Tragedy In Nairobi

Hi, just a quick note to say we're fine. It's been very sad to watch the details of the terrorist attack unfold on the news. Hoping that it will come to an end, soon, and that this is an isolated event. Our thoughts and prayers go out to the victims and their families.

Safety, First.

Is Kenya safe? A doctor who is thinking of working here asked me this tonight during a phone call. That is an interesting question to answer. Sagam village, where we work and live feels very safe. Tonight. like most nights in Sagam, is pretty quiet. The night air is filled with the hum of insects, occasional bird calls, the high-pitched sonar squeaks of bats on the hunt, and a particular rhythmic chirp from a frog that creates the image of a flashing red beacon in the night. And while the occasional inebriated man wielding a farming machete will get into a squabble and need suturing and casting at the hospital, I feel safer walking around here than I do in many big cities in the US.

One of the biggest safety concerns in Kenya, and in many African countries, is road safety.  A friend of mine recently wrote an informative blog entry on infant car seats, which can be found here. She's lived and worked in the developing world and can attest to the great disparities in car safety between countries. Common-place sightings here include small children riding behind handle-bars on motorcycles and being held on their mom's laps in overcrowded mini-buses.

Road traffic accidents, or RTAs as they are referred to in Kenyan hospitals, are very, very common here. The reasons are many, including poor road conditions, minimally enforced traffic laws, driving under the influence of alcohol, poorly maintained vehicles, lack of sidewalks for pedestrians, and near absence of emergency medical services and personnel, to name just a few. The other night we were brought face-to-face with the brutality of RTAs in a resource-poor setting. We were getting ready to sit down to dinner when we received a frantic call from the hospital. There had been an accident involved a car vs. multiple pedestrians, and the victims had been taken to our small hospital. We collected our gear and rushed over to do our part to help the many staff that were attending to the several victims. Though we tried our best with the skills and tools at hand, some were lost despite our efforts. The images from the resuscitation will stick with us for a very long time. These losses will only begin to decline with stronger government road safety regulation, as well as improved emergency medicine services. While I can't do anything about Kenyan road traffic legislature, hopefully the local clinicians and nurses we are training at the hospital, as well as the training program in family and emergency medicine that we are helping to initiate, will be a small step towards tackling this big challenge.

Some Notable Differences

As we were waiting in the car Saturday afternoon, trying to stay relatively dry during a heavy down-pour and getting ready to head home from the hospital, I saw something that I probably wouldn't have seen in the US.  An elderly woman we'd been taking care of during the week was wheeled down the ramp in the hospital wheelchair. I waved to her, thinking how nice it was that she had survived her hospital stay. A motorcycle taxi then pulled up to the end of the ramp, and the woman's daughter helped her get on the back of the motorcycle. The daughter then got on the motorcycle as well, sandwiching the patient between herself and the driver. The noteworthy part of this is that the patient was paralyzed on half of her body due to a stroke she had survived a few years ago. She also suffered from frequent seizures that were related to the stroke. I thought that a ride home on the back of a motorcycle down muddy roads turned into rivers was not exactly what the doctor ordered.  It reminded me that no matter what kind of control we think we have over patients while they're on the hospital ward, all that goes out the window once they've been discharged. We create a false reality. We order medications to be given to patients at specific times, we carefully follow vital sign measurements and titrate intravenous fluids. And then they get on the back of a motorcycle and head off into the rain.

We recently had an elderly patient come to the hospital that had fallen at home several times over the week and now was in a semi-comatose state. All of our limited blood test results were normal, and I was concerned about the possibility that she had bled into her brain due to one of the falls. In the US, regardless of her ability to pay, she would have been whisked to the CT scanner within minutes of arrival to the emergency department, diagnosed, potentially intubated to protect her airway, and transferred to the neurosurgical service for surgery or the intensive care unit for close monitoring, depending on the type of brain bleeding. But in many countries around the world there is little safety net for the poor. When we told the family member that had accompanied her our concerns and need for transfer to a bigger hospital just one hour away, she left the hospital in order to find other family members to discuss if they had enough money to pool together to make this happen. Even when our hospital offered to pay for the ambulance ride to the government hospital, the family declined immediate transfer, seemingly since they had little faith that they'd be able to manage the hospital bill associated with the CT scan (approximately $150 USD), the surgery, and subsequent hospital care. There is also no guarantee that she would have received quick and expert care at the referral hospital. The doctors and nurses there are often overworked, undertrained, and underpaid.

