Mama Obama

The weekend in Kisumu was fun.  We ate great Indian food, watched the Olympics (a bit of an upset to see Uganda take the gold in the men’s marathon, but still impressive that Kenya picked up the silver and bronze), and even made it to a club (not really my thing anymore, but fun to see what clubbing in western Kenya is about).  I’m back in little ol’ Sagam town now, and getting ready to turn in for the night; but I wanted to write a quick note about today’s events first.

Today was a good day. We met up with a group of US college basketball players that came to Kenya as part of a goodwill mission. They’ve been holding some basketball camps as well as visiting local sites, including some orphanages. None of the students had ever been to Africa, and many hadn’t left the States before this trip. They seemed pretty awestruck at this opportunity to see how a lot of the world lives.

After breakfast, we all hopped on a big, green, rattling school bus and headed out to the house of Mama Sara Obama, the grandmother of none other than President Barack Obama. Outside a pretty humble home (with the cool amenities of a satellite dish and solar panels), Mama Obama sat and chatted with us via a translator in her native Luo language.  She said that Barack had always been a good student, and she seemed very proud of him, having traveled all the way to Washington, D.C., for his inauguration in 2008 (though she said she remembered how very cold it was there).  We sat in the shade of a tree and listened to her talk about the importance of supporting orphans, while chickens, cows, rabbits, and a very fat turkey roamed the yard.  Barack’s grandfather (who apparently lived to reach 105 years) and father are buried there, and we were allowed to visit their graves. All in all it was a very nice visit, and I’m grateful for the chance to have met such a vibrant, pleasant woman. 

Sagam: First Impressions

It’s Friday night, and somehow it’s been a number of days since I last blogged. I’ll try to keep up a little bit better. 

Since I last wrote, we’ve flown from Nairobi out West, to Kisumu, Kenya’s third largest city. Kisumu is located on the eastern banks of Lake Victoria, and it’s the home of the Luo, one of Kenya’s major tribes. Barak Obama’s father was Luo, and actually I passed the road to his grandmother’s house a few days ago. Every day many people come to visit Mama Obama, as she’s known, and I hear that she has security posted at her house in case anyone wishes her, or the US, ill will.

We spent a night in Kisumu at a house filled with about 7 other Americans. Most of the crew was emergency medicine residents from Oakland and San Francisco, here to give a course in basic ultrasound to African health professionals. Ultrasound is a very learnable skill, is portable, doesn’t involve dangerous radiation, and is a game changer here in Africa. I’ve been learning more about using ultrasound at the bedside, and it’s been fascinating.

A few others at the house were from Boston, and they were involved in holding trainings for the uterine balloon tamponade device.  Many mothers in Africa still die during childbirth, and the major cause of maternal death is hemorrhage.  And the major cause of maternal hemorrhage is an atonic uterus (a floppy, flaccid uterus that does not contract appropriately after the throes of labor and delivery). After the baby and placenta exit the uterus, this expanded bag of muscle must contract down so that the its blood vessels stop bleeding. To encourage this, healthcare providers vigorously massage the uterus through the abdomen. If this fails to cause it to contract, additional measures are attempted, including emptying the bladder in case it’s in the way and giving various types of medicines to cause the uterus to contract. In the US, another method available is inserting a medically manufactured, very expensive balloon in the uterus so that the pressure from the balloon stops the blood flow and encourages contraction.  In collaboration with MIT, MGH has developed a similar balloon that is made from a simple urine Foley catheter, a condom, and a few pieces of string. The condom is attached to the end of the catheter, a few pieces of string attach it to the catheter, the apparatus is inserted into the uterus via the vagina, and clean water is used to fill up the condom in order to put pressure against the inside walls of the uterus and stop its bleeding. This kit costs about 5 dollars. The woman can then be given a dose of antibiotics, stabilized with intravenous fluids or a blood transfusion (if that's available, which it usually is not), and transferred to a facility with higher capacity to take care of ill mothers. It’s fascinating, and it seems to already be saving lives here in Africa.

We then made our way from Kisumu about an hour north to Sagam, a small town on the main highway. We were taken directly to Sagam Community Hospital, a small, clean, private hospital run by Nelson Rogo, a “retired” businessman and veterinarian. It’s here that we’re setting up our home base, and it’s where we hope to help establish various programs that strengthen medical education in the area. The plan is to meet next week with Maseno University, where they have recently started a medical school, in order to help them set up a family medicine residency.

