Day 4 - Thank goodness for nurses

Today at the hospital I was reminded how much US hospitals can accomplish solely because of nurses. I was once again in ward 6 with Dr. Hussein. Despite the limited training and resources he has available to him, he is quite capable and clearly cares for the patients he is treating. I am used to a system where the doctor writes an order for something and the nurses carry it out.

This is not so in Kenya. Yesterday as I left the hospital, I was having a hard time understanding why the patient I was assigned in DKA was still having drastically uncontrolled glucose readings.

(As an aside glucose is measured  by different units here and so it is takes me quite some time to figure out what my patient’s blood glucose even is. Finally made myself a chart with the conversion so I am a little faster and don't think "How is my patient even alive with a glucose of 3.2?!?!" Definitely made me worry on the 1st day.)

Each day, the chart had orders written that were more than appropriate and yet his sugars remained uncontrolled. Today, I began to understand why this is the case. The nurses (and there are many of them – at least 9 for the ward of 20-30 patients) had not been giving the patient the fluids or insulin ordered. Once I learned that this is a common occurrence and something that Dr. Hussein deals with constantly, we hooked up our own IVF and infused our own insulin. This is something I genuinely don’t mind doing and have done even in the US, but back home I did it because the nurses were busy with other things. The nurses here sit behind the nurses’ station and talk. I really only see them get up to do “obs rounds” once each morning when they get vitals on the patients and hand out some pills. Literally, anything that we want done for the patient is up to us to do.

I find this particularly dismaying because the nurses I have worked with in the US are really so awesome. They are the people that the patients regard as their advocate and often the nurses know a great deal about the patient because they are the one there for the patient throughout. It is undoubtedly frustrating for the doctors here to try to get things done without many resources or the benefits of supportive help.

I saw about 25 patients today on rounds including a case of rheumatic heart disease that will require a mitral valve replacement (if… and it is a big if… the patient can afford it), TB encephalopathy, and multiple complications and consequences of end stage AIDS.

After our time in the hospital, I went out for dinner at the beach with 2 guys I met the first day that are medical students from the UK. Fortunately for me, Sidharth is actually Kenyan having lived in Mombasa before going to university in the UK so he is able to help fill us in because there are a lot of things done in Swahili that I can’t understand. The other, Gaurav, is a friend of his from the same university who is visiting Kenya for the second time himself. Fortunately, he speaks as little Swahili as I do, so I know someone is staring at the patient equally blankly when they explain their symptoms to the ward team.

(Side note...I love to listen to Sid and Gaurav speak. They call the OR "theater." Hehe! Dede, you would love it! But I think they are equally tickled to hear me when I say "ya'll.)"

Gaurav and Sidharth, respectively

The view from our table... GORGEOUS!

We just had some food and chilled by the beach at a restaurant up the coast a little bit at Bamburi beach. The view was fantastic. I had a seafood pizza complete with “lobster, tuna, and shrimp.” Or at least that is what the menu said. From the looks of it, there was also calamari and some mussel or clam. Don’t really care either because it was delicious. All of the seafood is fished locally and is easy to tell because of how fresh it is. We just sat and talked about the differences between our health care systems, the incredible amount of local prostitutes that walked arm in arm with their much, much older and white clients along the beach, how much more debt I have and how much more I'll be making as a resident, and many other things. I have plans to keep hanging out with them as Sidharth is familiar with the city and well accustomed to taking his friends from the UK around Kenya. I’m looking forward to it and that idea that I'll get to experience a good deal of Mombasa with them.

Camel on the beach that kept falling asleep.  It proved to be a great source of entertainment to watch its head bob on its long neck down to the sand. (The other camels I saw on earlier days weren't meant for riding and didn't have the seats strapped to their backs.)

Day 3 - A new ward and lotsa crocs!

Today was much better because I found Dr. Hussein. He is the doctor in charge of ward 6 and loves to teach while doing rounds. He pimps, but I’ll gladly sign up for that if it means that I get to learn throughout the day. (For the non-medical people reading… pimp is a term used in medicine for the type of teachers that ask questions that are designed to “Put [students] In My Place”. It isn’t usually done maliciously but used as a tool to see how much you know or don’t know about a particular subject.) Plus, he has assigned me patients to take care of. I have a patient in DKA that I’ll be managing starting tomorrow. I wish it was something I was a little less familiar with, but I’m sure that even DKA management won’t be without its challenges given the setting.

