Monkeys!

I’m starting to contemplate stealing the IV stand in the hospital and setting up a coffee drip so that I can get more things done in the short 24 hours I’m given every day. It’s both refreshing and terrifying how much I have on my plate- J-term, MGH work, GAMSAT prep, staying sane… I’ve been alternating between states of efficient confidence and hysteria/ depression. My deep seated desire to plan, plan, plan for the future isn’t really compatible with, well, not being a psychic. I’m terrified of not getting into med school, and it’s a daily battle to take the high road and use that fear as fuel for studying instead of sinking into an irreversible state of panic. It may sound a bit melodramatic but I’ve got a lot riding on getting in.

That being said, it was a welcome change to go to Kenya’s last rainforest, Kakamega, this past weekend with the J-term students. A short 2 hours away, Kakamega is a haven for hundreds of fern and orchid species, 9 species of primates (HUZZAH!), and dozens of birds. We went on a 4 hour hike through the forest and then climbed to the highest point in the park (~ 3000ft) for a brilliant view of the park and Kakamega town. On our way down the hill we ventured into an abandoned coal mine (it was safe, mom) and saw two species of bats. It was hilarious to see the division in the group between those who like bats and those who reacted as I would have if they had been flying spiders. One of the girls threw her headlamp off with a piercing scream because she thought she had a ‘cave cricket’ on it- and ironically woke all of the bats up- and left us in pitch blackness for a minute. I couldn’t help but laugh! I’m possibly the worst counselor ever. 

The highlight for me however, was seeing all of the primates. We saw red tailed monkeys, blue monkeys, and some black-and-white colobus. If I was allowed I would have stayed all day to watch them run and swing around in the canopy. I almost died of happiness when I saw some blue monkey juveniles exhibit altruistic behavior (distracting predators- a.k.a. us) while the others were climbing down to the watering hole for a drink. A fabulous sight! We learned all about the plant species endemic to the area that are the primary food source for the black-and-white colobus. I couldn’t help but think about the pair I saw last month at the Wild Animal Park with my mom and grandma and wonder if they were being fed their natural food source and if they were distressed at being so far away from home. 

We all had a really fun day away from our projects and stresses back in Sagam, and I am definitely taking my parents there when they come over in July. The work week started back  up the following day with meetings, Skype calls, conferences, and more interesting cases at the hospital. We were even treated to 3 days without running water to make us all feel nice and refreshed. Such a treat! We all had a “day off” today at the house as a precautionary measure for the Primary’s in case anything went poorly in the community. Everything has been pretty calm here, and we even played frisbee with some of the local children in the afternoon. Sagam seems like an eternally peaceful place. 

This weekend our J-term team is getting back together and going on safari in Nakuru. They have rhinos (versus the Masai Mara that doesn’t) and we will be staying at a really nice resort on a student rate! It should be another wonderful break from work (though I will be studying organic chem in the safari vehicle) and I will keep my fingers crossed that we see some more primates. 

Photos to follow soon.

Carelessness and Comas

Today was another rough day. I feel like I’ve started far too many blog posts with that phrase, but such is life in a third world hospital. Before I continue I want to give a HUGE shout out to Mairead and Jeff, the starts of today, for their phenomenal dedication and saint-like patience.

The J-term students and I started rounds at 9am this morning in good cheer after meeting and greeting most of the staff at SCH, but the mood turned more serious with the first patient- a 9 year old boy presenting with severe malaria (defined by loss of cognitive function). The boy was admitted Saturday night with the same presenting problems and a history of four days’ headache, inability to eat independently, and fever. The doctors sussed out pretty quickly that it wasn’t cryptoccocal meningitis or bacterial meningitis, but the boy was still in a poor state. Unfortunately, the boy got a rash from taking quinine so, as a second line, the doctors ordered an artemether injection to be given at some point during the night. It wasn’t given because the pharmacy closes at 5pm, and no one could reach a pharm tech to come in to get the medicine. So, instead of calling a doctor or the hospital director to get the keys to the pharmacy, the boy just went without. I can’t decided if it’s carelessness or…I don’t even know. The boy could have died over night and they did literally the least they could for him. Throughout the day we ended up seeing another severe malaria pediatric case, a broken patella, the baby girl from the previous post (breastfeeding now, but running a 39C fever with a pulse of 202), and an HIV+ woman with diabetes.

