Day 25 - Last Day in Kenya

Today everyone seemed to be in a fighting mood. 3 seperate assaults. Huge black eyes, busted up eye brows, rib fractures. Standard brawl stuff really but all in one day.

We also had a woman come in with something that I can only try to describe because I would at best be guessing as to her actual condition. She was an older woman (not sure of her age exactly) but probably in her 60’s who came in with respiratory distress. She had a scarf wrapped around her neck as that clearly was where he problem was. Once we unwrapped her neck, the vicinity just filled with a stench. A stale, almost moldly smell came out.  On the L side of her neck, her check and neck puffed in and out with each rapid breath she took. Tachypneic to probably ~40 breaths/min but I didn’t count it out. The L side of her neck actually heaved as the subcutaneous tissue filled with air and then emptied with each breath. The R side had a small hole where the air rushed in and out of her neck past what I’ll describe as a fungating mass.

I had never seen anything remotely like it. When they briefly put the Life-Pak on her to check her vitals, her SpO2 read 44, and I am inclined to believe that was correct. She had a GCS to match an oxygen level of 44 that had been there for quite some time. A man who had come in with her said that she had been like this for almost a week and had quit responding all together 3 days ago. Blink… blink… blink. She has been like this for 3 days, maybe more.

I have no doubt in my mind she will pass by the end of the day. I’m actually a little surprised she hadn’t sooner. They did administer some oxygen when she got there, but it is undoubtedly not enough to fix an SpO2 in the 40’s especially with a hole in her neck and goodness knows how much extra dead space. My best guess… and I might be REALLY wrong… is that she had some type of CA in her throat and it eroded through the trachea and neck.

We also saw a small boy who had fallen off of a motorbike (undoubtedly unhelmeted because I don’t think I saw a helmet the whole time I was here). He had a bloody nose, fat lip, and lac through his eyebrow. When he opened his mouth, it was clear that his mandible was fractured. His 6 lower teeth were completely visible from crown to root and oriented straight out (crown towards us, roots pointing not into the mandible but back towards his uvula).

After the hospital, we rushed back to the hostel for our henna appointment. A woman came to the hostel  (apparently we aren’t the first people to request this) and did each of us in turn. I got both of my feet done as did Charley, and Caroline got her hand done. The woman who applied the henna was shockingly quick and accurate. The designs intricate and effortless at the same time.  I actually rode to the airport with no shoes on to ensure the henna fully dried. Now I’m sitting in the airport with my feet bandaged in toilet paper (a tip we read online about henna care) then socks, shoes, and jeans for the flight. No one here is the wiser, and I can’t wait to get to Egypt to take a shower and see the final product.

Next stop… EGYPT. (Or well… Nairobi, then Amsterdam, then Paris…. Then Egypt.  But same difference.) J

Day 24 - Really becoming a local

Today when I walked into A&E, it was chaos. I didn’t have time to set down my bag, and much less take a look around the department, before the manager of the minor theater (really more of a procedure area… where they do minor surgical type things. Stitches, chest tubes, etc.) asked, “ You can put in a catheter, right?” I confirmed that she meant a urinary catheter and that she wanted it put in the old fashioned way (because they do suprapubic caths in the minor theater like it is no big thing here). Then I said that I could. The man had a catheter in place that clearly wasn’t doing its intended job. The bag was empty… actually dry. Not a drop in there. And you could actually visualize this man’s bladder. Thin, scaphoid abdomen with a round swelling at the base to almost halfway up to his umbilicus. Really full bladder. I admit I kinda got a little worried. Clearly, someone had botched this before. He was older… maybe he had a HUGE prostate or worse, prostate cancer.

Luckily for me, the cath went really easily. The previous cath had been blocked up by a long thin blood clot that was clearly visible when I put the cath in and got 850 mL of urine immediately. Poor guy must have felt so much better after getting that 2^nd cath in, in place of the 1^st one.

Then, they asked to borrow my penlight to check on a woman’s pupil reactivity… or well… more correctly the lack thereof. Not only were her pupils fixed and dilated, she was cold obviously having been dead for several hours and no one had noticed. I found this disappointing but not surprising because regardless how precariously someone is clinging to life, they aren’t monitored. There is 1 life-pak machine that is used to take vitals and theoretically resuscitate someone (although I haven’t seen it happen). What I was dismayed about was the fact that the MO intern wrote a note saying that this woman had been “resuscitated vigorously” and had failed resuscitation.  What resuscitation? She was found dead, and not just dead cold in the department. She had come in the night before, deemed an acute abdomen, and that was it. No nurses notes from overnight. No one had rechecked on her. I can’t even herald a guess as to when she died, but I know it wasn’t the 8:30 AM that the MO intern wrote down. I found the circumstances surrounding her death to be so sad. She came into the hospital for help and seems like she didn’t get it (not because it wasn’t available for once) because no one noticed her.