Today, I got to see about 20 patients including a peritoneal tap to analysis of ascetic fluid. I’ve seen only 2 done in the US, but they were both sterile procedures with lots of draping and sterile gloves. It was a little different here, non-sterile gloves, a little alcohol rubbed on the skin and then a needle into the belly. Hooked up to a urine collection bag no less because that is the only thing that was readily available, but hey it works (assuming of course that this patient doesn’t develop SBP).

Later into the evening, Benson took me to Mamba Village which is a crocodile farm (supposedly the largest in all of Kenya). “Mamba” is the Swahili word or crocodile, so it is fitting. There were hundreds of crocodiles there of all ages. 

Sign outside of Mamba Village

Larger picture of the plaque seen in the picture above

Walking into the Mamba Centre where I bought my ticket to go in

They were separated into enclosures according to their ages. A guide took us on a tour of the crocodile farm itself, then we switched over to another guide who took us on a tour of the botanical gardens, aquarium, snake and spider house. I have to say that compared to the sheer amount and size of the crocodiles, the 2^nd part was a bit of a let down. Since I’ve been told that March and the beginning of April are an incredibly hot time in Kenya, the “botanical gardens” looked a bit wilted and well… dead for the most part. Plus the aquarium had fish that I was mostly already familiar with from helping an ex build his own aquarium. They did, however, have mud skippers. I’ve seen them in several documentaries, but it still was fascinating to see a fish that was moving along in the water just get out and hop himself over to a rock and sit. Really cool and definitely a first for me.

Crocodile!

Another big crocodile (These few pictures don't even begin to capture how many crocs there were)

Momma crocodile that would creep out of the water and growl when she heard you get close. She had little baby crocodiles all around her

Then at the very end, it was feeding time for the crocodiles. One of the guides walks out onto a platform over a pool filled with alligators and dangles goat meat over their heads. The crocodiles then jump several feet out of the water snapping their jaws (which make this sickeningly hollow clunk as they clamp together). It was a cool display and terrifying to think what these animals are capable of in the wild.

(My camera battery cut out within the first 10 minutes of being in Mamba Village so I don’t have many pictures of the crocodiles, but I have included the few that I got.)

Day 2 - Frustrated

I don’t really know that I can do justice to how frustrated I am. I just got home from my second day at the hospital, and I feel helpless. I don’t feel like I did anything today to help anyone. I feel like I just watched the patients and system flounder around me.

Take this case for example. On Mondays and Thursdays, the doctor comes by to do round with the MD intern who is in charge of the ward. The patient in question is a previously healthy 22 year old male with bilateral lower extremity 2+ pitting edema to the knees that has now been present for 7 days despite treatment at the hospital. I suspect it is not improving because he is being treated for the wrong condition. He was diagnosed as having “DVT/cellulitis.” Bilaterally? In a healthy 22 year old? With no predisposing conditions?  I didn’t think so.

Anyway during rounds yesterday, the physician mentioned that the diagnosis that this patient had been assigned was probably incorrect and the cause was probably more systemic to cause bilateral symptoms. I wrongfully assumed that this would steer the patient’s care in a more appropriate direction. Today the chart still reads “Dx: DVT/cellulitis,” and he got antibiotics and Lasix for 7^th day. It isn’t a surprise to me that his condition is not improved.

We are drastically limited in what we can do and test for by the patient’s finances. I would have liked a urinalysis, CMP, CXR, etc. There are very few tests that the patients can afford, if any at all. Plus, I was told that even a hospital bed for a day cost about 700 Kenyan shillings (Ksh) which is just shy of $10 US dollars in a place where the majority of people live on less than $1/day. It was on my insisting that I would be willing to do the ultrasound myself if I could just have a little time with the machine – one of the few tests that might offer some tiny bit of information that I know we could do for “free” if I could just get my hands on an US. (I know that I am no expert with the US, but my thinking was that it would be in the best interest of the patient to get an US done rather than just sit and wait through another day of antibiotics.)

Keep in mind that none of this happened particularly quickly because it took the better part of the morning. My estimate would be that it took like 2 hours.) The guy working the ultrasound was more preoccupied with some “dilated loops of bowel” (which I admit I didn’t appreciate, nor would have it explained the edema well) than the patient’s heart, liver and kidneys. The ultrasound seemed grossly normal to me. So I doubt the ultrasound will be of great help in the long run. More frustrating news because I doubt we will be able to do any further testing. I felt like I was doing the right thing in advocating for the patient but I don’t know if it helped at all.

