November 28, 2009
Thanksgiving was great—Kathy Trotter even made a little dish of stuffing outside the bird for me, just like my mom does! We invited one of the Kenyan interns along, Samuel. He had his very first turkey ever, and we got to share stories of our different cultures for most of the evening, including learning about his 6 weeks spent at Duke doing surgery. He was overwhelmed by the number of commercials on TV and how many things you could buy, anytime, anywhere. I learned that you never put fresh pineapple into a jello mold—and brought jello soup as my contribution. I’m sure Samuel thought that was weird.
I was on call yesterday and last night, and today and tonight, then climbing mount Longonot on Sunday morning (10K ft). Last night I went in around 8pm to check on things in the labor ward, and saw one of our patients lift her leg while standing and push her baby’s head out. I grabbed some gloves and delivered the baby and then couldn’t deliver the placenta, but noticed that in the bed next to her, the patient wasn’t sounding so good on the monitor. So I handed off the first patient (who was HIV positive… glad I grabbed gloves) and had the nurse work on the placenta, while I printed an NST for the second patient, and realized the baby was in distress, so took her back for a cesarean section fast. I called my intern to help with the c-section, and when we got her started, the nurse came in asking for help with the placenta, which still hadn’t come out (now about 45 minutes later). So I sent my intern to help with the placenta, and I did my first solo cesarean section! It kinda rocked. Until there was a lot of bleeding, and every time I tried to stop it with another stitch, I caused more bleeding with my needle. It was pretty scary, thinking to myself “where do I get off doing a c-section by myself? Who do you think you are, Alyson?” Luckily I stopped the bleeding, got her closed up and ran to help with the placenta, which still wasn’t out… and the HIV positive woman had lost about 3 liters of blood in the process. So I ran for blood, and got the OR switched over for an emergent D&C to remove the placenta. I called for back-up on this one, and one of the OBs came in to help (thank God)—it was pretty tough, but the patient was glad for some anesthesia, and some blood, and she looks better this morning.
I got back to the labor ward, and realized that the patient I’d wanted to start oxytocin at 10am to help her contract more since she wasn’t progressing at all, was still not started on oxytocin at midnight, and was still only dilated to 4cm, same as 30 hours ago. I put her baby on the monitor and there was fetal distress, so, much to the dismay of our poor OR team who had also been awake all day, I took her back for a cesarean section too. I made it home around 1:30am, and slept until 3 when the dog barking next door woke me up… at least it wasn’t the pager.
Today is a rainy day—the first one in weeks. It’s nice though, to have a rainy Saturday on call. Reminds me of Seattle! Right now Vy, Dustin and I are hanging around, reading and drinking Kenyan coffee. Vy is also on call, and spent her morning giving intra-thecal methotrexate to a baby (chemotherapy into the spinal cord)—ah, family medicine. Hopefully today will be peaceful and I’ll get some rest for my climb tomorrow morning—we leave early to see the most animals and birds on the mountain. And maybe I’ll get in a nap today…
Saturday, November 28, 2009
Wednesday, November 25, 2009
OB/GYN
November 25, 2009
Ok, what would you do? A 30yo female who is pregnant with her 3rd child comes to the hospital because her water had broken. She is only 35 weeks (5 weeks early, confirmed by my ultrasound) and she has had 2 previous cesarean sections. In the US, we are able to keep babies inside for a few weeks when moms break their water early, but not in Kenya—she had to deliver today. She also really wants a tubal ligation (tubes tied) and her husband agrees (in Kenya, the husband signs the consent for the tubal). So we do her cesarean section, and two things go wrong: #1 when we open her abdomen, there is a “window” in the uterus, meaning that the uterus wall is so thin, that you can see her baby through the uterus—if she had stayed pregnant any longer, her uterus would likely have burst open, so she was very lucky to be having a cesarean early! #2 the baby looks terrible—she does not breathe on her own, and looks “floppy” and blue. She gets taken to the nursery by the pediatricians and gets oxygen and is not looking well even 30 minutes later. So, what would you do? Would you tie her tubes during the operation, since she wanted permanent contraception prior to her cesarean, with her newborn potentially not surviving? Or do you leave her tubes intact, so she can have another pregnancy if this baby dies, with the risk of a thin uterine wall that could burst, potentially killing her and her fetus in her next pregnancy?
I ended up not tying her tubes. I over-sewed her uterus in two layers, to hopefully strengthen the wall, and decided that a tubal could be done in the future if the baby did well—you can always do a tubal, but it can never be un-done. I asked Vy and Dustin, and they both would have tied her tubes, since she is at such high risk in her next pregnancy… ugh. I don’t know if it was the right decision, but I do know that having babies is the most important thing to a Kenyan woman—it is valued above almost everything. I’ve become more in tune to that way of thinking, apparently.
Just yesterday, I was scrubbed in assisting one of the obsetricians doing a myomectomy and tubuloplasty (removal of fibroids and fixing the fallopian tubes) for a 42 year-old woman who had never been able to conceive. Her husband’s other wife had 6 children, so the problem wasn’t him… when we opened her abdomen, we found that her uterus was so full of fibroids and she had two large fibroids that were completely blocking her tubes. There was nothing to be done. We tried injecting purple dye into the uterus to see if any would come through the tubes, but saw none. She and her husband had been told prior to surgery, that if things looked bad enough, we would do a hysterectomy (remove her uterus entirely) and so that’s what we did. It felt awful, since this was her last-ditch effort to have a chance to conceive, and now we would take away all hope. We worried that her husband would leave her, or treat her poorly, but we knew that she was at risk of severe bleeding or abdominal pain that would require a hysterectomy years later if we left the fibroids there, and she may not have money for another surgery in the future. So we did the hysterectomy after we both convinced ourselves it was the right thing to do. Unfortunately, as we cut the left tube to remove the uterus, we saw purple dye. Who knows if this tube was open enough for an egg to pass the whole way through? I seriously doubt it, since she’d been trying for 20 years without a child, but I think I would have felt better cutting her ureter by accident, than cutting through this tube. I’ll have the chaplain come see them today.
We delivered 3 babies in 30 minutes this morning. I came in early, since it was “staff chapel” at 8am. That was my first mistake. I saw a patient who had been admitted about 2 hours earlier, and I asked a nurse about her—they told me she was 8cm dilated and had “Grade 2 meconium” meaning the baby had its first poop inside her. But no one had monitored the baby, and I asked for some monitoring, and saw fetal distress (heart tones down to the 80s with contractions) and so checked her myself and thought she was 9cm and took her back to the delivery room and vacuumed the baby out fast! I had to cut an episiotomy without any anesthesia to make room, and the mom kicked me really hard when I did it! But once I got her baby out, I couldn’t keep the mom on the table, because she was yelling “praise Jesus!” and “I love you doctor!” and trying to hug me, while hemorrhaging all over the floor and my shoes! Sharon, one of the other OBs ran and vacuumed another baby out that was having bad heart tones and at the same time, one of my patients that I’d admitted yesterday with a really poorly controlled “seizure” disorder (I put it in quotations, because I saw her “seize” and it looked fake—unfortunately, she was being given phenytoin, phenobarbital, and carbamazepine in pregnancy for her disorder—all potentially harmful to her baby). Anyway, I could smell something foul and heard from the nurses that she was going to the bathroom all over the floor, and when I got to her, there her baby’s head was hanging out. So I delivered her, and then she had a major hemorrhage—nearly 2 liters of blood loss. No problem! Stopped that bleeding and then went and started my day! People will think I’m a sinner, since I missed staff chapel… again.
I’m hoping to make it to the vegetable stand today, to get some ingredients for Thanksgiving tomorrow! I couldn’t find Velveeta cheese, for my favorite broccoli casserole, but I’ll just have to get creative!
Ok, what would you do? A 30yo female who is pregnant with her 3rd child comes to the hospital because her water had broken. She is only 35 weeks (5 weeks early, confirmed by my ultrasound) and she has had 2 previous cesarean sections. In the US, we are able to keep babies inside for a few weeks when moms break their water early, but not in Kenya—she had to deliver today. She also really wants a tubal ligation (tubes tied) and her husband agrees (in Kenya, the husband signs the consent for the tubal). So we do her cesarean section, and two things go wrong: #1 when we open her abdomen, there is a “window” in the uterus, meaning that the uterus wall is so thin, that you can see her baby through the uterus—if she had stayed pregnant any longer, her uterus would likely have burst open, so she was very lucky to be having a cesarean early! #2 the baby looks terrible—she does not breathe on her own, and looks “floppy” and blue. She gets taken to the nursery by the pediatricians and gets oxygen and is not looking well even 30 minutes later. So, what would you do? Would you tie her tubes during the operation, since she wanted permanent contraception prior to her cesarean, with her newborn potentially not surviving? Or do you leave her tubes intact, so she can have another pregnancy if this baby dies, with the risk of a thin uterine wall that could burst, potentially killing her and her fetus in her next pregnancy?
