Beautiful Souls

This trip across the Atlantic has been an emotional one, partly due to the intensity of the Kenyan wards and also because of reasons much closer to home. In mid-September, we learned of the passing of a good friend and choir buddy back in Indianapolis. While she had spent some time in hospice care at her home, we grieved her loss from many miles away.

And now, today, we learned about the passing away of my dear grandpa Phil. While also neither sudden nor unexpected, it was still a great emotional blow, especially to learn about so far from home.

Grief is such an individual experience, and as a physician I have both the advantage and the disadvantage of experiencing death and grief in a very objective way. So objective, it seems, that I don’t know quite how to deal with it personally. We spent most of today, our last day in London (as planned) the only way we could in such a situation: lights off, curtains drawn, in silence.

My grandfather battled over the last decade with leukemia, bone marrow transplants, infections, graft-versus-host-disease, and chronic lung infections. Despite his all-too-frequent trips to various hospitals across Indiana, I will always remember and admire my grandfather’s perseverance, positive attitude, and faithful spirit. Though his leukemia diagnosis in 2000 started a tumultuous and at times heartbreaking last decade of his life, it was also one of great milestones and triumphs in our family. Five grandchildren graduated from high school, two from college, one from medical school; two grandchildren married, a seventieth birthday, a fiftieth wedding anniversary, and even the birth of an eighth grandchild – these are just a few of the many, many celebrations we’ve had in our family since 2000. He had said, and I truly believe it, that he would not have traded the last ten years of his life for anything. I hope that when my time comes, I can say the same thing.

And so we grieve. Individually, and as a family. We grieve not as for the young, in a life lost too soon. Our grief is a mixture of sorrow for ourselves, for the loss of a presence in our lives, as well as joy and celebration. We celebrate the ending of pain, of suffering, of being trapped in a failing earthly body.
My medical training has brought me greater understanding over the past few years of everything that Grandpa went through. Despite the knowledge of the risks and tolls of two bone marrow transplants and the severity of the myriad infections he suffered, I will not remember him this way. To me, he will always live in my mind’s eye, in my heart, as the young, strong, whistling farmer in overalls who could do no wrong in young Meagan and Brant’s eyes. In my childhood, he knew everything, could do everything, could be anything. Quick with a corny joke, never a man to lose at cards, and always demonstrating a love for his land and for his animals, these were the essence of my ‘Pa, to me. And they always will be.

Today, thinking about Andrea and Grandpa Phil, thinking about these two Beautiful Souls who have passed from this world in the last two months, I am finally ready to go home.

Goodbye to Africa

After a long day of travelling behind us, and an even longer one looming up before us, it is time once again to bid a fond farewell to Africa. This goodbye feels different than the first, if only because I'm fairly certain I will be back again.

Our travels through Kenya were adventures both big and small, and will have seperate posts dedicated to them. In short, Masai Mara was as grand and amazing as I remembered, and Mombasa was beautiful, but very touristy and not quite what I expected.

This entire trip has been a very interesting packing experience, as we've never had to pack for a safari, a beach vacation, and a week in Europe in the fall in one fell swoop. Also take into consideration six weeks of work supplies, and it's a grand understatement to say that our luggage situation is out of control. With two checked bags apiece as well as two carry-ons, we've had no small amount of trouble figuring out how, exactly we will be transporting ourselves and all of our stuff from Heathrow to City Center tomorrow. Our Nairobi hotel room tonight looked like a war zone as we literally upacked and then repacked every piece of luggage.

Regardless of the minor annoyances and hazy details of actually travelling, I still do love to travel. I am very much looking forward to the second half of our vacation. I think it is well deserved for both of us, assuming we make it to London with ourselves, our luggage, and our sanity intact.

Despite the anticipation of another week of leisure, I am still reticent to leave Kenya. It has once again been an experience full of triumphs and tragedies, happiness and heartbreak, beauty and sorrow, life and death. I am quite sure that the shock of returning to Western culture will be much greater than when I arrived, as I found when I returned home the first time. It is just so difficult to remember why all the things that matter actually do, after seeing the struggle for basic survival in a developing nation.

I hope I will have a greater opportunity to reflect on and report more of my experiences from this, my second trip to Africa.

Life and Death on Upendo Ward

During my short six weeks working at MTRH, I have had the opportunity to learn medicine in a whole new way. I have seen disease processes here that I will never see in the US, I’ve witnessed children die of pathology that is easily cured only a half-day’s plane ride away, and I’ve treated a wide, wide variety of infectious diseases with the same four antibiotics. Mostly, I’ve had the privilege of caring for an entirely new population of amazing little people and their families. The lessons I’ve learned from their reactions to serious illness, tragedy, and economic hardship will stay with me long after the milligrams-per-kilo dosing of antimalarials and HIV-treatment algorithms have faded from my memory. Below are just a few of the many children I have cared for this season at MTRH.

Shelly – The most memorable of the deaths on our firm, I actually cared for Shelly twice in the course of six weeks. Stricken at a young age by rheumatic heart disease (the sequela of un-treated strep throat, unfortunately very common here where strep throat is not often diagnosed or treated), she had had chronic heart problems and symptoms of heart failure for the past three to four years. Now, at age 14, she presented with acute worsening of her symptoms, was short of breath at all times and completely unable to lay flat. We improved her symptoms with medication during the first admission, but she returned five days later with even worse complaints, as well as a new requirement for supplemental oxygen. During the second admission, Shelly did not really respond to her medicines as well as the first time, and a repeat echo showed severely diminished heart function. One Friday afternoon with the help of an interpreter, my medical student and I had a very hard conversation with her mother. The “your child is going to die” discussion is never, ever easy, but it is even more difficult when you can’t even convey such an unthinkable concept in the same language. Thankfully, our interpreter had worked frequently in the peds heme/onc unit and did a wonderful job. At the end, when I asked Shelly’s mother if she had any questions, she said no, and with tears in her eyes said “I just thank God that you have told me this, because now we know.” As simple as that. I am rarely thanked at home when I actually do something helpful, but here, parents thank us for simply taking the time to talk to them, even when we are saying something horrible. As soon as we left the bedside, Shelly’s mom pulled the curtain around them, and woke up her beautiful, sleeping, 14 year-old daughter to tell her the news we had just delivered. I can’t even imagine the strength it takes to do so such a thing.

Shelly lived through that weekend, but started to clinically decline early the next week. We had told her mother our goal was to get her symptoms controlled well enough that she could go home; however, one look at her Monday morning and I knew this would not happen. Tuesday morning during rounds, the curtain was pulled around her bed, but we could all hear her groaning in pain and gasping for air. The Registrar told me that he had called the ICU about transferring her, but she was already pulseless in her extremities, so we knew it wouldn’t be long. Most unfortunately, and for many absurd and complex reasons that I won’t go into right now, Kenya has really no form of IV pain relief on a country-wide level. Morphine would have been a perfect drug in this case. Despite the fact that our team was essentially ignoring her (every time I asked the Registrar a question about her – his response: “We’ll see what the ICU wants to do.” Dude! She’s not going to make it to the ICU), I sent the pharmacy student to see what form of IV pain medicines we may have. The best we could do was an IM shot of ibuprofen. I knew we were doing the best we could do, but it was one of those times the best just wasn’t good enough. As I stood by Shelly’s bedside in her last moments, I put one arm around her mother, who had a single tear running down her cheek. That tear said so much: the loss of a child, the loss of life’s hopes and dreams that have been built over the course of 14 years, the failure of a medical system in a modern world to prevent this one very preventable death. Of all of the patients I cared for at MTRH, I felt the most attached to Shelly and her mother, and I was very saddened by her death. I have always found teenage deaths to be the hardest and the saddest. Teenagers are just becoming individuals with their own identities and plans for the future, they are old enough to understand when they are dying, and they are old enough to be mad about how unfair it is. It is, simply, unfair.


Sarai – one of many children abandoned at MTRH, Sarai was a patient on my team before I arrived. She was found alone outside the hospital at the beginning of August. Immediately noticeable was her macrocephaly (fancy doctor talk for “large head,” and truly, the largest head I’ve ever seen) as well as severe malnourishment. She was estimated to be about a year old. Her head CT on admission showed hydranencephaly – basically a condition, usually congenital, where there is far too much fluid in the head and the remaining brain structures don’t form correctly. Indeed, Sarai has very little-to-no brain tissue, she essentially has a brainstem and that is all. Sad to say, but she will never have anything we would consider any quality of life; she will never roll over, sit, walk, talk or interact meaningfully with the world around her. She has primitive brainstem reflexes (including sucking, which is probably how she is still alive), and will require skilled medical care for the rest of her life. She has had a complicated medical course since admission, and I have advocated several times to my team that discontinuing further aggressive medical management might be the most ethical course. Sarai’s case is further confounded by the fact that she was abandoned, and is therefore now a ward of the state, so the legal aspects of stopping further care must also be considered. Even if Sarai could reach a point of being medically ready for discharge, the chances of finding a children’s home that could attend to her many complex medical needs are slim to none. As it is, on my last day on the wards I left my team still piecing together the vast moral, ethical, and legal components of Sarai’s care, and I don’t think there will be a resolution any time soon.