Sagam is lovely. The weather is moderate during the day and comfortable at night. Unlike Juba, where due to a lack of city power the sound and smell of diesel generators are impossible to escape, I’m awakened by roosters and the music of song birds. The landscape is lush and verdant, and the horizon is undulating. The hospital has no doctor but three capable clinical officers that are eager to teach, learn, and show their impressive clinical skills. I’ve been impressed with what I’ve seen.

I'm being well taken care of.  We’re staying in a four-bedroom guesthouse on the Rogo family compound, where we usually have electricity and so far always have had running water. When not at the hospital, we’ve gone on runs, played soccer with the local students (and where we're introducing Ultimate Frisbee!), and played some music (I brought my sax to Africa for the first time; Michele plays violin and Luke plays the guitar). Tonight we were invited to Nelson and his wife Jane’s house for dinner and Olympics. We had a fantastic meal of chapatti, bitter greens, cabbage, potatoes, lentils, and ugali, a maize based food that’s what the child of cornbread and polenta would be. We saw Kenya pull ahead at the end of the 5,000 meter race to grab the silver, as well as the amazing American women’s 4x100 relay that won the gold and set the new world record. The local news was all about the Kenyan from the Masaai tribe that won the gold for the 800 meter race (his father had won a silver for the same race in the past). Apparently all the Kenyan runners train at altitude in the next province over, not too far from the town of Eldoret that we’ll be visiting to learn more about their family medicine residency (the first one in Kenya, at Moi University).

Tomorrow we’re off for a few days in the “big city” of Kisumu, where we hope to finalize opening our bank account, buying some things for the house, and watching the men’s 4x100 relay final. Hope you’re well, and thanks a lot for reading.

Jeff

Getting To Know You

Today was a pretty chill day of running errands and getting to know Nairobi a little bit.  Michele and I went to the new US Embassy to look into getting more pages for our passports.  I’m ashamed to admit that I knew almost nothing about the bombings of the US Embassies in Nairobi and Tanzania on August 7^th, 1998, arranged by the Egyptian Islamic Jihad and Osama Bin Ladin (http://en.wikipedia.org/wiki/1998_United_States_embassy_bombings). 

In Nairobi alone, approximately 212 people were killed, almost all local citizens that were living, working, or just passing by the day of the blast.  Approximately 4,000 people were injured, including many eye injuries: an initial blast and gunfire caused many people to go to their windows to investigate. The subsequent truck-bomb blast blew out windows for a 1 km radius. 

What destruction the human race is capable of.

We next went to the medical council to register as doctors in Kenya. Getting and maintaining a medical license in Kenya costs about $240 per year, which is surprisingly more than it costs to maintain a medical license in California. The outing was also a chance to get to know the famous traffic of Nairobi.  With the combination of sufficient wealth, a lot of people, and “flexible” driving practices, Kenya’s capital has traffic to rival Mumbai, and makes sitting stationary on the 101 in NorCal pretty bearable in comparison. Thankfully, the area in western Kenya where we'll be working is going to be a lot less congested. 

Lunch at the Pizza Inn at the local gas station was mostly remarkable for the following interaction with a woman with a Middle Eastern accident:

-Woman walks past our table into the building.

-Same woman walks back to our table and points at me, and says, “I thought… no I shouldn’t tell him…but now I feel like I must.  You. You look like Chuck Norris. A young Chuck Norris”.

Thanks, ma’am. Much appreciated.

And I’m thankful for Luke, our Aussie-American friend working with us who then introduced me to this link: http://www.chucknorrisfacts.com/chuck-norris-top-50-facts

Have a good day.

Sincerely, 

Chuck. 

Back To Africa

Wednesday, August 1, 2012

Today, I am a fellow. Officially. I am a Massachusetts General Hospital/ Contra Costa Regional Medical Center Global Health Leadership Fellow. Or a MGHCCRMCGHLF, for short. Kind of has a nice ring to it, huh? Sort of like trying to talk with one too many Fluffy Bunnies in the mouth. So here I am, a MGHCCRMCGHLF, sitting on a plane, heading from San Francisco to Nairobi, via Amsterdam (“Amster, amster, shh shh shh”, for those of you who know the song).  Over the next two years of the fellowship, we hope to help start a family medicine residency in East Africa in order to help address the shortage of trained health care providers in the area. 