I ended up not tying her tubes. I over-sewed her uterus in two layers, to hopefully strengthen the wall, and decided that a tubal could be done in the future if the baby did well—you can always do a tubal, but it can never be un-done. I asked Vy and Dustin, and they both would have tied her tubes, since she is at such high risk in her next pregnancy… ugh. I don’t know if it was the right decision, but I do know that having babies is the most important thing to a Kenyan woman—it is valued above almost everything. I’ve become more in tune to that way of thinking, apparently.
Just yesterday, I was scrubbed in assisting one of the obsetricians doing a myomectomy and tubuloplasty (removal of fibroids and fixing the fallopian tubes) for a 42 year-old woman who had never been able to conceive. Her husband’s other wife had 6 children, so the problem wasn’t him… when we opened her abdomen, we found that her uterus was so full of fibroids and she had two large fibroids that were completely blocking her tubes. There was nothing to be done. We tried injecting purple dye into the uterus to see if any would come through the tubes, but saw none. She and her husband had been told prior to surgery, that if things looked bad enough, we would do a hysterectomy (remove her uterus entirely) and so that’s what we did. It felt awful, since this was her last-ditch effort to have a chance to conceive, and now we would take away all hope. We worried that her husband would leave her, or treat her poorly, but we knew that she was at risk of severe bleeding or abdominal pain that would require a hysterectomy years later if we left the fibroids there, and she may not have money for another surgery in the future. So we did the hysterectomy after we both convinced ourselves it was the right thing to do. Unfortunately, as we cut the left tube to remove the uterus, we saw purple dye. Who knows if this tube was open enough for an egg to pass the whole way through? I seriously doubt it, since she’d been trying for 20 years without a child, but I think I would have felt better cutting her ureter by accident, than cutting through this tube. I’ll have the chaplain come see them today.
We delivered 3 babies in 30 minutes this morning. I came in early, since it was “staff chapel” at 8am. That was my first mistake. I saw a patient who had been admitted about 2 hours earlier, and I asked a nurse about her—they told me she was 8cm dilated and had “Grade 2 meconium” meaning the baby had its first poop inside her. But no one had monitored the baby, and I asked for some monitoring, and saw fetal distress (heart tones down to the 80s with contractions) and so checked her myself and thought she was 9cm and took her back to the delivery room and vacuumed the baby out fast! I had to cut an episiotomy without any anesthesia to make room, and the mom kicked me really hard when I did it! But once I got her baby out, I couldn’t keep the mom on the table, because she was yelling “praise Jesus!” and “I love you doctor!” and trying to hug me, while hemorrhaging all over the floor and my shoes! Sharon, one of the other OBs ran and vacuumed another baby out that was having bad heart tones and at the same time, one of my patients that I’d admitted yesterday with a really poorly controlled “seizure” disorder (I put it in quotations, because I saw her “seize” and it looked fake—unfortunately, she was being given phenytoin, phenobarbital, and carbamazepine in pregnancy for her disorder—all potentially harmful to her baby). Anyway, I could smell something foul and heard from the nurses that she was going to the bathroom all over the floor, and when I got to her, there her baby’s head was hanging out. So I delivered her, and then she had a major hemorrhage—nearly 2 liters of blood loss. No problem! Stopped that bleeding and then went and started my day! People will think I’m a sinner, since I missed staff chapel… again.
I’m hoping to make it to the vegetable stand today, to get some ingredients for Thanksgiving tomorrow! I couldn’t find Velveeta cheese, for my favorite broccoli casserole, but I’ll just have to get creative!
Sunday, November 22, 2009
The Weekend
November 22, 2009
I’m blowing dusty boogers out of my nose! After two days of travel this weekend (Saturday to Nairobi, and Sunday to Hell’s Gate) and driving on these crazy, extremely dusty Kenyan roads, everything seems to be coated in dust, including my nose and lungs!
Nairobi was fun—we packed our day with several stops, including a shopping trip at an outdoor bazaar, a visit to “the Giraffe Center” where we all got big wet kisses from Laura the giraffe, a little learning at the Nairobi national museum (many of the famous skull and skeletons of early hominids were found in Kenya!) and a dinner at a restaurant called Carnivore (perfect for the vegetarian) where they served giraffe (poor Laura!), zebra, ostrich, wildebeest, and more!
Today we got up early and headed out to Hell’s Gate national park. When we arrived, our guide said “welcome to hell” and we descended into a deep canyon of lime stone with waterfalls of hot water from geothermal sources. There was beautiful obsidian stone to be found all over the ground from previous volcanic activity. There were also many animals in the park, including really cute (but cute in an ugly way) warthogs and warthog families, more giraffe, gazelles, impala, zebra…
I have pretty much given up taking pictures… I had no idea how inferior my camera is until I took some pictures with Dustin’s camera the other day, and realized was mega-pixels are all about. My camera is from medical school, which doesn’t seem that long ago, but Dustin’s has 8 mega-pixels and mine has 3, and what a difference it makes! None of us has a really nice camera, but the animals are amazing no matter how you photograph them—sometimes I think they pose for us!
We got home today, and I went for a run and Dustin played ultimate frisbee with some of the doctors, and Vy took a nap. Then we all met up for dinner at the Rift Valley Academy cafeteria—they charge us 250 kenyan schillings ($3.25) for a really good buffet and you can eat with the students, and avoid cooking for a night!
I can’t believe it’s Thanksgiving week! We’ve been invited to the Trotter’s home for dinner Thursday. Not sure what we’ll bring—baking is difficult due to the elevation. But the ladies up the street sell amazing fresh fruits and veggies (we eat mangos at 50 cents a mango, amazing pineapple for $2 each, and they have delicious root vegetables, tomatoes, peppers, etc). They like for you to buy something from each of them, so best to bring a list of what you want, and they divvy it up amongst themselves so everyone gets paid. It’s a confusing, but sweet system. Very Kenyan.
I’m going to get off the computer and give Vy and Dustin some time to journal and email. On call tomorrow, and a busy week ahead. I can’t believe our time here is half over! I’ll be looking forward to hearing everyone’s Thanksgiving plans…
I’m blowing dusty boogers out of my nose! After two days of travel this weekend (Saturday to Nairobi, and Sunday to Hell’s Gate) and driving on these crazy, extremely dusty Kenyan roads, everything seems to be coated in dust, including my nose and lungs!
Nairobi was fun—we packed our day with several stops, including a shopping trip at an outdoor bazaar, a visit to “the Giraffe Center” where we all got big wet kisses from Laura the giraffe, a little learning at the Nairobi national museum (many of the famous skull and skeletons of early hominids were found in Kenya!) and a dinner at a restaurant called Carnivore (perfect for the vegetarian) where they served giraffe (poor Laura!), zebra, ostrich, wildebeest, and more!
Today we got up early and headed out to Hell’s Gate national park. When we arrived, our guide said “welcome to hell” and we descended into a deep canyon of lime stone with waterfalls of hot water from geothermal sources. There was beautiful obsidian stone to be found all over the ground from previous volcanic activity. There were also many animals in the park, including really cute (but cute in an ugly way) warthogs and warthog families, more giraffe, gazelles, impala, zebra…
I have pretty much given up taking pictures… I had no idea how inferior my camera is until I took some pictures with Dustin’s camera the other day, and realized was mega-pixels are all about. My camera is from medical school, which doesn’t seem that long ago, but Dustin’s has 8 mega-pixels and mine has 3, and what a difference it makes! None of us has a really nice camera, but the animals are amazing no matter how you photograph them—sometimes I think they pose for us!
We got home today, and I went for a run and Dustin played ultimate frisbee with some of the doctors, and Vy took a nap. Then we all met up for dinner at the Rift Valley Academy cafeteria—they charge us 250 kenyan schillings ($3.25) for a really good buffet and you can eat with the students, and avoid cooking for a night!
I can’t believe it’s Thanksgiving week! We’ve been invited to the Trotter’s home for dinner Thursday. Not sure what we’ll bring—baking is difficult due to the elevation. But the ladies up the street sell amazing fresh fruits and veggies (we eat mangos at 50 cents a mango, amazing pineapple for $2 each, and they have delicious root vegetables, tomatoes, peppers, etc). They like for you to buy something from each of them, so best to bring a list of what you want, and they divvy it up amongst themselves so everyone gets paid. It’s a confusing, but sweet system. Very Kenyan.
I’m going to get off the computer and give Vy and Dustin some time to journal and email. On call tomorrow, and a busy week ahead. I can’t believe our time here is half over! I’ll be looking forward to hearing everyone’s Thanksgiving plans…
Friday, November 20, 2009
ET Richardson
My sister, Katie, teaches 7th Grade at ET Richardson in Springfield, PA. She teaches half the year about Africa, and her students have been following my blog and have posted really good questions... and here are the responses:
Katie said...
