What We're Reading

I always like to pick up a good book before we get on an airplane.  But this venture especially has allowed for more reading besides just the time in transport.  When traveling to a foreign country I especially like to learn something about the history and culture we are to be immersed in. 

So, how to find writings from and about Kenyans?  I began this investigation by refering to the 'Literature' entry in the Lonely Planet guide to Kenya at Richland Public Library.  African literature often runs in to the problem of lanuage.  Some prefer to write in their native tribal tounge.  Others find it necessary to write in English in order to increase readership.  Several authors were mentioned in Lonely Planet, some with Kikuyu publications, some in Swahili, some in English, some whose work had be translated from Kikuyu to English... availablilty of many works is often limited...

A search of the authors in RCPL system produced only 2 hits.  One was a novel written for children, a 150 page tail.  It is quite a moving story about a Kenyan boy who befriends the grandson of a British expat, all set around the time of the Mau Mau rebellion.  I really enjoyed this simple story and can't remember the name of the book!  Sorry!

The second hit was “Gods and Soliders, The Penguin Anthology of Contemporary African Writing”.  This is a book of short stories and articles, both published and unpublished, written within the last 10 years by Africans.  The entries are organized by regions.  Some are small works of fiction, others are political commentary, some discuss issues of African identity and voice in literature.  After language, the problem of grouping a collection of writings under the title 'African' is that each country is so different.  Many share similar stories of western colonization followed by a struggle for independence.  But the details of each story are so complex relative to their political makeup, tribes, geography, and culture.  Many very intriguing works from a contininent searching for a voice.  However, it did not give me the insight into Kenya specifically that I was searching for...

A book that has been suggested to me by a fellow Tumutumu volunteer is “Britian's Gulag: The Brutal End of Empire in Kenya” by Caroline Elkins.  The book is a detailed account of the MauMau uprising in rejection of British colonialism, gathered from interviews of both Kenyans and Brits.  The book is huge and it sounds a bit dry and dense for me, but perhaps a few chapters would shed light on that time in Kenya.

As previously mentioned, we consulted our friend Sarah Cooper Searight on an appropriate reference for ministry she suggested Henri Nouwen's “Gracias! A Latin American Journal”.  Though the culture of this book is Catholic and the local is South America, many of the issues of poverty transfer well to our setting in rural Kenya.  We hesitate to use the word “mission” to describe our trip... it can have such negative connotations.  But the tone of this journal and his approach to ministry is alligned with our philosophy.

'“It is the change from selling pearls to hunting for treasure.”  Indeed, not too long ago the task was seen as selling the pearls of good news to the poor and ignorant people.  Now a radically new perspective dominates... to search with the poor for the treasure hidden in the ground on which they stand.  It is the shift from spiritual colonialism to solidarity in servanthood...'

So many exerpts speak to us and this place.  We have been reading it aloud daily during our time of devotion.  We highly recommend it!

Matthew has been brushing up on his knowledge of tropical medicine by referencing “Principles of Medicine in Africa”, borrowed from Dr. Daniel Everett, a physician from the states also staying at our guest house.  He says it has a lot of infectious disease information and some about more common problems such as diabetes and heart failure. It's a little out of date, but it's nice to have something to reference for the diseases that aren't often seen in the US.

Geo-tagging

I'd like to take a brief moment and talk about my latest obsession in photography. While Christina works on perfecting her framing, white balance, contrast, and composition my concern is different- mainly where is the picture being taken. While I was travelling recently, I found that my phone has the ability to Geo-tag. For those of you who are not familiar with this, basically some cameras and phones have the ability to attach GPS coordinates of longitude and latitude to the picture being taken.

I realize this may not be that important to most people. I also realize that most people aren't as nerdy as I am. That's OK. We can't all be perfect. To me this has been like putting a digital push-pin on the map of places I've visited. Instead of finding an interesting picture, I often find myself thinking, “Do I have a picture that I've taken in Chicago? No? Well, let me take a random picture in the airport so that it'll show up on my map.”

Right now, I don't have any data access on my phone. I looked into the cost and basically it's about $15 US per kilobyte. For me to use my phone as I normally would this month, it would cost me in the ballpark of $1,500US. So I'm leaving the phone off. However, it still picks up the GPS signal. So I guess I can check Africa off the list. Maybe we'll get to Australia some day...

