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.

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.

Karatina Market

On this first weekend we soon ran into a funny problem at Tumutumu.  Mainly, what's next?  How American of us, to expect a planned itinerary as soon as we arrived!  The hospital is closed on the weekend (except for the in-patients) and the Head Doctor, Dr. Kariithi, who is responsible for organizing us and appointing us positions at the hospital, wouldn't be in until Monday.  So Matthew and I, who are rather goal oriented, would be without a mission until Monday.  (Also, we would be without internet!  Sorry Mom!).  On top of which we were, temporarily, the only guests at the guest house. 

We asked around and expressed our desire to get out and see and do something on Saturday.  So hastily we were shuffled from host to host.  We received an impromptu tour of the hospital from Leah (see Matthew's post for details).  Then it was arranged for a driver from the hospital, Paul, to take us on a driving tour of Karatina.  There we met Carol, a nursing student of Tumutumu, who showed us around the Saturday market where an abundance of produce was sold: oranges and bananas, avocados, melons and mangoes, beans and lentils, onions, tomatoes and garlic, potatoes and yams....

Paul's tour of the city was interesting because he was the first person to discuss and address class with us.  There are several apartment buildings which have water and electricity.  This is where the upperclass people live.  They are also the only ones with cars.  Middle class residents live by the river so they can easily wash their clothes in the river because they do not have running water.  He didn't discuss where the poor lived.  The markets are even divided.  Wealthier patrons shop in 'boutiques', or stores with permanent locations in the downtown area.  If you can't afford the boutiques then you shop second hand clothing and shoes in the open air markets by the train tracks.  There is a third market, the food market, where sellers (mostly lower class) come on Tuesdays, Thursdays, and Saturdays to sell produce.

A Boutique Shop

Market

So here we get a glimpse of what poverty looks like.  I've seen it in India and Cambodia and Thailand and it has the same face here.  It is dirty, it is crowded, it smells really bad.  It is mismatched clothing and shoes worn through their soles. It is homes made of wooden slats and roofs of tarp and thatch.  

How do we reconcile this?  I think this is what I struggle most with:  I am here, a comfortable Christian, and even if I give all of my money and self to this place the problems will not be solved.  That is still not enough.  There will still be periods of drought when people go without food.  There will still be disease and poverty.  It begs the question what is the use?  Why bother?  Theologically, this is right up there with “Why do bad things happen to good people?” and “Why does evil exist in the world?”.  I hate to disappoint you but I am without simple solutions to these too.

There isn't an easy, trite phrase to make this all add up.  I think just being here in fellowship has something to do with it.  I'll refer to Nouwen again (as I think I often will in these posts) to share some insight on the problem:

“The mystery of ministry  is that the Lord is to be found where we minister.  That is what Jesus tells us when he says:  “Truly I tell you, just as you did it to one of the least of these who are members of my family, you did it to me.” (Matthew 25:40).  Our care for people thus becomes the way to meet the Lord.  The more we give, help, support, guide, counsel, and visit, the more we receive, not just similar gifts, but the Lord himself.  To go to the poor is to go the Lord.”