Going Home

Bonjour from Charles De Gaulle airport in Paris. I'm headed back to San Francisco after a little more than 9 weeks in Kenya. This was my last of 5 trips to East Africa as part of the MGH collaborative (the first trip to Juba, South Sudan, and the subsequent four trips to the village of Sagam in western Kenya). It's been a nice ride. I've certainly learned a lot, made many good friends, and met my future wife in the process. How could I ask for anything better?

Friday was full of good-byes and well-wishing at Sagam and the nearby city of Kisumu. While Paula was rounding on the patients in the hospital, I had a chance to say good-bye to some of our clinical officers (Stella and the new eye CO, Audi), nurses (Margaret, Samuel, Mercy, and others), accounts team (Mr. Ofula and Eunice), lab personnel (Erick and Mary), pharmacy tech (Edwin), and of course Walter, our chief medical officer. There were lots of hugs and pictures with the canteen staff, that group of great women (Emily, Millicent the younger, Millicent the elder, and Janet) that has brought us great food day in and day out. And of course the hardest good-bye was to Jane and Nelson Rogo. They have been  my extended family out here and take care of us like one of there own.

We wrapped up the day with dinner at the Kisumu "Yacht Club", and I said good-bye to the medical team from Sagam. The next morning, I headed out for possibly my last run on the Kisumu loop that includes the Milimani neighborhood, goes past the Hindu and Hare Krishna temples, returns down the gauntlet that bring
s the cool lake wind at your face, and around the bend of the Impala Park animal sanctuary. Brunch with the Kisumu house crew (Anna, Griffin, Jackie and also Brianna) was at by far my favorite restaurant in Kenya, Gopala's Vegetarian Restaurant, followed by a cup of cafe and a very moist slice of chocolate fudge cake at The Laughing Buddha across the street.


As far as my role in the project goes, the question at the end of the day remains, have I done more good than harm? And my answer is still a slightly shaky, "I hope so". There are those in this line of work (NGO staff, global health volunteers, foreign aid workers and the like) that are 110% convinced that their projects are beneficial. I imagine that they sleep soundly with slight smiles on their faces as they dream of all the happy, well-fed children who's lives they are improving. I'm not in that camp. I know I have gained much from this and other projects. And I know there are some patients that are in a better place because of our presence. I also think that the doctors, nurses, and clinical officers that I've taught and learned along side with are better equipped to deal with a variety of challenges they face in the hospital on a daily basis. I do hope that the overall benefits of our presence in western Kenya (and foreign aid's presence in the developing world, in general) outweigh the harms. I don't know for sure, and I probably never will. But as I spend some time back home, catching up with my family and friends, I will have some time to think about it.

Thanks for reading along. Signing off for a little while.

Jeff

Thursday - Last Night In Sagam

Today went by quickly. Paula was rounding on the patients admitted to the hospital, so I had the chance to catch up on work emails, contact a few consultants regarding some of our patients, and do an ultrasound to take a better look at an elderly gentleman's heart, kidneys, bladder, and prostate. Being able to use ultrasound has been a true game-changer out here. Not long ago a good friend of mine was telling me how point-of-care ultrasound, or using the ultrasound machine at the bedside to aid in diagnosis and treatment, could be learned rather quickly. I didn't believe him. When I was a resident, one of the attending physicians told me I should be able to read basic echocardiography of the heart - that it wasn't all that hard. I didn't believe him either. But now just about 2 years into using ultrasound on a routine basis, I feel like a whole new dimension of medicine has opened up to me. I'm thankful that I've had the opportunity to learn about it, and I'm happy to get the chance to pass on these skills to other clinicians in training that are interested in learning.

After work I came home, took a nap and tossed the frisbee around a bit. We then made an all out Mexican feast of refried beans, Mexican rice with garbanzo beans, pineapple salsa, chips and guacamole, and tortillas. A little chocolate for desert and good dinner table conversation topped it off. It was a good last night in Sagam.

A Day Off

I had today off after a week of daily rounds at the hospital. The electricity was out for most of the day, so I took the opportunity to sleep in. We are a busy house, often with 5 to 9 guests in fairly tight quarters. So it's nice to have the chance to read quietly or play guitar without worrying that you'll be bothering anyone. I'm reading a book about Americans who choose to live off the grid, which is a little ironic, since so much of Africa and the rest of world lives off the grid by default. The rest of the team living at the house came home in two groups. I had a chance to throw the frisbee with Rachel and watch the sunset with Rachel, Lana, and Brianna, which turns out to be a very nice way to spend a late afternoon. We whipped up some sautéd veggies and potatoes au gratin, and followed dinner up with fresh pineapple and dates. Sanjat and Paula got home late after a long day at the hospital. I have only two days left in the hospital before heading back to California. Time is slipping by.

Tuesday: Last Day of Rounds

Today was my last day of rounding with the clinical officers (COs) on the wards. With the trolly of lab and x-ray order forms tagging along with us, we visited the patients first on the male ward, then the female ward, and finished up with the pediatrics ward. One of our patients passed away suddenly last night. We knew she was elderly and quite sick, but I was still surprised and taken aback by the news. Her family had been doing such a good job caring for her at the bedside. I hope they are doing OK.

