move into the “theater” where I proceed to put on a reusable gown that is probably left over from the Lister era (19th century). It practically disintegrates as I pull it on. Not to mention that I am bigger (read wider) than most Kenyans so I’m pretty much bulging out of it. We then prepare and drape the patient with multiple reusable sterile towels, more on this later. Then, I don’t know if it’s their practice, as this is a mission hospital, or if it was their lack of confidence in me, but before we started the “theater” circulator asks if we can pause to pray. Hey I’ll take any help I can get. The cesarean pretty much is going according to plan until we get to the uterus and come to find out the suction has stopped working. Remember the sterile drapes? Reusable ones don’t seal. Therefore as the uterus is entered the combination of lack of suction and non-seal drapes results in amniotic fluid spilling everywhere, and I mean everywhere. We are practically swimming in it. So the boy is delivered and then the fun begins. She starts to bleed, and I mean bleed. No suction means very difficult to see anything, they also use reusable laps (towels). I now know why we don’t use these in the states. After something has been washed and sterilized a couple hundred times it loses its absorbent capacity. So basically I can’t see a thing. The problem stems from the fact that the patient is found, upon exteriorizing of the uterus, to have a bicornuate (two horned) uterus. An obvious predisposing factor in uterine atony and subsequent postpartum hemorrhage. Well the long and short of it is thanks to some pitocin and hemabate and not in any small part, I'm sure to that initial prayer we got her uterus to contract down, closed her up and she is now doing well.
Page goes off at 2 am. The nurse at the other end informs me the patient is negative…ah, now I can sleep...

less lost

4-9-08 most interesting Maasai patient today. Not so much for her medical issue but for her dress. It was very hard for me not to stare. Dressed in brightly colored clothes with large loops in here ear lobes through which were strung a rainbow of beads. Along with terracing beaded necklace. I continued to be distracted and imagine myself as a true Dr Livingstone battling disease in a remote far-off land until I was brought back to reality by an annoying beeping in my ear. As my conscious cleared I was mortified to see this women who appeared to be out of National Geographic pull out a cell phone and procede to carry on a conversation with some far-off soul. Well civilization even reaches dreams, so much for my romanticism…
Went for a hike during my free-time in an attempt to get lost. Obviously given the fact that I am writing this, adventure did not find me. Locals very friendly. Every child I passed said “how are you?” and before I could respond they answered their own question with “fine”. Apparently this is the first english phrase they all learn. Everyone wanted their photo taken, hopefully photos are not taboo here. While I was returning, still probably 2-3 miles from the hospital I was joined by a young man. I don’t know his name as I speak no Swahili and he speaks no English. However that didn’t seem to keep him from telling me about everything we came acrossed. I must have told him 20 times that I don’t understand. Finally I gave up and just smiled and nodded at what I felt where appropriate times. He just jabbered on the whole way. By the end of our time together I came to realize that I was probably walking with a Kenyan “Forest Gump”.
As opposed to Americans who go to their physician at the hint of an idea that they have some illness, usually at the prompting from an article in the repudiated medical journals Cosmo, RedBook or Oprah, the people I have had the pleasure of treating here wait until the last minute at times to be treated. A couple examples from just today:
Miriam is a 73 years old female who was brought in by her son and daughter-in-law, weighing only 60 pounds, unable to keep food down, happily demented, and unable to walk due to hip pain. They had undergone a work-up at Kenyatta Regional Hospital but now came to our tiny little outpost for a second opinion. We were able to perform a fairly quick evaluation with labwork, x-rays and ultrasound of her kidneys. She has a fractured left hip secondary to metastasis from her probable renal cell carcinoma. I expained to the family that at this stage there is nothing that can be done and he should be thankful she seems fairly happy. I sent her on her way with morphine for pain and reglan for nausea.
Ibrahim is a 10 month old male who was brought in by his parents as he just couldn’t gain weight and seemed sickly. He has a cardiac defect that unless repaired soon will likely end his short little life. The chances of him getting this repair is slim to none. You smile at the parents and tell them they will likely lose their son.
Here in Kenya people have the option of waiting months to be seen in one of the public hospitals or paying exorbitant fees to be seen at a private hospital. AIC Kijabe Hospital attempts to fill the void. It doesn’t provide free care. All patients pay. However the cost is extremely low by most standards. For example a c-section costs about $300. Compared to approximately $6,000 in the US. This fee allows the hospital to keep it’s doors open. Stats on the hospital as follows:
Income: 212,396,409 Kenyan shillings (only 20% of which comes from donated money or services)
Expenditures: 274, 303,148 Kshs
$1 = 63Kshs
Admissions: 13,089 (93% avg bed occupancy)
Total surgeries: 5674
Total outpatient visits: 97,027