Jake – another very sad little boy I took care of. A previously healthy 3 year old, he came in with a story that sounded a lot like meningitis. He received appropriate treatment for his meningitis, as well as treatment for pneumonia and malaria, but he just did not get better. In fact, he got worse, to the point where he was very lethargic, could not sit, walk, talk, or eat on his own. In the end, based on his lab studies and clinical course, it was thought he likely had a viral encephalitis (inflammation of the brain). Even in the US, sometimes kids with this condition recover, and sometimes they don’t. As with other conditions caused by viruses, most of the time there is not a specific treatment either, and we just have to wait and see if the child will improve over time as the brain re-wires itself. Yet another one of my difficult Friday afternoon conversations was with Jake’s mother (why did we always do these on Fridays? I don’t really know. “Friday Death Rounds” my team leader glibly called them). We actually had the Kenyan medical student caring for Jake have the conversation with his mother, and she did a fantastic job, and said it was a meaningful experience for her, which was about the only silver lining. Again, Jake’s mother’s response to us telling her that her previously normal and healthy son would probably never be normal again was: “Thank you so much for telling me.”


Jane – very similar to Jake, a 2 year old previously healthy, beautiful little girl who came in looking and sounding like meningitis. She was even in the same bed he had previously occupied, which was more than a little uncanny. When we did her LP (spinal tap), she had frank pus that came out of her back (should be clear, like water) so our diagnosis of meningitis was a little more confident. Unfortunately, like Jake, she showed no improvement, continued to be very lethargic, irritable, unable to sit, walk, talk, or eat on her own. She also continued to have high fevers for at least a week on what is considered appropriate treatment for meningitis, indicating that the infection was not adequately treated. Suspecting bunk drug product (all too common here), our pharmacist advised us to change from the generic to the brand form of one of the antibiotics, which did seem to make an improvement in her fever curve. Unfortunately, by this time, the damage had been done and she showed no clinical improvement. It’s hard to know if her deteriorating condition was the result of un- or under-treated meningitis, a complication of meningitis (ie brain abscess), the result of an adequately treated but bad case of meningitis, or even some other condition such as seizures. In her case we will probably never know, though it makes no difference now to Jane or her mother.


Steven – a very, very malnourished little guy, 2 years old, who came in about the weight of a 3 or 4 month old. Upendo peds wards certainly sees its fair share of malnourished children; however, Steven was quite severe. He also had HIV (actually AIDS based on clinical criteria) for which he had not received treatment, and chronic diarrhea and poor feeding. We were able to make little headway with him in the short time he was on the wards, and he died suddenly one night. His case is a perfect example of how long diseases can go on at home here before being brought to medical attention, as well as the still-present devastating effects of untreated HIV infection.


Emmanuel – by far the biggest diagnostic dilemma we saw, Emmanuel is a 10 year old with a six month history of worsening abdominal swelling, fatigue, and fevers. And by “abdominal swelling” I mean he looks like he’s nine months pregnant. Or really, like twelve months pregnant. He has a massive, massive spleen that is taking up most of his abdomen, in addition to stealing his blood cells from his peripheral circulation, making his white blood cells, red blood cells, and platelets dangerously low (leading to infection, anemia, and bleeding, respectively). The list of diagnoses that causes such a huge spleen is short, even in Kenya. Despite its brevity, we were still unable to make a diagnosis. His bone marrow aspirate showed no malignancy or infection, his abdominal ultrasound showed nothing but a big spleen (which we already knew about), and his splenic aspirate was negative for the two most likely infections. So, he sat. Sat and waited for expert opinions, for more blood, more platelets, more answers that we could not provide. Every day on rounds we would discuss the risks and benefits of just treating him for one or both of the infections that this could be… but the tests were negative… but it depends on how reliable you think those tests are here… well why did we get them if we weren’t going to believe them… and on and on and on we talked ourselves in circles until every day, we decided for one more day to “wait and see.” By the time I left the wards he had been there for three weeks and really nothing had been accomplished. In addition to my most difficult diagnostic dilemma, Emmanuel’s case was also my most frustrating.

And now, so I don’t convince everyone (including myself) that MTRH wards are all death and despair, a few of the kids I’ve taken care of who did well.

Elizabeth – ok, so I’m not sure if she really belongs in the “happy ending” category, but I have a lot of hope for her, so here she is. Also on my team before I even arrived, she is a darling 19-month old little girl who presented in early August with severe malnourishment, cough, and fevers. In the course of her workup, she was newly diagnosed with HIV, which resulted in a new diagnosis for her mother as well. She was also diagnosed with and started on treatment for tuberculosis. Her primary problem continues to be poor weight gain. She weighed 5kg (~10lb) when she was admitted in early August; when I left her in mid-September she weighed 4.97kg. This child is eating massive, massive amounts of calories every day and refuses to gain weight. Because of the severity of her illness when she came in, she was not immediately started on treatment for her HIV, but by the time I left, our team thought that antiretrovirals might be the key to her weight gain. The reason I think, hope, and pray that she will do well in the end is her mother. Despite a devastating new diagnosis for herself, Elizabeth’s mother has been the absolute model of patience, devotion, and dedication to her little daughter. Despite the tedium of a (so far) six-week hospitalization, not to mention an eventual bill she can’t even dream of paying, she is always smiling, has a fantastic attitude, and celebrates, even leads our team in celebrating Elizabeth’s small victories. That Elizabeth is tiny carbon copy of her beautiful mother made these two my favorite people to see every day on rounds. I truly hope she will eventually experience a significant improvement.


Franky – a very sick, scary little guy when he first came in. 3 months old, HIV-exposed but not yet diagnosed, he was admitted with a short history of respiratory symptoms: cough, wheezing, and fast breathing. The first day we rounded on him, he was still on oxygen, looking so-so, but being treated appropriately for pneumonia. On the second day of his admission, the Registrar and I took one look at him, and I thought to myself, “ok, so THIS is how today is going to go.” He had probably the most severe respiratory distress I have ever seen in a baby, and frankly, looked about 75% on his way to being dead. Very quickly, the registrar got an IV in the baby and called the ICU, while I frantically wrote for, tracked down in pharmacy, and administered myself every medicine that I thought would possibly be helpful. We ended up broadening his antibiotic coverage for bacterial pneumonia, as well as starting him on treatment for PCP (a specific type of AIDS-related pneumonia) and tuberculosis. He actually turned around so quickly that by the time the ICU came to see him later that day, he was no longer sick enough to have one of their beds. After three or four more days of good IV antibiotic treatment and steroids, he looked like a new man, normal oxygen levels, feeding well, looking for all the world like a normal baby. In addition to some good teamwork, we were helped out that day by a few other things. First off, he happened to be in the very first bed. If he had been later in the rounding queue he very well might have died before we got to him. Secondly, his mother had told us earlier that she had a previous child die from some type of respiratory infection. While not uncommon, I think this revved up our team’s “not to this baby, too” mentality. Lastly, one of the very first things I personally collected was a resuscitation bag and appropriately-sized baby mask, just to help ward of the bad joo-joo. I truly think it helped in Franky’s case.


Milo – Very similar story to Franky’s, was admitted only a few days later. A 17 month old little boy, also HIV-exposed but not diagnosed, he too came in with pneumonia-like symptoms and low oxygen levels. He was an irritable and cantankerous little squirt who refused to keep his oxygen tubing in his nose. Problem was, whenever he yanked it out he would become lethargic, dusky, and very, very hypoxic. The sat monitor would mostly read “lo” or somewhere in the 40s or 50s. This is bad. Luckily for him, he got very sick a few days after Franky, so we were prepared for his foray into the world of Trying To Die. Like Franky, with a little more antibiotic on board, PCP treatment, and TB treatment, he came off of his oxygen and turned around quite well in the end.


Irene – a fantastic 4 year old girl who came in with seizures and history concerning for meningitis. I actually assisted with her LP (spinal tap) and got to talk one of my med students though the procedure, which he completed successfully. In addition, I supervised her conscious sedation for the procedure. Conscious sedation is when we give kids (or adults) a little (or a lot) happy juice medicine to sedate them for painful procedures; specifically procedures where they need to hold still. While this is fairly common practice in the pediatrics world, CS in the US is not something any resident should ever, ever, under any circumstances do without a staff physician present. Considering I was the only physician for miles around even involved in the procedure, that left… me. To direct my first unsupervised conscious sedation while teaching one American med student and two Kenyan clinical officers about CS and LPs. Oh poo. It actually went very well, and overall I was happy with the teaching-learning-patient care dynamic that had taken place. Irene turned out not to have meningitis, and after she recovered from her seizure and its associated medications, she got to go home happy as a clam.


