Amani Ward

Friday was my last day on the Amani ward, which serves up 50 or so adult women. Daily, we rounded at the bedside, usually a junior student presenting the patient, sure not to leave out any details.


The patients and patients' families do an extraordinary job of taking care of each other. Neighboring patients will pick up food for two, if their neighbor isn't able to walk. Families of patients will translate, if another patient doesn't speak Swahili. (Below is patient breakfast)



The stories of many of the patients I will carry with me for quite some time.

I met a patient my first week on the wards who was carried to the hospital by her sister. She was a cachectic, wasted, skeleton of a woman, sweating, and short of breath. She was found to be HIV positive, and put on treatment for a pretty nasty pneumonia, infectious diarrhea, and oral thrush. Later, she gained enough strength to take walks, eventually making all the way to the hospital entrance. Upon her impending discharge, she asked me for something to remember me by. Joe took this picture of the two of us, that we printed, and gave to her.


I had another patient whose grandchildren and great grandchildren brought her in for a headache and neck stiffness. The patient spoke only Nandi, the first language spoken in the region I traveled to last weekend. I asked the family how old the patient was, and a lively discussion erupted as to whether she was 80 or 90 years old. Regardless of her age, this patient was very sick, and the family very close. Kenyan patients have to pay for major services as they go, such as imaging and expensive drugs. We suspected that this patient might have a head bleed, and so asked the family if they could afford CT. They had the money together faster than any other family I've seen. I commented how quickly it happened, and they clued me into the fact that this patient had over 150 grandchildren and great-grandchildren, so it was relatively easy.


Her head CT confirmed our suspicions. By the end of her hospital course, the patient was more comfortable, and she thanked me for helping to take care of her. The family all gave me hugs, even after I explained to them that their loved-one might have a limited recovery, and prognosis.


A third memorable patient was an incredibly sweet 15 year old with Rheumatic Heart Disease (RHD). The incidence of RHD and Rheumatic Fever sharply declined in the West after the discovery and widespread availability of penicillin to treat streptococcal pharyngitis, of which RHD is a sequelae. This particular patient has had RHD since an undetermined, very young age, and is suffering from end-stage heart failure because of it. She came to the hospital with shortness of breath on exertion and swelling of her lower legs, as well as gross ascites (fluid around the liver). We were able to alleviate her immediate and severe symptoms, but to correct her disease, she really needs a heart valve replacement (and needed one years ago). Nairobi is the only place those are done in Kenya, and her mother, who was there day and night for her weeklong stay, is not able to pay for such a surgery.


The students on my team were hard-working and very caring. Here are the sixth years, who graduate in December 2009 (medical school admission is directly from high school and for a total of six years).


Next week I will begin pediatrics, which will frighteningly be some of my last training in the field before I start residency. My classmates and I are currently in the window period. We have submitted our final rank-lists to the national residency match program, but will not find out until March 19th. So keep your fingers crossed! More on our lovely weekend later. Lala salama.

- Anne

Sarah Obama picked to lead tsetse fly fight

In Current Events Kenya, it appears that executive ability runs in the Obama family. Eighty-seven years old and still taking on new challenges. I, for one, am impressed.

Also, Iran's President continues to give beards a bad name... and in Kenya, no less.

Then, police death squads. For or against? Let the debate begin.

And finally, a sampler of the hottest new Nigerian pop star. All the young Kenyans are digging P-Square.



-joe

Wiki tatu

My third full week on the wards was interrupted by a day spent with Dr. Joe Mamlin in his clinic at a rural health center in an area called Mosoriot. I tend to remember just how much I enjoy outpatient medicine each time I return to the clinic... be it in Providence or Mosoriot, and this day was one of my favorites during my time in Eldoret two years ago.

Dr. Mamlin and his wife, Sarah Ellen, are central to the story of all that has been accomplished since Indiana University first established a relationship with Moi University & its Kenyan physicians in 1989. At some point thereafter, the AIDS pandemic swept through Eldoret. To hear Dr. Mamlin speak of the experience is moving. He gives a tour to the students who accompany him each week to Mosoriot, pointing out the tiny room where AMPATH first set up shop. Starting with funding to treat just 15 HIV+ patients (the existence of whom village elders once denied), AMPATH today cares for upwards of 120,000 HIV+ Kenyans.

The AMPATH map with a map of Kenya below. Find Eldoret just below the "K" in Kenya.



