Friday, September 24, 2010

trees through roof!

John's face said it all as he walked down the hill for lunch..."Hmmm....Wow." And then, "Mom! the bathroom no longer has any privacy!"
Yes, that is our bathroom and bedroom under that hole. Too bad the cutters didn't quite get the fall line right?! Another day in our African adventure...

A few more vignettes....

1-a 35 year old woman comes in complaining of nausea vomiting and abdominal pain for the past few weeks. X-rays show high grade small bowel obstruction. Surgery finds multiple small abscesses; congealed material and small bowel adhered together, requiring side to side re-anastomosis. After seeing her in the ED I reconnect with her in the ICU where she is a few days post-op and I am on call for the weekend. Her breathing worsens over the weekend requiring intubation and her CXR shows evidence of ARDS; not good. I am unable to save her in spite of pressors and respiratory support. I won’t know what she had but I bet it was likely reactivation TB in her abdomen. My Kenyan colleagues tell me that they are seeing more TB in places other than the lung with no history of a prior known TB infection in the lung. Lots of TB around here, without all the isolation paranoia that we have; I won’t be surprised if I turn PPD positive by the time I’m done around here.

2-a 33 year old known diabetic with a history of pneumonia one month ago comes in complaining of increasing shortness of breath. The resident calls and tells me that the patient has pneumonia on the CXR and should do well on oxygen and antibiotics; but maybe a good idea to keep an eye on him in the ICU. I come in to check on him in the Unit and he is breathing 50 times per minute with a believable pulse ox of 66% on mask oxygen. Clearly he’s not talking much and his sugar is high-say around 600. His BP is around 220 systolic which I am glad about since it’s always nice to have more blood pressure than less; that goes for sugar too. But the CXR looks more like CHF than pneumonia and besides the patient is a little puffy. Another intubation and this time out comes pink tinged frothy sputum like a small soda fountain; just like the textbooks said ( I think that’s what they said, at least the lecturer must have said something like that). A little suction, a little lasix, and the sat’s perk right up to 88% which I consider a cure. 4 days later he’s out on the general ward. If you had seen the general wards here at Kijabe that would mean something to you. You’d better basically be ready to go home if you want to survive out on the general ward. Think of the hospital scenes from the English Patient and you have a good mental image; except throw in a little more grime and smell.

A few medical thoughts:
-Try managing ventilated sick patients with no ability to order ABG’s; it’s possible to do.
-Remember my sick newborn that I ventilated and bagged for an hour and never could figure out the old German ventilator? Well a pediatrician came this week for a month and we have two preemies on ventilators, so I got a bit of an in-service on them and now feel confident that I can set up a tiny little baby on a ventilator should I need to.
-Can patients survive without the ability to order vicodin? Yes they can, and they don’t die. I guess they just feel miserable.
-Little sticky electrodes that we use for hooking people up on telemetry monitors are really good things and when you don’t have them it is a problem. I guess they are a donated item; must be expensive.

Wednesday, September 22, 2010

first visitors!

Our beloved friends, Mickey and Carol Berberian, just left. They spent the past 4 days with us and it was wonderful! They were on their way home from accompanying their daughter Christina and Victor as they brought baby Yohani home to Mozambique for the first time! So this was a bonus treat for us...and we are so grateful it could happen!

We heard stories from Mozambique, showed them our new place, drove on crazy roads, walked among the giraffe, zebra, wildebeest, antelope on Crescent Island...and shopped in the Maasai Market. We saw the locales for Out of Africa and Born Free and obsessed about Lord Delamere. They got a good feel for some of the experiences Warren is having at the hospital, as he was working in and around our adventures. They heard of some of the pitfalls of this kind of medicine...and some of the bad outcomes that can come as a result of minimal death, quite a lot of it actually! But they also got to meet some of the wonderful people he is working alongside.

It will be quiet without them here now...unfortunately I doubt they will get by without taking our horrid colds with them, so we will be forefront in their memory for a few more days!

