Monday, April 4, 2011
Are We Heading Back to Kenya Anytime Soon?
Masai Mara....A New Respect for My Mortality
“Really, Dickson (our safari driver) I don’t need to stare in the eyes of a lion, a safe distance will do.” What an adventure! Words cannot describe the Masai Mara, endless green savanna, frosted with zebra, gazelle, impala, warthogs and elephants. Not to mention hippos, cheetahs, lions, giraffe, water buffalo, ostrich, jackals and hyena at your fingertips...and the most brilliant, outlandish birds. Just breathtaking! And as our guide pointed out....the Masai. They always talk about seeing the Big Five (lion, cheetah, rhino, elephant and leopard) and the Masai being the Sixth. They just live out here. You’ll see a lone warrior just walking along.....in this absolutely wild land.
We stayed at the most beautiful safari camp....Amani Mara...the architecture was so unique and the owner a conservationist so the camp and the structures were built ecologically. We could lay in the pool and watch the hippos. The staff were so friendly and we planted three trees before leaving. Gus will have to go back one day and see his fig tree.
Here is a picture of where we ate breakfast one morning (lion pride in the bushes behind me). All was well until our guide said we should head back to the car....quickly....seeing a lion dart out of the bushes. OMG...I grabbed Gus and ran so fast. Then he called us back as the lion had turned and ran away. And it was just one lion after-all. Hmmm....one thing I learned traveling in the Mara is that there is never just one lion. There’s always a pride of lions. 
I think Dickson was playing a joke on us the first day, giving us a glimpse of our mortality. First our jeep got stuck next to a pride of lions, sheer panic....thank God for land rover power and giant tires. Once that frightening experience was over, within the next 10 minutes the jeep’s battery died, again next to the pride of lions. Of course this is when Gus decides to throw a tantrum. The lions had been sleep...then they woke up, one staring right at us. Me panicking again, “Here Gus eat a cookie.” Zach taking pictures. OMG...I never need to see another lion. The safari staff was teasing me later, saying “Katy you don’t like the lions but this is their home.” Me, “oh, I like lions, just from a distance.”
---Katy
Rethinking Medical Missions
One of the many reasons we came to Kijabe was to get an idea of what it would be like to live and practice medicine overseas on a longer term basis. I always thought this would be part of my practice in the future but have not been sure how it would all play out. I also always saw myself in a Spanish speaking country as I speak Spanish but didn’t want to limit myself and thought Sub-Sahara Africa sounded like a new adventure.
But one of the difficulties in making a long term commitment is not only language and culture differences, it’s educational and social reasons as well. You miss your friends and family. I’ve had the pleasure of working with Drs. Jennifer and Scott Mhyre this month. They are physicians who had been working in Uganda for 17 years, raising their four kids there (even through the ebola outbreak!). Scott and I had a great discussion during an hour long paracentesis while draining 5L of ascitic fluid out of a woman’s abdomen who most likely had cancer in her liver (very slow due to the tubing available). I was asking him how they overcame these obstacles of being a westerner in a foreign land. He said that through World Harvest, his organization that led him to Uganda, they went as a team with five families of close friends. He said the group changed over the course of the years but they always had a core group that stretched over the 17 years. He said it was ideal and really the only way he’s seen missionaries make it. You always have someone to hold your accountable, especially important in medicine as staying up with the latest information is daunting even in the states. It gave me an idea.....thinking about my fellow Swedes (residents) back home. Want to go together? Even cooler would be my closest girlfriends from med school, we all chose different specialties, we’d have a surgeon, ER doc, pediatrician, internal medicine doc, OB/Gyn and 2 family med docs. Not a bad team. Who’s up for it?
So "Stat" Means Do It Yourself
This post is a couple weeks late but I have composed many blogs in my head and am just finally now getting the time to post them on our 10 hour flight back home.
