Lake Nakuru

Our weekend trip to Serena Mountain Lodge just teased our appetite for wildlife. So on our final weekend in Kenya we squeezed in another quick trip to the wildlife park at Lake Nakuru. We arranged to travel on Friday evening, have a tour of the park on Saturday morning, and return to Tumutumu Saturday night. We traveled with Kris and Lucy, a couple of British medical students also working at Tumutumu Hospital.

Typical matatu and patrons

Our objective: see amazing animals as quickly and cheaply as possible. Per Google Maps Nakuru is approximately a 2.5 hour drive from Karatina. We priced hiring a car and driver and instead decided to engage the most common method of public transportation: a matatu. Matatus are 14 passenger vans that travel between communities at a nominal rate. They are notorious for being over crowded and their drivers are notoriously aggressive and reckless. When debating whether or not to travel by matatu Matthew often said “More people die in Kenya every year from vehicular accidents than die from malaria”.

Rooster in Matatu

We were determinied not to visit the ATM machine during the trip and only use the shillings in hand. We through caution to the wind and decided to travel by matatu.

The trip to Lake Nakuru took 6 hours on 3 different matatus. Highlights of our journey included a passenger carrying a rooster in her lap (quickly revealed by sound and smell), an hour delay in Nyeri as we waited for our van to fill, and a deteriorating highway riddled with potholes. The highway itself was so poor I'm not sure what difference a private car would have made... I'm certain the asphalt was poured without the proper gravel subgrade. It was an exhausting journey.

When we arrived in Nakuru we checked into our hotel and we had a nice dinner at a Chinese restaurant. It was a lovely and welcome meal – good food and good company. At 6:30 the next morning our tour guide met us at the hotel with an open top van. We were oogling at the animals of the park by 7:30.

And then it was all worth it! Lake Nakuru is well known for the variety of birds it attracts, most famously, pink flamingos. But in addition to spectacular birds we saw loads of baboons, zebras, giraffs, hyenias, rhinosorases, cape buffalo, warthogs, empalas and antilopes. We saw them laze about, get in fights, feed each other and play with each other. All quite close from the safety of our open top van. The only regret is that the lions and the lepords, which are present in the park, did not make an appearance.

White Pelicans

We stopped for a snack break at an overlook at 'Baboon Hill'. We climbed out of the van with our packed lunch and before we knew it a baboon had snuck up and stolen our bread and biscuts! So much for sandwiches! Obviously we were not the first victims... they had practiced well and are known for stealing bananas and other goodies right out of the hands of distracted tourist

Matthew and I with Kris and Lucy at Baboon Hill.

The animals were fantastic and such a wonder. It is easy to see how they are personified in in 'The Lion King'... they each have such distinct character and habits.

Our return matatu trip only took 5 hours. This journey featured a sick passenger, vomiting out the window adjacent to Matthew. We were also seated on the back row and which meant little leg room with the wheel well and spare tire under our feet. The trials of being jostled around the back of a matatu was enough to make us admit our age and that we just weren't interested in this type of travel in the future... the extra expense would be worth the comfort of a safe journey.

Worship at Tumutumu

Christina and I have had the opportunity to worship with the people of Tumutumu Presbyterian Church. This has definitely been a cultural experience for both of us and departs from our traditional Presbyterian services back home. Both of us have worshipped outside the US before, but it is always a blessing to share the intimate act of worship with new community.

Tumutumu Presbyterian Church

Africa has always been a place of music, rhythm, and dance, and the church service was no different. Most of the service consists of clapping, singing, and even dancing in the pews. The service starts with serveral songs before the leadership arrive in the church. After their arrival, general announcements are performed and visitors (like us) are introduced. A time is given for testimonials, which are generally given in a song representing their dedication to Christ. A time of prayer follows and then the reading of the scripture. A leader then gives a brief sermon (usually preceeded and followed by more singing.) and then performs the benediction.

On Sundays, the Tumutumu church has two services- a 9AM English service and an 11AM Kukuyu service. Often the music flows from the end of one service to the begining of the next. (This sometimes made it difficult for Christina and I to know when to leave.) Most of the music was in swahilli although a few English hymns were attempted. The Africans had some difficulty with the rhythms and pitch of the hymns, but what they lacked in talent was more than made up for in passion and volume.