When I think of the most difficult parts of working in two very different countries, the most challenging is seeing patients succumb from conditions that they wouldn't have died from in the US. It's tough losing a patient, from any cause, and in any country. And often times the people that we lose here wouldn't have made it in the US either. But when an infant dies because the hospital was out of oxygen, or a teenager dies for lack of a blood transfusion, or a postpartum mother dies for lack of transportation to a health center, those are the hardest times.

I got off the phone tonight with my dad back in Texas who just celebrated another birthday. I've been so lucky to have him around all these years. Thanks, Dad, for being a role model and a good listener.  Thanks for the help with homework, for the fishing trips, and for supporting me during all these years of study and work far from home. Love you.

Pediatrics Ward: Some Bread And Butter

Doing rounds on the pediatric ward today gives a bit of a look into what is ailing kids around the developing world. What are the big killers of kids under 5 years of age? Pediatric cancer? Congenital heart defects? Not in countries like Kenya. In places like this, the big 5 are pneumonia, diarrhea, malaria, measles, and HIV. When was the last time a doctor in the US saw a child die from a bout of diarrhea, or even saw a case of measles? Things are very different here.

On our ward now we have a few kids with malaria. One little girl came in yesterday afternoon, weak looking and barely awake. A drop of blood was taken from her finger, spread out on a glass slide, and examined under the microscope. Staring back up at the laboratory technician were hundreds of malaria parasites growing and reproducing in her red blood cells, bursting them open when they were too many to be contained in a single cell. Probably due to the infection's effect on her bone marrow and spleen, her platelets are also quite low, potentially leading to the inability to form blood clots. She is sitting up in a little princess dress today, and smiling shyly at us. She's not out of the woods yet, but we're still happy and continually amazed to see children like her bounce back so quickly.

A boy sitting next to her with HIV and resolving malaria has been giving us high-fives for a few days. He's ready to go home, but we haven't seen either of his parents during rounds for the last few days. I'm amazed how parents can leave small children at the hospital without a care-giver. In the States, this would be considered child neglect. Here, it's often a reality of having to be at home to care for other children and chores.

The young boy next to him did not look quite as well. When he came in to the hospital yesterday morning, it was clear to us from across the room that he was having a hard time breathing. As he lay on his bed, weak and quiet, we could see his chest heaving rapidly. The average child his age breathes in about 20 times per minute. We counted his respirations, and he was breathing-in 88 times in a minute. With each breath in, his nostrils flared, and the soft tissues between his ribs sucked in slightly, showing us that he was using additional muscles to get the oxygen his body required. He was started on a powerful IV antibiotic and monitored for the possible need of adding oxygen (in the US he would have

definitely been given supplemental O2; here, where oxygen is expensive and precious, children with pneumonia are started on O2 when their blood saturation of oxygen falls below 90%).  Today he's sitting up and looking much better. He would have almost certainly died if he had stayed at home much longer. Now, with even just a few doses of antibiotics, he is on his way to recovery.

There are a lot of patients admitted to the hospital that we cannot save, based on limitations of diagnostics and treatment. But these cases of sick kids that turn around quickly make our day.

The Week Of The Cervix

Hello from Bungoma. We're in a medium sized Kenyan city located about half an hour east of Uganda and a little more than an hour west of Eldoret, the area of Kenya where most of the amazing long-distance runners come from. Svjetlana, Mimi, and I have joined up with a group called PINCC, Prevention International: No Cervical Cancer, this week to help train Kenyan health workers to screen for and treat pre-cancerous disease of the uterine cervix. Cervical cancer is a big deal. It's the main cause of cancer-related death among women around the world, and it's almost 100% preventable. With relatively simple examinations to detect pre-cancerous changes of the cervix and fairly straight-forward procedures to either freeze or cut out the abnormal cells, women can avoid the slow and painful death caused by cervical cancer. Cervical dysplasia, the term used to describe when normal cervical cells turn into abnormal cells, is caused by HPV, the human papilloma virus. HPV is very common around the world, and depending on the subgroup, up to 75-80% of people will have been exposed to it over their lifetime. Some people never have problems from it, some develop genital warts, and others - predominately women - have pre-cancerous disease and thankfully, much less commonly, cancer. In the US, we screen women for cervical dysplasia caused by HPV by using pap smears. Abnormal pap smears require women coming back for a longer examination with a magnifying instrument called a colposcope. During colposcopy, biopsies are taken of abnormal appearing tissue, sent to a pathologist, and if they are minimally abnormal, the patient is just watched with serial examinations. If the tissue changes appear more advanced, then an office procedure called a LEEP is necessary to remove the cells before they become cancer. This process doesn't work so well in countries such as Kenya, since it is expensive and requires women to return for several visits. We are teaching a procedure used more and more commonly in the developing world called VIA, where the cervix is swabbed with a 5% solution of acetic acid (household vinegar), examined for dysplasia that is highlighted by the vinegar, and then the abnormal cells are either frozen with a technique called cryotherapy, or cut out with a LEEP. This requires fewer visits than the typical US approach, and the results have been very good.