The most interesting and tragic case of the day however, was an 18 year old male that had attempted suicide by drinking something that we suspect was similar to paint thinner or pesticides. He had slipped into a coma and rated a 3 on the Glasgow Coma Scale (GCS scale goes from 15- you and me- to 3- fully in a coma and unresponsive). His pupils were dilated, his breathing labored, and his chance of survival very small. He had a nasal cannula to assist with breathing, which seemed to be helping, until the power went out. We were still on rounds when Mairead rushed in asking for help because he was decompensating due to the lack of oxygen. We had to rush him down towards Radiology, plug his machines into the generator, and try to insert a oral airway in the hallway of Outpatient (in the dark and in the rain too). Unfortunately, he had too much fluid in his lungs and wasn’t making progress with or without the O2 concentrator, so we reluctantly wheeled him back to the ward and called his family. The J-term students stood by and watched the whole thing enfold (Natalie even stepped up and helped Mairead with some things). I really hope this isn’t scaring them away from medicine, especially since in their two days here they have almost seen a baby girl and a teenage suicide attempt die. Thankfully the baby girl is improving (slightly), but I’m not positive about the coma patient. We may lay off rounding for a while.  The family finally came to be with the boy, and we left the hospital because there was little else to do but wait. I’m praying for improvement.

 

Back in Sagam

Whew! I’m finally back in Kenya! The flights weren’t a positive experience, but being back in this beautiful country makes it hard to dwell on anything negative. Kenya greeted me with cool weather (~ 75 F), red soil, blue skies, and green earth and I couldn’t help but feel a sigh of relief at being home. I missed it here.

However, I had a wonderful time at home in Carlsbad with my family and friends for three  weeks. Dad had one of his knees replaced (the next to follow Jan 28th) and it was nice to be home with him to help out, tease him a bit (as every good, loving daughter does), and catch up. It was rather fun, what with his missing tooth, hobble, and “Arrgg”-ish grunting, he looked rather like a pirate.  Mom, dad, grandma and I spent our small but cheerful Christmas together, feasted on lots of goodies, and celebrated grandma’s birthday with some festive cupcakes. I love Christmas at home. It was also a memorable trip home because I got to reunite with some of my high school friends that I hadn’t seen in 1 1/2+ years. For a short while at least, it felt like the old “group” had gotten back together. Everyone is a riot, and had lots of stories so I had my fair share of laughter on my trip. But after all of the Christmas celebration, a rather lackluster NYE, and more shopping than I had a right to do, it was time to come back to Kenya. Hopefully my parents will make a trip out here in July, but I most likely won’t be back in the States until August.

So now I’m here, and busier than ever! We are hosting 8 Harvard undergrad J-term students here in western: 4 in Kisumu with Genna (usually based in the MGH office in Boston), and 4 in Sagam with me and the team. They will be here for three short weeks, and will mostly be working on a child malnutrition assessment project. They are all members of IECM (Initiative to End Child Malnutrition) and will be replicating/ developing the program MGH already has with IECM in Nyakibale, Uganda. I am keeping my fingers crossed that MGH decides to implement the malnutrition program here in Sagam because the children here are in dire need of some help. Our students, all bright-eyed and bushy tailed, are fabulous so far and I am really looking forward to working with them. It will be a learning experience though, since I’m not used to being “den mother” or a camp counselor. Fingers crossed again there aren’t any shenanigans (though we live in a rural village, so I’m not sure what they could actually do…).

