NorCal

I'm back home.  Friday, after consulting on a few patients and saying my goodbyes, I left the village of Sagam and headed to Kisumu. From there, I hopped the quick 35 minute flight to Nairobi and hung out for about three hours until taking the red eye to Amsterdam.  At the Schiphol airport, I had the pleasant experience of hanging out in the KLM frequent flyer lounge (that included free hot showers) until my flight to SFO. All in all, travel time from Sagam to the North Bay was about 30 hours. Besides forgetting my pair of running shoes on the plane, I had a nice, uneventful journey. I'm now farm-sitting my friends' place in the lovely town of Healdsburg. It's a lovely 66 degrees. The sun is shining, the internet is fast, and the hum of the clothes dryer reminds me that I'm no longer in rural Kenya. But my thoughts linger a continent away. What is happening to the little 9 year old girl with HIV and swollen glands that may be a sign of either TB or lymphoma? How is she after her needle biopsy? What about the 23 year old woman with heart disease that may need surgery to repair one of her heart valves? I'm out of Kenya, but many of my thoughts and worries are still there. The truth is the patients are in excellent hands. Michele, the family doc on the ground now, is amazing and will take wonderful care of them. Nevertheless, it's hard to leave it behind.

If things go as planned, I won't return to western Kenya until August. I haven't been in the same country for 6 straight months in a while. A year ago in March I headed to Malawi for a month, then worked for two months in South Sudan, hitting a few other places on the way home. I came back to California for two months then did two and a half months in Kenya, two months in California, two and a half more months in Kenya, and now I'm back here in NorCal. I'm ready to be home.

Much will need to happen for the Family and Emergency Medicine residency to be ready to start in September. The curriculum needs to be accepted, applications need to be reviewed, faculty need to be chosen, and agreements between hospitals need to be finalized. An emergency ward needs to be built at Sagam Community Hospital, additional staff need to be hired, and systems need to be improved. There is plenty of work to keep us busy.

Thanks everyone for reading the blog these last few months. Please tune in around early August if you'd like to keep up with my travels.


















Jeff

Keeping Busy

Thank you for those that have checked in about the blog. I'm doing well, here in Sagam, though we've been kept busy with a lot of work at the hospital. Since coming back from the States, little Sagam Hospital has been hopping. The patient census has been high, as has the acuity of some of the patients' illnesses. We have helped treat some tough cases, and have been lucky and blessed to see a number of the patients get better and walk out of the hospital.

A few of the cases that have been on my mind:

We recently had a child living with HIV who came in with a severe case of malaria. He was weak when he was admitted, was slow to respond to questions and was not acting like himself. When he wasn't responding to the various medications we were giving him for malaria we also added a strong antibiotic in case we were missing a bacterial infection in his brain.  Due to the swelling caused by infection (malaria or bacterial meningitis or both), the pressure in his brain was building up to dangerous levels.  He started having seizures, and the brain swelling caused him to slip into a coma and begin to hold his body in a rigid posture, called opisthotonus (see photo).  We did all we could, and I was pretty sure he wouldn't make it until morning.  When we checked on him in the little pediatric ward the next day, he was alive but still doing about the same. But still, he was alive, and so there was still some hope. We continued our treatment and later that day, though still comatose, his muscles were a bit more relaxed.  Again, as I went home, I was pretty sure there would be an empty bed the next day. But lo and behold, little by little over the next few days, he came back to us. He emerged from his coma, he began to follow us with his eyes, and eventually could take a little porridge, answer questions, and then the big one - smiled at us. Today the clinician in charge, Benard, signed him out of the hospital, and the little guy walked out. He's still in danger, as he missed several days of his HIV medications, and there is risk that his virus is now resistant to one of the medications. But nonetheless, he has a chance.

