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.