After that, we had a 5 year old child with Down’s syndrome come in with burns to about 40-50% of his body.  The estimation was complicated by the fact that this is not a normal 5 year old as his size is much smaller than that of a normal 5 year old. Fortunately, the burns were fairly superficial, but I’m still concerned about the survivability of burns to such a significant surface area of skin. My biggest concern for him was 2-fold. One, the shear surface area that was burned and the amount of fluid I was already watching him lose. Secondly, infection. His mother was putting forth a great effort trying to keep the flies from landing on her son’s open wounds trying to drape a sheet around his shoulders without touching his sensitive burns, but there were just so many flies and he had so many places for them to land.

We learned that this child had gotten a kettle of tea on himself. I admit that I initially had some concerns for abuse (because of the circumstances and especially in a special needs child… in Africa), but I was pleasantly surprised to see the way his parents tried to calm him. Also he had a steady stream of extended family (more than everyone else in the department) that came to see him during this stay in A&E. This actually prompted a discussion between Caroline and I about Down’s syndrome in developing countries, and how we thought this child was probably the exception rather than the rule.

After the hospital, I took care of something I have been itching to do for a while. Caroline, Charley, and I took a matatu into the city center. We felt that it was important that we got a picture of the single thing that Mombasa is most well-known for… 2 sets of tusks that cross over the road. Okay so they are replicas of tusks, and much, much larger, but it is supposed to be representative of some important event. I’m not sure of the details but it has to do with a king and welcoming someone into the city. See requisite tourist picture here.….

Now the real reason I wanted to go back to the city center was to get a pair of flip-flops I had seen on previous trips to the market. They have a dot that comes up between the big toe and the remaining toes and then just a strap across the top of the foot. And this is where it gets fun. Knowing that I’m heading back to residency and knowing that I’m gonna be getting myself new shoes to work in the hospital with, I had already concluded that the shoes I had worn each day to the hospital would not be coming back to the US (and certainly wouldn’t drag through Egypt) with me. So I had brought them from home thinking that they wouldn’t come back with me. There was nothing wrong with them, but they had had their run with me, and it was time. However, I had started to think over the course of my time here that I might trade them for the shoes I had started to like in the market. Kill 2 birds with 1 stone… and save money doing it. Heck yeah!

I am proud to say that I now feel like I’m getting good at bargaining (and trading). I ended up getting a even swap… no money exchanged. My old shoes traded for a new pair of flip-fops.

We then had a special dinner at a really yummy restaurant at Bamburi beach that I had been to with Sid and Gaurav before called Yul’s. The girls insisted that I had to try the burger there. A burger? At a seafood restaurant? In Kenya? I’m glad Ii did though because while it was a burger, it was a Kenyan take on a burger and really good. Covered in some sauce (not sure what). Then we just went back to the hostel the girls are staying at  to hang out, but mostly to make sure that we got a henna session scheduled for the next day (after the hospital, but before I left). All set.

Day 23 - Back at the hospital

I am back at the hospital on A&E for the 2nd week. I was pleased to see that Dr. Abu looks a bit less frantic than he did in the first few days I worked with him. It seems like the trial by fire works.

Today was kinda... dare I say it... calm. I'm thinking that I'm only saying it after the fact it doesn't break all the ED rules about actually saying the bad words of the ED. (See also... "slow," "quiet," "not busy," etc.)

We saw some bread and butter emergency type stuff... a guy who had a stellate laceration to the  eyebrow from where someone had hit him. It sounded like he said that police did that to him. I do appreciate that the dynamic with police seems to be almost universal. A woman who has a long history of psychosis who seemed to be rather content just bouncing around the free beds in the department. And the nurses seemed content to let her do it because she was easier to manage that way. At least when she was playing musical chair with the beds, she was willing to leave her clothes on. Which begs the question that I'm not really sure how they handle psychiatric patients after they leave the emergency department.

There was 1 case that really fascinating and unusual. A woman in her 50's who came in after a fall with a swollen knee which was clearly a large effusion of some sort except she didn't have the ability to really straighten that knee. Dr. Abu told us that it was a patellar tendon rupture. I admit I had my doubts but all of the clinical signs confirm his suspicions. Flexion seemed to be a little limited by the amount of fluid and some pain, but relatively easy for her to do. She could only extend the leg herself by inching her toes along the bed. On the knee exam, there was a distinct difference comparing R to L. The tibial tuberosity on the afftected side was really prominent and had a indentation proximal to it where the patellar tendon should be. It was a really cool and interesting exam.