Zungu

4-8-08 (still lost…) Kenyans refer to white people as “Zungu”, which means dizzy. This harkens back to the early colonial times when the europeans (British) came here and were so buzy running around trying to accomplish so much that they appeared as if they would pass out from dizziness. I must fit this description perfectly. I have a feeling the nurses on the ward cringe when they see me coming as I will ruin their perfect morning with incessant questions and requests for interpretive services. I seem to create a lot of work for them without making any progress in the realm of patient care. My questions are as basic as: Where is the sink? Where is the bathroom? Where is the door? Fortunately they are very gracious with me, smile and answer my questions for the umpteenth time.
The Kenyans that I have met are very gracious, thoughtful, conservative (in dress and speech). In the waiting rooms for the outpatient clinic, where a couple hundred people will wait to be seen (they see about 300 outpatients/day, I say they because I contribute very little to the hospitals total work load) it is as quiet as an Episcopal church service. You can easily hold a conversation without raising your voice above a whisper. However that doesn’t keep me from raising my voice so the elderly Maasai gentleman can understand my English. In the labor room (yes, I mean room… there is only one labor room… with eight beds, no more than an arms length apart) women don’t scream or yell or swear or spit or bite or kick, they occasionally moan through a contraction. And no, there are no epidurals.
People come from all over eastern Africa (Somalia, Ethiopia, Sudan, Uganda, Tanzania) to this little hospital where they’ve been told great things happen . They may travel for days by multiple modes of transportation. Because of this we have the opportunity to see people from many eastern Africa cultures and tribes. I love to just stare out the window of the hospital and watch as moms hold their babies or have them strapped to their back in their brightly colored clothes and the Maasai men may have their ear lobes adorned with bones or wood carvings. I am truly overwhelmed at times at my good fortune of being able to be here and hopefully be of some assistance to these gracious people.

day #1 of work (day #1 of feeling lost)

4-7-08 Day #1 of work. Inundated with HIV/TB. Reading up on everything. G.K. passed away peacefully last night. Tonight am OB consult to the Resident. Four in labor with a partial previa at 32 weeks on bedrest. We’ll see how things go.

Decided to abandon caution and drink the water. Too much of a hassle to always use bottled water. I’m sure there will be more on this later…will keep all informed.

Another beautiful day. Blue skys, temperate, breezy. Am trying to download photos onto the blog but having trouble with interenet connectivity.

Kijabe

4/6/08 – arrived in Kijabe. It is beautifully situated on the side of a hill overlooking the Rift Valley. I have a great view looking outside my front window. Have already received report for one of the teams (Blue) for Steve Letschford who is a Med/Peds doc . He is going to intensify his study of Swahili while I am here.
My service today consists of the following patients:
1. G.K. a 71 yo female with brain mets (unknown primary) who is basically recieving palliative care only.
2. H.G. a 80 yo male with NYHA class IV heart failure, diabetes, renal insufficiency.
3. A.A. a 38 yo male with HIV, hypernatremia, delerium.
4. F.G. a 70 yo female with probable cholangiocarcinoma and malaria.
5. K.S. a 45 yo male with HIV, hyponatremia, TB.The hospital here has 250 beds, current census is about 230.

Into Africa

4/5/08 – After 18 hours of total flight time and 28 hours of travel, I have arrived at the Mennonite Guest House in Nairobi. It’s nice to be in a bed. The trip started fairly interesting as I had the pleasure, shortly after take-off from Sea-Tac, of caring for a gentleman who had a brief loss of consciousness. Amazing that with all the travel I have done that this was my first in-flight “emergency”. He was doing well by the time we arrived in Newark and I hope he is now enjoying his vacation with his lovely wife on the outer banks of N.C.
Here in Nairobi I was met at the airport by Chris and in the brief drive to the guest house he was able to relay to me that the struggles of parenthood (he has a 10 years old son and 8 years old daughter) are similar and in fact the same as in the states (there goes my plan of moving to Africa to be a better father). Also unemployment of 50%, recent civil unrest which has led to inability of farmers to get their crops planted as well as poor rainfall has meant this will be a challenging year for the Kenyans.
Well, got to try to get some rest, tomorrow we drive to Kijabe (approx 1 and a half hours) and hopefully start work.

testing to see how to import pictures before I go... here's a picture of my dog Aldo. She's not too happy I'm leaving.

pre-trip checklist

Tomorrow I fly out. On my way toAfrica Inland Hospital at Kijabe, Kenya. Have gone over my checklist multiple times and hope I have packed all the necessary items. Have decided to forgo malaria prophylaxis at Tuggy's advice...don't know if I know him well enough to be placing my life into his hands. Things seem to have calmed down in Kenya for now and I anticipate this will be a trip full of learning and I hope I will be of some help to those there instead of a burden.