I last posted on this blog when I was spending May and April in Juba, the capital city of the new nation of South Sudan.  I was working with a team of talented people who were partnering with the Ministry of Health and the national referral hospital to establish post-graduate training. South Sudan is the world’s newest country, born after two civil wars that spanned most of the last fifty years and claimed more civilian lives than all American military casualties since the birth of our own nation in 1776. This new country was born under a difficult moon; it is a country short on infrastructure and big on problems. Larger than France and not much smaller than Texas, it has about sixty miles of paved roads and some of the worst education and health indicators of any country in the world. Tensions along the incompletely demarcated border with the Sudanese to the north run high, inter-tribal warring within the many tribes in the south continues, and the almost entirely oil-based economy is balancing precariously.

Unfortunately, especially in the face of all the need, we’ve had to put our efforts to train family doctors in South Sudan on hold. There were many factors involved, and the decision was not an easy one. Overall, I think it’s the best decision for this point in time.  But for the young physicians interested in furthering their skills and career, and more specifically for the poor and often powerless patients of South Sudan, it is a loss.  Thankfully, other MGH/Boston programs in South Sudan, such as the training of front-line health workers in safe pregnancy and delivery management, the laboratory support program, and the government nursing collaboration will continue.  There are plans in the works between the Ministry of Health and NGOs to possibly implement advanced training for clinical officers in the country. Rapidly training mid-level providers who are more likely to stay and work in the country may be just what South Sudan needs right now.

But for the fellows, instead of returning to our little house and community in Juba, we are moving our efforts to western Kenya.  I admit, the switch feels a little strange. We are leaving a country where a woman has a higher chance of dying in pregnancy than finishing secondary school and arriving in one of the most developed nations in Africa. But there are a few reasons that make me think this is a good move.

For one, the need is there. Even though Kenya as a country is far more advanced than many in Africa, Western Kenya isn’t Disney Land. For example, about 14% of adults there are living with HIV, compared to an overall percentage of 0.6% in the United States.  Secondly, Kenya’s Ministry of Health is committed to furthering the development of family medicine. They have programs on the ground now, and they have a mandate for each medical school to have a training program in family medicine. Third, and most importantly, the local Kenyan medical school and associated hospitals have invited us in and are keen to partner with us.  Good intentions mean little when your vision doesn’t line up with what the people on the ground have in mind.

Tomorrow, hopefully, I’ll be meeting up at the Nairobi airport with Michele, the other MGHetc fellow, and Luke, an Australian doctor in training that is working with us.  They’re coming from Juba where they’ve been wrapping up the program, packing up supplies, and saying goodbye. We’re excited to be staying for the next few days in Nairobi with Megan, a family doc who is working with UCSF and Aga Khan University to establish their training program in Nairobi.  The next few months are likely to be full of meetings, some clinical teaching, and hopefully plenty of opportunities to get to know western Kenya. 

Thanks for reading,

jeff 

Last Day In Juba

I'm sitting in the airport terminal at the Juba airport, preparing to return to the US after my first stint working as a teacher of junior doctors at Juba Teaching Hospital. As I watch expatriate aid workers arrive on the incoming flight from Nairobi, I feel like a seasoned veteran. "Ha, look at those newbies", I think. And yet I've only spent two months here. Sixty measly days. Barely any time to even get acquainted with a place. Eight short weeks. In some ways, though, and as many people who've been in Juba would agree with, it certainly seems like it's been longer.

Working at the Juba Teaching Hospital has been, well, challenging. Lack of essential medications, equipment, and skilled manpower makes taking care of very sick patients even harder than it should be. Certainly, some patients present too late to be saved, even if they were cared for in a first-class institution like the marbled halls of Massachusetts General Hospital (I haven't been to MGH yet, so there may not actually be any marble there). But many patients present very sick, yet early enough that they have a chance. Unfortunately, many that should make it do not.

On my last day there, we saw a chronically ill-appearing woman who had been admitted the previous day. I was surprised to see that she had survived the night. The report the day before was that she had been ill for a very long time and had been thrown out of the family by her husband. As she lay on the dirty concrete floor of our ward, as there were no available beds, I performed a brief evaluation. Cachectic, with abdominal swelling but no evidence of heart failure. But today, she was worse. She was minimally responsive, her pupils were dilated and hazy, and she had an unrecordable blood pressure with a fast heart beat. "Give fluids", I told the intern, "and make sure she gets her gram of ceftriaxone". The head nurse shook her head at me, "We're out of fluids. The whole hospital is out. They'll have to go to the pharmacy across the street". The intern asked a patient a few beds away if he could have her unopened bottle of IV fluid. She agreed. And, thankfully, one of the harder working nurses showed up with a box full of IV fluid. Apparently the whole hospital wasn't out. About 600 mL of fluid later, I re-examined the patient. She was worse. I had given her too much fluid, and now she was in pulmonary edema. Blood pressure still unrecordable, but she was breathing harder and her heart was struggling. If I had a way to place a central line, I would have administered strong medications that would have supported her blood pressure and strengthened her heart contractions. If I had a ventilator machine, we could have intubated her and breathed for her while removing fluid from her lungs. All I could do was give a small dose of furosemide, a diuretic that would hopefully relieve the strain on her heart without dropping her blood pressure too much. A female relative began to squeeze fresh orange juice into the patient's mouth until we stopped her. She was struggling to breathe and was not alert enough to safely swallow. Within half an hour, she had passed. Her 20ish year old son, now alone at her bedside, stormed outside in silence.