I literally walked into the Women’s Ward this morning to find an 85yo acutely ill woman with pneumonia with a heart rate in the 200’s. (Normal being 60-100). Luckily she was stable though requiring oxygen, mentally just fine. Knowing the monitors are not always accurate I checked the woman’s pulse and listening to her heart. It was definitely atrial fibrillation (a.fib), an irregularly irregular rhythm and quite disturbing as it was so fast. I tried to understand what was going on, asking her nurse how long she had been in that rhythm and that I needed a stat EKG. The nurse said she didn’t think the monitor was correct overnight and that she had been rechecking with a pulse oximeter which read high 90’s. I tried to explain that a pulse oximeter is a brief moment in time, not as accurate as a monitor but to be sure the best test is to feel the woman’s pulse. I think she understood and we examined the patient together and she agreed the patient’s pulse was abnormally fast. But alas, no EKG yet. We called to find out what was taking so long and were told all the EKG techs were at chapel and not available. I said...where is the machine located, I’ll do it myself. So I went and got the machine, ran it myself and then determined that yes we need some IV medications to slow this heart rate. Well, supposedly they didn’t have IV beta-blocker or calcium channel blockers in Kijabe Hospital, hum. I walked over to the ICU to find out how one corrects this problem here as surely this was not the first patient with atrial fibrillation. No attending docs were available. I knew my other option was to shock her back into a normal rhythm but I didn’t think that could possibly be the best option for an 85yo woman who at this point in time was stable, though I wasn’t sure how long she would stay that way with a heart rate that fast. Randomly, an ICU nurse overheard my questioning and said they have some IV heart medications in the theatre (OR). So I headed down there to find what I needed. Long story short, IV labetalol was available (only option), I gave it, corrected the situation and the patient did well. But what a round about way of doing it. It was good practice for a similar situation a few days later. That one was a little more complicated because the patient wasn’t already on a cardiac monitor and I had to wheel her bed into the more acute monitoring room myself. I guess “stat” means....do it yourself. Reflecting on these situations, Dr. Mhyre (a supervising doc) teases the nurses saying, “Dr. Katy is going to pull out all of her hair....how much does Martin (my counterpart) have to pay to get some assistance?”
---Katy
Wednesday, March 23, 2011
Hell's Gate National Park
We got to see Thomson's gazelles, warthogs, impala, giraffe, a giant water buffalo (who are notoriously dangerous) but alas no big cats yet. Gus says his favorite is a cheetah, if we don't see one on safari in the Masai Mara then we can go to a animal orphanage in Nairobi where you can supposedly pet them!
Monday, March 21, 2011
Comfort the Children International
Malaika mean "angel". At CTC Intl, there are the Malaika kids, children with various disabilities, and the Malaika Mums, the children's mothers who are working in the sewing room. This place has been a double blessing for these families, allowing the mothers to earn a living and the kids to receive therapy and an education. Prior to providing these services, it was common for mothers to "hide" children with disabilities and deformities out of shame or humiliation. Additionally in these circumstances, the father has left, so it becomes very difficult for the mothers to support their families.
I was also greatly impressed with the additional community outreach which is being facilitated here. Faith, the admin director, provided me with the grand tour and introduced me to everyone. Meanwhile Gus ran amuck, exploring the facilities and playing in the various classrooms. Some of the things happening there included: Mentoring for the students, like a big brother and big sister type of program; an Environmental Club, where they are planting Jetrophar trees which produce oils to be used as biofuels as well as direly needed shade and reforestation; and a Health Education outreach primarily for AIDS education.
We were able to donate some stuff we had brought from home, including some dresses made by local NW women (these will likely be distributed to the IDP-Internally Displaced Persons- camps, which are prevalent in this area of the Rift Valley), as well as art supplies, toys and books for the students and their visitors (local families and schoolchildren regularly visit the school to play with the students to raise awareness and acceptance of persons with disabilities). As we unloaded the goods from the car, I asked Gus if it was okay to give these toys and books to the school and he happily agreed. These were all things he has been playing with daily. Bravo Gus!
