I Bless the Rains

Watermelon Seed

2012-01-12T19:08:00.001-08:00

Gathering with family over the course of the past week, I heard number of stories about my grandfather: some whimsical, some bittersweet, some ribald, some downright unbelievable. Their variety spoke to what a truly unique and diverse life my grandfather led. The most amazing story by far was related by my dad, and is as follows:

Just after returning home from his deployment, my grandfather and his twin brother took a trip to Michigan together. (My dad was hazy on the details of said excursion, but in his words: “I don’t think they were going to church camp.”) On the way home, with my great-uncle driving and my grandfather sleeping in the backseat, they were involved in a terrible car accident. Upon arrival to the hospital, my grandfather was declared dead, sheet pulled over his head, and his gurney rolled into the hallway to await transport to the morgue. A doctor walking by happened to see my grandfather’s foot move, at which point, per grandpa, “the doctor slit my throat” (grandpa speak for a tracheotomy), and removed a single watermelon seed from my grandfather’s trachea.

At this point in the story my brother and I looked at each other incredulously. I suppose I should mention that this accident happened prior to my grandparents marrying and having children, before they even met. We were both thinking: this is how close we came to not existing? Unbelievable.

To think that my existence in this world was decided on so narrow a margin is both mind boggling and eye opening. How can I ever take life for granted again when I came so close to not even being? How can I not live every day to its fullest, when any minute alteration in timing or circumstance could have stolen them before they began? And most importantly: how can I ever look at a watermelon the same way again???

When I think about my grandfather’s watermelon seed, I am amazed. When I think about the fact that he was born a healthy twin in 1936, I am incredulous. And when I think about the fact that his own mother was also born a healthy twin in 1916, I am awestruck. If I ponder too long the curious set of happenstance and circumstance that led to my life, I begin to feel that I have to right to exist at all.

Except for this one thing. Purpose. I truly believe, with every fiber of my being, that we all exist for a purpose. We were placed on this earth thoughtfully and intentionally, with a set of skills and circumstances uniquely our own to complete the task at hand. I also believe that the vast majority of us will never fully comprehend the purpose for which we were placed here, or understand the amplified magnitude of our seemingly inconsequential every day existence. It could be that my purpose is simply to be a physician. It could be that I was placed here because my children will do amazing things. It could be that I rescued a stray dog that would have otherwise injured or killed someone. Most likely it is an infinitely intricate tapestry of opportunities, decisions, and circumstances interwoven to create my Purpose.

If you find my grandfather’s story a little far-fetched, I don’t blame you. My grandfather was a consummate story teller, and he did enjoy the odd embellishment every now and then. Regardless of the details though, the significance for me remains the same. We all have those watermelon seeds in our lives: those near misses, those almost never was-es, those too close to call moments. The thing is, most of us never even realize it. The point is not to drive yourself crazy thinking about it though. The point is to realize that life is indeed an extraordinarily precious and rare gift, and that we as people should be much better about living every single day like the miracle it is.

Beyond

2012-01-09T06:03:00.001-08:00

“It’s very sad,” said my mom.
“Yes it is,” I replied. “But it happens to all of us, at some point.”
Replied mom, “Yes. I’m glad this isn’t the only world, that there is another after this life, that we go…” She paused.
“Beyond?” I offered.
“Yes, beyond.”

I suppose it’s a little inauspicious that my return to blogging (one of my goals for 2012 is to start writing more) picks up where my 2010 blog left off: with the death of a grandfather. My dad’s dad passed away peacefully with his oldest son, my uncle, at his side on Friday night. But I also suppose that there is no better way to honor his memory than to share what I remember of him, what I knew of him, and what I loved about him.

One of my earliest memories of grandpa is from Christmas, when I was 3 or 4 years old. The only thing I REALLY wanted that year was a Cabbage Patch doll (which was the toy to have that year and impossible to find). But of course, grandpa found one for me. He never did tell me how many people he had to wrestle for that doll. I still have Rory, packed away in a box somewhere. He reminds me of that Christmas, and how important my happiness was to my grandfather.

When I was in Kindergarten, grandpa came for “bring your grandparents to school” day. I remember thinking that was the coolest thing, to spend an entire day at school with my grandpa. I can now imagine that spending an entire day with 30 5-year olds was not the most tranquil day of my grandfather’s life, but he was there nonetheless. He sat in the circle, talked to my friends, and played with me at recess. One of my favorite pictures of the two of us is from that day. Outside on the playground, grandpa in a baseball cap and suspenders, me in a bright red sweater and a huge smile.

There are countless other memories, some overwhelming in their significance: Grandpa at our wedding, at my medical school graduation, Grandpa going to France for his 70th birthday, him meeting my daughter for the first time the day before he died; while some are small moments: the feeling of riding behind Grandpa on his motorcycle, Grandpa taking Brant and I and the dogs to Dairy Queen in the El Camino, the way he would always say “Hey, Meagan, what do you know?”

Not all memories are particularly happy either: Grandpa’s life-threatening motorcycle accident when I was very young, and the all-too frequent visits in Indianapolis with him when he was hospitalized at the VA over the past decade. These are all a part of life though, and when I think of Grandpa, it is easy to call to mind a host of happy memories to overcome the sad ones.

So now he is no longer with us, his physical pain and frailty have passed, and he is Beyond. Capturing a multitude of ideas and concepts in 6 letters, beyond has long been a favorite word of mine. It is a particularly germane description of death, being a word that means both “farther on than, more distant than” and “outside the understanding, limits, or reach of.” Grandpa is farther on from us now. His life now is outside our understanding. He is Beyond.

Given Grandpa’s lifelong love of travelling, it is very comforting for me to think of him this way. It is also comforting for me to consider who is waiting for him there, who preceded him beyond this world into the next: his mother, his father, his twin brother, his sister. Numerous other friends and family whose separation from this world was as difficult for him as his is for us. It is comforting for me, as I consider my own mortality, as I consider this great gift of life that we all only receive once. It is comforting for me to know that, when my own time comes to pass beyond this world into the next, those who have gone before will be waiting for me.

We gather as his friends and family to mourn his death and celebrate his life. Though not always perfect, I would judge his life to have been a good one, full of love, friendship, happiness, and the constant companionship of his faithful dogs. He will be missed, but I will remain perpetually grateful for his presence in my life.

Beautiful Souls

2010-10-15T15:35:00.001-07:00

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

2010-10-08T12:19:00.000-07:00

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

2010-10-06T13:16:00.000-07:00

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

2010-10-06T13:15:00.000-07:00

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

2010-10-01T18:49:00.000-07:00

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

2010-09-26T10:30:00.002-07:00

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

2010-09-17T07:43:00.000-07:00

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

2010-09-16T03:35:00.000-07:00

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

2010-09-14T02:52:00.000-07:00

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)

2010-09-05T07:25:00.000-07:00

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

2010-09-01T11:42:00.000-07:00

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

2010-08-31T07:23:00.000-07:00

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

2010-08-28T12:51:00.000-07:00

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.

Kenya Article

2007-12-03T16:09:00.000-08:00

Below is the article I recently wrote for Iatrogenesis, IUSOM's student newspaper.

Expectations of Kenya

“Was it what you expected?” is probably the most common question I get about my elective in Kenya. It’s a hard question to answer, because I don’t think I went into the experience with any specific expectations. Or if I did, I no longer remember what they were. Yet somehow, living as a Kenyan medical student for two months far exceeded the expectations I did not know that I had. How is that possible? After nine weeks back in the U.S., that’s a question I’m still trying to answer.

I loved my trip to Kenya. I watched hippos on Lake Victoria; took a sunrise hike to the highest point in Kakamega Rainforest; fed eagles on Lake Baringo; cooked lunch in Lake Bagoria’s hot springs; went white water rafting on the Nile in Uganda; and took a three-day safari on Masai Mara National Reserve. Adventures aside, Kenya was much more than a two-month vacation for me. I made friends – good friends – of many nationalities, races, and cultures: Kenyan, Ugandan, American, Canadian, Dutch, Swedish, and Indian. I found in these communities a wide variety of people with whom I could truly relate. I discovered, to my immense surprise, that we are all very much the same at a basic level, regardless of color or nationality. Did I ever expect to learn this lesson from a medical school elective? Certainly not. And certainly not in Eldoret, Kenya.

While working on the wards at Moi Teaching and Referral Hospital, I found that the bond I had with my patients was as strong as any I had experienced in the U.S. Contrary to one of my primary concerns about the elective, language was not an issue. If anything, I learned that language at times can be a hindrance; allowing us to gloss over sensitive patient issues with a carefully chosen word or a deliberately ambiguous question. When words are no longer a concern, eye contact, facial expressions, gestures, and actions become universal and are more than sufficient. I could give my 52-year old CHF patient a bright smile every morning, which she would immediately reward with a smile of her own and rapid, animated Swahili. Over two months, I saw dozens of mothers being told that their 18-month old children were definitively HIV-negative. My congratulatory hugs did more to connect us than words ever could have. The abandoned children that lived on the ward knew that I cared about them because I smiled at them, hugged them, and played with them every day; not because I could tell them how precious they were in their native tongue. Did I expect that my connection with patients would be enhanced by the fact that we didn’t speak the same language? No.

Of course, I also learned a lot of medical stuff while I was Kenya. Treatment protocols for TB, malaria, HIV, meningitis, and malnutrition that were so foreign in August became second nature by September, and sadly were forgotten by November. But that’s all just book learning anyway; book learning that was the primary reason I went over, and the first thing that I forgot when I got back. I continue to think about Kenya on a daily basis, and I almost never think about all of the factual information I gleaned from the rotation. Could I have ever imagined that medical knowledge would become the least important part of a medical elective? Never.

While my experience in Kenya was beyond fantastic, I realize that this elective is not for everyone. The cost alone is prohibitive for many; and work, home, and family obligations do not allow others the luxury of spending two months away. However, I think that one of the most valuable aspects of the IU-Kenya program is the chance to see medicine practiced outside of the Ivory Tower walls of IU. Members of my class have done electives in Tanzania, Nigeria, Honduras, Haiti, and even Yellowstone National Park. The great thing about fourth year is that it can give us a much wider range of experience than third year clerkships alone, experiences that teach us much more about medicine than simply book learning. Whether fourth year is right around the corner or is some far-off dream in the distance, consider doing an elective outside of the med center. Even if it is ‘just’ at a local community hospital, you never know how valuable that experience may be to your training. It may even exceed your wildest expectations.

A month later

2007-10-29T12:16:00.000-07:00

Is it true? Can it be? Have I really been home for a whole month now?

What with a lot of people to see, a lot of pictures to share, and an overly full to-do list, the month has flown, and I feel like I've had little time to actually reflect on my experiences, and what it's been like to be home. Now that I've seen a lot of my people, spent many hours sharing pictures, and checked a few things off of my list -- including one very big one today: "Take Step 2" -- I think I can say a little bit more about October. Primarily, that it's been hard. First off, going from the most amazing 2 month elective to one that I'm less than thrilled about has understandably induced some depression. Of course, I don't think I could have scheudled anything in October that wouldn't have paled in comparison to Kenya.

And the rest of life has just been...life. You know, the random minutiae that must be dealt with on a day to day basis. Stuff that, in the end, really doesn't matter, but you still have to do it just the same. Going to work, coming home, housework, homework, meetings, assignments, tests, etc.... it's all just such a drag. Much more so than usual. I find myself, strangely unfulfilled.... in a way that I wasn't before. Not to say that there's anything wrong with my life. Not at all. I just experienced the fullness that my life /could/ have... all of the things it /could/ be... and now that it's not like that anymore... well, it just sucks. I know it sounds weird, to be happy and not happy at the same time. I guess the best way to describe it is going into your attic to find your favorite painting has been stored in the sunlight for years, and now the colors are less bright, less vivid, and it won't ever be the same again.

And of course I've channeled all of these emotions into busy-ness and a full schedule... until this afternoon, when all I could think about was Kenya. This afternoon was also my scheduled time to start taking out my braids, which, at 6:20, I still haven't started yet. To be quite honest it makes me sad. Once I start, there's no turning back -- I don't imagine half-braided hair would look good at all. If I didn't have my first interview in a few weeks, I think I'd leave it in longer, but I suppose the longer I leave it in the harder it will be to take out (logistically and emotionally). It's about the hair and it's not about the hair. I can't remember the last time -- if ever -- I had a hairstyle that I liked every single day and that took about 60 seconds every morning. I really think I've gotten a significant amount more sleep this month than I would have otherwise. So yeah, I'm really gonna miss that. But, it's more about what the hair represents. On any give day in clinic 2-5 parents would ask me about my hair, how long it took , was it all my own hair etc. It was an automatic and easy way to talk about Kenya, I got to do it 2-5 times a day, and I didn't even have to be the one to bring it up. With my hair, it felt like a small part of me was still in Kenya, still a part of the country. And after it's gone...it's almost like my last tie to Kenya in the US will be falling on the floor in chunks along with my synthetic extensions. The other huge thing is that I said goodbye to Joe and Sarah Ellen on Sunday, as Wednesday they're heading back to Eldoret after their month in the States.

Goodbye to the Mamlins, goodbye to my hair... it's like all those difficult goodbyes from a month ago are happening all over again. No matter how hard I've tried to cover it up and move on, a month later, I still miss Kenya just as much as I did the day I left.

The Journey Home

2007-10-01T19:10:00.001-07:00

My week of "vacation" in Eldoret was anything but, especially the last half of the week. The many friends I made while in Kenya were a blessing, but when it came time to leave they all wanted to say goodbye to us, which really made for quite the busy social calendar.

On Monday we had goodbye lunch with Laurien, then on Tuesday it was goodbye and evaluation lunch with Hao. On Wednesday I had goodbye lunch with Joy, then it was our last dinner out with IU house that night. On Thursday our medicine Registrar Dr. Akwanalo took our team out for lunch, then that night it was our last dinner at IU house. On Friday our pediatric registrar Julia invited us to her home for a delicious lunch, which we could only stay for an hour of before we had to catch our plane.

Full and sad, we said our goodbyes to friends at IU house, then jumped into one of 3 taxis that had been hired to transport us and our tons of stuff to the Eldoret airport. The 3 cars weren't /all/ for us -- we happened to be going back at the same time as 2 other Indy people: Ellen and Dave who were in Eldoret on behalf of the Umoja project. Priti and my luggage had been sitting in the office, and as we were standing outside for goodbyes, we hadn't actually witnessed the drivers loading it into the cars. I was just about to jump into our cab, when my paranoid personality took over, and I ran into the office just to make sure that everything had been loaded. I'm glad that I did, because my smaller duffel bag carry-on was still sitting in the office; which included, among many other important things, my passport and my plane ticket from Eldoret to Nairobi.

Our time of departure from IU house was projected to be 2:00 in order to make our 3:00 flight, which in KT was really about 2:20 or so. On the way to the airport, our driver stopped to get gas, which in Kenya (of course) is no short 5 minute stop. Especially when your driver gets out and talks to everyone he knows on the street. Now, I realized that flights in Kenya probably also operated on KT, but I was still a little nervous when we pulled out of the gas station with about 25 minutes to go before our flight took off. Luckily our driver thought he was Speed Racer, so we made it to the airport in about 20 minutes or so. We arrived just behind Ellen and Dave's car, so we all grabbed our own luggage and headed into the airport...except... it wasn't all there. Priti was missing her big suitcase and I was missing the IU trunk jammed full of Stuff that I bought. Short moment of panic later, the drivers assured us that it was already inside -- apparently the 3rd taxi had come earlier with just those 2 pieces of luggage, and the other 2 taxis were for people and the rest of our luggage. Kenyan efficiency at its finest, but we didn't really have time to question. (As it turns out, the car with our 2 errant bags had been sent to pick up the pilots of the flight we were about to get on...so at least we were really in small danger of missing the flight).

After passing through "security" in the Eldoret airport, we approached the one and only ticket counter. Sure enough, behind the counter and already on the luggage belt were our missing suitcases -- they apparently had already passed through security without any escort. Hmm... Speaking of our luggage, there was a 10 kg (22 lb) limit TOTAL per person for all luggage, which clearly we were way, WAY over. The total overage was 5,000 some shillings which is about 100 dollars. Yikes. I guess they count on how much muzungus like their stuff. And actually we had so much luggage that they wanted to send us on the 3pm flight to Nairobi with some of our luggage and then send the rest of our luggage on the 6pm flight. We told them in no uncertain terms that that was completely unacceptable and not an option. We were paying enough, we wanted to make darn sure that our luggage actually got to Nairobi, not to mention not leave our property sitting in Eldoret unattended for several hours. Oh yes and also the flights into Nairobi fly into dinky little Wilson airport, and international flights out are from the much larger Jomo Kenyatta airport that is clear across the city. We would have had to be at Wilson at 7:00 to pick up our bags. No, I don't think so. Our bags were on the flight with us. Checking in provided another challenge in that Dave didn't have his return ticket. It was a huge miscommuncation that involved at least one phone call and at least one turning inside out of Dave's bag. It was worked out about 3:10. We then turned around to walk to the "gate" (literally, directly behind us), and as soon as we started walking that way the entirety of the people waiting also got up and headed for the door. Clearly, we had been holding up the flight.

Like sardines into a can, 15 or so people crammed onto the smallest plane I've ever been on. Well, maybe a few of the planes I flew on on transplant surgery were a bit smaller, or at least the same size, but on those planes we had 3 to 5 people max. This plane was one of those twin prop deals, with no bathroom and no cargo area -- everyone's luggage was just piled up in the back of the plane.

The ride to Nairobi was... hot and nauseating but blessedly short, only about an hour. The birds-eye views of the beautiful countryside were almost worth the price of admission. Really the flight was extremely turbulant, and poor Priti ended up throwing up onto the aisle toward the end. Even after a short 60 mintues, I have never been so glad to be back on the ground.

We unloaded our luggage at Wilson. Priti has a family friend that lives in Nairobi, and he came to pick us up at the airport. His name is Narendu, and amazingly all of our luggage, plus the three of us, fit into his small Nissan. He drove us back through the city to his house, where we met his wife and his two kids -- a very nice family. They took us on a short drive through the area around their neighborhood; took us to a VERY nice mall with a HUGE market that I could have spent significant time in, and they even drove us past the US Embassy in Nairobi. It was... big... very American-looking. Surrounded by high walls, barbed wire, and lots of signs warning against picture taking or film making of any kind. Apparently absolutely nothing inside is foreign -- even the pens are imported from America. Hmmm... I couldn't help but wonder: At what point do you pass secure and get to paranoia? At what point do such extrememe measures actually compromise security by making everyone live in a constant state of fear? I'm not sure...

After a brief and delicious meal back at their house, it was time to jet off to Jomo Kenyatta. Now, Shawn at IU House had told us to get to the airport around 7:00 for our 10:00 flight. Narendu said if we left his house by 7:30 to get to the airport by 8:15 we would be fine. Not wanting to argue with our host and source of transportation, we went with his plan. Nairobi is a big city, but Kenya is still Kenya, so Narendu (being Indian) does not drive at night. They actually have a (Kenyan) driver named Peter, and he took us to the airport. Traffic is absolutely horrendous in Nairobi, and we spent more time sitting than actually driving. Again, I realized that even at the international airport things are probably still run on KT, but still... missing the one and only daily flight to Amsterdam was not really something I wanted to do; not really the best way to start my trip home. It was about 8:15 by the time we reached the outskirts of the airport.

We approached the police roadblock/security checkpoint, and we were waved over by two policemen. They came up to Peter's window and were speaking in rapid Swahili to him. Then, Peter stepped out of the car and disappeared into the shadows with one of the policemen. Yeah, heart started beating a little faster just then. The other cop stayed by the car, and was shining his flaslight in the windows at us, directly in our faces. He was going on and on about how the two suitcases stacked on the seat beside me (in the back seat) were dangerous and there's no way we could be allowed to go on like that. Yeah... I'm /sure/ that my safety was the first priority on his mind. But, I tried to be overly polite, just explaining yes, thank you for your concern, but we're on our way back to AMERICA (stress the AMERICA part) after 2 months in Kenya, and we had a lot of luggage, and the boot was full. Still, the flashlight-holding cop lectured on and Peter had not returned. Meanwhile, there are groups of random people (men) walking by the car, stopping to look in the windows, and I can see the lights from the airport up ahead of us. In everything I've been through in Kenya, that was the first experience I had where I was really, truly scared; or felt threatened by a person.

After what seemed like an eternity, Peter came back to the car. When we asked him if the cop wanted money, he said yes, but he was arguing with him and wouldn't give him any. I almost wanted to shout WHAT?!? at him. OF COURSE give him money! You don't argue with a man with a semi-automatic weapon strapped to his back, no matter the superiority of your position! Give him the money man! I just want to go HOME!!! The real issue was that Peter didn't have much on him, so the cop was telling him to ask us for money (being the wealthy Americans.) Which, by the way, I WOULD have given to him. But, Peter was explaining to the cop that we were the guests of his employer, so to ask us for money would have been unforgiveably rude. Moreover, our mood was not likely to be improved by the fact that the more they argued, the higher the chance we would miss our flight home. While it's admirable that Peter was trying to do the right thing... seriously man... just give him some money. The solution they worked out was that the cop kept Peter's license and he was free to drop us off at the airport; but, he had to stop there again on the way out and "argue" (pay??) with the cop some more. I sincerely hope it turned out ok for him.

How such blatant and disgusting corruption can exist in such a beautiful country is beyond me... it was really not what I wanted one of my last memories of Kenya to be, though I suppose it's a dose of reality.

At any rate, Peter got us to the terminal. Everything thereafter until we got on the plane was just stressful. Of course we felt like we were running rather late. We had to get carts, as we had 4 bags apiece, and then to even get into the airport you have to pass through security screening. The guy outside the door was giving us a hard time about not having our tickets -- which of course we didn't have yet because we hadn't even checked in yet...we finally got to pass through security -- unload the carts, take out liquids, take off jacket, take off shoes, show passport, go through screening, then scramble to collect all of your belongings in reverse, while trying to find replacement carts for the ones you left outside... it was just a huge hassle. Then we had to stand in another line to have our luggage weighed. The guy told me my suitcase was too heavy. Yes, I know, but I can pay extra, yes? Oh, you want to pay? Yes. Because your suitcase is too heavy. YES, THANK YOU. It was not a shining moment on my part.

My luggage appropriately labeled, we then get in another (much longer) line to check in. The woman checking passports wanted to know why we didn't have our tickets. Because we haven't checked in yet! We are standing IN LINE to CHECK IN!!! Meanwhile we're also trying to fill out our immigration/declaration papers while juggling 4 bags apiece on big carts, trying to write and maneuver through the long turnstyles at the same time. Luckily it was such a horrendously frustrating experience that we just laughed about it. I was so glad that Priti was there though, and we could help eachother out. If she hadn't been there I might have had a nervous breakdown. We finally get to the front of the line about 9:00. It turns out the guy checking me in is originally from Eldoret, so we had a nice conversation about that. He was so busy chatting that he didn't charge me for my extra heavy bag (clearly labeled) and I wasn't about to speak up about that one. Bags checked, tickets in hand, we wait in yet another line to clear customs/immigration, then upstairs to the terminal. Nairobi is another one of those airports that does security screening at the gate, so we immediately get into yet another line to go through the gate security checkpoint. Well, Priti got in line and juggled 4 bags while I went to the bathroom, then we switched. Also, we both had quite a bit of Kenyan money left that we didn't want to take with us, so Priti ran off down the terminal to find an exchange place while I scooted/juggled our 4 bags again. She got back just in time for us to start going through security. I called Mike for just a quick hi we made it to the airport and will be on the plane shortly; which turned into a hi your car got broken into while sitting in our driveway and my wallet and the garage door opener were stolen, so I've had to cancel all of our credit cards - type conversation. A bad mood that got somehow worse....

Got through security ok -- well I did. They made Priti throw out all of her liquids/gels for some bogus reason, then she was so flustered she almost left her second bag at the security checkpoint -- she remembered it right as we were getting on the plane. We had just enough time to sit in a corner at the gate and send our last text message from Kenya before we got on the plane. Yikes. But, we made it on the plane, with eachother and all of our stuff, which is really the most important thing.

Pretty soon after taking off, I was out like a light for about 5 or 6 hours. Aside from being a completely full flight, the trip to Amsterdam was uneventful. After landing in Amsterdam, I had just enough time to brush my teeth, call Mike (who was still awake at whatever time it was in Indiana) and grab a quick breakfast with Priti before getting in line for security for my next flight. Of all the goodbyes I'd said, I think saying goodbye to Priti was maybe the hardest. Not that we wouldn't ever see eachother again, but saying goodbye to the person that I'd spent the last 60 days with meant that my time in Kenya was really over. When I got up to the checkpoint, one of the questions they asked me was "are you travelling alone?" I had to catch myself as I answered "N--Yes." When was the last time that I actually travelled anywhere alone? It was a strange feeling.

The flight to Boston was long and nondescript -- I slept some, watched a few movies, read, re-braided some of my hair -- you know, the usual. I was nervous about landing in Boston, as we would have to gather up all of our luggage (including our checked luggage), take it all through passport control and customs, then re-check it onto the flight to Indy. I had a little under 3 hours to do all of this, which I thought would be plenty of time, but sometimes you never know. As it was, the whole process couldn't have gone smoother. We were one of the first, if not the first, flight to land in Boston that morning, so passport control took all of 5 minutes by the time I waited for the 3 people in front of me. I was able to grab a cart right away, and I only had to wait about 10 minutes before both (yes, both!) of my bags came out of baggage claim. I wheeled my cart right through customs -- the guy didn't even ask me any questions, just looked at my passport and my declaration list and said "Have a nice day." Re-checking my bags was not even a problem -- the airport was basically deserted aside from our flight, and I just handed them to an NWA agent at the ticket counter. She didn't even weigh them (so I yet again got out of paying an overage for my too-heavy suitcase), just put them on the belt and said "Have a nice day." Going back through security was quick and easy too, and I got to the terminal area with 2 1/2 hours before my flight. I freshened up (one does not want to see one's husband for the first time in 2 months looking like one has been traveling for 30 hours, even if one has been), called Mike again, then I spotted the promised land -- STARBUCKS! I was even more excited when I realized that I was home in time for the best Starbucks Season -- fall. Java in hand, I sat in a rocking chair by a large window with the sun shining in and sat and thought... thought about anything and everything. I was so focused on not wanting to leave Kenya that I underestimated how good it would feel to be back in the US. But, sitting in the pristine modernity of the Boston airport, drinking my grande non-fat pumpkin spice latte, listening to American music on my Ipod, it was a good feeling. A feeling of being home.

As good as it did feel to be home again, I also thought a lot about Kenya, and I realized how much I already missed it. I wondered how I could ever reconcile the feeling of now having 2 homes, and how can I live in one and not miss the other, or at least remember it? I think that will be the hardest part of readjusting -- learning to live not just as an American, and not just as a Kenyan -- but to live as both.

Finally it was time to board the 4th and last plane. Of course it was tiny, and of course it was the longest 3 hours of the whole journey; they were all that stood between me and seeing Mike and the kids again. The very first thing I noticed when I sat down was that it was a plane of 40 white people. As a small flight going to the heart of the midwest, it's not all that surprising, but still... a bit of a shock compared to living as a definite minority for the last 2 months.

We finally got to Indy. As we were circling around waiting to land I got the greatest view of downtown, and I'll admit, it made me a little weepy. It was just SO good to see my home again, after being away for what felt like a very, very long time. And inside, I saw Mike, flowers in hand, and that was an indescribable moment as well.

All of my luggage in tow (yes!), Mike drove me to Chile's for my first American meal, which was quite satisfactory, I might add. Then it was on to home for my reunion with Ms. Thing and The Boys, which was a very loud, but fun, event. After PJ time and playing show Mike every single individual thing that I bought in Kenya (for which he was a fantastic sport), I passed out on the couch about 8:00. (I'm actually surprised I made it that long). Then I woke up at 3am bright and shiny and ready to start the day. Whoops.

