Tuesday, August 31, 2010

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.

Saturday, August 28, 2010

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, 2nd 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 3rd 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.