Another recent challenging case was that of a young man in a coma who was brought to the hospital on the back of a motorcycle.  He smelled strongly of a chemical that made me think of turpentine, and he was not responsive at all. Thankfully he was breathing on his own, and he had a heart beat; but otherwise he was in a deep coma.  On questioning the family, it turned out that he was in a argument with a family member and purposely ingested a poison called Triatix, which includes the compound known as amitraz.  This chemical agent acts as an alpha-2 agonist (an example of a medicine that is an alpha-2 agonist is the blood pressure medicine known as clonidine). In the US he would have had a breathing tube placed down his windpipe, hooked up to a ventilator machine that would do the work of his lungs for him, and two dozen tests and imaging studies would have been ordered before he had spent 30 minutes in the ER.  Here, we had a very limited number of tests and treatments at our disposal. So we gave him oxygen through a machine and suctioned the oral secretions that he couldn't swallow due to being in a coma. Those worked until the power went out. We were able to start a diesel generator the size of a suitcase and run it intermittently when he needed it, keeping in mind that we needed to ration fuel.  When his pupils remained dilated and unresponsive to bright light, and he showed no other signs of cholinergic poisoning or prior treatment with atropine, we called the family to let them know that he we thought he had brain damage and would likely not recover.  We waited until they arrived and then went home with heavy hearts. But yet again, we were pleasantly surprised to see him in the morning.  He started to grimace when we suctioned his oral secretions. His pupils were no longer dilated. As the day went on he began to become a little more responsive. When I walked into the wards the next day, he was watching the medical team and responded to our greetings. Amazing. Again, we were wowed and humbled. Thankful for his recovery, we are still cognizant that his road ahead to good mental health and well-being will likely be a long one as well.

Newborn Distress

Tonight I'm back in Sagam after a long set of flights from the US. I was kindly met in Kisumu by Jennifer, and after some food and running some errands in Kisumu we prepared for the trip back to Sagam. About that time I got a call from Mairead, our nurse who is volunteering at Sagam, that a newborn wasn't breathing and was undergoing resuscitation by the Kenyan nurse on duty.  We discussed how to best support the child, and I hopped in our very packed car and headed back to Sagam with the rest of the team (that now includes 4 Harvard undergraduate students that will be volunteering with us for the next 3 weeks).

After ongoing phone reports on the road from Mairead that the child was stabilizing and breathing on her own, we decided to transfer the baby to a bigger facility with neonatal trained nurses and physicians. I called a Kenyan pediatrician I know and was saddened to hear that Kenyan health workers in public hospitals were on strike regarding poor wages. If we sent the newborn to a public hospital, she would be refused entrance to the facility.  He suggested the child stay with us, since even though we aren't adequately equipped to deal with very sick neonates, at least we would try.  We double-checked with the family to see if they could afford care at a big, well-supported private hospital in Kisumu, but they could not.

I was surprised and happy to see that the little girl was alive and still breathing on her own by the time we got there. After struggling with several attempts to get intravenous access in order to start antibiotics, we were finally able to get an intraosseous line placed in her femur. This is a thick but relatively short needle that is drilled into the bone so that medicines and other fluids can be administered into the bone marrow. After being infused into the marrow, the medicine then leaves the bone via many small veins and enters central circulation, getting wherever it's needed all throughout the body.  I'm very thankful for Dr. J's donation of these needles to us.

We left the hospital sweaty, tired, hungry, but happy that the little one was still holding on. I'm not sure if she'll make it through the night. But thanks to Mairead and the rest of the Kenyan and US team, she has a fighting chance.

Funerals, Hades, And The Meaning Of Life

Funerals aren't much fun.  They are hard because you feel the empty space left by your loved-one. There are questions that you'll never get answered and goodbye's that you'll never get to really say.  You also see your friends and family suffering, remembering the good times and lamenting the missed opportunities, and their grief is also painful to watch.

Friday morning before getting out of bed I found myself wondering about the two big questions. First, what happens after we die?  As part of Uncle Mike's eulogy, my dad read an excerpt from Socrates' final speech that I have looked to in the past when asking this difficult question. Before taking the hemlock sentenced to him, Socrates attempts to allay the lamentations of his disciples by explaining his view of death and what may come next. He states that one of two things must happen. If death is simply the cessation of life and there is no afterlife or continued consciousness, then death must be similar to a perfect, dreamless night. There is no fear, nor longing nor discomfort of any kind in a dreamless sleep, and therefore such a state would be a welcomed alternative to the suffering that is our day-to-day existence. If, on the other hand, the soul is transferred from one plane of existence to another, such as the Greek's Hades or Christianity's Heaven, then all the better. What a great way to pass eternity, chatting and debating with Homer, or any other writer, philosopher, or for that matter, friend or family member from the past. Regardless of which of these possibilities is true, I can take refuge in knowing that one way or another, the dead no longer suffer.

The second big question that came up Friday morning: what is the meaning of life? While I believe that the answer to that question is different for different people, I do think a common thread runs through the various answers. Many of us would like to think that our life has been successful if we leave the world a better place, and that people's lives have changed for the better having known us. As I heard the testimonies from the many students, coworkers, friends and family members, detailing Uncle Mike's life and good deeds, I know that he did just that. And while that does not completely remove the sadness of his passing, it does help with it.

