Meetings, Patients, and Insanity

Man, time flies. It’s easy to get wrapped up in the day to day and forget to blog. Life continues to be fairly sweet in sleepy Sagam. Since I last wrote, we’ve made some progress in getting the relationship going between MGH/Contra Costa family med residency in NorCal and Maseno University here in western Kenya. We’ve also continued to consult on patients in the hospital

We met the head of the local district level hospital, Dr. Omoto, who is an OB-gyn doctor.  Siaya district hospital is one busy place. They see around 300 patients per day. Besides being plain busy, they had several programs of interest. For one, they were using an electronic health record system that had been put together for them by a programmer in California. Patients were seen by clinical officers, the CO would type the info from the visit into a laptop that was bolted to their table, and with the hit of a button, the prescription from that visit was sent to the hospital pharmacy around the corner. I’m not sure if that definitely will lead to improved patient care, but it was at least neat to see. Impressively, we came to a quiet room where HIV positive patients were receiving chemotherapy for Kaposi’s sarcoma, the blood vessel cancer that I mentioned in a previous post. They also had screening for cervical cancer using VIA, or visual inspection with acetic acid. Many developing countries like Kenya use VIA in lieu of pap smears, since results from a pap smear, if they ever come, can come very late. Using the VIA technique, vinegar is applied to the cervix. Abnormal areas of the cervix, like those that could be affected with the human papilloma virus (HPV), can be biopsied right away, obviating the need for an initial pap smear.

We’ve also had a few meetings with the faculty at the med school. They are interested in a collaboration that involves us helping to teach medical students, train family medicine residents, and help out in other ways. They are a motivated bunch of docs, and there is good potential here.

The patient consultations continue to be interesting. I’m inclosing the picture of a tumor that has been growing out of the head of a patient over the last 4 years or so. The point of view is from above her head – a bird’s eye view. Amazingly, it’s almost as big as her head. We wrote a referral note to the specialists at Moi University, located about 4 hours away by public transport, with the hope that she will be seen by an ear, nose, and throat specialist as well as a neurosurgeon. The mass is almost certainly benign, since the patient is still doing so well despite the large mass.

Other cases have included a very sweet 85 year old woman with an ankle that was shattered and dislocated during a fall. We’ve tried twice to get the ankle back into place by giving her medicine to relax her and take away the pain, and both times, the xray showed that it was still out of place. The first time we tried an intramuscular injection of ketamine, an amazing drug that puts a person into a bit of a trance, in order to do a normally painful procedure like a reduction of a dislocated joint. The second time we injected lidocaine directly into the joint, in order to minimize the pain while avoiding the risks of generalized sedation (she suffers from high blood pressure, a heart arrhythmia, and she had just eaten a big meal, which might complicate things if she were to vomit and aspirate the contents into her lungs). We’ve referred her to the large public hospital an hour away for orthopedic surgery where they hopefully will open the ankle up, reduce the fracture, and then put metal hardware to keep it in place.

Another case involved a young man that ingested large amounts of alcohol as well as probably some sort of poison. He was so sedated from his ingestion that he couldn’t protect his own airway and was at risk of asphyxiating. In the US, where we have a respirator machine that would breathe for him around every corner, I would have intubated him (put a tube down his windpipe).  But here, without a working ventilator, we just watched him closely and hoped. I suppose if he had gotten to the point where he stopped breathing, we could have intubated him and had staff and family alternate squeezing the ambu-bag to breathe for him until he recovered enough to breathe on his own.  He is now awake and conversant, but he has a fever, a fast heart beat, and is breathing quickly. He likely got some liquid into his lungs and basically has a chemical burn and a bacterial pneumonia. Hopefully, he’ll do alright on antibiotics.

We continue to see malaria cases most days, patients with HIV (both new diagnoses and those who come in already on HIV therapy), and tuberculosis. We are definitely seeing lots of diseases of the first world - non-communicable diseases, often related to diet and lifestyle, like high blood pressure and diabetes. We recently had a nice elderly woman who felt fine, but when her blood sugar was checked, it was reading a value of 600. A normal value is usually around 140. We have had a number of patients with infections like gangrene due to uncontrolled diabetes. We are working to improve the weekly diabetes and hypertension clinic, so that fewer people get the complications of these diseases.