The students had a rather shocking welcome to Sagam last night. After their boat ride on Lake Victoria to see the hippos, we had a lovely lunch by the water, relaxed, did some grocery shopping, and said our goodbyes to the Kisumu team. About 20 minutes into our drive up Jeff got a call that there was a newborn that wasn’t breathing spontaneously, and was in a critical condition. The students listened with rapt attention as it was explained to Jeff that the family couldn’t be transferred to a larger government hospital with a Newborn Unit, because all the nurses and most doctors were on strike. The family couldn’t afford to go to Aga Khan either, a larger private hospital in Kisumu which meant we were their best option. Scary.  By the time we got to the hospital the baby was breathing on its own, but the doctors feared it was septic. Apparently the mother’s water broke 2 days ago, was sent home by someone here at SCH (they will have A LOT of explaining to do), and the baby became septic due the exposure to bacteria in the vagina. All of the students wanted to go see what was going on, so we all got out and went in to the ward. I think we were there for 2 hours. That whole time Jeff, Mairead, and Yousef (nurse) were unsuccessful at getting in an IV line for antibiotics. They even tried cutting the umbilical and getting a line in that way. No success. I think it was a bit too much for two of the girls to handle because they had to leave the room and sit down. I mean, there was a lot of stress, blood, crying, darkness, and frustration in that room. I ended taking them home because they were visibly distressed and not dealing with it well. It was shocking to me how complacent I have become to this third-world, haphazard medical system because not long ago I was in the same boat they are.  Eventually the rest of the group came home, after FINALLY getting an IO into the girl’s left femur. We all gladly had some drinks, and went to bed.

I just got an update that the baby is doing better this morning, though she still needs more antibiotics and lots of monitoring. I hope she is OK.

It’s a wild world out here, and I hope the students learn a lot from being here. As for me, there are still lots of other projects going on like: the ToT (training of trainers) for the UBT roll out, building the ER at SCH, revamping the pediatric ward, finalizing a curriculum for the post-graduate residency program with Maseno University, installing our methane biofuel system at the house, balancing our budget, and last but not least, studying for the GAMSAT in March! Wow! My room is covered in sticky notes, and my planner is so color-coded it’s giving me a headache! It should be an exciting couple of months.

 

Busy

Everything is starting to pick up here in western Kenya. There are plans for: an insurance fair, a bio-fuel construction project at the house, the construction of a new ER for the hospital, and the development of a residency curriculum for Maseno University, on the drawing board right now. So I’m busy, busy, busy! Not more than six hours ago I was on the phone with the Kenyan Minister of Health (MOH) setting up a meeting in Nairobi! It’s all a bit surreal really.
My next week will have a lot of traveling to and from Kisumu and a trip to Nairobi on Thursday. The Nairobi meetings are actually really exciting because the MOH has decided to go with a national roll out of the UBT (uterine balloon training program)!!!! This is such an amazing event for both the women of Kenya and for MGH. For those of you who managed to escape my passionate rants about the uterine balloon, it is a device that assists in stopping postpartum hemorrhaging. In the western world it is around 300USD, which is unaffordable in the developing world. Dr. Thomas Burke and a team of very ingenious people devised a much cheaper uterine balloon consisting of a condom, foley catheter, syringe, and some string that only costs around 3USD! The idea is that you tie the condom around the end of the foley catheter with the string and fill the condom with sterile water via the syringe and the pressure of the water will hold back the walls of the uterus and thus prevent/halt further bleeding. Most of the research is anecdotal right now but it seems that 11/12 women have stopped hemorrhaging within 12 hours and survived. This is especially important in places like South Sudan (where the project was first put into place) where the highest cause behind maternal mortality is postpartum hemorrhaging. There is a training program by MGH through the MNCS Initiative and KMET that teaches midwives, nurses, clinical officers, and other health professionals how and when to use the uterine balloon. The device comes in a pack with one of each of the aforementioned components as well as a visual diagram of how to use it. They even used the uterine balloon at Sagam Community Hospital once and the woman stopped bleeding within 3 hours! Amazing!
So yes, this meeting is going to be really exciting! Not only does this allow an economical way for hospitals and community health workers to address the issue of postpartum hemorrhaging, but the larger sample size of the UBT roll out will allow MGH to collect more data and possibly expand the project to other countries. I am also going to start working with KMET on data collection at UBT sites around Kisumu. Talk about an amazing addition to my CV!
In my free time I learned to drive stick shift on the Pajero! It took about 2 days to get really comfortable with driving the SUV but I think I have the hang of it. The Pajero constantly breaks down or has some strange malfunction so it keeps the process exciting (if a little terrifying). It is so nice to finally know how to drive a manual, and on the opposite side of the road!
I know it’s a bit after the fact but yay Obama! It was absolute insanity here with people celebrating and congratulating us on our President’s success. Ward rounds completely stopped as we all huddled around the hospital’s TV watching the acceptance speech in rapt silence. I even heard that some businesses in Nairobi closed down for the day so people could celebrate! It was definitely a life experience that I’ll never forget.

