Taking the stairs

For some reason, Harmony and I became avid stair climbers during our trip to Europe. It all started in Paris...

Arc d'Triomphe - 284 steps
Notre Dame Cathedral - 387 steps

Duomo Cathedral, Florence - 463 steps


St. Peter's Basilica, Rome - 323 steps (after the elevator.)
Okay, so we took the easy way out paid the two extra Euros to take the elevator up the first two hundred steps. It was our last day and our feet hurt...:)

The views were all spectacular and worth every one of the 1,457 steps.

Guess it will serve me well if I do THIS again next year...

Europe! Part 2!

Florence!

As far as cities go, Florence was probably my favorite. It was less busy and crowded than Rome, and less claustrophobic than Venice. And we found the best food of our trip in Florence.

We spent the two days in Florence exploring and eating. We also visited Michaelangelo's David (unfortunately no pictures allowed) which was much more impressive than you would expect from seeing his pictures in books and postcard. We also spent time at the Ufizzi gallery looking at famous and not-so-famous Renaissance paintings.
The Duomo (the 4th largest cathedral in the world) dominates the city (and my pictures of Florence) and it's dome, marblework, and baptistry doors were simply amazing.


We also maintained our new afternoon routine of stopping for gelato. Everything about the food in Italy was just...better. The pastas and sauces were all homemade, and the ingredients so much fresher. While I don't know a lot about wine, we stuck with the house wine with our dinners and were never disappointed.

Sadly, this is the only picture of food that we actually took. Harmony demonstrates how to eat "Big Salad with Tunafish"

Rome!

While Florence may have been my favorite city based on the people and it's character, Rome certainly wins out in terms of sights to see. Our first day we devoted to exploring ancient Rome - the Colosseum, Roman Forum, Palatine Hill.

The Colosseum
The Roman Forum...the arch in the background is the Arch of Titus commemorating among other victories the Siege of Jerusalem and destruction of the Temple in 70 AD

And we made sure to stay well hydrated...since it was about 90 degrees in the shade.

The following day (and our last in Italy) we traveled across the Tiber River to the Vatican. We spent the morning in the Vatican museum, which is filled with sculpture and art, including many paintings by Raphael. Unfortunately the Sistine Chapel was another "no pictures allowed" destination.
We then spent the afternoon at St. Peter's Basilica, which is breathtaking. The pictures just don't do justice to the immense scale of the cathedral.

The next day Harmony parted ways for our trips home. In an unexpected turn of events though, it turned out that my sister and her boyfriend were in London during my 18 hour layover.

London!
After finally making it to London I was able to enjoy some pub food and a Guinness with Sara and Marty, though unfortunately we all forgot to get a picture. The next morning Sara and I were able to walk around and see some sights and catch up. Note Big Ben in the background.

And later that day the backpack and I were on a plane headed back home.

Europe!

Many of you know that I spent the vacation following my trip in Kenya traveling in France and Italy with my friend Harmony. Aside from the night train, it was a great trip. Here are a few highlights!

Paris!
We spent two nights in Paris, and took the city by storm! Our first night we took a river cruise on the Seine. While the architecture was impressive, even more impressive was our tour guide. In her early 20s, she pointed out all the sights and gave a brief overview...in French. And then in perfect English. And THEN in Spanish. She switched between the three languages without ever missing a beat while the boat cruised up and down the river for over an hour! At the end of the cruise we got a great view of the Effiel tower.
Over the next two days we walked Champ-de-Elysees and toured the Arc d'Triomphe, went to the top of the Eiffel Tower, visited the Louvre and the Musee d'Orsay, and Notre Dame and Sainte Chapelle cathedrals.

But don't worry, we still managed to squeeze in macarons, crepes, and lots of excellent French food. Our take on French food is that it's familiar, just better.


Venice!

Well, you've already heard about the "night train incident" here. After arriving in Venice, exhausted and smelling of train, we had little time for sightseeing. We did enjoy a walk through the narrow streets and exploring this city of canals.
We also had our first Italian gelatto.


We also took a "tour" of the city by vaporetto - the local public transportation. Our guidebook outlined the important buildings and gave us a little overview of the history of the city. Also, it's just fantastic that the buses are BOATS. While we were less than excited to head back to the train station the next morning, we were excited about our next stop: Florence!