I find that number staggering.. in a good way. Even moreso when followed by Dr. Mamlin's ambitious plans for the next few years. Two years ago, on the same strip of road back from the clinic & in the same car, Dr. Mamlin described his vision of a home-based HIV testing program. Those words are today a reality with a vast expansion planned in the near future. There is reason to take Dr. Mamlin at his word, it seems.

But for as much as I find big numbers and "never been done before" plans exciting, it all pales by comparison to meeting just one Kenyan patient who would have died years ago were it not for these efforts. One woman called Dr. Mamlin "her father". She had lost sight in one eye due to a zoster infection but described Dr. Mamlin's care bringing her back from blindness. An elderly man lit up each time Dr. Mamlin passed through the waiting area. This man has Parkinson's disease and is able to walk only because the Mamlins' imported a year's worth of PD medication. As we departed from introductions made to the Outreach team, Dr. Mamlin described meeting its leader years prior as she was carried in to the clinic, oxygen saturation of 70% with a P. jiroveci pneumonia... an opportunistic infection and an AIDS-defining illness.

One very sad young woman had been rejected by her parents, had her home sold out from under her by a husband who disappeared and was having trouble finding school fees let alone a roof for her child. A terribly difficult time in what has probably been a very difficult life. It's possible that the medical care, mental health services, social worker, food program and job training will help get her through it. I shudder to imagine the alternative. Sadly, that alternative is still more the rule than the exception. Eighteen clinics with more by the year care for many like her each & every day. In conclusion, yet another memorable experience at Mosoriot. I have the good fortune of working with Dr. Mamlin next week on the inpatient wards as well.

I presented the case of a 33-year-old father of four this morning at AM Report. Hepatitis B & hepatocellular carcinoma, and a discharge with hospice. I do hope that is what it sounds like though my definition of end-of-life care is surely quite America-centric. Neither do family meetings have the same place in the decision-making process here. My registrar was away this AM so I led rounds from start to finish. Both the presentation & rounds went fairly well. I briefly had thoughts of an attempt at humor in my presentation but gave up as the hour got late last night. I did save this fine picture and would like to share it. Tom, I'm sure you remember this gem of a movie. Meet Turbo & Ozone.


We travel tomorrow evening to an area called Mount Elgon, located near the Kenya-Uganda border (see map above). There will be plenty of hiking, hopefully a good deal of cooking and perhaps some spelunking. Surely, Anne will fill in the details on Sunday. As we head into "the bush" for the weekend, I'll make a wish for continued GI stability. The toilet paper here is named "TENA", or "Again" in Kiswahili, which I find ironic.


And finally, Philip & I were handed our IREC approval letter today. Four weeks after our arrival but infinitely earlier than some might have predicted, we will commence interviewing outright tomorrow.

Tutaonana baadai,

Joe

A week in the life...

Anne & I have been spending what feel like long hours in the hospital. We each round with our teams all morning and return in the afternoon, working until dinner. We walk to and from the hospital together each day... which is lovely. Views from my walk below.



We have been studying Kiswahili as often as possible with our teacher, Wycliffe. Nilijifunza Kiswahili kwa mlimu yangu Wycliffe. Nilikula maharagwe jana usiku na nilinyamba sana baada ya kulala. Pima, Anne.


A Morbidity & Mortality review held by the Medicine Department revealed that approximately one in seven patients admitted during the month of January died while in the hospital. As I was thinking, "Man...", the Chairman of the meeting and my Attending (present at rounds exactly three times in nearly three weeks) commented that the number was unusually low.

He conducted the meeting much the same way rounds proceed in his presence... A heavy emphasis on the less-than-important, a keen focus on failure and blame and an utter lack of decisions made or action taken. I didn't enjoy the meeting. I sensed that role models at the Attending level were lacking.


On a related but unrelated note, as a proud Rock for Riley alum, it is my sincere pleasure to take part in the announcement of Rock for Riley V... to be headlined by The Avett Brothers. This is one of my favorite Avett Bros. tunes in recognition of an often used but questionably effective teaching method.

