safari!

it was a luxurious safari weekend! peter, isaac and I spent 2 nights in the maasai mara, a famous game reserve about 5 hours down the dirt path from here. it was fantastic - we saw most of the animals possible to see - including a leopard, cheetahs, lions (and babies), water buffalo, giraffes, elephants (and babies), etc.! we stayed in a tented camp - but they were luxury tents that had toilets and showers! the food was delectably gourmet, although the portions were a bit small and they wouldn’t give us any more. overall though the safari was definitely worth it despite the price tag. it was just the 3 of us to a huge land cruiser with openings in the roof so we got to stand in the open air the whole time! on friday, which was actually the day we were supposed to leave on safari but didn’t because we didn’t plan things out in advance well enough, we went into nairobi to a western style shopping mall called village market, and I was reminded anew of my appreciation of american consumer culture. I am definitely going to go back there just for the warm fuzzy feeling one gets when looking upon aisle upon aisle of any item one could wish to buy (it’s a rarity in africa).

last week i did rounds with dr. b. (the doctor [aka superman] I am staying with) in the early mornings, which I have been doing every week, and then rounds with peter and the pediatrics team, and worked on my research. we also learned a lot about diabetes in africa. the director of a major international diabetes organization came and gave a lecture on that topic. it is becoming a lot more common because more and more people are switching to a western style diet. there is also an obesity epidemic looming in africa, because for many it is culturally desirable to be large (it means your husband is capable of providing). in this culture it is also considered completely strange to be seen exercising, a fact that I am constantly reminded of by the quizzical stares everyone gives me when I go on my daily run. interestingly, non-caucasians are actually more prone to obesity and diabetes than are caucasians when all other factors are constant. the diabetes expert suggested this was because caucasians were the first in history to begin consuming lactose/dairy products, allowing them to consume more calories. this allowed for a gradual selection of genes that made them less calorie efficient. interestingly there is a third form of diabetes in the developing world which has been (creatively) named type III diabetes. it is caused by malnourishment. in other health news, they found some e-coli in the kijabe water source. someone came rushing into the house to tell us not to drink the water - immediately after i had just chugged about a liter of it after a long run. we all felt a little sick for a few days.

other highlights have included a visit from my cousin who i shall not name, who lives in a country which i shall not name, lest government officials from said country google "name of said country" "and" "jesus", find that both exist in this blog, and hunt my cousin down. i wouldn't want that. i also had a harvard and oxford educated doctor roommate one night in the b.’s loft where i sleep. i hoped some of his intelligence would emanate in my direction as we slept, but the fact that I am writing this sentence right now probably proves that it didn’t. the hospital has also been hosting weekly seminars on islam, and it has been very interesting to compare the african-christian perspectives on islam with the arab-muslim and other perspectives we got in the middle east when I was studying there. this week peter and isaac left. they were the medical students that I spent basically every waking hour of the the last month with - in casualty, pediatrics, various trips to maasailand and nairobi, and playing copious amounts of settlers of catan and basketball with. i’m going to miss you guys.

research

i thought i’d write a little bit about the research I’m doing, as some of you might be interested. only read if you are. we are looking at the incidence of post-operative infection in children who have had a shunt inserted for the treatment of hydrocephalus. hydrocephalus is caused by a blockage of the normal circulation of the cerebrospinal fluid (csf; the clear fluid that bathes your brain and spinal cord) - it causes increased pressure on the brain which must be relieved. a hole is drilled in the skull, and another one made into the peritoneum (the cavity in which all your organs reside). a tube is then shoved under the skin, with the help of a blunt metal stick, from hole to hole. one end of the tube ends up in a ventricle of the brain, while the other end drains the excess csf into the peritoneum, where it is resorbed by the body. this is called a ventriculoperitoneal shunt (vps). a doctor who was here before me compiled a bunch of information into a spreadsheet, so we thought it would be rather easy to just figure out how many of the patients had developed shunt infections after their surgery. we decided to define shunt infections as csf infections exclusively, because other infections such as wound infections can be caused by a number of factors other than surgery. we also decided not to include patients who have had spina bifida as well, because these patients all would have had another surgery to close the meningocele (neural sack) on their back, which greatly exposes the csf, leading to much greater chance of infection. normally there wouldn’t be very many cases of spina bifida in relation to hydrocephalus, but because kijabe is a pediatric neural referral center, about half of the hydrocephalus cases here also have had spina bifida. most kids with spina bifida end up getting hydrocephalus - this could be because they have were born with (congenital) central nervous system issues, or because their csf is exposed to infection (because of the defect on their back), which can cause hydrocephalus.