Zach
Sunday, March 20, 2011
Salome Patients - Taking Stock
One of the many questions we as resident doctors ask when signing up to go to Kijabe is what type of medical problems will I be seeing? Will I be prepared? I am cleaning out my notebook today and thought I'd take stock. I have a wide variety of patients on the Women's (Salome) Ward ages 20's to mid 80's. Most are from many miles away and have traveled days to get to Kijabe. As for the preparedness, I say yes, thank you to all my attendings and senior residents at Swedish, though it would be nice to have a cardiologist, nephrologist and gastroenterologist.....to consult with. :)
My currently admitted patients are struggling with:
Diabetic foot awaiting amputation x2
Class IV Heart Failure and End Stage Renal Disease with refractory volume overload
TB Meningitis with history of stroke
Community Acquired Pneumonia
Pneumonia with Pancytopenia
Delirium of unknown origin
Tuberculosis of the spine "Pots Disease"
Intrahepatic Cholestasis most likely due to toxin
Pneumonia with Lung Collapse history of TB/fibrothorax (see chest x-ray)
TB Meningitis
Uremia due to Acute Renal Failure (attempting transfer for hemodialysis)
Metastatic Cancer x2
Discharged:
Pneumonia x3
Consultation service:
All maternity/gynecology patients with hypertension
Postpartum hyperthyroidism
Surgical Clearance
Pneumonia in Pregnancy
Postpartum rule out pulmonary TB
Deceased:
Victim of assault with head trauma
Methotrexate Overdose
This last case was a tragedy. A young 34yo woman with a presumed diagnosis from an outside hospital of scleroderma and rheumatoid arthritis was prescribed toxic doses of methotrexate (I assume an innocent mistake) 20mg daily instead of weekly? This seems like a high dose for even weekly. She came in with severe pancytopenia, interstitial pneumonitis, stomatitis and renal failure. The antidote leucovorin would have saved her life if they had come in when her first symptoms first came on, but unfortunately she made it to us a week later, very ill but still really with it and fighting for her life. Her family were able to get leucovorin from Nairobi but it was to late to rescue her. She was transferred to the ICU the next day and attempts were made to get her to Nairobi for hemodialysis (to wash out her blood) but it was too late. She passed away within 3 days of entering our doors.
The above cases are only a glimpse of the tragic stories this women have. The patient with uremia due to acute renal failure is one week postpartum after a still birth. Her pregnancy was complicated by pre-eclampsia (high blood pressure in pregnancy to put it lightly) and then following delivery she developed endometritis but became so sick she was admitted to us with "puerperal sepsis," a creatinine of 10 (normal is less than 1) and hallucinating. She needed urgent dialysis which means transferring to a hospital one hour away. After being disconnected seven times trying to get a hold of the renal unit by phone I was told she'd have to go through the ER "casualty" anyway. After all that....time stood still....her family had to come in and accept the transfer...wow, you've got to be kidding me!
My heart breaks everyday. Thankfully some do get better and go home. Kijabe can be a beautiful place, patients surrounded by 10 family members singing and praying, each taking their turn to feed the patient or tend to the needs of the patient as nursing care can be a little too slim. Bad news is broken with prayer and hope of God's presence and strength during this time of suffering and unknown prognosis. I don't know if it this element or the fact that I am surrounded by my patients and their families all day long as I do my work that I feel more connected to my patients here than I do at home. I cannot simply check on a lab or vital sign without passing family and giving updates to each and everyone of them. At home I feel like we are always running off to our outpatient clinics, teaching sessions, our patients are scattered all over the hospital and discussions with family are over the phone. I am pondering ways to bring this home with me. Maybe more bedside rounds....