Thankfully, a lot of patients were doing better and several went home. The patients were here with varied afflictions - from malaria to malaise, and from acne to AIDS. As usual, some patients didn't really need to be in the hospital. Others needed to be in a  much better equipped hospital than ours. But we did the best that we could with what we had at hand.

I've enjoyed working with our cadre of full-time COs. They are hard working and have their hearts in the right place. Their clinical skills have also really advanced over these many months.  As I watch the decisions made by some of the visiting part-time COs that pass through, I'm at once disheartened by the quality of education they've received but also impressed with how far our great COs have come. It's been a pleasure working with them and hope they continue to care for their patients and teach their peers for many years to come. 

Sunday, Lovely Sunday

Ahh, what a nice Sunday. We worked steadily on rounds and were able to be out of the hospital a little after midday. The crew at the house fixed up an amazing brunch of savory and sweet crepes, banana bread (with a chocolate swirl), and mimosas. We got some work done in the afternoon and then had a blast tossing the frisbee around the yard. We played a little guitar and then had some leftovers and more good dinner conversation. Electricity...check. Hot water...check. Internet...sort of check. Good people. Good times. What a Sunday.

Sagam Saturday

Today we had a visiting doctor from a company in the US that sells mostly used medical equipment at reduced rates to the developing world. Our hospital has benefitted from their equipment, and it was interesting having her see how the equipment is being used. Not all of it fits perfectly in our setting. Though in general it has been much more appropriate than many donations I've seen over the years at other hospitals. Well-intentioned American hospitals will often donate their unwanted, outdated machines to struggling hospitals in the developing world. The donors feel good about their generosity, and the receiving hospital uses it until it breaks (if it could ever be used in the first place) and then allows it to sit, derelict, on the hospital grounds for years like a wrecked ship. In contrast, last night, the surgeon operated in our theatre that her company helped outfit. Today, we had a delivery on their donated delivery bed, did an EKG with a machine from her shipment, and used our well-loved and oft utilized ultrasound machine donated by a separate group. These were all helpful, showing that smart, carefully selected donations can make a difference.

Friday Rounds

We rounded on the patients in the hospital, starting around 830AM as per our usual routine. The kids on the pediatric ward were getting over their malaria and diarrhea and got to go home. The men in the male ward were getting over their malaria and pneumonia and also went home. The female ward was another story. We have a mix of acutely and chronically sick patients, few of which were well enough to go home. One patient, who has been on the ward for about 3 months, looks like she will finally go to the operating theatre for removal of a pin that was placed to hold her fractured leg bones together. She is calling her family members to raise money for the procedure. The whole cost, including the hospital fee plus the outside surgeon's and anesthetist's fees will be about $300. This would be a bargain in the US but would be out of reach for many in the area. She will get the surgery tonight, and we'll work out the finances later.

We have had electricity for most of the day. When the power goes out, we start a generator the size of a suitcase that can run one power strip. This allows us to give oxygen via an oxygen concentrating machine (oxygen via the tanks typically used in the US is too expensive for most of the world), to run a few labs, and to charge lanterns. But today we were doubly lucky: plenty of electricity and no patients sick enough to require oxygen. I count that as a good day, indeed.

Last Week On The Wards

Time flies. I have less than two weeks left before finishing up my time here in Sagam. This is my last scheduled trip here. I'll have several months left of the fellowship, but those will all be spent in the US. I haven't been blogging much, and I'm not sure why not. Sure, we've been busy at the hospital, and internet or electricity are often out. And there is no lack of interesting material to write about. But I just haven't been putting my thoughts down, and I'll probably regret that eventually. Overall, things are going well here. We have a full house of volunteers currently: Sanjat, hilarious med-peds resident in New York, Shannon, an ob-gyn resident in Boston, Svjetlana our ob-gyn fellow, Paula, our internal medicine fellow, Brianna, our nurse fellow, Rachel, our logistician extraordinaire and Rashmi, visiting doc from Nepal.  It's a good group. Tonight there is good energy at the house as we cook up an eggplant pasta with focaccia bread and look at all the goodies that Svjetlana brought us from Olympia (flax seed, chocolate, coffee and the like). After a week on the Sagam Hospital wards (where I took this shot of the praising praying mantis), I had a little time to breathe and stretch, which was good for the soul. A chance to strum the guitar and sing badly, to go for a run, and eat some great South Indian food at Gopala's Veg Restaurant. I start my last week on the wards tomorrow. I'll see the patients with the clinical officer, and we'll do our best to make the right diagnoses and get the patients on the right treatments. No matter how long I work in Kenya and countries like it, I think I will always struggle with the challenge of seeing patients with conditions that we could treat in the US but cannot here. Sure, come in with malaria, pneumonia, or diarrhea, we can probably help you out. We're even slowly getting better at treating chronic diseases like diabetes, hypertension, and mild heart failure (though we don't do that great of a job in the US, some would argue). But come in with an advanced neurological condition, a surgical need that requires anything but a general surgeon, an advanced heart condition, or an eye problem other than a cataract, to name a few conditions, and you're probably out of luck. If you have wheels and cash, you can get to Nairobi and to the sparkling, towering Aga Khan University hospital. And even if you have medical insurance, this really only takes you so far, as it covers a daily inpatient bed fee, but doesn't cover surgeries, outpatient visits, costly medications or labs, etc. Granted, access to care here is a lot better than in most other countries in sub-Saharan Africa I've worked. And the medical infrastructure seems to slowly be moving in the right direction. I'm thankful for what we have. It's still just tough. Two weeks left. I'll try to keep the updates coming as things wind up. 