London Geo-Tag

Case Presentation 1

Case 1

25 yo female with no PMH presents with convulsions. She has been in her usual state of health until the day of presentation. She has spent the day travelling on a bus from the Rift Valley to Karatina. She states she packed her own food and did not eat anything offered to her on the bus. On arrival to Karatina she had a convulsion as described by the fellow travellers. Patient was admitted and was witnessed in hospital to have several more convulsions that started with facial spasms and generalized to tonic clonic convulsions. The convulsion lasted for "a while" and was broken by giving 30mg of diazapam slow IV push. Patient returned to baseline and was noted to have brusing on her tongue.

ROS: + for HA on and off for the past month, relieved with paracetomal. No HOB, no blurriness of vision. Otherwise negative.

PMH:-

FMH:-for epilepsy

Social: Denies EtOH, tobacco, drug use.

Medications :none

Allergies: NFDA

PE: T36.7 P80 R20 BP: 140/60

General: Well developed African female, NAD

Head: ATNC

Eyes: Conjunctiva pink, sclera anicteric, PERRL, EOMI

Neck: No menignismus, Fullness of R thyroid with no appreciable nodules.

CV: RRR, no MRG; peripheral pulses present, symetric; cap refill <2sec

Resp:LCTAB

GI: AB S/NT/ND/BS+

MS: FROM

Skin: No rashes/bruises/lesions

NEURO: CNII-XII intact; sensation intact B/L; strength is 5/5 throughout; no dysmetria; abulation without difficulty; A&Ox3

A/P: 25yo with new onset convulsions

Obtain full Hemogram, UEC's and Pregnancy Test. Order CT head for masses/bleeding. Admit for observation. Diazapam PRN for seizures, PCM for headaches. Re-eval in AM.

Discussion:

This was an interesting case for me, not because of the medical aspects itself, but it brings up some important social issues. As is probably evident in the case, Kenyan's don't really use the term seizures, but convulsions. It's really a minor difference, but there are many of these language problems I've run into during rounds. They tend to call congestive heart failure (CHF) congestive cardiac failure (CCF). Fevers are hotness of body (HOB). A basic metabolic profile (BMP) is equivalent to a urea, electrolytes, and creatinine (UEC). They are very subtle differnece and it's not difficult to adapt, but they use abbreviations as commonly as we do and I feel I slow down discussion some by asking what each of these mean.

As mentioned above, the patient had an enlarged thyriod that was picked up on physical exam. After more discussion with the patient we found out that it was evaluated several years ago at an outside hospital. She was told then that she needed her thyroid taken out. This I actually seemed very familiar to me. I can't count the times that patients have been told they needed a procedure, a scan, an xray, or just follow-up and haven't- either because they were scared or just couldn't afford it. Strangely, I felt reassured that somehow all people are alike.

The patient did very well and had no more seizures throughout her hospital stay. However, the CT was never performed for 2 reasons. One was that she was afraid of what the scan might due to her. The other was that she and her family could not afford the test. While many of the service Tumutumu provides are cost-reduced (such as medications, laboratory tests, and meals) any of the tests obtained outside of the hospital (such as CT's, MRI's, Ultrasounds, and EGD's) are paid for in advance by the patient. Ultrasounds cost about 2,000 shillings (about $25 US) and CT's cost about 10,000 ($126). Although that doesn't sound like much but the average salary in Kenya is $730 US. Often patients have to call family and friends to help come up with the money. Often this can delay the test (and often diagnosis) by days.

Our patient ultimately decided that she did not want the test and wanted to be discharged home. This comes up alot here and seems to be to be a real contrast to how we practice in the US. Here in Kenya, if patients want to stay, the doctors are not really apt to forcing them out. If they want to go, there is no discussion on leaving against medical advice and documenting risks as we would in the US, patients are just discharged. That's not to say that the patients aren't informed, it's just that there isn't much malpractice out here to worry about.

I really hope that the patient does well, and hope that she follows up in clinic. I think many patients are lost to follow-up because of distance, time, and cost. I guess like many things out here in Kenya, it's out of our hands.

The Pharmacy

One of the questions I was frequently met with as I prepared for this trip, and a question I liked to avoid, was, “So,  Matthew will be seeing patients in Kenya, and what are you going to do?”.  It distressed me a little.  I was assured that I was needed and that I would be put to work but my exact function was unclear.  I had this fear, with such a loosely defined role, that I would be only superficially needed, or that I would have time on my hands.  I've had jobs like that and nothing is worse than watching the clock, waiting for lunch or the end of the day.