 

Life

I know it has almost been a month and for that I am sorry. For those of you who are procrastinators I’m sure you know that the longer you wait to do something the harder it is to get around to doing it- especially if it is writing.  The thought of writing in my blog would pop into my head during some key points over the last month but I always managed to find an excuse to put it off: no internet, too busy, not in the mood to write, etc. But finally, FINALLY I have something to write about. A monumentous catalyst for getting back into blogging. And a perfect follow up post to my last, depressing, entry…..

I helped deliver a baby! Yes! A baby! It was a terrifying but profoundly beautiful event and I can’t imagine I will ever forget it. Let me explain…

Before rounds on Monday Martha, a Clinical Officer (CO) at Sagam Community Hospital came into the nursing station and announced that a woman was in labor in the maternity ward. Paula and Luke suggested that I watch so I ran after her eager and intrigued. I imagined that I would be on the side lines for this one but Martha immediately ordered me to put on gloves, an apron, and get down on the “messy side of things”.  The baby was already crowning by the time I arrived and it took another 20 minutes for it to be born. The whole thing was a startlingly calm process with no maniacal screaming on the part of the mother during contractions…she just pushed and bam! there he was. I helped catch the baby after the last push and placed him on the scale for weighing. Besides a minor vaginal tear everything seemed to go by the books.  While the midwife was suturing up the tear I followed little Ryan out to the ward and sat by him. I feel a bit silly now that I was sitting there singing lullabies to him but I couldn’t pull myself away. And in watching him in his first few moments of life something clicked. I marveled at the complexity in such a small creature, his innocence, and at the life he might have. This little boy, so new! has so much potential. He is being born into a world with many problems, but into an increasingly globalized world with access to education, unprecedented opportunities for women, amazing medical advancements, and more means for personal development than ever before. I told him to always make the most of his opportunities, to question everything, and to keep those that love him close and above all to believe in himself. He will not remember me but I will always remember him.

So in my first month here I have experienced life taken and life given, both in children, and both with profound emotional repercussions. I have learned, concretely, that death is a part of life and that it isn’t always fair. It can happen at unexpected times to unexpected people but inevitably it happens to all of us. But I have also learned that our world goes on. In sadness there is the knowledge that there is a generation of children being born into this world that have the potential to shape their communities, their countries, and their planet into something new, and greater.  Death is not a reason to stop hoping or caring, but a reaffirmation that we should do the most with the time that we are given. Life is a beautiful and grand gift that we have all been given and I hope that you and I, and the little Ryan’s of the world, will make the most of it.

 

 

 

Difficult

Today was a hard day. We did rounds at Siaya District Hospital and I followed Godfrey and Luke into the pediatric ward. As we were sitting in the ward a boy around 4 years old went into respiratory arrest and despite our attempts at helping the boy died. The mother was inconsolable and as she stood over her dead son she wailed and beat her fists on the ground in the purest display of grief I have ever seen. My heart broke today watching that poor woman lose her child. It was the first death I’ve seen and I had no coping mechanism for processing the grief. I spent the rest of the ward rounds on an emotional roller coaster ride: mad at the injustice, ashamed at my inability to help, distraught about the loss, selfish for thinking about me instead of the mother, and shocked at seeing death. It will all just take time to process I guess… I just pray that I never, NEVER have to lose a child.

After rounds we came across a 2 year old boy that was highly anemic, severely dehydrated, and having breathing difficulties. The IV line they had set up for transfusion wasn’t working so Luke tried an IO (intraosseous) infusion which goes through the bone into the marrow. Unfortunately it was incredibly difficult on this boy because of dehydration and they, along with Barry’s eventual help, had to try 6 or 7 times before they got the line in. After some blood they put in simple saline to re-hydrate him. During the attempt of putting in the IO line Luke was sprayed with some fluid from the boy that got in his eye. At that time we didn’t know the boy’s HIV status but Luke had it tested for obvious reasons. I can’t even imagine finding out the boy was HIV+. Thankfully there is a very low risk of infection and there probably wasn’t any blood in the fluid that sprayed him so he’s on some meds that should kick anything out of his system.

