Hell's Gate National Park

We had a wonderful opportunity to explore a natural wonder where geothermal vents come up from the ground at Hell's Gate National Park. Kenya harvests this natural power to supply energy for half the country. Surrounded by Africa's natural wildlife we explored the park and got to go hiking in a beautiful ravine. Watch our for flash floods!

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!

Comfort the Children International

Yesterday afternoon Gus and I visited a special needs school in Maai Mahiu, a small town down in the valley just below Kijabe. The town is much like a truck stop, as it is on the main road from Nairobi and Mombassa (the port city), transporting goods to Uganda. Check out the entire picture album on the Picasa link at the upper right of the blog. You will see some pictures of the surrounding shops and road, in addition to the school itself. I also have some video of the Shooting Stars class (this is their advanced class) singing a couple songs for us. Gus sang "Head, Shoulders, Knees and Toes" for them and then they sang their songs. Unfortunately, I didn't get Gus's song on the video (sorry the video is not uploading properly-will see if it can be added to Picasa).

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

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. :)

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 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

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

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

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.

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

Everyday stuff

"Good Morning" says Gus, except he uses this expression all day and night when greeting people. Everyone tries to correct him, but he doesn't get it yet.

Gus has discover constellations, specifically Orion and Taurus. He got himself dressed to go outside this night to see the stars, hat on sideways and rubber boots. He prefers to wear his boot all day, because he can easily put them on and take them off himself.

Okay, this is not everyday stuff, but when we do have a day off our favorite thing to do is go hiking. This is from the top of Mount Longonot. It was pretty hot and dusty going up the 5km climb to the rim. There is a trail along the rim all the way around, 10km more. Maybe we can do it next time.

Again, not everyday for us (and I would confidently say never for Katy), but I did yesterday and this is a very typical kitchen and meal for many Kenyans. Ugali, a cornmeal mash, is cooking here over the fire. It will thicken and then they press pieces into their hands to use to eat the other food in the meal. Cooked cabbage salad, with some spices and tomatos accompanied the ugali and was served to our construction crew. You'll here more about this in my next post. They gave me a spoon to use, since I wasn't able to properly was up (no soap). It's not bad when you're hungry.

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.

cooking in kijabe

A couple people have asked how the fish turned out and I realized that I forgot to report on it. You know that cooking is a great pleasure of mine, so I've been working with the minimal kitchen and supplies available to me and trying to eat well. Our house here was not stocked with any kind of spices except salt and pepper. At our big grocery trip I only picked up curry, chicken masala, and pilau masala spice mixes.
The fish was common carp and after spending quite a bit of time filleting it (rather poorly) the night before, I coated it with the chicken masala and fried it hard on the skin side and then a bit on the seasoned flesh side. And it did in fact taste good; though way too many bones. I forget what they call the extra line of smaller bones in the fillet, but they make it a little tedious to eat carp.
Tonight, I made chicken coconut curry with potatoes, onions and collards (wishing I had a tomato to throw in) and masoor dal (lentils) with the pilau seasoning and rice, again worried about the lack of spices and ingredients at my disposal. Low and behold, another decent meal.
Tomorrow will be mac and cheese casserole and the neighbor family of four is coming over. I'll have to borrow some flour for this from the neighbors first.
Later in the week I'll soak some beans, buy some chapatis (tortillas) and hope to find some chili powder and attempt "mexican"
Tomorrow will also be shopping day at the market, for fruits and veggies and fresh samosas (every tues and sat). I'll have to take some pictures of bananas and pineapples in their native environment and add them later.
Now you are probably getting hungry for dinner. bon appetit.
zach

Mount Longonot

Kijabe looks right out over the Rift Valley and directly at Mt. Longonot. Today we took the morning to climb up to the view point. Breathtaking. We didn't traverse the rim with our little G, but don't have any regrets as it was a hot and dusty hike. Feeling satisfied with a little exercise and a pretty view.
---Katy