We debated doing a joint aspiration, but elected against it because there were precious few signs to indicate that it was infection rather than trauma that caused the effusion. So, we wrote for a x-ray of the knee. However... TIA... the power was out, hence to x-rays while I was there to confirm that this was, in fact, a patellar tendon rupture.

After the hospital, I was slated to go volunteer at the local school that is run for some impoverished children who live close by with Dolas. The school is run entirely on  donations. The school's primary function is to offer a safe place for these kids to come during the day. Many of them are orphaned, abandoned, or neglected by their parents. They come to school for 2 meals/day (breakfast and lunch) and get educated in the meanwhile. It is meager but the head matron seems to have a real calling for it. There was a miscommunication, however, and the kids had already been sent home for the day when we arrived. I took some donations (just some exercise books, rulers, pens, and candies for the kids) and left them at the school with the promise that when I returned the next day the kids would be there for me to hand out the things I had brought.

So... we headed back to the house. I was content to lay by the pool basking in the warmth of Mombasa (that I had so dearly missed in Nairobi and Masai Mara which were much colder than the coastal town I am now accustomed to sweating bullets in). I also used the afternoon to just catch up on some computer stuff... emails, school work for classes and graduation, etc. especially since I'm not sure what, if any, internet connection I'll have while in Egypt. Already looking forward to it! These last 2 blocks of medical school are undoubtedly the best!!!

Day 18-22 - SAFARI

Once again, I promise I'll do some more serious posting here when I have a bit of time to document my adventures, but here's a quick run down for now.

Day 18 (Thursday) - Travel to Nairobi... long, hot, boring, cramped.
Day 19 (Friday) - Drive to Masai Mara.... less long, less hot, and somewhat entertaining then evening safari game drive
Day 20 (Saturday) - ALL DAY SAFARI!!! OMG, AMAZING! (Here is a teaser picture for the time being. Many more to come with a faster internet connection.)

Lions! (Yes, I did take this picture. And yes, we were that close.)

Day 21 (Sunday) - Morning safari and drive back to Nairobi
Day 22 (Monday) - Travel back to Mombasa

Day 17 - First day alone for the interns

I feel like all of the days I have spent in A&E (accident and emergency) have been so intense, and today was no different. The medical officer that I had been working with, Dr. Bule, was not there today. From what I have gathered, a new crop of medical officer intern started at the hospital last Wednesday. They worked with the MOs for 1 week, and now they are on their own. Kinda a brutal way to learn, but I guess it is just how it works here.

So today just me and Dr. Abu held down A&E. I think he was very thankful to have me there, and I was thankful to have more to do than usual. We had a drunk patient (you gotta love the patients who manage to be wasted at 10 am) who had multiple lacerations to his head. There were at least 4 separate lacs that combined to about 30 cm of laceration length. Plus, his ear was split along the cartilage. Sewing him up was pretty brutal for everyone involved because he kept thrashing about, I think more because he was drunk than he was in pain. He was given diazepam and local anesthetic but you can’t reason with drunk. He was already restrained to the bed, but we had to get 2 other patients (!?!?!? I know, right!) and a police officer to help hold him down to keep him still enough to sew. Still a moving target, and we didn’t have the benefit of staples to make this go faster. Dr. Abu (poor thing… I can’t imagine being left in the emergency department on my own 1 week into internship) started to sew. I helped him trouble shoot this one most complicated stellate lac, and then he turned the needle driver over to me. I think I’ve had more opportunity to suture than he has and was more than willing to shorten this ordeal for patient and everyone involved. Still took FOREVER.

There was also a patient with a crush injury of his index finger. It was so mangled that the only real option was amputation. (Poor Dr. Abu… he was going to have to figure that one out after I headed home. Never done an amputation before.)

We also saw a 27 year old patient who was referred to the hospital from an outside hospital with a 2^nd and 3^rd CN palsy. He had a brain tumor… not sure which kind… that had been allowed to keep growing because his adoptive parents (he was a former orphan and street child, so quite lucky to have been adopted in some regards) didn’t have the 0.5 million shillings for the operation. It was so surprising to me to see that this had been going on for 5+ years (since he had some pretty notable symptoms), and he just didn’t have any real access to curative treatment.