---Katy
 |
| Yes, some patients are in the hallway, it's so crowded. |
My currently admitted patients are struggling with:
Diabetic foot awaiting amputation x2
Class IV Heart Failure and End Stage Renal Disease with refractory volume overload
TB Meningitis with history of strokeCommunity Acquired Pneumonia
Pneumonia with Pancytopenia
Delirium of unknown origin
Tuberculosis of the spine "Pots Disease"
Intrahepatic Cholestasis most likely due to toxin
Pneumonia with Lung Collapse history of TB/fibrothorax (see chest x-ray)
TB Meningitis
Uremia due to Acute Renal Failure (attempting transfer for hemodialysis)
Metastatic Cancer x2
Discharged:
Pneumonia x3
Stroke x2
Heart Attack
Acute Renal Failure
Hyperosmolar Hyperglycemia State
Cryptococcal Meningitis
Pancytopenia
Prolong heavy vaginal bleeding due to cervical tumor
Bacterial Meningitis
Congestive Heart Failure
Metastatic Cancer x3
New HIV diagnosis
Excessive Salivation
Anemia
Pyelonephritis
All maternity/gynecology patients with hypertension
Postpartum hyperthyroidism
Surgical Clearance
Pneumonia in Pregnancy
Postpartum rule out pulmonary TB
Deceased:
Victim of assault with head trauma
Methotrexate Overdose
This last case was a tragedy. A young 34yo woman with a presumed diagnosis from an outside hospital of scleroderma and rheumatoid arthritis was prescribed toxic doses of methotrexate (I assume an innocent mistake) 20mg daily instead of weekly? This seems like a high dose for even weekly. She came in with severe pancytopenia, interstitial pneumonitis, stomatitis and renal failure. The antidote leucovorin would have saved her life if they had come in when her first symptoms first came on, but unfortunately she made it to us a week later, very ill but still really with it and fighting for her life. Her family were able to get leucovorin from Nairobi but it was to late to rescue her. She was transferred to the ICU the next day and attempts were made to get her to Nairobi for hemodialysis (to wash out her blood) but it was too late. She passed away within 3 days of entering our doors.
The above cases are only a glimpse of the tragic stories this women have. The patient with uremia due to acute renal failure is one week postpartum after a still birth. Her pregnancy was complicated by pre-eclampsia (high blood pressure in pregnancy to put it lightly) and then following delivery she developed endometritis but became so sick she was admitted to us with "puerperal sepsis," a creatinine of 10 (normal is less than 1) and hallucinating. She needed urgent dialysis which means transferring to a hospital one hour away. After being disconnected seven times trying to get a hold of the renal unit by phone I was told she'd have to go through the ER "casualty" anyway. After all that....time stood still....her family had to come in and accept the transfer...wow, you've got to be kidding me!
My heart breaks everyday. Thankfully some do get better and go home. Kijabe can be a beautiful place, patients surrounded by 10 family members singing and praying, each taking their turn to feed the patient or tend to the needs of the patient as nursing care can be a little too slim. Bad news is broken with prayer and hope of God's presence and strength during this time of suffering and unknown prognosis. I don't know if it this element or the fact that I am surrounded by my patients and their families all day long as I do my work that I feel more connected to my patients here than I do at home. I cannot simply check on a lab or vital sign without passing family and giving updates to each and everyone of them. At home I feel like we are always running off to our outpatient clinics, teaching sessions, our patients are scattered all over the hospital and discussions with family are over the phone. I am pondering ways to bring this home with me. Maybe more bedside rounds....
---Katy
Friday, March 18, 2011
It's raining folks and boy is it muddy!
The driver gunned the engine of the matatu (passenger van), while shaking the steering wheel back in forth to gain traction and avoid getting stuck in the mud. Never mind that the road was severely rutted and meandering, with school children and farm animals making sure to get out of our way. Thankfully, Duncan, our driver is as good as they come on these roads.
All of us were tired, a little wet and ready to go home to our families, after building a new roof for Milka, a widow that we were helping through Flow of Hope missions. John uses these guys regularly for these kind of projects. Visiting Msungo's (white people) pay for the materials; and we all work together to improve peoples lives. Rain or shine; and this day, it was mostly rain; the first big rain of the season. A blessing to the land, but possibly not the ideal conditions for roofing.