We were able to attend the Good Friday service at Tumutumu and it was quite a departure from our traditional somber service. There was only one service that day and it was in Kukuyu. It was a joyous noise that arose from the little church and it was well attended. It was somewhat difficult for us to follow the sermon, but a few of the lines were punctuated in English- "there is no life without Christ," and "The American's are used to 1 hour of worship. Today will be 3 hours!" Many of the people around us helped us through the motions to the songs and although we did not understand the language, we easily felt The Spirit.

We also attended the Easter Sunday service and although many hymns were sung, Christina was upset that we didn't sing "Jesus Christ is risen today." The sermon was surprisingly taken from the Old Testiment and we are pretty sure that the word "Easter" was not actually uttered through the whole service. Perhaps as lively as the services are, every Sunday is considered Easter. Or at least celebrated as exuberantly.

Case Presentation 3

(If you are squeemish, please do not click the pictures below.)

Patient is a 47yo male with no past medical history who presents with one month history of rash. He denies any "hotness of body," nausea, vomiting, or other symptoms. He states the rash started on his hands and feet and have now spread to the rest of his body including his face and scalp. The rash is itching and sometimes painful. He has come in now because his feet have started cracking and weeping. The patient's vital signs are within normal limits and he denies any other systemic complaints. His DTC was negative as was his VDRL. His hemogram was normal. Please see pictures below at your own risk.

Discussion:

This is a case of Norwegin Scabies. When I first saw it, I thought about syphilis, but with the negative VDRL and the lack of other symptoms (such as a preceeding chancre), we took that off the list. This is pretty much the worest case of scabies I've ever seen. He also has a bacterial superinfection on his feet too. We wanted to start him on Ivermectin and dicloxicillin, but unfortunately the pharmacy doesn't carry Ivermectin. In those cases, we write a prescription and the family members have to pick the medication up at an outside pharmacy. To my knowledge, we are still waiting for the Ivermectin...

Another point this brings up is in infection control. There are very few measures taken on the wards to keep patients from infecting each other. The doctors all walk around with individual hand sanitizer, but I'm pretty sure the nurses wash their hands a few times a day (mostly before eating). There are some gloves available, but they are often difficult to find, and each glove used are charged to the patient. So our patient is probably sharing his scabies with the rest of the ward.

It makes me itch just thinking about it.

Mobile Clinic

Gatithi Medical Clinic

This week, both Christina and I were able to help out with the HIV mobile clinic. Basically it is like the Comprehensive Care Clinic that has been loaded into a land rover. On the day we helped out we stopped at Gatithi, a small town about 30 minutes outside of Tumutumu. There is a small clinic there that is still under construction. There we unpacked large boxes of medications, patient files, equipment, and other various paperwork. We even took our own table and chairs.

The idea of the mobile clinic is to create a satellite of the CCC that is more accessible to the patient population. Even though Tumutumu is only a 30 minute drive, many people do not have cars and do not have the money to pay for the matatu to the hospital. Without this service, many of the people would be non-compliant with their medication regiment, an act that would not only be dangerous for them, but also for the rest of the community.

The people walk from their homes to the clinic and line up hours before the team arrives. The patients check in with a nurse who weighs them, takes their vital signs, counts their pills, and provides teaching on their medications. Education is really stressed and patients are expected to know what medications they are taking and at what times. The nursing staff is fairly aggressive and will chastise those patients who fail the quiz.

From there, the patients see the doctor and describe any symptoms they might be having. Mostly the patients were complaint free, but occasionally we would treat a simple upper respiratory or skin infection. There were also a variety of muscle and joint complaints although no seriously ill patients. After seeing the physician, the patient goes to the mobile pharmacy and picks up their HIV medication and any other antibiotic or pain medication prescribed. This is where Christina worked and it kept her pretty busy. The pharmacist provides further counseling and education on their medications. Again, all the anti-retroviral medications, multivitamins, and antibiotics are free to the patients and provided by USAID.

The mobile clinic is a great addition to the CCC and an invaluable resource to the patients it serves. We saw about 50 patients, many of which were either pediatric or elderly and would not have the time or the energy to get their badly needed medication. It was also a great opportunity for Christina and me to see the patients out in the community and to see the patients in their home environment. The poverty was sobering. There were fewer nice suits and dresses, which you see a lot of at Tumutumu, and more tattered, second-hand clothing (one 45 year old gentleman had an "Ohio State Grandma" sweatshirt). It was a chance to reach out to the community at large and witness their daily struggle first hand.

