Adventures in Nakuru

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

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

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

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

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

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

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

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

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

Systems Based Practice

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

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

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

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

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

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

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

How Far We've Come (Or, Cake)

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

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

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

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

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

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

Evans

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

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

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

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

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

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

Ryan

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

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

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

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

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

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

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

Thoughts on the Journey & Settling In

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

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

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

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

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

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

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

Until next time, Faithful Readers.

Kenya Article

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.