Sunday was Church Day, which was great for several reasons. Obviously, it was great to see all the people I had been missing, and they all had hugs and nice things to say about my hair :). During the Sunday School hour, there was a presentation from the group of people who had gone to Eldoret for 2 weeks in April to see all of the various church-sponsored programs there. They talked about their trip, showed pictures, and answered questions. Sitting in the Fellowship Hall, half asleep and jet-lagged, looking at pictures of the hospital and the town where I had just been a little over a day ago -- it was SO SURREAL. It was just.... weird. I don't know how else to describe it.

Sunday passed too quickly, and soon it was Monday morning and time to go back to work. Getting ready to go went about as well as you might expect (read: absolute train wreck) with half-unpacked suitcases sitting all over the house. Between getting ready, packing my lunch, packing my gym bag, finding my white coat, medical equipment, books, car keys, letting out the dog... I played the "where's my...." game numerous times on Monday morning. The other thing I realized on Monday morning was that my school parking pass had expired in August. Whoops. Usually, if you renew it online and put the receipt in your window, they won't ticket you until you get your new pass in the mail. Well, I got it ordered, but no receipt was available. Instead I got an error message stating that my order hadn't gone through, but my credit card had been charged. Wait a minute... Running rather late at this point, I printed off the error message and hoped it would be good enough.

Surprising myself that I actually rememberd how to drive a car (on the right side of the road, no less) and how to get to work, I made it downtown without incident. Work was strange... I kinda felt like I was just floating through the day. I still don't think I'm 100% awake yet. I didn't really make my best showing, but I hope they'll understand. One of the fellows who worked in the clinic -- Laura -- went to Kenya a few years ago as a resident. It was nice to chat and trade stories about something that obviously meant a great deal to both of us. I think my biggest fear in assimilating back into normal life is that over time, Kenya will sort of fade into the background behind all of the lists, bills, appointments, tests, etc that pile up in everyday life. I think maybe by talking about it, to whoever will listen, it will always seem real to me. Like if I tell people about it, then it actually happened. And if I don't, then it seems more like a dream or some fantastic story that I just made up. Sounds strange, I'm sure.

After work, I got back out to my car to find -- you guessed it -- a parking ticket. *Sigh* Welcome home, Meagan. I drove right to the parking office, where I explained very politely to the nice man that I was out of the country for 2 months, tried to renew my parking pass online, but the computer wouldn't let me, and for crying out loud the office already /had/ my 150 dollars, and what I really needed was my parking pass and not a week's worth of 20 dollar parking tickets. The nice man was very nice about it -- he printed me a receipt, told me my pass would be mailed to me in 7 days or less, cancelled my ticket, and validated my pass to get out of the garage. Thank you, nice man.

Testing out my theory that the best way to resume my old life is to just jump right back into it, I went to the gym after work. I saw some more people that I knew, and got to talk about Kenya some more, which was great. (The hair was a great idea for this reason -- it's a natural conversation starter about the elective.) Then Monday I actually did some domestic-type activities AND I submitted my residency application! It was a lot more stressful than I thought it would be even though all I had left was to select the programs I wanted to apply to. But, as I was clicking the little boxes all I could think was that 'one of THESE hospitals will be my home for at least 3 years.' Frightening. And also expensive, by the way, but after much hemming and hawing and prodding by Mike, I did finally click the 'submit' button. I applied to 12 programs: IU, St Vincent (Indianapolis), Vanderbilt, UT Memphis, Louisville, Cinicinnati Children's, Cleveland Clinic, Children's Hospital of Philadelphia, Boston Children's, Salt Lake City, Duke, and UNC. Hopefully at least ONE of those programs will want me, eh? ;). And then this morning I was rather late to work, because I couldn't find my car keys. Turns out they were actually locked inside my car (the result of a very convoluted story involving Mike, #20 fuses, and his back window not rolling down). So, Mike had to drive all the way back from work to let me into my car, and I got to clinic about 30 minutes late. I really don't think I've made the best impression these first 2 days, but I suppose there's nowhere to go but up from here (I sincerely hope).

So, I'm back now. And it's still strange, thought its strangeness is wearing off faster than I thought it would. I'm in the process of sorting and posting my pictures, though with boards to study for and residency interviews to prepare for, I foresee it being a slower process than I would like. My old life was here waiting for me, and in some respects, I was waiting for it. Not getting stared at absolutely everywhere I go is certainly nice. As is my own house and my own bed, my own washer, dryer, and dishwasher; my own car, my own friends. I'm having dinner with Priti and Dayna tomorrow night, then I'll go out with Emily and Lindsey sometime this weekend. I think reconnecting with people has been the best way to feel completely happy about being back. That and the fact that I came back at the beginning of one of the most beautiful months in Indiana. It's cool in the mornings and the evenings, but just the right temperature to be outside during the day. The trees are starting to change color, and the media is saturated with the die-hard predictions and pompous know-it-all of the football crowd. And, Starbucks has pumpkin spice lattes.

I still think about Kenya at least a dozen times a day. The way the wind blows through the trees or a child speaks to me in clinic -- anything can remind me of Eldoret. I miss it. And I already can't wait to go back.

Kwa Heri from Eldoret

2007-09-27T10:00:00.000-07:00

It’s Thursday night. This will be my last post from Eldoret.

I’ve said (most of) my goodbyes, I am (mostly) packed, and I feel (mostly) ready to go home.

There’s a certain feeling I have that I’ve left some things undone, some things unsaid. But, I suppose that’s probably normal.

It's so strange...how at the beginning two months seems like forever; an eternity to be away from your home, your family, and everything familiar. But sitting here tonight, looking behind me at the amazing and terrible things that have happened... it seems like just yesterday I was looking up at the stars in Eldoret and thinking how I felt so terribly far from home. But now this is home, and the heartbreak I had 8 weeks ago at leaving is revisiting me, in a different way.

We’re leaving from IU house at 2:00 tomorrow, to catch our 3:00 flight to Nairobi. Nairobi to Amsterdam at 10:15. Amsterdam to Boston at 8 ish. Boston to Indy at 1 ish. Then at 4pm I'll get to see Michael's smiling face after 2 long months.

The Blog will probably continue to be updated for awhile, as I post my hundreds of pictures and some stories about readjusting, as well as my final paper (or at least part of it) for the rotation. After that, who knows? Maybe it will sit in cyberspace for a few years, until my next trip to Africa.

Kwa heri, Afrika, na asante sana.

Marafiki

2007-09-27T09:52:00.000-07:00

…”Friends” in Kiswahili. One of the 3 major commandments given to us before coming to Kenya was “dignify relationships.” I’d like to share a little about some of the wonderful friends and relationships I’ve encountered here. I’ve learned something from every single person mentioned, and clearly my life would have been different, less rich, if the following people had never been a part of it.

Priti. Probably best to start with my roommate, as she figures prominently into most of my stories about MTRH, Eldoret, and Kenya. I didn’t know Priti that well before coming to Africa, but I was very lucky that she was the other student drawn out of the hat at the same time as me. She’s a very fun and silly person, and often adds lightness to my often too-seriousness. She’s going into internal medicine – she hates developmental milestones and I hate COPD and CHF; so medically we make a well rounded pair. In addition, we share a lot of the same views on life, the world, and med school and we’ve had many late-night discussions about these various topics. We both come from rather different backgrounds (Priti being a first-generation Hindu American whose parents are from India) so we bring different perspectives to any issue. Most importantly, she loves to shop. Between being there for each other through various illnesses, mood swings, and work frustrations, I think I’ve made a friend for life.

Dayna. The 3rd of the 3 IUSOM seniors here during my time, I regrettably only got to spend one month in Kenya with Dayna. But, what a fun month it was. Dayna was a lifeline to Priti and I when we first got here – not knowing our way around town at all, anything about the hospital, how much things should cost, where the good shops, groceries, banks, etc were in Eldoret. It would have been infinitely harder to move into the hostel if Dayna had not already been here. I really admired Dayna’s strength: soon after she arrived in Eldoret she found out that her mother had a serious medical condition. Being close to her mom, it was hard for her to not rush home, but she stayed and made the most of her time here. Dayna spent her 2nd month doing OB/GYN – her future career – and we could always count on her for a wide variety of stories from the delivery rooms and ORs: funny, bizarre, sad, tragic. We miss Dayna a lot now, only a small part of that being because she had a vast library of “Scrubs” episodes on her laptop. There is no better way to unwind from a frustrating day than watching your chosen profession get parodied relentlessly.

Venus. Oh Venus. The only ‘blonde’ Chinese girl I’ve ever met. Venus is a girl with a heart of solid gold, with such a sweet and innocent disposition that you can’t help but like her immediately (Think Tiff, but a Chinese Canadian). Venus is a business major at U of Toronto, and she spent her 10 weeks here working with the Family Preservation Initiative (FPI) arm of AMPATH. FPI works on issues like food security, small loans to private businesses and families, etc. Venus’ real passion while she was here, though, was playing with the kids at Sally Test. She used her camp-counselor persona to come up with absolutely brilliant arts and crafts to do with the kids. They all loved her. When she left, they made her a poster with all of their handprints on it. Being such a sweet person, Venus had a hard time saying no, and consequently gave her phone number out to just about everyone in Eldoret. By the end of the time here, she didn’t even answer her own phone anymore, as more likely than not it was some random guy calling with another marriage proposal. She was often subject to incessant teasing by the group – especially Sonak (since she left, Sonak has been on an earnest hunt for the “new Venus”), but she always took it well, and she knew that we all loved her.

Laurein. A 6th year medical student from Holland, I met Laurein on my first night in Eldoret when she came to dinner with us. I have no idea how she got hooked up with our group, as she didn’t know any of us at the time. That first night, I just remember being jet-lagged and exhausted, and thinking “who is this crazy Dutch girl who’s yakking my ear off?” Verbosity aside, it didn’t take long for me to love Laurein. She has a refreshingly European way of saying exactly what she’s thinking, and she can tell some of the funniest stories I have ever heard. Very outgoing and gregarious, she throws herself into whatever she is doing with gusto, whether it’s her studies, her patient care, or her friendships. Because of her work ethic, she has become essentially tri-lingual; applying the same fortitude in her Kiswahili lessons. On her way to becoming an international health worker in Doctors Without Borders, Laurein is currently starting a month-long rotation in rural healthcare in Kapenguria, Kenya, the she finish up her 4 month stay in Africa with a month of OB/GYN in Cape Town, South Africa. The thought of four months in Africa does not phase her, despite not knowing anyone in any of her destinations. Her ability to make friends wherever she goes is one of her strongest assets, and I believe she is going to do a huge amount of good in her medical career.

Abby. A social work student from Indianapolis, Abby will be spending 13 weeks in Eldoret, working with Sarah Ellen to improve and really get off the ground the rape/sexual assault center at MTRH. Her passion for women’s advocacy is very inspiring, despite the horrible, HORRIBLE things she sees every single day. Instead of letting the countless tragedies make her emotionally paralyzed, she uses these patients to drive her work and remind her of her purpose. I admire that so much. She actually reminds me a lot of Laura, which is part of the reason I like her so much. (And, it turns out that she actually lived on the same street in Chicago as Laura and Daniel for basically the same stretch of years. Uncanny, no?) In addition, she’s a very good basketball player, and it’s always amusing to watch her school Sonak at hoops. Her OCD-esque quirks and dry sense of humor have made her a real joy to have on trips.

Natalie. A senior medical student from University of Utah, I wasn’t quite sure what to make of Natalie at first. After only a short time; however, she really grew on me. We really only spent about 3 weeks together in Kenya, but it was 3 intense weeks, as they included the rafting trip to Uganda and she was our next door neighbor in the hostel. Natalie has a work ethic that I really admire, going back to the wards almost every afternoon to do procedures, check up on labs, or admit patients. She basically talked me into interviewing at the peds program in Salt Lake, and it will be great to see her again when I go out there.

Angela. A 3rd year peds resident from IU. Angela was one of my residents when I did my 3rd year inpatient peds rotation, and she was a lot of fun. She was also one of the night-float residents when I did NICU at Methodist, so when I found out one month of our time in Kenya overlapped, I was very excited. As one of the other NICU residents said “Angela could have fun at the bottom of a well.” I think that’s true. We’ve enjoyed quite a few fun and crazy moments courtesy of Angela in the past 4 weeks, including rafting on the Nile together and staying in the same hotel at Masai Mara. Not only is she extremely fun, she’s also extremely smart, and she has taken on the care of the children in the wards as a personal mission. Many days she has gone over and above the call of duty or expectation to find an inhaler for a kid that really needed it, made sure a dehydrated baby got enough fluids, or found a way to get an antibiotic that was out of stock.

Sonak. One of the smartest, if not /the/ smartest guy I’ve ever met. Sonak is 26, has his PharmD, did 2 years of residency in infectious disease, got his MPH (masters of public health) and is now a fully salaried professor through Purdue pharmacy school. Oh yes, and he’s on a tenure track. And ALSO, he worked for a year in Kisumu before getting his job in Eldoret. He got here the day before Priti and I did. Sonak was hired on for at least 5 years (but probably more) to rev up the pharmacy student exchange program that had sort of gotten into a rut. And he has really thrown his full energy at the job. His head is practically bursting with new, innovative ideas for AMPATH funding and HIV/AIDS research. (The 2 latest ones being global Wii tournaments with a buy-in that goes to AMPATH, and his most recent brainchild: Drinking and Dancing for Drugs. This involves a bi-monthly dance party at his house, where he will sell at-cost liquor and beer for a huge markup, and give the money to the Pharmacy program for emergency and out of stock drugs. After it gets off the ground in Kenya, he wants to live-link all of the cities in the ASANTE consortium, as well as sell t-shirts and other merchandise). His energy really does seem endless, and he is a constant source of information about all things related to international health. And to top it all off, he is an honest to goodness nice guy. He’s so patient about driving the girls around town to go shopping or run various other errands, especially when it’s raining. Whenever any of us are sick or has a problem, he’s so good about following up with us to make sure we’re ok. (Even Dr. Mamlin said – “that Sonak, he’s so cute. What a nice guy.”) And, really, he’s a lot of fun. He has a pool table in his house which is almost always in use, and he just recently acquired a 46-inch flat screen TV for his wall – sports viewing and all 3 seasons of “The Office” being the primary objectives. He also regales us with his lofty plans of building a fully-stocked bar in his house, in addition to a water cooler so he can be fully “self-sufficient” and not have to rely on IU house for anything. His role models are Paul Farmer and Joe Mamlin, and despite his young age he’s well on his way to being on par with those men; Sonak is going to do great things – things on a global scale to improve the health of developing nations, I am absolutely sure of it. I consider the newly-arrived pharmacy students very lucky to have such an energetic and optimistic teacher, but I think I may be a little bit luckier to have him as my friend.

Hao & Robert. Hao is a pediatrician, Robert is a medicine/pediatrics doc. It was a strange and new experience, being friends with my attendings, though not at all an unpleasant one. Before coming to Kenya to be the IU medical team leaders for a year, Hao and Robert spent quite a few years living on a Navajo reservation in America, providing medical care for the tribe. Right after getting married, they took a year off of medical school to do malaria research in Peru. Romantic way to spend your first year of marriage, eh? At first glance, it seems as though they have lived very exotic lives, but when it comes down to it they are very nice, very normal people raising 3 kids, trying to have as normal a life as possible while doing what they really love. I think they are very inspiring, and I certainly look to them as role models for having a family and practicing medicine – practicing international medicine at that.

Benson. A former street kid taken under the Mamlins’ wing, Benson serves as an invaluable asset to the American students in Eldoret. He shows us around town, goes out with us, takes us to the safe places, and makes sure we all get home ok with reliable taxis. A very fun and very nice guy, he’s in the process of finishing up his primary schooling so he can go to pharmacy school in Nairobi. I am amazed that, after years of revolving-door friendships, he still takes the time to get to know us all personally.

Joy. A 4th year medical student on my pediatric team from day 1. I was very intimidated by Joy at first, but after I got to know her, she became by far the best Kenyan friend I’ve made here. She possessing a very quirky sense of humor and the most uncanny way of imitating our Consultants that have earned us reprimands on rounds more than once. Aptly named, I have never once seen her looking down about anything or say anything negative about anyone. She checked on me when I was sick, and after we weren’t on the same team anymore, would send me random text messages to see how I was doing. Through our many and various discussions, I was pleased and surprised to find out how much we had in common, despite growing up on opposite sides of the world and in very different circumstances. I appreciate the way that Joy just seems to get me; understanding exactly who I am the way a lifelong friend would. I’m sure it’s very ignorant of me, but I did not expect to make friends in Kenya the way that I did. Perhaps a part of me figured ‘aside from working in medicine, what else could we possibly have in common?’. Clearly Joy (and the rest of my Kenyan friends) proved that ignorant notion wrong. I would not have loved Kenya nearly as much as I did (do) if it hadn’t been for Joy’s friendship, and I will miss her very much. She aspires to complete her residency in the U.S., and I sincerely hope that she does.

Ben. A 6th year student on my pediatric team. Nicknamed “The Professor” because he always has an answer for everything (usually the right answer) and he always has a lot to say about everything as well. Ben is one of the few non-traditional students at MTRH – he’s 38 (though he doesn’t look a day over 25) and worked for several years as a clinical officer before starting med school. He’s married and has 2 kids, and since he lives at the hostel during the week, his idea of a good time on the weekend is going home to see his family. Ben is very down to earth, very knowledgeable, and very good with his patients. He wants to be a pediatrician, and I know he will be an excellent one.

Allan. Also a student from my pediatric team, a 4th year. Allan was the student who sort of guided me through the first few very confusing weeks on the wards. He helped me with admissions, found the patients/parents who spoke English, and kept me updated on the ever-changing class schedule so I could go to lectures. Along with Joy and Ben, Allan really helped me feel like a part of the team and less like an outsider.

Wycliffe. The faithful Kiswahili tutor. How many times over the years has he heard muzungus butchering his native language? Too many to count, I’m sure. Still, he soldiers on with us in his infinite patience. Always very encouraging, even with the smallest of accomplishments, never laughing at me but allowing me to laugh at myself. (And my mastery of the Kiswahilli language is indeed, quite laughable). One of many IU House Kenyan regulars who witnesses the revolving door of our community, he still manages to never forget a face or a name. If I’m ever back in Eldoret, I’d like Wycliffe and Kiswahili to give me another chance.

At lunch on Tuesday, Hao asked Priti and I what our favorite part of the experience had been. I didn’t even have to think before answering “the people.” The hospital has been educational, the trips have been amazing, but none of it would have meant half as much if it hadn’t been for the people there around me. I hope that in coming to that realization, I have fulfilled the purpose of the program. I hope that by making this experience about the people, it will mean much more, and stay with me much longer than just ‘these 2 months I spent in Kenya once.’

Sleeping and Reading

2007-09-25T22:50:00.000-07:00

That’s what I’ve been up to for the past 2 days. More sleeping than reading, really, as I’m still battling this cold/flu thing. Not the best way to spend my last week in Eldoret.

Today was not the best day. Even though I’m technically on vacation, I went to rounds in the newborn unit (basically the NICU) with Hao, as it’s something I’d wanted to see and hadn’t yet had the chance. First off, I got terribly lost, and every time I asked anyone where the newborn unit was, they looked at me as if I was speaking a foreign language (which I very well could have been). I finally met up with Hao, and she took me to the unit – which I never would have found by myself. There was a small ante-chamber type area, where we had to take off our shoes and put on these slipper-type sandal things, as well as leave our gear and coats, to minimize the germs entering the unit. As soon as we opened the door into the actual unit, a wave of heat nearly knocked me down. Since they don’t have individual incubators, the small 3 room unit is packed to the brim with at least 25 space heaters on full blast. Great for the babies. Bad for the adults. I was in there for all of 3 minutes before I was sweating profusely. Between being sick and it being about 100 degrees in the teeny tiny unit, not to mention there were about a dozen of us all crammed together, I was not much of a champ during rounds today. I had to leave every 10 minutes or so to go sit down in the antechamber area and drink some water, lest I end up losing consciousness. It’s the first time that heat alone has made me feel like I was going to pass out.
And then Laurein came by the unit to say goodbye. So that was hard. She was crying, I was crying – a big cry-fest. So I eventually wander back into rounds with my eyes wet and red, my nose dripping, completely sweaty, and Hao just looks at me and says “are you ok?” Uh…yeah. Great. Never better. I managed to rally somewhat and made it through the last 30 minutes of rounds without leaving (or fainting!). Overall the morning was not my most shining moment.

After rounds Priti and I had our de-briefing lunch with Hao, to talk about the program, what we liked, what we didn’t like. Hao had some really nice things to say; that she appreciated our attitudes during the whole experience and that we were able to be so flexible. Some people rolling through IU house these 2 months have had nothing but negative things to say about the wards and the experience, so I appreciated that she separated us from that group. We also ended up eating with some of the Kenyan Registrars, including my favorite peds regirstrar, Julia. Julia, and most of the other registrars, have been to the US (or will go at some point) for 6 months to train. Juila was at IU during the horrible snowstorm(s) this winter, and hearing her stories of this experience are always quite entertaining. She is an incredibly intelligent person, and in the course of these 2 months, I’ve learned many many things from her – both medical and about life in general. She’s also very passionate about her work and her country. One day a few weeks ago, I asked her if she ever considered moving to the US. She said yes, she did, but when she thought about it she decided the children of Kenya needed her much more than the children in the US. American kids, she said, will always have doctors to care for them, but not so for the children of Kenya. Her only qualm is that her son would have more opportunities in America, and that’s something she struggles with. Seems like working moms struggle with a lot of the same things, no matter where they live.

During the course of our lunch, a downpour started (by the way, the rainy season is not over yet) and continued for a good 90 minutes. So, we all sat around the table chatting about anything and everything. I really enjoyed listening to the Kenyans’ stories about growing up, going to school, and now working in Kenya. They reminisced about the ‘good old days’ when they shared one or two room houses with their large families, not owning anything, being too poor to own shoes, etc. While it may sound terrible, they universally said that they remember those days with fondness; the days when life was simple. To hear those attitudes was amazing, and it was also amazing to think about how this group of people had risen from such poverty to become physicians. It makes me look like I was born with a silver spoon in my mouth. I guess, compared to them, I was. Priti and I also discussed our time in Kenya with the Kenyans, and they were happy and somewhat surprised when we told them we didn’t want to leave, and we would really miss being here.

It continued to rain and rain and ran and rain and RAIN (rainy season is still ON, did I mention?), so Priti and I decided to brave the 10 minute walk back to the hostel with only 1 small umbrella between us. We may as well of not had had it, for all the good it did us. By the time we got back to our room, we were thoroughly soaked and cold, and generally cranky in disposition. Napping being the best thing to do on a cold rainy day, I decided that was the best thing to do. Being my 4th nap in 2 days, I felt somewhat guilty being so lazy, but I really am trying not to bring the African gleeb back to Indiana. Also, I’ve been trying to use this downtime to rest up for my new elective that starts on Monday, as well as have some time to reflect on everything that’s happened. I’m trying to anticipate the various difficulties I will have in becoming an American again, in order to ease the transition. Still, though, I know it’s going to be hard. I know that many well-meaning people will ask “How was Africa?” and how can even BEGIN to answer that question? A short ‘fine’ or ‘good’ or even ‘great’ will not even begin to justify the experience, while attempting a more thorough explanation will just frustrate me, because I never can really, fully, explain it all.

I think the hardest part will be helping people understand how Africa has changed /me/. That I am not the same person I was when I left 2 short months ago; that the experiences and the people here have changed so much about how I look at the world, medicine, and just human beings in general. I am a part of Kenya now, and it is a part of me, but how can I fully convey that to everyone who was not here with me? This is something that I’ve wanted to do for the last 4 years, and now that it’s almost over – is that just it? Is it just over? I hope not, and I don’t think so. We’ve joked about Kenya reunions after we all get back to Indy, and the closer I get to leaving, the more I see how much we may all need that. Just to be with people who saw what I saw, who understand the beauty and the horror and the sorrow and the joy of Kenya without having to explain. It’s not that I don’t want the people in my life to understand, it’s just that I don’t know how I could ever convey it all.

Tomorrow begins a new round of farewells – we’re having lunch with some of our Kenyan team-mates and friends, then it’s our last Wednesday night dinner out with IU house. I suppose it’s appropriate that it’s at the same restaurant I had my very first IU house dinner.

I know this seems all tears and melodrama, but it’s really not so terrible. Goodbyes are hard, but I will keep in touch with the friends I’ve made here (Kenyan, Dutch, American, et al), and I’m not saying goodbye to Kenya forever…more like… see you later, or until next time…

Masai Mara

2007-09-23T08:13:00.000-07:00

Acacia in the Sunset

Me and Elephants

Well, I suppose I can allow myself to leave Kenya now, as I saw both a lion and a giraffe thisweekend…in addition to SO many other animals. What a fantastic safari.

Nine girls – 5 pharmacy girls, me, Priti, Abby, and Laurein – left bright and early on Friday morning. It was a long drive to Masai Mara, about 7 hours in total. Luckily I was able to sleep for most of the drive, despite the constant bouncing of the van. When I woke up, we were in Maasai Land, and it was beautiful. It was completely different than any part of Africa I’ve yet seen. It looked exactly like the picture I (and many people, probably) have in my head of what Africa looks like. Bright sun, clear blue sky, and the brown-green of the savannah grassland stretching out to the distant mountains as far as the eye can see.

I should explain more about Masai Mara. The Masai Mara National Reserve is about 1500 square kilometers of grassland that is essentially the northern extension of the Serengeti Plains of Tanzania. It is located in the south of Kenya, on the Kenya-Tanzania border. Its name comes from the famous Maasai tribe (more about the Maasai later) that resides in the area and the Mara River that flows through southern Kenya. Basically, Masai Mara is to Kenya as the Serengeti is to Tanzania – it is the most famous safari destination in the country.

The drive through Maasi Land was beautiful. The Maasai are one of the few tribes in Kenya who live largely in traditional ways, shunning modernization and city life, so I really felt like I was in Africa. We saw numerous Maasai along the way, traditionally dressed in their bright red shukas and elaborate jewelry, both men and women. The Maasi are a nomadic, cattle herding tribe, and we saw many, many people out in the fields with large herd of cattle, in their traditional Maasai dress. It was just fantastic.

Just outside the entrance to the park, our driver Erick let us browse at a ‘cultural’ gift shop for a few minutes. This place was like the Eldoret Cultural Shop (our favorite store here) on steroids. It was a very large tin building packed (I mean packed) with anything and everything, including masks, soapstone carvings, spears, Maasai shukas, and of course: tourists. The prices for everything were inflated at least 200 percent, if not more. Having lived in Kenya for some time, we just laughed at the outrageous prices they were asking. But, as the majority of their customers fly into Nairobi then come straight south for Safari, they really have no idea how much things should cost. I think they were making pretty good money there. We ended up stopping there again today on our way home, and a few of us bought some things after we haggled them way down to a more reasonable price. I bought a really pretty batik canvas painting of the plains with giraffes and elephants around an acacia tree.

After the shop and after entering the gate to the actual reserve, the road quality dwindled from bad to worse to an adventure in its own right. Our hotel was a 45 minute drive from the gate – 45 minutes on bad roads. But, this was offset by the gobs and gobs of wildlife we saw on the way in, mostly zebras, various types of antelopes, and wildebeest. The other good thing about the long drive was that it meant our hotel was smack dab in the middle of the park.