John and I purchased tools, hardware, roofing and the wood the day before, so that it would be all ready in the morning for pickup. The van was loaded, with the materials and the crew and the sun was shining. We made a last stop for lunch supplies that Milka would cook for us later and then arrived at her house. Surprise! Of course, John did not tell her that we were coming (or, necessarily that she was getting a new roof). I think he likes to show people how miracles happen out of the blue. He says it increases their capacity to hope.
Within a quick couple hours, we had the old sheeting and roof supports (I am reluctant to call them trusses, as they we just small trees and sticks nailed together) off the house and were well under way of building the new trusses, but the clouds were increasing. And it started raining, waves of heavy showers, broken by short durations of lighter rain and occasional reprieves from the onslaught. Yes, Milka's house was missing it's roof. She threw sheets of the old roofing over the beds and couch and chairs. The carpenter and a couple others put plastic bags on their heads and backs. Duncan covered up with his shawl. I gave my hat to Micheal. We stood under cover or against a building. And we worked.
These guys, Africans, were great, good spirited, never complaining and thankful for the rain. They were also wet, undoubtably cold and most volunteering. It was a long day. I was home by 7:30pm and in the bath after scarfing down some food. My hands were stained from the clay soil and I relished the feeling a full days work. Most importantly, Milka and her grandchildren were likely cleaning their muddy house, but marveling at the shiny new roof above their heads and lack of drips falling from above.
I am thankful for this time to get to know some Kenya guys, see the fruits of our labors and bless some people that live life with so little. These trips for us, to the undeveloped world as we call it, always help to re-assess our values and sense of our needs and lifestyles back home. Inevitably we will fall back into the clutches of consumerism and excess little by little. But for now I can enjoy a simpler life and explore the possibilities of a more socially and environmentally equitable world. My prayer is for less want, more love and always to trust that God provides. Always. Amen.
(There's more pictures in an album. Just click on the Picasa picture at the upper right side of the blog.)
Zach
 |
| Duncan a little worried that the van is too full |
All of us were tired, a little wet and ready to go home to our families, after building a new roof for Milka, a widow that we were helping through Flow of Hope missions. John uses these guys regularly for these kind of projects. Visiting Msungo's (white people) pay for the materials; and we all work together to improve peoples lives. Rain or shine; and this day, it was mostly rain; the first big rain of the season. A blessing to the land, but possibly not the ideal conditions for roofing.John and I purchased tools, hardware, roofing and the wood the day before, so that it would be all ready in the morning for pickup. The van was loaded, with the materials and the crew and the sun was shining. We made a last stop for lunch supplies that Milka would cook for us later and then arrived at her house. Surprise! Of course, John did not tell her that we were coming (or, necessarily that she was getting a new roof). I think he likes to show people how miracles happen out of the blue. He says it increases their capacity to hope.
Within a quick couple hours, we had the old sheeting and roof supports (I am reluctant to call them trusses, as they we just small trees and sticks nailed together) off the house and were well under way of building the new trusses, but the clouds were increasing. And it started raining, waves of heavy showers, broken by short durations of lighter rain and occasional reprieves from the onslaught. Yes, Milka's house was missing it's roof. She threw sheets of the old roofing over the beds and couch and chairs. The carpenter and a couple others put plastic bags on their heads and backs. Duncan covered up with his shawl. I gave my hat to Micheal. We stood under cover or against a building. And we worked.
These guys, Africans, were great, good spirited, never complaining and thankful for the rain. They were also wet, undoubtably cold and most volunteering. It was a long day. I was home by 7:30pm and in the bath after scarfing down some food. My hands were stained from the clay soil and I relished the feeling a full days work. Most importantly, Milka and her grandchildren were likely cleaning their muddy house, but marveling at the shiny new roof above their heads and lack of drips falling from above.