It's been a psychologically tough two days. We've seen several cases of probable cervical cancer and one case of probable advanced breast cancer. Due to financial reasons, these women, unlike their counterparts in the US, will likely never see the medications, radiation, and chemotherapy necessary to either cure them or at least extend their lives. It's hard to watch. But we soften the blow by reminding ourselves that we are here to strengthen these clinicians' ability to prevent more cases of cervical cancer. That, at least, is some solace. We'll be here through Friday, when we return to Sagam. Stay tuned for more updates.

The End Of The First Week

It's been a good week, though somehow it seems like more time has passed since our arrival here in Kenya. We had busy days on the wards seeing patients along with the clinical officers. The common diagnosis of the week, like always, has been malaria. Both children and adults have come down with bouts of the parasitic infection that is a plague for so many in Africa and a vague notion of an illness to so many in the developed world. Other admissions to the hospital have been for uncontrolled diabetes and hypertension, suspected bacterial blood infections, complications of HIV disease, and pneumonia and potential tuberculosis. We continue to work on how to help improve the systems operation of the hospital, instead of just focusing on treating one patient at a time. Are the vital signs being taking appropriately? Is there a better way to assemble the team in an emergency? Answers to these and other questions will hopefully improve care for these patients and many others to come.  The days have been long, so unfortunately I haven't had the chance to do much outside of the hospital. Mimi brought me to a nice sunset spot a few minutes walk from our house yesterday. We saw two huge crowned cranes prancing in the distance. This is what they look like.

We were all happy to see the arrival of Dr. Svjetlana Lozo, one of our new ob/gyn global health fellows. She'll be on the ground in Kenya for months at a time, off and on for the next 2 years. She's excited to get working on some challenges encountered in the care of women at our hospital. It will also be nice just to have another doc on the ground when things get difficult.

We'll be working through the weekend and then heading out to the town of Bungoma. We're joining a team called Prevention International: No Cervical Cancer (see www.pincc.org for more details) to screen for and treat women with pre-cancerous lesions of the uterine cervix. More on that as the week unfolds.

Hope you're all well, and thanks for reading.

Jeff

The First Weekend

Mimi and I arrived safely in Nairobi after a few very smooth flights from San Francisco. The biggest unknown variable in the process was whether our arrival into the Nairobi airport was going to be delayed due to the fire at the international terminal. Thankfully, they were running things pretty smoothly out of tents, and we got from the landing strip to the car in only about two hours. We spent the night, Friday, at an apartment that has graciously been made available to us by one of our friends and partners in Kenya. The next morning we woke up bright and early due to the jet lag and headed back to the airport, seeing some humongous marabou storks chilling in the acacia trees lining the roads on the way (see below). A short 30 minute flight took us over the Rift Valley and into Nyanza provence. We circled around the large, hyacinth-choked Lake Victoria and landed smoothly into Kisumu, Kenya's third largest city after Nairobi and Mombasa. We met Fred, our Kenyan driver, who is more smile than mass, and he whisked us the hour northwest to Sagam village. The sleepy little village was bustling with a mega-medical camp that was being held to reach the people of the Sagam community, bringing members of parliament, dozens of doctors from around Kenya, and thousands of patients. It was quite the introduction/welcome back to Sagam for Mimi and me. In the evening, around the time that my body was telling me that I probably shouldn't still be awake, we headed off to catch a continuing medical education talk held between the Independent Medical Legal Unit of Kenya and the Kenyan Medical Association. It was a pretty interesting debate regarding the doctor's role in protecting human rights for their citizens. Sunday was the second day of the medical camp, and we saw patients at the hospital and performed some
ultrasound scans of patients that had been referred for imaging. Particularly interesting results included a gentleman with the biggest dilated bladder and kidneys I've ever seen due to an enlarged prostate that he must have been battling with for years, as well as a pre-teen boy with a very large heart due most likely to an infection that lead to rheumatic heart disease. We'll be working to help them and others out that were diagnosed in the medical camp. It's a little hard to believe that tomorrow is the start of the week!

