Sunday, May 29, 2011

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)

Saturday, May 28, 2011

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.

Tuesday, May 24, 2011

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!

Friday, May 20, 2011

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.

Tuesday, May 17, 2011

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 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 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!

Wednesday, May 11, 2011

Out of Stock

One of the daily tasks here is figuring out what medicines are actually available on the wards. If we order a particular medicine and it's not available, the patient doesn't get it and typically we don't find out until the next day when we see what's been checked off on the order sheet.

We currently have a patient who has cryptococcal meningitis, an opportunistic fungal infection seen in HIV patients, and is being treated with amphotericin B, a drug that causes low potassium levels. The common practice here is to empirically give supplemental potassium and check renal function and electrolytes a couple of times a week. Along with a shortage of drugs like heparin, ceftriaxone, chloramphenicol, and paracetamol (tylenol) we are currently out of potassium.

The solution?

Tuesday, May 10, 2011

IU House, Wards, and Yoga

I'm trying hard to resist the temptation to rant about the wards today. So instead I'll try to tell you a little more about IU House and life here. IU "House" is really more of a small subdivision or compound about a ten minute walk from the main hospital.

When you drive up to the main gate, you meet Michael, one of the friendliest people I've ever met. He's nicknamed me "Queen of England" after learning my name was Elizabeth. Every day he greets us by name, though sometimes he mixes us up...after all, all Mzungus look alike, I'm told.

Once you enter the main gate into our "subdivision" you arrive at the IU House gate, into the main IU House complex. At the IU gate there are also guards, but their presence seems
mostly a deterrent.

IU House itself is made up of a series of houses. Mackenzie and I stay upstairs in House 1. Downstairs there is a library - filled with medical references and other reading material, where we have our weekly "fireside chats" or group discussions about various topics. This past week the topic was on Kenyan attitudes toward death and dying and I think this week the topic will be on research ethics in resource-limited settings. The library is also where Wycliffe, the Kiswahili tutor usually can be found given lessons.

House 2 is the "Food House" with a large kitchen and a common dining area. Food is served buffet style and is really quite good. Today we had a Kenyan food for lunch, but the menu rotates on a weekly basis. Usually we walk back to IU House from the hospital for lunch in the afternoon, and then return to the hospital to finish up the day's work in the afternoon.

Between House 2 and House 3 is a small "banda" or gazebo, which provides some outdoor seating and is new since my last visit. House 3 contains the IU House office, where the business of maintaining the compound happens on a day-to-day basis, and House 4 has a common computer room and a laundry.

All of the houses have guest rooms upstairs, with shared bathrooms. A few rooms have private bathrooms. I share with Mackenzie, one of the other medicine residents, and we have a fairly large room with two beds (with mosquito netting!) Compared to the student hostel, where I stayed on my previous two trips, it's enormous.

I'll say a little about wards today since I'm including some pictures - our registrar apparently had clinic, so he wasn't around for rounds, so it was the intern and I, as well as our two clinical officer interns (clinical officers are somewhat similar to physician assistants in the US) and some medical students. We had quite a few new patients so it took a while to get through rounds, with the usual hangups of medicines being out of stock and results taking forever, but I did at least feel like I had more of a handle on who patients are and what the major issues are. I think the medical students are starting to warm up to me, or at least are less afraid of me and starting to ask questions.

After work today I came back to IU House and found out that apparently Tuesday here is Yoga Day - Karin, who is an economist working here for a few months is leading yoga classes outside in the "banda" It was certainly a nice way to decompress from the wards and to get a little exercise in before dinner. There are a lot of young active people here, so evening activities include yoga, dodgeball, basketball, soccer, and there are rumors of ultimate frisbee starting up soon.