We finally arrived at our hotel the Fig Tree, which was quite lovely. We had just enough time to check into our cabins – also very nice with real bathrooms and hot showers – and eat a quick lunch before going on our first game drive. Being as this was our first drive, everything was new and exciting, and being as we are 9 girls, pretty much everything we saw was squeal-worthy. After a lot of zebras, antelope, and wildebeest, and even a few warthogs, we came across some lions. I must say, it was pretty exciting. There were 6 or 7 other safari vans gathered around, taking pictures, but the lions – a male and a female – just lay calmly in the grass. Clearly they are very acclimated to humans. Now, this blog is G-rated, but let me just say that it is apparently the lions’ mating season, which we got to witness...several times. Erick told us that lions will mate 300 times a week. Hmm… no wonder we saw so many lions this weekend. After spending at least an hour looking at our first lions, we drove onward. We came across 3 elephants feeding, and they were beautiful. Thirty minutes and at least 2 dozen pictures later, we found some more lions – 2 young males and a female. These lions were just sleeping, so our pictures were not that exciting, though I got a really cute picture of one of the males rolled onto his back with his legs in the air – reminded me so much of Fred. The term “Big Cat” is not a misnomer; they purr, play, and generally act just like my two Big Cats at home.

By this time it was getting dark, so we headed back to the camp. Just outside the entrance, we came across a very young male lion hanging out in the bushes. He was not as used to us as the others, he acted very skittish, but I got a nice picture of him peeking out from behind a bush. After a delicious dinner and a hot shower, it was time to call it a night.Saturday was an early morning; we left at 6:15 for our first game drive. We left a little earlier than most of the other vehicles, which was nice, in that we got to sort of lead the pack and see animals before dozens of roaring engines scared them off. Almost as soon as we pulled out, we saw 2 lions – a male and a female again – prowling across the plain. The male was absolutely HUGE, weighing at least 150 pounds I’d guess, with a big full beautiful mane. They really didn’t give two hoots about us, and we were able to get so close it was unbelievable. Erick said it looked like they were hunting their breakfast – and indeed there was a very large herd of various grazers nearby (all of them looking alert and nervous). But, very soon there was a bevy of safari vehicles following the lions, so I think our chances of seeing a kill were minimal. We moved on, and soon came to a mamma giraffe and her baby. I was so excited! They were just beautiful. They moved so gracefully. Clearly they were very skittish, and we couldn’t get terribly close, but I got some fantastic pictures of them anyway. Pretty soon all of the late-start safari-ers roared up behind us, and the giraffes ran off.

The other highlight of the morning was finding a large pride of female lions lazing about on some rocks, and one of them had 2 little lion cubs! They were so cute. Much squealing was heard from our vehicle. Again, they reminded me so much of little kittens they way they played and jumped about. They didn’t give their mother a moment’s peace. In fact, she kept getting up and moving a little farther off, and they’d bound along right behind her and jump on her as soon as she plopped down – biting her ears, batting at her tail, etc. It was just too cute for words. After the lion pride we found another herd of elephants – 5 or so. Even though we were seasoned elephant viewers, having seen them for the 2nd time after all, they were still just stunning. We really saw so much wildlife in the morning, in addition to the mentioned we saw quite a few hyenas (most of them collared for some sort of research/conservation project), numerous zebras and antelopes, warthogs, jackals, meerkats (running along side the van – those things can move!), baboons, a tortoise, and dozens of beautiful birds. The morning drive provided some great pictures with the sun rising over the mountains, and many hot air balloons. Apparently sunrise hot air balloon safaris are quite popular, quite spectacular, and quite romantic. And also quite expensive. We all decided it’s definitely something we will do someday, when we find a rich gentleman to foot the bill. I’ve got the gentleman; now all he needs to do is win the lottery. Or publish his first novel.

After about 3 hours of driving, we headed back to camp for a fabulous breakfast, after which 5 of us decided to do the Maasai village walk. I’d heard mixed reviews of the village walk; some people had said it was a wonderful experience, while others said it was just one long sales pitch for various Maasai goods. I decided to go, not expecting a true cultural experience but hoping I would enjoy it anyway. The fee to enter the village was 1500 kSH, which bought us a personal Maasai guide, a tour of a Maasai hut, traditional dances by both men and women, and the right to take as many pictures as we wanted. Apparently it’s very culturally insensitive to photograph the Maasai (which is a shame because they are so beautiful). Unless you’ve paid for the privilege, I suppose.

At any rate, Jeremiah, the son of the village chief and our guide, started off by telling us a little bit about the Maasai people, that they are primarily nomadic cattle herders, etc. Their villages are really quite small – 10-12 small mud huts built in a circle with an open common area in the middle. The houses are surrounded by a fence of sorts made from sticks and bush. In the morning the cattle are driven out to graze, and at night they are driven back into the circle, and the fence completed. This is to protect the cattle from predators, though Jeremiah said it’s not uncommon for lions to jump over the fence and eat cattle. When this happens, the men of the village must find the lion and kill it, otherwise it will learn how easily it can get food at night. With cattle being the Maasai’s primary means of existence, that would be a disaster. It is illegal to kill lions in Kenya, but the Maasai are allowed because they are recognized as a self-governing tribe by the government – as long as they remain in the government-appointed lands. Jeremiah also told us that in order to be eligible for marriage, a young Maasai man must first single-handedly kill a male lion. While that is certainly a traditional Maasai practice, I had heard that it was largely obsolete now, so who knows. I guess it makes a nice story for the muzungus. Jeremiah is actually getting married next month, he said, to a Maasai woman he met in school. He said that since they are both educated, they are allowed to make the decision to marry themselves, and sort of ask their families’ permission, though it is not strictly needed.

We learned so many things about traditional Maasai culture, and it was very interesting. Traditionally, Maasai women shave their heads, while the men grow their hair long. However, if a woman is educated, she is allowed to grow her hair long. We saw one woman with long hair (or “big hair” as Jeremiah called it), she was the local school teacher. Also, at the age of 18 Maasai will typically start to put spacers in their earlobes to create the long dangling skin that is often decorated with colorful beads or earrings. But again, if the person (man or woman) has had an education, they can forego that practice. Jeremiah also told us about the Maasai shukas: bright colorful cloths worn by men, always in shades of red. The Maasai adopted the color red many years ago as a way of identifying each other in battles with other tribes. As a nomadic tribe, a village will pack up and leave every 5 years or so and start a new village elsewhere. The main impetus behind their continued nomadic lifestyle is the search for the best cattle grazing land.

When we entered the village the women performed traditional songs and dances for us for about a half an hour. I got some great pictures as well as a short video. After that Jeremiah took us into one of the huts, made completely of sticks and sealed over every inch with cow dung. We sat inside for awhile, saw where the Maasai slept, ate, and cooked in the home. It was pretty cool. We also saw the “calf pen” that every home has. Calves are kept in the pen, which is inside the actual house, at night, both to protect them from predators and to prevent them from nursing at night, so the cows can be milked in the morning.

After exiting the house, the Maasai men performed their traditional songs and dances. One of them involved a competition to see who could jump the highest. The winner gets the right to court (or maybe marry?) whatever woman they are fighting over. They really could jump quite high. Whichever young man has killed a lion gets to wear a tall hat made out of the lion’s mane. One man was wearing one, and the group danced around, taking turns putting the hat on each of us. I got a picture of myself in the lion mane hat, and I must say I look quite ridiculous.

Then the fun began as we were ushered into a smaller fenced-in circle adjoining the village, which was the “Maasai market.” We circled around tables and tables full of beaded jewelry, soapstone plates and carvings, gourds…pretty much everything. I ended up buying a Maasai shuka. I probably paid a little too much for it, but I think it was worth it. Overall the experience was rather touristy, but it was still enjoyable. It was at least nice to learn about the traditional Maasai culture, even if that’s not exactly how some of them live anymore. I mostly enjoyed seeing the traditional Maasai dress, on both the men and the women. It was so beautiful. The Maasai, especially the men, are extremely tall and thin. Their physique combined with the bright reds of their shukas and their piles of jewelry on every appendage was quite striking. They just look so…African.

Lonely Planet Kenya actually has some interesting information on the Maasai:

From “History:”
…Although control of the coast was largely sewn up, the interior, especially the Rift Valley and the Aberdare Highlands, was largely impregnable to outsiders due to the fearsome Maasai and other warlike tribes. A few explorers braved the Maasai heartland – including Gustav Fischer, a German whose party was virtually annihilated at Hell’s Gate in 1882 – but most attempts to enter the Rift Valley were doomed to failure.

The united front of the Maasai began to crack in the late 19th century, following a brutal civil war between the Ilmaasai and the Iloikop groups and the simultaneous arrival of rinderpest (a cattle disease), cholera, smallpox, and famine. Because of this, the British government was able to negotiate a treaty with Olonana (known today as Lenana), the laibon (chief or spiritual leader) of the Maasai, allowing them to march the Mombasa-Uganda railway line right through the heart of Maasai grazing lands. On one level, the Maasai were just accepting the inevitable – their end-of-the-world myth spoke of an ‘iron snake’ that would one day crawl across their land. Ironically, this once-crucial line now has just two passenger services, a far cry from its conception as the pride of East Africa.

With the completion of the railway, the headquarters of the colonial administration was moved from Mombasa to the cooler small settlement of Nairobi, and white settlers began to occupy the fertile highlands north of Nairobi. Their interests clashed with those of the Maasai, prompting the colonial authorities to pressure Olonana into restricting the Maasai to two reserves, one on either side of the new railway. However, the white settlers soon wanted the northern reserve as well and in 1910 and 1911, the Maasai who lived there were forced to treck south, despite Olonana’s objections.

From “Tribes of Kenya:”
For many, the Maasai are the definitive symbol of ‘tribal’ Kenya. With a reputation (often exaggerated) as fierce warriors, and a proud demeanor, the tribe has largely managed to stay outside the mainstream of development in Kenya and maintains large cattle herds along the Tanzanian border.

The Maasai first migrated to central Kenya from current-day Sudan, but in the late 19th century were decimated by famine and disease, and their cattle herds plagued by rinderpest. The British gazetted the Masai Mara National Reserve in the early 1960s, displacing the Maasai, and they slowly continued to annex more and more Maasai land. Re-settlement programs have met with limited success as the Massai scorn agriculture and land ownership.

Maasai women are famous for wearing vast plate-like bead necklaces, while men typically wear a red-checked shuka (Maasai blanket) and carry a distinctive ball-ended club. Blood and milk are the mainstay of the Maasai diet, supplemented by a drink called mursik, made from milk fermented with cow’s urine and ashes, which has been shown to lower cholesterol.

At around the age of 14, males become el-moran (warriors) and build a small livestock camp (manyatta) after their circumcision ceremony, where they will live alone for up to eight years, before returning to the village to marry. Morans traditionally dye their hair red with ochre and fat. Female genital mutilation is common among the Maasai, despite the best efforts of various human rights groups.

Tourism provides an income to some, either through being guides and camp guards (askaris), selling everyday items (gourds, necklaces, clubs, and spears), dancing or simply posing for photographs. However, the benefits are not widespread. In recent years, many Maasai have moved to the cities or coastal resorts, becoming doormen for restaurants and hotels.

“The Hard Sell:”
A common complaint among travelers, particularly in The Mara, is that the Maasai can be incredibly hard-nosed in business, and ‘cultural’ visits to villages often become high-pressured sales ventures the moment you arrive.

While it would be unfair to generalize, it’s certainly true that some Maasai, especially in high-density tourist areas, will treat you purely as a cash cow. Favorite techniques include dropping wares in your lap and refusing to take them back; coming into campsites to offer dances at non-negotiable rates; and charging for absolutely everything, from camping to crossing their land. While this behavior isn’t limited to Maasai, their aggressive and utterly unapologetic attitude upsets more travelers than day-to-day hassle elsewhere.

If you feel you’re being taken for a ride, Maasai or otherwise, stand up for yourself. Or, ask yourself this: If your people had been consistently dispossessed for over a century and were now subjected to constant streams of gawping foreigners with seemingly bottomless pockets, wouldn’t you do the same?

I think this is all very interesting. The weekend for me turned out to be as much about the animals and the safari as it was about the Maasai culture: their land, their traditions, and their history. I was surprised how much their story (and really the story of most of the tribes of Kenya) resembles that of the Native Americans back home. It seems we white people are capable of some pretty terrible things. Not that it helps to dwell on the past, but the question becomes, if we can’t undo what has already been done, how can you attempt to right the wrongs? I don’t know the answer, but surely there must be one. Surely there has to be a way for the Maasai to teach me about their culture, their real culture, in a respectful and authentic way. And surely there has to be a way for them to preserve what is native and important to them without selling their cultural identity to the highest bidder? I don’t know if going on the village walk was a help or a hurt. I learned about the traditions of a group of people wholly different than myself, and I definitely gained a new respect and knowledge of where they came from. But at the same time, was my presence there only perpetuating the problem of cultural tourism by confirming to them that their cultural identity could be sold for a price? I don’t know.

And then there’s the whole other issue I was re-confronted with this weekend (the first time being Baringo/Bagoria) of staying in absolute fantastic luxury while surrounded by some of the most destitute people in the world. I know I wasn’t the only one troubled by this, as we had several discussions about it in our group. Is it right? Is it wrong? Is it both? We never came to a consensus. Maybe we shouldn’t worry about it and just hope that the money we’re throwing around is doing some good for the people who need it the most. I just don’t know.

Maybe the answer to all of these troubling questions is not a matter of money or technology, or ‘westernizing’ people who wouldn’t necessarily benefit from it… maybe the answer just lies in an understanding. An understanding between people of different colors, races, cultures, and backgrounds. A learning that this is where you come from and this is where I come from; and neither one is better or worse, we’re just…different. An exchange of ideas. I highlight that because of this: from the very first meeting I went to about the IU-Kenya program, clear back in the first months of first year – we were told that was the emphasis of the program. The primary goal being an exchange: Of knowledge. Of ideas. Of experience. Of Understanding. I don’t think that I fully grasped that concept until now, 3 years after that first meeting, 7 weeks into my stay in Kenya. It’s still a powerful concept to try to wrap my mind around.

But I digress…(verbosely, it would seem)…

After the Maasai village walk, which I did enjoy very much, we drove back to the Fig Tree for lunch and chillin’ at the pool time. After a few hours of that, it was time for our afternoon game drive. We ventured into the less wildlife-populous places, having seen most of the big game, and now looking for the much more elusive cheetahs, leopards, and rhinos. We didn’t see any of the those, but a nice addition to our list of wildlife was some hippos. We actually saw them in 2 different places along the river. The first place was nice, nothing terrifically special, having seen hippos twice before. (I sound like such an animal snob). The second place we saw them, there were quite a few more. There was one especially large male who was being an absolute bully, and we got to see some pretty cool hippo fighting action. (As Abby dryly said: I would say those are some hungry, hungry hippos). On our evening drive we also saw some more elephants (see picture above). There were 7 in this herd (people here always tell us that elephants travel in 7s…though I’ve never heard that before), including 2 small little baby elephants who were just too cute. We parked the van and they plodded slowly by us, just yards in front of the vehicle. The neat thing about this herd was that they walked in a perfectly straight line across the plain, which I thought was just a circus trick (though they didn’t hang on trunks-to-tails, which probably is just a circus trick). I got some great pictures of the line of 7 elephants. We also saw several ostriches, as well as the elusive Eland – the largest antelope. The picture will make a nice compliment to the one I took of the dik-dik – the smallest antelope – at Lake Bagoria.

The ride back to the hotel showed us one of the most outstandingly beautiful sunsets I’ve seen in my life (of which many pictures were taken). Leisurely dinner and a hot shower were again the order of the night, as wake up call for this morning was even earlier.

We left at 5:50 this morning for our last game drive. I’m glad we left so early, as we enjoyed an equally fantastic sunrise over the plains, the backdrop for which was distant mountains and soaring hot air balloons. It felt pretty much like paradise. Abby said the animals were taking their day of rest this morning, which I had to agree with, as we didn’t see too many. We saw a few lions lying around, just a few antelope, but not too much else. The great, GREAT find of the morning by Erick was a herd (pack?) of giraffes feeding on some trees in the distance. There were about 6 or 7. We couldn’t see them that well, as they were pretty far off the safari path. Well, Erick just turned our safari van off the path and drove us across the grass right up to the grove of trees. The conservationist in me cringes, knowing that there are safari paths and protected grassland for a good reason; but the giraffe lover in me says it was one of the most amazing things I’ve ever seen and I got some fantastic pictures.

After the giraffes’ breakfast, we continued to look for rhinos, leopards, and cheetahs without success. The rhinos I didn’t really think we would see. There are only about 25 in the entire 1500 square kilometers of the park, and Erick said in all of last year doing game drives he only ever saw 2. Contrary to popular belief, it is rhinos, and not elephants, that are by far the most endangered species in Kenya. They were hunted to very near extinction in the 1960s and 70s. The cheetahs and leopards were not to be seen either, though I thought we might get lucky, but it was not meant to be. The other thing we had hoped to see was the tail end of the Great Migration – the migration of literally millions of wildebeest and zebras from the Serengeti to Masai Mara in search of more fertile grasslands. This typically happens in August every year, and then the animals head back to Tanzania around November. We did see the end result of the migration – thousands of wildebeest and zebras grazing in large herds all over the plains – though it was a little too late to get that infamous ‘fording the river’ picture that is on every nature show ever made. That, and the place where they cross the Mara River is about 70 kilometers away from where we were. I do think that would be a spectacular sight to see someday, but perhaps better appreciated from an aerial view.

We did end our last drive on a fun note, right at the end we saw a family of warthogs eating by the road, including 4 little baby warthogs, who were so cute in their own ugly little way. While mom and dad went about the important business of eating, the babies decided they were going to play head-butt and pick on the runt. It was quite adorable. Even that, at the end of the weekend, elicited girly squealing from the van.

Despite the relative lack of game sighting, I thought this morning’s drive might have been the best. One of the IU people here before us said that 2 days at Masai Mara was enough, because by the end you just get so sick of seeing the same animals over and over again, and it’s not nearly as exciting. While I agree that bouncing around in a safari van for hours at a time does get old, I don’t know how anyone could ever tire of looking at the African savannah – animals or no animals. It was quite brisk this morning, so most of the girls huddled in the van while we were driving around. It was cold, but I couldn’t help but stand and look out the top as we drove through the plains, seeing a full panoramic view of Masai Mara, seeing the sun rise, the mountains, the balloons, zebras grazing in the distance…seeing Africa just as I always dreamed it would look like. It was so beautiful.

I got some absolutely fantastic pictures this weekend, both of the landscape and the wildlife. As I was telling Mom when I talked to her, I think this is something that everyone should do if they can at some point in their lives. Seeing these animals in a zoo is absolutely nothing like seeing them in their natural habitat. In fact, I think after this weekend seeing these animals in a zoo might make me a little sad. Again, it’s really one of those things that cannot be captured on film – though I did try, I took over 500 pictures in the last 3 days alone! Amy (pharmacy student) said it best: “If one (picture) is good, then 10 must be better!”

After a quick breakfast and some last-minute camp photos, we packed up and headed back to Eldoret. Of course, the ride back was not nearly as exciting, as we had no safari to look forward to, plus we’d just spent the entire weekend in a car. The trip back took about 8 hours – 8 rather uncomfortable and hot hours, though there were some highlights. While driving through the Nandi hills we passed through a very long stretch of tea farms that were quite picturesque. The tea leaves are a very bright green, which makes a beautiful contrast between the more muted earth tones of the surrounding farms and hills. We had more fun in attempting to take pictures out the window of a bouncing van than actually getting the pictures.

About 3 hours from Eldoret, it started to rain. (I should say that last Thursday was an exciting day for us, as it was the 3rd straight day without any rain, at which point the rainy season was declared officially over. Huzzah! Just in time for me to leave! As it turns out, it did rain quite a bit in Eldoret today, so there goes that celebration.) After about 10 minutes of driving in the downpour…guess what song came on the radio… “Africa” by Toto. We totally cranked up the volume and enjoyed one of the greatest 80s songs ever written, especially singing “I bless the rains down in Africa” over the rain pounding down on the roof. Of all the fantastic memories of this trip to Africa, that one will stay right near the top.

Finally, though, we were back in Eldoret, just in time for dinner at IU house and some down time and TV at Sonak’s house. The real highlight after such an amazing weekend is that I don’t have to work tomorrow, as it is the start of my week off. The real lowlight is that I am definitely getting sick. Three of the girls started this weekend with a viral/flu type thing that’s been sweeping IU house (pretty much everyone has been sick) so I guess it was inevitable that I would get it after being in such close quarters with them for 3 days. Oh well, I suppose it’s better to be sick and be able to lie in my bed all day if I have to than to have to go to work. I do have a lot of things I want to get done this week though, and being sick is surely not on my list.

The other real bummer about tomorrow – much worse than being sick – is that Laurein leaves for her month of rural health care in Kapenguria tomorrow. As someone I met the first day I was here and have seen almost every day since for 2 months (not to mention all the trips we’ve done together), I consider her a very good friend and I will miss her a lot. Just the first in a long series of goodbyes I will have to make this week, most of which will be very hard. I am trying to offset the sorrow of goodbye with the joy of hello I will get to have when I see Mike, my four-legged kids, and the rest of my family and friends again.

Not that I want to end this post on a negative note. I had an absolutely fantastic weekend – surely the best trip I’ve taken in Kenya; maybe even the best trip I’ve ever taken period (If only Mike had been there). I did love Kakamega quite a bit, but I think that Masai Mara was better, because that belly-flipping feeling of ‘Oh my goodness, I’m actually in Africa’ didn’t leave for the whole weekend. Absolutely something that I want the people I love to see someday, and I hope that I’ll be able to be there when they do.

Last Week at Work

2007-09-19T06:30:00.001-07:00

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

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

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

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

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

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

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

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

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

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

Kenya

until I see a giraffe and a lion, so he better hope that works out for me.

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

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

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

My Hair is Braided!!!

2007-09-19T06:28:00.000-07:00

And it looks great!

And it only took FIFTEEN hours! But... I'd say it was worth it. I took a bunch of pictures of the process as well as the finished product, and I'll attempt to post them once they're loaded onto the computer.

The only major downfall is that my head is at least 1-2 pounds heavier than it was before, so I may have to start doing some neck strengthening exercises.

While sitting at IU house all day yesterday, we had a bit of excitement. I'll see if I can describe it accurately. Imagine the IU house compound is basically a large rectangle surrounded by a wall on all sides. On the 2 long sides of the rectangle, surrounding the perimeter, are the houses of the compound. Down the middle of the rectangle, going the long way, the compound is divided into 2 smaller rectangles by a hedge/fence. The fence has 2 gates in it, so we can walk back and forth between the 2 sections of the compound. Between the houses and the hedge is all cement -- driveways for accessing the various houses.

Well, it rained yesterday. (Shocking, I know). It was an absolute downpour for an hour or so. When it rains like this, water starts to collect in the driveways and pool there, as the driveways don't really run downhill and there's no drainage system. Essentially, IU house compound becomes a lake. This has happened a few times before, and not surprisingly it happened again yesterday. But, even after it stopped raining, there was still water pouring into the compound from somewhere. It turned out that the river just down the road had overflowed due to all the rain, and it was backing up into IU house. The water flowing through the gate(s) actually looked like a river, as it was gushing through and splashing all around. The water came all the way up onto the sidewalks and started coming into the houses. Shawn told us if it got worse we'd all have to start moving furniture. I took a bunch of pictures, as it was just unbelievable. It really looked like the houses had been moved into the middle of a river. Robert and Hao had their kids out playing in the water, which was SO cute, especially the baby who was wearing a shirt, teeny galoshes, and no pants. The water came up to his waist! Everyone was wading around, taking pictures. Hatari (one of the dogs) was playing the how fast can I run through the water and splash the other dogs game. Petite and Jack were not amused. It was quite the sight to see. Shawn said that it was the most water he's ever seen at IU house in his decade or so of living here.

I'm getting very excited about Masai Mara this weekend. I hope it will live up to the high expectations I have for it in my mind. The planning is turning out to be a nightmare, as it seems all planning for trips here does, but it will be worked out and we'll still have a great time.

The People in My Life

2007-09-15T06:47:00.000-07:00

Because I love this baby so much, here's another picture of Diana and me at Sally Test.

I'd like to start saying Welcome to My Blog to North Church! I really started this whole thing for Mike and my parents to know that I was still safe and well, etc, but apparently a little birdy revealed its existence to Ms Lela...and well, you know the rest of the story... :)

Since the Thursday night incident at MTRH, things have gotten better. I'm still bummed about it, but I'm trying not to think of it too much, or at least not dwell on it. This has been helped in large part to due to the people in my life, especially the residents here who listened sympathetically to the story, then shared their stories of First Deaths. They didn't tell me to get over it, just listened and said "that really sucks." They also didn't say that it gets any better, because I know that's not true, but apparently it does get easier, which is something to look forward to.

Of course Mike was very supportive as well (he is required to be) and I got the most amazing email from Emily that nearly made me cry. Not from grief, but from appreciation that I have such a wonderful friend who knows exactly what to say to make me feel better.

It had actually been a rather hard week for all of the teams at the hospital, so all of us IU house people went out last night to Places (a local club) with some of our Dutch friends, and we had A LOT of fun. I think we all just needed to blow off some steam, which we did quite heartily. We made a rule not to talk about medicine or the hospital at all, which was great, as I got to know Priti and Natalie better. It's nice to find out you have things in common with people other than just medicine. It was also fun because the 4th and 6th year Kenyan students just finished their end of rotation exams this week, so they were all out celebrating as well. One of the things I really love about Eldoret is the wide variety of friends I've been able to make in the last 6 weeks.

This morning Priti and I went about the serious business of gift shopping with much gusto. I spent a lot of money, bought a lot of stuff, and I'm ALMOST finished with shopping. I even bought my hair -- the hair that Christabel will use tomorrow when she's braiding mine! I'm pretty excited. We're starting at 8:30 and she thinks it will take 12-13 hours. I'm pretty sure that I'll look like a real Kenyan when it's done, and no one will be able to tell otherwise :).

Tonight the plan is to watch movies on Sonak's newly-delivered 46 inch plasma screen HD TV. Clearlythis will be a hardship, but I suspect we'll make it through somehow.

Kwa Herini!

The First One

2007-09-13T09:02:00.001-07:00

The First One.

I suppose I shouldn’t be surprised that it happened in Kenya.

I went back to the hospital this afternoon with Kelly and Amy (2 pharmacy students) to admit some patients and follow up on some labs, etc.

I had just gotten done admitting when Kelly asked me if we could check an oxygen saturation on an asthmatic patient of ours who is in severe respiratory distress. We finally tracked down the pulse ox machine, and got her sats at 92%, which isn’t too bad considering how distressed she looks.
We were getting ready to leave when a nurse came up and asked us to check the sats on another patient – someone on the other firm’s team, not my team. We went over there and were not able to get a reading on the machine despite trying for 5 minutes or so. The nurse told us the patient was 55, HIV+ and currently on treatment for PCP (a type of severe pneumonia that immunocompromised patients get). She was on an oxygen mask, and her bed was in the middle of the cube because she was in the process of getting transferred to the ICU.
All of a sudden the woman stops breathing, and we can’t find a pulse. So the nurse asks us to get the intern. I run over to my intern, who’s admitting a patient, and he points across the room and says – “that’s the intern on call tonight.” Very nice. So I go up to this guy, tell him there’s a patient (of HIS, mind you) that has no pulse and he says “ok” goes about his business and doesn’t come with me. So the nurses are looking at me to do something, they wheel the bed back into its corner, and I started doing chest compressions.

As soon as the intern walked by and saw me doing chest compressions, he dashed off to get a bag mask and came running back.

We did CPR for about 15 or 20 minutes – me doing chest compressions, the intern giving breaths and Kelly pushing the drugs. After countless rounds of CPR and 2 rounds of drugs, the intern was ok with declaring her.