Shame by The Avett Brothers



I spent last Friday morning working with one of the Radiology Attendings. Consultations are either very difficult to obtain or surprisingly easy & efficient. Said the Neurosurgeon, "We'll take him to the OR tomorrow." There's no middle ground on this. I introduced two cases to Dr. Wanene (who looked bizarrely identical to my landlord in Providence... but Kenyan) and he asked if I could get the patients to Radiology now. I agreed. A few corners may have been cut in regards to consent, time-outs, patient understanding of the purpose of the big needle and perhaps sterile technique... but overall both biopsies came off without a hitch. As I waited earlier that morning to speak with Dr. Wanene, a woman with the housekeeping staff requested a picture. I obliged.


It continues to feel very strange to know a very sick, young person is dying and then to watch them die. I believe I've written about this once already. I can create many explanations for why it is not feasible to resuscitate every dying patient at MTRH. There is plenty of room for spirited disagreement here. Nonetheless, it happens. Patients die while we round on the patient in the next bed.

I returned to rounds on Friday to catch the last few words of a discussion regarding a 36-year-old HIV+ man admitted with heart & renal failure. He had deteriorated overnight, pulmonary edema in the setting of an unrecordably low blood pressure was diagnosed and a rock & a hard place were noted. My Registrar and interns broke away from rounds minutes later to attempt resuscitation. Why this patient and not so many other patients, I don't know. I joined and attempted to help us clarify our options. At one point, my Registrar appeared offended by my clinical assessment and left. Others simply drifted away. It didn't go well, but unlike many others, this man did make it to an ICU bed... in which he passed away hours later.

I grumble at times about the occasional excessive use of critical care resources at home. I focus on this negative too often, I think. From here, well-trained critical care staff operating state-of-the-art equipment to save lives looks more like the vital resource that it is. Below, the three medical students who stuck it out throughout a long and unpleasant code. We shared a nice, long lunch... talking at length about George W. Bush, Barack Obama and politics both here and at home.



On Saturday, Anne & I were invited to church with our friends, Philip & Robina.


The service was very nice... and featured a fine, four-part harmony. Enjoy!

When Jesus Comes by the SDA Gospel Quartet

Nandi Hills

Kenya continues to have beautiful landscapes everywhere we've been.


Sunday I had the privilege to go with some of the medical and nursing students to a medical camp in Nandi Hills. An elder at the local 7th Day Adventist church described the area as having been inhabited by the Nandi peoples, who were fierce warriors and hunters. This lush area at the edge of the Rift Valley is now occupied by the Kalenjin, and covered in vast, green tea plantations.


The medical camp was extraordinarily well organized. There was health education given by public health students on hygeine, clean water sources, nutrition, etc.


Kids were de-wormed, then taught about teeth-brushing and keeping sugarcane consumption to a minimum (we saw several children with mouths full of caries).


People seemed to come from decent distances, all walking, to be seen by physicians, and prescribed free medicine.


Then later, after being cured of whatever ill, people stayed to socialize.


And the children played.


There was a sizable pharmacy, with most of the basics covered.


Many women came, children in tow, always asking for their children's problems to be heard first, then addressing their own health. I met a woman who was 22, with 6 children already. She spoke to the male medical officer, then pulled me aside and asked about contraception. She said she had been getting family planning shots (or Depo Provera) without telling her husband because he would be against the idea. Unfortunately, she had uncertain dating of the shots, and was likely pregnant again.


All in all, it was a wonderful trip, and great to get to know some of the students a little better. Here's the group mug.


- Anne

Umoja wards

Nearing the end of our second week here in Eldoret, we are both just beginning to get a sense for how things work in the hospital and how we might help them to work a little better or slightly faster. For every post describing a terribly sick patient or a tragic outcome, I will attempt to take a view from a more positive point. There is indeed a concentration of very sick patients on the inpatient wards. More importantly, at least in this post, there are some very smart residents, green-but-hardworking interns, eager medical students, veteran nurses, loving families and exceedingly tough patients.

Rounds begin roughly at 9AM each morning. With 3 "cubes" per ward, 8 beds per cube & approximately 1.5 patients per bed, rounds can push 1-1:30 on a long day. I have been fortunate to work with a very talented "registrar" or resident. She functions as the Attending most days, and does so better than the actual Attending... she is pictured teaching the chest pain differential and reviewing a CXR below.


I spent some quality time of Monday teaching the 4th year students the Frank method for interpreting chest X-rays... completely made up on the fly. It went very well. The CXRs that we're learning from aren't subtle.