Hi Alyson! My kids are enjoying your DETAILED blogs. I have to skip a couple things.
1. AJ asked whether you think that the one Masai woman realized she was blind and was trying to communicate that to you or if she had no idea what was going on based on the turning on the lights?
Really good question, AJ! I don’t think we know either. In the US, we’d get a cat scan of the brain and would be able to tell a little more about what was going on, but I don’t think this family can afford the trip to Nairobi or the CT scan. I think she does not know she is blind, but does not sense light, so is frustrated by that disability. I think the bleeding in her brain makes it hard for her to express what she is experiencing and I’m not sure she understands what is going on either. The language problem just added a layer of complication too! Even if she was telling us she was blind, I don’t think many people would understand her. It’s so sad to think about that. How scary for her, to be blind and unable to communicate with the people trying to care for her—she calls out for her twin babies all day, and they were just taken away from her by her family, who will care for them until she is out of the hospital.
2. Taylor wants to know if you are enjoying your time because she finds it hard to believe you can with all of the sad stuff.
I’m sorry my blog seems filled with sad things—I think I’m using the blog to help me to process these sad things, so it may be more prevalent in my writing. I’m also surrounded by happy things! I help to deliver plenty of healthy babies, and get to listen to Kenyan nurses singing in the hallways each morning! We take Chai breaks and eat yummy mandazis (doughnuts) often, and the weather and scenery is amazing here. I’ll try to include more happiness in my blog—thanks for the reminder, Taylor!
Ok a couple questions from my 4th period:
1. Do you get grossed out at all from this stuff? Not really. We get pretty used to seeing blood and guts in medical school. I can do some pretty nasty surgeries and then go eat lunch without any problem! That said, you never get used to seeing people suffer.
2. How much Swahili have you learned? I’m working on it. I can start a conversation well: Habari! Jina langu daktare Alyson! Unasema kingereza? Kuna nini? Uchungoo? That means “Hi, how are you? My name is doctor Alyson! Do you speak English? Is everything ok? Pain?” The language is pretty simple—you pronounce every syllable and put the emphasis on the second to last syllable every time. I just found the word for “toothpick” though, and it’s not so simple: kijiti cha kuchokolea meno. Huh?
3. Are you scared or feel in danger at all? Surprisingly, no. I’m living in a village of people who mostly work for the hospital and they feel very lucky to be a part of the community that is helping their people, and the Kenyan people are so kind. It has been really impressive to me—the Kenyans live with so little and suffer through so much hardship, but they believe firmly in God and never blame him for their suffering but feel that their work and suffering makes them stronger. They think it builds character to face challenges. Unlike Americans, who feel very strongly about making something out of yourself and to go from “rags to riches”, where we judge each other by the things we own, and our accomplishments, even at the expense of others, the Kenyans are very happy with who they are, and what they have. On the other hand, I do feel very scared on the roads here! We see so many tragic accidents in the hospital—the cars are unsafe and the drivers are aggressive—few cars have more than lap-belts and they pile people into cars to get around! I’m headed into Nairobi for the day tomorrow, and I’ll have to let you how safe I feel there…
4. Are you scared of getting sick from these people? Yes. Nearly 1/3rd of the world’s population has TB (tuberculosis, which is a lung disease that can travel to the rest of your body), and that is certainly an underestimate in Kijabe. I’d say most of our patients in the hospital have TB, and TB can stay in the air for along time after a patient coughs. No one wears masks here! The one good thing is that all the windows are open in the hospital, so that helps to move the TB outdoors. I also worry a lot about HIV/AIDS. AIDS is so prevalent in Africa, and is one of their leading killers. It is very taboo to have AIDS, so people don’t want to be tested, and don’t wear condoms, and very few people are on medications since they are in denial about having the disease. There are so many “orphans” in Africa because of mothers dying young from the disease—luckily there is such a strong family bond, that often the “aunt” is raising 4-5 of her own children and another 4 kids of her sisters who died of AIDS. A needle-stick in the hospital occurs often (not yet for me… knock on wood) but means months of taking anti-retroviral treatment (the medicines that can treat HIV) to prevent you from getting the disease. In general, the “standard precautions” of gloves and hand-washing are out the window here—there is just a shortage of soap and very few gloves to go around! I wash my veggies in vegetable sterilizer, and filter my water to try to prevent bad diarrhea, and brought antibiotics just in case!
5. How do you escape from a hard days work? It sounds lame, but we’ve been doing a lot of reading. Dustin and I went for a run today, which was a challenge, since we’re at 7,500 ft elevation, and used to living at sea level, so we’re short of breath, but slowly getting more used to it! We’ve been cooking meals together, and it’s so nice at the end of the day to have a warm meal together and process all the crazy things we saw!
6. What is the weather like? The weather has been beautiful. 75 degrees and sunny during the day, but super windy and sometimes rainy at night. I wrote about the drought and the weather more in my last entry.
7. Are you bored with no tv, computer, etc? Yes and no. I’d love to have a more reliable computer to keep in touch. I’d also love to have a cell phone! I miss texting! But it’s also love being away from technology for a month! We’re awake before 6am and work so hard all day, so we’re asleep by 9pm and don’t have time to be bored!
8. Where you are staying, is it enclosed from the wild? I’m kind of embarrassed to say, but we’re staying at a pretty nice apartment! We have running hot water and electricity (that likes to turn off several times a day). That said, we have monkeys climbing on the trees outside of our place, and the baboons steal things all the time!
9. What are the laws like in Kenya/Somalia...do these people get punished for things like shooting that girl? There are no speed limits or driving violations in Kenya! It sometimes seems that the laws in Kenya are bent for people who have money. The government is somewhat corrupt, and the different tribes believe in different leaders and different laws, which is a source of confusion about rules. What rules there are seem to be difficult to enforce, so people are less accountable for their actions. Somalia is a different world. I do not think that anyone was punished for shooting the girl in Somalia—violence is a way of life there and there is no government in Somalia at this time, and so groups of people who are heavily armed take it upon themselves to try to make everyone else suffer if they do not agree with their way of thinking. It’s a really scary country, and that is why we see so many Somali refugees in Kenya, who are trying to escape the violence and crime.
10. What are cars/businesses/technology like there? The cars are mostly old, but there are a few modern cars on the road. The main business is farming, and the fruits and veggies are amazing! In spite of the poverty, EVERYONE has a cell phone! They can’t feed their children, but they pay a cell phone bill (or actually pay for a card that has minutes for their phones)—Dustin mentioned the people he sees coming in to Casualty (their ER) who are covered in blood after a car accident, and they are on their cell phones calling their friends and family to come to the hospital to bring money so they can pay for the surgery they need! The ring tones are pretty funny too—lots of cheesy pop music, like Hannah Montana or something! But no iPhones or iPods around. Their electricity goes on and off all the time in the hospital—even in the middle of a surgery, all the lights will go out for a few minutes, so it’s good to have a flashlight on hand (they call them “torches”).
11. Do you ever feel like giving up? I’d have to say yes, a few times, I’ve felt like giving up. Most of the things I struggle with involve working in this backwards medical system of theirs, and not really patient care itself. I think I know the right way to take care of most of these patients, but I have to work twice as hard to accomplish something that would be so easy in the US. Sometimes the nurses won’t do things I ask for because I’m a white girl (a “Wazungu”) and it helps to have a Kenyan medical officer working with you to get things done. But like I said, the Kenyans are so patient, so kind, and so appreciative of the things you do for them. I’ve had several patients tell me they love me—I’ve never heard that from a patient in the US (aside from the crazy ones!) and several have invited me to their homes to meet their families (and one asked me to marry his son!) I feel very lucky to be learning from the Kenyans, and am fortunate to be allowed to be a part of their culture and their community, and I can’t imagine giving up on that!
12. Do you have to work nights ever? Yes! Only when there is an emergency that the Kenyan Intern cannot handle on his or her own, then I get called in to help!
Thanks for your interest and your great questions! Keep 'em coming!
Katie said...
Hi Alyson! My kids are enjoying your DETAILED blogs. I have to skip a couple things.
1. AJ asked whether you think that the one Masai woman realized she was blind and was trying to communicate that to you or if she had no idea what was going on based on the turning on the lights?
Really good question, AJ! I don’t think we know either. In the US, we’d get a cat scan of the brain and would be able to tell a little more about what was going on, but I don’t think this family can afford the trip to Nairobi or the CT scan. I think she does not know she is blind, but does not sense light, so is frustrated by that disability. I think the bleeding in her brain makes it hard for her to express what she is experiencing and I’m not sure she understands what is going on either. The language problem just added a layer of complication too! Even if she was telling us she was blind, I don’t think many people would understand her. It’s so sad to think about that. How scary for her, to be blind and unable to communicate with the people trying to care for her—she calls out for her twin babies all day, and they were just taken away from her by her family, who will care for them until she is out of the hospital.