At least 5 of the patients on wards have been diagnosed with “chronic kidney disease” (which I also admit that I doubt to some degree because only 1 of the patients has a documented elevation in creatinine). They all need dialysis but can’t get it because of the cost. Sooo… they, like the patent with the edema, are just sitting in the hospital without anything of substance being done for them. It is becoming apparent to me why there are at least a handful of casket makers right outside of the hospital.

Plus, 2 of the patients that I was most concerned about yesterday  (1 with severe pancytopenia and 1 who had a R sided ischemic stroke with resulting edema causing a midline shift) were discharged sometime yesterday after I left. Maybe they were discharged because we were unable to do more for them. Not sure but still concerned.

Overall, crummy day at the hospital. I feel I’m doing nothing useful. I will talk to the coordinator to see if there is more that I can do elsewhere.

Benson and Frank, respectively

I also went on a walk with Benson and Frank (2 of Elective Africa’s employees) this afternoon to one of the poor areas of town, a village called Shaurioko. (I highly doubt that I am spelling it correctly). He wanted to show me how most people in Kenya live. And the conditions were probably the worst I have seen, including the visit to the internally displaced people’s camp in northern Uganda. I know that millions of people live in conditions like this, but somehow it is still shocking when you walk through the middle of it. There were tons of dark little alley ways and a truly incredible amount of trash. Sanitation and clean water are clearly huge problems for areas like this. We also walked to a local open air market which somehow smelled 10x worse than the slums. I think the smell of discarded rotting fruits and vegetables is what made the market smell so unappealing.

Just a glimpse at all of the trash that surrounds these people's living space

Walking into the market

Despite the grim surroundings, I still heard calls of “Mzungu, how are you?” from the kids in the streets and market. I don’t know that they understand my response when I offer it in return, but the kids beam at being acknowledged. For those of you who didn’t go to Uganda with us, Mzungu is the Swahili word for “traveler” which over time has morphed into the slang term for a “white person”. I also kept hearing “picha” which fortunately sounds like its English equivalent “picture” as I walked with a camera hanging around my neck. Not very many words in Swahili are easy so I'll take as many easy ones as I can get.

"Picha" of some really cute kids

Day 1 - Orientation at the hospital and traffic guidelines

Today was set for getting an orientation to the hospital and a tour so that when I go back tomorrow. I will know what I’m doing. It took a good hour or two to get some paperwork in order. This is somewhat expected as the entire day is set aside to take care of just a few things, but hey… TIA. (TIA means “this is Africa” and can refer to the fact that things don’t happen with the same speed and efficiency that they do in the western world.) Then I went on a tour of the hospital which is all open to the outside. No AC which reminded me about one weekend during which the power system and the back-up generators failed at one of the hospitals in Pensacola. Apparently there is a mandate in Florida that patients cannot be made to stay in rooms that are warmer than 75F. Therefore these patients were all transferred to neighboring hospitals. I am not sure what temperature it was in the hospital today but I can undoubtedly say it was more than 75F and no patients were complaining. Plus, there were no divisions between patient rooms. The hospital wards are one long narrow room with beds lined up on either side and patients (some incredibly sick and with infectious diseases) lying in the beds without anything between them. Imagine the pictures of people in hospitals when the Spanish flu hit… the hospital looks a lot like those.

Wards are divided into men’s wards and women and children’s wards. I am to be assigned to ward 5 for the first week with Dr. Abdul on internal medicine. As today was my orientation day, I came in about halfway through rounds and tried to understand what was going on. It is a little challenging to try to decipher the conversation that happens with the patient in Swahili, but becomes a little clearer as the patient is presented in English. I got to hear about half of the patients’ problems which included severe pancytopenia in 2 cases, stroke, malaria, and kidney failure.

In talking to the doctor that I have been assigned to for this week and trying to explain where I am in school in relation to graduation. I learned to my surprise that I already have more training that he does in terms of the number of years of school. Dr. Abdul is a newly graduated MD intern (I think this is the equivalent of a PA in a way). However, because of the fact that doctors are so few and far between, he is charged with running a ward. It is strange and overwhelming to know that if I were here, I would be in charge of running a medical ward all by myself.

I was driven home at the end of the day by Kassim who is contracted by Elective Africa as a driver, and he drives a tuktuk. This is a 3 passenger taxi of sorts and there are tons of them throughout the city. They are relatively fast because their smaller size allows them to weave in and out of traffic between the larger cars and buses. Thank goodness that Kassim is a relatively conservative driver because traffic rules here are “more like guidelines than actual rules.”

Day 0.5 - Camel on the Beach!