Monday, May 9, 2011

Monday, Monday

Well, back to the wards this morning. In a way it felt a bit like starting over after having the whole weekend off. Three of the sickest patients were gone, having died over the weekend. One was a young woman with leukemia, another with presumed PCP (an opportunistic infection frequently seen with HIV, another who was likely septic from an unknown source.
There were more patients from over the weekend to fill the beds, however. Today we rounded with our consultant - "major ward rounds" with a consultant (attending) only happen on Monday and Thursday. Dr Kamano, our consultant, is thoughtful and likes to teach, and seems more invested in the outcomes than other consultants I've worked with. The role is different here - many consultants see themselves as a teacher, and don't really see themselves as having ultimate responsibility for the patients.
Much of that responsibility falls to the registrars and especially the interns. When Dr Kamano is not around our registrar functions as team leader, running rounds and determining the plan for the day. Our intern, Shamsh, takes care of everything else - ordering labs, notes, procedures, paperwork. I'm still trying to figure out my role - I don't want to add any more to her workload. I was advised to try to follow a few patients and see what I can do to facilitate getting things done, especially on days when our team is admitting new patients, like today.
Today after rounds we had a bone marrow aspirate (done by Shamsha) and another lumbar puncture (who needs a spinal needle when you have a long IV catheter?). I noticed while we were finishing up the procedures that they were wheeling in a particularly sick looking patient onto the ward from Casualty (emergency), and she died almost immediately after being moved into her ward bed - before any of us even had a chance to see her.
The next few admissions went a little more smoothly. I admitted a young woman with anemia - a hemoglobin of 1.8 - the lowest I've ever seen. (normal is around 12) She was actually being transfused as i left, but no other labs will be back until tomorrow. I'm so used to getting labs back almost instantly that it's very odd just leaving a patient like that - but there's really nothing I can do to hurry the process along. She's fortunate to get blood so quickly - there's been a critical blood shortage and patients have been waiting days to be transfused.
Well. I feel like today's post has been more depressing sounding than today actually was. There are patients who are getting better and actually going home. They just don't make quite the impression the others do.
Tomorrow is another day on the wards - hopefully one with more answers than questions!

Sunday, May 8, 2011

Lake Nakuru

With pictures as promised! This weekend we went to Lake Nakuru, a national park about 2 1/2 hours away. The trip was fantastic. My roomate Mackenzie (another IU resident) and I, along with two IU medical students and two peds residents from Brown all piled into a safari van early Saturday morning. These safari vans have roofs that pop up, so you can stand up and look out. Once we arrived we drove around the park for a few hours, exploring the lake and seeing lots of birds, zebra, rhinos, and buffalo.

We then made our way to the "lodge" and checked into our room and ate at the ridiculous buffet. The lodge, clearly catering to Westerners, was one of the nicest places I've ever stayed...our balcony looked out on the park, and you could seen baboons and buffalo from the balcony. (Fortunately there was a fence between them and us) We relaxed for a few hours and the afternoon we went out on another game drive.

The evening game drive was probably the highlight of the trip for me - at one point our driver, Steve, took off in hot pursuit of several other vans all converging in one spot - up in a tree not far from the road someone had spotted a leopard! Of the "Big Five" (also including lion, elephant, hippo, and buffalo) the leopard was the only one I'd never seen before! (Yes, there is a leopard in this picture. Now you see why they are hard to find.)

We stopped at Baboon Cliff overlook and learned from watching some other tourists why one should not feed the baboons. One old baboon climbed up on the car and wouldn't leave because he'd spotted food inside. Finally one of the men was able to sneak into the car and drive down the hill, leaving the others to walk down and meet him later.

Apparently early in rainy season is also baby season for many of the animals. We saw countless baby baboons, zebra, and buffalo, as well as a few teenager rhino.

This morning we set out on another game drive, and about an hour before we had to leave the park, Steve zoomed off again after speaking with another drive, eventually finding two lions! One lion was sleeping next to a kill (warthog perhaps?) and a few hundred yards away was a pack of hyenas, waiting for the lions to leave. Our van pulled up to within probably 10-15 feet of the nearest lion, allowing us a close look and some great pictures. The lion seemed to be much more interested in napping than in the crowd of safari vans.

On the way out of the park we finished with a quick stop by the lake with more pelicans and flamingo (and other birds that stand around in the water) There were hundreds, if not thousands of pelicans flocking in the sky over the lake, and it was one of the most beautiful things I've ever seen. The pictures don't even come close to capturing it.

Driving home, we crossed back over the equator, and stopped for a few obigitory pictures. This afternoon we arrived safely back in Eldoret and played some soccer and went for a quick walk before dinner. I'll try soon to post some pictures of IU House and around Eldoret so you can get a better idea of what things are like on a day-to-day basis.

Thursday, May 5, 2011

First Day

Well, I've safely arrived in Eldoret. After four flights and 36-odd uneventful hours of travel, I arrived at IU house as a total zombie yesterday. After a tour, a nap, dinner, and a good night's sleep I felt significantly more human today. Good thing, since we started on the wards bright and early.