2. Taylor wants to know if you are enjoying your time because she finds it hard to believe you can with all of the sad stuff.
I’m sorry my blog seems filled with sad things—I think I’m using the blog to help me to process these sad things, so it may be more prevalent in my writing. I’m also surrounded by happy things! I help to deliver plenty of healthy babies, and get to listen to Kenyan nurses singing in the hallways each morning! We take Chai breaks and eat yummy mandazis (doughnuts) often, and the weather and scenery is amazing here. I’ll try to include more happiness in my blog—thanks for the reminder, Taylor!
Ok a couple questions from my 4th period:
1. Do you get grossed out at all from this stuff? Not really. We get pretty used to seeing blood and guts in medical school. I can do some pretty nasty surgeries and then go eat lunch without any problem! That said, you never get used to seeing people suffer.
2. How much Swahili have you learned? I’m working on it. I can start a conversation well: Habari! Jina langu daktare Alyson! Unasema kingereza? Kuna nini? Uchungoo? That means “Hi, how are you? My name is doctor Alyson! Do you speak English? Is everything ok? Pain?” The language is pretty simple—you pronounce every syllable and put the emphasis on the second to last syllable every time. I just found the word for “toothpick” though, and it’s not so simple: kijiti cha kuchokolea meno. Huh?
3. Are you scared or feel in danger at all? Surprisingly, no. I’m living in a village of people who mostly work for the hospital and they feel very lucky to be a part of the community that is helping their people, and the Kenyan people are so kind. It has been really impressive to me—the Kenyans live with so little and suffer through so much hardship, but they believe firmly in God and never blame him for their suffering but feel that their work and suffering makes them stronger. They think it builds character to face challenges. Unlike Americans, who feel very strongly about making something out of yourself and to go from “rags to riches”, where we judge each other by the things we own, and our accomplishments, even at the expense of others, the Kenyans are very happy with who they are, and what they have. On the other hand, I do feel very scared on the roads here! We see so many tragic accidents in the hospital—the cars are unsafe and the drivers are aggressive—few cars have more than lap-belts and they pile people into cars to get around! I’m headed into Nairobi for the day tomorrow, and I’ll have to let you how safe I feel there…
4. Are you scared of getting sick from these people? Yes. Nearly 1/3rd of the world’s population has TB (tuberculosis, which is a lung disease that can travel to the rest of your body), and that is certainly an underestimate in Kijabe. I’d say most of our patients in the hospital have TB, and TB can stay in the air for along time after a patient coughs. No one wears masks here! The one good thing is that all the windows are open in the hospital, so that helps to move the TB outdoors. I also worry a lot about HIV/AIDS. AIDS is so prevalent in Africa, and is one of their leading killers. It is very taboo to have AIDS, so people don’t want to be tested, and don’t wear condoms, and very few people are on medications since they are in denial about having the disease. There are so many “orphans” in Africa because of mothers dying young from the disease—luckily there is such a strong family bond, that often the “aunt” is raising 4-5 of her own children and another 4 kids of her sisters who died of AIDS. A needle-stick in the hospital occurs often (not yet for me… knock on wood) but means months of taking anti-retroviral treatment (the medicines that can treat HIV) to prevent you from getting the disease. In general, the “standard precautions” of gloves and hand-washing are out the window here—there is just a shortage of soap and very few gloves to go around! I wash my veggies in vegetable sterilizer, and filter my water to try to prevent bad diarrhea, and brought antibiotics just in case!
5. How do you escape from a hard days work? It sounds lame, but we’ve been doing a lot of reading. Dustin and I went for a run today, which was a challenge, since we’re at 7,500 ft elevation, and used to living at sea level, so we’re short of breath, but slowly getting more used to it! We’ve been cooking meals together, and it’s so nice at the end of the day to have a warm meal together and process all the crazy things we saw!
6. What is the weather like? The weather has been beautiful. 75 degrees and sunny during the day, but super windy and sometimes rainy at night. I wrote about the drought and the weather more in my last entry.
7. Are you bored with no tv, computer, etc? Yes and no. I’d love to have a more reliable computer to keep in touch. I’d also love to have a cell phone! I miss texting! But it’s also love being away from technology for a month! We’re awake before 6am and work so hard all day, so we’re asleep by 9pm and don’t have time to be bored!
8. Where you are staying, is it enclosed from the wild? I’m kind of embarrassed to say, but we’re staying at a pretty nice apartment! We have running hot water and electricity (that likes to turn off several times a day). That said, we have monkeys climbing on the trees outside of our place, and the baboons steal things all the time!
9. What are the laws like in Kenya/Somalia...do these people get punished for things like shooting that girl? There are no speed limits or driving violations in Kenya! It sometimes seems that the laws in Kenya are bent for people who have money. The government is somewhat corrupt, and the different tribes believe in different leaders and different laws, which is a source of confusion about rules. What rules there are seem to be difficult to enforce, so people are less accountable for their actions. Somalia is a different world. I do not think that anyone was punished for shooting the girl in Somalia—violence is a way of life there and there is no government in Somalia at this time, and so groups of people who are heavily armed take it upon themselves to try to make everyone else suffer if they do not agree with their way of thinking. It’s a really scary country, and that is why we see so many Somali refugees in Kenya, who are trying to escape the violence and crime.
10. What are cars/businesses/technology like there? The cars are mostly old, but there are a few modern cars on the road. The main business is farming, and the fruits and veggies are amazing! In spite of the poverty, EVERYONE has a cell phone! They can’t feed their children, but they pay a cell phone bill (or actually pay for a card that has minutes for their phones)—Dustin mentioned the people he sees coming in to Casualty (their ER) who are covered in blood after a car accident, and they are on their cell phones calling their friends and family to come to the hospital to bring money so they can pay for the surgery they need! The ring tones are pretty funny too—lots of cheesy pop music, like Hannah Montana or something! But no iPhones or iPods around. Their electricity goes on and off all the time in the hospital—even in the middle of a surgery, all the lights will go out for a few minutes, so it’s good to have a flashlight on hand (they call them “torches”).
11. Do you ever feel like giving up? I’d have to say yes, a few times, I’ve felt like giving up. Most of the things I struggle with involve working in this backwards medical system of theirs, and not really patient care itself. I think I know the right way to take care of most of these patients, but I have to work twice as hard to accomplish something that would be so easy in the US. Sometimes the nurses won’t do things I ask for because I’m a white girl (a “Wazungu”) and it helps to have a Kenyan medical officer working with you to get things done. But like I said, the Kenyans are so patient, so kind, and so appreciative of the things you do for them. I’ve had several patients tell me they love me—I’ve never heard that from a patient in the US (aside from the crazy ones!) and several have invited me to their homes to meet their families (and one asked me to marry his son!) I feel very lucky to be learning from the Kenyans, and am fortunate to be allowed to be a part of their culture and their community, and I can’t imagine giving up on that!
12. Do you have to work nights ever? Yes! Only when there is an emergency that the Kenyan Intern cannot handle on his or her own, then I get called in to help!
Thanks for your interest and your great questions! Keep 'em coming!
Internet!!!
November 20, 2009
Internet! Finally! We've been trying for the last two days to connect with no success, and all the computers in the hospital are broken. I just tried to whine about it to Dustin, and he reminded me that we have running water "which would you rather have?" He's so wise... and such a smart ass.
Anyway, now that I have internet, here's the last entry from my word document. I don't want to try my luck, so I'll post fast! Missing everyone! And sorry to keep my "fans" waiting for this post!
November 18, 2009
I survived my first call! I managed to get a few hours of sleep last night (in spite of the barking dog that lives next door—I keep thinking about Dad, yelling at the neighbors’ dogs back home—could I get frustrated and sleep-deprived enough to yell out the window in Kijabe at 4am?)
My adventure began at around 10pm, when I decided to check on a patient I’d admitted with bleeding in pregnancy. She’d been bleeding for about 12 hours, and I suspected an abruption (separation of the placenta from the uterus), but her baby had been ok. She was supposed to get an ultrasound to decide how far along she was—no one seems to know their due date, since they usually do not see a doctor during pregnancy. But, just like so many of my orders here, that never happened, so I took her to the ultrasound myself and decided she was somewhere around 35 or 36 weeks along, and she was contracting and her cervix was dilating, so there was nothing to do about keeping the baby in longer. But when I came by at around 10pm, her bed was soaked with blood. As it turns out, patients have to pay for maxi-pads, and she couldn’t afford them, so she bled in the bed all day. I listened to the fetus for a minute, and realized it was tachycardic, so I dragged over the only monitor in the ward, and got a paper tracing that was pretty scary. I decided she needed a stat cesarean section. I called the consultant on call for OB, and he said “go ahead and do the c-section with the intern on call tonight” so we did. I walked into the OR and had to walk into 4 rooms to find anyone to ask about doing the operation. Unfortunately, the orthopedic surgeon was about to do an amputation on a patient, and there is only one OR team in the middle of the night. The orthopedic surgeon looked at me like I was speaking a different language (which, technically I was, since he is a Kenyan doctor) and grilled me about why the cesarean section needed to be done now, and why I didn’t do it earlier, and how long it would take, and if I thought his patient could wait… aaah! Time was ticking, and I was worried about this baby, but these people don’t know me, and obviously doubted my authority to have them to stop their operation and help me do mine. Fortunately, they did, and I delivered a very large baby boy, covered in thick meconium (baby poo) and attached to a completely abrupted placenta. The baby and mom are both doing well today—although I can’t say the same for myself. I pretty tired.