Headed Back To Western Kenya

Greetings from the air. Today I take off again for western Kenya, my first time bak in six months. Our collaboration with Sagam Community Hospital and Maseno University School of Medicine, situated within an hour's drive of beautiful Lake Victoria, continues to go well. Since my return from Kenya in February, I've continued to work at the Contra Costa Regional Medical Center in Martinez, California. As part of the obstetrics training of my global health fellowship, I'm slowly getting better at managing high risk pregnancies and performing cesarean sections and the like. I still have about a year left in the fellowship, and I'm looking forward to it. Five months of this year will be spent in Kenya in two divided trips. The rest of the time I'll be at Contra Costa. And while learning how to operate and creating a training program for doctors in Kenya is pretty cool stuff, the biggest news in my life is that I saw the new Star Trek movie recently. No, just kidding. The biggest news is that two months ago my girlfriend, Mimi, agreed to become my wife. Eventually. We don't have a date set, or a place, or the color of the napkins. But we're committed, super excited, and I'm the happiest I've ever been. We're making this trip to Kenya together. For Mimi, it will be her first time in sub-Saharna Africa (she was born in Egypt and has made one trip back there). She'll be teaching and volunteering with the kids in the local school and hospital. I'm grateful to have the opportunity to share this experience with her. Stay tuned; we'll keep you abreast of what's going on in Sagam.

NorCal

I'm back home.  Friday, after consulting on a few patients and saying my goodbyes, I left the village of Sagam and headed to Kisumu. From there, I hopped the quick 35 minute flight to Nairobi and hung out for about three hours until taking the red eye to Amsterdam.  At the Schiphol airport, I had the pleasant experience of hanging out in the KLM frequent flyer lounge (that included free hot showers) until my flight to SFO. All in all, travel time from Sagam to the North Bay was about 30 hours. Besides forgetting my pair of running shoes on the plane, I had a nice, uneventful journey. I'm now farm-sitting my friends' place in the lovely town of Healdsburg. It's a lovely 66 degrees. The sun is shining, the internet is fast, and the hum of the clothes dryer reminds me that I'm no longer in rural Kenya. But my thoughts linger a continent away. What is happening to the little 9 year old girl with HIV and swollen glands that may be a sign of either TB or lymphoma? How is she after her needle biopsy? What about the 23 year old woman with heart disease that may need surgery to repair one of her heart valves? I'm out of Kenya, but many of my thoughts and worries are still there. The truth is the patients are in excellent hands. Michele, the family doc on the ground now, is amazing and will take wonderful care of them. Nevertheless, it's hard to leave it behind.

If things go as planned, I won't return to western Kenya until August. I haven't been in the same country for 6 straight months in a while. A year ago in March I headed to Malawi for a month, then worked for two months in South Sudan, hitting a few other places on the way home. I came back to California for two months then did two and a half months in Kenya, two months in California, two and a half more months in Kenya, and now I'm back here in NorCal. I'm ready to be home.

Much will need to happen for the Family and Emergency Medicine residency to be ready to start in September. The curriculum needs to be accepted, applications need to be reviewed, faculty need to be chosen, and agreements between hospitals need to be finalized. An emergency ward needs to be built at Sagam Community Hospital, additional staff need to be hired, and systems need to be improved. There is plenty of work to keep us busy.

Thanks everyone for reading the blog these last few months. Please tune in around early August if you'd like to keep up with my travels.


















Jeff

Keeping Busy

Thank you for those that have checked in about the blog. I'm doing well, here in Sagam, though we've been kept busy with a lot of work at the hospital. Since coming back from the States, little Sagam Hospital has been hopping. The patient census has been high, as has the acuity of some of the patients' illnesses. We have helped treat some tough cases, and have been lucky and blessed to see a number of the patients get better and walk out of the hospital.