Matthew and a Medical Officer evaluating a patient.

Patients waiting to be seen.

Patient signing a compliance contract stating that he understands the medications being prescribed and will take the medications.

Kenyan Observations

Just a couple of cultural differences worth mentioning:

The dress code always errs on the side of formal. If in dought, dress up. Any occasion that brings you to the hospital, whether a visitor or patient, is reason to dress nice. Even if it is an ill-fitting, third hand, dusty sports coat it is dressy and should be worn. I think everyone is confused that Matthew wears scrubs daily (though he was told to bring them). Scrubs here are only worn in the surgery theater by those preforming the procedure. They change out of those scrubs, into their suits and ties, before walking back through the hospital. Everyone from nurses to bus drivers to doctors are better dressed than Matthew and I every day.

A couple of my favorite questions asked while I've been here: “How many tribes are in the United States?”. Its really an interesting question... yes, there are some unique cultures but I don't think it compares with their tribal identity. They are always shocked that I only speak one language and that that is common in the US.

“How much did your husband pay for you when you were married?”. They Kenyans raise a combination of money, crops, and livestock to pay for their bride. They will enter into a contract with a family and spend time raising the money, which is their engagement period. Depending on how beautiful and wealthy and well educated the girl this sum can be as high as $3000 US, which is quite a lot for their standards.

Food: We eat very well at the guest house. Breakfast is pretty international, toast, cereal, boiled eggs and sausage. Lunch and Dinner always brings more food than is necessary. Soup (usually a simple broth), two starches (usually a light pasta dish and potatoes), two meats (chopped beef in a gravy and either chicken or fish), and two vegetables (peas and carrots and a cabbage slaw). Fresh fruit for dessert. No cheese or yougarts. There is warm milk for the cereal at breakfast and in the tea.

Tea is at 10:30 and 4:00. Take your tea, take your time, enjoy it, do not be stressed about all the other tasks you must complete. Its amazing how that instantly becomes trivial and takes a back seat to the matter at hand: tea. Matthew gets frustrated that this is such a priority with nurses serving patients... tea before medications? Really?

Though the finest coffee in the world is grown and roasted in this region of Kenya you won't find it is served among the people. It's far too expensive. Instant is the only option if you prefer coffee. Matthew is surviving quite well. And sleeping much more than normal.

There is an interesting paradox between cleanliness and aesthetics. Everything is cleaned emphatically. Floors are mopped often, sidewalks are scrubbed. Much effort is devoted to keeping the hospital and any general living space clean. However, I can't say the same pride is always taken in construction of the facilities. I don't think a general design aesthetic is ever considered and the craftmanship of building projects is often poor. Paint jobs often reveal huge drips, linoleum tiles are askew with the wall and don't match up (often several un-coordinated tile patterns are used), concrete is poured inconsistantly and unlevel. Resources are obviously available, they just aren't always allocated and put together well. Regardless everything is well worn and used, and mopped and scrubbed.

The Presbyterian Church has a strong hold over the region. It seems 2 of every 3 civic institutions we pass along the roadway are PCEA institutions (Presbyterian Church of East Africa). Chuches, schools, hospitals, orphanages... And they seem to be well used and populated institutions.

Though it rarely gets below 65 degrees here this is still their coolest season which means the winter clothes come out. Kids run around in parkas. Everyone wears sweaters and knit hats. It's crazy.

Everyone here has a cell phone. Unfortunately this culture has not adopted a cell phone etiquette. No one puts their phone on silent. Doctors, students, nurses and patients will answer their phone if it rings, regardless of what they are doing at the time. Very few smart phones.

Yes, our guest house has running water and power. But this is really a temporal condition. The power blinks or simply shuts down for 'rationing' at any time (the hospital has a deisel run generator which is often used). And I haven't figured out why water has become a problem... I see water in the tank behind the guest house... but we have been without water for a few days now. Sometimes everything is working great but often one thing or the other is out of order. An emergency bucket of water is always wise for flushing the toilet or taking a sponge bath.

And my final observation... this is the first place I've ever been where no one has made a comment about my hair.  No one has asked to touch it or inquired if it's naturally curly... nothing.  I think maybe it far too common here to be considered special.