My other continuity delivery was a breech extraction of a 24 week demise. This mom is a 41yo G9P8 (she has delivered 8 babies, but has 6 living children, as the last 3 have died in utero). She came in to clinic yesterday and I saw her for decreased fetal movements, and found no heart beat and confirmed it on ultrasound. I’ll spare the long story, but I delivered her fetus this morning alone (scared, since I’ve never done this before) after monitoring her frighteningly high blood pressure and her emotional state all night. I’ll be tying her tubes next week.
Sorry for the depressing stories! I did get asked to marry one of my patient’s sons today, and I’m giving a talk for the staff tomorrow on cervical cancer screening, so that’s exciting. Dustin is cooking dinner for us tonight (curry? More goat?) and he promised me we’d get to watch an episode of Top Chef on his iphone tonight as well—he downloaded 10 episodes for us before we left, and it’s our little treat! It’s about the only time I completely forget where I am, and lose myself in reality TV!
Eric had asked about the weather—it’s their “short rains” season, so it’s pretty much gorgeous all day, from a pink sunrise to clear blue skies at 75 degrees all day, and then around 6pm every day, the wind picks up tremendously, and persists for a few more hours or long into the night. Then sometimes it rains during the night. It had been a drought for the last 3 years in Kenya, but this ended about a month before we arrived. You’d never know—there are amazing plants and everything seems very lush. But many of the plants are succulents—there are huge cacti everywhere. The dry, red soil is our only indication of recent drought, and our white coats are now stained slightly, along with all my white socks. Our trip last weekend to Naivasha was hot, since we were in the valley, and we all got sun-burned. Gotta love living on the equator!
I’m off to help Dustin with dinner! Hopefully the dog will be quiet tonight, so I can sleep… Too bad the Kenyans eat goat, and not dog….
Internet! Finally! We've been trying for the last two days to connect with no success, and all the computers in the hospital are broken. I just tried to whine about it to Dustin, and he reminded me that we have running water "which would you rather have?" He's so wise... and such a smart ass.
Anyway, now that I have internet, here's the last entry from my word document. I don't want to try my luck, so I'll post fast! Missing everyone! And sorry to keep my "fans" waiting for this post!
November 18, 2009
I survived my first call! I managed to get a few hours of sleep last night (in spite of the barking dog that lives next door—I keep thinking about Dad, yelling at the neighbors’ dogs back home—could I get frustrated and sleep-deprived enough to yell out the window in Kijabe at 4am?)
My adventure began at around 10pm, when I decided to check on a patient I’d admitted with bleeding in pregnancy. She’d been bleeding for about 12 hours, and I suspected an abruption (separation of the placenta from the uterus), but her baby had been ok. She was supposed to get an ultrasound to decide how far along she was—no one seems to know their due date, since they usually do not see a doctor during pregnancy. But, just like so many of my orders here, that never happened, so I took her to the ultrasound myself and decided she was somewhere around 35 or 36 weeks along, and she was contracting and her cervix was dilating, so there was nothing to do about keeping the baby in longer. But when I came by at around 10pm, her bed was soaked with blood. As it turns out, patients have to pay for maxi-pads, and she couldn’t afford them, so she bled in the bed all day. I listened to the fetus for a minute, and realized it was tachycardic, so I dragged over the only monitor in the ward, and got a paper tracing that was pretty scary. I decided she needed a stat cesarean section. I called the consultant on call for OB, and he said “go ahead and do the c-section with the intern on call tonight” so we did. I walked into the OR and had to walk into 4 rooms to find anyone to ask about doing the operation. Unfortunately, the orthopedic surgeon was about to do an amputation on a patient, and there is only one OR team in the middle of the night. The orthopedic surgeon looked at me like I was speaking a different language (which, technically I was, since he is a Kenyan doctor) and grilled me about why the cesarean section needed to be done now, and why I didn’t do it earlier, and how long it would take, and if I thought his patient could wait… aaah! Time was ticking, and I was worried about this baby, but these people don’t know me, and obviously doubted my authority to have them to stop their operation and help me do mine. Fortunately, they did, and I delivered a very large baby boy, covered in thick meconium (baby poo) and attached to a completely abrupted placenta. The baby and mom are both doing well today—although I can’t say the same for myself. I pretty tired.
My other continuity delivery was a breech extraction of a 24 week demise. This mom is a 41yo G9P8 (she has delivered 8 babies, but has 6 living children, as the last 3 have died in utero). She came in to clinic yesterday and I saw her for decreased fetal movements, and found no heart beat and confirmed it on ultrasound. I’ll spare the long story, but I delivered her fetus this morning alone (scared, since I’ve never done this before) after monitoring her frighteningly high blood pressure and her emotional state all night. I’ll be tying her tubes next week.
Sorry for the depressing stories! I did get asked to marry one of my patient’s sons today, and I’m giving a talk for the staff tomorrow on cervical cancer screening, so that’s exciting. Dustin is cooking dinner for us tonight (curry? More goat?) and he promised me we’d get to watch an episode of Top Chef on his iphone tonight as well—he downloaded 10 episodes for us before we left, and it’s our little treat! It’s about the only time I completely forget where I am, and lose myself in reality TV!
Eric had asked about the weather—it’s their “short rains” season, so it’s pretty much gorgeous all day, from a pink sunrise to clear blue skies at 75 degrees all day, and then around 6pm every day, the wind picks up tremendously, and persists for a few more hours or long into the night. Then sometimes it rains during the night. It had been a drought for the last 3 years in Kenya, but this ended about a month before we arrived. You’d never know—there are amazing plants and everything seems very lush. But many of the plants are succulents—there are huge cacti everywhere. The dry, red soil is our only indication of recent drought, and our white coats are now stained slightly, along with all my white socks. Our trip last weekend to Naivasha was hot, since we were in the valley, and we all got sun-burned. Gotta love living on the equator!
I’m off to help Dustin with dinner! Hopefully the dog will be quiet tonight, so I can sleep… Too bad the Kenyans eat goat, and not dog….
Monday, November 16, 2009
Monday, Monday
November 16, 2009
Today was a tough day—not really for any reason in particular, but more because it was Monday, and it’s our second week here, and I feel like I should be more useful at this point… and I’m not. I’m still struggling with how things work here. Resources are so scarce, that it’s difficult to feel like I can do anything for patients I see. So half the time I over-shoot—antibiotics for everyone! And half the time, I undershoot—“let’s just wait and see if the bleeding stops on its own.” Frustrating.
Monday is difficult too, since not many people work over the weekends. Saturday I came in and rounded on patients, and then Vy, Dustin and I actually left Kijabe for a really nice day at Lake Nayvasha. Sunday we went to church (along with everyone in the community) and then went for lunch at the Rift Valley Academy and relaxed, then cooked dinner for ourselves and a few guests. We’ve been eating well considering where we are, and often find ourselves reflecting on the fact that so many Africans are starving while we eat—kind of taints the teriyaki noodles Vy makes, and the peanut butter cookies that our guests made.
Lake Nayvasha was beautiful—we took a boat to Crescent Island, which is where “Out of Africa” was filmed in the 80’s (?) and there are hippos, zebra, giraffe, antelope, and monkeys, and a few more animals, but no predators, so you can walk around and photograph the animals safely! There were baby giraffes, one only one day old. The animals have never been hunted, so they let you walk right up to them. It kind of feels like cheating! But we deserved it after our drive there! So scary! The Kenyan people are patient, kind, and accepting, but not on the roads! There are so many traffic accidents that come through our ER, and I saw the reason—people drive so fast, all pass each other using the on-coming traffic side of the road, and there are people, bikers, goats, donkeys all on the same narrow road. I found myself closing my eyes, so I wouldn’t have a heart attack. I’ll try to find a way to post photos of the trip… not sure the slow internet connection can support it, but I’ll try!
I’m on call tomorrow… Dustin is on tonight, and when I left, he had a full ER and a line of people waiting to be seen too! I tried to help him, but he tells me that everyone in beds will be stuck there and cannot be moved because they are waiting for x-rays, labs, surgery, etc., so they can’t move people out and therefore, can’t move people in. Yikes! I hope he finds time for dinner.