So, I wrote the death certification. And after it was all over, I cried. A lot.

The first patient I’ve been with when they died, and I don’t even know her name. When I was in the NICU in June, we had 2 babies die, but by the time I got there the pulse and respirations were already gone, and resuscitation was already underway. These babies were intubated and sedated as well – from the moment of their births in fact – so I suppose as a defense mechanism I never really thought of them as /alive./ Today, this patient, was the first time I have been with someone as they crossed that mysterious and universal boundary between life and death. I’m sure it won’t be the last.

I guess the one small silver lining of this cloud is that I was really able to remain calm during the whole ordeal. If I thought about the fact that it was me (a medical student) and Kelly (a pharmacy student) in charge of the resuscitation from the beginning, I probably would have had a panic attack.

All of our CPR and ACLS classes seemed so excessive until now – you learn so many different algorithms and what to do in a code situation, but I was surprised how much of it came back to me – the endless cycles of 15 compressions to 2 breaths, give epi and atropine, check pulse, check breathing, repeat. You have to become a robot in those situations, or I think you’ll just go mad.

During, I asked the nurse if she had any family around. The nurse said “yes, a daughter.” I asked both so we could tell someone and keep them away at the same time. It really hit me afterwards, as they looked for her daughter, that this was a life, a human life. Someone’s mother. And we couldn’t bring her back.
I don’t know, I guess you can try to make sense of it all, or do as the Kenyan’s do and just accept that death is a part of every life. Maybe it’s a little bit of both. Or maybe, we all have to find our own path to understanding the horrible things that happen in this world, and we have to find a way to do that without becoming emotionally crippled for all our lives.

I think today was the beginning of my path to that place…wherever it is…

Still raining

2007-09-13T04:42:00.000-07:00

and how. More like MONSOONING. Speaking of lots of water, there's apparently a typhoon headed directly for Mombasa, so Priti and I will NOT be going there this weekend. That and the planning was becoming quite the nightmare, as we'd have to ride to Nairobi on some random bus, then take a train from Nairobi to Mombasa. And you can't buy train tickets until you're at the station, at which point, if the train is full, you have to wait for 2 to 3 more days until the NEXT train to Mombasa... so... maybe next time, eh?

We may attempt to take a day trip to Umbrella Falls, or we may end up staying around town for the weekend, which would be fine with me also. Then next weekend Masai Mara! Can anyone tell how excited I am???

We found out today that Diana is being taken to Neema House, the local orphanage for HIV+ children and orphans due to HIV. It's run by a Kenyan couple whom Sarah Ellen knows very well. It's a great place for her, and I'm so excited that she'll have a nice place to live, with loving a parents and lots of siblings to play with. The sad part is that she's probably going there today, so I went to Sally Test and took a bazillion more pictures and even a 60 second video of her scooting around on a truck. SO cute.

On Doctoring

2007-09-12T07:03:00.000-07:00

My first few days on the adult wards have been rather interesting.

I admitted my first adult patient last night. Rebecca, 57, came in florid congestive heart failure, with generalized severe body swelling, difficulty breathing, chest pain, and palpitations; all getting worse over the last 2 months. I actually saw some orderlies wheeling in this woman on a stretcher earlier in the day, and I just thought, "I bet she's coming to our ward." And sure enough, she was my patient. This poor woman could barely breathe, even on an oxygen mask, and her face was so swollen and edematous that she couldn't open her eyes. We got her on some Lasix though, and some cardiac meds, and already this morning she's off of her oxygen and can sit up in bed without huffing and puffing.

The other thing Rebecca told me was that she's had this cough productive of bloody sputum for the past month or so, and her roommate is currently being treated for TB. Great. She told me this AFTER I was all up in her face examining her, without my N-95 mask on. Oh well. Robert says that in the 25 or so years since IU's been here, only 2 people have converted to TB positive after returning to the states. So that's good. Yet one more reason I enjoy peds so much more -- it's very difficult to catch TB from a child.

At any rate, I got Rebecca admitted. Then Priti, who was also admitting last night, asked me to help her with her patient. A 3 month old little girl with diarrhea and vomiting for some time, as well as fevers and decreased feeding. Priti told me she looked bad and I was like "ok, just one sec." I walked over to the peds side and this baby looked bad bad BAD. The first real case of 'severe' dehydration I've seen yet. Her eyes were sunken, fontanelles sunken, very dry mucous membranes, breathing fast, fast heart rate, extremely pale, with a glazed over look in her eyes. I think she was only an hour or two away from coma and death. Seriously, this baby looked terrible. Obviously the first thing she needed was fluids, and they were written for and she had an IV in place, so we couldn't figure out why she hadn't gotten any fluids. We finally found a nurse who would actually talk to us, and she said that actually the IV was not in good position, they had tried fluids, and it had just infiltrated. After expressing the need for a new IV as NOW as possible, the nurses tried for 30 minutes or so to get an IV into the baby. They had no success, which is not surprising considering how small and dehydrated she was. They asked us if we wanted to try, which I was not really jumping at the chance to do. The intern on call last night was busy with crashing babies in the new born unit, so in order to buy some time we put an NG tube in the baby and gave her some fluids that way. Though really not the most efficient way of rehydrating someone, it was a temporary fix until the intern could get to the ward and get an IV in. Today she was doing a little better, but the team is still not quite sure what's wrong with her: malaria vs sepsis vs meningitis -- so she's being treated for everything. She's also HIV positive and severely underweight, which will do her no favors in terms of getting better.

We waited around on the wards until the NG was in and the fluids running, and in the meantime we played with Diana and her new crib-mate Gideon. Gideon is not technically abandoned, but his mom is currently being treated on the psychiatric ward, so he's hanging out on Ward 4 for now. Diana stays up way to late at night (it was about 9 when we were there) and is such a stinker she doesn't let Gideon sleep either. She was obviously very tired, as she was being an absolute terror -- screaming when we played with her and screaming when we put her down -- but there's really no one to put her to bed, so how can she know when it's time for her to sleep? I eventually gave her my pen and a piece of paper, and she calmed down and started drawing, allowing Gideon to fall asleep (he was quite fussy as well) and Blessing, who's in the next crib over. We even helped out the nurses by feeding Blessing and changing all 3 babies, which I think they really appreciated.

I've come to realize over the past few weeks that the hardest thing for me when I leave will be leaving the Sally Test kids, especially the abandoned ones. It's so easy to get attached (#1 rule of pediatrics being not to get attached), but I don't really think of them as patients, as they are for the most part healthy. Every day I look forward to rounds being over, partially because rounds can be extremely painful, but mostly because I can go to Sally Test and see Diana, Kevin, Phillip, and the other babies. If on my last day in Eldoret, someone handed me any of the 3 of them (or all 3 of them) and said "take them with you" I'm pretty sure I would. Especially Diana -- she is an absolutely precious baby. Although we learned today that it is illegal to immigrate to the US if you are HIV+, which applies to HIV+ children being adopted in as well. I was appalled to learn this. I guess I'll just have to sneak in Diana. As hard as it is for me, it's really even worse for the kids, who have already been abandoned by the people who should love them most, and now their time at MTRH and later in an orphanage will see a whole slew of people who come in and out of their lives -- loving them dearly and then leaving them again. It's a hard thing for a little one to understand. It's a hard thing for ME to understand, how someone could ever leave their child.

But, I suppose I should just enjoy the time I do have with them, and hope that some way the love of strangers will be enough for them, though I somehow doubt it.

I went to the Rescue Center again today, with Priti, Hao, Rhonda (4th year med/peds resident from IU who came last week) and Jeremy (pharmacy student). Again, it was so great. Since it FINALLY stopped raining for a few hours, we got a tour of the compound, which was nice. We learned a little bit more about the Center: the funding comes from a collaboration of churches in Eldoret, and though it's not a lot of money, it does pay for some full-time staff including the nurse, as well as the dorms, the meals, and the uniforms for the school-aged kids. When the kids first come in they get 1-2 weeks of counseling and catch-up education (longer if needed) then if they show that they are going to stick around for awhile, the school-aged kids go to primary (elementary) school. While primary school is free, secondary school is not, so the older kids either have to find sponsors in Eldoret or abroad or they have to work odd jobs in order to go to school. As you might imagine, the cost is prohibitive so some, so not a lot of the street kids end up finishing school.

At any rate it was nice to learn about the facilites and the demographics of the kids that live there. There are about 150 kids at the Center at any one time, though they do tend to come and go. Quite a few of the 'older' girls (12 and up) tend to come in with their own babies, though there was only one girl there today with an infant. We talked about the logistics of HIV testing for the kids -- something that is completely necessary, as well as some other nuts and bolts things. It was a great visit. Most of the girls we saw today were quite healthy. There was one little girl about 10 who was hit in the arm with the blunt end of an axe some time ago, and now her arm is very contractured and painful. We tried to see if we could bring her to the hospital today for an XRAY, but a lot of the staff are out sick so there was no one to accompany her. They promised they would take her in tomorrow. There was also a little girl with daily headaches and blurred vision, with difficulty seeing the board in school. She really needs glasses which seems like such a simple thing. But here, nothing is really simple. She needs transportation and a chaparone to the ophthamology clinic. If/when she can get that, she needs to have the money to pay for the visit, which is only about 100 shillings, and any one of us would have paid it, but the really expensive thing is the glasses -- 3,000 shillings and up. And then she'd need yearly exams and new prescriptions, and kids tend to break expensive things anyway... so.... But, we're going to have her go to the clinic and just go from there. Certainly we can't let her go without glasses, as that's no way to live.

Jeremy got a list of the meds that are available at the Center (not very long) and he's going to look into how to get more. I think we'll try to start with the basics: anti-fungals for tinea (which ALL of the kids seem to have), de-worming medicines, some basic antibiotics, things like that. The other thing that the center could really, really use is a car, but I think that's a bigger project that will come some time down the road.

Today was a really good day, despite the continuing rain. Priti and I are currently making plans for a long weekend on the coast in Mombasa, then it's on to Masai Mara next weekend! The weekend after that, I'll be home. It's very hard to believe.

Uganda

2007-09-10T04:32:00.000-07:00

Sorry for the relative delay in posting. After getting back from Uganda yesterday I was exhausted, and the electricity has been out at IU house for awhile.

So, on to Uganda. Wait, first I should say that I watched "The Last King of Scotland" for the first time last week -- about the life of Ugandan dictator Idi Amin. This was not a good thing to do just before traveling to Uganda, but I went anyway. Everyone made it back without any major mishaps on the river, so that's a good thing. We left on Friday around noon (which is really 1:30 KT by the time we picked up people at 3 different locations, stopped at the bank, etc). There was quite a large group of us that went -- 5 IU people, 3 Utah people, 4 pharmacy people, 4 dutch people, and our Kenyan friend Ken. We filled 2 cars. The drive from Eldoret to Uganda was on a fairly nice road, so that part of the drive wasn't bad at all. When we got to the border, we first had to fill out paperwork on the Kenyan side to leave Kenya, got our passports stamped, etc. Then we drove across a bridge (that belonged to Kenya? Uganda? No man's land? Kenganda?) to the Ugandan side of the border, where we had to fill out more paperwork to enter Uganda, get our passports stamped again, and pay an entry fee. Which apparently used to be 30 dollars, 20 dollars for students, but last weekend they changed it to a flat 50 dollars for everyone. Great timing, eh.

At the border, as soon as our cars pulled up to the customs areas, we were immediately surrounded by loads of people trying to sell us thousands of things. Bananas, chapati, samosas, cokes, you name it, they were trying to sell it to us. Most of the vendors were kids. After saying no to their bananas, then their cokes, then their chapati, then their samosas (all of them offered them in that exact order, it was like they had a script), then they would start asking us to give them things. Pens and books were popular items to beg for, and when we said no to those, they would ask for footballs, soccer balls, and then drop the whole charade and just ask for money. One thing I will say is that they were quite persistent. They were somewhat disarming in that they were children (dirty, clearly poor children at that), but when you get down to it they were really quite manipulative and knew exactly what they were doing. I had a conversation with a little boy no older than 6 or 7 that went like this:

Little Boy: Can I ask you a question?
MO: Sure.
LB: Are you from America?
MO: Yes.
LB: I heard that your president eats children. Is that true?
MO: Uh... I don't think that's true.
LB: So George Bush doesn't eat children?
MO: I really don't think he does.
LB: Ok.

As hilariously funny as it was, I'm pretty sure that someone (American or otherwise) taught him to say that. And in thinking that's something most American's will find amusing/true he probably hoped I would buy something from him because I found him so funny.

At any rate, the drive from Eldoret to Uganda was only about 2 hours, so the bulk of our 6 hour drive was in Uganda. The scenery was of course, completely amazing, similar to Kenya, but a little flatter I think. I thought it was going to be a great remaining 4 hours, in that the road was by far the best I've yet been on in Africa. But, that was short lived as I should have expected, and we soon started passing ominous signs announcing "Jinja road restoration project, 5 km." And then we happened upon one of the worst roads I've yet been on in Africa (thought NOT worse than the road to and from Kakamega -- that one still wins the grand prize). It was a bouncy 4 hours, and I was quite sore afterwards, though I did manage to protect my cranium a little better than on the last trip. Due the road construction, we had to drive multiple detours on our way, and ended up driving through lots of little villages. Though this meant a longer overall drive, I don't think I'll ever get tired of seeing the various African homes and shops and the people that live and work in them. My favorite thing was this hut -- literally a small, one room hut with an enourmous (HUGE) satellite dish by the front door. The dish was actually larger than the house. I would have liked to see the TV it was connected to. I tried to take a picture, but... bumpy roads...

We got to our campsite in Jinja a little before dark. The site sits on a huge hill overlooking the Nile, so of course the first thing we did was take a ton of pictures of the Nile. Which really, looks like a river. A very LARGE river, mind you, but still a river. But I thought it was exciting, I won't deny it. We got our stuff moved into our rooms -- a large dorm-style room with bunk beds, one for boys and one for girls, got some dinner at the camp restaurant, then hung out at the bar for a little while before turning in to rest up for our big trip on Saturday.

On Saturday morning we were loaded into a large flat bed truck (really quite like a cattle truck) and driven the 15 minutes or so to the main rafting office. There they served us all breakfast (In addition to the 17 of us, there were various other groups doing the rafting trip -- about 60 people in total) and we got to watch a video of some previous rafting trips. Really I think it would have been better not to show us this BEFORE the trip, but no one punked out after seeing it, so I guess that's good. After breakfast, a brief introduction, and picking up our life jackets and helmets, we were loaded back on to the cattle trucks and driven another 15 minutes to the rafting drop site, where we were put into rafts of 7 people.

I was on a raft with Priti, Abby, Ken, Jeremy (pharmacy student), and 2 Dutch girls -- Gwen and Kirsten. Our guide's name was Paolo. After getting into the boat we went over basic rowing, commands, and some safety stuff in a smooth part of the river. Paolo tossed us out so we could learn how to float (not that difficult with a life jacket on) with our feet first and he flipped the raft so we would know what it was like to be under the raft. Well this is all well and good when you're floating lazily down calm water, but it's so much different once you're actually in the rapids.

Soon we came to our first rapid -- a class 5. (Rapids are graded from 1-6, with 1 being hardly more than a dip and 6 being suicidal). About 12 different times I thought we had flipped or were going to flip, but we managed to stay upright. Actually, our boat did very well before lunch, only tipping once, and even then only the people on the left side fell out. After about 3 hours of rafting, we had lunch on the boat, then geared up for the afternoon. Our boat's luck was quite different in the afternoon -- we got dumped at every single rapid. The very first rapid after lunch was called Jaws, and while it was "only" a grade 3, if you hit it just right, it will rocket you out of the boat. Of course we hit it just right, and all of us were immediately sucked down into this churning vortex of water. Now, Paolo had told us that we might get caught in some "minor whirlpools" and if that happend to remain calm and wait for it to spit us out, as we'd waste more oxygen by struggling. We were all stuck in this "minor" whirlpool, and we'd break the surface with only enough time to see the same panicked look mirrored on 6 other faces before getting sucked back down into the water. In reality it probably lasted no more than 30 seconds or so, but it seemed like much, much longer than that. Of all the rapids in the 7 hour trip, it was the only one where I really started to think.... hmm.... am I going to drown???? Eventually, FINALLLY, we got spit out of the rapid, found our boat, our guide, and our fellow rafters, and climbed back in. Quite shaken. We were glad our first falling into the water experience was not a grade 5 rapid, though we would experience that joy soon enough.

Our boat got dumped at least 5 or 6 more times after that, though thankfully the other times I popped immediately up to the surface. One time was even directly over an 8 foot waterfall, even though Paolo told us we wouldn't flip -- we flipped, and we were the only boat that did so. On the course of our 30 km trip down the Nile, we went through 5 grade 5s, 5 grade 4s, 3 grade 3s, a dozen or so 1s and 2s, and we even got to see 3 grade 6s. As in look at only, as you have to be certified (certifiable?) to raft a grade 6. One of the 6s was named "the dead Dutchman" -- I'll let everyone figure that one out for themselves. Needless to say our Dutch counterparts wanted to steer very clear of that rapid. The last 6 was followed immediately by the last rapid we rafted, a grade 5 called "The Bad Place." The rapid was such that it spanned the entire width of the river, so we had to get out and walk around the 6 part to where the 5 began. In the meantime we got to watch to of our Kayaking safety guides raft down the 6. And Holy. Goodness. It was absoutely insane. The 2nd kayaker got stuck upside down in a rapid, so had to kick off the kayak. Down the rapids flew the kayak, and we watched in horror as the water just tossed this guy around and around before he flew down the river, yards and yards away. We found out later that he broke his arm in the process.

After finishing the last rapid, we all hiked (barefoot, mind you) up a huge hill to where the trucks were waiting, and had a long, cold ride back to the campsite. We ate dinner, then got to watch the video of our trip that the company had been filming all day. It was actually quite shocking to watch people getting dumped and tossed about like rag dolls by the river (especially our boat!) and to think... WHY did I just do that??. But, I did by a copy of the DVD so my family can be as mortally terrified as I was :).

I have been white water rafting in the US a couple times, but this was a different experience altogether. The Nile is just so... HUGE, and we've gotten so much rain lateley that the rapids were.... well.... rapid, and just unbelievably enormous walls of water. Coming straight at you, on either side, behind you. But, the company did a very good job. The guides were all very experienced, the equipment in good condition. There was one boat with the most experienced guide by himself -- his job was to go to the bottom of the rapid ahead of everyone else and wait there with the safety equipment (including antivenom for the Nile snakes -- something I'm glad I found out about afterwards). Then the Kayakers would go down the rapid -- about 15 in all-- and every time I fell out of the boat there was at least 1 if not 2 waiting right there for me when I popped back up. But still, at times a rather harrowing experience. I'm so glad that I decided to go, but I don't know if it's something I would ever do again.

It was another early night on Saturday, being exhausted and quite sunburned, then we left about 10 on Sunday morning to commence the bumpy road back to Kenya. We had to do customs in reverse -- check out of Uganda, and back into Kenya, and tell the same children no to the same things they wanted us to buy. Needless to say, after getting rocketed out of a boat a half dozen times, then pulling myself back in, then a long, bumpy ride back to Kenya, I am rather sore today, though I still maintain it's worth the experience I had.

Today was my first day on the adult wards. Priti and I switched for the last 2 weeks we'll be working, just to get the experience of the other side while we're here. I definitely don't like it as much as I like peds (which further confirms my decision to go into peds), though it is interesting, and I'll never see this sort of pathology again, I'm sure. But, I made sure to spend time in Sally Test today playing with my friends; especially Diana and Kevin. Diana and I played a fun game of take-off-my-nametag-and-put-it-on-Diana-then-take-it-off-Diana-and-put-it-back-on-me that lasted for about 30 minutes. And when I walked in Kevin was actually laughing and squealing at the top of his lungs. He looked SO happy, and it was adorable. His walking is much better in just these few short days, and he's getting around very well all by himself now.

Other than that, really just planning on studying for the rest of the rainy afternoon (my boards coming up much sooner than I would like). And yes, it is still raining. Though I am assured by multiple Kenyans every day that the rain will be over "soon." No one can seem to say how soon, though. I think even the weather runs on Kenyan time.

Kwa herini!

Rescue Center

2007-09-06T07:39:00.001-07:00

Yesterday Hao took Priti and I to the Eldoret Rescue Center – the camp/school/home for the street kids of Eldoret. This is the place founded by the German missionary who rescued Frances, Mwangi, and Benson from the streets (see “Eldoret Street Kids” post). He has since moved to Nakuru and the center’s operations taken over by a Kenyan group (funding from Kenya? Germany? America? It’s not really clear).

The experience at the center was very interesting. We went for the afternoon to do checkups with the kids. Since we had a limited amount of time yesterday, we tried to see the kids who had the most urgent medical needs. The staff at the Rescue Center tried to triage the kids for us from most to least sick. We saw a lot of kids with chronic cough, most of them with simple URIs/colds from persistently damp conditions and little in the way of clothing. Unfortunately not much we could do for them, though it’s standard practice to prescribe antibiotics for colds in Kenya. We saw one boy with a horrible ear infection, one boy with costochondritis, one boy with chronic dermatitis. I saw Elvis, an 8 year old little boy who was dropped off at the Center 2 days ago by his mom. His legs were covered in deep gashes and he had a big laceration on his scalp. Apparently his mom had been beating him. The injuries on his legs really looked more like burns to me, but he said they were from being hit with something (a cane? Bat? The translator didn’t understand the word he was using). He had the sweetest face and the saddest eyes. All I really wanted to do was give him a big hug, and all I could think of was that line from The Green Mile, where Big John says that he’s tired, tired of people being ugly to each other. There’s not much we could do for his wounds, as the Rescue Center doesn’t have wound care supplies, so we just told him and the Center supervisors to keep them clean, dry, and covered as much as possible. His physical wounds will heal, but his psychological wounds…who knows?

As sad as it was to see children in such desperate situations, I really, really, really, really enjoyed the afternoon. I actually felt useful, QUITE useful, in that we were diagnosing mainly colds, aches and pains, and a few open wounds. This is stuff I actually know how to treat. I want to go back. We really only scratched the surface of the need there. We saw about 25 patients in our 2 ½ hours, which was only about half of the ones that were picked out to be seen. Which wasn’t nearly all of the boys, and we didn’t even see ANY of the girls at all. There is a full time nurse on staff at the Rescue Center, but she is very limited in the resources that she has available to her, and the staff there today were so appreciative that we had come. Hao wanted to go back in 2 weeks, but when she saw that Priti and I were so enthusiastic about it, she considered maybe going back next week.

I discussed the Rescue Center with Sarah Ellen Mamlin at dinner last night, and she had quite a bit of insightful and helpful input. IU used to do consistent weekly or bi-weekly clinics at the Rescue Center, but that fizzled out once AMPATH really got going and IU diverted more of its resources there. Which is fine, but I think (and Sarah Ellen wholeheartedly agrees) that IU has not really tapped the resources it has in its residents and students. I think the Rescue Center would be an ideal project for them. The residents that come here are senior-level residents with plenty of experience, and a lot of the stuff we would see the students would be able to diagnose and manage. And again, it would make the students and residents feel very useful. I know our medical directors are very busy, which is part of the reason that the Rescue Center clinic fell by the wayside, but this is something that I don’t think necessarily needs full-time staffing by an attending physician. Except in the unusual or rare cases, I think we underlings would do a fine job. The clinic is something that Sarah Ellen would really like to see started again, and I’m hoping I can sort of help out with that implementation in my remaining weeks here. We would have to find out how to get certain resources that we need, like medications and supplies, etc. Another big part would clearly have to be HIV testing, but Sarah Ellen thought we could work out something with AMPATH to get the tests for free or at greatly reduced price. I’ll have to talk to my friendly neighborhood pharmacist (as Sonak likes to call himself) about that one. Really I just see so much potential here to do something really, really good for a lot of children; children who’ve never really had anyone care about them. And apart from finding funds to make the program sustainable, it really wouldn’t be that hard.

I’m pretty bummed that this visit took place so late into my time here, as this is something I could get totally involved in.

The morning was interesting too. Wednesdays I spend in Module 4, the pediatric clinic at AMPATH. We saw a few patients early on, but then spent most of our time with Sophia. Sophia is a 12 year old little girl, not really sure how long ago she was diagnosed with HIV. She was started on antiretrovirals in the middle of July sometime, then was seen in clinic about 2 weeks ago with complaints of generalized body swelling. I talked to Hao about Sophia, and it turns out that Hao actually saw here when she was in in August. At that time, she had “mild facial swelling.” Well today, this poor girl. Her face was swollen she could barely open her eyes, and she had so much fluid in her legs that her skin was pulled taught. When I pushed on them to check for pitting edema, fluid actually oozed from her skin. Since being here 2 weeks ago, she has gained 5 kilograms (over 10 pounds) of fluid. When someone has this much fluid retention, it’s due to either a cardiac problem, a liver problem, or a kidney problem. Her heart sounded fine, and her chest xray was normal. On exam, her liver was not enlarged, and all of her liver labs came back normal. Her stepmom did say that she’s had some decreased urine output, but her kidney labs were all normal, and her electrolytes were normal. A time when you actually want something to be abnormal so you know the diagnosis and how to treat it. So Victor, the clinical officer, called one of the consultants – the consultant that saw her 2 weeks ago. She said that it’s probably due to one of the antiretrovirals that got started in July, so we should take her off of them completely and see her again in a few weeks. Victor looked quite dubious when he got off of the phone, and asked me what I thought we should do. I said, admit her. So, we did. Sophia also has a huge mass on her tongue that is most likely Kaposi’s Sarcoma (KS) – a type of malignancy that HIV patients get frequently; and is actually an AIDS-defining illness. She also had multiple nodules of likely KS around her ear. So not only was her face completely swollen, it was also very bumpy. This poor girl was not at all comfortable. Even though the other team was admitting tonight, hopefully she’ll come to our ward because she’ll need chemo for her KS.

So the big trip in the works for this weekend is to Uganda for white water rafting on the Nile. Which, as totally awesome as that sounds, I’m thinking about not going. Though I finally admitted this to Mike tonight, and he told me I had to go. And, as I definitely do everything Mike tells me…
My main concerns are these: It’s expensive. Though really, probably my only chance to ever do something like this. Really my only chance to do it, as they’re damming this part of the Nile in a few weeks, so the company that does the rafting will have to locate elsewhere. Another concern is of course, safety. Not that I’m a total nervous Nellie, but it is generally better to do these types of things when easy evacuation and trauma ERs are in ready supply. But, I found out today that you can choose an “easy” “medium” or “hard” raft in terms of rapids. IF I go (IF IF IF) I will be on the easy raft. The other thing is that I’ve been white water rafting several times in America, and while it’s been fun, it’s not like the most amazing thing I’ve ever done. (Though I did enjoy my first trip, as I was on the same raft as a boy that I liked very very much…) I’d rather spend the money on Masai Mara next weekend (which WILL be one of the most amazing things I’ve ever done), plus I always thought this would be something that Mike and I would do together, so that’s kind of a bummer. Really, I just keep going around and around about it, and I haven’t decided yet. It /would/ be a lot of fun, and definitely a once in a lifetime experience. My deadline for decision is Thursday morning.

I’ll keep everyone updated.

*And here is the update* Since writing this post I have decided to go to Uganda this weekend. Prayers much appreciated.

Watoto...

2007-09-04T03:43:00.000-07:00

...means "children" in swahili.

Unlike the beginning of my rotation here, the past week or so, we've had relatively few patients on Ward 3 (meaning only 2 patients per bed instead of 3 or 4). So, we've been getting done with rounds fairly early and I've been spending a lot more time in the Sally Test pediatric center with the kids.