Comprehensive Care Clinic

Today I had the opportunity to help out at the Comprehensive Care Clinic (CCC). This clinic serves individuals with HIV and Tuberculosis. Mainly, this is clinic provides free medications to those with HIV and TB and follows up on routine concerns such as CD4 counts and treatment failures. As part of the CCC, community workers even visit the homes of patients to ensure medication compliance. The workers often go on daily runs and has a fleet of bicycles, motorcycles, and a vans to accomplish this task. Fortunately most people are very reliable and appreciative of the care that they receive.

The clinic sees an average of about 50 people a day. Most of the visits are very short and consists of checking vitals, refilling medications, and occassionally checking CD4. However, a few patients do require additional testing to evaluate for pneumonia or other infections. These tests and their medications are all provided at no additional costs to the patient and is funded by USAID (United States Agency for  International Development).

Clinicians will take bicycles and motorbikes into the community to find non-compliant patients. 

It was a good chance to see many different members of the community. Even some of the Tumutumu hospital employees frequent this clinic. The patients were all very friendly and grateful to be seen. Often times working in the emergency department is a thankless job... it is nice to be able to provide care to patrons who truly appreciate it.  

Case Presentation 2

Patient is a 57 yo who has ISS and TB who presented with confusion and decreased intake. The family states the patient was started on medication for the above diagnoses about 2 weeks ago. Patient has become more and more confused and has not said anything in the last 24 hours. He seems to have "hotness of body" and hasn't had anything to eat or drink in 2 days.

When we evaluated the patient, he was not febrile but was minimally responsive to pain and verbal stimuli. He was tachycardic and appeared very dehydrated. He was found to be tachypneic and his oxygen saturation was 92%. The patient was given IV fluids and started on Co-tramazole, Ceftriaxone, and Acyclovir. ECG was performed to evaluate his tachycardia. Complete hemogram, UEC, and chest xray were ordered and a lumbar puncture was performed.

Discussion:

There are a few points that I would like to discuss about this patient. The first is the fact that the patient is "ISS." This stands for "immuno suppression syndrome". There is such a stigma here in Kenya against HIV that even doctors can't discuss this openly with patients. It goes so far that you cannot order a rapid HIV test. Physicians instead order a DTC-diagnostic testing and counciling. Even the HIV clinic has a euphamistic name- the Comprehensive Care Clinic. Apparently if it was called the HIV clinic no one would come. That's not to say that we don't have a stigma in South Carolina as well, but I feel that in SC we can speak more openly about the subject.

This is one of the sicker patients that I have seen here. In the emergency department he's what we would call an easy admission. With the limited resources, it makes it very difficult to treat the acutely ill. We were able to obtain an EKG, but this took several hours. The machine is not very portable and is almost on par with putting the patient's hands and feet into buckets of water. Acutally there are clamps that are attached to the limbs, and the precordial leads are held in place by bulb-suction devices. The leads are printed out one at a time and the clinical officer has to cut them all out and tape them onto another sheet of paper to place in the chart. The process takes anywhere from 30-45 minutes from start to finish not including the cutting out (and you thought it took awhile to get one at Richland).

Oxygen is often difficult to get onto the patient and tanks have to be wheeled to the bedside. This takes a lot longer than you would really want and sometimes makes me nervous, but often there just isn't a tank available. These tanks are not very portable which means if a patient is needs O2 they can't go anywhere. Even getting a simple chest xray is impossible. Forget a stat CT- that requires raising funds and a day of travel. Sometimes I forget how easily these diagnostic studies are obtained at home.

The patient is currently being treated for TB and I asked about placing him in isolation. Basically there is no isolation here. The doctors practice on the theory that it is basically endemic to Kenya. "Everybody has TB here, just not everyone shows it," is what the intern told me. To which I replied, "I don't have TB!" She simply shrugged and told me not to breath too deeply.

We were able to obtain CSF and it was actually negative. I was able to walk the clinical officer through his first successful LP (or more likely he succeeded despite my misdirection). The lumbar puncture kits are very simplistic and they cannot get an opening pressure or perform cultures. However, they can obtain cryptoccal antigens studies and these were negative as well. Still, we threw everything but the kitchen sink at this guy. In addition to antibiotics, patient received IVF and tea through NG tube. Apparently it is customary to place an NG twice a day to make sure the patients get tea time.

Over the last few days, the patient has done very well. He is now off oxygen and has vastly improved, although still confused. We still don't know the underlying eitiology of his illness although the current theory is either sepsis (unknown sources) vs IRIS- immun-reconstitution syndrome. I am glad to see him improve everyday even if he has no idea who I am.