Tio Mike

Yesterday my uncle, Tio Mike, suddenly and unexpectedly passed away. He was a wonderful man, and a well-loved professor of English at Del Mar College, in Corpus Christi, Texas, for many years.  Older brother to my mom and my Tio Jack, he was the first in his Mexican-American family to go to college, quite a feat especially considering that before him, my grandmother Tita held the record for furthest advancement in school - reaching the 7th grade. My grandfather Papo worked as a filling station attendant, and growing up, my grandmother helped clean houses.  They both saw the advantages that a good education would offer and supported his decision to attend college, first at Del Mar and then East Texas State.  Now, as I'm combing through the web on this grey, rainy day in western Kenya, I came across an article detailing his receipt in 2004 of the highest teaching honor awarded at Del Mar, the Dr. Aileen Creighton Award For Teaching Excellence. The article states he was "probably the most respected and influential person on the Del Mar campus". A few years ago, he was named Professor Emeritus. Papo and Tita would have been proud.  I truly regret not sitting in on his classes to glean teaching pearls from him, though I'm happy for the handful of my friends from college that did get to take his classes.  Since I was in college, hanging out with Tio Mike was consistent and comfortable: we'd usually start with catching the latest sci-fi/fantasy movie, where he wouldn't let me pay, and this would be followed by philosophizing over a beer and pizza at B and J's Pizza in Corpus.

Working in African hospitals, death is no stranger. And while, after years of studying and practicing medicine I have a better understanding of the causes and processes of death, it is always a different experience when it is your loved one that is ferried by Charon across the river Styx. Having seen the suffering involved in long, painful deaths associated with cancer, TB, and AIDS, I'm comforted knowing that this was not in Tio Mike's cards. But what a sudden death takes away from us is the chance to ask the departed those questions we've been meaning to ask, to ask for forgiveness, and to say thank-you, I love you, and good-bye.

I'm heading home to Corpus in a few days for the funeral and to see the familia. And if I'm lucky, we'll go see a good fantasy movie, perhaps the Hobbit, and sit over a good beer and pizza at B and J's, and we'll have a chance to reminisce and be thankful for the time we had with our Tio Mike.

First Marathon

I just ran in my first marathon. Now I use that phrase liberally, as i just ran in one, but didn't actually run an entire one. I went for a jog this morning in Kisumu, and lo and behold, there was a marathon going on at the end of my block. Tall Kenyan runners without an ounce of fat glided gracefully down the street past me.  I thought why not - might as well join them for a little while.  The support crew at the water stations laughed and cheered me on, perhaps because I did not appear like an official race participant. I must have joined them for just the last 5 miles or so, and I still couldn't keep up with most of them. The race ended in the city center park, and I veered off before the finish line to keep from taking anything away from their hard work. I finished the loop back by our house near Lake Victoria. Since there wasn't anyone around to take my finish line victory shot, i decided to take it myself. 

Look Both Ways

Life in western Kenya continues to treat us pretty well.  While we lose power almost every day, and the water on occasion goes out for days, we are reminded that we are still part of a relatively small group of lucky individuals in this part of the world (for starters, simply by the fact of having electricity and indoor water and plumbing, for example). Though several of the cases are challenging and saddening, most of the patients have been doing relatively well. We see a patient with a new diagnosis of HIV, TB, or malaria most days. But thankfully, there is treatment available now for all of them.  It’s those that wait the longest before presenting to the hospital that have the hardest time recovering.  Besides the common cases of infections, we have recently cared for some patients that have suffered various types of trauma. An adolescent girl was hit by a motorcycle as she ran across the road and presented with a swollen face. The x-ray revealed a fractured jaw. Motor vehicle accidents are a major cause of death in Africa. She was one of the lucky ones that could walk away from one. She was referred to the regional hospital for evaluation by the surgeons to see if she needs her jaw wired so that it can heal well. An adult woman came in after being beaten by her son with a hammer.  Thankfully she has no broken bones and will heal, though I can’t imagine what the psychological and family healing processes will be like.

I witnessed an interesting cultural phenomenon today. An elderly man with advanced chronic illness passed away as his wife took her lunch in the next room. When I suggested that someone go tell his wife, every Kenyan health worker I asked said to allow her to finish eating before telling her the news. They said that she would be mourning for a number of days and would probably not be eating during the process.  The cafeteria crew seemed to know the family, and after she had received the news of his passing, brought her to his bedside and sang a local hymn to the tune of Amazing Grace.

The weather has been mostly fair, with cool nights and mornings, sunny blue skies in the day with temps up to the mid to high eighties and a short shower in the evenings. We can tell that the rains are letting up though, which means fewer blackouts, and hopefully, fewer malaria-carrying mosquitos.