I am thankful for this time to get to know some Kenya guys, see the fruits of our labors and bless some people that live life with so little. These trips for us, to the undeveloped world as we call it, always help to re-assess our values and sense of our needs and lifestyles back home. Inevitably we will fall back into the clutches of consumerism and excess little by little. But for now I can enjoy a simpler life and explore the possibilities of a more socially and environmentally equitable world. My prayer is for less want, more love and always to trust that God provides. Always. Amen.
(There's more pictures in an album. Just click on the Picasa picture at the upper right side of the blog.)
Zach
Thursday, March 17, 2011
Everyday stuff
Zach
Baboons in the Mist
I made an uncanny realization early this morning at 3AM as I was walking home from the hospital down a lonely dirt road past a cemetery in the mist was that what I was most afraid of was not the boogie man or a man at all but a fear that I may have an encounter with a baboon. The males are enormous according to Zach who ran into a pack of them getting in the garbage cans, three times the size of Isis (our dog), and apparently not afraid of women. Great. Of course they were probably sleeping like most creatures at 3AM, but it was definitely a funny reminder of where I am.
I was on call at the hospital, my second call in Kijabe. The first was spent finishing up the out-patient clinic which ran until approximately midnight, then spent hours in the ICU trying to get an IV line on a 8mo little girl gravely ill with cerebral malaria and intubating a women with status asthmaticus who made it a few more days on a the ventilator before passing away.
I got a little more sleep this second call dealing early in the evening with a patient who was unresponsive and trying to work through the work-up etc. with the intern on the phone. It was all I could do not to go up to the hospital and do it all myself but she wouldn't learn anything if I did it for her. I did do some sneak phone calling to the nurse so I could feel good about the situation and did check on the patient after being called up to the hospital for another reason. A difficult reason too. An 11mo little boy was severely dehydrated with fever, abnormal electrolytes, lethargy...sick kid...and the mother was refusing admission. All the nurses, physician assistant and intern (all Kenyan) had spent hours trying to convince her. Apparently they don't have CPS in Kenya. We would have just involved the police in the US. I don't know why they thought I, a white girl with a funny accent, would have more luck convincing her, but luckily I did. She was of course concerned about the cost on an admission to the hospital but most of all that she would lose her job if she did not show up for work the next day. She unfortunately had been visiting her sister in Kijabe when the child fell ill and had quite a distance to travel in order to ask permission to miss work, apparently a phone call by her or by the hospital would not be sufficient. I guess a little coaxing and lot of listening was enough, we agreed she could have her sister come stay with the child in the hospital while she traveled the following day. Not bad for 3AM.
I was on call at the hospital, my second call in Kijabe. The first was spent finishing up the out-patient clinic which ran until approximately midnight, then spent hours in the ICU trying to get an IV line on a 8mo little girl gravely ill with cerebral malaria and intubating a women with status asthmaticus who made it a few more days on a the ventilator before passing away.
I got a little more sleep this second call dealing early in the evening with a patient who was unresponsive and trying to work through the work-up etc. with the intern on the phone. It was all I could do not to go up to the hospital and do it all myself but she wouldn't learn anything if I did it for her. I did do some sneak phone calling to the nurse so I could feel good about the situation and did check on the patient after being called up to the hospital for another reason. A difficult reason too. An 11mo little boy was severely dehydrated with fever, abnormal electrolytes, lethargy...sick kid...and the mother was refusing admission. All the nurses, physician assistant and intern (all Kenyan) had spent hours trying to convince her. Apparently they don't have CPS in Kenya. We would have just involved the police in the US. I don't know why they thought I, a white girl with a funny accent, would have more luck convincing her, but luckily I did. She was of course concerned about the cost on an admission to the hospital but most of all that she would lose her job if she did not show up for work the next day. She unfortunately had been visiting her sister in Kijabe when the child fell ill and had quite a distance to travel in order to ask permission to miss work, apparently a phone call by her or by the hospital would not be sufficient. I guess a little coaxing and lot of listening was enough, we agreed she could have her sister come stay with the child in the hospital while she traveled the following day. Not bad for 3AM.
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