After the hospital, the staff of Elective Africa held a BBQ dinner for me and kindly allowed me to invite Caroline and Charley over for it. It was wonderful! Yummy food that included chicken burgers, grilled fish, chicken and sausages, and salad. Plus, they put little cubes of watermelon in the drinks. (This is something they learned from some Swedish students they had a while back, and definitely an idea I’m going to have to steal. We just ate and relaxed in and by the pool. Incredible way to send me off for my safari. Can’t wait!!!

Dolas grilling food. Yummy!

Us eating... AKA no one looks good stuffing their face

Day 16 - A Day of Firsts

Today was something else! I experienced 2 new firsts for me, neither of which were good things.

First, I saw a case of tetanus. Actual tetanus. Lock jaw. Opisthotonos. Real tetanus. A 2 year old child came in seizing, for how long we aren’t entirely sure. Once we calmed the seizures down a little bit, we were able to note the posturing. It was so distinctive that I actually asked out loud if this was tetanus and Dr. Bule confirmed what I had only read about… well no… not really. I haven’t even really read much about tetanus because it really doesn’t happen in the US. I’m pretty doubtful that this child is going to survive based solely on how long he was seizing because I really don’t know much about the survivability of tetanus.

My other first was that I called my first time of death today… on a baby. Dr. Bule was getting an IV on the child who was seizing with tetanus and sent me to examine the patient that they rushed back to the department. It was that kind of day. The baby, a 1 year old, was extremely pale and not breathing. I had the nursing student bag the baby while I checked for a pulse. No femoral pulse. No carotid pulse. No notable heart movement in the chest. I checked each site at least twice. Nothing.  Pupils fixed and dilated. I remember taking a step back and shaking my head. Despite the fact that the child’s mother didn’t speak my language and I didn’t speak hers, she understood what was happening, burst into tears, and crumpled to the floor.

I don’t think I have the words for how badly I felt. Like I was personally responsible for the death of this baby. Like if only I had done more or tried harder or been there sooner, maybe things would have been different. In retrospect and with a little reflection, I know that isn’t true. The reality is that this baby was dead when he came in.

The biggest thing where I’m still not sure if I did the right thing was when I asked the nurse to bag. At the time, I was thinking that if this baby had a pulse and a beating heart… ABCs. Airway and breathing. They come first for a reason. I didn’t want to neglect the airway while looking for pulse. The options here are so limited. Despite running through my ABCs, I know that intubation isn’t really much of an option here and somewhat mitigate the way I go about handling serious conditions like this. But now, I’m not sure if I mistakenly gave the mother hope where none was warranted by bagging the baby. Although I somehow can’t get myself to believe that not bagging was the correct choice either.

Afterward, I took a moment and walked outside still keening aware of the mother’s cries inside. I needed to clear my head and think. Think about the things I have reflected about here and also pull myself together. I have seen people die before. I think it is always harder to lose a child compared to an adult, but it had never before been my call. My call to stop and say that this person is gone. Tough call.

I made a point to talk to Caroline and Charley about it on the way home because I knew that it would be better to talk about it than just clam up and dwell on it myself and that helped. I felt like once I told them what happened it wasn’t all mine to bear anymore. I was tempted to skip out on the plans I had made earlier to go to Fort Jesus with the girls because of the rough shift I had in the Accident and Emergency department, but once again thought better of it. If I went home, I would just dwell and rethink every decision I had made. So, we went off to the center of Mombasa and Fort Jesus.

Charley, our guide, and Caroline taking pictures inside Fort Jesus

View out of the fort over the entrance to Mombasa port

Fort Jesus is a fort built originally by the Portuguese and taken over during different points in history by the English and Arabs. The guide told us everything in order of how it happened but I think I was too busy taking pictures to keep up with the finer details and dates. It is rumored that the place is called Fort Jesus because the actual shape of the fort looks like a person with a head, 2 arms, and 2 legs. I’ll admit that sounds fishy to me… I mean Jesus wasn’t the only person to ever have a head, 2 arms , and 2 legs. Cool fort, but kind of poorly preserved which is a bummer. Then we had some ice cream on the way home. Certainly a better end to an unforgettable day.

One of the remaining British cannons in the fort

One of the beautiful Arab doors in the fort (The carvings around the outside document the fort's history.)

Another view from inside Fort Jesus

Day 15 - My kinda place

Now this is more like it! My first patient of the day was stabbed. (Not that I want people to be stabbed, but I certainly want to be there to fix their hemothorax if and when it does happen.) Today, I started in “casualty” or the “accident and emergency department”, and this is where I will remain for the rest of my time for this rotation in Kenya. Totally looking forward to it! I’ve already gathered that affordability of care is still going to be an issue even here, but it does seem like there will be more for me to do regularly.