She was a patient that may have been too sick to save anywhere. I had not seen her sit or speak since admission. In addition to a weak heart, she probably had tuberculosis, HIV, or a host of other infections. And yet it's hard not to second guess myself. Should I have tried 250 mL of fluid at a time? Did I at least pull the intern aside to make sure he understood what had been the probable course of events today? Should we be putting our efforts in prevention instead of treatment, so that fewer and fewer patients present this late in the course of their illness?

The most striking part of it was that her death was lost amid the day's business. My stream of consciousness was probably something like: she was just too sick, brought in too late, but should I have been more careful with the fluid? But there's no other way to treat hypotension and tachycardia here. Need to check in on the guy with TB and the nasal septum abscess, hope the pus hasn't re-accumulated, I wonder how the postpartum woman with heart failure is, need to see her next, I can't believe the woman with stroke and aspiration pneumonia in bed 14 is doing better today, we've got to get some of these patients transferred to ward 4, what on earth is causing the woman in bed 16 to be so altered?, gotta check in on HK to see how he's doing on the male ward, getting a call from one of the expats now regarding his shortness of breath; where are the other doctors?, gotta make sure the four women outside get seen before the interns leave, where are the nurses? Oh, the guy that is saying hi to me outside is the one with HIV that I discharged and was afraid had a pulmonary embolism - and he's doing great! Yes! Wow, does that guy really have a hemoglobin of 1.5?...

And her death, and the processing that goes along with it, was pushed to the back.

Our goal is not to bring MGH to Juba. That is neither possible nor would it be a good use of time or funds if it was. With diligence, patience, and a cooperative attitude, we hope to raise the level of care to one that is expected of a national referral hospital in Africa. That is feasible. That is necessary. But it won't be easy.

There is so much work to be done. When an elderly patient admitted to our ward with diarrhea and weakness, unable to care for herself, receives no nursing care for 24 hours, I get angry inside. Why won't the nurses help clean her? Why doesn't she have a relative here to help her? When less than half of the junior doctors show up for a lecture I worked on 'till three in the morning, I feel disheartened. Why don't they take the opportunity to learn about a subject that is important and that they know little about? When a patient dies because there is no IV tubing to give medications and fluid, or when a patient with severe anemia fails to get the prescribed blood transfusion because no one walked the 25 meters to the lab and brought the blood to the patient, I feel like it's time to pack up. Get your bags, kids, we're going to Disney World!

Yet for some reason (maybe because it's hard to get a last minute flight from Juba to Orlando), we get up the next morning, and we try again. We calmly encourage the nurses again to clean the patient who's been lying in her diarrhea. We work with visiting pharmacists and lab specialists to address the myriad of medication and laboratory issues plaguing the hospital. We'll continue to bring in expert nurse and public health instructors to coordinate between the ministry, hospital, and the school of nursing to improve nursing care at the national level. And we'll continue to work side by side with the young physicians that are charged with caring for one of the most impoverished and traumatized people of the world.

I don't know what things will be like when I'm due back in August. Perhaps our continued presence and efforts will have made some visible and lasting changes at the hospital. Maybe things will run more smoothly, and morale will be higher. Perhaps Sudan and South Sudan will have resolved their differences and will base their economy on green energy and the exportation of love and daisies. We'll have to wait and see.

When a patient dies on Flinder's inpatient medicine service at our residency in Santa Rosa, CA, we light a candle during rounds to honor their life and their passing. The speed and bustle of rounds slows down a bit on those days, and we are reminded of the blessings we have. I think that was a partial motivator for my last night in Juba, as we turned off the noisy generator that is the only source of electricity for our house, started a fire in the yard, and lit about 30 candles to light our way. Yes, it was still about 90 degrees outside, and maybe hotter inside the house. But we took a moment to sit, to stare into the flames, and to remember.