Diana – by far the most memorable clinical experience in Kenya, probably in my life of medicine thus far. Diana is a 3 month old baby, not even on my team. All of the American doctors and medical students happened to be on the pediatric ward one afternoon during a teaching session; we were there because the only XRay viewer happens to be on the peds side. One of the medical students looked at me and asked “is THAT your patient?” Past his pointing finger I saw a baby, looking for all the world like she was dead, being frantically, ineffectively bag-masked by a nurse. Our peds team leader had gone out to Mt. Elgon for the day, so as the only pediatrician, all eyes were on me. Oh boy, here we go. I turned the baby, positioned her, corrected the nurse’s bag-mask technique (the mask was actually upside-down on her face, this is what we were dealing with), quickly assessed the rest of the situation. No breathing, no heart rate, this baby was dead. Bagging continued, I started chest compressions, we gave epinephrine. The rest of the Americans found the baby’s chart and tried to track down at least one Kenyan physician for me to confer with. In the pauses between cycles of bagging, chest compressions, and epinephrine, I listened. For the sake of full disclosure, I must say that I didn’t expect to hear anything, and that eventually I would be pronouncing this baby. But, against all odds, eventually I did hear something. Faint at first, thinking I was only imagining things, but yes, the baby DID have a heartbeat again. We stopped giving epi, we stopped compressions, and eventually we were even able to stop bagging the child. Many, many things were happening during this resuscitation; people were running meds, starting additional IVs, taking over bagging when the nurse got tired, holding up the baby’s mother who was literally on her knees in anguish… but in the end, my little team of people, we saved this baby. We pulled her back from the brink. When I met her she was dead, when I left her, she was breathing on her own and stable enough not to go to the ICU. This is the first time I have led a code, the first time I have seen a code result in non-intubated survival, the very first time I have said to myself “Holy Shit, I’m a doctor.”

Overall it was one of the best run resuscitations I have seen or been a part of. I’m not sure if it’s because I actually knew what I was doing or if everyone else was so scared they ended up listening to the only person talking (me). Diana and I owe a huge debt of gratitude for the outcome to the nurses, clinical officers, and medical students who were there with me. We were also assisted tremendously by an angel in the form of a respiratory therapist named Mark. Here I will break my “do not use first names” rule; the fact that he shares the same first name as my father and appeared at exactly the time I was desperate for some respiratory expertise confirms my belief that he was sent to me by a Higher Power. After the baby was breathing on her own again, but still very sick, Mark, Respiratory Therapist appeared out of nowhere and just got things done. In minutes, he found the nebulizer machine and medicine that I had been asking for for a half hour, administered the treatment, was able to obtain a blood gas and run it in under five minutes, hook up the oxygen tank and tubing the nurses had been struggling with, and make the old, microwave sized suction machine work with only a few curse words and a swift kick. For all of that and the thousands of other things he was helping me with, his long white coat fluttering out behind him looked like nothing more than the cape of superhero. In short, this man saved me, and in doing so, he saved Diana.

Having never, ever seen an RT at MTRH until this very moment, I was curious to find out more about him. Turns out Mark started out as a clinical officer (Kenya’s equivalent to NPs) in Eldoret, but then went on to train as an RT in Chicago for three years. Now he works mostly in the ICU but does do some things in the regular wards as well. He and I chatted for a long time afterwards about what is possible in the MTRH wards and what are the limitations. It is true, as he says, that many lives could be saved with a few simple respiratory interventions: more oxygen, more tubing, more advanced support such as CPAP and BiPAP. He communicated to me a desperate need for more nebulizer machines, and especially the tubing and masks that go with them. In America, we discard these after one use, but at MTRH, the same masks and tubing are used for every patient on the ward. In the end, I thanked him profusely for his invaluable help (which he deferred by saying he was “just doing his job”) we exchanged contact information, and I promised to keep a sharp eye out for discarded respiratory equipment once I return home.

In the end, this is both a remarkable and an unremarkable story. In the end, yes we were all just doing our jobs. Though I personally had little hope for a good outcome of this code, there was never any question of whether I would be involved. It’s what we do. As physicians, it’s who we are. Despite the chaos of any code (especially in Kenya), when it comes down to it, the training just takes over, it’s automatic. Position. Clear. Bag. Chest Rise. Compressions. Cycles. Epinephrine. Re-Assess. It’s been engrained into me over years of study and good medical education. Because of where I was at the right time with the right people and the right training behind me, a child now lives. It’s this exact experience that we all hope for when we write our personal statements for medical school, with the vague intention of going into medicine to “help people.” At the time, I hadn’t the foggiest idea what that meant. Now, because of Diana, I do.

Kakamega

A few weekends ago, Mike and I, along with two of our IU House buddies, went to Kakamega Rainforest. Many of you will remember Kakamega as one of my favorite trips from Kenya v. 1, and I was excited to go again, as well as to have Mike with me this time. Also exciting was that we got to spend the weekend at Rondo House, which is the best place to stay in Kakamega (Rondo was booked when I went the first time, so we ended up camping instead). It’s actually an old compound of manor houses dating back to the British Colonial times, now converted into a very nice, if a bit quirky, hotel. We stayed in the main house, which has a full wrap-around patio with excellent views of the rainforest.

We left Eldoret Saturday morning, and in a quick ninety minutes on surprisingly good roads, we were at Rondo. We spend the rest of the morning reading & relaxing, then left after lunch for our afternoon hike. We hiked for about three hours until we reached the Yala River, which, according to our guide, flows directly into Lake Victoria. The views of the forest on the way to the river were as stunning as I remember, with countless birds, flowers, trees, insects, and monkeys to keep us (and our cameras) occupied along the way. After reaching the Yala, which was a sight to see in and of itself after all of the recent rain, we hiked another two hours through the forest, through a large guava orchard, and then finally along the road back to Rondo. We were lucky in the weather department, we got rained on only once and for not that long. As soon as we got back to Rondo; however, the skies let loose an impressive deluge that we rather enjoyed from the porch. Being in it probably would not have been nearly as much fun.

After an early dinner and a quick game of Catan (which I won, by the way, DESPITE the fact that Mike was also playing), it was an early bedtime for everyone. At 5AM on Sunday morning, we awoke for our sunrise hike. We hiked about an hour in the dark, up some very steep and muddy trails, but the view at the top was so worth it. We saw a beautiful sunrise over the rainforest canopy, took tons of pictures, then hiked back down for breakfast. Afterwards, we spent the morning reading and relaxing. I found a reading spot further out on the grounds, right next to the forest, and proceeded to fall asleep almost immediately. I awoke to the sounds of a church service occurring in the compound’s tiny chapel right next to me, including familiar hymn tunes with Swahili words. Interesting. After lunch we checked out, made the quick trip back to Eldoret, and got ready for another week. On the way home, Mike was able to get some great shots of the various things you see along the road in Africa: the bustling Sunday markets, families walking home in their Church Best, donkeys and goats mingling with shopkeepers and matatu stands… it’s easy to describe the individual components, but the collective image of everything is difficult to convey completely. As our new buddy Danielle says (one of the IU House crew this time around): “TIA!” Which simply means: This is Africa.

Safari Salama

I can hardly believe it, but it's time to leave Eldoret. My six weeks on the wards here have flown by, and this morning Mike and I will start our two weeks of vacation before heading back to the states. We'll be spending variable amounts of time in Masai Mara, Mombasa, Nairobi, London, and Paris prior to our flight back, so needless to say we have a fairly busy schedule ahead of us. We are looking forward to the vacation and our time together.

I will hopefully have a chance to complete some more blog posts that have been half started, either on paper or in my head. My work schedule was more demanding as a resident than as a student, so I did not have the chance to blog nearly as much as I had wanted. The plan is to back-log some blogs at some points along the way, as well as updates on our progress across the globe.

Kutembea, Looking Up

There are many things I enjoy about my daily morning walk to work. Generally I try to leave a few minutes early, in order to avoid the mass exodus of white-coated mzungus that traverse the well-known path between IU House and MTRH every morning, in order to have 15 minutes of uninterrupted time to myself, to think.

The musings on these daily strolls range from the absurd (why is that man carrying a lawnmower on the back of his bike?) to the practical (note to self: avoid the cow dung) to the introspective (what should I blog about next?) to the mundane (what do I need to get in town today?). On occasion, I will just allow myself the opportunity to spend 15 minutes thinking about absolutely nothing and simply enjoy a walk in the early morning Kenyan sunlight. On these occasions, when I take the time to not think, I find that I take the time to notice.

On my left, just outside the IU House gate, a school, busy with the hustle and bustle of a new school day starting. Uniformed children of varying sizes exiting the school bus, toting their school books, waving goodbye to their parents for another day. I notice that the sounds of children playing, talking, teasing, and laughing are the exact same in any language. If I close my eyes, the lilting, high-pitched timbre of their voices could be transplanted to any playground in America with no translation needed. I notice, every day, a little girl who lags behind the others. She is probably 9 or 10, wears braces on both of her legs, thick glasses, and hearing aids. She walks to school every morning, with her mother trailing protectively a dozen steps behind her. There is an unspoken code between them: how close the mother is allowed to come to the school gate, when the girl must turn to acknowledge that she has made it through that gate, the nod of understanding that passes between them. I notice that a child’s desire to fit in and be accepted by her peers is not a feeling constrained by country boundaries or cultural norms.