As a resident, one experiences a lot of "first days." Every month brings a new rotation, and it's essentially starting a new job every month: new patients, new attendings, new co-workers, new expectations. In some ways it's refreshing - if things get bad, hey, it's only a month, right?
Sometime around the beginning of this year (my third of residency) the "night before" jitters started to get a little better. I'd finally figured out how to figure things out at all of the hospitals where I work, or at least who to ask. Here, not so much.

The day started with morning report, today's topic was put on by the IU OB/Gyn residents. Following that I started rounding with the medicine team. The medicine wards are divided into a men's ward and a women's ward, and each has two team. I joined a team that was already well into rounds on the women's side (per Laura, one of the team leaders, it's the "less smelly"), and caught the last few patients. "Major Ward Rounds," ie, rounds with a consultant (attending) take place twice a week. Our patients were varied - a 50some woman with HIV and respiratory distress, but we couldn't narrow it down any further since the chest xray machine wasn't working, a teenager with low blood counts for unclear reasons, who will probably get a bone marrow aspirate in the next few days, several with altered mental status. Following rounds, the consultant quickly departed, and the registrar also had to leave, which left the post-call intern, Shamsa, with all the work, and the resident assuring her that I would be able to help. (Just to be clear - I'm not much help)

I quickly realized that some parts being an intern in Kenya aren't so different after all. From scraps of paper with lists and check-boxes to a seemingly endless series of phone calls, internship is always about being the one to do the work no one else wants to do. However, when the psychiatry consultant showed up he expected Shamsha to write all of his notes as he dictated them. In addition to that, she had to stay until 5pm post call and continue admitting patients.

Not too long after rounds, we responded to my first Kenyan "resuscitation." A patient who had been on the wards for about a week, HIV positive, confused and spiking fevers despite treatment for meningitis, had continued to decline. The family had donated blood on Sunday, but it wasn't able to be processed until today, and she looked quite bad on rounds. She had just started getting the blood when one of the nurses noted that she was longer breathing and had no pulse. Shamsha responded, started doing CPR while I bagged the patient, and one round of adrenaline and hydrocortisone was given without any response, and Shamsha pronounced the patient dead. The resuscitation was obviously less than would be done at a code in the States, but also more than I expected than could be done here.

Following that, there was still much work to be done - a periotoneal (abdominal fluid) tap, several lumbar punctures, and several new admissions to see, and deciding which of the two available antibiotics to start them on. I was happy that I could remember enough Kiswahili to understand most of the patient interviews, though my vocab is lacking that I can't quite carry one out myself.

Tomorrow should be interesting - to see what parts of our plans actually happened, and what other new patients come in overnight. I'll try to keep you updated tomorrow, especially now that I've completely broken my promise not to use to much medicine jargon. I think we are going on a brief sarfari to Lake Nakuru this weekend, so I will make up for it by posting pictures of rhinos and hippos and flamingos for the rest of you.

Monday, May 2, 2011

At the airport.

I've had a number of friends ask if I would be posting a blog during this trip, and at least here in the airport with free Wi-fi it seems like a great idea. I'll try to keep it updated and post pics when I can. I'll try to keep the mediciney jargon to a minimum but no promises!

So, I will admit to being a chronic overpacker. This usually is a consequence of putting off packing to the last minute and trying to stuff everything I could possibly imagine needing into the biggest suitcase I can find. This time though I have resolved to travel light! I'm the proud new owner of a Terra 35 backpack. I'm gong to carry it on and that's all I'm taking. It certainly helps that I've been to Eldoret before and know I can pick up just about anything I really need there. And it seemed like a catchy blog name.

For those of you just tuning in, Hi! I'm going to Kenya! This will actually be my fourth trip to East Africa and my third trip to the same location Kenya. I'll be living and working in Eldoret, a city in Western Kenya. Indiana University has a longstanding partnership with Moi University Teaching and Referral Hospital, and I'll be working alongside Kenyan residents on the wards there. Though it's my third trip there I'm trying not to take too many expectations about what it will be like, as this will be my first trip since I've graduated from medical school.

stay tuned for more...I'll do my best to keep in touch!

PS - this blog represents my own personal reflections and opinions and is not affiliated with or sponsored by Indiana University, Moi University, or any other institution or organization.