 Let me start with 4 words… camel on the beach!!!

A.      Kenya has camels. News to me. I wrongfully assumed that camels were a desert thing.

B.      Camels go to the beach like people do. What? Really? Um… yeah, they do!

C.      They just are chillin’ out there like it is no big thing. Yup, that’s right. Right in the middle of a soccer game on the beach… camel.

Anyway, so later in the afternoon, I walked down the beach with Benson and got my very first view of the Indian ocean. Nyali beach (close to the house where I’m staying) is stunning. The water is really clear, very few waves, and incredibly fine sand.

Now a special note to Mary… I can say with the utmost confidence that I was the whitest person on that beach by far and now know what that feels like. It is weird for sure. Can’t say I liked that feeling either.  But both on the beach and off, I feel somewhat like a novelty. I stick out for sure. For example, on the way home from the beach, a little girl who was probably about 4 or so beamed when she saw me. She made it a point to drag her family (her father and 3 boys who didn’t seem much older) over to talk to me. I’m not sure if she wanted to practice English or just get a closer look at the person who so obviously didn’t fit in. It was incredibly sweet and cute either way and I appreciate the honesty that comes with childhood.

·         *A little side note about pictures… I took pictures of the beach (including the 2 camels there) but because I had left the SD card for my camera at the house the pictures saved to internal memory. And I didn’t bring the cord that lets you upload the pictures form the camera to the computer without the SD card. Woops! I promise to take more pictures when I go to the beach and/or post the ones I have later.

Day 0 - Arrived in Kenya and getting settled

I was lying in bed, a totally new bed to me because I’ve arrived in Kenya, and couldn’t fall asleep. Mosquito net overhead and sweat beading up on my neck and back. (The AC hasn’t fully kicked in yet and it is something like 12,000 degrees outside. Not sure of the conversion to/from F to C but I'm sure it is about 12,000 either way.) I’m fairly certain it is about 1 AM currently here, but I’m wide awake. Jet lag is no fun. (Flying to the east is so much more difficult than flying to the west, and the journey home hopefully won’t have the same effects.)

Flying over the Alps

This whole thing started on Friday morning when my parents so graciously drove me to the airport. Honesty moment… I think they were a little bothered by the idea of driving to Miami from Gainesville to drop me off when I first told them but I don’t think they would have it any other way. I mean they watched as I cleared security in Miami (see also “slow as molasses in January”). So I can only imagine that they would really like the idea of saying good bye as I drove my own self down to Miami much less.

I'm totally the loser who was taking pictures of inside the plane.

And thus began my 27 hours (or roughly 2 days) of travel, depending on how easily you can wrap your head around the idea of time travel. There was some sitting around in Miami because you have to show up waaayyy early for international flights, not 1 but 2 8.5 hour flights, and then a little puddle jumper flight once I got to Kenya from Nairobi to Mombasa. Really at that point, I don’t know that adding an extra hour of flight onto the tally is much in the grand scheme of things. With all of that traveling, I didn’t think it was  all that bad which tells me 2 things.

1.       Medical school has really upped my tolerance for horribly long and miserable ordeals

2.       27 hours of travel sucks, but it all got done with no missed flights, no delayed flights, and no lost luggage. I’m going to call it a win even if it means I’ll put together a blog entry at 1 AM before actually going to sleep.

The living room

So despite the prolonged travel, I’m now here. Laying in a truly quiet house, the kind of quiet that makes me re-examine the fact that I call my apartment in Pensacola quiet. The only sounds I hear are the AC humming quietly and a sprinkler in the front yard. With that, I’m going to give sleeping another shot.

My bed complete with mosquito netting

New day, or well same day just several hours of sleep later.  It is now morning on Sunday 3/25/12; a fact that took me a good 5 minutes to figure out last night on the way to the house from the airport. I couldn’t figure out if it was going to be Sunday or Monday morning today. Got it figured out and feel like a complete fool for having struggled with that. I think the fatigue of travel plus the utter confusion that comes with traveling through so many time zones really set me up.

Monkeys!!! (Right on the wall around the house)

I am now rested, showered, mosquito repellant-ed and fed. No complaints. The house which seemed absolutely lovely last night in the darkness has proven to be everything I expected. The accommodations are simple and perfect. Call me weird but I think there is something almost magical about sleeping under a mosquito net (and not just the part about not getting malaria). I have now wandered around the house and met the monkeys that apparently come by the house each morning! Not an interesting thing to locals but incredibly cool to me. There were lots of them, too. Probably about 20 and several of them were babies.

