Tragedy In Nairobi

Hi, just a quick note to say we're fine. It's been very sad to watch the details of the terrorist attack unfold on the news. Hoping that it will come to an end, soon, and that this is an isolated event. Our thoughts and prayers go out to the victims and their families.

Safety, First.

Is Kenya safe? A doctor who is thinking of working here asked me this tonight during a phone call. That is an interesting question to answer. Sagam village, where we work and live feels very safe. Tonight. like most nights in Sagam, is pretty quiet. The night air is filled with the hum of insects, occasional bird calls, the high-pitched sonar squeaks of bats on the hunt, and a particular rhythmic chirp from a frog that creates the image of a flashing red beacon in the night. And while the occasional inebriated man wielding a farming machete will get into a squabble and need suturing and casting at the hospital, I feel safer walking around here than I do in many big cities in the US.

One of the biggest safety concerns in Kenya, and in many African countries, is road safety.  A friend of mine recently wrote an informative blog entry on infant car seats, which can be found here. She's lived and worked in the developing world and can attest to the great disparities in car safety between countries. Common-place sightings here include small children riding behind handle-bars on motorcycles and being held on their mom's laps in overcrowded mini-buses.

Road traffic accidents, or RTAs as they are referred to in Kenyan hospitals, are very, very common here. The reasons are many, including poor road conditions, minimally enforced traffic laws, driving under the influence of alcohol, poorly maintained vehicles, lack of sidewalks for pedestrians, and near absence of emergency medical services and personnel, to name just a few. The other night we were brought face-to-face with the brutality of RTAs in a resource-poor setting. We were getting ready to sit down to dinner when we received a frantic call from the hospital. There had been an accident involved a car vs. multiple pedestrians, and the victims had been taken to our small hospital. We collected our gear and rushed over to do our part to help the many staff that were attending to the several victims. Though we tried our best with the skills and tools at hand, some were lost despite our efforts. The images from the resuscitation will stick with us for a very long time. These losses will only begin to decline with stronger government road safety regulation, as well as improved emergency medicine services. While I can't do anything about Kenyan road traffic legislature, hopefully the local clinicians and nurses we are training at the hospital, as well as the training program in family and emergency medicine that we are helping to initiate, will be a small step towards tackling this big challenge.

Some Notable Differences

As we were waiting in the car Saturday afternoon, trying to stay relatively dry during a heavy down-pour and getting ready to head home from the hospital, I saw something that I probably wouldn't have seen in the US.  An elderly woman we'd been taking care of during the week was wheeled down the ramp in the hospital wheelchair. I waved to her, thinking how nice it was that she had survived her hospital stay. A motorcycle taxi then pulled up to the end of the ramp, and the woman's daughter helped her get on the back of the motorcycle. The daughter then got on the motorcycle as well, sandwiching the patient between herself and the driver. The noteworthy part of this is that the patient was paralyzed on half of her body due to a stroke she had survived a few years ago. She also suffered from frequent seizures that were related to the stroke. I thought that a ride home on the back of a motorcycle down muddy roads turned into rivers was not exactly what the doctor ordered.  It reminded me that no matter what kind of control we think we have over patients while they're on the hospital ward, all that goes out the window once they've been discharged. We create a false reality. We order medications to be given to patients at specific times, we carefully follow vital sign measurements and titrate intravenous fluids. And then they get on the back of a motorcycle and head off into the rain.

We recently had an elderly patient come to the hospital that had fallen at home several times over the week and now was in a semi-comatose state. All of our limited blood test results were normal, and I was concerned about the possibility that she had bled into her brain due to one of the falls. In the US, regardless of her ability to pay, she would have been whisked to the CT scanner within minutes of arrival to the emergency department, diagnosed, potentially intubated to protect her airway, and transferred to the neurosurgical service for surgery or the intensive care unit for close monitoring, depending on the type of brain bleeding. But in many countries around the world there is little safety net for the poor. When we told the family member that had accompanied her our concerns and need for transfer to a bigger hospital just one hour away, she left the hospital in order to find other family members to discuss if they had enough money to pool together to make this happen. Even when our hospital offered to pay for the ambulance ride to the government hospital, the family declined immediate transfer, seemingly since they had little faith that they'd be able to manage the hospital bill associated with the CT scan (approximately $150 USD), the surgery, and subsequent hospital care. There is also no guarantee that she would have received quick and expert care at the referral hospital. The doctors and nurses there are often overworked, undertrained, and underpaid.

When I think of the most difficult parts of working in two very different countries, the most challenging is seeing patients succumb from conditions that they wouldn't have died from in the US. It's tough losing a patient, from any cause, and in any country. And often times the people that we lose here wouldn't have made it in the US either. But when an infant dies because the hospital was out of oxygen, or a teenager dies for lack of a blood transfusion, or a postpartum mother dies for lack of transportation to a health center, those are the hardest times.

I got off the phone tonight with my dad back in Texas who just celebrated another birthday. I've been so lucky to have him around all these years. Thanks, Dad, for being a role model and a good listener.  Thanks for the help with homework, for the fishing trips, and for supporting me during all these years of study and work far from home. Love you.