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.

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.