It was a very dramatic day indeed and I can’t imagine I will sleep well tonight. 

Learning new things!

Today was a very educational day. I spoke with Nelson Rogo, the director of the hospital (and brother of Khama Rogo, Minister of Health/World Bank) and got some National Protocols straightened out for the RN training. We had a long, lighthearted chat about Obama, the Governator and Islam’s role in western Kenya and Tanzania. Really nice man. But what was most exciting was getting to witness two very interesting procedures. The first was a knee tap for a woman who had torn the meniscus around her knee, leaving it about 1 1/2 times its regular size. I learned how to apply local anesthesia and draw the fluid from her knee. Of course I didn’t do the procedure but it was still very interesting! The CO drew about 25 cc’s of fluid from her knee before it went back to normal size! The second was a vaginal exam for a woman who turned out to have VD  and trichinosis.  I got to see the slightly green tint that tric leaves in the vagina and I learned how to perform an exam looking for PID. I’m sure that isn’t your cup of tea but I found the whole thing very educational and I am appreciative of the experience. It is also interesting to see people being treated for the STIs and conditions that I have long cautioned and taught about.

Tomorrow is another busy day with rounds at another, larger hospital called Siaya District Hospital. Hopefully I will get to network some more and learn new things! It has started raining now and the power is bound to dip out any minute so I’d best be off.

 

So it begins…

(To those of you whom I promised a short entry and frequent posts I apologize. The internet has been out since I arrived and this is the first chance I have had to post. Asanteni!)

Well, I am finally here! It was a long and tedious trip across three continents but after 22 hours of travel I am finally here.  I flew into Nairobi in a jet lagged daze and was greeted by Jeff the driver (versus Jeff the doctor) who was kind enough to carry my bags and deliver me to the Red Court Hotel about 20 minutes from the airport. The hotel was nice enough and I was treated to a lovely breakfast in the morning that included curries, chapatti, “pancakes”, beans, and fresh fruit.  It will be hard getting used to the large portions again, especially after being in southern CA.

I got into Kisumu on Wednesday afternoon in one piece much to my surprise, filled with excitement, nerves, and a reaffirmed hatred of small planes.  Kisumu looks stunning from an aerial view with lots of rolling hills, lush farms and beautiful red soil and it definitely didn’t disappoint once I was in a car driving around. I hadn’t really felt like I was back in Africa when I was in Nairobi even though it was an urban landscape similar to Dar but in driving up to Sagam I finally felt like I was home. It was notably cooler and more lush than Tz and I had a hard time focusing on conversation with Luke because I was staring out the window at the landscape. Luke is a very nice Aussie-American M.D. that picked me up at the airport and drove me back to Sagam. Much to my surprise we stopped at Sagam Community Hospital on the way where I got to sit in on a weekly meeting held by the staff there on TB case studies.  There I met Megan (a pediatrician from Colorado), Paula (and Internal Medicine specialist from New York), and Barry (OB) as well as all of the Kenyan staff. The hospital is on its way to becoming a “center of excellence” as Barry calls it (the Mr. Fix-it M.D. at the house) so that medical students from Maseno University can use it as a learning facility and eventually as a teaching hospital. Everyone at the hospital is very eager to learn and do the best they can do for their community. I am honored to be part of such a momentous and heartfelt project.                                                                                                                                                          I must have looked exhausted because the team whisked me to the Sagam house after the meeting (not that I’m complaining…I was). The road to the house, about ½ mile, is an incredibly bumpy dirt road that makes for a rather roller-coaster-esqe ride and it is lined with traditional mud and clay houses, goats and smiling children. But the house! Oh it’s amazing! There are three houses on the acre property with trees everywhere, chicken scurrying about, song birds in the canopy, and of course a resident vervet monkey. It is my little, tranquil piece of heaven.  There is yoga on the front porch in the morning to the songs of birds, a cozy common area with couches and Japanese lanterns, and a family dining table where we all sit down to dinner. And the running water and electricity don’t hurt the appeal of the place either!

