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.