Oh, and we're doing some Insanity. That is to say, we stand in front of a laptop, and listen to Shaun T (pictured here) lead a gym full of fit men and women, along with the home audience, through some insane workouts. The Kenyans think we're pretty hilarious, doing high-intensity aerobics on our porch. I think they're right. We look hilarious. But we're preventing diabetes. Actually, I heard that Insanity is huge on the Navajo nation. Supposedly the Navajo, a group of people at high risk for diabetes, hypertension, and obesity, fill a big facility on the reservation and do this ridiculously intense aerobic work-out. Not so insane after all, I suppose. 

Life at the house here in Sagam has been good. We have been whipping up some nice meals. Luke made an Israeli dish last night with bread, lentils, eggs, tomatoes and other veggies. Tonight we're in "finish what's left in the house" mode since we're heading to Kisumu tomorrow. We heated up some leftovers and also whipped up a potato and veggie scramble that was, albeit not as good as what is routinely made on the Dolan Finca, was still noteworthy. 

The weather continues to be quite nice. Even though we pass the equator when we make the 15 minute trip to the med school, due to the elevation, it's not what most people would imagine when you mention equatorial Africa. We get some showers every day, and it rarely gets warm enough to be uncomfortable.  In the mornings, Luke and Michele are usually wearing long sleeves or even a jacket as they eat breakfast on the porch. The rains keep the flowers blooming, and I've attached a few pictures of flowers we've seen in our 'hood. 

Thanks for reading, 

Jeff

Tuesday In Sagam

Here is a bit more info about an average day for me in Sagam village.

Woke up, had some green tea, muesli and yogurt while listening to the calls of the many birds that live in the area. I got online to catch up on the news and look up answers to some clinical questions that have come up over the last few days and weeks (e.g., does malaria infection cause the type of white blood cells called lymphocytes to increase? what is the dosing of rifabutin for HIV positive children also on the drug Kaletra? what, exactly, is the sound of one hand clapping?). Then Luke, the hardest working of our lot, went to the hospital to see patients with the clinical officers. We waited around for the plumber and electrician to come and check out various things around the house (they didn't show up), and to see if we were meeting with the dean of the university (he had to postpone). So we headed into the hospital to see what cases Luke and the rest of the team wanted us to take a closer look at with them.

The cases were interesting and varied.  We reviewed the case of a child with sickle cell anemia (a genetic disorder that developed over the centuries to make it more difficult to be infected with malaria) who came in with severe pain in his sternum from clogging of the small blood vessels in that bone.  We examined an adult with HIV and likely Kaposi sarcoma, a blood vessel cancer that is caused by a virus that affects people with weakened immune systems. The patient seems to have tumors in his skin, lungs, and lymph glands. We saw a young man who we had played soccer with last week that had been in a machete fight and had a blow to his head. There were patients with complications from diseases like diabetes and hypertension, such as gangrene of the toes from a poor blood supply and infection, or a ballooning of the part of the aorta that lies in the abdomen, probably due to long-standing high blood pressure. We also saw a woman that was about 5 months pregnant and taught the clinical officer a little bit about how to use ultrasound in pregnancy for checking the fetal heartbeat, seeing the amount of amniotic fluid that is surrounding the baby in the uterus, and how to measure the head, abdomen and leg length of the fetus to determine how far along the pregnancy was.

We then had a nice lunch of beans, greens, and tasty, greasy chapati. We walked the 15 minute long journey home (included is a pic from the walk, as well as a look at some of the trees on the grounds where our house is), and then had a chance to read, go for a run, and even play a little music (I brought my sax, and so far haven't been thrown out of the house for practicing). Luke whipped up a pasta dinner, with a side of avocado from our tree, and we watched a moving documentary on Darfur, Sudan, that was directed by our new friend Mark.

I'd say, all in all, it was a pretty nice Tuesday.