Bleeding Room

Having dealt with blood shortages the entire time I was in Kenya, I had planned on donating blood from the beginning of the trip. (However, given that we were living at about 6000 ft elevation it seemed prudent to wait toward the end of the trip) On my second to last day, my friend Gillian and I walked down to the regional blood transfusion center to donate. We were directed here:

The blood center looked much like a blood center here. We filled out a similar questionnaire and watched as the techs opened the donation bags and needle sets from the individual wrapping. A sixteen gauge needle stick later (ow) and I was good to go!

They did take the 450 mL of blood a little faster than in the States, but I didn't really feel dizzy or bad at all afterwards. After donating I got a wristband and a big bottle of Coca-Cola. We chatted with the tech about the blood supply and some of the issues they have at the blood center.
I do have to say that Gillian did an excellent job with her first ever blood donation and was an absolute champ about the needle in her arm! (pictured above)

Home Sweet Home

For those of you playing along at home, I did make it back to Indiana. More posts and pics soon to come!

So...You want to take a night train from Paris to Italy?

There were really two fundamental flaws with this plan:
1.) Neither Harmony or I speak French OR Italian.
2.) Everything we knew about European train travel we learned from Harry Potter.

The trouble started when we arrived at our four person compartment and met the other two travelers - an elderly French couple who didn't speak a word of English. After a lot of pointing and awkward staring we did eventually get the sleeping arrangements sorted out.

So when we booked our tickets we ended up in a four person "couchette" compartment. A couchette is apparently a padded bench. We were lucky enough to have the top level couchette - suspended about six feet above the floor with nothing but two widely spaced straps to keep us from falling out of the "couchette" while we tried to sleep...on a MOVING TRAIN.

But wait, I'm getting ahead of myself. Before bed, we went in search of the dining car. And found...two Italians guys pushing a cart filled with wine and a few cans of Pringles. So, Pringles and nutella wafers for dinner it was!

After a rather restless night we woke up and ate some more nutella wafers with our coffee, pretending to be refreshed and ready for our single day sightseeing in Venice. At right around 9:30, the arrival time on our ticket, and 13 hours after leaving Paris the train slowed down and pulled into the station...at Milan. THREE HOURS from Venice.

We still have no idea what the delay was - apparently there was a "problem" overnight (assuming "problem" means the same thing in Italian as in English). As Harmony pointed out, "We should never have taken a Muggle train."

We did eventually get to Venice and figure out the vapretto system - boat public transit! - and find our (surprisingly upscale) hotel. Our bathroom alone is a 12 on my 10 point scale.

Our sightseeing today mostly consisted of finding an ATM, food, and gelato and taking pictures of buildings that might be famous - since Harmony's photography strategy is "take a picture now and then look up what it actually is later before I post it on Facebook".All that to say that I arrived safely in Europe. I'll be sure to post more photos when I get home. (since reading about sightseeing is even more boring than looking at a million pictures of the Eiffel tower) However I will keep you posted on any exciting train adventures or funny quotes by Harmony.

I'll leave you with an example:
Scene- at the Louvre
Beth: Didn't you have to take Art 101 in college?
Harmony (aghast): No! Of course not! Everything I know about art I learned from the Da Vinci Code.

Wrapping up

So, today is my last full day in Kenya. I can pretty easily say that I'm not ready to leave. While it's been challenging at times it's overall been a fantastic experience.

I haven't been that great lately about keeping my blog updated, part of that is related to the intermittent internet and part to sheer busy-ness. I've been spending the last 3 weeks rounding on the pediatric side, and found it difficult to blog about for several reasons. It's harder for me to see children with chronic diseases (rheumatic heart disease, malnutrition, etc) and know how disparate the care is between here and the US.

There were certainly kids who came in sick with acute illnesses (pneumonia, gastroenteritis, dehydration) who we were able to manage and send home after just a day or two. However, they aren't the ones who will haunt me when I go home.