That’s all for now—I’m going to bed early after a difficult day. I miss everyone back home! And I miss the football—how are the Eagles doing??? I saw a Kenyan man in a really old Eagles jacket and we saw another Kenyan man in a Chase Utley t-shirt at church on Sunday, so I at least people here have the right idea! It’s nice to see a little reminder of home every once in a while!
Today was a tough day—not really for any reason in particular, but more because it was Monday, and it’s our second week here, and I feel like I should be more useful at this point… and I’m not. I’m still struggling with how things work here. Resources are so scarce, that it’s difficult to feel like I can do anything for patients I see. So half the time I over-shoot—antibiotics for everyone! And half the time, I undershoot—“let’s just wait and see if the bleeding stops on its own.” Frustrating.
Monday is difficult too, since not many people work over the weekends. Saturday I came in and rounded on patients, and then Vy, Dustin and I actually left Kijabe for a really nice day at Lake Nayvasha. Sunday we went to church (along with everyone in the community) and then went for lunch at the Rift Valley Academy and relaxed, then cooked dinner for ourselves and a few guests. We’ve been eating well considering where we are, and often find ourselves reflecting on the fact that so many Africans are starving while we eat—kind of taints the teriyaki noodles Vy makes, and the peanut butter cookies that our guests made.
Lake Nayvasha was beautiful—we took a boat to Crescent Island, which is where “Out of Africa” was filmed in the 80’s (?) and there are hippos, zebra, giraffe, antelope, and monkeys, and a few more animals, but no predators, so you can walk around and photograph the animals safely! There were baby giraffes, one only one day old. The animals have never been hunted, so they let you walk right up to them. It kind of feels like cheating! But we deserved it after our drive there! So scary! The Kenyan people are patient, kind, and accepting, but not on the roads! There are so many traffic accidents that come through our ER, and I saw the reason—people drive so fast, all pass each other using the on-coming traffic side of the road, and there are people, bikers, goats, donkeys all on the same narrow road. I found myself closing my eyes, so I wouldn’t have a heart attack. I’ll try to find a way to post photos of the trip… not sure the slow internet connection can support it, but I’ll try!
I’m on call tomorrow… Dustin is on tonight, and when I left, he had a full ER and a line of people waiting to be seen too! I tried to help him, but he tells me that everyone in beds will be stuck there and cannot be moved because they are waiting for x-rays, labs, surgery, etc., so they can’t move people out and therefore, can’t move people in. Yikes! I hope he finds time for dinner.
That’s all for now—I’m going to bed early after a difficult day. I miss everyone back home! And I miss the football—how are the Eagles doing??? I saw a Kenyan man in a really old Eagles jacket and we saw another Kenyan man in a Chase Utley t-shirt at church on Sunday, so I at least people here have the right idea! It’s nice to see a little reminder of home every once in a while!
Friday, November 13, 2009
Settling in in Kijabe
November 13, 2009
I think I'm finally getting a sense for things here at the hospital-- things are crazy. Vy, Dustin and I have been meeting up at Vy and my place for dinners when we all get done, and we play a game of "who saw the most bizarre things today." Tonight's competition went something like this:
Dustin: "I saw a patient today who was using a bread bag for a condom catheter”
Alyson: "I told a 23yr old that the reason she hasn't had any periods yet is because she has no uterus, and maybe has testicles in her, and not ovaries, but we're not sure"
Vy: "I saw a kid with blue sclerae" (the whites of his eyes were blue)
Alyson: “ I saw a woman with endometriosis of her belly-button—it bleeds every time she has periods”
Dustin: “ I saw a patient with an umbilical hernia the size of a grapefruit on top of a stomach that was so full of fluid, it was the size of a watermelon”
It went on like this for the next 30 minutes. Back home, Dustin and I have a rule about talking about work—we try hard not to do it. It is different here, without TV, much internet, or much of a social life, we are forced to process things we saw and did during the day, and I think it’s a good thing, because we see and do a lot that is really difficult.
Kijabe Hospital takes care of a lot of Somali refugees. They stand out because they don’t speak English or Swahili, and the women are covered from head to toe. They are some of the most difficult patients to care for, partly because of the language barrier, but mostly because they have such sad stories. I operated on an 18 year old Somali woman to repair a fistula (hole) between her bladder and her vagina, that was causing her to leak urine all the time. This was the result of trauma that I don’t need to describe, but she also had a colostomy bag, and that was the result of being shot in the stomach, while she was pregnant. She woke up in a hospital in Somalia with no baby, and no uterus. Gunshot wounds are not uncommon in the Somalis, but I suspect their trauma goes much deeper than these wounds. They live in camps and tents all over Kenya, and in spite of Kijabe being a primarily Christian area, they travel very far to come here for their care.
The language issue is a big one—Kenyans have many different dialects that are all very different from one another, depending on region and tribe. I have a Kenyan medical student who translates for me—he is very timid and sweet! Most educated Kenyans learn both Swahili and English, but most of the patients I see speak only Swahili, and even the nurses in the hospital have a difficult time understanding me. Most of the doctors speak Swahili, but all of the medical records and orders are in English (thank God!)
One of the most impressive experiences with language I’ve had thus far just occurred today. One of the patients I’ve been following since arriving here is a 19 year-old HIV-positive Kenyan woman who delivered twins at home, and then presented 2 weeks later to the hospital in shock from blood loss from a massive post-partum hemorrhage that was made worse by the fact that she had a platelet count of 10,000 when she arrived. Her hemoglobin was 1.3—the lowest I’ve ever seen. She spent about 4-5 days in the ICU comatose. She’s been on the maternity ward since then, and I see her daily. She is considered to have suffered a massive hemorrhagic stroke (we suspect she bled into her brain) and so we understand her to be confused, and probably will always remain mentally impaired after such an insult. She is Masai, and so does not speak Swahili or English, and there is only one Kenyan intern who speaks enough Masai to ask her how she is doing each day. She would ask for the lights to be turned on every morning, when the lights are on 24/7. Everyone assumed she was just confused. She developed a severe headache yesterday, so I did a neurologic exam, and her pupils did not really respond to light, and she had trouble following my finger when I’d move it in front of her, but I assumed she did not understand my commands—then it hit me. She is blind. We’d been helping her eat and feed her infants, and we all thought it was because she was simply weak, but no one could communicate well enough with her to find out she actually cannot see. We will call her family tomorrow to ask them if they can collect enough money to transport her to Nairobi and pay for a CT scan of her head to see how much bleeding she had in her brain, and if anything can be done to help her.
Everyone pays up front for any medical care they receive at Kijabe. Patient will spend a day or two in the ER waiting for their families to collect enough money so that they can afford the surgery for their broken bones or the medications they need for their pulmonary TB. It’s a difficult system, but most things are not terribly expensive (a CT scan in Nairobi costs 6,000 Kenyan schillings, which is less than $80), and it promotes communities caring for their own. But surgeries get delayed, treatments do not happen, and I know that people die, because they are poor in this country. It makes me think hard about everything I use during the day, and every test I order—patients pay for every pair of sterile gloves you use in the OR or during their delivery. When I think about how wasteful we are in the US because of the abundance of supplies and resources we have at our fingertips (like oceans of ultrasound gel, endless packs of sterile gloves, disposable speculums and mountains of bandaids and q-tips!) it makes try to imagine what one of the Kenyan nurses would think about Swedish hospital. Oh to have a translator phone! Something I’ve complained about using and taken for granted for years! In the mean time, I’m working on my Swahili… lala salaama.
I think I'm finally getting a sense for things here at the hospital-- things are crazy. Vy, Dustin and I have been meeting up at Vy and my place for dinners when we all get done, and we play a game of "who saw the most bizarre things today." Tonight's competition went something like this:
Dustin: "I saw a patient today who was using a bread bag for a condom catheter”
Alyson: "I told a 23yr old that the reason she hasn't had any periods yet is because she has no uterus, and maybe has testicles in her, and not ovaries, but we're not sure"
Vy: "I saw a kid with blue sclerae" (the whites of his eyes were blue)
Alyson: “ I saw a woman with endometriosis of her belly-button—it bleeds every time she has periods”
Dustin: “ I saw a patient with an umbilical hernia the size of a grapefruit on top of a stomach that was so full of fluid, it was the size of a watermelon”
It went on like this for the next 30 minutes. Back home, Dustin and I have a rule about talking about work—we try hard not to do it. It is different here, without TV, much internet, or much of a social life, we are forced to process things we saw and did during the day, and I think it’s a good thing, because we see and do a lot that is really difficult.