And baby monkeys!!!

Today is slated for orientation to the program. I am to walk about the local area to see where the market and beaches are; kind of get my barings. Plus, get set up technologically which means I’ll be getting  a local phone that can make international calls (Yes, Mom that means I can actually call you.) and a modem so I can start posting my writings and my pictures to the internet. I also learned that I will be headed for my safari at Masai Mara on an extended weekend on April 13^th. Super pumped!

Rooster - that actually kept quiet this AM

Tomorrow I get to start at the hospital. I’m excited and nervous about it all. I want a taste of what medicine is like here in Kenya so I am going to split my time between a few different areas; general medicine, maternity wards, and the emergency department (which kind of sounds like it is combined with surgery here). I am really looking forward to getting to see all of these different areas of medicine and how they are similar and different from how things are in the US.

Match Day!!!

I freakin' matched at my #1 choice - emergency medicine at Orlando Health!!!

"Congratulations, you matched EM at Orlando Health!" (AKA too excited to stay still for a good picture)

Me and my mom before the ceremony got started

Okay... so Match Day really has nothing to do with me going to Africa other than I strategically planned my 4th year schedule so that I matched and then got whisked off to Kenya soon after as a kind of reward to myself and fun way to end my last year of medical school. But I thought my blog deserved an update for the momentous occasion that happened yesterday.

For those of you that don't know, Match Day is the one day where they pair up 4th year medical students with the residency programs they will be at the next however many years. The students make a rank list of the programs they are interested in attending, and the residency programs make a rank list of the students they would like to have as a part of the program. Then through some computer algorithm that is well beyond my understanding matches the student with the highest program on their list that will take them. So, I feel like it is a pretty big deal that I will actually get to go to my #1 choice.
  

The students from the Pensacola campus after we announced our matches

Even though I only found out about matching yesterday, I have already gotten a brief introduction to the 13 other people who are going to be members my intern class through a powerpoint from Orlando Health's EM program. Its a little weird seeing a picture of these people and knowing that they are going to be some of my best friends without even knowing them. I can't wait to really get to know my class.

I don't know that I  still have the words to fully explain how I feel about this because I am so excited about what this will mean for my future. I feel like it has set the stage for not only a fantastic trip but a great upcoming 3 years of residency!

Pre-trip planning

This is the part of every trip that I absolutely hate. Whoa... wait... did I say "hate"? That is probably not strong enough of a word. This is the part of every trip that I loathe and abhor.

I once read a study that said people are actually at their happiest before they leave for a trip. This is because they dream of how perfect their vacation is going to be and that the reality of any trip could never live up to that lofty expectation. Not me. I really hate the weeks before a trip. The tedium of getting the necessary items for my trip all while still functioning on a rotation is exhausting. Not to mention the fact that the week before my trip is Match Week! (Little side note- I'm so excited about Match Day!!! I just can't wait to find out where I'll be doing my residency!)

As much as I don't like going through the motions, I know that if I just muscle through the things I need to do, I'll find myself on the plane to Kenya soon enough.

I even feel like I've really done my research when it comes to expect when over there. I've talked to Brian Cogburn and Michelle Cormier (who went to Kenya with the same program earlier this year... and had an absolute blast). They've talked to me about what I can expect. I've also poured over country-wide health statistics that compare Kenya to its neighboring countries including Uganda, which I am somewhat familiar with. I've done what I can to prepare myself. Yet I know that no amount of preparation can really get me ready to be in the thick of things for the month.

So, I have the countdown on my computer desktop ticking away, and as of this moment there are only 14 days, 0 hours, and 43 minutes until I'm on a plane for the adventure of a lifetime. (Never mind the fact that I plan to go on many, many "adventures of a lifetime".) This will be one for the books, and I'm ready.

Introduction

Hey all,

Thank you for taking the time to read my first ever blog!

My intention is to accomplish 2 things with this blog. First, I am going to Kenya for an international medicine rotation (almost my very last of medical school!!!) and one of the requirements for the rotation is that we keep a journal of what we see and do overseas. So, I'll include a report of the kind of things I am seeing and doing while on my rotation from a medical perspective. Secondly, this will serve as a way to keep friends and family informed about my trip both in Kenya while I'm on my rotation and during my spare time, and when I head to Egypt. I will try to include as many pictures as possible because... let's face it. I think that pictures can probably do a better job of illustrating my adventures than I can through words.

I hope ya'll enjoy reading it as much as I'm sure I'll enjoy putting it together.