One of the Kenyan pulmonary fellows commented today about the chronically ill patients (after rounding today on a 27 year old with HIV, dilated cardiomyopathy and presented with a STEMI) - "Patients like this, you know you see them in clinic over and over, and then when you don't see them anymore and you wonder, but you are afraid to ask. You know what happened, but you just don't want to ask."

However for this patient, a young mother, being able to receive ICU level care, anticoagulants and inotropes, may buy her at least a few more months than she would have otherwise. It's easy to get so overwhelmed that you lose sight of the person right in front of you that you can help, and the diffrence that it makes to them.

So this one time in Uganda...

Back By Popular Demand Following Technical Difficulties!

So, when I told everyone I'd have regular internet here, I may have been lying. THe internet has been pretty sporadic, so I have used that as an excuse to ignore the blog.
So - a quick update!
Last week I started out on the peds wards, switching from adult medicine. There is a lot I could say about that - initially was a very tough transition, mostly due to some very sick kids (by Kenyan OR US standards). However, things have settled down a little this week, fortunately.
Last Friday I also had the opportunity to travel to the AMPATH clinic in Turbo, a nearby village with Dr. Mamlin. I sat in with the clinical officer seeing patients, and it was a good experience seeing how AMPATH is transitioning from providing HIV care to providing primary care for thousands of patients here in Western Kenya. There are still a lot of challenges, but I'm optimistic that it's actually working! As anyone who has been here before knows, it's hard to spend any amount of time with Dr. Mamlin and not be inspired.

While at Turbo I was able to sit in on an initial visit, which was an interesting experience. A young man and his wife came to the clinic after he tested positive for HIV the previous day while being treated for malaria. Once he tested positive, his wife was also tested and her test was negative. You could feel their anxiety in the room. The husband's only question after the history and physical was "So, I am now positive for the virus, pbut my wife is negative. What do we do now to keep her and our children safe?" The young man was enrolled in the AMPATH program and had an initial laboratory evalutation, and we gave him medicine for oral thrush. Sagita, the clinical officier, counselled this man and his wife on safe sex practices and discussed what it means to be a discordant couple. He will come back in a couple of weeks for follow up to see what his CD4 count is and to determine if he needs antiretroviral medications. However, by the end of the visit, though obviously still reeling from this diagnosis, they seemed to leave with a sense of hope.

Sagita, the C.O and Lillian, a mental health practioner

Rose, the cook in her kitchen

One of the clinic workers demonstrating how to eat ugali

At Turbo I was also graded on my ugali-eating skills. Ugali is the local staple - made of boiled corn flour. I've described it before as having the texture of polenta but the consistency of playdoh. Regardless, I think it's delicious! This ugali, cooked by a woman named Rose was some of the best I'd ever had! I was given a ridiculously large hunk of ugali, along with some kale and meat, and managed to eat all of it, and so scored an "A." I was pretty proud of myself for that.

After Turbo we spent the weekend in beautiful Lake Bogoria, in a tent that could only be described as "princess camping" The tent itself had an attached bathroom (score of 10/10) and beds, as well as a balcony from which you could watch the sunset. It was a nice weekend of relaxing, birdwatching and hippo spotting.

Princess camping tent, complete with bed and freestanding wardrobe!

Sorry for the long delay - hopefully the next post will be sooner!

Kenyan Bathroom Rating Scale

As you will quickly learn in Africa, there is a broad spectrum of bathroom experiences, and no blog is complete without a picture of a typical "choo." To simplify things, I am working on a numerical scoring system for rating bathrooms.



Toilet (as opposed to hole in the ground) = 2 points
Toilet seat = 2 points
Toilet paper = 2 points
Running water = 2 points
Soap = 2 points

The choo pictured above received a score of 4 points. (Toilet paper + running water)