This is why I have been so pleased with my position helping out at the pharmacy.  One major pharmacy serves both the out-patient needs and the wards.  The unit is always busy and I have always felt needed.  My first afternoon was spent learning the system and becoming familiar with the drugs – the commonly used trade names vs. the generic names.  All of which are a little different than what is used in the US.  My tasks range from restocking shelves to filling prescriptions. 

Most often I account for which medications and how many are distributed to which patients in the computer system.  The hospital uses a hybrid system of processing drug requests.  Most orders are handwritten and logged in the computer.  The pharmacy then reviews and verifies the orders and reconciles any discrepancies.  It is a somewhat tedious task that often reminds me of creating a plant schedule where size, number, common name and scientific names are specified, a common task during my time as a landscape architect.

I am most grateful for the people I work with in the pharmacy.  Everyone is unfailingly kind and patient.  They are always interested in teaching and never bothered by my endless questions.  Everyone who comes to the counter, patients and staff, is interested in the white girl, often greeting me with a smile and welcome.  It is truly a reflection of their culture that this has been such an easy transition.  After a few days here I have begun to feel comfortable (with my handmade cheatsheet of drugs), familiar enough with the rhythm of the day that I am able to anticipate the next task. 

The one regret is that I don't deal much with patients.  The mystery of this place is that three different languages are commonly spoken: Kikuyu (the tribal language wildly spoken in the central highlands), Swahili, and English.  And then there is another variation that is a hybrid of Swahili and English.  The pharmacist (there are 2 working in overlapping shifts) exclusively interact with the patients and staff in Kikuyu.  This leaves me in the dark.  They make jokes that I am not included in (maybe they are about me!).  But also, comments from staff and their exchange with physicians and nurses are always beyond my comprehension.  

An unexpected benefit of this position is that finally Matthew and I are working in the same world.  I know this sounds silly, but the endless talk about his work is now a little more of our common work.  Though much of it still is tedious and goes without comment from me it is nice that we are vested in the same interest of patient care and a well run hospital system.

Retreat

Childlike.  Lack of Control.  All is new a different.  Routines and schedules are forgotten.  We are here empty, starting anew. 

What was initally a frustration has become quite liberating.  All the daily concerns and distractions of home are absent.  No cell phones, no internet, no TV, no vehicles. 

Think about that!!!  This is what I've learned:

• A phone call is not required everytime my husband is late or my hands are idle.  He'll show up.  I can be patient.  

• I only really require 10 minutes on the internet once a day to check my email and cut and paste a blog entry (written the night before).

• A book can be just as entertaining as the television.  Chances are it's a lot more educational too. 

• Walking is virtuous.  The fresh air, a stunning landscape, and the sounds of the environment are worth the extra time and effort.  There are never traffic headaches on our dirt path!

    

 

All we are left with is quiet.  And it is so refreshing.  Matthew and I, who I think have a strong relationship, have spent more time talking and listening to each other.  Problemsolving.  Creating.  Sympathizing.  Supporting.  We have really made an effort to make time to communicate.  To discuss issues and life in a way that our routines at home don't allow.  Time to share and time to pray.

In this way it has become a retreat for us.  A way of recentering our life, refoucusing our energies, a way of discerning what is really important and where we are being lead.  It is a great way to begin this next phase of our life... as we leave the great community we've built in Columbia... as we become infants again in California. 

Rain

April is supposed to be the wettest (and coolest) month in Kenya but since we've arrived we've had little rain.  It's felt more like South Carolina in June!  Dust from the red earth fills the air and sticks to your clothes.  The driness concerns everyone. 

On Sunday afternoon the security officer at our guest house, Tony, took us for a little walk and showed us how desperate the situation was.  He showed us the holding tanks for the water for Tumutumu Hospital and all it's supporting buildings (they have several guest houses for interns, medical students, nurses and doctors, and dormatories for around 60 nursing students).  The water is carried by pipe from an adjacent river to this holding tank which then distributes to 3 large cisterns. 

In times of drought in Kenya everyone is asked to ration water.  Use the pit latrines instead of flushing toilets.  Sponge bath instead of shower (or don't bathe!).  Many people are helpless as they sit back and watch their crops dry up in the sun.  So they eat less in anticipation of having a light harvest. 

In Kenya 80% of the economy relies on agriculture.  On a side note there is a seed shortage in Kenya, due to corruption on the retail price of seedlings, that is also complicating the issue of agriculture in Kenya.

Which brings up and interesting point in terms of landuse:  every scrap of land is used to plant and harvest vegetables, which grow year round.  Land used for recreation or aesthetics, like the church yard, often dually serves as a feeding ground for sheep and cattle.  The land can produce in abundance and no one takes it for granted.

