Thursday, August 30, 2012

Meetings, Patients, and Insanity

Man, time flies. It’s easy to get wrapped up in the day to day and forget to blog. Life continues to be fairly sweet in sleepy Sagam. Since I last wrote, we’ve made some progress in getting the relationship going between MGH/Contra Costa family med residency in NorCal and Maseno University here in western Kenya. We’ve also continued to consult on patients in the hospital

We met the head of the local district level hospital, Dr. Omoto, who is an OB-gyn doctor.  Siaya district hospital is one busy place. They see around 300 patients per day. Besides being plain busy, they had several programs of interest. For one, they were using an electronic health record system that had been put together for them by a programmer in California. Patients were seen by clinical officers, the CO would type the info from the visit into a laptop that was bolted to their table, and with the hit of a button, the prescription from that visit was sent to the hospital pharmacy around the corner. I’m not sure if that definitely will lead to improved patient care, but it was at least neat to see. Impressively, we came to a quiet room where HIV positive patients were receiving chemotherapy for Kaposi’s sarcoma, the blood vessel cancer that I mentioned in a previous post. They also had screening for cervical cancer using VIA, or visual inspection with acetic acid. Many developing countries like Kenya use VIA in lieu of pap smears, since results from a pap smear, if they ever come, can come very late. Using the VIA technique, vinegar is applied to the cervix. Abnormal areas of the cervix, like those that could be affected with the human papilloma virus (HPV), can be biopsied right away, obviating the need for an initial pap smear.

We’ve also had a few meetings with the faculty at the med school. They are interested in a collaboration that involves us helping to teach medical students, train family medicine residents, and help out in other ways. They are a motivated bunch of docs, and there is good potential here.

The patient consultations continue to be interesting. I’m inclosing the picture of a tumor that has been growing out of the head of a patient over the last 4 years or so. The point of view is from above her head – a bird’s eye view. Amazingly, it’s almost as big as her head. We wrote a referral note to the specialists at Moi University, located about 4 hours away by public transport, with the hope that she will be seen by an ear, nose, and throat specialist as well as a neurosurgeon. The mass is almost certainly benign, since the patient is still doing so well despite the large mass.

Other cases have included a very sweet 85 year old woman with an ankle that was shattered and dislocated during a fall. We’ve tried twice to get the ankle back into place by giving her medicine to relax her and take away the pain, and both times, the xray showed that it was still out of place. The first time we tried an intramuscular injection of ketamine, an amazing drug that puts a person into a bit of a trance, in order to do a normally painful procedure like a reduction of a dislocated joint. The second time we injected lidocaine directly into the joint, in order to minimize the pain while avoiding the risks of generalized sedation (she suffers from high blood pressure, a heart arrhythmia, and she had just eaten a big meal, which might complicate things if she were to vomit and aspirate the contents into her lungs). We’ve referred her to the large public hospital an hour away for orthopedic surgery where they hopefully will open the ankle up, reduce the fracture, and then put metal hardware to keep it in place.

Another case involved a young man that ingested large amounts of alcohol as well as probably some sort of poison. He was so sedated from his ingestion that he couldn’t protect his own airway and was at risk of asphyxiating. In the US, where we have a respirator machine that would breathe for him around every corner, I would have intubated him (put a tube down his windpipe).  But here, without a working ventilator, we just watched him closely and hoped. I suppose if he had gotten to the point where he stopped breathing, we could have intubated him and had staff and family alternate squeezing the ambu-bag to breathe for him until he recovered enough to breathe on his own.  He is now awake and conversant, but he has a fever, a fast heart beat, and is breathing quickly. He likely got some liquid into his lungs and basically has a chemical burn and a bacterial pneumonia. Hopefully, he’ll do alright on antibiotics.

We continue to see malaria cases most days, patients with HIV (both new diagnoses and those who come in already on HIV therapy), and tuberculosis. We are definitely seeing lots of diseases of the first world - non-communicable diseases, often related to diet and lifestyle, like high blood pressure and diabetes. We recently had a nice elderly woman who felt fine, but when her blood sugar was checked, it was reading a value of 600. A normal value is usually around 140. We have had a number of patients with infections like gangrene due to uncontrolled diabetes. We are working to improve the weekly diabetes and hypertension clinic, so that fewer people get the complications of these diseases.

Oh, and we're doing some Insanity. That is to say, we stand in front of a laptop, and listen to Shaun T (pictured here) lead a gym full of fit men and women, along with the home audience, through some insane workouts. The Kenyans think we're pretty hilarious, doing high-intensity aerobics on our porch. I think they're right. We look hilarious. But we're preventing diabetes. Actually, I heard that Insanity is huge on the Navajo nation. Supposedly the Navajo, a group of people at high risk for diabetes, hypertension, and obesity, fill a big facility on the reservation and do this ridiculously intense aerobic work-out. Not so insane after all, I suppose. 

Life at the house here in Sagam has been good. We have been whipping up some nice meals. Luke made an Israeli dish last night with bread, lentils, eggs, tomatoes and other veggies. Tonight we're in "finish what's left in the house" mode since we're heading to Kisumu tomorrow. We heated up some leftovers and also whipped up a potato and veggie scramble that was, albeit not as good as what is routinely made on the Dolan Finca, was still noteworthy. 

The weather continues to be quite nice. Even though we pass the equator when we make the 15 minute trip to the med school, due to the elevation, it's not what most people would imagine when you mention equatorial Africa. We get some showers every day, and it rarely gets warm enough to be uncomfortable.  In the mornings, Luke and Michele are usually wearing long sleeves or even a jacket as they eat breakfast on the porch. The rains keep the flowers blooming, and I've attached a few pictures of flowers we've seen in our 'hood. 

Thanks for reading, 



sarah said...

I would love nothing more than to mosey by your place and find Chuck Norris jumping around 'insanely', eyes glued to a laptop. Is this training for the Vine Man?

silvanus ogutu said...

Heey Jeff, what happened to the Juba Teaching & Referral project you people were doing in Juba, South Sudan. The last time you people visited me at the URG Clinic, we talked on how to start and improve the Blood Bank at the Hospital . I can read that you people are now at sagam community hospital in westrn Kenya. Did your project at JT& R failed ?