Kijabe Hospital takes care of a lot of Somali refugees. They stand out because they don’t speak English or Swahili, and the women are covered from head to toe. They are some of the most difficult patients to care for, partly because of the language barrier, but mostly because they have such sad stories. I operated on an 18 year old Somali woman to repair a fistula (hole) between her bladder and her vagina, that was causing her to leak urine all the time. This was the result of trauma that I don’t need to describe, but she also had a colostomy bag, and that was the result of being shot in the stomach, while she was pregnant. She woke up in a hospital in Somalia with no baby, and no uterus. Gunshot wounds are not uncommon in the Somalis, but I suspect their trauma goes much deeper than these wounds. They live in camps and tents all over Kenya, and in spite of Kijabe being a primarily Christian area, they travel very far to come here for their care.
The language issue is a big one—Kenyans have many different dialects that are all very different from one another, depending on region and tribe. I have a Kenyan medical student who translates for me—he is very timid and sweet! Most educated Kenyans learn both Swahili and English, but most of the patients I see speak only Swahili, and even the nurses in the hospital have a difficult time understanding me. Most of the doctors speak Swahili, but all of the medical records and orders are in English (thank God!)
One of the most impressive experiences with language I’ve had thus far just occurred today. One of the patients I’ve been following since arriving here is a 19 year-old HIV-positive Kenyan woman who delivered twins at home, and then presented 2 weeks later to the hospital in shock from blood loss from a massive post-partum hemorrhage that was made worse by the fact that she had a platelet count of 10,000 when she arrived. Her hemoglobin was 1.3—the lowest I’ve ever seen. She spent about 4-5 days in the ICU comatose. She’s been on the maternity ward since then, and I see her daily. She is considered to have suffered a massive hemorrhagic stroke (we suspect she bled into her brain) and so we understand her to be confused, and probably will always remain mentally impaired after such an insult. She is Masai, and so does not speak Swahili or English, and there is only one Kenyan intern who speaks enough Masai to ask her how she is doing each day. She would ask for the lights to be turned on every morning, when the lights are on 24/7. Everyone assumed she was just confused. She developed a severe headache yesterday, so I did a neurologic exam, and her pupils did not really respond to light, and she had trouble following my finger when I’d move it in front of her, but I assumed she did not understand my commands—then it hit me. She is blind. We’d been helping her eat and feed her infants, and we all thought it was because she was simply weak, but no one could communicate well enough with her to find out she actually cannot see. We will call her family tomorrow to ask them if they can collect enough money to transport her to Nairobi and pay for a CT scan of her head to see how much bleeding she had in her brain, and if anything can be done to help her.
Everyone pays up front for any medical care they receive at Kijabe. Patient will spend a day or two in the ER waiting for their families to collect enough money so that they can afford the surgery for their broken bones or the medications they need for their pulmonary TB. It’s a difficult system, but most things are not terribly expensive (a CT scan in Nairobi costs 6,000 Kenyan schillings, which is less than $80), and it promotes communities caring for their own. But surgeries get delayed, treatments do not happen, and I know that people die, because they are poor in this country. It makes me think hard about everything I use during the day, and every test I order—patients pay for every pair of sterile gloves you use in the OR or during their delivery. When I think about how wasteful we are in the US because of the abundance of supplies and resources we have at our fingertips (like oceans of ultrasound gel, endless packs of sterile gloves, disposable speculums and mountains of bandaids and q-tips!) it makes try to imagine what one of the Kenyan nurses would think about Swedish hospital. Oh to have a translator phone! Something I’ve complained about using and taken for granted for years! In the mean time, I’m working on my Swahili… lala salaama.
Thursday, November 12, 2009
The Wards
November 12, 2009
This was my third day on the wards! It’s pretty crazy. I’m working on the Maternity Ward, Vy is on pediatrics (spelled Paediatrics here) and Dustin in on Medicine. Kijabe Hospital is not what I’d expected. It’s a fully functional teaching hospital with a few catches—need a paper towel to wipe the ultrasound gel off your patient? Not so much… there’s a shortage (and there’s a shortage of ultrasound gel too, so when you hear “there’s no fetal heart tones”, usually you have to look to see if they are not using any, and then scoop the last drop out of the tube with your finger, and try yourself). A q-tip is non-existent. We re-use a single amnio-hook for all the patients, but wash it between.
That said, I’m doing an unbelievable amount of relatively advanced surgeries that I never expected to do in a third-world country. Fertility is huge here, so I’ve done several myomectomies (removal of fibroids from the uterus) and a few tubuloplasties (fixing tubes that are scarred, usually from Chlamydia), so women can have more babies. More babies!! It’s such a huge priority for these women. But there’s a catch—infant mortality is high enough, that even when women have had 4 or 5 babies, they may only have 2 that are still alive. So the surgeons hesitate to do a c-section and a tubal-ligation in the same surgery, because if that baby you just delivered does not survive…
I’ve gotten to primary on 3 c-sections already! (Mike, can I log that in new-innovations?). I also took out a uterus the size of a basketball today (fibroids) and assisted on 3 crash c-sections, one for eclampsia (the mother was seizing and had a blood pressure of 180/115), one for a baby in distress that had sat on the ward overnight with a BPP of 4/8 and a very non-reassuring NST—that baby may die, and is still on the ventilator today (day 2) and there is only one ventilator available for babies.
I don’t do normal vaginal deliveries—the nurse midwifes do them. I’ll be called for breech deliveries (something I’ve never done, since they all get c-sections in the states) and operative deliveries. But during the day I’m in surgery and doing some outpatient women’s health as well as taking care of the women who are admitted. I just admitted someone yesterday with a complete placenta previa (her placenta is completely covering her cervix, so if she were to go into labor, she would bleed to death) that I found on ultrasound that I did for some bleeding at 28 weeks pregnant. I had to ask her family members to donate blood in case she were to bleed. I estimated the fetal weight to be about 1.3kg, and apparently the babies that are over 1kg do well at Kijabe Hospital, so that’s good news, but I suspect that this patient may need a hysterectomy after the delivery. Not the worst news, since she’s 40, and one of the family members who will donate is her 21 year old son!
The hospital is very well-staffed—there are many medical officers (like our interns) who are well-trained, and there are clinical officers, who are like our PAs. There are also many medical students, other residents, nurses and nursing students and many attending-level doctors who donate years of work at Kijabe.
I’m actually really enjoying the food—they have some staples, and they include ugali (corn-meal porridge) and sukuma wiki (which is stewed spinach) and they have yummy mandazi, which is like an un-sweetened doughnut. Chai is huge here—in fact, there is a “tea room” in the surgery theater where there is always a big pot of boiling milk for chai and lots of doctors and nurses drinking between surgical cases.
The hospital is part of what I would call a “village” of people, most of whom work at the hospital. There is also a great boarding school call the Rift Valley Academy and there are about 800 students there. We are planning on this weekend going to see them put on the musical Seven Brides for Seven Brothers. We may also go for a trip to Lake Nakuru to see the flamingos if we have time, but none of us is on call this weekend, so we’ll have to take advantage!
We are exhausted, but having fun—we’ve been asleep by 8:30pm and we’re up around 5-6 daily. I don’t know if it’s the elevation, the jet-lag, or just the stress, but we’re definitely happy its dark by 6:30, so we feel less bad about bed at 8! I miss everyone, but am so glad to have Dustin and Vy here—it’s so good to see their faces every few hours in the hospital, when I’m feeling overwhelmed or like such an outsider! Dustin is ever-positive, and good at keeping me grounded and giving me perspective when I need it. Anyway, hopefully more to come this weekend!
This was my third day on the wards! It’s pretty crazy. I’m working on the Maternity Ward, Vy is on pediatrics (spelled Paediatrics here) and Dustin in on Medicine. Kijabe Hospital is not what I’d expected. It’s a fully functional teaching hospital with a few catches—need a paper towel to wipe the ultrasound gel off your patient? Not so much… there’s a shortage (and there’s a shortage of ultrasound gel too, so when you hear “there’s no fetal heart tones”, usually you have to look to see if they are not using any, and then scoop the last drop out of the tube with your finger, and try yourself). A q-tip is non-existent. We re-use a single amnio-hook for all the patients, but wash it between.
That said, I’m doing an unbelievable amount of relatively advanced surgeries that I never expected to do in a third-world country. Fertility is huge here, so I’ve done several myomectomies (removal of fibroids from the uterus) and a few tubuloplasties (fixing tubes that are scarred, usually from Chlamydia), so women can have more babies. More babies!! It’s such a huge priority for these women. But there’s a catch—infant mortality is high enough, that even when women have had 4 or 5 babies, they may only have 2 that are still alive. So the surgeons hesitate to do a c-section and a tubal-ligation in the same surgery, because if that baby you just delivered does not survive…
I’ve gotten to primary on 3 c-sections already! (Mike, can I log that in new-innovations?). I also took out a uterus the size of a basketball today (fibroids) and assisted on 3 crash c-sections, one for eclampsia (the mother was seizing and had a blood pressure of 180/115), one for a baby in distress that had sat on the ward overnight with a BPP of 4/8 and a very non-reassuring NST—that baby may die, and is still on the ventilator today (day 2) and there is only one ventilator available for babies.