Tonight I will put up pictures from our Crescent Island visit, one of the most surreal, magical...out of this world places I have ever been.

Sunday, September 12, 2010

Sandra's first time driving on the left side/right side of the car/wrong side of the road?

Posted by Picasa

another kind of outcome...

A Kenyan man comes into the ER agitated, saying, "I have a sick boy outside..." I grab an old wheelchair and walk out with him to find a white truck with two people inside. We don't have any spare stretchers at the time, so three of us help wheel him into "Casualty"(ER) and kick someone healthier off a stretcher. Once on the stretcher the boy is found to be pulseless and apneic and we proceed with a trauma resuscitation...Kenya style. Someone initiates lightweight CPR. I intubate the boy. We establish two IV's quickly with fluids running in, adrenaline is found and given, there is an ancient Zoll defibrillator that actually charges with a whine and delivers a solid shock! I am encouraged by the fact that the machine works. However, it is clear that the teenage boy doesn't. It is a sad moment to realize that he is beyond our help. We can only stop and ask what happened??
Apparently the truck was going down a nearby stretch of road, that is much like driving down a dry river bed, when the boy ran out in front of the truck while collecting firewood. The two men in the truck collected the boy and drove him to the hospital. Here in Kenya it is important that we keep the truck and the driver from leaving the hospital while the driver must walk to the nearest police station and bring the police back to the ER for an investigation. The truck was locked in behind gates in the hospital parking lot. Eventually some police officers did show up, as did some family members. Things seemed surprisingly calm, quiet and low key really. I couldn't understand much of what was going on so I asked one of the residents to tell me what was happening. Apparently the truck driver had to bribe the police at the station before they would come to write a report. The resident said the report stated that the boy was in the truck when it accidentally rolled over.
Clearly police reports aren't about investigating the facts. So much revolves around bribes and manipulating situations so that you can get on with your day. Never mind the loss of life or the long term impact on the family.

Saturday, September 11, 2010

making friends with sammy...

One of our main reasons for coming to Kenya was the hope that we would be able to meet and get to know Kenyans. As obvious as this may sound, it can be challenging when you find yourself on a station with a lot of ex-pat people who are involved in the same work. Although everyone is very friendly, and we learn new names of Kenyans every day, tonight was the first time where someone came over and spent time with us in a way that felt like we might become friends.
This past Thursday Warren and I had the opportunity to ride in the hospital ambulance to a clinic across the Rift Valley where we got to spend the day together seeing patients at a small understaffed and under supported community clinic. Doctors from Kijabe Hospital visit this clinic once each month. We also had a CO intern with us (like a physician assistant in training) and a nutritionist. Most, if not all, of the people we saw there are Maasai. On the way there we saw many of them along the side of the road herding cows and goats, most of them in the traditional bright clothing and beads that we think of due to National Geographic pictures we have seen. Amazing.
One of the patients mentioned that she had a family member who works at Rift Valley Academy as a gate guard. So...last night when Warren and I were on a walk, just before dark, we met Samuel...the family member. He initiated the conversation and we made the connection. We invited him to come over today. This evening he came...with many beautiful beaded things that his wife has made, and full of stories and easy conversation. We had chai and icecream and heard about his life growing up in a Maasai village. His wife and kids are still living in a Maasai village, only a short distance from here, and he goes to be with them on his days off. He is quite eager for us to come to his village and meet his family.
Warren was asking about the animals they come across and where they are. He could not emphasize enough how dangerous elephants are! He must have said this 10 times. Apparently you can run from them if you are running downhill because the elephants ears fall over their eyes and make them blind!? But are in trouble. They are fast and their ears are back against their head! Keep this in mind!
This seems like valuable information and none of our other friends have ever shared this with us!

Monday, September 6, 2010

Baby boy...born Sept 4, Kijabe

First night of call in Kijabe...