Just What the Doctor Ordered

I am really starting to like my work on the Women's Ward. Most likely because I'm getting to know the patients that have been there all week with me as well as the nursing staff. It's very different than working at the hospital at home, in Kijabe all the patients are located in the same 4 rooms on the same floor instead of spread throughout a 12 story building in a high-rise in Seattle. The same nurses come in everyday and you start to get to know them more each day and well as the idiosyncrasies of working here and within the Kenyan culture. And all 16 patients are mine, I take care of them from 7am to 6pm (and sometimes late at the night or the weekends when I'm technically off but know no one is watching after them or knows their stories as well as I do). I do have a wonderful teammate Martin, a clinical officer which is like a physician's assistent, who is brand new out of training so has a lot to learn but is motivated and a great help with "scut work" and translation. Dr. Scott Myhre is also on our team, a US trained physician who is also new to Kijabe, but has been working in Uganda for several years and who's awareness and depth of knowledge about treating tuberculosis and HIV related complications is invaluable. It's a lot of work and we have some very sick patients but I feel very dedicated and honored to do it, just wish I had my fellow Swedes (residents) here to whip this hospital into shape!

After Saturday morning rounds Zach, Gus and I headed out of town for the afternoon to Lake Naivasha. We went to a beautifully landscaped country club with a pool and also took a boat out to see the wildlife. Gus finally got to see hippos! As well as many birds, giraffes, monkeys, etc. It was a very relaxing day, just what the doctor ordered.
---Katy

Flow of Hope

I've been hanging out with John Njane quite a bit and getting to know the area outside of Kijabe, which is quite isolated from the typical Kenyan lifestyle because of the missionary influence. For instance the Rift Valley Academy (RVA), which is a large school for missionaries children, is as nice as any school back home, with amazing ball fields, gyms, playgrounds, etc. And then the troops of baboons that hang around the perimeter are just a bonus. John is very motivated to help improve his community and has been a blessing to many people. He received some generous support from an individual when he was younger which allowed him to complete school and learn his trade in mechanical engineering. He was profoundly affected by this gift and opportunity to better his life and I suspect he will spend the rest of his life passing that blessing on to others.

Flow of Hope is his mission and is based on direct involvement from its benefactors, with the ideal that seeing and participating directly with community improvement here is the most practical for all. His mission is to instill a sense of hope in people so that they can strive to better their lives and to continue to hope for better and better things, thus the continued "flow" of Gods love and desire for us to care for each other. So, I will try to provide a brief overview of Flow of Hope here, which I have found to be very well thought out and organized.
Flow of Hope is the umbrella structure for multiple outreaches. Widows of Hope, I believe, was the first to develop and provides assistance to older ladies that are often supporting multiple grandchildren and kids in the community with little to no resources. These women have received house improvements, livestock, seeds, and assistance with school fees. As their houses are improved, it enables then to continue to care for their children and alleviate the risk of losing them to the streets (if there is not enough room at home, kids will leave to fend for themselves).

Then there are multiple trade programs targeting different groups. Thread of Hope is providing sewing machines and training for young women that often resort to prostitution as a means to support themselves. There are the street boys, which for now, John tracks down in the community to act as a role model and instill in them some pride in their appearance and demeanor, so that they may have a better chance of getting work. Currently he has organized soccer tournaments to get these kids involved. He hope to develop Wood of Hope (wood shop), Metal of Hope (metal shop) and Wire of Hope  (computer training).
With the sewing machines he plans to provide machines to individuals through a kind of micro-loan program, where they will be able to earn money and pay off the cost of the machine. The basis for all of this work is to enable people to be able to provide for themselves. The people here are very laid back, so if they are given too much, they will not be motivated to care for themselves. Another example of John's contributions are with school fees. The widow we visited yesterday owes a balance in school fees. John provided her with half of the money, a little more than $1 worth and expected her to work for the rest. When we arrived at her house, she provided a receipt showing the payment to the school that she made which was for more than he had given her. So, it is working.
Below is a picture and hopefully we will be back next week to do the work. Please pray that this will be a fruitful gift, beyond anything we can imagine in the short term. It looks like the cost for the roof will be around $500 and any contributions made to Katy's doctors account with World Medical Missions/Samaritans Purse will be  used for this project. (note, Flow of Hope is actively working on NGO status in Kenya and nonprofit status in the US, so that financial support can be direct, but for now, this is what we have come up with for interested donors. Please don't hesitate to contact Katy or myself directly with questions or interests in getting involved). Your continued prayers and thoughts are being received and very much felt in our hearts. It takes a special kind of grace and patience to be here and it is not something that we are accomplishing alone.

Peace,
Zach