A few of the cases that have been on my mind:

We recently had a child living with HIV who came in with a severe case of malaria. He was weak when he was admitted, was slow to respond to questions and was not acting like himself. When he wasn't responding to the various medications we were giving him for malaria we also added a strong antibiotic in case we were missing a bacterial infection in his brain.  Due to the swelling caused by infection (malaria or bacterial meningitis or both), the pressure in his brain was building up to dangerous levels.  He started having seizures, and the brain swelling caused him to slip into a coma and begin to hold his body in a rigid posture, called opisthotonus (see photo).  We did all we could, and I was pretty sure he wouldn't make it until morning.  When we checked on him in the little pediatric ward the next day, he was alive but still doing about the same. But still, he was alive, and so there was still some hope. We continued our treatment and later that day, though still comatose, his muscles were a bit more relaxed.  Again, as I went home, I was pretty sure there would be an empty bed the next day. But lo and behold, little by little over the next few days, he came back to us. He emerged from his coma, he began to follow us with his eyes, and eventually could take a little porridge, answer questions, and then the big one - smiled at us. Today the clinician in charge, Benard, signed him out of the hospital, and the little guy walked out. He's still in danger, as he missed several days of his HIV medications, and there is risk that his virus is now resistant to one of the medications. But nonetheless, he has a chance.

Another recent challenging case was that of a young man in a coma who was brought to the hospital on the back of a motorcycle.  He smelled strongly of a chemical that made me think of turpentine, and he was not responsive at all. Thankfully he was breathing on his own, and he had a heart beat; but otherwise he was in a deep coma.  On questioning the family, it turned out that he was in a argument with a family member and purposely ingested a poison called Triatix, which includes the compound known as amitraz.  This chemical agent acts as an alpha-2 agonist (an example of a medicine that is an alpha-2 agonist is the blood pressure medicine known as clonidine). In the US he would have had a breathing tube placed down his windpipe, hooked up to a ventilator machine that would do the work of his lungs for him, and two dozen tests and imaging studies would have been ordered before he had spent 30 minutes in the ER.  Here, we had a very limited number of tests and treatments at our disposal. So we gave him oxygen through a machine and suctioned the oral secretions that he couldn't swallow due to being in a coma. Those worked until the power went out. We were able to start a diesel generator the size of a suitcase and run it intermittently when he needed it, keeping in mind that we needed to ration fuel.  When his pupils remained dilated and unresponsive to bright light, and he showed no other signs of cholinergic poisoning or prior treatment with atropine, we called the family to let them know that he we thought he had brain damage and would likely not recover.  We waited until they arrived and then went home with heavy hearts. But yet again, we were pleasantly surprised to see him in the morning.  He started to grimace when we suctioned his oral secretions. His pupils were no longer dilated. As the day went on he began to become a little more responsive. When I walked into the wards the next day, he was watching the medical team and responded to our greetings. Amazing. Again, we were wowed and humbled. Thankful for his recovery, we are still cognizant that his road ahead to good mental health and well-being will likely be a long one as well.

Newborn Distress

Tonight I'm back in Sagam after a long set of flights from the US. I was kindly met in Kisumu by Jennifer, and after some food and running some errands in Kisumu we prepared for the trip back to Sagam. About that time I got a call from Mairead, our nurse who is volunteering at Sagam, that a newborn wasn't breathing and was undergoing resuscitation by the Kenyan nurse on duty.  We discussed how to best support the child, and I hopped in our very packed car and headed back to Sagam with the rest of the team (that now includes 4 Harvard undergraduate students that will be volunteering with us for the next 3 weeks).

After ongoing phone reports on the road from Mairead that the child was stabilizing and breathing on her own, we decided to transfer the baby to a bigger facility with neonatal trained nurses and physicians. I called a Kenyan pediatrician I know and was saddened to hear that Kenyan health workers in public hospitals were on strike regarding poor wages. If we sent the newborn to a public hospital, she would be refused entrance to the facility.  He suggested the child stay with us, since even though we aren't adequately equipped to deal with very sick neonates, at least we would try.  We double-checked with the family to see if they could afford care at a big, well-supported private hospital in Kisumu, but they could not.

I was surprised and happy to see that the little girl was alive and still breathing on her own by the time we got there. After struggling with several attempts to get intravenous access in order to start antibiotics, we were finally able to get an intraosseous line placed in her femur. This is a thick but relatively short needle that is drilled into the bone so that medicines and other fluids can be administered into the bone marrow. After being infused into the marrow, the medicine then leaves the bone via many small veins and enters central circulation, getting wherever it's needed all throughout the body.  I'm very thankful for Dr. J's donation of these needles to us.

We left the hospital sweaty, tired, hungry, but happy that the little one was still holding on. I'm not sure if she'll make it through the night. But thanks to Mairead and the rest of the Kenyan and US team, she has a fighting chance.