Celebrating Life

Today was a pretty good Sunday. I went for a pretty decent run around the less-traveled byways of the village. I had a good running mix on my old and faithful iPod, the skies were pleasantly overcast, and the land was verdant. We had power for over half the day, and that allowed me to catch up a little on my emails, to do some work,  and to finally taste the squash that we'd been trying to cook for the last few days due to intermittent power outages. The highlight of the afternoon was going to the house of one of our patients to celebrate his 66th birthday. His pastor, church choir, and several family members were in attendance to celebrate this man's successful survival of multiple ailments that he's been treated for at our little hospital over the last 6 months. We hummed some hymns, ate a meal of green grahams, pilau, fries, chapati, avocado, and banana, and then sang different renditions of happy birthday as he cut  into his pink and white icing birthday cake. We were touched to be invited and wish him a wonderful 66th, and an even better 67th revolution around the sun.

Pineapple Upside-down Cake

This was all that remained of Hugh's pineapple upside down cake mere minutes after we descended upon it. We joyfully singed our palates with the still steamy pineapple pieces. The meal preceding it was as well over the top. Refried beans, guacamole, corn cakes, and other things that now that I can't specifically recall. We were full to the brims and shouldn't have contemplated even a dinner mint, yet we diligently waited for the upside down cake to get out of the oven. And it was definitely worth the wait. Anything with that amount of butter and sugar in it must be good. The few pieces that were left by the next morning indeed made a very tasty breakfast. Times like this remind us that we're not really roughing it out here. 

Tough days

We've been having some hard days at the hospital. The wards have been busy, and there have been a number of really sick people, both adults and kids. The challenges, similarly seen at just about every hospital in the region, are many: not enough staff, medication shortages, not enough diagnostic tests, trouble getting specialists to come when they say they will. We're doing a pretty good job, all things considered. The hospital has made some amazing strides in the last one and a half years. And the attitude of the staff is overall positive, which is a big difference from a lot of African government hospitals I've worked in. As tired and frustrated as we all get sometimes, I feel like this hospital is doing better and better, and the community seems to be benefitting. 

Dangerous Side Effects

Last night as I was getting ready to leave the hospital, one of the nurse assistants told me there was a patient that needed review. An older woman who had been admitted to the ward with symptoms of potential heart burn was having trouble swallowing. From the outside, things looked OK. Her lips weren't swollen. And when she opened her mouth, her tongue looked normal. When we got a look at her soft palate, or the roof of her mouth towards the back of her throat, we could see a serious amount of swelling on both sides. This was coming on quickly, and we knew right away that she was potentially in serious trouble. If the swelling continued, the opening to her windpipe would swell shut and she would lose the ability to breathe. At this moment in the US, I would be on the phone with an anesthesiologist who would urgently come to her bedside and evaluate her. If he thought that she was going to lose her airway quickly, he would give her medicines to sedate her, and then use a fiber-optic scope to place a tube into her windpipe. She would then be placed on a ventilator machine and would stay on it until her swelling was improved and she could safely breathe on her own. Here, we didn't have that option. So we gathered what we had available to place a tube in her windpipe, and even materials to perform an emergency cricothyroidotomy if her throat was too swollen. This scary procedure involves trying to cut a hole in the front part of her neck down to her trachea, slip a breathing tube in, securing it to the skin, and then breathing for her by squeezing a bag for the next 12 hours or so. We gave her some emergency medications to try to stop the swelling, watched, and thankfully (so very thankfully), she remained stable over the next few hours. The swelling was not worsening. We reviewed her medications and found that she was on enalapril, a medicine for hypertension that is in the ACE inhibitor class. By her family member's report, it seems like she might have had a similar episode in the past. In case this reaction was caused by her medication, we stopped it and warned her never to take it again. Today, she remains stable. We are all very thankful.

Welcome back

Hi, again. Mimi and I have just returned for another trip to the village of Sagam in western Kenya. We made the journey from Penngrove to San Francisco to Amsterdam and then on to Nairobi, Kisumu, and then little Sagam. We were quickly reminded how tough things can get at this little hospital. I was seeing patients when we heard a great commotion outside and people running down the halls with wheelchairs. A truck had brought in multiple victims of a crash between a motorcycle and a vehicle. One of our nurses was involved and is pretty seriously hurt. At the same time, a woman with a preterm pregnancy presented with a complication involving the umbilical cord coming out of the uterus prior to delivery of the baby. The cord then becomes compressed and oxygen-rich blood from the mom ceases to flow to the baby.  Unfortunately, the infant did not survive. The medical team here is great and supportive during these tough times. Here's praying that these times will be few and far between.