Sally Test is basically a very large classroom on the pediatric side of the hospital. It was built as a place for the kids in the hospital to come and play, read stories, have snacks, etc. It's also where we have parent education classes every Monday and Friday. (I did yet another one yesterday, on sickle cell disease. Luckily I had just presented this topic to my ward team, so I had recently read about it.) It's fully stocked with all kinds of books and toys, and there's even a very nice outside area with jungle gyms and swings where the kids can go play. So yeah, the medicine is nice and all, but I think I could just play with babies for the next 3 1/2 weeks. Some of our more colorful characters:

Diana. Diana is 2 1/2 and EVERYONE in the hospital knows here. She is HIV positive, abandoned, malnourished, and had been living at MTRH long before I got here. She is on Lorein's side of the pediatric wards, and Lorein fell in love with Diana the moment she saw her, so we've all been getting daily Diana updates. When I first met her, she was the saddest little baby I had ever seen. She would just sit in her crib all day, staring out into nothing. Not interacting, not talking, not walking, no normal toddler stuff. Well, since she's been getting appropriate nutrition and medical care, she's turned into a completely different kid. She refuses to stay in her crib anymore, and spends her whole day toddling around Sally Test playing, eating, and generally getting spoiled. Whenever anyone new walks in, she runs up to them and cries until she is picked up. She has just recently learned to walk, and she is just fascinated with her newly-found independence. She walks around and around and around Sally Test, no destination in particular, she just loves to walk. I played with Diana for almost 2 hours today, and she is just the most precious baby. Very curious, very playful, and very demanding; she thinks she's much bigger than she is (she likes to try climbing to the top of the big kids' slide by herself). This is a baby who could really use a good home. I hope she finds one. (The picture above is of me and Diana in Sally Test).

Kevin. I've mentioned Kevin before. He was like Diana was at first, so sad, so withdrawn, just sitting in his crib all day. Well, on Monday, as soon as I walked into the wards, I noticed that someone was singing a gibberish song at the top of their lungs. It was Kevin. He was standing up in his crib, naked as a jaybird, just singing as loud as he could. He was also jumping up and down and banging the crib against the wall, then scooting it away from the wall (reminded me of something Brant used to do all the time as a kid!). Clearly he's feeling much better. After being relieved of various parasites and getting regular meals, who can blame him. So Kevin has been accompanying his brother Phillip to Sally Test for 2 days now. Like Diana, he is still much delayed in the areas of walking and speech, though he was motoring around pretty good today when he had someone to hang on to him. (It's a rough job, but somebody's got to do it). He and I played stacking blocks today. We would stack them way high then knock them down. A very amusing game for a 3 year old. I'll have to take my camera back to the hospital with me, so I can get some pictures of new & improved Happy Kevin.

Phillip, Kevin's 5 year old brother. This kid is Ornery with a capital Rotten. He just LOVES to pick on his brother. Tease him, pinch him, steal his toys -- normal brother stuff. However, he gets VERY angry whenever anyone else picks on Kevin. Today when we were on our way in from the playground, Kevin fell down. Phillip turned around, helped him up, and held his hand as they both walked back into Sally Test together. It was so adorable I almost cried. Again, 2 kids who would do superbly in a good home. I hope they can get placed together.

There are also quite a few infants -- all abandoned -- that live in Sally Test. "My" baby is Zawadi, which means "gift" in swahili. He's 6 months old and cute as a button. Priti's baby is Blessing; she's a little older, maybe 2 months. So many babies that need good, permanent homes.

We also lost a patient overnight. His name was James, he was 8 and he had Hodkin's lymphoma. Usually kids with Hodkin's do pretty well, but he had "lymphocyte depleted" type Hodgkin's, which usually has a pretty poor prognosis. He'd been here at least as long as I have, gotten multiple rounds of chemo, but just was not responding. He was severely wasted and no longer eating or drinking, in addition to having jaundice and a huge mass in his abdomen that was probably metastatic disease. Yesterday we had just begun the discussion of sending him home with morphine, but he died before anything was settled. A very sad situation, especially for his dad, who was (of course) a very nice guy. But, this is another one of those kids who suffered so much, and we can only rejoice now that his suffering is over.

Crazy Pills

2007-09-01T03:25:00.000-07:00

At one of the hot springs at Lake Bogoria. The smile is fake, as you may notice. I was willing Lorein to take the picture as fast as possible, as the hot springs were well, HOT. And boiling water and steam splashing on you on a 90+ degree day is not the most pleasant feeling in the world.

Ever since hitting my head on the matatu roof last weekend, I've had a headache. No big surprise. A few days ago I started being very dizzy at all times of the day, and it got to the point in Friday that my vision was getting blurry and I had to sit down or pass out. That being just as scary as it sounds, I talked to Robert about it, and he did a neuro exam. Which was normal, by the way.

So we were talking about what it could be (dehydration, viral prodrome, etc) and I asked if it could be related to the malaria prophylaxis I'm taking (Mefloquine/Larium). So, we went to his house and read the package insert for side effects, and pretty much anything you can ever have was there. The main side effects are neuropsychiatric -- insane dreams, anxiety, depression, feelings of impending doom, irritability, emotional lability, insomnia, and a sense of dissociation from your body. Oh, and also dizziness/vertigo is on there, as well as nausea, vomiting, diarrhea, muscle aches... the list was literally a page long. So... I'm not taking Mefloquine anymore. And looking back on it now, I think a lot of things I've been experiencing in the last week or so are due to the Mefloquine. Definitely the insomnia and crazy dreams (though that could also be due to the loud music played in the hostel 24/7). And all day yesterday I felt like I was walking around in a fog. I was walking and talking normally, but it felt like I was /watching/ myself do it instead of actually being the person that did it, if that makes any sense at all. Sort of an out of body experience. Robert's whole family was on Mefloquine when they first got here, but now all but the baby aren't taking it anymore, because he said it made them all crazy. So now I'm off the crazy pills too, and hopefully this dizziness thing will resolve, though it's not much better today If it's not getting better in a week or so, Robert wants me to have a head CT, though I'm not really jumping at the prospect of exposing my brain to all that radiation. I sometimes wonder if it would just be better to get malaria than to go through all the weird and uncomfortable side effects that all malaria prophylaxis seems to have.

Priti and I got up early this morning and walked 45 minutes to the Imani workshop with 5 of the 6 Purdue pharmacy students that arrived on Wednesday (the 6th one being a boy, and not so keen on the idea of bag/skirt/jewelry shopping with 7 girls). It was a very nice morning. We were ASSURED that the dressmaker would be there today, so we could get measured for our skirts. Well, we get there, and the workshop is not even open. I was more than a little peeved. On our way back, a guy on a bike told us that he worked there and would open if we wanted to go shopping. Well of course we said yes. He even called in the dressmaker to measure us, since we had come all the way out there. So, I finally got measured for my skirt (and I ordered quite a few other gifts), and it will be ready on Thursday. I'm very excited.

Afterwards Priti and I stopped at Ukwala (local grocery store) to buy some gifts for a kids' birthday party we were invited to. Then back to the hostel, then to IU house, then to the party, then back to IU house. I've walked a lot today. The party was fun -- it was for 2 of Robert & Hao's 3 kids, who turn 4 and 2 on Sunday and Monday, respecitively. It was actually at Shawn's house, which is very nice and has a pool. Robert and Hao's kids are adorable, and there were all sorts of children there -- white, African, Indian... it was fun to see them all playing together. For some reason the party made me really miss Mike, more than I have yet, I think. I'm not sure if it's because there were gobs of adorable families there, or maybe being here has made me realize even more how important your family is. Life here is so tenuous, and people here hold onto each other even tighter, because you must never know... I really think it's also because football season is starting in the US. As weird as that sounds, I really enjoy the fall and football season, not only is it just a really fun time, but also it inevitably reminds me of when Mike and I first met, as well as the early and exciting days of our friendship and relationship. Though now we're just a boring married couple, right hon?

The rest of the weekend is filled with strenuous plans to relax and bum around town. There's a restaurant/amusment park (yes, actually an amusement park -- we've seen some of the "rides" and you couldn't pay me enough to get on those things. It makes Fun Spot look like Disney World) close by that apparently has a hut and informative display on all of the different tribes in Kenya, so we'll probably go see that tomorrow. I think it should be interesting. There's not nearly as much tribal unrest or tribalism here as there used to be, especially in the big cities and especially in my peer generation. However, everyone here knows exactly what tribe they belong to, and Africans can generally tell tribes by appearance and last name, so I think that's interesting. Otherwise...probably not much. As nice as travelling is, it's also nice to have weekends off.

Kwa Herini!

Marion

2007-08-31T03:48:00.000-07:00

I've been thinking a lot about Marion lately, but I don't think I've yet blogged about her. She's a little 5 year old girl who was admitted on my very first day in the wards, about 4 weeks ago. She presented with bone pains, fatigue, and weight loss. From her lab work, she had terrible anemia and low platelet counts, and during her stay on Upendo ward we had a horrible time controlling spontaneous bleeding from her gums, nose, etc.

This poor little girl went through hell. Suspecting some sort of leukemia, we attempted 3 bone marrow biopsies on her that were "dry" (no marrow). Not knowing what else to do, we did an excisional biopsy of a huge lymph node she had under her chin. The next day, the pathologist was finally able to get a succesful bone marrow biopsy. Waiting around for the results, she just kept getting worse and worse. Eventually she needed oxygen support, and we were continuously trasfusing either blood or platelets. Her lymph node biopsy came back as lymphoma, but her bone marrow showed no malignant cells -- really it didn't show any cells, so the pathologist called it aplastic anemia. Our consultant suspected that she had a leukemic lymphoma, that is a lymphoma that had infiltrated the bone marrow and caused a leukemia-type picture. Even though we weren't sure of the diagnosis, the team decided it would be best to start on cytotoxics (chemo) anyway, as she was so sick. The last time I saw her was yesterday. Her mother, crying, was holding her, as Marion looked like she was literally on the brink of death. Well, she was. We got to the wards today, and the intern said that she coded right after rounds got over.

I really liked this little girl (who was my patient), and her mom, who was SO nice. So, it is sad. But at the same time, I don't think prolonging her life with chemo and its horrible side effects would have been that great for Marion either. It's always sad when a child dies. But, when a child is no longer suffering, I think that's a blessing. And this little girl suffered more than any other child on the ward, with countless sticks for biopsies, blood draws, and transfusions. It got to the point that she screamed whenever anyone besides her mother touched her. I'm less grieved and more retrospective about this death, due in part to a very encouraging email I got from Emily today, and also due in part to the fact that our team worked very, very hard to figure out what was wrong with Marion. In the end, I really think we did all that we could have. Even in the United States would likely have been a little girl that didn't survive.

Ups and Downs

2007-08-29T04:08:00.000-07:00

One more picture! This one is of me at the Crying Stone on the way back from Kakamega.

It's been a relative blogging dry spell (really only 3 days), but I've been unbelievably busy lately. I didn't /really/ want to be as busy in Kenya as I am at home -- I was looking forward to it as a sort of vacation. But, alas. I had 2 presentations to give on Monday, and the pediatric student lectures have really revved up now -- we usually have 3 or 4 on a given afternoon. I don't necessarily make it to /all/ of them, though I do try to make most. If I did go to morning rounds, afternoon lectures, and admit patients at night, I would never have time for laundry, reading, going to the bank, etc. You know, normal life. I don't know HOW the Kenyan medical students do it -- as they are required to be at all lectures and have read on the topic ahead of time. Joy, one of the Kenyan students on my team (who I like a WHOLE lot) told me she hasn't done laundry in 4 weeks. Too many things to do and not enough time -- yet another thing about medicine that I've found is universal.

Dayna left on Monday. It's kinda weird that she's not here. When Priti and I first got here, we thought we would be sharing a room at the hostel, then when Dayna left one of us could move into her room. I may have told this story already, but about a week ago, Shawn the IU house administrator told me that actually two Utah students were coming as soon as Dayna left, and would be moving into the hostel. Two girls. Ok, I guess that's fine. Well, Shawn called us early Monday morning to say that -- whoops -- the 2 students from Utah were actually a male and a female, so they would each be taking one of the hostel rooms and Priti and I would be moving back to IU house. Oh and by the way be ready to move at lunchtime today. Sure, no problem. Let's frantically pack all of our stuff and try to round in the morning. So... we were set to go, when Shawn called us yet again in the afternoon to say, hey, it makes more sense to have Natalie (new Utah student) move into the empty room, Teanu (new Utah student) stay at IU house, and Priti and I just stay put. (That was my EXACT thought when he called us that morning at 7, but I wasn't about to complain about moving back to warm showers, big rooms, and internet access). In the end it's probably for the best, because when we go back to admit at night it's much easier to walk across the street than to take a taxi from IU house to MTRH and back again. It's also nice to live with the other students, especially since we know many of them now and have made friends. Plus, it's weird to try to make yourself part of a team and live as a Kenyan medical student if the place you actually live is much better than where they do.

I spent today in "Module 4" -- ie the pediatric AMPATH clinic on MTRH campus. (Nothing to do with HIV/AIDS is actually called that here, as I've learned. People use a lot of euphemisms like "exposed" "seropositive" "ISS positive" "DCT positive" "been to room 54/Module 4, etc." Which I think is too bad. Because if healthcare professionals can't even say HIV/AIDS, how can they expect their patients to? A good example of the stigma that AMPATH is still fighting to eradicate). The clinic was pretty fun. Most of the kids were healthy little people, who I got to play with while the clinical officer and the mother spoke in Swahili. I was surprised that so many of the children aged 11 to 14 or so came by themselves. Many of them were orphans who lived with their "aunties" (could be a relative or just caretaker) who had to work or take care of their own 5 children. I just cannot fathom children having the presence of mind to keep clinic appointments, get there by themselves, and then communicate in a mature way with the CO. Not to mention have the presence of mind to self-administer something as complex as antiretroviral therapy and the various prophylactic drugs that they're on. Yet, I saw many examples of it today. I suppose that growing up hard makes you grow up fast. And of course, it was nice to get out of the wards today. It can honestly be such a depressing place.

Right now we are taking care of two abandoned little boys -- brothers, ages 3 and 5. The history is a little fuzzy, but apparently the landlord (or possibly a neighbor?) of the house the boys lived in heard them crying off and on for a few days. Eventually he went over to the house, looked in a window, and found them locked inside. He broke in, and no one else was home. Who knows how long they had been in there by themselves? They were taken to a childrens' social services type place, then immediately to MTRH for de-worming, nutrition, not to mention treatment for some sort of TERRIBLE skin rash/infection they have on their hands and feet. The Kenyans keep calling it "chiggers" but I'm thinking it's something else. It looks really bad. A few days ago, we found out their names: Philip and Kevin. So, I immediately took to them even more than I had already. Since coming and getting adequate food and water, Phillip the 5 year old has turned into a real crazy kid. He's constantly climbing out of the crib that he and his brother share and running all over the ward like a maniac, "rounding" with us, stealing things out of our pockets, trying to be goofy to get us to laugh -- which often works. He's actually really funny, and very smart too, and he likes to spend time playing with the other kids in Sally Test. Kevin, the little one, is a different story. He's the saddest little boy I've ever seen. He never gets out of the crib unless someone takes him out. Most of the time he just sits in the crib, staring with the saddest face I've ever seen. No matter how we try, we can't get him to smile. When he's in Sally Test, he just sits there with the same slumped posture and defeated face, watching the other kids play but never joining in. It's the saddest thing. Who knows what kids can remember, especially at such a young age, but being abandoned by your parents clearly has a profound and lasting psychological effect.

We also have Enock, a 5 year old boy with Burkitt's Lymphoma (VERY common here -- a cancer caused by the EBV virus [same virus that causes mono]). He was diagnosed in January, got some chemo but was then lost to follow up like so many of our patients. When he came back he had horrible disease, which this time did not respond to treatment. Now he's just getting palliative care, which includes morphine and low-dose chemo. The chemo is making him so ill, so a bunch of us are pushing to send him home with generous amounts of morphine, but for some reason he's still here. Everyone really likes Enock, because he's always in Sally Test, attempting to play and smile, even though he's the sickest kid there by far.

I've been here for 4 weeks -- halfway done already. It's so hard to believe. Though I will be so excited to get back to my family and friends, I can see already that I'm going to miss Kenya, despite its many problems. For sure I will be back someday.

Baringo and Bogoria

2007-08-26T10:16:00.000-07:00

What a weekend. Let's see if I can get this all out.

We left for the Rift Valley at 6:30 Saturday morning (7am KT). The valley stretches north to south along the length of Kenya, and is home to 6 spectacular lakes: Turkana, Baringo, Bogoria, Nakuru, Elmenteita, and Naivasha. Our destination on Saturday was Lake Baringo.

I don't know how many different ways I can try to describe the landscape here, but suffice it to say our drive there was beautiful. We hired Ashley to drive us again this weekend, and he was very good about pointing things out along the way and letting us stop and take pictures. Our drive took us out north of town, where we soon found ourselves driving along the rim of the Kerio Valley -- the Cherangani Hills and Tugen Hills on either side. There were several vista points that we stopped at along the way to take (a bunch of) gorgeous pictures of the sun rising over the hills, the valley sprawled out below. The drive itself was less than ideal -- lots and lots of steep, hairpin turns on a pot-hole filled road. I had to concentrate very hard on not being ill. At one point Ashley took a speed bump at full speed, I flew up and hit my head on the celining of the matatu and completely hyperextended my neck. The only very bad thing about this weekend was that I spent it with a headache and feeling like I'd been in a car accident.

The drive to Baringo was about 3 hours. Just outside the lake entrance, we stopped in a little town and picked up a Kenyan named Douglas, who was apparently educated at IU and Shawn (from the IU house office) had called to be our guide for the weekend. Ok, fine. Never know who you'll meet in Kenya. It's a good thing he was with us, though, as we soon found out. Apparently about 5 years ago the road into Lake Baringo was completely washed out by a huge rainstorm. Sure enough, where the road should have been, was a huge pile of rocks and dirt about the height of the matatu. So, we had to go onto a worn dirt path, and pretty soon we come to a river. Douglas was able to navigate us across the river pretty well, but I was holding my breath and white-knuckle-ing it the whole time. Luckily the river was considered "low" at the time. After the great fording of the river, we get back on the real road and get to the lake entrance; drive down to the jetty, where a boat (basically a canoe with a 30 horsepower motor on it) was to take us to the island we were staying on.

The boat ride out to Ol Kokwe island was spectacular. It actually reminded me a lot of Lake Tahoe. The lake itself is huge, at least 15 km long and 10 km wide, the water is completely brown from the inflow of river silt, and it is rare in that it is a freshwater lake -- most of the other Rift Valley lakes are salt water. It is also completely surrounded by mountains in every direction, so the contrast of the landscape was just gorgeous. There are 7 islands in Lake Baringo -- only 2 of them inhabited, and we were heading for Island Camp Baringo on the southern tip of Ol Kokwe island -- smack dab in the middle of the lake. It was about a 15 minute boat ride out there, and we loved every minute of it.

When we docked at the Camp, we were immediately greeted by porters to carry our bags and the owner/manager with glasses of fresh pineapple juice. (I should mention that we decided to go for the high end place this weekend, in the name of relaxation and in honor of Dayna leaving tomorrow). We were shown to our tents, which really weren't much like tents at all. Well, they were /actually/ large tents, they looked like about 15 person tents in reality, but they were outfitted very nicely for 2 people, with 2 actual beds, 2 tables, and connected to the back was a cement building that was a REAL bathroom with hot running water. Our tents each had an entry way area with chairs to sit in that faced the lake -- the view was spectacular.

So, the 6 of us got settled in and went about the difficult business of lounging about the pool. The southern part of the island is basically one big hill, with the tents/bandas spread out stepwise up it, and the pool and clubhouse being at the very top of the hill. It was an amazing feeling to swim in the pool, at the top of the island, and be able to look out and see the lake below, the mountains beyond. Big surprise, we took a ton of pictures. After a few hours at the pool, it was time for lunch, which was delicious, and SO much food it was unbelievable. Then a few more hours at the pool, before Douglas met us to go on a short walk through the village on the other side of the hill. In theory this sounded like a good idea, but I was wrong.

From the moment we set foot in the village, it was clear that they were expecting us. Not in itself a bad thing, but we were immediately set upon by children and other villagers telling us over and over again about the 700-plus impovereshed villagers on Ol Kokwe island, whose only source of income is from selling things to tourists. Everything just seemed so...played up, dramatized even. They couldn't afford motors for their boats (oh yeah, except that one we saw like 10 minutes later) or walls for their church, etc etc. They were friendly, for sure, but overly so, I thought. It was just so obvious that they wanted, expected something in return for walking through their village, whether it was buying the necklaces, etc that they were selling (and carried along beside us as we walked) or even Abby getting asked by a man to be his sponsor. Their expectations were so apparent, they were tangible - you could feel them in the air. The whole thing just seemed SO contrived -- even the cats and dogs ran up to us begging for food! Not that I thought their poverty was made up; no, that was quite apparent. Shabby one-room huts, dirty little children in tattered clothing or nothing at all, genuine looks of desperation on the womens' faces. No, that was real. So real. They told us it was ok to take pictures, but I really just couldn't. Some things can't be captured on film, and other things shouldn't.

In the end, we hightailed it out of there pretty quickly. I didn't buy anything. Who knows, maybe I'm just too much of a cynic. Maybe buying something from the village /would/ have been the right thing to do. They very clearly needed the money. How is it, though, that I can feel like I was used by people who have universes less than I do? Is that a selfish way to feel? I really struggled with the whole situation after we got back. Was my denying them anything in return for their "hospitality" a basic injustice and a cruelty toward them? Did I, in fact, owe them something after all? We are told not to cling to earthly treasures, but to store up our treasures in Heaven. But then, aren't we also told to "do to the least of these"? I just don't like the feeling taht every encounter or relationship here is heavy laden with expectations and pre-conceptions about me as a Westerner, right from the outset. But show fault is this? Is it the Kenyans' fault for expecting so much from our white skin? Or is it our fault -- the West's -- as we flaunt our wealth everywhere, exporting our culture and modern ways? No doubt these poor people have had ample opportunity to witness the ugly side of rich Westerners.

So what, exactly, is the answer? SHOULD I have given money to the villagers? If yes, does that mean that the answer to 3rd world poverty is tourism? Should we all travel around Africa, etc spending our money? Something tells me no, that the solution to poverty is not just money. It is such a complex problem, I think, so too is the answer. Besides, I believe that all people have some intrinsic amount of pride, and I know I would not like to pander to the wealthy as a way of living. How could I think so ill of these people who wanted my shillings, as I sat atop my Ivory White Tower (literally -- the Camp [full of white people] sat atop the hill overlooking the village) of luxury, with more food than most see in a month, the sound of the generator that gave me electricity and a warm shower drowning out the sounds of the evening? We've set ourselves as gods above them, in a way, so how can I be surprised when they attempt to gain some advantage from that? Who knows, maybe I was just so uncomfortable sitting there in my absolute luxury, pondering these questions, that what I was really upset about was me.

At any rate, after we left the village we swam for just a little bit more, as all of a sudden a HUGE storm rolled in across the lake. The wind was whipping around us, and from the top of the hill we could look out over the lake and see the storm clouds pouring rain into Baringo, coming directly at us. There was even a rainbow. The storm was short lived, then it was time for dinner. At the pool, where there were tents and candle-lit tables set up, and the most amazing barbecue I have ever been to. Sitting with 5 new friends, eating fresh foods from the island, and looking at the moon behind the mountains, shining over Lake Baringo in Kenya. It was a nice moment.

We woke up at 6 this morning to go on a sunrise boat ride around the lake with Douglas. Fantastic, all around. We bought some fish from a local villager, Douglas stuffed them with balsa wood so they would float, then we drove around the islands, searching the cliffs for eagles. When we found one, Douglas would whistle very loudly, launch the fish into the water, and here would come the eagle -- soaring right over our heads, dipping down gracefully into the water to grab the fish, then back up to the perch for breakfast. It was unbelievable. I got 3 great pictures of eagles skimming the water and even one video. After we fed the eagles, we got sort of a general tour of the lake, and we drove around the only other inhabited island -- Parmalok Island. Also called Teddy Bear Island, because it looks like a teddy bear floating on his back in the water. Douglas told us that one man lives there with his 5 wives and 28 children, which started an interesting conversation about polygamy and dowrys in Kenya. Being somewhat pigheaded and being with 6 girls, Douglas almost got tossed in the water several times. Apparently, if a man wants to marry an educated woman, he needs to give her father about 8 cows (cows not being cheap, about 10,000 kSH each). But, if he wants to marry an UNeducated woman, he needs to come up with 24 cows. The logic behind it is that uneducated women are more likely to stay home, raise the children, help on the farm, etc etc. Which makes sense. But, Douglas said it's also because all educated women do is spend their husbands' money on makeup and clothes. Cue time number 1 of Douglas almost being pushed into the water. This led to more interesting conversation, and I decided it might be a good idea to ask Mike how many cows he thinks I'M worth. So... what do you think honey? 8 cows? 24 cows? More? I'll give you awhile to think about it. I expect an answer when I get back.

After the islands, we went in search of hippo. Which we found! We maintained a respectable distance, as hippos are quite dangerous and territorial, but I got some great pictures of their pink little ears and noses poking out above the water. We also saw 3 or so crocodiles, but apparently they are quite "shy" and wary of humans, so they maintained a respectable distance from US, which I appreciated. The other wildlife we saw was amazing -- the birds. The lake was chock-full of them, of all sizes and colors. At the camp they are so acclimated to humans they will come and perch all around your table while you eat, waiting for crumbs to fall. I got some great pictures of various birds as well.

After our lake tour, we got back to camp in time for delicious breakfast, then we put our minds again to the great task of swimming and sunbathing until lunch. After lunch, we packed up and got back on a boat for the mainland. We met Ashley at the Jetty, where he proceeded to take us the 45 minutes or so to Lake Bogoria.

Lake Bogoria is actually a natural reserve run by the government, so it was just teeming with wildlife. We saw ostriches, zebra, dik-diks (the smallest kind of antelope), antelope, gazelles, warthogs, and some monkeys. The most amazing thing about the lake was its flamingo population. We drove the length of the lake, which took about 40 minutes itself, and the shoreline was completely lined with flamingos. They were beautiful! Every now and then a group would take off, all in a single-file line, and wherever the leader went, the rest would follow, up, down, up, down, then landing again elsewhere in the lake. The other main attraction of Bogoria is the hot springs, a row of about 5 or so geysers of hot water. And I mean hot. This is a popular place to picnic, especially on Sunday, and many people were there cooking their lunch in the springs. We had brought along eggs and potatos, which we put in a bag and cooked in the spring. It was fun.

After eggs and potatos, it was time to head back to Eldoret, which was another beautiful yet hair raising ride through the mountains, and we got back about an hour after dark. I am now at IU house, in the process of working on one of two presentations that I have to give tomorrow. Not the best timing, but well worth the price of the fantastic weekend I had.

Kwa Herini!

PICTURES!!

2007-08-24T04:12:00.000-07:00

Ok, maybe more like pictURE, as the internet is being finicky owing to the massive rain/hail storm we're currently experiencing. I loaded all of my pictures up to now (all 250 of them) onto a computer at IU house, and I really wanted to post them all onto my kodak site, but... the connection here is so slow that it took over an hour to upload 20 of them... so I'll have to wait to do a full picture expose when I get home. For now I'll just put this one up -- it's me at the top of the mountain in Kakamega. Notice how dirty my pants are!

Plans are set for the weekend -- We'll be staying at a nice resort/hotel on an island in the middle of Lake Baringo, spending the day Saturday at Baringo and Sunday at Lake Bogoria. We decided to save money and only stay for one night, so we're leaving tomorrow morning and coming back Sunday. This way we can stay at the really nice hotel that has a swimming pool, etc. I'm excited. I'm sure there will be fun stories (and 100s more pictures) after the weekend is over.