Family Medicine and Cheetahs

Our trip to Webuye was a success. Our main goal was to learn from those that started family medicine in Kenya, in order to find out what was needed to start their program, to see if another family med program in Kenya makes sense, and what the graduates were doing with these additional years of training under their belts. The overall answer is, it's not clear. And this was surprising. I had expected that training family medicine doctors in Africa was a slam-dunk deal. Of course a physician that is well-trained to handle the majority of things that come through the door at their district or community hospital is a good thing, especially if they are also trained in assessing the needs of their community through basic research and can help manage a hospital. But the reality in Kenya hasn't been so clear. I think overall, family medicine in Kenya makes sense, but the definition is still evolving. It will be interesting to be here at the relative beginning.

From Webuye we took 4 hours of public transportation to Kisumu, our other home city on Lake Victory. We met with medical school faculty at New Nyanza Hospital, the big, five-hundred bed provincial hospital known locally as "Russian", as it was built by the...wait for it...Russians, back in the 1970s. The facility doesn't look like it's had much work done to it since then, but there were some cool features. They have a 5 bed ICU, though they only have oxygen piping for 3 beds, and I'm not entirely sure that they had a working ventilator. They had a big room for adult hemodialysis, though only two machines that were able to be used. While limited in scope, I was still excited to see functioning machines. In all my time working in Africa, I've never seen dialysis take place. In South Sudan, a country bigger than France and with a population around ten million people, there wasn't a single place to get dialysis. Dialysis centers are almost on every corner in the US, especially in my native South Texas, where there is so much uncontrolled diabetes and hypertension and therefore resultant kidney disease.

Otherwise, the weekend was spent catching up on sleep and petting cheetahs. Well, that's a bit of an exaggeration.  Only a small amount of time was spent petting cheetahs. We visited the wildlife preserve that's located about a block away from our house in Kisumu. They have free roaming vervet monkeys and impala (can you imagine that they have animals named after cars??), as well as a whole host of other animals in cages - ostrich, white rhino, water buffalo, unicorns, etc. We even got to enter the cheetah cage and pet them for a minute. It was all great until our guide accidentally stepped on one of their paws while Luke was petting one of their heads. That got everyone's blood pumping. Also realized as we were leaving the cage that the guide expected quite a big tip for about 60 seconds worth of cheetah time. Oh well, I guess that's still cheaper than our potential hospital bill from cheetah mauling. All's well that ends well.

Matatus to Webuye

Today Michele and I traveled to the town of Webuye. We took the public transit system, which in Kenya, like many places in Africa, is based on the matatu.  A matatu is basically a mini van that closely resembles a sardine can - boxy, usually rusty and without cushions, often smells like fish, and can really pack people in. On one of the rides today (since you almost always have to take various matatus to get where you're going if the destination isn't close), when the seats filled up the attendant pulled out some short wooden planks to span the aisle between seats so additional passengers could sit. At another point, the matatu was so full that three guys were hanging on to the outside of the van as it cruised along at about 40 mph.  The basic rule of matatus is that they'll usually get you where you need to go, about an hour later than you expect. You walk up to a parked matatu that is going in your direction, sit inside, pay your fare, and then wait until the van fills up with passengers. Departure time is when the van is full. But the other rule of thumb is that they're cheap. Our trip to Webuye took four hours and involved three different matatus, and it cost us each five bucks. It's an experience, and actually pretty fun. For a little bit. Once in while.

Michele and I went to Webuye to meet the previous residency director from the Moi University family medicine training program. He is still part of the residency faculty (one of only four family docs on faculty), and is now working and teaching residents at the Webuye District Hospital. Moi had the first family medicine program in Kenya, started in 2005, and it is still going strong. Family med is pretty young here, and there is only one other program in Kenya, associated with Aga Khan University; and it is less than a year old.  Our friend Megan from UCSF is now helping lead the AKU program, a private hospital based residency in the capital city of Nairobi. We learned a lot today about the benefits, challenges, and unanswered questions about family medicine in Kenya and Africa in general.  We also had a very nice dinner of fresh garden greens, including the best tasting cilantro I think I've ever had, homemade Southern cornbread, and hot chocolate with amarula liquor. We are feeling pretty well cared for.

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