I walk on, noticing the steady stream of diesel-belching trucks, passenger-laden matatus, and bicycles carrying impossibly high and precariously balanced loads of people, wood, cloth, and everything else that can and cannot be imagined. As this eclectic assortment of traffic traverses the busy Elgon View Road, I notice how intent everyone seems on their destination, not unlike morning rush hour traffic in the US. One does not need to speak Kiswahili to recognize the unmistakable appearance of people heading to work. The most remarkable thing about me noticing them is that they hardly notice me. Granted, Eldoret has seen its share of mzungus in the past two decades, but this is still Africa, a place where the owner of a white face can attract a great deal of unwanted attention for what that skin color historically represents. However, I usually receive no more than a cursory glance or two, with a “how are you madame?” thrown in for good measure, and pass my walk to work quite undisturbed. There is no glaring conceit, no open hostility, no obvious disdain for me as an American. Despite what some would have you believe, there is no grand conspiracy. I truly believe that the vast, vast majority of people in this world are too occupied with trying to live to think about much else. I notice that here. I notice an entire city of people: not whispering, scheming, or plotting; but simply trying to…live.

Further up on Elgon View Road, just before the left hand turn onto Nairobi Road, a construction site, a high-rise building going up. Again I notice industry, progress, people working. I notice an entire line of trench diggers along Nairobi Road, rhythmically pounding their rusty pick-axes over and over into the rock-hard, red clay soil of Eldoret, making slow progress. I notice the intense physical demands of such a job; a job few Americans could or would undertake. I notice the woman selling maize at the same corner every day, effortlessly fanning the flames of the same Giku with the same palm frond every day. She always has her daughter with her, and I notice that they wear the same clothes every day. I notice that the woman sits at this same corner from dawn until dusk, probably earning the equivalent of one US dollar per day selling her maize, which is maybe all that stands between her family and starvation. I notice an intense feeling of guilt mixed with appreciation and gratitude every time I pass by her.

Most especially on my daily walk I notice how carefully I have to place each step. The roads and footpaths are riddled with a figurative minefield of rocks, potholes, trash, gravel, and animal flotsam. One misplaced footfall can easily turn an ankle or even topple to the ground all but the most wary of travellers. I notice, if I’m not careful, how easy it is to spend the entire 15 minute commute staring at my feet, never looking up at the world around me. Do I really want to have spent the majority of my time in Eldoret, in Africa even, staring at the ground? Not really.

Then the more I start to notice this, the more I start to think again. What would it be like to live every day in this way: to have to so carefully monitor each step that you never lift your eyes to see what’s ahead? Seems a perfect analogy for African life if you ask me. For Westerners, one of the most frustrating aspects of Kenyan culture is the apparent inability to look toward the future, to make a long-term plan. Kenyans, our patients especially, stereotypically think of today as the only day of concern. They may spend an entire project budget on only one line item, they have difficulty with the concept of saving, and they spend a month’s pay in town on “paycheck Friday.” On rounds, whenever I ask questions along the lines of “Well, that temporary fix will work for today, but then what do you want to do tomorrow about this exact same problem?” my Kenyan colleagues look at me as though I have a third eye. From an outside perspective, Kenyans seem frivolous, bad with money, poor planners, and completely unable to think things through beyond the problem at hand. It is an extraordinarily frustrating system for us to work in, because Americans are culturally a goal-oriented group, especially physicians.

The more I think about the physical act of walking to work though, the more I get it. The average Kenyan navigates potholes in their own lives the size of which we can scarcely fathom; women and children especially. Rural Africans are up at dawn, possibly walking miles to fetch a single day’s supply of water before beginning the routine of cooking, cleaning, childrearing, farming, and possibly even running a small business selling fruit or clothing. Days stretch late into the nights as they go about the affair of simply surviving. Throw into that mix intolerable levels of disease and death, and the whole “one day at a time” concept becomes more than just a cultural norm, it becomes a coping mechanism. Today is filled with enough travails and challenges to worry about, how can impoverished Kenyans be expected to anticipate the needs and worries of the next day, let alone months or years in the future? The thing is, the average Kenyan can’t look up from the road they’re walking to see what’s ahead. The thing is, maybe today is all they have.

The majority of Americans, even poor Americans, have never had to walk such a fine line of survival. Looking forward, planning for the future, is a luxury we have. We can afford to take our eyes off of today, because today is already taken care of. We take for granted, for the most part, that we will have water, food, warmth, shelter, and health for ourselves and our children. Our basic needs are met, so we can think about, dream about, and plan for the days ahead. How can the woman selling maize on the corner possibly be expected to do the same? Her entire day is consumed with earning the money she needs for this day. How can we expect her to also be thinking about her daughter’s secondary school or university fund? Our Western ideals of planning, saving, and looking toward the future are completely incongruous in this setting.

In Kiswahili the verb “to walk” is kutembea. Kiswahili verbs in general are tricky; however, I have a tendency to confuse kutembea with the unrelated verb kujifunza, “to learn.” Maybe it makes sense that these two words would be so related (or even interrelated) to me. I walk as I learn. I learn as I walk. Maybe the only way we can help a “one day at a time” culture start to see the big picture is by walking alongside its people, learning what it is like to live as they do. And now, again, I think I’ve arrived at a perfect example of what the AMPATH concept aims to do. Westerners partnering with Kenyans to think about, plan for, and arrive at a brighter future for their country. It is not a perfect system, nor will it ever be, as disease and poverty with always exist. What AMPATH can do, though, is relieve some of the burdens of disease (via HIV/AIDS care), poverty (via FPI and HHI), and childrearing (via OVC) associated with daily life in Kenya. Then, and only then, can Kenyans start to look up, see a future, and pursue it with the hope that today may not be all that there is.

Orphans and Vulnerable Children

Instead of going to the wards on Friday as per my usual, I got to spend the day doing home visits with the Field Director of AMPATH’s Orphans and Vulnerable Children (OVC) Program. The OVC arm of AMPATH aims to identify and assist children in the AMPATH catchment area who are either orphaned or vulnerable to lack of support due to HIV/AIDS. There are many situations that qualify children for assistance from OVC. In general, these include things such as loss of one or both parents to HIV/AIDS, being HIV positive without one or both parents alive and healthy enough to care for them, or extreme poverty. The goal is to intervene as early as possible to improve children’s outcomes in all areas of their lives: health, education, emotional, financial, and independence.

I left early this morning with Emma, the Field Director. We drove out to Mosoriot – the site in Western Kenya of AMPATH’s first satellite clinic as well as the rural clinic to which I travelled with Dr. M during my first visit to Kenya. We stopped briefly at the clinic, picked up two of the Mosoriot social workers, and drove out into the community. Per Emma, these weekly field visits are completely unannounced. The social worker(s) identify families and patients at clinic who need closer follow up and/or a home assessment, put them on the weekly docket, and essentially just point Emma in the correct direction every Friday.

The first home we arrived at was a small, one room mud hut with a single bed, the size of the room approximately the size of my kitchen at home. In this room lived Beatrice and Sylvia, 8 and 6 years old respectively. Their mother died from complications of HIV/AIDS (maternal orphans) several years ago, and their father, as well as their two younger siblings, are currently admitted at Mosoriot Hospital with severe AIDS-related infections. Since that time, the girls have been living and caring for themselves alone. We spoke with a neighbor who has been helping to care for the girls, but she has two children of her own, so admitted to us that it is “difficult.” Especially difficult is ensuring that Beatrice is consistently taking her medicines, which, after a quick pill count, we discovered has not been happening regularly.

After taking some basic information from the neighbor, the social worker conducted a quick home assessment, making note of the strengths (structurally sound, intact roof, stove, tap outside) and weaknesses (dirty mattress/bedding, piles of laundry, broken window) of the dwelling. She also conducted a quick assessment of the girls themselves, asking them some basic questions. In addition to lack of care and supervision, the second major issue that arose was that the girls are not currently in school. We spent about an hour in house, discussing strategies for assisting the girls amongst the neighbor, social workers, and field director. In the end, the neighbor agreed to continue to assist the girls as long as the father was hospitalized. This is a great short-term solution; however, there was further discussion between the OVC team regarding the father’s medical prognosis, as he apparently has had significant issues in the past with treatment compliance. Ergo, there needs to be a plan of care in place for all four children if and when the father dies. Unfortunately, there is no extended family to care for them; the father’s father has died, his mother is re-married “somewhere in Nakuru,” and he has no siblings. The mother’s parents are still living, and when she became sick she went back to live with them. She took her youngest baby with her (there are actually five siblings total), and died in their home. Now that she is gone, and the mother and father were never married, the mother’s parents want nothing more to do with the children’s father or the remaining four siblings (though they do still have the baby). This is what we in the US would refer to as a “hot mess.” In the end, it was decided to refer the case to the DCO (District Children’s Officer – essentially like our DCS or CPS at home) both for the truancy issue as well as the potential for the children to become true orphans without identifiable caregivers.