Perspective in Mosoriot

2007-08-22T08:16:00.000-07:00

Perspective in Mosoriot

Today I went to the AMPATH clinic in Mosoriot with Dr. Mamlin. This came none too soon, as the wards have really been starting to wear on me, and with Patel and 2 other kids dying, I really needed a break. It was great to get out of the city and drive through the countryside. The scenery here is completely beautiful. I could take thousands of pictures and never quite capture it, I think. Every time I look at it, I can’t help but think “I wish the people I loved could see this.”

So, the Mosoriot clinic. It was great. I’m so glad that I went. When we first got there this morning, I got a little tour of the place. It’s a government rural health clinic, so there’s a lot of different services there every day – OB/GYN, General practice, peds, etc. There’s even a very small 6 bed “hospital” (3 beds on the male side, 3 beds on the female side) as well as a mess hall and a dormitory. Mosoriot was the very first place that Dr. Mamlin started an AMPATH clinic. First, maybe I should back up and explain a little more about AMPATH. It stands for “Academic Model for the Prevention and Treatment of HIV/AIDS.” Back in 1982, IU School of Medicine was looking for a foreign medical school to have an exchange with. It took several years of looking, but eventually Moi Teaching and Referral Hospital (MTRH) in Eldoret was chosen. The program continued as just a simple US/Kenya faculty, resident, and student exchange for a few years. But, this was about the time that HIV/AIDS was becoming a true and recognized epidemic in Sub-Saharan Africa. The IU faculty and residents on the wards felt powerless as literally dozens of people died every day from HIV/AIDS. As the story goes, Dr. Mamlin was rounding with his team one day, when one of the Kenyan medical students kept leaving rounds and reappearing. Eventually Dr. Mamlin asked him where he kept going, and the student replied that his friend and fellow medical student was very sick in a bed in the other ward, and he had just recently been diagnosed with AIDS. Dr. Mamlin and the rest of the faculty realized that an exchange was worthless if they were not addressing the epidemic disease right in front of them – a disease that they saw could affect anyone. So, AMPATH was born.
At its minimum, the program is two-fold – addressing the prevention of HIV/AIDS transmission, as well as treating those who have the disease. But it’s really so much more than that. AMPATH, over the years, has attempted to address the AIDS epidemic as a whole. One major component is through education, attempting to reduce disease stigma and therefore compelling more people to get tested. Another huge part of the program is food security through various AMPATH farms and the Family Preservation Initiative (FPI). If a patient cannot afford food for his/her family, or spends all of their energy in the acquisition of that food, there is no hope of them being compliant with their antiretroviral therapy. So, AMPATH has attempted to address this major facet of noncompliance. The other major issue with treatment compliance is transportation. 150 kSH for a round-trip matutu trip to Eldoret is out of the reach of so many Kenyans. So, AMPATH went to where the patients were. First, by putting an AMPATH clinic in the pre-existing clinic building at Mosoriot. As that took off, various other clinics sprung up, and there are now 25 or so spread out through western Kenya. The distance from clinic issue has also been taken one step farther, as I saw today. Just before we got to the clinic, Dr. Mamlin pointed out to me a shelter that had been built about 2 years ago using funds from North United Methodist Church (the church that Mike and I are members of, as well as the Mamlins, when they lived in the US). The people who stay in this shelter are the sickest of patients, those who need to be seen every week or two times a week, and who otherwise would never be able to come to clinic. I met one such patient today. Her name is Jane.

Jane is 45, she was diagnosed with HIV not too long ago. At the time, she was severely malnourished, weighing only 26 kg (about 57 lbs) and days away from death. She was immediately put in the shelter right by the clinic, where she was initially visited by a CO (clinical officer) every day. Her weight is up to 32 kg, and she is now coming to the clinic once per week with the help of her daughter. I met Jane today, and she is still so emaciated you think a gust of wind would knock her over. The main thing Dr. Mamlin discussed with her and her daughter today was food. Making sure they had enough, where were they getting it, what were they eating, etc etc. He gave them money out of his own wallet so they could buy food. He took a picture of me with Jane, so I could “show (my) church what they’ve done.” Afterwards, I saw her daughter in the hallway, she had tears in her eyes as she gave me a huge hug, just saying “asante, asante asante” over and over again. It was amazing.

The rest of the clinic was great too. I saw some interesting things – like a woman with an 8 year history of “leg sore” that was the biggest, ugliest sore I’ve ever seen. The skin on her foot and leg was completely necrosed away, and you could see her bone underneath. We referred her immediately to orthopedics, but it’s likely she will need an amputation. Mostly, though, it was good to see healthy people. Sure, they all carried the diagnosis of HIV, but for the most part they were completely med compliant and living healthy lives. Our last patient of the day was great – it was an HIV positive mom who had been bringing her little girl to the clinic for monthly checkups. Because of maternal antibodies, you have to wait until a child is 18 months old to determine if they are truly HIV positive. Well, this little girl had her 18 month check-up, and she was negative. The mother was so happy she cried. (And then I mad the little girl cry by trying to give her a sticker, but she just screamed and jerked her hand away. Ah, I’m going to be a great pediatritican).

The other thing I enjoyed about the day was just chatting with Dr. Mamlin. I find him to be such an inspirational figure with what he has created in AMPATH. And it’s absolutely proof that one person can change the world. He told me that when he first went to Mosoriot, he had only one room at the clinic, so he put a wall down the middle of it so one side could be for check in/check out and the other side for examinations. He went into the local village and said “I have enough money to treat 15 people” and he was immediately told his presence was unnecessary, as no one in Mosoriot had HIV/AIDS. So, Dr. Mamlin sort of scratched his head and said, ok, send me the people with diabetes and hypertension, then. They came, were tested, and what do you know, Mosoriot had HIV after all. Eventually the clinic grew far larger than 15 people, and a generous but anonymous donor from Indianapolis gave funds for AMPATH to have their own independent building at the Mosoriot clinic. The building houses rooms for counseling after diagnosis, adherence counseling (a HUGE part of AMPATH. Antiretrovirals and clinic visits are completely free through AMPATH, but patients have to show compliance by showing up to 3 visits straight before they are even given the initial treatment. If they fail visits, they have to start the process all over again), nutritional counseling, and a fully functional pharmacy (Dr. Mamlin said that when he first started at Mosoriot, he could carry all of AMPATH’s meds in one small backpack). Plans for a psychiatric counseling component of the clinic are currently underway. Mosoriot AMPATH clinic was the first free-standing rural clinic for HIV/AIDS treatment built in Eastern Africa. And until a few years ago, it was the only one.

And so the program continues to grow. But of course things are not free, so funding is always an issue. AMPATH is currently run fully out of a grant from PEPFAR, but someday even this money will be gone. Last week’s fireside chat was about the ethics of treating “third world” diseases, who pays, and where do we get the money after the grants are gone. It was very interesting and uncomfortably thought-provoking. If, for example, you had the choice between treating 100 people with 1st line antiretrovirals or 50 people with 2nd line antiretrovirals (which are fore more expensive), which would you choose? The obvious answer seems the 100, but say 25 of those 100 people are going to end up needing 2nd line drugs eventually because of resistance mutations in the virus and noncompliance issues? And, how do you or should you even reward compliant patients? How do you measure true compliance, when so many of the reasons our patients don’t take their drugs or show up to clinic are valid? And, what motivation can we give to US pharmaceutical companies to allow developing nations to produce necessary medications for free? It was a great discussion. So many questions that I want to help the world answer.

Overall, it was a great day. I certainly feel a little more inspired about what I’m doing, and today reminded me of all the reasons I wanted to come here in the first place.

Patients

2007-08-21T04:17:00.000-07:00

The bright side to all of the sad cases on the wards is that I’m seeing a lot of pathology that I will never get to see in the states. A few of the little kiddos currently on Ward 3:

--Harriet. A previously normal, healthy 11 year old girl with a 9 month history of worsening headaches. About 6 weeks ago, she woke up one morning and was blind. Since then, she’s had increasing paresis of her limbs, as well as decreased overall level of consciousness. By the time she got to our ward, she was essentially in a coma. It took awhile for her family to get the money, but she eventually had a head CT, and it showed that she had a massive craniopharyngeoma (brain tumor) that was pushing on her optic nerves (hence, the blindness) as well as jamming up the normal flow of CSF, so she also has hydrocephalus. The neurosurgeon took her immediately to the theater (OR) to put in a CSF shunt. If she improves, they will consider attempting to remove the tumor, though she presented so late that her prognosis is not good.

--Patel. Again, previously healthy, 7 year old boy. He’s had a 6 month history of yellowing eyes and increasing abdominal girth. This boy’s liver is massive – by far the largest liver I’ve ever felt on an adult or a child. He had an ultrasound that showed a large mass in his liver – what the radiologist thought was hepatocellular carcinoma (liver cancer), but this would be extremely rare in a kid this young. So, we’re thinking he has either a lymphoma of some kind or some kind of parasitic liver infection. But, we haven’t yet been able to biopsy, as you first have to be sure his blood clotting ability is normal (the liver synthesizes most of the blood clotting factors), and the lab has been out of reagent to run the test for the past week. Supposedly they got some today and hopefully we’ll soon know exactly what he has.
*Edit: Though I am posting this on Tuesday, I actually typed it up on Monday night. I got into work this morning and found out that Patel died overnight. Sigh... I don't know how much more of this I can take*

--Mary. 13 year old girl with a history of rheumatic heart disease, now in florid congestive heart failure. She had an echo that showed terrible heart function, and that she really needs 2 of her valves replaced. Of course, in a resource-poor setting this is extremely difficult. If the family can get the money (a very big if), she would have to go to Nairobi to have the surgery done. And, as pediatric cardiothoracic surgeons are few and far between, she would have to be placed on a 6 month to 1 year waiting list. Sadly, I don’t think she has 6 months to 1 year to wait. The family is still discussing the options and working with our social worker, but things are not looking great.

--Robert, 8 years old. I may have mentioned Robert before. He was a favorite of mine. He had AML, and presented SO late that his eyes were essentially completely out of his head. He had frequent nosebleeds and gum bleeds, as well as bleeding from his eye sockets. He was getting massive chemo, and was actually improving somewhat for awhile. We got to rounds on Friday, and the entire right side of his face was swollen. I mean, hugely swollen. He was almost unrecognizable. The consultant thought it was probably a dental infection/abscess that just progressed at lightening speed since Robert had no immune system left (and dental care here is quite bad). The plan was to drain the infection, start on heavy-hitting antibiotics and wait till he recovered to start chemo again. None of that ended up happening, as Robert died over the weekend. It may have been sepsis from his infection, or just his leukemia finally taking over, or maybe both. Either way it just makes me so sad. And of course, his dad is such a sweet, nice guy. He is one of the few parents we have here who speaks English, so I always liked going in to say hi to him and Robert. He was very calm about his son’s illness, saying that if it was God’s will for Robert to live, then he would live. And if not, he would try very hard to accept that.

How about something a little more uplifting. Today I got conscripted to lead a parent discussion group. These happen every Monday and Friday, where a physician (usually Dr. Tran) will sit in the Sally Test Pediatric Center with any of the parents of our patients and discuss a certain topic and answer questions. Well, Dr. Tran’s nanny has malaria, so she was trying to find someone else to watch their kids, and asked me would I mind going? So of course, I don’t mind. Oh and by the way the topic is potty training. Yeah, don’t really know much about that one. So I go in, and the translator is there, and he says, ok, let’s get started. Go ahead. So I’m like, ok… um…does anyone have any questions to start off with? Well, of course no one does. So, I ramble on about everything I remember learning about potty training (the expanse of my knowledge filling all of 5 minutes), and then we still have 55 minutes left. Enter awkward silence. Luckily the translator had done this particular topic before, so he was able to engage the moms (and one dad) a lot more. By the end of the hour, the parents were swapping stories and tips back and forth. Which really is more helpful than a white coat yakking at them for an hour anyway. The other interesting thing about the conference was that one of the moms there had a baby with Down’s Syndrome. Definitely the first African baby I’ve seen with it, but unmistakable nonetheless. The baby’s almost 2 years old, and her mother was expressing frustration that she hadn’t even started potty training yet (kids start quite young here compared to the US – as early as 5 months!). It was uncomfortable for me to try and explain to her that her child would be delayed in all areas – including this one. Not that I couldn’t do it in a tactful way, but it was awkward with 15 other parents listening intently. Ah well, at least there’s no HIPAA here to worry about.

After work I walked into town by myself for the first time. I went to the bank (exchange rate was up one whole shilling today, wahoo!) and the grocery store and I didn’t even get lost! Afterwards, I met up with Priti and Dayna and we shopped around town for a bit, then walked up north of town to the Imani workshop. Imani – meaning “faith” in Kiswahili – is a part of the AMPATH program. It is a workshop that employs only HIV positive Kenyans, and they make and sell a wide variety of very nice things such as bags, jewelry, shirts, skirts, etc. The dressmaker was out today, but we’re going back Wednesday, at which time she will measure us, we’ll get to pick out our fabric, and she’ll custom make African skirts for us. We got to look at the fabrics today – there were SO many and they are all absolutely gorgeous. I’m very excited about my skirt.

Lorein got her hair braided. Actually, it was a 2 day process, totaling about 18 hours. It looks SO good. I’m totally sold now, I figure if a pale, blond-haired, blue-eyed Dutch girl can have braids and have it look so great, I should be able to pull it off ok. I’ll probably get mine done in a month or so, just before I go home.

Planning for a new adventure this weekend is underway. In honor of Dayna’s last weekend (she leaves on Monday), we’re planning a nice, relaxing weekend in the Rift Valley, at Lake Bogoria or Lake Boringo. If we hire a private driver – which we probably will – we’ll spend one day at each lake. Lake Boringo has hot springs. It will probably be the 5 girls who went to Kakamega, plus Abby, a social work student from IUPUI who just arrived this week. I’m excited!

In other not so exciting news, I found a cockroach in my bed tonight. Actually, a mamma cockroach and a bunch of baby cockroaches. Eww eww eww eww EWWW! I’m normally not a complete girly girl when it comes to bugs and such, but really, IN MY BED??? Come ON!!?!?! So, I immediately stripped everything off, put clean sheets on, and hung my blankets outside for while. Still though, really really gross. Priti immediately checked her bed over as well.

Here’s hoping I’ll remain bug-free for the remaining 5 ½ weeks. Lala salama!

AIC

2007-08-19T03:46:00.000-07:00

This morning a group of us from IU house went to church at the African Inland Church. It was pretty fun. (Despite the fact that we were up until about 3am this morning at Spree. I just can't do that anymore. Those days have flown).

The church itself was very big, and as the service went on, more and more people kept showing up. By the time the service was over, people were packed into every pew and aisle. There were even quite a few people standing outside. One of our Kenyan friends told us that churches here tend to be like that anyway, as over 80% of the population is Christian. But today it was a little worse, as we had 3 special guest speakers at the end of the service. These were 3 men who are currently running for Kenyan president, so they were there basically drumming up support for their campaigns. One of the men was the clear favorite, and our Kenyan friend told us that he is the most powerful member of Parliament right now. He's who most people hope will win, I guess, because he stands the greatest chance of ending government corruption.

I'm usually one that tends to shy away from such blatant mixing of politics and religion, but at least there were multiple candidates there instead of just presenting one viewpoint. More importantly, in a place like Kenya where many people don't own TVs or buy newspapers, campaigning at churches is the easiest way to reach the most amount of people. The sermon was appropriate too -- it was about the wisdom of Solomon and how political leaders need to emulate him.

The service iteself was in English, though they did sing a few songs in Swahili. They do 2 English services and 1 Swahili service every Sunday -- I think it would be fun to go to a Swahili service at some point. It "started" at 9:00, though the doors the church didn't open until about 9:15 or so. And, it "ended" at 10:30, which really means 11:15 in KT (or, Kenyan Time, as we like to call it). The choir was very good, and overal we had a good time.

Then it was time to cook Sunday Brunch with the crew at IU house -- we made omlettes and chai. Very tasty! And now, now it is time to nap. Then Swahili lesson and gearing up for another weak on the Nyayo Wards.

Kwa Herini!

Med Student Article

2007-08-18T08:16:00.000-07:00

I know it's an anomaly for me to post twice in one day, but I read this article by a first year med student about the struggles of going into medical practice, and I thought it was pretty good. It broadly covers what most med students go through when trying to pick a specialty that they like versus a specialty that is more well-paid.

And also, pedatrics is primary care.

And one more thing -- I got the results of my Step 2 CS today -- and I passed! I wasn't really worried about failing, but it's still good to know that one more thing is out of the way...

Chill Weekend

2007-08-18T01:46:00.000-07:00

Unfortunately I'm not at the street children's fair, as I got quite ill last night and I'm taking it easy at IU house. (Yeah, going up 2 flights for the bathroom is NOT fun when one is sick).

So here I am, doing some laundry, trying to hammer out my personal statement and work on other residency application things (Scary!), another swahili lesson and generally relaxing on this absolutely gorgeous day.

Yesterday afternoon the girls went to the Matumba market on the far west side of town. This is a market that's mostly clothes, and it only happens on Fridays. Unfortunately it rained (poured, really) for a few hours yesterday afternoon, so we didn't get to go right after lunch like we'd wanted. I wish we had, because this market is absolutely MASSIVE, with piles and piles of clothes just laying on the ground. It's sort of Eldoret's version of Goodwill, I suppose. (Ironically enough, many of the clothes still had Goodwill tags on them!) So, we spent a lot of time digging, but I found a few good buys. As my only pair of non-work pants got totally ruined at Kakamega, I bought 2 pairs of running-around-town/weekend adventure pants. I'm sure I payed too much for them, but I wasn't in the mood to argue with the vendors and they were both less than $5 American. I also found an ADORABLE bright yellow skirt for only 100kSH (a little over $1). I might not wear it here -- I don't want it to get all muddy!

The clothes they had there were just crazy -- Priti got a really nice Banana Republic skirt for like 200kSH, and there were all of these random American t-shirts that were obviously not current. I want to find some really funny American t-shirts for Mike and Brant, just to say I bought random American clothing in Kenya. But, I didn't really see anything that grabbed my eye (and I didn't really think Mike or Brant would /wear/ an Eminem or Snoop Dog t-shirt anyway, no matter how cheap it was).

So, after the market was when I really started to feel unwell, so I didn't join the rest of the girls for dinner/dancing. I'm kinda glad I didn't, as Priti got robbed at Places, the club they went to. She had a backpack on, and it all of a sudden felt lighter. When she took it off to look at it, there was a giant gash in the bottom, like from a knife, and the only thing left were her tic-tacs! Her wallet was gone, thankfully with not too much cash in it, but it also had credit cards and ID and social security card in it. How terrible. Her parents were able to immediately cancel her cards, which is good. Her phone got stolen too, so we want to text the number and tell whoever stole her stuff what a not nice person they are! I guess it just goes to show you really can't be TOO careful. (And only wear your backpacks on the front of you, I suppose).

The plan is to go out to a different club tonight, and I suppose I'll tag along. I'm pretty much past the point in my life were "going out" is a regular part of my schedule (I'm an old, boring married person after all!), but it should be fun to go with my friends. I'm just not at all interested in being harassed by random men (which is VERY common here, regardless of marital status). Even if I was single -- you know, didn't really come to Kenya to find someone to date. Alas, I guess that's why we go in big groups, with our guy friends. And one of our Kenyan friends told us not to be afraid to tell the guys to "piss off." Not very nice, but maybe I just will.

Kwa heri!

An overly frustrating day

2007-08-16T08:09:00.001-07:00

The inefficiencies of the hospital really got to me today. Well, it's really the inefficiencies of the healthcare system as a whole, reflected at MTRH.

Yesterday, we had an M&M (morbidity and mortality) conference for the pediatrics department. In America, these once- or twice- monthly meetings are used for different departments to present cases that had bad/avoidable outcomes (such as infection, prolonged stay, disability, or death), in order for the department as whole to discuss them and see what improvements can be made to avoid such outcomes in the future. So I thought it would be here, but I was wrong. For example, newborn unit presented a few-day-old infant who came in overnight basically in septic shock. The intern overnight was not able to get an IV in this baby (IVs in children tend to be very difficult), and it was not clear as to whether this intern had called for backup from the registrar or consultant. Long story short, this baby was delayed getting fluids for about 12 hours, and the infant ended up dying in about 48 hours. The lack of immediate IV fluid resuscitation was pinpointed as the critical moment in this case. Which, it probably was. But instead of discussing with everyone how this can be avoided in the future, it turned into a slam-fest, with the consultants completely lambasting the team for their "terrible" doctoring, "In my opinion, it's like this patient was never seen at all." Yes, it's all well and good to blame the intern. The ONE intern, who I might add, is in charge of both pediatric wards at night, which means seeing ALL of the patients that get admitted that day (which can be anywhere from 20-50), as well as deal with all of the patients who are crashing. And in a ward where 60% of the kids would be in the ICU in America, that's a tall order. Yes, the intern should have taken steps to get an IV in the infant, there's no question. But can we not arrive at that point without completely beating everyone down? Apparently not. The most frustrating thing about the conference was that the consultants want to get all up in arms when things go wrong, but they take absolutely NO responsiblity for anything. For example, on my particular team we're supposed to have 3 different consultants. Dr. Tran (the IU doc) rounds with us on Mondays and Wednesdays, Doc 2 on Tuesdays, and Doc 3 on Thursdays. Dr. Tran rounds with us faithfully, I've seen Doc 2 all of ONE time (She showed up for 10 minutes of rounds 2 days ago), and Doc 3 has NEVER once been to rounds. She was on the ward today, but blatantly looked at our team then turned around and walked away. So.... basically the interns and registrars end up making all of the decisions all by themselves, and you know, I really think they do the best they can. It's not like they blatantly neglect or harm patients on purpose. But without the guidance of the more experienced, how can you not expect things to go wrong??? A system that gives the most responsibility to those with the least amount of knowlege and experience is patently wrong. Yes, the interns and registrars need to LEARN, but how can they if no one is ever there to TEACH???

In America, it works as a pyramid. The Attending is in charge of all of the patients on the team, they take ultimate responsibility for what does or not get done for or to the patient. Then the upper level residents, they are in charge of about half the patients on the team, then the interns, about a third, and the medical students one or two patients each. This way, when the medical student misses 10 things that needed done for the patient, the intern will catch five of them, the upper level resident the next 3, and the attending will catch the last two. This greatly reduces patient harm, and in the process everyone LEARNS, and the next time the medical student only misses 9 things, and so on. But here, it's totally backwards. The INTERN is actually in charge of all of the patients, and the consultants apparently, put no responsibility on themselves. I'm going on and on about this, but if the healthcare system here is ever going to change, it's the CONSULTANTS who have to place it on themselves to start that change; by taking responsibility for patient outcomes and training those under them to do the same. At least that's my opinion.

Overally it is just so frustrating. Patients wait for hours before getting fluids, tests are not ordered, or are ordered but not sent, or are sent and then lost...and all the while patients are dying around us, and the consultants just seem to scratch their heads and say "how can this be?" We have one little girl who is SO sick. She came in with severe pneumonia but then got septic, and we've been treating her with antibiotics but she just keeps getting worse. So we switched to 2nd line antibiotics, and she just keeps getting worse. Well, it turns these past 7 days we've been ordering antibiotics she's not actually been GETTING them. Any of them. At all. Not even one dose. How can this happen?!?! In America the staff responsible would be immediately fired and then probably sued. (Robert says what the Kenyan medical system really needs is a bunch of US lawyers.) And this kind of thing happens every day, on every ward, to multiple patients.

I just have to realize that I'm not here to make systemic changes. If I tried I would be this unbelievably frustrated every day, and I'd burn out very quickly. All I can do is try to make a difference one patient at a time. And if I can get my patient IV fluids in 3 hours instead of 6, well then I will have to count that as a major victory.

Eldoret Street Kids

2007-08-15T07:06:00.001-07:00

Well, I’ve been here for 2 weeks now, and things are finally starting to settle into a sort of routine. I’m definitely feeling more like part of the Ward 3 team now, and definitely starting to be friends with the Kenyan medical students, instead of just acquaintances. The other exciting thing is that I admitted my first patient on Monday night! The mother spoke English, so I was able to do it all by myself, too. The patient was a 3 ½ year old little girl with earache, fevers, and vomiting. Her blood smear was positive for malaria, so we’re treating her for malaria, BUT I also looked in her ears and diagnosed her with an ear infection. Go me. Usually they just get an ENT consult for ear infections here, because looking in kids’ ears is not bread and butter pediatrics here as it is in America.

Every Thursday night after dinner at IU house we all gather in the lounge and have a “Fireside Chat” about an important non-medical topic. Last Thursday’s was on Eldoret Street Kids. Let me start by saying that I was somewhat unprepared for the street children here. There are quite a few of them, and every time we go into town, they target us (being the wealthy Americans) to ask for money. They’re what you might imagine – dirty, malnourished, desperate. Not to mention persistent. Once they find you they’ll follow you up and down the streets, waiting outside stores for you, saying “muzungu (white person), money for bread” or “muzungu, 20 bob” and when you tell them “Hapana (No)”, they ALWAYS ask “Why?” It’s so heartbreaking. But, we are advised not to give them money, because unfortunately and shockingly these gangs of small children are drug addicts. The main thing the street children do is sniff glue (it’s a cheap, easy high), or they will smoke marijuana or drink alcohol if they can get it. It’s just awful. The alternative is obviously to give them food, which we do whenever we have any with us. The majority of the kids are boys, as girls are more readily taken in by friends or family – they can help care for the house and the children, and there’s a relative assurance that girls will eventually leave the house to get married, in addition to bringing in a dowry payment when they do get married.

So, at our fireside chat last Thursday we had 3 men speak: Frances, Mwenge, and Benson – all of them former street kids. Their stories and experiences were things I could not even fathom. Either one of many, many kids in a house with too many mouths to feed; or abandoned by parents; or attracted to the street life for any reason, these 3 found themselves living on the streets of Eldoret. They told stories of the drug/glue/alcohol addiction, the purpose of the high being strictly to distract them from their hunger or cold or loneliness. Mwenge and Benson are brothers who lived with their grandparents as young boys. In 1992 there was a lot of tribal unrest in Kenya, and one night they boys were forced to flee their home with their grandparents as a rival tribe attacked their village. “With only your feet and your God to protect you” as Mwenge said. Benson was 6 at the time, and he remembers cowering under a bush, being discovered, and having semi-automatic weapons pointed at him as the attackers shouted, demanding to know where the grown-ups where. All he could do was cry. Can anyone imagine ever going through anything like that? I know I cannot. All 3 boys were rescued from the streets by a German missionary who came to Kenya to start a school/home for street kids. Frances is now married with 2 kids, Mwegne is a university student in Nairobi, and Benson wants to go to pharmacy school once he catches up on his primary schooling. Their stories were harrowing, and I couldn’t help but feel incredibly grateful for all that I have; even in Kenya. Yes, I may complain about our small hostel room and our cold showers in sketchy bathrooms, but the fact of the matter is that I have so much more than most of the people in this country. It’s a very humbling thought.