I had an interesting morning today - we went to an outreach for street children. Many of you know that Eldoret has a large population of street children. There are several organizations that work with these kids, notably one called Tumaini Center, which is a drop in center for the kids. There are a lot of reasons why kids end up on the street - some are orphans, others live with relatives and enjoy the freedom of the streets day to day, others are homeless and have no one.
The outreach today was a soccer game for the older boys, and several of us played ultimate frisbee with the younger kids - probably 7-13 yearolds for the most part. The kids were all very friendly and seemed to enjoy the game, once they figured out the rules. One thing that really bothered me was the amount of substance abuse among these kids - glue sniffing is rampant. Almost all of the kids had bottles of glue, and many of them were playing ultimate with while holding the bottles in their mouths. Many of the kids were bright and engaging; the glue sniffing just seems like such a waste!
It was nice though to meet the kids on their own terms and to see them having a chance to play and be kids After the games we passed out bread and milk. Afterward we saw a few of the kids on the street in town; they seemed happy to see us. I hope I get to go back again, just to hang out with the kids. No pictures of this event - both out of fear my camera would be stolen and not wanting to come off as that mzungu who just wants pictures of the kids for my own purposes- maybe another time.

Overdue pictures of animals! And Mountains!

Well, I had meant to post this over a week ago, but our internet has been very spotty this last week. Also, I like posting pictures and it always feels a little awkward to take pictures of patients on the wards. Last weekend we took a trip to Hell's Gate, Lake Naivasha, and Mount Longonot National Park. I have to say, it was probably the most fun trip I've been on in my three trips to Kenya.

It was about a 4 hour drive to the parks, and we started on Saturday with Hell's Gate. There aren't any carnivores in the park, so you can hike and even rent mountain bikes to bike around the park. The bikes were all probably 15+ years old with varying braking and shifting capacities - mine was nice and had TWO working gears. :) As you bike along the dirt road you can see ostrich, zebra, warthogs, giraffe, and assorted gazelle-like animals, and eventually reached the gorge.


With our driver and tour guide-extraordinare, Javann, we hiked down into the gorge.
The gorge is probably at least a mile in length, with high walls carved by the river at the bottom (just a stream while we were there) After hiking through the gorge and then back to the top, we were ready for the bike back to the gate. However, due to poor planning on the part of the Kenya Wildlife Service, the bike back to the gate was entirely uphill. :)

The next morning we woke up early to go to Lake Naivasha, where parts of the film Out of Africa were shot. We took a boat tour to see hippos and birds and were able to take a walking tour of Crescent Island, where giraffe and wildebeast and zebra and assorted gazelle roam freely.

After our boat tour we headed over to Mount Longonot national park, an extinct volcano, standing about 9,000 feet high. You climb up the mountain to the rim of the crater, and then hike around the rim. It was a long hike, but definitely worth the sunburn (and subsequent two days of residual soreness) once we got to the top!

Things I Have Learned in Kenya

Disclaimer - If you are squeamish or expecting pictures of animals, you might just want to stop now.

Lesson #1: With a certain amount of desperation, determination and an 18 G Branula you can access almost any bodily fluid.

In the past 2 or so weeks on the wards, I've had the opportunitiy to do/supervise a LOT of procedures. Meningitis is common here, and the diagnostic test of choice is a lumbar puncture. Likewise, I've had the opportunity to do several paracenteses and thoracenteses as well. Today, we did all three. In the US, we have separate kits and needles and whatnot for every procedure. Here in Kenya, we have the trusty "branula," or IV catheter. It's a flexible plastic catheter over a fairly large bore IV needle, about 2 inches long. We use it for essentially every procedure we do on the wards.

Desperation: Today we had a patient with a massive pleural effusion (accumulation of fluid in the cheltst cavity) who was having significant respiratory distress despite oxygen. It was clear that she needed to have the fluid removed, however, her platelet count was only 19,000. (Normally I would want them to be greater than 50,000) In the US, this wouldn't be so problematic, simply transfuse some platelets and do the procedure. Here, however, there were no platelets to be transfused(due to some of the difficulty with the blood supply that I've mentioned previously) So here was the choice - do the procedure with the low platelets (and increased risk of bleeding) or not do the procedure, knowing that the patient would probably not survive the weekend due to her respiratory comprimise.

If you know me very well you can probably guess what happened next.

Determination: After inserting the ubiquitous branula, our choices for draining the fluid were still rather limited - the fancy three-way valves we use in the US just aren't so easy to get here, and there is no such thing as wall suction. However, with a 20 mL syringe, it's pretty impressive how quickly you can remove 800 mL of fluid. I'll probably have a blister on my thumb tomorrow...