As the Kalenjin conversation went on over my head (the OVC social workers and community health workers are all members of the actual community, so they speak the local language), I found myself looking at and contemplating the children. Beatrice, the biggest, the eldest, also HIV positive, but appearing relatively healthy. I could see already the weight of responsibility she carried, as she never made eye contact with anyone, stared mostly at her feet, never smiled, and answered only in short hapana (“no”) or ndyio (“yes”) answers. She was far too somber for such a young age, and the magnitude of the sorrows and burdens she has experienced were poorly reflected by her small size. Sylvia, the 6 year old, HIV negative sister, peering out occasionally from behind the protective stance of her older sibling. She wore a bright pink dress that looked like flower girl attire, clearly too big for her with dirt ringing the bottom and the lace edging torn and hanging in several places. She would occasionally peek out from behind Beatrice, make quick eye contact with me, smile, giggle, and quickly duck back to where I couldn’t see her. If anyone can be lucky in this family, I suppose she would be the one – the only sibling to be HIV negative, clearly not yet schooled in the realities of her life, and sheltered by a fiercely protective older sister. The neighbor’s two little boys were also in the house, the older one looking to be around 4 or 5, the little one looking like he just recently learned to walk. All four standing close together, staring at me, backlit by a halo of early morning sunlight beaming through the open door, they made one of the most beautiful pictures of Africa I have yet seen. Sitting there, looking at them, dirty, little, and vulnerable, I was overcome by an enormous wave of sadness about their situation and the enormity of the problem. How are these four children any less worthy of the same privileges and opportunities afforded the hundreds of children I have cared for in the US? The simple answer is that they are not. Simply, they were born in Africa, which has been an unfortunately disadvantaged continent since white man first made his mark here. Here stood just two of thousands of sick, vulnerable, and orphaned children in the AMPATH catchment area alone, and we were struggling to find viable solutions for them. It was a somber first visit.

The second visit was a much more positive one. We made our way to the house of Gloria and her mother, a four-acre farmstead with several buildings; including a grain storage house (per Emma, the size of the storage house directly reflects the wealth of crops, and this one was mid-sized), chicken coop, cow pen, as well as a large garden. Gloria is a 40 year old HIV positive woman with a 17-month old son. She has some type of heart condition, and was told from a young age that pregnancy could make her sick and that she should not have children. Therefore, when she discovered that she was pregnant, she was afraid and “ashamed” (in her own words) to seek medical attention. Unfortunately, this meant that she received no pre-natal care, including no treatment for HIV, which greatly increases the risk of transmission to the baby. Luckily, her baby has thus far tested negative for HIV, with the definitive lab test coming up soon at 18 months of age. She is currently taking her ARVs (anti-retrovirals) regularly, has no health complaints, and told us she was feeling positive about life. Her baby also is currently taking no medicines, is growing well, and has received all of his immunizations. It seemed almost too good to be true. In fact, it wasn’t, and if the baby tests negative at his 18 month visit, the plan was to un-enroll him from the OVC program. This is a good thing.

The third visit was to a farmstead much further away, down 60 minutes of winding, dirt roads. We made it out there after stopping several times to ask for directions (including at a school, where the appearance of two muzungus clearly interrupted the outside class that was taking place). We found a house close by, and a neighbor walked us down to the farm. We met the patriarch, a white-haired gentleman in overalls probably in his 60s. He greeted us enthusiastically (having no idea who we were or why we were there) and proceeded to give us a tour of his substantial farm. Like a proud father, he joyfully pointed out his various plants and trees (passion fruit, avocado, banana, guava), crops (corn, beans), and livestock (goats and cattle). He showed us how he had cultivated the rockier ground that is poor for crops into a tree farm, periodically cutting down the trees and selling the wood, always making sure to re-plant and have a constant supply. Overall, he had a very impressive homestead, totaling about 13 acres (all of which, thankfully, he did not make us tour). After finally figuring out that we were not there to give him anything, he graciously introduced us to his daughter, who we were actually there to see.

Rebecca, one of the farmer’s nine children, lives and works on the homestead with her parents and several siblings. Sadly, tragically, she was raped eight years ago and not only became pregnant but also contracted HIV. Now she, as well as her 3rd and youngest child (a daughter) are AMPATH patients. I was awed at how calm and collected she was while telling us her story, which she began by saying: “I am Rebecca, and I am positive.” Despite the leaps and bounds made in HIV/AIDS care in the past ten years, there is still a social stigma associated with HIV infection, even in Western Kenya. This was further evidenced when Rebecca spoke of her own mother, saying that she would not allow Rebecca and her daughter to share utensils with other members of the household, or allow Rebecca’s daughter to play with her HIV-negative cousins. Despite the many obvious hurdles Rebecca had faced in the past decade, she was clearly determined to live her life as well as possible. She had created a business for herself, buying fruit from her father and then selling it for profit at the local university. Through her business, she has been able to put her three children through school thus far, as well as start saving for school fees for secondary school (high school) for the two older boys. I was completely amazed at her strength in the face of adversity, including open animosity from her own mother.

While we were visiting the last farm, it began to rain, and by the time we finished it was an outright deluge. Even though we had three more homes to visit, it was decided to delay these visits, as the muddy roads become impassible even after a short rainfall. As it was, Emma had significant difficulty navigating the car through the various potholes, mud puddles, and nearly washed out roads we needed to drive to get back to Mosoriot. It was a white-knuckle drive for all of us. The best I can compare it to is driving on an ice covered road in the US, without any traction but with the addition of large rivers of water flowing across and deep ravines on either side. But, we made it back to the paved roads, back to Mosoriot clinic to deposit our social workers, then back into Eldoret by mid-afternoon.

Today was truly another great day in Kenya. I think the faces of the four children at the first home will stay with me for a long time, hopefully continuing to remind me of why I am here.

To learn more about AMPATH’s OVC program, click here.

Adventures in Nakuru

A group of us from IU house went this past weekend to Lake Nakuru National Park. It’s one of the smaller National Parks here, about three hours southeast of Eldoret right in the middle of the Rift Valley, most famous for its rhinos and flamingos. Like all good trips in Kenya, this one finally came together about 36 hours before we left, which was at 6AM on Saturday morning.

Nine of us (and our stuff) and our driver piled into the safari van early Saturday morning, and after a quick stop at the bank, we were off to Nakuru. Now, some of you may remember that during Kenya v.1 I took a car (instead of a plane) from Nairobi to Eldoret when I first arrived. Some of you also may remember my description of the road we travelled (or “road” as I called it), its most treacherous stretches lying between Nakuru and Eldoret. Much to my delight, the highway between Nakuru and Eldoret has now been paved, though this did not improve the drive as much as you think it would. In many parts of the road there are deep grooves in the asphalt where the tires travel that prevent the car from changing lanes very easily. Not such a big deal, unless your safari van happens to be in the wrong lane, facing oncoming traffic, and unable to get back over. Add to this fun construct of the asphalt multiple speed bumps, pot-holes, hairpin turns, and large trucks moving up steep hills at a snail’s pace, and we had a traditional Kenyan adventure not for the faint of heart (or stomach).

Finally arriving in Nakuru more or less unscathed, we set about the task of finding our hotel. Unfortunately, all of the lodges within the park itself were full for the weekend, so we had booked at a place called Mbweha Camp in Nakuru Town. I say “in” Nakuru Town meaning that no one in Nakuru Town had any idea where this place was. We spent a good 60 minutes driving around, asking various shopkeepers, matatu drivers, children, and possibly a goat or two if they knew where Mbweha Camp was. We mostly got blank looks, and I’m pretty sure we were pointed in a different direction every time. We eventually made our way to the main gate of the park, asked around a few of the guards, and got some directions that seemed a little more substantial. While parked at the main entrance, when we got out to stretch our legs and such, a devious little monkey climbed into the van through an open window, where we caught him red-handed (red-pawed?) furiously digging through one of the other resident’s bags. She did not find this nearly as humorous as the rest of us did. We were able to buy our park entry tickets at the main gate even though we wouldn’t be entering there, so tickets and fresh directions in hand, we climbed back into the safari van.

The guard at the gate had told us that Mbweha camp was “not too far.” One must always take Kenyan directions with a grain of salt, and what was billed as “not too far” ended up being another hour and 15 minutes in the van before reaching the camp. I think distance wise it probably was “not too far,” however, the majority of the drive was along a gravel-strewn, formerly paved road littered with matatu-sized potholes and treacherous chunks of asphalt for the driver to dodge. If that wasn’t enough, part of the road was actually closed, and we had to take a detour for some distance. (“What does it take to get a road closed here?” queried one of my fellow travellers. The consensus answer was an act of God.) After driving through and towards what seemed like nowhere, we finally saw the turnoff sign for Mbweha Camp (hooray!). And we turned onto… another dirt road. This one was at least hard packed dirt, without the gravel but still with the ruts to content with. After driving for about 10 minutes, we saw a sign that said Mbweha Camp (hooray!), but upon closer inspection it actually said “5km” underneath. And this is where the fun really began! After the 5km sign, there were stretches where the road literally disappeared, and it seemed as though we were just driving through open grassland without any real path. Our driver seemed to know where he was going, though I’m not quite sure how. At any rate, a very long and slow 5km later, we did, FINALLY reach Mbweha Camp, and it was as nice as promised on their website. Quickly ushered to our rooms and luggage unloaded, we all re-packed ourselves into the van to start our safari.