I don’t do normal vaginal deliveries—the nurse midwifes do them. I’ll be called for breech deliveries (something I’ve never done, since they all get c-sections in the states) and operative deliveries. But during the day I’m in surgery and doing some outpatient women’s health as well as taking care of the women who are admitted. I just admitted someone yesterday with a complete placenta previa (her placenta is completely covering her cervix, so if she were to go into labor, she would bleed to death) that I found on ultrasound that I did for some bleeding at 28 weeks pregnant. I had to ask her family members to donate blood in case she were to bleed. I estimated the fetal weight to be about 1.3kg, and apparently the babies that are over 1kg do well at Kijabe Hospital, so that’s good news, but I suspect that this patient may need a hysterectomy after the delivery. Not the worst news, since she’s 40, and one of the family members who will donate is her 21 year old son!
The hospital is very well-staffed—there are many medical officers (like our interns) who are well-trained, and there are clinical officers, who are like our PAs. There are also many medical students, other residents, nurses and nursing students and many attending-level doctors who donate years of work at Kijabe.
I’m actually really enjoying the food—they have some staples, and they include ugali (corn-meal porridge) and sukuma wiki (which is stewed spinach) and they have yummy mandazi, which is like an un-sweetened doughnut. Chai is huge here—in fact, there is a “tea room” in the surgery theater where there is always a big pot of boiling milk for chai and lots of doctors and nurses drinking between surgical cases.
The hospital is part of what I would call a “village” of people, most of whom work at the hospital. There is also a great boarding school call the Rift Valley Academy and there are about 800 students there. We are planning on this weekend going to see them put on the musical Seven Brides for Seven Brothers. We may also go for a trip to Lake Nakuru to see the flamingos if we have time, but none of us is on call this weekend, so we’ll have to take advantage!
We are exhausted, but having fun—we’ve been asleep by 8:30pm and we’re up around 5-6 daily. I don’t know if it’s the elevation, the jet-lag, or just the stress, but we’re definitely happy its dark by 6:30, so we feel less bad about bed at 8! I miss everyone, but am so glad to have Dustin and Vy here—it’s so good to see their faces every few hours in the hospital, when I’m feeling overwhelmed or like such an outsider! Dustin is ever-positive, and good at keeping me grounded and giving me perspective when I need it. Anyway, hopefully more to come this weekend!
Tuesday, November 10, 2009
Arriving in Kijabe
November 9, 2009
The sunrise from the plane this morning was incredible. I guess the sunrise always looks incredible from 30,000 feet, but this was our first sunrise over Africa! We woke up this morning flying over the top of Mount Kenya (the highest point in Kenya at 15,000ft). I was worried that Vy might be sleeping through this—she is an amazing sleeper, and I think she slept through every leg our our trip so far, including 3 hours from Seattle to Minneapolis, 8 hours to Amsterdam and then another 8 hours to Nairobi. Luckily they woke us all up for food—I got served a vegetarian, dairy-free breakfast on Kenyan Air—I had tried to tell them that dairy was fine, but I guess I clicked the wrong box on the website a few months ago when I bought my ticket.
Amsterdam was beautiful. We lucked out on the weather for a little while, and had 60s and sunshine so we could enjoy walking around, but then the sun disappeared and it was suddenly very cold and windy, and we were so tired! But it was nice to walk around and see a new city. We walked through the famous "Red-light" district. So odd to see women in the windows on their cell phones, texting--I guess it gets boring!
Arriving in Nairobi was surreal, but things went amazingly well. Our driver, Davis, picked us up after we flew through the visa line and whizzed through customs (“what did you pack?” “umm, just clothes”; “ok, enjoy your stay”). Too easy. Davis took us to a supermarket in Nairobi to do all of our grocery shopping for the month. I was feeling tired and overwhelmed, and had a difficult time wondering how many kilos of rice Dustin, Vy and I would eat in the month. Somehow we made it out of there and spent about 16,000 Kenyan schillings (about $200, since it’s about 77 schillings to the US dollar). We even got a delicious cup of iced Kenyan coffee, breaking the rule of not eating ice or water in a foreign country—whoops! But so worth it! Then off to Kijabe, with a quick stop at a look-out point over the Great Rift Valley, where we were heckled to buy Kenyan trinkets and in our sleep-deprived, foreigner naiveté, we spent WAY too much on necklaces, dishes, elephant carvings, etc, just to get out of there!
Kijabe is at just over 7000 ft elevation, and tucked away in the hills after passing slums, farms, sheep, goats, donkeys (no elephants yet, but we did see a herd of giraffe already, just as we left the airport in Nairobi!). We have met many very kind people so far, and everyone is eager to teach you about Kenyan culture and a few words in Swahili. Jambo, salama and habari, are all words to say hello, how are you, nice to meet you, etc. It is customary here to greet everyone and shake hands with everyone. Vy and I are staying at a beautiful complex, with a huge window overlooking the valley. We have 5 beds and a large kitchen and living space, but Dustin has to stay in a house about 200 yards away, since it would not be culturally appropriate to have Dustin staying with the two women. He has a housemate who is an engineer from Mississippi who is helping to build a surgical “theater” in Kijabe. Apparently, Kijabe Hospital has a great reputation for its surgery. We just had dinner with Doug and Kathy Trotter (from the pacific NW) and Doug tells us that of the 27 doctors on staff at the hospital, about 20 are surgeons.
Grand rounds tomorrow AM at 0700—our first time in the hospital and I think off to a running start! I’m sure I’ll have much more to write about then… I suspect I’ll sleep well tonight, in spite of the anxiety about my day tomorrow!
The sunrise from the plane this morning was incredible. I guess the sunrise always looks incredible from 30,000 feet, but this was our first sunrise over Africa! We woke up this morning flying over the top of Mount Kenya (the highest point in Kenya at 15,000ft). I was worried that Vy might be sleeping through this—she is an amazing sleeper, and I think she slept through every leg our our trip so far, including 3 hours from Seattle to Minneapolis, 8 hours to Amsterdam and then another 8 hours to Nairobi. Luckily they woke us all up for food—I got served a vegetarian, dairy-free breakfast on Kenyan Air—I had tried to tell them that dairy was fine, but I guess I clicked the wrong box on the website a few months ago when I bought my ticket.
Amsterdam was beautiful. We lucked out on the weather for a little while, and had 60s and sunshine so we could enjoy walking around, but then the sun disappeared and it was suddenly very cold and windy, and we were so tired! But it was nice to walk around and see a new city. We walked through the famous "Red-light" district. So odd to see women in the windows on their cell phones, texting--I guess it gets boring!
Arriving in Nairobi was surreal, but things went amazingly well. Our driver, Davis, picked us up after we flew through the visa line and whizzed through customs (“what did you pack?” “umm, just clothes”; “ok, enjoy your stay”). Too easy. Davis took us to a supermarket in Nairobi to do all of our grocery shopping for the month. I was feeling tired and overwhelmed, and had a difficult time wondering how many kilos of rice Dustin, Vy and I would eat in the month. Somehow we made it out of there and spent about 16,000 Kenyan schillings (about $200, since it’s about 77 schillings to the US dollar). We even got a delicious cup of iced Kenyan coffee, breaking the rule of not eating ice or water in a foreign country—whoops! But so worth it! Then off to Kijabe, with a quick stop at a look-out point over the Great Rift Valley, where we were heckled to buy Kenyan trinkets and in our sleep-deprived, foreigner naiveté, we spent WAY too much on necklaces, dishes, elephant carvings, etc, just to get out of there!
Kijabe is at just over 7000 ft elevation, and tucked away in the hills after passing slums, farms, sheep, goats, donkeys (no elephants yet, but we did see a herd of giraffe already, just as we left the airport in Nairobi!). We have met many very kind people so far, and everyone is eager to teach you about Kenyan culture and a few words in Swahili. Jambo, salama and habari, are all words to say hello, how are you, nice to meet you, etc. It is customary here to greet everyone and shake hands with everyone. Vy and I are staying at a beautiful complex, with a huge window overlooking the valley. We have 5 beds and a large kitchen and living space, but Dustin has to stay in a house about 200 yards away, since it would not be culturally appropriate to have Dustin staying with the two women. He has a housemate who is an engineer from Mississippi who is helping to build a surgical “theater” in Kijabe. Apparently, Kijabe Hospital has a great reputation for its surgery. We just had dinner with Doug and Kathy Trotter (from the pacific NW) and Doug tells us that of the 27 doctors on staff at the hospital, about 20 are surgeons.
Grand rounds tomorrow AM at 0700—our first time in the hospital and I think off to a running start! I’m sure I’ll have much more to write about then… I suspect I’ll sleep well tonight, in spite of the anxiety about my day tomorrow!
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