Last Week at Work

In honor of the 2 funny emails I got from my parents regarding Ms. Ozzie, here is a picture of the dog at the campsite in Uganda who looks like Ozzie's twin brother.

(Note: This post and the following are new. The previous one was typed this weekend, but just posted now due to internet issues.)

Hard to believe. And it's been a doozy.

Yesterday morning, the very first patient we rounded on was a new one, admitted overnight. A 29 year old woman named Lucy. Lucy was HIV-positive, but the primary reason she was admitted was severe heart failure. The mitral valve in her heart was severely, severely stenosed (tightened, or strictured), probably due to rheumatic heart disease, which affects many children in Kenya. The disease affects the heart in such a way that children develop heart failure slowly, over many years. If not treated with valve replacement(s), most people die in their teens and 20's. At any rate, we gathered around her bed, and this poor woman looked so bad. She was gasping for breath, and each breath she took was clearly very hard work. She was moaning and crying, kept asking for water, but the registrar said that most of what she was saying was gibberish. She had been on oxygen overnight, but the tank had run out, and we were waiting on a new one to be brought over. We checked her oxygen saturation, which was 70% -- not good. The plan we formulated was to get her back on oxygen and load her up with morphine; basically paliative care, as there was not much else we could do for her.

Because of her severe valve stenosis, she had a pretty classic heart murmur, which the registrar wanted us to listen to. I was the last student to listen, and I heard the murmur, or at least I thought I did. As soon as I started listening, her heart rate started dropping and dropping and dropping, and within a few seconds it wasn't there anymore... I stood up and looked at Rhonda, my resident, and I said "Umm.... I think she's dead." The Kenyan registrar asked me what made me say that, and I said "She doesn't have a heartbeat anymore." He listened, and sure enough, no heartbeat, no pulse, no respirations, and we declared her dead. It would have been more sad if it hadn't been such a bizarre, surreal moment. First she was alive and there, and then she.... wasn't. And then the team just moved on to the next bed. It was so strange.

I think this second death was easier than the first, partly because it wasn't the first, and partly because there really was nothing else we could have done for her. She was suffering so much that death was a blessed relief for her. That's one thing that Kenyans really have on Americans -- the understanding that there truly are things that are worse than death.

My patient Rebecca is doing better, her swelling is much much improved, though she still has a lot of edema and can't walk due to newly-formed ulcers on her legs. She had an ekg that showed significant bradycardia (slow heart rate) and a strange heart block/arrhythmia. Her echo showed that her aortic root is severely dilated and is resulting in her aortic valve malfunctioning. She is such a sweet lady, I really like her a lot. She has assumed that since I know swahili greetings and greet her every morning that I am fluent in the language. After I greet her she starts speaking to me in rapid swahili, and all I can do is stand there and nod, say uh-huh, and then later ask the registrar or the intern what she said. I'm afraid that she's not going to do well though, her heart is very bad. If she were in the US she would need a very extensive and involved cardiac surgery. That's just not a possibility for her here.

I admitted a woman named Jennifer on last Thursday night. She's 27 and was referred from AMPATH clinic for severe persistent anemia. There was a note from the clinic that day in her chart, but when I asked her about being an AMPATH patient, she straight out told me that she was not a patient at AMPATH. So, I just let that one go. She's gotten several blood transfusions, though we're not sure what exactly is causing her anemia. It's possible that it's a side effect of her HIV meds, though she was taken off of the one that usually causes anemia a few months ago. It's also possible that it's due to the virus itself, though her other cell lines are normal, and you would expect to see all of them decreased. She also has a pleural effusion (fluid in her lung) that /I/ got to put a needle in and drain yesterday. It was cool! She also is a very sweet lady, though very reserved. She has several scars on her face that look like burns, but when asked about them she pretends she doesn't know what we're talking about.

I also admitted a patient on Monday night, a 19 year old girl named Sheila. She's also HIV positive. She was admitted for meningitis. When I saw her she looked very, very sick. She could hardly move and she had a very high temperature. She was only being treated for bacterial meningitis, but no coverage for cryptococcal meningitis(a fungal meningitis that immunosuppressed patients often get). I talked to a couple of the pharmacy students who were still there, and we got her started on meds for that too. She got a lumbar puncture (spinal tap) and we're still waiting to see what exactly is wrong with her. She still looks sick, though she is looking much better now. She is classified as an HIV orphan -- her father died of HIV and her HIV positive mother abandoned her and her siblings. It's so sad. Again, she is a very sweet girl (I seem to get all the nice patients).

Things are FINALLY worked out for Masai Mara this weekend. Nine of us are leaving at 6am Friday morning, will get to the reserve to eat lunch, then afternoon game drive. We'll do a total of 5 or 6 game drives in the 3 days and I am SO excited. I told Mike I'm not leaving Kenya until I see a giraffe and a lion, so he better hope that works out for me.

Since we're leaving on Friday, that means that tomorrow is actually my last day of work on the wards, as we get our last week in Kenya off as vacation. It's so hard to believe that I'll be leaving in a little over a week. On one hand the 8 weeks have just flown by, but on the other hand it seems like an entire lifetime ago that I was in the U.S. As much as I'm looking forward to seeing my family and friends again, I know it's going to be very hard to attempt resuming normal life in Indiana. Aside from missing my family, I've been very, very happy in Kenya. Aside from my family, what do I need that I have in the US that I don't have in Kenya? Absolutely nothing. In many ways, I even have more in Kenya than I do in the U.S. Life here seems much more fulfilling in many ways, because I don't have to deal with distractions of TV, media, celebrities, and the overall superficial selfishness that pervades American culture. Here the focus is more on relationships and understanding another's point of view. Certainly in Kenya I've made friends -- good friends -- that I would never have made in the U.S. Here, people understand the value of one another, because life is so fleeting and so difficult, and it can be over at any time.

And here, I've gotten to see first-hand the amazing work of the Mamlins and the AMPATH program, and I've seen with my own eyes the countless lives that they have changed. But that's for another post.

I'm so excited to go home, but I'm also so very sad to leave. I have come to love Kenya, and I know I will miss it terribly. I also know, without a doubt, that I will be back.