18 Gauge Branula: The green guy pictured below. After pulling off the fluid by hand, we taped the branula to the skin and attached it to a Foley bag to let more fluid drain by gravity. It will be interesting to see if it's still there on Monday!

Lesson #2: Calling the ENT clinic at 4pm on a Friday and demanding that they see a patient goes over just as well here as in the US.

We had an elderly lady admitted overnight with nosebleeds, and had nasal packing twice on the ward. Late this afternoon, she started bleeding again, and we had quite a time getting it to stop, and by the time we got it to slow down there was a decent puddle of blood by the bed. I eventually got ahold of the ENT consultant (attending) who told me that the patient should be brought to clnic. I then called the clinic to tell them she was coming, and they informed me they were getting ready to close and wanted her there...NOW. Since we had trouble rounding up anyone to take her, I grabbed a wheelchair and pushed her there myself. Judging by the looks I got, we must have been quite a sight - a Mzungu doctor pusing an old lady in a wheelchair who every few minutes would spit out a mouthful of blood. (hey, I WARNED you, squeamish person!) I kept having to ask for directions, but eventually we made it there, and they packed her nose nicely. However, when we got back to the ward, her family was in a panic, as she was not in her bed and there was a puddle of blood on the floor when they arrived! I tried to nicely explain to them that we had taken her to another part of the hospital to have the problem fixed, and I think they were just relieved to see her.

Finding My Footing

This week has been up and down so far on the wards. Towards the middle of last week, it seemed that a few of our sicker patients were getting a little better (whether because of or despite our interventions, I'm not sure.) However, over the next few days they all seemed to get worse again, though one did go to the ICU over the weekend.

Monday started off particularly rough...as I walked in to meet up with my Kenyan resident and intern they were seeing an elderly patient who looked absolutely terrible, in respiratory distress and non-responsive. I'm not sure if it was due to her initial illness or management overnight, but as we started to get together basic equipment like oxygen, blood pressure cuff, etc, she stopped breathing and lost pulses. So far I've deferred starting CPR/coding patients to my Kenyan counterparts...given that we don't have cardiac monitors, defibrillators, OR the ICU capability to manage them even if the resuscitation is successful. It quickly became apparent that this attempt was not going to be successful. No matter where you are losing a patient is never a good way to start the day.

Today when we got to the last room we had not one but TWO patients that were in significant respiratory distress. It was an interesting dichotomy - one is a young (30ish) patient with HIV and probably an opportunistic lung infection called PCP who was just admitted on Sunday. The other is an older woman with HIV and meningitis which we have been treating for over a week with no real improvement. I felt that for the young woman we have a chance of getting her through this, but for the older woman we don't have much left that we can do for her, and it takes so much labor to get anything accomplished.
Though it's hard, I tried today to focus more of my energy on helping her...making sure she was on the right medicines, and getting blood for a transfusion. We did get the blood in a matter of hours (which is AMAZINGLY FAST) and hopefully she will make it through the night, as I doubt our other patient will.
At home, I always tell students that the most valuable skill to learn is how to figure out a hospital system and how to get patient care accomplished. Now is the time to put my money where my mouth is - since we have so many sick patients I am getting a little better feeling for how to get things accomplished here...how to call consults, get lab results, etc. Much like the hospital at home, you can dial the operator and figure out how to get ahold of who you need to talk to. If the operator can understand your American accent.
And yes, some of our patients are getting better and being discharged! It's just not as therapeutic to write about.
Now, because I can't figure out captions - the pictures are 1.) The grounds of the hospital, with the large white AMPATH building in the center, our wards are off to the left behind the tent. 2.) The entrance to the medicine wards - Umoja (unity) ward is the men's ward and Amani (peace) is the women's ward. 3.) Rounds, with my intern Shamsa and resident Kaguri in the center. The rest is a gaggle of students and nurses, only half of whom you can see in this picture! 4.) Our pharmacy intern Marion with the treatment sheets (medication order sheets) She is a lifesaver on rounds and helps make sure all the orders are written as we are talking about them.
Just for the record, it's not nearly as dark on the wards as the blue paint makes it look.

Thanks for tuning in...more pictures of fun animals and weekend adventures in the next day or so!