So thats why it was a joy, rather than a nuisance, when it started pouring yesterday afternoon as we were leaving work.  The past two nights we've been woken at 1:30 to absolute downpours.  The heavy clouds never produce a drizzle or scattered showers.  Always it is big fat rain that pounds on the tin roofs.  I hope this continues to be the season of rain for the welfare of this community.

I must share this side effect of the rain.  It knocked out the power last night.  Which meant now that there is plenty of water it was looking like we would face a nice cold shower (an electric heater warms the water right at the tap).  As I was about to step in there is a knock at the door.  Margaret, who was preparing our breakfast, boiled a couple of gallons and brought a bucket of warm water to our door.  What a welcome blessing!

First Impressions

4.13.11

Tumutumu Hospital is definitely an interesting place to work.  After spending 3 days in the hospital I have a somewhat better understanding of how this place and the Kenyan health system operates. Tumutumu hospital's inpatient service is divided into 4 teams- internal medicine, general surgery, pediatrics, and OB/GYN. I am currently placed on the internal medicine team. On the team is an intern, a clinical officer, a consultant, and often a foreign medical student.

The intern is a recent graduate of medical school in Kenya and serves for a year here at Tumutumu. She rotates through the 4 sub specialties in 13 weeks blocks. Basically she runs most of the service as an upper-level resident. Over the year, not only will she lead the medicine and pediatric inpatient services, she will be requried to perform deliveries, c-sections, appendectomies, hysterectomies, cholecystectomies, open reductions with internal fixation, ect. For most of the surgeries a consultant  will not be present. After this year, she will chose either to practice medicine as a general practitioner or continue her training as a specialist. Obviously, this is a big contrast to the way we practice in the US and the interns are given a great deal of autonomy at such an early level in her training. And while she has a good knowledge base, the diversity of her education makes it difficult to go in depth in any particular field of interest.

The clinical officer serves in a role comparable to a physicians assistant or nurse practitioner. He has had 3 years of training in medical education and is now fulfilling a year of clinical duties. He is a hard worker and tends to do the brunt of the paperwork and minor procedures. 

The consultant is basically an attending position. They have specialized into an individual field will oversee the intern. Often the attendings are very busy and will cover multiple hospitals in the area. Often times this means he will show up at sometime during rounding and often leave before or shortly after finishing seeing the patients. He is there to help in difficult cases or solve problems that may arise, but generally leaves the majority of responsibility to the intern. Currently our consultant is covering three hospitals and while he is very intelligent and knowledgeable about Kenyan diseases and treatment he does not have much time for formal teaching.

As in the US, there are often medical students that rotate through Tumutumu. Their responsibilities are not quite as intense as the clinical rotations in the states. There is no pre-rounding on patients and no real clinical duties except to be present and participate in discussion if called upon. Currently we have a UK student who is fulfilling her pre-clinical duties after finishing her exams. She is very bright and engaged and often brings up salient points of discussion. She does not have that much clinical experience, but in her defense, she is required to have a minimum of 7 years of post-graduate training before receiving full privileges as a physician.

Rounding starts at 9:00am-ish. Time is sort of relevant here in Kenya. As noted above, there is no pre-rounding and basically the whole team discusses the patient, recent labs, vital signs, and comes up with an appropriate treatment plan. We start on one side of the ward and walk from patient to patient until everyone has been seen. Once finished with the first ward, we take a tea break and then see the second. The second ward tends to be rushed because visiting hours start at 1:30p, so the team tries to see everyone before their families arrive. In general, we see about 30-35 patients per day, so the service stays pretty busy.

I think the team does very well with the resources it has. Thought goes into every patient in terms of evaluating the deferential, treatment of pain, cost of procedure/diagnostic test, and compliance on discharge. It has a well stocked pharmacy and decent lab (we can even get thyroid studies!) However, the hospital does have its limitations. Basically there is very little that can be done for the unstable and crashing patient. Without an ICU, there is no equipment outside of the operating room to intubate a patient. There are no monitors, no pumps, no Bipap. The lab does not have the equipment to measure HCO3 so no way to detect acidosis. I asked if they could run an ABG and the intern laughed.

Despite these setbacks, I think the treatment here is very good. It's definitely been a learning experience in how to make do with what you have. The physician's physical exam skills are expertly honed and I think it shows me what skills I've lost because of the ease of laboratory testing. I hope that I can impart some small amount of knowledge to them as I am very grateful for what they have taught me.