I followed the doctors on rounds the next couple of days and I am convinced that after 10 months here I am going to end up enrolled in med school. I have learned to read the various signs of TB in children, the difference between Nephritic and Nephrotic syndromes, how to read an ultrasound of the lower abdominals, how to feel for an enlarged spleen, read chest X-rays, and how to conduct neurologic tests on a beautiful 6 hour old baby girl! The M.D.’s, especially Barry, have been really helpful about explaining everything they are doing and it helps that they all go on rounds with the Sagam staff so we’re all kind of on the same page. There is however, lots of work to be done at the hospital.  With the exception of Nelson Rogo (who runs the place and doesn’t conduct ward rounds) the highest level of staff is the equivalent of our Physician Assistants.  There is very poor history taking and often time simple tasks (i.e. taking vitals throughout the day) are overlooked.  But Luke, who has been here for 2 months already, has said there has been a dramatic increase in the work of the clinicians and staff once there was the support from MGH. I take this as a very promising sign.                                                                                             OK, so let me briefly go over just what, exactly is happening with MGH and Sagam Community Hospital.  There is a university down the road a bit, Maseno University that has its first year of medical students. Eventually these students are going to be involved in a program with a curriculum heavily focused on family medicine (FM) and emergency medicine (EM) and partnered with MGH. What MGH is trying to do at Sagam Community Hospital is to try and create a “center of excellence” for both the local community and for the medical students that will eventually conduct their residencies there.  There are also plans to build a new ER for the hospital with an ICU and operating room. That is a gross oversimplification but basically the doctors and I are trying to make the hospital a revolutionary, community-focused, sustainable force in the area that will introduce FM and EM to western Kenya.  So what does this mean for me? Lots and lots of work!

My days are filled with emails, meetings and Excel spreadsheets already and it hasn’t even been a week! But you’ll not hear me complain because I am living the dream. For those of you who know me well, you know how desperately I searched for a program like this that is sustainable, equitable, encourages education, and will ultimately revolutionize a community’s approach to medicine.  I cannot wait to see what happens in the next 10 months!

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This weekend we all went down to the house in Kisumu for a change of scenery and some much needed internet access. The house is lovely as well and has a view of Lake Victoria from the second bedroom balcony.  Megan stayed in the master with Paula because she left on Saturday for the US after 2 weeks of teaching pediatric care to our Ugandan consultant Godfrey. I, special lady that I am, got the “Bieber” room. The front door has a giant Taylor Lautner poster and the inside walls are covered with Edward Cullen, Bieber, his girlfriend (kind of happy I don’t remember her name) and more Lautner posters. The curtains are covered in sparkles, the bed comes complete with “Princess” and pink pillows, and the mosquito net is large enough for a 4-post queen bed and made entirely of lace. I’m surprised I didn’t dream of unicorns and rainbows.

As a farewell lunch to Megan we went to the lakeside “Tilapia Beach” restaurant where you can pick out your fish of choice from a rack of dozens and they fry or grill it in front of you. The food was yummy but it started to rain while we were there and the restaurant cleared out in a matter of seconds. Only the wazungu stubbornly stuck it out.                                                                                                                                            Kisumu is a nice city and for being “the third largest city in Kenya” it has a really small feel to it. Unlike Dar I feel completely safe walking around and far more relaxed. Don’t worry mom, I will still be careful.  The Indian food is to die for and I’m sure I will take advantage of it every weekend when we come down.

Overall I have to say my favorite part about Kisumu is falling asleep to the sound of lions roaring in the nearby nature park. I truly feel at home in Kenya.

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Well, I’m back in Sagam again preparing for the busy week ahead of me. It’s nice to be back, especially since we were greeted with a bat flying around our heads as soon as we settled down.  I guess my next big news is that I will be going to Rwanda again in a week or so. Barry has a motorcycle in Rwanda from when he worked there last year and has offered to sell it to Luke. Being opportunistic we turned the offer into a road trip with the remaining 5: Me, Paula, Barry, Luke and Godfrey. We will stay at Godfrey’s house in Uganda on the way there and back, and we’ll be taking a day to go gorilla trekking!! I thought once was an amazing opportunity but never did I dream I would be able to do It again! I do love my primates.

Sorry for the long post…I will try to keep them more frequent and more concise. I can’t make any promises though as internet is kind of spotty here but I’ll do my best. Until next time!