Of course, driving back to the park meant driving back over 5km Dirt Road and Matatu Pothole Road, but at least there was a park entrance gate not too far down Pothole-Asphalt-Gravel Road. Once into the park, we ate lunch (the hotel had had “box lunches” ready for us upon arrival to take with us. What is an African boxed lunch like, you might ask? Turns out it’s not too bad!) and kept our eyes peeled for animals. Almost immediately we saw a momma and baby rhino. Rhinos can actually move pretty fast when they want to, as we found out. We also saw a giraffe, hawk, tons of flamingos, an eagle, two lions, and dozens of baboons and other monkeys.
Overall the safari itself was quite satisfactory, especially as we got to see rhinos, which I had yet to see until this weekend. We spent the most time on the lake shore watching the flamingos. The sheer number of them was amazing, and collectively they make a noise that sounds like the combination of a woodpecker and someone grinding their teeth. They would take off from the lake in small groups at random, and settle further down. The contrast of their collective bright pink color against the gray-blue of the water and mountains beyond was quite beautiful.
At one point we drove up a cliff and saw the lake from a high vantage point, which was also beautiful. From there we also got to see a big rainstorm coming down over the lake, which we then drove through for some time in the park. We drove the majority of the park in one day, stopping many times to watch the rhinos, lions, or baboons. On the way out of the park we drove through a more wooded area where we happened upon a large family of baboons hanging out in the trees and the side of the road. Literally right next to where I was standing was a fallen tree on which were sitting two momma baboons and their teeny babies. The little ones wanted nothing more than to harass each other, and the moms were trying their hardest to make them behave themselves. I was close enough that if I reached out I could have touched them (if I had a death wish, which I didn’t). I got some great pictures.

About sundown, we headed out of the park, back down Large Pothole Road (in the dark, not as much fun as you might imagine), then back onto One Lane Dirt Road, which by this time had become One Lane Mud Road after all the rain during the day. Going was VEEERRY SLOW along this last road, as visibility was poor, and we kept getting stuck in the mud. Thankfully we never had to get out and push, though there were a few times I was sure we would have to.

Finally, gratefully, we made it back to Mbweha Camp. We had a lovely dinner, discussing our favorite things from the day, sat around a fire for awhile, then went to bed. The great thing about travelling out to the middle of nowhere to get to the camp was that it was… in the middle of nowhere. We were actually right outside the park, but there was nothing around us. In fact, they have askaris (guards) with flashlights and large sticks escort everyone around at night, as the animals can come right up to the camp. Our askari said the sticks were “in case of buffalo,” but of course we were imagining evening visitors of a more carnivorous nature. As it was, the evening passed uneventfully, and by morning, our nighttime askaris had disappeared. We all slept in, enjoyed a delicious and leisurely breakfast, and spend the day Sunday lounging at the camp and enjoying the natural beauty around us.
All too soon, it was time to pile back into the van and undertake the Road Adventure once again. No worse than the previous three times, we made it back into Nakuru downtown in about an hour, had a quick lunch downtown, then headed back up the rutted road that by this time seemed like the best road ever paved. We stopped briefly at the equator for a few pictures, and were back in Eldoret by dinner time.

The adventure wasn’t quite over; however, as when we got back to IU house the back of the van (the hatch) was stuck and wouldn’t open, so we couldn’t get our bags out. We ended up clearing a few of them out through the small back windows, then sent our tiniest person into the back to hand them out the front. And then, of course, Tiny Person got locked in the van (with the keys), and no one could figure how to get him out. We ended up opening a front window and passing him out through the window as well. Ah, Africa. Travel here is truly like nowhere else.

Overall, it was a great weekend, despite the multiple snafus, which really are all part and parcel of the fun and memories. My favorite part was definitely seeing the rhinos, which gets me one step closer to seeing all of Africa’s Big Five.

Systems Based Practice

The Accreditation Council for Graduate Medical Education (ACGME) has six core competencies around which American residency programs are to design their educational curriculum. One of these six is Systems Based Practice. Among other things, the Systems Based Practice competency states that residents are expected to “work effectively in various healthcare delivery settings and systems relevant to their clinical specialty, coordinate patient care within the health care system relevant to their clinical specialty,” and “incorporate considerations of cost awareness and risk benefit analysis in patient care.” To be honest, I have never given much thought to the SBP competency. The transition from medical school to residency was relatively easy from a systems standpoint, as I remained at the same training institution. Now, practicing clinical medicine within a completely foreign (in every sense of the word) system, I have finally started to think about what Systems Based Practice may actually mean.

My team leader had warned me that week two on the wards is usually the hardest for residents, and she proved to be quite correct. The excitement and novelty of working on the Kenyan wards has worn off, and the systems and structures here that tend to frustrate the Westerners start to become more apparent. In short, week two proved to be an extraordinarily frustrating one for me. First and foremost, my firm (team) had not had a registrar (Kenyan resident) since the first day I rounded. We had a new intern start this past week, so of course she didn’t know any of our patients overly well. Also, this week was the first week for our American pediatric team leader to act as Consultant (staff physician) on the wards, and while she is great, she knows only a little more than me about the way the hospital system functions here (this being only her third week in Kenya in the team leader position). The combination of all of these factors, in addition to some very sick patients, made me dread rounds every morning. We stumbled and fumbled through rounds most mornings, with our patients getting sicker by the day.

To use a patient example – on Monday we admitted a 10 year old boy with DKA (diabetic ketoacidosis). This is a very serious condition caused by diabetes (usually because of new-onset or very poorly controlled diabetes) that can be life threatening if not treated appropriately. In the US, kids in DKA will usually go to the ICU, as they require large amounts of IV fluids, continuous insulin infusion, and blood sugar and electrolyte monitoring every 30 to 60 minutes. At MTRH, ICU care is relatively limited, with few beds in the ICU, almost all reserved for patients needing ventilators, so our DKA patients here are cared for on the regular ward. I have taken care of my fair share of kids in DKA in the US; however, when we were rounding on this particular patient, it just seemed as if no one (including myself) had any idea what to do. Problem number 1: blood glucose values are reported with a different scale here (ie range of normal at home is 100-200; here is 4-10); Problem number 2: No one was sure if the strips used in the accu-check machine were good or actually working, as the patient’s blood sugars fluctuated greatly and didn’t make sense with his clinical picture, not to mention they were only being checked once every 2-4 hours; Problem number 3: Kids don’t get insulin drips (continuous infusions) here, they get hourly injections of insulin, but not at the same time every hour; Problem number 4: We were worried about his electrolytes, but to send a set of blood electrolytes to the lab would take at least a day if not two to come back, and then we’re making decisions based on old data; Problem number 5: MTRH does have a protocol for treating DKA (great!), but no one seems to know what it is, where it is, or how to get ahold of it (one of a few key times this week a registrar would have been extremely helpful).

These are five of about fifteen different problems we had with this one patient, multiply that times 30 patients on the ward, and I left the hospital most days feeling utterly defeated and completely exhausted. There is so much medical need here, and really not an insignificant number of resources to address those needs, but it is matching up the patients with the resources that is proving to be the most difficult. Effective delivery of appropriate medical resources to patients? Sounds like systems based practice to me. Now if only I could figure out how to do it here.

So I wonder: is that why week two is the hardest? Because I’m working in a different system? Possibly. The more I think about it though; I think it may actually be because I spent almost all of last week working against the system. The majority of week two for me was ruminating on the various limitations we had in caring for our patients, and beginning every sentence and thought with “Well, in America, I would…” Clearly this is counterproductive. All of that energy and time could have been put toward learning exactly what IS available and how to obtain it; ie finding a registrar on another team who may know what or where the DKA protocol is, finding out how to get accu-check strips that are, well… accurate, or strategizing with the nurses to ensure that our patient would receive his insulin precisely every hour. I can see the need here, I often know what SHOULD be done, but I’m still figuring out the HOW. If I learned one thing this week, it is that patient care cannot be delivered without at least a rudimentary understanding of the system in which it will be administered. As much as we physicians often loath the systems aspects of medical care, it is essential that we operate effectively within those systems if we are to care for our patients, which should be our ultimate goal.

In the end, I think the true benefit of learning systems based practice is that once you understand the system, you can start working to improve it; for yourself and for your patients. The ACGME also acknowledges the value of systems-wide change, stating that in SBP residents are also expected to “advocate for quality patient care and optimal patient care systems, work in inter-professional teams to enhance patient safety and improve patient care quality,” and “participate in identifying system errors and in implementing potential systems solutions.”

Clearly I cannot hope to master the Kenyan medical system in two short months here, and the noble goal of system-wide change is one more appropriately tackled by the long-term presence here (IU-Kenya partnership, AMPATH), and is indeed one of its greatest benefits. I think that the lessons in systems based practice that I have and will learn here are much more valuable as personal changes and improvements that I will take back with me to the US. I have already learned the value of a good, thorough physical exam in guiding diagnosis and management, as well as judicious use of laboratory and imaging studies, as patients all pre-pay for these studies before they are done. Operating within this very different system, while still taking care of patients to the best of my ability, will clearly make me a more efficient and effective physician in the US. One more of many things that working in Kenya has taught me, that I can only hope to repay over the next six weeks.

How Far We've Come (Or, Cake)

It has been another cold & rainy weekend in Eldoret. The first week on the wards was full of ups and downs, but overall I’m still very happy to be working at MTRH. I probably pushed myself a little too hard this week, amid walking back and forth between IU House & MTRH 4-6 times per day, soccer, jogging, and yoga, (all at an altitude I am completely unaccustomed to), not to mention some degree of baseline mild dehydration, I gave myself a pretty nasty muscle pull yesterday. This is frustrating to me, as I am decently active at home, and I would like to think my injury is more a result of my new environment, and not simply because I am getting old. Be that as it may, I am under strict orders from my team leader to take it easy today. With the rain, the cold, and a strained quad and hip flexor, I’ve had quite a bit of time today to reflect not only on the last week, but on the past several years as well.