Unfortunately, we see abandoned children not only in the streets, but also in the hospital. Many times kids will be brought in and parents disappear, or a baby will be born and the mother won’t take it with her when she leaves. Unimaginable I know, but a fact of life here in Kenya. Nine times out of 10 the abandoned child is HIV positive, or again is one more in a long line of too many mouths to feed, or both. And what can MTRH do but treat the child and wait for placement in one of the few already overcrowded orphanages? We have one little boy now, Benhein, he’s about 3. He’s so cute and playful, and he especially likes to grab the “torches” (penlights) out of our pockets. We’re not sure what the story is with his father, but his mother has recently married and had another baby. The new husband does not want to care for the child of another man, especially now that he has a son of his own, and especially since the Benhein is HIV-positive. So, Benhein was left at MTRH by his mother. It’s so easy to be outraged at the mother, but she probably has limited options available to care for herself and her new baby, so she had to agree to her husband’s terms. The whole situation is just incredibly sad. When I was at the hospital admitting Monday night, it was about 9:30 or 10, and Benhein was just up running around, acting like a total nutcase (normal toddler, if you will). My immediate thought was “why isn’t he in bed?” And then it hit me, he has no mother (or father) to put him to bed. He has no structure whatsoever, no one to teach him how to eat, sleep, or survive. He eats if he goes up to the foodcart when it comes around, otherwise… who knows? There is no one person assigned to his care. Horribly tragic.

And of course the worst part is that children almost never get adopted in Kenya, especially not HIV-positive children. The real injustice is that international adoption out of Kenya is impossible for various political and social reasons that I need to learn more about. HIV is becoming such a chronic, treatable condition now, especially in the West, so I really feel like international adoption may be the only hope for kids like Benhein.

Again, I don’t want to sound like I’m criticizing Kenya or the way things are here. There are changes that need to be made for sure, and I think eventually circumstances will be much better for Kenya and Africa, if the West can assume its critical role in the process. The happy part about the Eldoret Street Kids story is that, this Saturday, there is going to be a fair of sorts for all of the street kids at a local school. It’s a project organized by the Swedish medical students who are currently here. They’ll get fed, get some general health check-ups, and will even have some basic antibiotics and other meds available for them. Most importantly, Benson will be speaking to them, telling his story, and letting them know of the resources available to them to get them off of the streets. The organizers have asked the other med students to come and help out with physicals, etc, so I’m pretty excited about it.

Sorry this was such a depressing post. I just think I have to share the realities of life in Kenya, because if we can’t understand something, how can we ever change it?

Since things have settled down here, I’ve had quite a bit more time for quiet time/devotions, and I just wanted to share a few quick things. I’m currently working my way through Acts, which is one of my favorite books – I think the stories told about the original Church are just great. Acts chapter 2 tells the story of Peter and the apostles converting the 3,000 at Pentacost. “And all who believed were together and had all things in common, and they sold their goods and possessions and distributed them to all as any had need.” Chapter 4, verse 32 goes on to say “Now the company of those who believed were of one heart and soul, and no one said that any of the things which he possessed was his own, but they had everything in common…There was not a needy person among them, for as many as were possessors of lands or houses sold them, and brought the proceeds of what was sold and laid it at the apostles’ feet; and distribution was made to each as any had need.”

A very convicting few passages for me, especially as I am re-reading them while actually living amongst the poorest of the poor. Before I came to Kenya, I really resented the fact that I would immediately be identified as the “rich westerner.” Me? RICH?! I’m a STUDENT for crying out loud. Six figures in debt by graduation!!! But the reality is, compared to so many of these Kenyans, I am wealthy. What’s 10 shillings when bartering at the market? Next to nothing to me, but it could mean all the difference to the person I’m paying. These are just the things I try to keep in mind.

Keep the emails and prayers coming my way. I appreciate them more than words can say.

Adventures in Kakamega

2007-08-12T04:37:00.000-07:00

Before anything, let me first say:

HAPPY BIRTHDAY MICHAEL!!!!!!

If you're reading this, you should DEFINITELY call or email Mr. Mike to wish him a Happy 26th, especially since his stinky wife is not in the US to celebrate his birthday.

Ok. Now. About this weekend. It was amazing. In so many ways.

On Friday night, some of the 6th year Kenyan medical students took out the Americans as a sort of welcome to Eldoret type thing. These guys had just recently returned from spending 2 months at IU as part of the exchange between our universities. First we went for dinner at The Klique (the same bar/restaurant where we watched the soccer game last week), which was really fun. It was nice to chat and get to know them better, and hear about their experiences in American and what they thought of our med school. It turns out that they stayed in the same apartments that Mike and I first lived in when we moved to Indy -- the ones that were constantly being set on fire and flooded and whatnot. They've been rennovated recently, and apparently are much nicer now. It was also nice to laugh and joke with them, about how some things in medicine are universal -- such as attendings with egos so big it's amazing they fit through the hospital doors.

Dayna had mentioned that she wanted to hear some live music, so after The Klique, we took some cabs over to a bar called the Wagon Wheel, where there was a live Kenyan band playing. The music was quite good, though I had no idea what they were singing. Most of the other patrons there were in their 30s and 40s, and also quite drunk. There was one guy there (who was two-fisting it the whole night) who became our best friend once he learned that we were from Indiana. Apparently he graduated from IUPUI, but that's all I could understand, as he was slurring his words quite badly. He even decided to buy me a Tusker (local beer) and call me "Miss Indiana! Miss Indiana!" for the rest of the night. He also introduced me to his wife, who apparently is a clinical officer at the hospital, and kept wanting me to come over for dinner to meet his son. Yeah, no thanks. Once I told him I was already quite happily married, he asked who the single girls were and started harrassing them to come over for dinner and matchmaking. He provided quite a few laughs though, and now everyone likes to call me Miss Indiana.

After staying up late on Friday night, Saturday morning came very early. We were supposed to leave for Kakamega from IU house at 7. Well, it was raining in the morning, and we didn't feel like carrying all our bags, bedding etc down the wet and muddy road in the rain. So Priti and I walked to IU house, helped Venus pack up our matatu with food & supplies from IU house, drove to the guesthouse to pick up Lorein, then back to the hostel to pick up Dayna and all of our stuff. So, we didn't really leave until about 7:45.

The ride to Kakamega itself was not to long, but we had to turn off of the main road and drive along a very primitive, bumpy, and muddy road to get to where we were staying. The Rondo, which is a fairly nice & expensive hotel where the IU people usually stay, was full for this weekend, so we had made reservations and booked a tent at a place called the Forest Rest House (or so we thought). We finally find the Forest Rest House, which was quite a bit farther down the road than the Rondo, and they have no idea who we are or why we're there. Great. Apparently they don't rent tents, and have no idea who would have told us that we had a tent reservation. Luckily, one of their bandas was opening at 11am, so we could get that for the weekend. Otherwise it would have been back into the matatu for another hour drive over bad roads to the next closest hotel/camp site. It worked out fine, actually, as the banda house site was beautiful -- smack dab in the middle of the rainforest.

Because of the time it took to figure out our housing fiasco, we got started on our first hike much later than we had wanted. We left about 11:15 for our short hike. This one was just in the forest around the campsite. Our guide, Smith, spent a lot of time telling us about Kakamega rainforest, its various plant and animal species, and the efforts that began in the 1960s to conserve the area and stop deforestation. The rainforest now is massive -- it covers about 24,000 hectares. Before Western colonialization, it used to cover over 350,000 hectares. Yikes. So this was a fun hike. The forest itself was BEAUTIFUL beyond description. So many interesting and massive trees. I probably took 50 pictures just of various trees. Smith was also very good about pointing out various plants that locals use for medicinal purposes. At one point we stepped into a beautiful clearing that contained a massive tea leaf farm. The purpose of the farm is to prevent local villagers from living directly next to the forest, in addition it actually employs most of the local villagers. This was a fun hike too in that we saw quite a lot of monkeys -- Colobo monkeys, blue monkeys, and red tail monkeys. It was so cool to watch them feeding high in the trees and hopping from branch to branch.

We got back from our first hike about 1:30, grabbed a quick lunch, then left with Smith at about 2:30 for our "long" hike. Yeah, marathon was more like it. He told us that if we left at 2:30 and picked up the pace a bit, we would make it back by 5:30 or so -- plenty of time before dark. This hike took us past some local farms before we went into the forest, where we saw some more monkeys, and a lot more interesting plants and birds. We spent some time on the main road that runs through the forest, which was the main area for seeing butterflies, flowers, and a lot more very beautiful birds. I took SO many pictures. We went up through a guava orchard, where Smith picked us a bunch of guavas to eat -- they were very good. The orchard also had some fantastic views of the surrounding mountains. We even saw a baboon in the orchard!

Soon after the orchard, we turned off of the beaten path into the part of the forest that is completely untouched except for the few trained guides in the area who take hikers in there. It was completely astounding. EXACTLY what I have always pictured a rainforest to be like. The trees were much taller and closer together, and the canopy above allowed very little light to shine through. It was just unbelievaby beautiful. We walked through as quietly as we could, just absorbing the scenery and listening to the many, many sounds of the forest. We stayed in this part of the forest for about 90 minutes, then Smith took us down to the river rapids, 'rapid' being a severe understatement of the fact. This was the most violent and powerful display of water I have ever seen. Smith said that anyone who has ever gone in that water has never made it out. It was fantastic. Again, I took a ton of pictures. Because there has been so much rain recently, we had to find a different path away from the river, as the one normally taken was flooded over. By this time it was about 5:30, but Smith tells us we still have a little way to go. This was when the fun really started. We really picked up the pace. Now, I should mention that these trails are incredibly muddy, so we were just slogging through ankle deep mud as fast as we could. Up hills down hills, over trees and branches, across bridges and rivers, all at a rather punishing pace. Despite the fact that I was WORN OUT, it was absoultey FANTASTIC. After about an hour of this, we rest a bit at the top of the hill, and Smith proceeds to tell us that we still have another HOUR left and we need to pick up the pace even MORE. Holy goodness. So, we're pretty much running through the rainforest at this point. And it's raining now. Which I actually didn't mind, as it was getting quite warm, and what's the point of being in a rainforest if there isn't any rain.

So, we're running and running (and slipping and falling quite often, due to the mud and the rain), and we turn off of the path. Smith tells us that as it's now past 6, the park gates are closed, so we can't take the main road back in, but have to take a "shortcut" through the forest. The shortcut actually took us through the roosting grounds of the black and white crested hornbills we had been seeing at a distance all day, so that was quite amazing. We startled them of course, so they would take off from the trees en masse. It was quite the site to see. They are also called helicopter birds, because of the sound their wings make when they're flying. It was just amazing. By the time we made it onto the main forest road, it was definitively dark. I was inexplicably the only one in our party to bring a flashlight, so 6 people were sharing one small flashlight on a pitch black muddy, hole filled road. Not so fun. Smith kept telling us it wasn't much farther, but we must have walked on the road for at least another 30-45 minutes. By the time we FINALLY made it back to the campground, it was almost 8pm, and we were very sore, extremely dirty, tired and hungry. Thankfully, we had ordered dinner from the Forest Rest House canteen before we left on the hike, so we had a lovely meal of chapata and greens waiting for us. Between that and the chips and cookies that we brought, as Dayna said "it was the best random meal I've ever had." After dinner we sat around a fire and had an interesting conversation with 2 people who were there -- a civil engineer who has lived in Kenya most of his life, though his family and culture is Indian and his citizenship and education are from England. The woman he was with was born in Holland, had lived in Kakamega for 2 years some years ago, and now resides in Canada. You never know who you might meet in the middle of a rainforest, eh?

Being exhausted, I slept very soundly that night. We woke up at 5am this morning to go on our sunrise hike. We were kinda bummed when we woke up, as it was raining steadily and had been raining all night. Smith assured us that we would still be able to see a lot from our viewpoint, if not the actual sunrise. We had arranged with our matatu driver Ashley to drive us all to the trail starting point, so we wouldn't have to get up quite so early. So, the 5 girls and Smith pile into the matatu, and we're on our way. Well, as it had been raining all night, the roads are an utter mess at this point. The matatu is basically a big minivan, so of course we get stuck. So the 5 girls and Smith pile OUT of the matatu and push it up the hill. In the dark. In the rain. With mud getting spattered everywhere. We finally made it to the trail starting point, and we being a 30 minute steep uphill climb. We ended up about 250,000 meters above sea level, starting from about 75,000. It was tough, especially as I was quite sore from yesterday. Before we got to the summit of the mountain we were climbing (Smith says it is just a "big hill", but I say it was a mountain), Smith took us into a bat cave. Not my favorite thing. The ceiling was very low and there were bats flying in and out right over our heads. I know that they're harmless, but there's something about shining your flashlight down a deep cave and seeing hundreds of pairs of beady little eyes looking back at you that just gives me the willies. Being 5 girls, we hightailed it out of their pretty quickly.

After the cave came the last 10 minutes of our hike to the top, and they were the hardest. We were going pretty much vertical for this part. It was very strenuous, but more than worth it. What we saw at the top defies description. We were standing on the highest poing of Kakamega rainforest, looking out over miles and MILES of canopy in the early morning light. We could hear thousands of sounds of the forest as well as flocks of birds soaring over the trees, landing, then taking off again. It was AMAZING. We were actually standing above the cloud cover, and we could watch the low-lying clouds move over the canopy, and hear the rain being dumped into the forest. We didn't get to see the sun acually rise, as it was a little too cloudy, but it was the most beautiful thing I've ever seen anyway. As I told Mike, if he had been there, it would have been by far the best moment of my life. I took a bunch of pictures, and even a couple videos, but I know this was one of those things that can never be fully justified on film.

After having breakfast at the top of the rainforest (what really felt like the top of the world), we headed back down. Ashley drove us back to the campsite, where we packed up and cleaned up as best we could (all of us being completely caked in mud and soaked through by this time) and packed up. We had a little bit of time to hang out before Ashley came back to pick us up, so we sat out in the sun (which was out by this time) and read. I'm so glad we did, because the group of blue monkeys that lives nearest the Rest House came through. Smith told us they probably would. They were on their morning feed, and the sound they made as they lept from tree to tree overhead was unbelievable. We just sat outside and looked straight up at the monkeys eating. Unbelievable. At one point, the male (he was by far the biggest of any of them) came down and sat on the ground no more than 10 feet away from us. According to the camp staff, they are very acclimated to humans, and will raid banda houses and kitchen if they are not closed securely enough. The male monkey just sat there in front of us for about 30 minutes, not really bothering much with us (of course we were taking pictures like maniacs), surveying all of the females feeding in the trees, eyeing our snacks, before he finally climbed a tree again. It was fantastic!

So, Ashley comes, we pack the matatu, and he says, I'll take you on the other road around Kakamega and show you the crying stone. We say sure, why not, and we're off. Well, this 'other road' was the least road-like of ANY of the roads I've yet been on in Kenya. It was one giant mud pit. It was honestly like driving in the winter in Indiana when there's a thick layer of snow on top of the road with a sheet of ice underneath. The matatu was fishtailing and sliding all over the road. We kept saying "pole pole!" (slower!), but of course the back end fishtailed into a ditch and got soundly stuck in the mud. Us 5 girls jump out -- all wearing flip-flops -- and immidiately sink into ankle-deep mud. Despite our awesome buffness, our pushing of the matatu was if anything, getting it stuck more. So, about 20 of the local villagers come out and help us push, we eventually get unstuck and are on our way again. We drive for a little bit more, swerve around uncontrollably for a bit more, and of course, get stuck again. The back end of the matatu, in a muddy ditch. We were NOT amused. Ashley told us not to get out this time, and again a bunch of local villagers manage to get us pushed out of the ditch. This was not nearly the most fun I've ever had. Soon after the 2nd time of getting stuck, the road improved a great deal (though I can't imagine it getting much worse), and we drove through Kakamega town. It was quite pretty. The sun was very bright, and there were even more people out on the roads than usual, as it was a Sunday and everyone was going to or coming back from church.

Just outside Kakamega town, we stopped at the Crying Stone. It was beautiful. It's a gigantic (and I mean huge -- as wide as 2 skyscrapers and as tall as one) rock formation that looks like a person -- a big broad rock for a body and smaller round rock for the head. It was quite a ways back from the road, so we had to walk through a little village to get to the actualy formation. By the time we climbed up it, we were trailing quite a few of the villagers, most of whom were children helping us up the rock (again, all of us wearing flip flops that recently got a mud bath). The view from the rock was very nice -- we could see the surrounding countryside and villages quite nicely. Ashley told us the story of the Crying Rock: Many years ago, there was a great Kenyan warrior who was the leader of a great tribe. All of the other tribes envied their greatness, and he was constantly being attacked by other tribes. During battle, he was indestructable, as his skin could not be pierced by a spear. The leaders of his rival tribes came up with a plan to have this great warrier fall in love with and marry one of the rival warrior's daughters. This happened. Some years later, the great warrier fell sick, and in order to be healed needed to be pierced on his skin and have medicine injected. He told his wife that the only way to pierce his skin was to pierce his shadow, which she did, and he was healed. His wife went back to her father and told him of the great warrior's weakness. The rival tribes attacked the great warrior, stabbed his shadow, and he died. It is said that when he died, he became a great stone statue that weeps because of his betrayal. Sure enough, there was a steady stream of water flowing from the top of the rock to the bottom. Sort of Africa's version of Samson and Delilah, I think. It was very cool. Again, I took a ton of pictures.

After the Crying Rock, we enjoyed a blessedly uneventful drive back to Eldoret and IU house, where I took quite possibly the most refreshing shower of my life, scrubbing VERY hard to get all of the mud off. Now it's about 20 minutes until my 2nd swahili lesson. (Most of us are taking some basic swahili lessons from Wycliffe, a local tutor. I had my first lesson on Friday, it was fun and went quite well! I won't become fluent by any means, especially not on this visit to Kenya, but I do hope to be able to at least communicate in some way with my patients).

It was a perfectly fantastic weekend. It was only my first real weekend away trip here, but I think that it's going to be hard to beat. We'll see what other adventures Kenya holds.

Been here a week

2007-08-09T02:39:00.000-07:00

Well, I've spent a week in Kenya. In many ways it seems longer than that, as so much has happened. In other ways it seems like it flew by, and I think that the next 7 will as well.

I'm slowly getting more used to the wards, and getting more integrated into the team. The Registrar even asked me a few questions today! I went back to the hospital yesterday afternoon to help the team give our heme/onc patients chemo. That was an interesting experience. We got a big box of meds from the pharmacy, and we took them into the procedure room, where the interns proceeded to mix, measure, and dose the meds themselves. Now, understand that in America, chemo drugs (being highly toxic) are strictly regulated, mixed by trained pharmacists under strict body protection by suits, masks, and eye shields, and the doses are calculated and measured very precisely. None of us being oncologists, yesterday we read many of the package inserts to figure out the dosing, then calculated the actual doses on a phone calculator. Moreover, it was a very crowded room with needles everywhere, and our only protective equipment was latex gloves. Again, I don't want to sound like I'm criticizing the Kenyan way of doing things, as they really do the best with what they have. I just find the differences between here and the US very striking.

So after mixing our chemo drugs, it was time to administer. One little boy, who's not as sick as the others, came to the procedure room to get his intrathecal (in the spine) chemo. No pain meds or anything, just a big needle in his back. He didn't even flinch. (One thing I've certainly noticed -- the patients here are extremely tough, especially the kids). The other 3 kids who got chemo yesterday we did at the bedside. Two of the boys IVs' were blocked, so they needed another stick before they got their drugs. The process of actually giving was a little hocus-pocus as well -- you can't generally give these drugs in one big bolus, in fact the US they're usually given via a pump for a constant small infusion of drugs over a certain amount of time. But here, there are no pumps obviously, so the interns just injected slowly, guessing at the rate by trying to keep the rate of IV fluids going in about the same. The worst part about the whole thing was that these drugs burn going in, and after about the 2nd or 3rd syringe, the kids started getting really sick and vomiting. It was awful. It was the first time I've almost cried in the hospital. In a way, it's great that we can offer chemo to these kids for a chance at palliation or even a cure, but in a way it made me feel like we were just torturing these children.

Last night was the big IU house dinner, we went to an Indian restaurant, which was quite good. They brought us out plates and plates of food, and when they took away my plate I was full. But then they brought out BIGGER plates and new utensils. I asked Sonak if there was more, and he informed me that the first "course" was just the appetizers! Good Heavens. The IU people go out as a group every Wednesday, and they cook dinner for the students at IU house on Thursdays, so I won't be eating beans, rice, and ugali for /every/ meal.

This weekend 5 of us are planning a trip to Kakamega -- a rainforest reserve about 2 hours from Eldoret. We'll be camping for one night, and going on 3 guided tours of the forest while we're there. I'm pretty excited about it. I'm sure I'll have a lot to say about it when we get back.

Keep sending your emails (or start, if you haven't sent any! ;)), I like to hear from home.

First Days at Work

2007-08-07T07:50:00.000-07:00

The first few days at the hospital have been somewhat overwhelming. It's difficult to learn a new system in a new country with patients having diseases I've only read about in books. Despite this, I'm trying to stay positive. The first few days of any rotation are hard, because everything is new, and I expect this is magnified greatly by the fact that I'm in a different country.

The medical teams are organized differently than in the US. There are the Consultants (basically the equivalent of our Attendings), the Registrars (upper level residents), Interns (Interns), Medical Officers (like Nurse Practitioners or Physicians Assistants), and Medical Officer Interns. Add to that 5-10 medical students of various nationalities and stages of traning, and you've got one big team huddled around small beds.

I've started on peds wards, where the patients (and their mothers) are always 2 to a bed, usually 3 or 4 if the hospital is busy. The wards are pretty much what you might expect in a developing nation -- crowded, hot, and not subject to the strict standards of sterility, etc that US hospitals are.

In my 2 brief days, I've seen quite a few interesting things. Lots of malaria, of course, quite a few cases of HIV (often newly diagnosed in both patient and mother), and a few kids with TB. We have one little boy who I think is very interesting -- he's 13, and has had intermittent facial and leg swelling for almost a year. In the past 6 weeks he's been hospitalized 6 times for the same thing (at an outside hospital) and has been diagnosed with heart failure every time. Well, this time his mom reported a big decrease in urine output and change to "coca cola" colored urine -- basically this little boy has kidney failure for unknown reasons. Because of it he's having a lot of problems with hypertension and all-over body swelling, as well as needing a special diet very low in salt and protein (not as easy to do as it sounds). He really needs a renal ultrasound, healthcare here is all pre-pay before you get the service, so tests usually take a few days to get, so the family has time to get the money. Sometimes the registrar or consultant can choose to waive the fee if the patient really needs someting, which I think we might do for this little guy.

The other really difficult thing about the past 2 days is that our team covers the peds heme/onc ward as well. These little guys are so sick. And most of them present so late in their illness that most care is palliative. We have some AML and ALL patients, as well as a few Hodgkin's disease patients. One little boy came in with a midline cranial tumor that has basically taken over his face. It's very sad. They all get chemo and pain control, but unlike in the US, there are a very limited number of chemo drugs available, and what is used may not neccesarily be what is the very best for treating a particular kind of cancer.

Not to make this a depressing post. I'm very happy to be here doing what I'm doing, and learning about things I will rarely see in the US.

Yesterday Priti and I moved into the hostel. This was an amusing experience. Being girls, we both have a lot of stuff, naturally. Well, this is pretty much the smallest room imaginable, and we have to cram 2 people and their stuff in it. If anyone remembers my freshman dorm room at Anderson (mom? dad?), this room is actually about half that size. But, it forces us to be social, as we're only in the room to sleep basically. Once Dayna goes back to Indiana at the end of this month, one of us can move into her room, so that will give us a little more space. The hostel itself is -- functional -- but definitely the roughest type of place I've ever lived. The 2 rooms that IU rents from the hostel are on the 1st floor, which is the male floor, so we actually have to treck up to the 3rd floor for the bathroom & shower. I say "shower" very lightly, as it's really nothing like in the US or even at IU house. It's all cold water, and most of the time there's not enough pressure to have water coming out of the shower head. Most people take bucket-type showers, which I did last night -- that was an experience. Luckily, IU students sort of leave stuff behind in the IU hostel rooms, and someone left a plug-in water warmer contraption, so at least our bucket showers will be warm!

I bought what I thought was a converter yesterday, so could charge my camera batteries. Well, I plugged in the charger and it didn't turn on, so I thought either the converter was bad or I had ruined the charger by trying to use the Kenyan outlets (which is likely). So, I decide to plug in my hair dryer to see if it was the converter. As soon as the prongs touched the converter, there was a loud bang, a ball of fire and smoke leaping from the outlet. So of course I screamed, and quickly moved the curtains and the mosquito net out of the way, so as to not set the hostel on fire on my first day there. Apparently what I bought was just an /adapter/ and not a /converter/ so much. Doesn't really matter now, as I've already ruined the only 2 electrical appliances I brought with me. It's ok though, I can just buy batteries in town and I don't need my hair dryer anyway.

We had the afternoon off today, so Priti, Larien and I braved town for the first time on our own without Dayna and Erin (who know where everything is), and we actually did quite well. I found the bank where I can change my Ameican money (which I did), though apparently you need to bring your passport with you every time. The teller let me use my student ID this time though. Then we went to the Eldo-Chem (pharmacy) where I bought the rest of my malaria prophylaxis -- it's much cheaper here than in the US. Drugs and such are much less regulated here than in the US -- you can buy pretty much anything over the counter, but of course the selection of available drugs is much less.

I really don't mean this to be a negative or complaining post. I'm pretty satisfied with how things are going thus far, though I do look forward to more familiarity in terms of the living conditions, wards, and the town. Although I am already much more used to being stared at everywhere I go.

I read this in the Lonely Planet guide to Kenya recently, and wanted to post it:
"AIDS IN KENYA. Like most of its neighbors, Kenya is in the grip of a devastating AIDS epidemic. There are 2.5 million Kenyans with full blown AIDS and nearly 700 people die from the disease every day. AIDS is predominantly a heterosexual disease in Kenya and now strikes all classes of people. At least 890,000 children have been orphaned and many others are infected while in the womb. Teachers have been badly affected - at least 18 die daily - because they are predominantly in the 20 to 29 age group that's most affected by HIV/AIDS, and Kenya is facing an education crisis as a result, leaving even fewer people to spread the AIDS-awareness message. Around 85% of prostitutes are affected, and young girls are especially vulnerable, due to the widespread belief that AIDS can be cured by sleeping with virgins. Drug treatments that are available in the West to increase the lifespan of AIDS sufferers and reduce the risk of infection passing to the fetus in HIV-infected women remain well beyond the financial reach of most Kenyans, few of whom have access to even basic health care. The problem is unlikely to improve as long as Western drug companies refuse to allow developing countries to produce much cheaper generic versions of their products. Currently the cost of treating a single AIDS vicitm for a year is US $34,000, while the annual wage of most people in Kenya is under US $500."

Those statistics make me cringe. Though I do think things are getting better -- albeit slowly. At least in Eldoret, AMPATH has gone a long way to reduce the stigma of HIV/AIDS, and more importantly educate people about transmission and prevention; as well as giving treatment access to those who need it. I read that and I'm reminded of a large reason I decided to come here.

Now it's time for dinner and a shower at IU house!

A quick update

2007-08-05T22:04:00.000-07:00

So yesterday was pretty chill. I slept in a bit, got up and had a leisurely breakfast with Priti, and Dr. Mamlin was back from his weekend away, so we talked to him for awhile. He was telling us a bit about what he did over the weekend -- took a long ride into Uganda, then out on a boat to an island in Lake Victoria, where they did an HIV/AIDS educational program, then to an orphanage, and another long ride back to Eldoret. I wish that I had half of his energy.

We were feeling brave, so we made our own lunch in the kitchen -- pasta with a sauce that we kind of invented on the spot. Venus, Priti, and I ate with Sonak (an PharmD/MPH who will be living here for 5 or more years getting a pharmacy exchange program off the ground), and we met 2 of the Kenyans who live in IU house -- Benson and Simon.

After lunch the 6 of us walked into town and met up with Dayna and Erin. We went to the market, where I found a fleece almost exactly like the one that got left in the Subaru, for 300kSH -- not bad! I also bought some more phone cards. I can see spending a significant amount of money on those things. We went to a cafe and had some chai & coffee, then Sonak took Priti and I to Nakkumat -- basically Eldoret's version of Wal-Mart. There's actually quite a lot of stuff there, and a fairly wide selection of electronics and home goods as well.

