Tuesday, August 27, 2013

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.

Tuesday, August 20, 2013

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.

Friday, August 16, 2013

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

Sunday, August 11, 2013

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.