The fourth year medical students here have recently been in a flurry of activity and anxiety over their ERAS (Electronic Residency Application System) profiles, as the online system has recently opened for submission. This is the most significant event yet in their medical careers (only one of many more accomplishments to come), and I can remember those feelings of doubt, angst, and even fear that I would not match into a residency program. Looking back on it now, it seems a very minor step on the road that I’ve travelled, though I can certainly recall that it seemed more like Doomsday at the time.

All of the senior medical student talk of residency programs and their futures has really got me thinking about How Far I’ve Come. From the juncture mid-way through my freshman year in college when I decided to “go pre-med” until now has been an indescribable journey, a prolonged process, a road of pure joy and true hell. I can hardly remember a time when I wasn’t focused on my medical career. Starting in undergrad: concentrating on getting good grades, joining the pre-med club, volunteering and extracurriculars, planning for, studying for, and taking the MCAT, med school applications, interviews, selection, matriculation, and white coat ceremony. Then history seemed to repeat itself from the very first day of medical school: worrying about grades, clubs, extracurriculars, projects and volunteer experiences, not to mention working harder than I ever had on clinical rotations, applying for residency, interviews, ranking, match day. And THEN starting the entire process again from day one of intern year: working harder than I ever had, projects, volunteer work, extracurriculars, research, publishing, chief application, interview, and selection. Throw into the mix the various board exams along the way (USMLE Step 1, Step 2 CS, Step 2 CK, and Step 3), and it’s no wonder that most residents graduate feeling about 50 years older than when they started. Not to mention that at every step along the way I became a little more interested in actually having a life. I have recently begun to comprehend, appreciate, and understand the extraordinarily long, never mind expensive, road I have been navigating since I was 19 years old.

Even as I type all of this now, I can’t help but think: this is completely insane! Why would anyone want to do this?! I admit there have been more than a few times over the past 3-to-9 years when I’ve thought: “no really, why am I DOING this?”. It is a question that I will probably never completely answer. Even though it has been hard, it has not been without its rewards. I cannot imagine life now without the friends I have made in both medical school and residency, and the support and encouragement I have received from my comrades-in-arms has seen me through the darkest of times. I have learned, I have grown, I have grappled with the meaning of Life and Death, contemplated my own existence, and been forced to confront my own humanity and the darkest aspects of the human soul. I saw my family less but started appreciating them more, I learned that book knowledge is necessary but by no means sufficient to make a good physician, and I realized that being a successful pediatrician means treating all patients as children, but not all children as patients. I started this nine year process with great deal of naiveté and idealism, but I have been tried, tempered, formed, and emerged on the other side a better doctor, and a better person.

And really, though I still have 10 months left before (my last?) graduation, the rest starts to become Cake now. It’s not that I’ll ever stop working hard or putting in long hours, ever stop studying or learning, but the steep and seemingly impossible learning curve has finally started to plateau. Now I get to look at the anxious faces of the MS4s here and tell them it’s going to be ok and know, actually know, that everything is going to be ok. Because now, for me, I can finally stop focusing on what’s going on my CV and start focusing on what’s going on in my life.

Though I may not have known it, when I decided at 19 years old that I was going to be a doctor, I was committing myself to a very career-focused life for the next decade. Though I may still wonder why I did this; why I let the last 9 years of my life be dictated by how good my grades were, what med school I could get into, and how competitive my residency application was, in the end it was my decision. I will probably always regret the family birthday parties missed, the holidays spent in the hospital, the homecomings not attended, the friendships that have lapsed; but in return I get the great and awesome privilege of caring for other people’s children. I get their trust in me to guard the health of the most precious things they have on earth. And that, to me, is amazing. Amazing, and completely worth it.

Evans

I went to work this morning only to discover that one of our patients had died overnight last night. This was the very sick little boy who I mentioned in yesterday's post. I'm not completely sure of his whole story, as he has been in the hospital for several weeks, but Evans was a 9 y/o boy initially admitted at a rural hospital for fevers, was being treated for malaria and not getting better, so was transferred to MTRH for further evaluation. The concern (and most likely diagnosis) was that he had leukemia, as he had had a longer history of fatigue & weight loss to go along with his fevers. His initial bone marrow aspiration was indeterminant, and these results took several weeks to come back, so we repeated another one yesterday. Yesterday when I left in the afternoon, he was not looking very well, was having a very difficult time breathing & looked very uncomfortable. His platelet count that morning was 13 (very low... with a normal count being at least 150) and he was having persistent nose bleeds, so we wrote to transfuse him with some platelets. The system being... the way that it is, as of 4PM yesterday his platelets had not arrived yet. Apparently shortly after that he started coughing up large amounts of blood and went into respiratory arrest. With his low platelet count & persistent bleeding, it seems he probably died from a pulmonary hemorrhage, though we will probably never know from exactly what.

In the end, Evans was a very sick little boy who would have required ICU-level care in the US. The frustrating thing in this case is that even though his particular chances of survival were not good from the beginning, I still don't feel like we did absolutely everything that we could have for him. It's mostly systems issues in this case; the delay in getting a read on the first bone marrow biopsy (about 7 days) before we knew we needed a repeat, the delay in getting platelets, and ultimately the delay in starting (chemo)therapy because we didn't have a diagnosis. His clinical picture & severity of illness was consistent with leukemia; however, childhood ALL (the most common type of childhood leukemia) actually has a good 5 year survival if treated (somehwere in the 80% range, but my heme/onc colleages would need to help me out with that one). I just feel like this is case where, if we were in America, the diagnosis would have been made much sooner and the treatment would have begun immediately. Who knows if the outcome would have been different, but it's just universally unfair for Evans to have started at such a disadvantage simply because he was born in Kenya.

Of course the real kicker is that he had (has)an amazingly nice family, including an older brother who was with him night & day, and who, yesterday afternoon I could tell was preparing himself for the worst. The rule of nice family equals poor outcome for child apparently applies in Kenya too. I saw his brother this afternoon on the wards (families have to pay the hospital bill before the body can be released), and all I could say to him was "pole sana" (I'm very sorry). What else can you do?

On a happier note, when we went to work this morning, Ryan was still there, and actually went to the theater early this morning during rounds. I think he'll probably stay on the surgical ward now, but I will try to check up on him at some point.

And, just so this isn't all depressing subject matter: through a long, random process of hyper-linking, I managed to stumble upon my old blog. Not Kenya v.1, which is at this address, but my OLD blog... the one I started as a first year med student and actually kept up with regularly until this one was created. Now, I'm not usually one to toot my own horn... but I was funny. Instead of doing all of the things on my to do/wish list tonight, I spent the entire evening reading through blog archives, and I laughed aloud on multiple occasions. Self-congratulating aside, it was actually nice to remember how I used to look at the world (very idealistic) as a young twenty-something, as well as read the comments from my friends... back in the day when we were all young twenty-somethings without real jobs and actually kept up with our blogging (I'm looking at you: Jaybeus & IRMcK). I'll probably link to specific posts as the time goes on, but for now, read at your own peril: http://parasolmd.blogspot.com/. Remember, I was 22 when this blog started. The post about the mysterious red box from April 2005 is a must read for any former or current IUSOM student (I'm looking at you, E. Pearce).

Tomorrow will be another day on the wards. Until next time.

Ryan

I realize that a great deal has changed over the last three years, especially in the realm of the internet, electronic media, social networking, and online privacy. With that being said, I found that most meaningful and memorable experiences from Kenya v.1 almost all revolved around people, with many of those people being my patients and their families. I would like to continue to try to communicate those experiences, both to help my Faithful Readers understand a little better what my life and work are like here in Kenya, and also to help myself process the disease & suffering that surrounds us here on a daily basis. While HIPPAA (or a similar concept) does not exist in Kenya, I still believe that the children I take care of (& their families) are entitled to their privacy, and for the sake of full disclosure I must mention that I have not explicitly asked their permission to tell their stories on the internet. For that reason, I will not use the real first names of the patients I talk about, nor will I try to include any specific identifying information about them. It's an area of struggle for me, as clearly I could not keep any sort of blog about my patients while working at home, and I don't think that the children here deserve less than we think standard in the US. Thoughts & comments on the above issue much appreciated.

Monday was my first day of rounding on the wards, and as I'm a resident now, I will be spending the entire 8 weeks working with kids only. No adults this time. This makes me very happy. The first day was, pretty much like most first days on the job. It was hectic, chaotic, and I spent most of the day feeling like I didn't know what was going on. My firm (team) had admitted the night before, so there were many new patients for the consultant (staff pediatrician) & registrar (upper level resident) to learn about. For any of you who know about how thorough Kenyan med students' presentations are, you might imagine that rounds took a long time. We rounded on about 15 patients yesterday, most of them two-to-a-bed (or really 4, if you count their mommas), a pretty decent mixture of "bread-and-butter" Kenyan peds: malnutrition, dehydration, vomiting & diarrhea, malaria, pneumonia, and one very sick little boy with a great family who probably has leukemia (more on him in a later post).