Overnight call for the medicine wards and ICU was quiet until a 5:30 phone call. Obonyo, the first year intern, notified me of a full term emergency C-section little boy coming to the ICU. The baby was born blue, with no pulse or respirations. After 5 minutes of CPR, intubation, epinephrine and glucose the baby regained a strong pulse. However he had little respiratory drive and we were bagging him on the way to the ICU. I had no experience with the ancient German ventilators in the ICU. So I just kept bagging the baby and called the doctor on call for Peds. He didn’t have much luck with the ventilators either but he told me that babies here cannot be ventilated for any length of time. They need to breath…or they die. By now I had been bagging the baby for about an hour and he was looking better all the time. He started out dark blue, with just a few retractions, but by now he was looking pink and was starting to breath on his own. We took him to the neonatal unit, took out his breathing tube, gave him a mask with oxygen and I went home hoping he would survive the day.
Today John, Sandra and I stopped in to see how he was doing. The nurse pointed to a vigorous crying baby who looked nothing like the baby I saw yesterday. She had to show me the chart so I could believe it was the same little person. He wasn’t even on oxygen and he looked like he was rooting for a good meal.
Sometimes stories turn out better than imagined.

Sunday, September 5, 2010

weekend with wheels...sort of...

The weekend was one big adventure…both because we got out and about, and because we did it with all the inefficiency of a good solid African experience! Our route to the nearest shopping center became a detour through the heart of Nairobi…which includes huge traffic jams, what feels like millions of people, iffy roads, crazy driving…constant near misses...really harder to believe that you aren’t crashing than it would be to be having multiple crashes! We finally arrived at Village Market, well secured by guards carrying AK47’s and Billy Clubs. This did make the inside quite relaxing. If anyone tries to do anything too crazy there they will pay…at least it appears that way! We hung out, did some grocery shopping and had great food in a food court type of place…Chinese for John and Indian for Warren and I. It seemed like every nationality in the world was represented in that mall…incredible assortment of people…very cool.
Today we decided we would take a drive down into the Rift Valley and try to find some wild animals. We got ourselves all ready, got some directions and ideas from our neighbors here, got in the car ready and excited…Car won’t start. After multiple attempts, jumper cables, additional gasoline...we gave up. We went for a walk , stopped in the hospital for a peek at the baby Warren helped rescue, and I got a blanket and a book and went out under a tree. About that time Warren gave the car one more try…and it starts! At this point we have about 2 ½ hours until dark…one of the major limiters here(does not feel safe to be on the road after dark, and darkness comes at 6:30), so we jumped in the idling car and took off. The first 5 km down to the valley took us nearly 40 minutes on an unbelievable road…(Nicaragua friends: think that river bed we went up to go ziplining!). Another 40 minutes and we were on the shore of Lake Naivasha. As soon as we got to the end of the dock there was a large hippo swimming by! And on our way out we saw zebra, giraffe, an antelope type of creature…and lots and lots of monkeys as we pulled into Kijabe.
No recognition of Labor Day here of course, so we are back to our daily activities tomorrow. I now have a functioning washing machine, John made the tennis team!, and we will be doing what we can to celebrate Warren's bd! I found bd candles on Sat, and will make my first attempt at baking a 7000 feet!, with a completely capricious idea what temperature is happening in there, or how to control it! Should make for another adventure!;)Having a birthday in Africa is probably treat enough!

Thursday, September 2, 2010

warren here...