Thanks for reading,

Jeff

Pump Failure

This morning we watched a man almost drown on dry land. He came in to the hospital, breathing fast, looking bad. He had the tell-tale signs of uncontrolled chronic heart failure. His legs were swollen. His hands were swollen. His belly was likely full of fluid. But most dangerous at that moment, what was causing his acute distress, was that his lungs were full of fluid. Since the left side of his heart, normally tasked with moving freshly oxygenated blood from the lungs to the rest of his body, was failing, his lungs were backed up with fluid. Having to deal with the extra work for too long, the normally relatively weaker right side of his heart had also failed, as evidenced by his water-logged extremities.

We hooked up our minimally functional, minimally clean oxygen machine and tried to convince him to keep the uncomfortable mask on his face. We administered IV furosemide, a diuretic that helps open up the veins in his lungs as well as gets the kidneys to dump fluid out of the body. One, two, three, and then four doses of increasing strength (up to a cumulative dose of 240 mg) and we weren't seeing a response. We gave him a pill of a different diuretic, spirinolactone, with the hope that it would potentate the action of the first diuretic, a risky move without knowing how well his kidneys were working. He was so short of breath he wasn't able to swallow it. The intern brought sublingual nitroglycerine from the pharmacy, hoping that he could place a tablet below his tongue that would then dilate the veins in his lungs and allow him to breathe easier. He spit out most of the dose along with some frothy sputum.

I could see that he was getting tired. That is a very bad sign in the world of heart and lung disease. In my hospital in California, respiratory therapists would have been paged to the ER a long time before this point and would have placed him on BiPAP. This non-invasive ventilator machine works by pushing fast-flowing oxygen into the lungs of a patient via a tight fitting mask, forcing the fluid out of his alveoli so he can breathe again. Failing this, he would have been intubated, placed on a ventilator, perhaps put on a nitroglycerine drip, maybe even dialyzed if his kidneys couldn't take off the fluid.

But instead he sat there, in severe respiratory distress, leaning onto his thighs, hands and arms cold and clammy due the reduced circulation and stress of the moment. And I thought he was going to slowly suffocate due to the fluid in his lungs, or perhaps have a build-up of carbon dioxide that would cause him to get confused and then take away his drive to breathe, or maybe have a heart attack or cardiac arrhythmia.

Amazingly, his breathing slowed a bit, his pulse began to improve, and he began to look interested in his surroundings. The medications had taken effect, and he was turning the corner. I have no guarantee that he will make it through the night. There are a dozen things that could go wrong between now and AM rounds. But the junior docs saw that such a sick patient could be stabilized. And we will hope and pray that he survives until morning.

Sunday Funday

Ahh, Sunday. It's nice to have a day off. Clinical work often times doesn't give you a day of rest, a chance to clear the mind. But today I'm off. I had time for a cup of hibiscus tea (from Khartoum), some bread (from behind our house) and cheese (brought in from Santa Rosa, CA), a piece Tiger Cake (Kenya) and some yogurt (Uganda).

We had a nice meeting with a group of physicians and public health clinicians from University of Alberta, in Edmonton. They have a lot of international experience and are hoping to expand their work into Juba. There are plenty of opportunities to get involved.

Aid is such a tricky thing. What is the best formula for bringing the developing world out of poverty? The big opposing camps are: 1. We're on the right path, what countries like South Sudan need is more money and more help from multinational donors and NGOs, 2. Our current approach for aid isn't working, and is actually making things worse, so it's better to pull out completely and let the countries take control and run things themselves. I go back and forth between these. As I'm writing this from Juba, clearly I'm currently a believer that aid can make lasting changes, especially when it comes as education. But there are certainly days I feel that we should all pack up and get out, let the situation get so bad that there is an internal revolution of sorts, and that changes are made from within that equal the playing field a bit between the haves and have-nots.

Just received a call from the house officer (intern). A patient with heart failure has low blood pressure and a fast heart rate, as well as signs of fluid overload and clammy skin. This would be a difficult patient to treat in California. Let's try some gentle fluid boluses and antibiotics and see how she responds.

Frisbee, a twice weekly bright spot in the schedule, lies ahead. I have just about a week and a half left in Juba for this trip. I'm looking forward to giving a few lectures before I leave, evaluation of chest pain and HIV opportunistic infections. Then, a chance to step away for a few months to bring some needed perspective.