I actually got to draw blood and start a handful of IVs, including one on a 2 day old baby. What? Awesome… I know! And I did it with only 1 stick. Kind of amazing, if I do say so myself especially since he was dehydrated to start with. Now that I have been overly congratulatory to myself, I got to see about 20 patients and a great deal of variety. Presenting patients included sepsis, trauma (stabbings and lacerations), and regular run-of-the-mill ER stuff like confusion and syncope.

I did find 2 things to be quite shocking and disturbing. First, there was a 3 week old baby  that was brought in because he was “sick.” On first glance, it was clear to me that something was horribly wrong with this child. He was green, not like the “green” before someone throws up, but really and actually tinged green. Certainly not a normal color for a baby, or well anyone really. Plus, he was breathing like a fish out of water. I don’t think the child’s mother understood the seriousness of the situation because she asked if admission to the hospital was really necessary. I don’t know that anyone really explained to her how incredibly sick her child was, and I suspect that this child won’t make it through the night as intubation isn’t an option because ventilators aren’t readily available.

The other thing I was introduced to and found disturbing was the BID form. At one point, Dr. Bule talked to a police officer (speaking in Swahili so I didn’t understand) and said to me that we have 2 BID forms to fill out and that I was to follow her.  Upon seeing 2 bodies unceremoniously laid in the back of the truck the police officer led us to, I started to deduce that BID stood for “brought in dead,” the Kenyan equivalent of DOA. Dr. Bule was just called out to certify that these people were, in fact, dead. These 2 were involved in a road traffic accident (or RTA as they call it here) and had clearly exsanguinated at the scene. I was surprised by the way they were brought to the hospital… just put into the back of the truck, nothing covering them, and shown to Dr. Bule in front of patients waiting by the lab.

I also noted a distinct difference today because it is a holiday here, Easter Monday. Apparently, it is standard to give people both Good Friday and the Monday following Easter off here. The hospital was pretty quiet compared to the chaos it usually is. I went in because I am going on safari next weekend and will have some scheduled days that I am to miss going to the hospital.

After the hospital, Caroline and Charley joined me by the pool for some relaxation from the weekend trip and cassava chips with chili powder. Soooo  yummy!

Day 14 - Malindi Marine Park and the drive back

Sunrise on Golden Beach in Malindi

Early the next morning, we woke up to walk along the beach for the sunrise. The mosque that is right next door to the hotel worked as insurance that we actually would wake up for this because the call to prayer was broadcast pretty loudly. It was really nice to just explore Malindi and work up a good appetite for breakfast. We had breakfast at the hotel, and then headed off to Malindi Marine Park for a half day of snorkeling and being near the water.

Vasco De Gama Point - Like I'm gonna pay 400 Ksh to see what I can see for free from the beach?!?!?

Kiosk in Malindi Marine Park - Still haven't figured out what a "pant" is...

The snorkeling was incredible!!! There were so many fish, and they were beautiful. Plus, they were all pretty new to me since I haven’t been underwater in the Indian Ocean before. Also the reef was quite healthy and vibrant particularly when I consider that they bring many boatloads of people out to this site 7 days per week. After an hour or so of snorkeling, we got back on the boat and were taken to a sand bar that becomes a small island at low tide. Charley, Caroline, and I swam (or well crawled in the water) around the circumference of the island in the shallow water. Some areas of the water were so shallow and the sun so hot that the ocean water was actually warmer than I would set a bath.

View of the beach that we left from to go snorkeling... our boat is one of those in the background

Our boat, the "Ya Sir"... that we rode on with an Indian family of at least 20 people

After snorkeling, we had lunch at a restaurant called The Old Man and the Sea. It was delicious! As has become pretty standard for us, the girls and I got a few dishes to share so that we could maximize the number of different foods we get to taste and eat. We got lobster. (Caroline and Charley had never had lobster before so it was a real experience for them, not to mention the fact that it was soooo good.) We also got a seafood platter and some gazpacho. Then it was time to head back home. For the drive home, we had wised up. We paid less than we had previously and had a more comfortable ride… but a much less memorable experience. Overall, amazing weekend and really thankful that I met Caroline and Charley. 

Charley and our fancy glasses of passion fruit juice. (SOOO gonna miss fresh passion fruit juice when I leave)

Grilled lobster with coconut rice

Seafood platter with gazpacho in the background