You can see three cubes on each side of this hallway, making up the men's "Umoja" ward. Umoja means Unity in Swahili. The other wards tend to be named for various other ideals. At 1PM precisely each day, families of patient's flood into this and every other ward. Many sit with their loved ones throughout the day, picking up where the nursing staff leaves off. The food served by the hospital is a single thick piece of bread and a mugful of a thin, brownish-grey liquid. Many families bring food to supplement this very basic diet.


Looking out the back door of the ward to an open area where the more mobile of the patients tend to congregate. Fresh air is pan-cultural.


Decisions each day, critical clinical decisions are made based on all the data that is available... and can be afforded by the patient. Before ordering any of the more moderately priced studies, a member of the team discusses the recommendation with the patient. A quite literal cost-benefit analysis. More commonly, we round the following day to find that a head CT, for instance, was not done because the patient could not afford it. Hopefully, a family member is home working on collecting the money.

A bill sits in the flimsy pink folder that is each patient's chart... right alongside H&Ps, daily notes and lab slips. Many patients spend extra days on the wards after they are discharged because they are unable to settle up with the cashier on the wards. This is good and bad. There are certainly risks to the combination of immunosuppression and a coughing neighbor(s) with pulmonary tuberculosis. For instance, one patient had what appeared to be his first psychotic break on day four or so after treatment of anemia. This would fall into the "Good" category had his discharge plan not been entirely inappropriate. Tomorrow, though, I hope to pull of a biopsy in a patient discharged days ago with a plan for this same biopsy as an outpatient... which would be good. Below, the sign at the security post at the exit to the medical wards, staffed daily by two or three soldierly men.


Finally, back to Current Events Kenya, the front page of the paper today alleges a link between corruption and famine. Seems plausible.

We will be learning profound statements in Kiswahili during our eighth lesson. Until then, nitaamka kesho asubuhi halafu nitaenda kwa hospitali na kuona wagonjwa.

Joe

Joseph Technicolor or Joseph the Dictator

We continue to have beautiful weather and wonderful weekends here. Friday we went to dinner with several of the Moi Medical students Joe had become friends with on his prior visit to Eldoret. We did a lot of laughing, and loved the description of Kenyan marriage rituals. According to our friends, the practice of the groom paying a dowry, is very prevalent, the more educated the woman, the higher the price, up to a million Kenyan shillings in some tribes ($13,000)! Joe was chastised for the amount of fish parts (bones, meat, facial parts) he left on his plate.



Saturday we took off to Kerio View, a restaurant and inn near to Eldoret with spectacular panoramic views of the Rift Valley. We hiked down from the viewpoint towards the valley, weaving through small farms, and encountering plenty of friendly children. One such meeting involved kids sledding on scrap plastic down a hill. One kid (repeatedly!) crashed directly into some brush.



The children were also amused by our whiteness, and some took a liking to Joe's name, calling him either Joe the Dictator or Joseph Technicolor. Sometimes they would walk with us, repeating English phrases like "How are you?" or smiling and saying "Wazungu!" (foreigner).


In the picture below, the sledding boys had started alternating between rapping for us and speaking in frog voices.

Our guide, Koech, standing in the background, seemed to know many of the people on the walk. He also did what was a pretty burly downhill portion of the hike in flimsy sandals more aptly than Joe or I.

The hike took us past his home, and he pointed out his sheep and cows.


Kerio View is also known as a wonderful place for paragliding. These kids had created their own small versions of plastic bags and twigs that worked really well!


We had a delicious dinner, and even had Kenyan tea and dessert. The food here has been really good. Tea and coffee are of the most flavorful I've ever tasted. (And the milk is in triangle cartons!) We've had a plethora of fresh fruit, including mangos, papayas, bananas, and oranges. We woke up Sunday for the Sunrise over the Rift Valley, and it was spectacular.


You can see Mt. Kenya in the background here.


And just a couple more closer to sunset (we're moving backwards in time).




Lala Salama. Tutafanya kazi kesho asabuhi.

One Hippo Snoring

The IT department has finally gotten its act together. We expect all were anxiously awaiting the arrival of this bit of audio. Self-explanatory.

-Joe

Evaluating ASANTE

Anne so eloquently recapped a lovely weekend... And so briefly, the first installment of a topic that I really hope will have many future installments. Months ago while wandering around Boston, Anne & I first tackled the subject of a research project here in Eldoret. Fewer months ago, my friend Philip Owiti & I kicked off an email correspondence regarding the same. I first met Philip on one of my very first days on the wards here in Eldoret two years ago, and then again when he did an overseas rotation of his own at Brown last spring.