At the end of one week of African medicine it has already been an experience. Figuring out how I fit in continues to occupy a significant part of my day. I am happy to be interacting with many African MD’s, nurses and CO’s(physician asst’s). Kijabe Hospital is a training center for nurses, medical interns, family practice residents, CO’s…and also has MO’s(medical officers) who continue to work after their internship year as they pursue coveted spots in Kenyan residency programs, which they will have to pay for, rather than get paid like we do in the US. Patients arrive in cars, buses, taxis, carried by family…There aren’t any ambulances to bring people. They arrive in every level of acuity and sickness. In the last few days I have treated infected open fractures, heart failure leading to cardiac arrest and death, a young man with recent pneumonia who shows up with an empyema that we could drain with a chest tube, a young woman treated for malaria with abdominal pain who actually has appendicitis…The Western doctors in the hospital come and go regularly and it is never certain what kind of physicians you will actually have available. Normally there is no radiologist, however, for the next year we will have a great doctor from Toronto who can even do some invasive radiology. For the next 2 months we have an experienced Australian surgeon who can make use of the laporoscope equipment that the hospital already has but can rarely make use of.
For my medical friends, here is a little vignette: 49 year old complains of shortness of breath, weakness and high heart rate for one month. Vital signs: HR 160, O2 sats 80’s and low blood pressure. I asked him, thinking that he couldn’t live like this for more than one day, how long he has actually felt this bad. And he says, “One month”. I don’t believe him. However, he comes with an EKG and a CXR from 3 weeks ago, done at a clinic in Nairobi by a doctor who looks like he is a Hem/Onc specialist. The CXR shows significant CHF and a very large heart. The EKG shows HR 120 and not in sinus rhythm. So what do they do for him? I am not sure, but he also comes with a detailed report from 5 days later of an upper endoscopy. His stomach looked fine. You wouldn’t want to start any cardiac meds of course. So after that I actually believed that he was feeling like this for the past month. He started to decompensate. And, as a good ER doctor, I thought…let’s treat him. Nitroglycerine seems like a good idea, but we don’t have any. I would like IV morphine but, after a call to pharmacy, they are out of that drug. How about an IV beta blocker? We don’t have IV beta blockers, but we have Propranolol PO, so why not? We did have Lasix, and oxygen is a drug. However, in the end, a month of untreated heart failure was too much for him. This is an example of inadequate medication and support and also a lack of appropriate decision making. In contrast, I am working with a 3rd year resident level Kenyan doctor who has a fund of knowledge and ability to come up with complex differential diagnoses that is much more than my ability. It can be astounding to see Kenyan trained physicians who have the ability to function at a high level in a Western hospital but are left working with so few resources and little opportunity. Not to paint Kijabe Hospital as a backword undeveloped facility because in fact it is a true light throughout Eastern Africa; I have treated patients who have traveled from as far as Somalia, Sudan and the far edges of Kenya. Injured people on the streets of Mogadishu know to come to Kijabe.

Wednesday, September 1, 2010

a few photos...

running at elevation...

This morning Warren and I went for our second run since arriving here at Kijabe. 7000 feet in the air makes our efforts quite a bit more challenging...and the course, around the school campus, is full of ups and downs, a few especially steep ups. Our hearts were pounding and we were thinking about how strong we will be if we ever get to the point where we can run the course without stopping and without feeling like our hearts are about to beat out of our throats! Maybe this is a good metaphor for this experience. Life here is a bit more challenging in most areas, but we hope to be stronger for it...?? The people here are certainly stronger than we are in a million ways. Warren has been telling amazing stories about patients already...including the distances they have traveled to be here, the sickness they live with on a chronic basis, and the way he needs to think about cost so as not to burden them with unnecessary bills.
Yesterday our stove was exchanged for one that has a working oven and we happily ate chocolate chip cookies throughout the evening! Warren has been eyeing the rhubarb growing in our "garden" and is hoping for a pie...He kept turning on the broken one and hoping it would turn on if he just waited long enough!
I spent the day in Nairobi learning about food shopping and internet modems. And I saw the American embassy, surrounded by high walls, guards and barbed wire. It looks like a penitentiary. But the previous one was bombed so I guess this is understandable. As we came around the corner to pick up our friend who had gone into the embassy to pick up a letter related to the adoption they are trying to accomplish, a matatu zipped by...and the door flew off! (matatu is the word for the common taxi. they are small mini vans which seat as many as possible and they are everywhere!) The matatu stopped and a few guys ran back to pick up the door! I didn't see if they were able to re-attach it. That seems like a stretch, but who knows?! Maybe this was routine for that particular ride?
My goal is to post a few pictures before the end of today. I think I have enough internet capability for that be determined later!