After Nakkumat, we met back up with Benson, Simon, Erin, Dayna, Venus, and Laurien, and we all wen to a bar called The Klique to watch Man U vs. Chelsea. Futbol! It was quite fun, as everyone in the bar was very into the game. I even learned more about soccer (which wasn't difficult, as I knew next to nothing to begin with). As someone in the group said, it was a lot like America's Monday Night Football experience, and it was a lot of fun. I could definitely get into soccer more if America cared more about it, but as I told Mike, we'll have to see if there's a Beckham effect.

After the game we walked back to IU house (not my favorite thing -- as it had just gotten dark, but still too early to call a taxi, and we were a large group and had 2 Kenyans with us), where we met Robert and Hao, our medical directors, who had just gotten back from a weekend away as well. We talked a little about the next 2 months -- I'll be starting on Peds wards for 4 weeks, then moving to medicine wards for 3 to 3 1/2 weeks. We also met our 2 American residens -- Hank and Linda, who had also been away for the weekend. So there are now quite a few people at IU house.

We're meeting Hao this morning at the hospital for more orientation and tour, and we'll do a more thorough orientation after rounds. Then this afternoon, we re-pack and move to the hostel. It will be nice to get a little settled and stop living out of a suitcase.

Lala Salama!

A long overdue post...

2007-08-04T11:05:00.000-07:00

so... I made it to Eldoret. The ride was... interesting. But let's start from the beginning...

After quite despondantly leaving Mike at the airport (or, he left me there, rather), I had an uneventful flight to Boston. But then the fun started. Of course the plane from Indy to Boston was a little puddle jumper, and we didn't get a real ramp thingy to get out of the plane. We walked down the stairs and into a back door of some sort that led to a maintenance area of some sort that led to a baggage claim area of some sort. Except it was actually the baggage claim area. So.... I had to go BACK through security, which is Boston is a huge deal, and I ended up waiting in line for about an hour. Luckily I had plenty of time. But, of course my bag with medical supplies got scanned twice and then searched (due, I think, to my reflex hammer, which has a sharp metal, dagger-like handle) as it did in Indy, so by the time I got to the gate at Boston, I was quite perturbed. As I left my American cell phone at home, I tried to call Mike on a pay phone, but the first one ate my quarters and then the second one kept telling me I was dialing an out of order number. But by the third phone, I got through.

Flight from Boston to Amsterdam was about 7 hours. I was planning on trying to sleep most of the way, which didn't work out so well. I was in a row of 2, in the window seat, and of COURSE my seat was broken and didn't lean back. But, the seat next to me was never claimed, so I could lay down of sorts. Which really wasn't all that comfortable, with my head jammed uncomfortably against the arm rest, and my feet hanging out into the aisle and getting rammed into by passengers or drink carts or whatever every other minute. The hour or so that I did manage to get some sleep was when they brought dinner around. Of course. After that I couldn't get comfortable so I just ended up watching movies -- Shrek 3 & Spiderman 3. On this plane we had our own individual screens, so that was nice.

So I arrive in Amsterdam, dirty, tired, and schlepping about 100 lbs of stuff behind me. This airport is HUGE -- it really was like being a shopping mall that just happened to have airplanes parked outside the windows. I wandered for a bit, got some breakfast, bought a phone card and checked in with Mike again. Then I met up with Priti, and it was time to -- you guessed it -- go back through ANOTHER security line! Apparently at Amsterdam, security checks happen at each individual gate. After getting my bag searched (again), we get on the plane. And I mean, this was a PLANE. One of those double decker things. They even had 2 separate rams depending on which rows you were sitting in. So I go up my ramp, and one of the flight attendants directing traffic looks at my ticket and tells me to go left. Well, left was the wrong way. I consider myself a fairly intelligent person, but I got totally lost on this plane. The numbers made no sense (plus I was sleep deprived), and the aisles were super narrow, so my suitcase kept getting stuck, plus I was going against the flow of traffic most of the time. I eventually just threw my suitcase in a random bin, and finally found my seat. It was in a little secluded section of the plane, right by a bathroom and a water fountain (fancy!), I was on an aisle seat with no one behind me, and the seat leaned back, so I was thinking this was pretty sweet. I had been sitting there no more than 2 minutes when a flight attendant asked if I would be willing to switch with a man who was traveling with the 2 women next to me (they were African) who didn't speak English, and he wanted to be near them to translate. So I think, ok, I guess, I'm a nice person I will do that. I pick up my bag, fight back through the streams of people entering (seriously, I have never seen a boarding process so chaotic), and we find the guy. Well, he's not even in his right seat anyway, so we were confused about where I was supposed to sit -- but of course it ended up being one of the middle seats in a row of 4. It also turns out that I was once again sitting next to 2 (different) African women who were traveling with this man, and they didn't speak any English either. Now I'm wondering why I gave up my great seat? Luckily, once again, the aisle seat next to me was never claimed, so I moved over to the aisle seat. But apparently, that's what the woman next to me thought she should to too, so she moved over to sit directly next to me again. But atleast I was on the aisle again. All in all, it was a long and uncomfortable flight (there's definitely something to be said about shelling out the extra money for business class when flying halfway around the world), especially since the African women communicated mostly by hitting, nudging, and shoving whenever they wanted something or wanted out.

But, we FINALLY made it to Nairobi after a little over 9 hours. The scene at the airport was total chaos. We stood in line to exchange money, stood in line (for over an hour) to get our visas. Luckily ours were pretty much the only bags left by the time we got through immigration. And everything made it intact! Then we stood in line to go through customs, and then we had to try to find our driver. If I thought the airport was chaos, then the transportation area was an absolute zoo. Or a circus. Or a zocus. We were told to expect it, but people just start randomly grabbing your things, telling you that they are your driver, or they will take you to the hotel, or whatever. So that wasn't fun. But we did find our driver eventually (who by this time was wondering if we had made the plane or not), and he was very friendly and took us to our hotel.

The hotel in Nairobi was quite nice. It had a nice little work out room and a fabulous breakfast in the morning. We felt quite safe, as our driver had to pass through 2 security checkpoints, and the locked front door was guarded by a locked gate. We sort of crashed when we got there, ordered pizza and watched some American TV (J.Lo is present even in Africa). After breakfast the next morning, we checked out and our driver met us to take us to Eldoret.

Our driver's name was Netta, and she is a "white Kenyan" as she said -- having been born and raised in this country, now working mostly as a safari guide. She knew a ton about the city and the country, and answered all of our random questions. The ride out of the city was awesome, as it was the first time we had seen Africa by day, and there were people everywhere. We passed most of the downtown buildings, and an enormous market with thousands of people selling millions of things. A little farther out of the city, we passed an area that wasn't a game preserve, but near it, so we got our first look at some African wildlife. We saw several herds of anetelope and some impala, as well as many random herds of zebra grazing along side of the road. The coolest thing was the baboons, though. They sat on the side of the road eating whatever was thrown. We got to see them running, too, and they are quite quick!

The scenery along the drive was phenomenal -- we drove up to the peak of a mountain that overlooked the Rift Valley, drove down into the valley to Nakuru, then climbed back up into the hills where Eldoret sits. Overall, the trip took about 6 hours. The first 2 hours were awesome, as the road is brand new and there was so much to look at. About halfway to Nakuru, it started to not be fun. This is where the new road ends and the old "road" begins. I say road in only the very broadest and most generic sense. Certainly, it was paved, at some point in the past, but that was it. There is no repair whatsoever and the potholes are unbelievable. To get around this, people drive pretty much wherever they want (though technically driving is on the left here), and you just avoid other cars and people (both of which there are many) as best as you can. The best part is when you're clearly on the wrong side of the road either avoiding potholes or passing another car(s) and the plumes of dust are rising so high that you can't tell if what's coming directly at you is a bus or a bike. The other not so fun thing is the random police stops every few miles or so. Netta said they really like to pull over matatus (taxis) because they tend to break the most laws regarding safety belts, speed limit, number of passengers, etc. If they get stopped, they usually have to pay a ticket (ie bribe) in order to keep going. So that's frustrating on a personal and institutional level. At any rate, we only had to actually stop once, and as soon as Netta started speaking in Swahili, they knew we got to leave again pretty quickly. We stopped in Nakuru quickly, then we climbed the mountain to Eldoret. Again, the scenery was just amazing.

The best part of the drive was stopping at the Equator and taking pictures (of course), and a local guy there showed us the water trick, which I'd never seen before. The water trick involves a pitcher of water and a bowl with a hole in the bottom. When standing north of the equator, the water, when poured into the bowl, will come out the hole in a counter-clockwise fashion. This was demonstrated by putting a piece of straw in the bottom of the bowl, which did in fact turn counter-clockwise. Then, while standing south of the equator, the straw turned clockwise. And when we stood directly on the equator, the straw lay perfectly still in the bottom of the bowl while the water poured out. It was the neatest thing!

Once in Eldoret, we came to IU house, where we're staying for the weekend before going to the student hostel on Monday. IU house is actually a compound of houses owned by IU and used for the staff, residents, and visitors that come here. IU house is where computer access is, as well as laundry and some meals of the week. It's about a 10 minute walk from the hostel (and the hospital, which is across the road from the hostel). After getting settled in, we went out for Indian food (which is apparently quite popular here) with a ton of people. I was so tired at this point, I barely remember the meal.

This is long.... but... on to today.
Today I went to Kisumu with 5 other girls. Kisumu is the 3rd largest city in Kenya (Eldoret is actually 5th -- it has a population of 1 million), and it sits on Lake Victoria. We took a matatu for 300kSH (about 5 US dollars), and it was a 2 1/2 hour ride (once again, on not so great roads). Again there was chaos when we got there, because the matatu stand is right in the middle of the market. Of course it was Saturday, and of course we all stand out as blatantly tourists, so we were getting sales pitches left and right. We made it to the edge of the market, where we each hired a bota bota (basically an elongated bicycle -- there's an extra seat on the back and the drivers make money by peddling people around) to take us to Hippo Point. The lake was absolutely beautiful, and I got some great pictures. We spent about an hour at the lake, and we did actually see some hippos. They were about 50 yards away from the shore, and they were feeding and sunning. It was pretty cool. We had lunch by the lake, then hired bota-botas back to town. This was more of an adventure, as the chain broke on Dayna's bota bota, so she got left behind (the other drivers did not stop), and my driver was last in the pack and had no idea where he was going. We were speeding down a hill and I saw the rest of the group, I shouted STOP and the driver stopped to fast I thought we would both flip over the handlebars. Eventually Dayna made it back into town, and we walked around for awhile. Erin really wanted some fried Tilapia, which we found, and it is actually a whole, entire fish, pulled from the lake and fried. Needless to say, I declined. We meandered back to the market and did some shopping, then got back on a matatu and headed for Eldoret.

Once back in Eldoret, we got some dinner, then wandered over to the video store (bootlegged DVDs, apparently most of them are obviously filmed in a theater). By this time I was exhausted and getting nervous, in that the #1 thing they tell you NOT to do in Eldoret is be out at night. I was apparently the only one concerned. By the time we left the video store it was definitely dark (it gets dark about 7 here), and there are no lights. So, we are searching for a cab, can't find one, dashed in and out of traffic (again, the driving is just crazy here) to get a a corner where the cabs and matatus leave, and no cab will take all 6 of us. We didn't want to split up, so Dayna called a cab driver who knows the med students, but he took forever to show up (turns out he didn't actually know where we were), and the whole time we're standing there (again, standing out like sore thumbs) getting harassed by drunk guys and matatu drivers -- "where you go, where you go? You go to Nairobi tonight?" Yeah, no thanks). Luckily there were 6 of us, but it's still not a situation I want to be in again. I was actually really mad about it, as it was a stupid situation for us to get in, especially as it's only my 2nd day in Eldoret. Eventually our cab showed up though and we made it back to IU house fine.

The group I was with today was actually pretty diverse in terms of culture & experience. There's me, there's Priti (who's Indian though born in the US), then we met Erin, a 1st year Candian medical student who's been here for 10 weeks (she leaves Wednesday), Dayna, an African-American 4th year IU student who's here for July/August. We also met Venus, a business major doing a project here. She's also from Canada, but her parents are Chinese; the last girl is Laurien, a 6th year med student from Holland. So overall, we really REALLY stood out today.

I know this has been very long, but I feel like so much has happened already. I'm sure it will all start to seem more common and less amazing as I get more used to being in the country. Tomorrow is kind of a relax day, and Priti and I will meet with our medical directors to figure out which services we'll be on while we're here. Then we'll move to the hostel either tomorrow or Monday, and start work at the hospital on Monday. I'm very excited.

Asante sana for all of your thoughts and prayers.

Hujambo from Nairobi!!!

2007-08-02T23:39:00.000-07:00

This will be a quick post, but just wanted to let everyone know that Priti and I made it to Nairobi safely. The 24 hour journey around the world was quite exhausting, and I slept more than soundly last night.

Our taxi to Eldoret will pick us up in about 20 minutes, and then it will be 5 1/2 hours or so on the road before we get to Eldoret.

I'll post more about the journey later, when there's more time and we're not paying for the internet by the minute.

tutaonana

2007-08-01T06:49:00.000-07:00

I'm officially off the airport in about 10 minutes. It's hard to believe this day is here already.

Thank you, everyone, for all of your emails & calls. I've really appreciated them.

I'll be updating Mike on my progress across the world, and I'll try to post as soon as I can after I reach Eldoret.

Your thoughs and prayers are so much appreciated right now.

best.walk.ever.

2007-07-19T17:42:00.000-07:00

got delayed by the rain. stepped in a hole, turned right ankle. ozzy ate goose droppings. ozzy ate dead fish. ozzy ate more goose droppings. fell off sidewalk, turned left ankle. mike played with willow branch that snapped in half and flew directly into my eyeball.

went home. iced ankles. decided that outside wins today.

very important!

2007-07-18T19:05:00.000-07:00

I forgot to mention -- I am married to an officially unofficial sports writer now. Well, at least one that is now receiving a nominal fee for his efforts.

All joking aside, Michael is an excellent writer and he definitely has the talent to make a paying career of his hobby. Which is great, because I think everyone should love what they do for a living.

And, you know, he's real cute too.

PICTURES!!!

2007-07-18T17:26:00.000-07:00

Here it is -- the first of probably several posts to include many random pictures. These blogs will be brought to you courtesy of the fact that Mike and I, together, have finally decoded Kodak's secrets -- though I'm pretty sure it involved the staff of Ra and something to do with our firstborn child. I'll try to do this somewhat chronologically. This first pic to the left is the front of our house this past February when we had a ridiculous amount of snow. Notice the massive ice hanging from the gutter (which is apparently a bad thing, I found out. Who knew?)

Here I am in front of the Capitol Building on my awesome trip to D.C. for ACP's Leadership Day in May.

With the Bride & Groom at the Kidd/Sokel wedding...

...and at the Moody/Shoup wedding...

...and at the Nichols/Alleshouse wedding....

(it's difficult to get Mike to take serious pictures)

And I'll end this post with me at the finish line of the Morse Park Triathlon this year. I finished! Hooray!

(NOTE: though I've decoded Kodak, Blogger still has many mysterious and enigmatic ways. Hopefully I'll continue to unravel them and my posts will start to look less funky...)

marching forward.

2007-07-10T18:28:00.000-07:00

well.. June has now come and gone, and I'm already a week in to my July elective. June was a fun & busy month, though not too much happening on the Africa front.

NICU was fantastic -- aside from the whole critically ill newborns thing. The elective didn't absolutely convice me to go into neonatology some day, but it didn't rule it out either.

July already seems to be running away from me -- it's only about 3 weeks until I leave. I actually started packing yesterday, though I think I'm probably already over the 50 lb limit and I haven't actually packed any clothes yet. Or medical equipment for that matter. Both fairly important things.

Things are coming together, thought it seems like there is still SO much left to do -- both in terms of getting ready to GO to Africa, as well as getting ready to LEAVE the US, if that makes any sense at all. The biggest thing right now is getting as much residency application stuff done as possible before I leave. Which has been stressful, to say the least.

This is a short post, but hopefully soon I'll be able to post a bunch of pictures detailing the whirlwind that has been this spring/summer: 3 exams, 3 weddings, and a triathlon, to name a few things.

Until then...

Done! (Sort of!)

2007-05-21T06:38:00.000-07:00

Well, all of my clinical responsibilibies for 3rd year are DONE, and now we have a little "break" between now and June 1st, when we start 4th year. I say "break" because it is not really one for me. Tomorrow I take my senior OSCE, then a week from tomorrow it's Step 2 CS in Chicago, then 2 days after that I'll take my final exam (surgery) of THIRD year. So yeah, lots of studying to do in the next 10 days. I'm kinda bummed about not really having a break, but I did it to myself, so it's ok. I'm also hoping to get my MESS of a house cleaned in the next few weeks as well.

My fourth year schedule looks as such:
June -- NICU (VERY excited about this)
July -- Developmental/newborn follow up outpatient
Aug -- KENYA
Sept -- KENYA
Oct -- Peds cardiology
Nov -- Peds therapeutics (hopefully). If I don't get into this elective, I'll be doing Peds infectious disease
Dec -- VACATION (and residency interviews)
Jan -- Radiology
Feb -- Emergency Medicine
March -- Peds heme/onc (and MATCH DAY!!!)
April -- Medicine Sub-I (The only worse month to have your Sub-I is in May)
May -- VACATION (and graduation!)

So there you have it. Only 12 short months until I have in my posession a very expensive degree and hat. Kinda scary, eh?

In other news, the ACP leadership Day in DC was pretty great. The first day, I learned quite a bit about specifically what issues the medical community has identified as needing priority action. I also learned more about the structure and theory behind the medicare program, and we touched a little on medicaid as well. It got me (re)interested in public policy, and once again I'm thinking that may be part of my medical future. I also got to see Jay and India, which was fun. Overall, it was a good trip, but now I really need to go back so I can do touristy things (as the last time I was in DC before this, I was about 10).

The books are calling. But far away in the distance, I think I can finally see an end in sight!

I'm leavin' on a jet plane

2007-05-05T17:19:00.000-07:00

step 1: tickets bought -- check!

well, my flight's been booked, that's a big step done. I'll be leaving 8/1 in the afternoon --> arriving in Eldoret 8/2 in the evening. Return flight leaving 9/28 and I'll be getting back to the US sometime on 9/29.

Whee!!!!

In other fun news, Mike and I ran the mini today. Well, we ran the 5K portion of the mini. I was really set on finding time to train for the 13.1 this year (as I've been for the past 3 years), but unfortunately having surgery block during prime training time was not conducive to that. So, NEXT YEAR. Next year I WILL train for the full (half) marathon and do it! All in all, the event itself is really something to see. All of downtown, and many surrounding streets are completely closed down. By far the biggest 1/2 marathon in the country; 35,000 people run the 13.1 portion, with an additional 3500 running the 5k. Afterwards, the entirety of Military Park is full of various booths and vendors, massage tables, radio stations, etc. Not to mention boatloads of free stuff. It was actually really fun. (Even Mike thought it was, though he is not the biggest fan of running). Afterwards, we went to see Spiderman 3, which I highly reccomend.

Overall, it's been a good day. Now I'm chillin' watching movies while Mike is downtown doing press coverage for the Fever game. Then it's back to work tomorrow. Blah.

BUT I HAVE PLANE TICKETS!!!!

First Meeting!

2007-05-02T18:36:00.000-07:00

Huzzah!

Actually, it was pretty fun, to get to bond and chill with all the other MS3s (soon to be MS4s!) going to Kenya in various other months. It turns out that 2 of the other students planning on going in August/September switched to different months, and 1 other one dropped the elective. So now (as far as students going), it will be me and 2 pretty good girlfriends from school, so I think we're going to have a great time together. Also, one of the residents who will be there in September with me was one of my inpatient peds residents last November, and she was tons of fun.

So really, we talked about some logistics (important) and a lot about safety (VERY important), buying our visas, money, that sort of thing. There were some questions that I didn't really get answered, but I want non-administrative (ie -- other students') answers. So I'll ask around.

Next week is the SHOT meeting, we'll get to spend the first in a long line of large sums of money for protection against Hep A, typhoid, polio, and yellow fever. Wee-haw!

In other news, tomorrow I leave the blissful world of anesthesia and return to transplant. But for only 12 more days!

Addendum: Just so you understand how much school has been sucking lately, I COMPLETELY forgot that Tori's new album, American Doll Posse, came out yesterday. Ack! How can this be?!?! Lucky for me, wonderful Mo drove around tow to find it for me tonight :D.

Happy May Day!

2007-05-01T05:34:00.000-07:00

Today marks the three-months-to-go mark until I'll be in Kenya! Well, at least I'll be in some sort of vehicle on my WAY to Kenya. This week is also super exciting because Wednesday is the first of several group meetings about the elective, and hopefully I'll get a few questions answered so we can buy plane tickets some time in the next week.

Aside from occasional moments of sheer panic when I think about actually LIVING in Africa for 2 months (without my husband, no less), I'm getting REALLY excited about going. Third year is so close to being done I can hardly stand it, then it's off to DC for a few days, taking my first exam of fourth year (before fourth year even starts -- how does that work?), taking the first part of step 2 boards, then learning swahili, and I'll be good to go. Or something like that.

And also, tomorrow is my dad's birthday.

HAPPY BIRTHDAY DAD!!!!
(now if anyone has any suggestions on gifts, send them my way)

human

2007-04-14T19:17:00.000-07:00

though this is not technically about Africa, I have to blog about the experience I had on Tuesday.

My 2nd day of transplant service, and I get to go on an organ procurement with one of the transplant surgeons and my intern. First of all, I was asked about 7:45 if I wanted to go, and oh by the way we need to leave at 8:00. So my intern and I drive at lightning speed to the airport (really -- we were going 90-100mph the whole way), and we hop on a little Cessna to fly 2 hours to where the donor is. The weather in Indy at that time was quite terrible (as it continues to be), so the takeoff was very rough in our teeny little plane. The weather at our destination was not that much better either, and by the time we took our rollicking ambulance ride from the airport to the hospital, I was feeling quite green.

The real spectacle, though was the procurement itself. And I don't mean spectacle in a bad way -- it was just...wow. To start off with, the incision went from neck to groin, as well as 2 cross-wise abdominal incisions so everything would be exposed completely. Gross anatomy this was SO not. Everything looks so much different -- much more /real/ in a live patient as opposed to a cadaver. We were there to get liver, kidneys, and pancreas, and there was a local doc there to get the heart. Since our team brought 3 people and he didn't have anyone with him, I got to 2nd assist with the removal of the heart. I helped remove a heart. A beating heart. I still don't think I have fully processed that fact. To make a long story short, some unexpected things occurred with the procurement, the aorta was punctured and the donor patient had a lot of bleeding. As it turned out, after the kidneys came out it was deemed that they were not usable due to their prolonged lack of blood flow. This was of course quite disappointing, but we were still able to leave with a liver for a patient, and the pancreas went to research. We got the heart out too, which was quickly rushed off to a locally waiting patient.

I was excited to be able to go, to experience something that aside from these 6 weeks I'll never get to experience again. But, I was also surprised at how sad it made me feel. Primarily because this patient represents a whole life lived, a whole family now with one less member, a wife and kids grappling with a mountain of grief. I think a lot of it also had to do with the fact that this was a quote-unquote living donor (that is, he was brain dead, but physiologically all of his other organs functioned), and so in the beginning when we opened him up it seemed just like countless other surgeries I've scrubbed on. But to see his heart still beating, and then us working hard to get it out -- that was a large concept to try and grasp. Medically, this man was dead. He had no brain function and would never again have life as we understand it. That being said, why is it that it wasn't until we took the heart out that I really thought of him as being dead? Was it the fact that we were responsible for his physiologic death? Or maybe because a small part of everyone wants to hope that brain dead patients will make a miraculous recovery? Though in his case this wouldn't have been true -- I understand why it's hard for families to let go of such patients; because they look well aside from persistent unconciousness. After his organs were out (lungs were also removed for research purposes), the intern and I helped the IOPO staff stitch him back together. I was just struck at that moment how much it seemed like we had left a formerly living, human person in utter desolation. Other than stomach and small intestine, his formerly functional body had been reduced to an empty shell of bone, muscle and fat. It was so striking.

But overall, it was quite awe-inspiring. I don't want to talk anyone out of organ donation or in anyway detract from the completely selfless gift that this man made. Even though it was (and is) so hard to move on from the image of taking out his beating heart, after it was all over and we were back on the plane, I couldn't stop thinking to myself that I helped save someone's life today. Somewhere, right now, a wife, husband, son, or daughter is recovering from receiving a brand new heart. This patient and his/her family has no doubt gone through many, many ups and downs on the road that had lead them to the point of needing a new organ. And now, today, they are experiencing a hope and joy that they likely haven't felt in a long time.

Experiences like this really make you contemplate the Big Questions -- the meaning of life and all that. What is it to be alive, anyway? It's clearly not just the physiologic, native functioning of our many organs. If that were the case, our donor patient could have 'lived' for many more years. Conversely, it's not simply brain function -- your brain can work perfectly and you'll still die when your heart gives out. No, there must be something more than that; something more that makes us truly ALIVE and gives us our humanity. Many people, myself included, believe that this is what defines the soul of a person. And I also believe that the soul is the part of the person that goes on existing after the physical body has died.

As obvious as it sounds, the experience was difficult because I am still a living, breathing person. It is impossible for me to fathom losing any part of the body that I have lived in for 25 years. I still cling to 'the things that are seen.' This man though, our donor patient; he understood that after his physical death, he had absolutely no need for his liver, kidneys, and even his heart. His time had come to move beyond the things of this world into 'the things that are unseen.' In the end, it wasn't the surgery team that saved 2 lives that day, it was the patient. He took what would have been 3 deaths and saved the lives of 2 others -- 2 strangers nonetheless. What an amazing legacy for him to leave with his own passing from this world.

off to a roaring start

2007-04-09T14:47:00.000-07:00

with this blog, eh?

I really will be trying to post more often now, for a few reasons
1. ONLY 5 WEEKS LEFT OF BEING AN MSIII!!!
2. I finally was able to recover the password to this blog, which was quite the feat in that I created it 3 months ago, forgot what email I signed up with, and forgot my user name as well.
3. Hopefully I'll be buying my plane tickets toward the end of this month

4. Most importantly: this article about Joe Mamlin was in yesterday's Star. Sure, spending 61 days in a 3rd world country makes me feel anxious at best and terrified at worst, but when I think about the work that Dr. Mamlin has done, I can't /help/ but be excited. In his short lifetime, he has transformed a country and given hope to thousands, probably millions. I am going to be a part of something that has changed the world. Something that will continue to change the world, as Dr. Mamlin's multi-disciplinary approach to fighting HIV/AIDS spreads to other countries in Africa, and more partnerships between American & African institutions are formed.

Joe & Sarah Ellen have created a legacy, a legacy that will last for many years regardless of whether or not he wins the Nobel Peace Prize. Though I personally think he should. (And it would be really cool, seeing as I've had dinner with the Mamlins). But mostly because he seriously deserves it.

hujambo!

2007-01-24T17:39:00.000-08:00

well, Old Blog has temporarily (or perhaps permanently) mosied on over to New Blog. The purpose of New Blog is to chronicle my adventures in Africa and the goings-on and happenings that occur leading up to departure. I'm still not sure what internet access will be like in Eldoret, so a lot of stuff may not be posted until after I get back. New Blog will probably be pretty bare-bones for awhile, as I'm starting surgery block & 15 hour days next week. But, check back, I'll try to keep everyone up to date as I know more things about the trip.

tutaonana! (for now).