Shortly before leaving Providence, we received the go-ahead from the IRB at Brown to begin a study interviewing Kenyan medical students, asking them to reflect on their experiences with visiting American students and physicians & soliciting suggestions for improvements to the IU-Kenya Partnership... today also known as the ASANTE Consortium. Philip had done a great deal of heavy lifting to keep things moving over here in the meantime. The IREC (the IRB on the Kenyan side) has yet to give us the green light... and realistically, may prove to be an obstacle we just can't get around. Nonetheless, Anne, Philip & I took part in an excellent discussion with a "focus group" of Moi medical students today. They dissected our goals, plans and questions. They provided an enormous amount of very thoughtful feedback. They delicately pointed out those areas where I remain entirely clueless.

We will again submit our IREC application tomorrow. Until we hear back and while we check in at the IREC office each day, I will look forward to posting something other than waiting to hear and continuing to check in. Halafu, tutafurahi... And, one more Sunrise photo,

Joe

Obama!

Asking "How are you?", exchanging names and agreeing that we all love Barack Obama have been absolutely crucial to making friends here in Kenya. President Obama's father was a member of the Luo tribe, today residing primarily in western Kenya near Lake Victoria. Our driver this weekend, Stephen Ogot, was proud to play this track a couple of times on our way to Kerio View.

Interestingly, we've been told that even though most/all Kenyans love Barack Obama, he probably wouldn't win an election here in Kenya... it appears tribalism runs quite deep.

-DJ Anne

2.14.09--Ninapenda mchumba wangu

So it's Saturday morning, Valentine's Day, after our first full week in Eldoret and on the wards at Moi Teaching & Referral Hospital. More on our time at the hospital in a paragraph or two...

We are staying at IU House, a compound that has grown dramatically since my first visit in 2007. IU House is currently hosting what must be one of its biggest groups yet, filling a spacious dining room each evening. Comprised of a large contingent of IU folks in addition to guests from all over the US & the world... students, residents, faculty and their families, people working in medicine, pediatrics, surgery, obstetrics, microbiology, research, public health, engineering, information technology, economics, etc. It has made for interesting answers to the question, "And what do you do?"

It is a kind of oasis from the city beyond its walls. It can be somewhat isolating but the comforts, I think, tend to ease the transition for most guests. There is a crew of friendly guards ("askaris"), who are glad to serve as volunteer Kiswahili teachers, and four playful but territorial dogs. Anne & I share a room in the back corner of the place. Very comfortable, with the small exception of the mosquito that had infiltrated our sleeping net for two consecutive nights... until his demise yesterday. On at least two occasions, I full-on smacked myself in the face in my sleep in an effort to kill whatever it was that had been buzzing in my ear throughout the night... unsuccessfully.

The front door(s)... That's the bedroom/office/living room on the left, and the bathroom on the right.
Our front "yard"...
There is a lovely "banda" on the grounds. That's Anne under there reading something or other.

Located at 7,000-ish feet above sea level and not far off the Equator, the weather in Eldoret is beautiful. A cool breeze takes the bite off the equatorial sun. The occasional cloud floats by... none were available for this picture.


Staggeringly less visually appealling are the sights on the wards. A combination of many things, not doubt, most obviously HIV & the lack of critical care resources leads to an all-too-common experience of watching young people die. I've never felt particularly drawn to critical care. I have often focused on its excesses at home. Just days into my time here, the other side of that coin becomes so very apparent.

A 20-year-old young man admitted comatose two days ago died yesterday with his family looking stoically on. We (I) never had much of an idea as to the nature of his illness. On rounds on the day of his death, we made plans to consult the ICU (All five beds full, refused an actual evaluation, I've yet to see this happen here), ordered two medications that I think we all new weren't available or wouldn't be administered anytime soon, and discussed a Neurosurgical evaluation that he would never be "stabilized" to receive. It was awful.

Other diagnoses aren't as challenging. A tension pneumothorax in a young man with pulmonary TB...
Miliary TB... a common theme thus far. And below, a follow-up CXR a few months after this miliary picture, showing fluid where it doesn't belong.


We are shortly headed to a place called Kerio View, boasting gorgeous views down into the Rift Valley for a date on Valentine's Day. We hope everyone is well.

Mom, be sure to log onto your Gmail account on Sunday morning so I can wish you a Happy Valentine's Day in person.

-Joe