Today was actually significantly better. The students had an exam all morning, the consultant didn't come to rounds (unfortunately a common occurrence), and our registrar had a meeting, so it was just the Kenyan intern & me rounding on our patients. It was enjoyable in that I really like the intern on our team, he is thorough & thoughtful, very hard working and does what is best for our patients. It was also a little intimidating, in that the intern asked my opinion on most of his decisions and psuedo-staffed most of the patients with me. While this is not an unusual occurrence in the US (for an intern to get help from an upper level resident), it is a bit unsettling here in that the intern knows far more about the disease processes, available treatments, and how to get things done at MTRH than I do. At any rate, we made it through rounds relatively quickly, I examined all of our kids and got a much better handle on what is going on with them.

Shortly after we were done rounding, the IU resident on the other firm (team), who is admitting patients today, asked me to review a head CT with her. The little boy was a new admission, just rolled onto the wards from casualty (the ER), head CT in tow. We looked at the scan and both had what can best be described as an "oh poo" moment. Per the very brief casualty history (parents spoke Swahili only, so we couldn't ask any more questions initially), Ryan is a 7 y/o boy who parents brought in for a 3 day history of headache, nausea, vomiting, and abdominal pain. They became concerned when he stopped using the right side of his body today (which also happens to be his birthday. Completely unfair). The CT scan from casualty showed a very large mass in the left front side of his brain, most likely an abscess. The most worrisome thing about him was that he was not very responsive during our exam, and his pupils were unequal, with the left pupil being dilated and minimally reactive (non medical people: this is bad!). Our main concern initially was that the abscess was causing an increase in the pressure of his brain, which if left untreated can lead to death. The third worrisome thing was that he was bradycardic (low heart rate) and hypertensive (high blood pressure), which can also be a sign of increased pressure in the brain. Of course we were the only 2 physicians (Kenyan or otherwise) to be found. We decided to give decadron right away, a medicine used to decrease pressure in the brain from a variety of causes. We also wrote for three different antibiotics, after considering what were the most likely causes of his abscess. In the meantime, we were able to get in contact with the intern for the team, who was coming back to the hospital.

This all sounds horrible, but I was really amazed at how quickly everything happened. As soon as we ordered the decadron, we took the order sheet to the pharmacy, who immediately gave us both that and the antibiotics, found his Sister (nurse), who was GREAT and extremely helpful, who gave the decadron right away and the antbiotics quickly after. By the time the intern came back, Ryan had already received his decadron. The intern quickly reviewed the films & examined the patient, then went to call neurosurgery right away. Within 45 minutes of calling them, the neurosurgeon was at the bedside reviewing the film and giving recommendations. From the time we initially looked at the CT scan to the time the neurosurgeon arrived was all within 90 minutes or so, which is really pretty good even by American standards. Initially the plan was for Ryan to get some blood and then go to the Theater (Operating Room) to have his abscess drained immediately after. We went back to check on him this afternoon, and it seems that his procedure won't be until tomorrow morning, but he already looked much better. His vital signs had improved, and he was much more responsive than before. He will stay on the decadron overnight. I hope he will do well.

What really struck me about this case was that it shows how much we underestimate what "resource poor" settings can do sometimes. Though the system for getting things accomplished is very different here (and can often be EXTREMELY frustrating to the Westerners), there really is a great deal available here to help even very sick patients. The other thing I was struck by was the attitude of my Kenyan counterparts. The Kenyan medical students and interns especially are very overworked & largely underappreciated, but in the end we all (Americans, pharmacists, nurse, intern, surgeon) were doing what we knew how to help this particular patient. I realize that it often doesn't come together in such a team effort (in Kenya or America), but today it did, and I hope that it means something good for Ryan & his parents.

It's been a busy first two days, but I am truly enjoying caring for my patients, which is a feeling that can be few & far between during residency. I am grateful.

Thoughts on the Journey & Settling In

As most of you know by now, after 36 hours of traveling, I made it safely to Eldoret on Friday morning. Thankfully, my apprehensions and worst “what if” scenarios never came to pass (I was more than a little anxious about traveling alone this time around), and the journey was blessedly uneventful. The only glitch (not even that, really) was that the hotel originally booked in Nairobi had to be changed last minute, as Friday also happened to be a national holiday to celebrate Kenya passing its new constitutional referendum. What that meant on Thursday night when I got in was that most major roads were closed; and not just closed, but with mega-police barricades and guards. Of course this also meant the roads around the hotel I was originally to stay in. But, the new hotel was fine, and my driver got me back to the airport in plenty of time Friday morning to make my flight to Eldoret.

Since arrival, I’ve found myself settling into the rhythms of Kenyan life quite easily. Granted, it’s convenient that I arrived on the first morning of what turned out to be a three-day holiday weekend. As I’m now a resident, I’ll be staying at IU house for the full two months while I’m here instead of the student hostel. Part of me is glad to be closer to the more modern conveniences (internet, warm showers), but part of me also will miss that very rich experience I had of living as Kenyan medical student for two months, not to mention the wonderful friends that I made. A large group of IU students and residents went to Kakamega Rainforest this weekend, so IU house has been very quiet, relaxed, and peaceful, which is precisely what I wanted.

I’ve already met a new cast of characters who will feature prominently in my tales of Kenya this time around; a few oldies but goodies; mostly new faces though, as I realize I’ve been gone for a full three years. They will all be introduced in due time, but I will say that after only two days here, I am already amazed at who you may meet halfway around the world, and how much you might find you have in common with them.

I’ve also recently been contemplating what exactly I expect from this second (and not last, I am sure of that) visit to Kenya, and the simple answer is that I’m not quite sure. Well, at least I do have a general idea, but I know that as clear as my memories seem after three years, I have selectively blocked out a portion of things that were not so great the first time. Not to mention that it has been three years; years that have seen significant violence & tribal tensions as well as the recent passing of the constitutional referendum. I’m sure there have been physical changes to the city, hospital, and even IU house (some of which I have already seen), not to mention the innumerable ebb & flow of people that have since come and gone from IU house & MTRH.

The discussion of this experience as similar yet also different would not be complete without mentioning that I, too, have changed a great deal in the past three years. Anyone who has ever known a resident even a little bit could tell you that the three-to-five year process changes a person enormously. Acute on chronic sleep deprivation & seeing some of the worst that our society has to offer has made me more cynical, bitter, impatient, and skeptical (this coming from someone already with “glass half empty” tendencies at baseline.) On the other hand, all those hours of lost sleep, split second decisions, heart-rending 2AM conversations with families, and seeing the best of what our society has to offer has also made me more assertive, confident , compassionate, and a better leader. It is the latter qualities I hope to bring with me my second time through MTRH.

If the reasons for coming to Kenya in the first place were complex, the reasons to return a second time are even more so. Every person is different, but for me it’s a mixture of curiosity, adventure, and love; and largely a true sense of calling that I haven’t felt since first applying to take the MCAT & go to med school. While I always hope to give more than I get, I can’t help but hope that the next two months will be extremely restorative to me; a chance to get back to the basics of patient care as caring FOR patients, not simply taking care of THINGS for patients. As physicians, and residents especially, we are daily overwhelmed with an inexorable line (a tidal wave, really) of admissions, daily notes, medication reconciliations, discharge paperwork, faxing, phone calls, dictations, prescriptions…. And the list goes on. (As my dear friend Mandy recently told me: “I usually try to think of my ‘to do’ list as more of a wish list.”) While some would argue this is actually all a part of patient care, I would return that for the last six months or so, I have spent 60-70% of my days at work doing the former, while only 20-30% of my actual physical time in a hospital is spent in my patients’ rooms. While I will leave the current state of our healthcare system for a future discussion, I do sincerely hope that the next two months will re-remind me of why I wanted to be a pediatrician in the first place. You don’t have to talk to me for very long to know that I am simply… tired. Intern year was a harsh introduction into residency life, sleep deprivation, and missing my family, 2^nd year had its utterly disheartening moments, and the last six months have held truly some of the most difficult moments of my life. Part of the reason for coming to Kenya so early in 3^rd year was because I knew I would need a break, a refresher of sorts. It is my sincere hope that Eldoret once again will refresh me, recharge me, and remind me of that deep inner calling to medicine I felt those many years ago, as it did the first time I was here.

And of course, the most important and exciting reason that this time will be different is that Mike will be joining me in 3 short weeks. The expectations we have of this time together in Kenya truly cannot be put into words. All I can say is that I’m sure we will both grow a great deal individually (and together) in a short period of time. His job very graciously gave him a month of leave to make the trip, so he will be working on a variety of projects, mostly with S, the PharmD from Purdue who lives in Eldoret full time & manages the pharmacy exchange side of things, not to mention about 50,000 other projects. (Some of you will remember him from Blog v. 1, he definitely falls into the “oldie but goodie” category). Speaking of blogs, I would be remiss if I didn’t mention that aforementioned Husband will also be keeping a blog. If you’ve made it this far and actually want to keep reading, check it out here: http://the-world-is-calling.blogspot.com

Until next time, Faithful Readers.