the study includes about 300 cases. what we didn’t realize until after I had written up the paper and everything was that about half of the patients had insufficient follow-up, which we decided should be at least 9 months after their surgery. you can’t really say that you have an infection rate of x% if you don’t even have any information for half of the patients. any critic would just say that it is possible that all the patients that were unaccounted for had shunt infections. this is probably more likely to be the case in africa than in the west. in the west someone would take their child to the hospital if they got sick after an operation. but because many of the children here live sometimes days journeys from the hospital and often have no means of transportation or financial resources, combined with the fact that there are large families living at home who would have to be neglected if the parents had to make the long trip to the hospital, if the child gets an infection they often die and are forgotten. of course, probably most of the patients who don’t come back for follow-up are doing fine, but we have no way of definitively knowing that. there can also be a stigma associated with hydrocephalus here that causes parents to neglect these kids - there are even stories of communities burying alive children with hydrocephalus during times of drought to try to appease their animist gods.

so i had to go about trying to gather more information on these patients. I searched an electronic database that the hospital has, and found some extra information. then I had to pull the charts from the medical records room of the ones who still had insufficient follow-up and look through those for more information that may have been missed. then, i made up a little questionnaire form with some questions about the patient and their phone number, if i could find it, and had nurses call the family to see if the child is still alive and if they have ever gotten a shunt infection. everything seems to be a logistical challenge in africa though. for some reason that I do not understand many of the kids don’t share their parent’s last name. a lot of the patient’s records didn’t have phone numbers. many of the ones that did didn’t work, because most people in kenya just use cell phones, and there is a lot of number turnover. also, there was post-election violence here a few years ago and many people were displaced from their homes so are not able to be contacted because they still live in internally displaced people (idp) camps or have resettled somewhere else. additionally, many of the people who come to the kijabe hospital are somali refugees and don’t speak kiswahili, or have moved back to somalia where they can’t be reached. many of the kenyans are from remote areas and belong to tribes that don’t speak kiswahili. i probably would have called it quits there, but dr. bransford wanted to find more of the patients. the more we find the more viable the results will be. so, we split up all the files of the ones we couldn’t get ahold of into tribes and towns throughout the country, and are trying to get a loose coalition of chaplains throughout the country who are associated with the hospital to go out into their communities and find these people. hopefully this works, although you can probably imagine the difficulties inherent in trying to get someone to get someone else to conscript some other people to go find some other people and ask them some questions… in africa. we’ll see how it goes.

maasailand and matatu rides

on thursday we went to another mobile clinic an hour and a half away in maasailand. the maasai are a tribe that raise livestock and essentially subsist exclusively off meat, blood and milk. apparently this diet contains everything needed for good health, as they consistently live to be over 100 years old. they live in makeshift homes of sticks and mud that they pack up and move around when their livestock need some fresh grass. they also stretch their earlobes out as far as possible with progressively larger loops - some have earlobes that dangle so low that they hang them over the top of their ears to keep them from getting in the way! they also always wear a lot of red. the boss on the clinic trip was a dr. thor - a large, very high decibel, door slamming (not because he’s angry, but because that’s just the way he is) kind of guy. he also falls asleep at every opportunity. he is really cool. we saw some interesting cases; a lot of malnourished kids and some with rampant iss (medical code in kenya for hiv/aids). i also got to inject an elderly lady in the buttock with some pain medication (i know that probably doesn‘t sound too appealing, but it was my first injection and it got my adrenaline going!), and I learned how to find someone’s blood pressure the old-fashioned way - with a stethoscope, hand pump and stopwatch.

the next day I went with peter and isaac (the medical students from chicago) to the home of a really nice maasai guy named givan to kill and eat a goat. after arguing for about an hour on the way there with the sneaky but persuasive car driver about how much the trip should cost, we finally reached an impass and he offered to let me drive, maybe just to try to appease us. it was great fun, heading out across the savannah, shifting with the left hand, not allowed to slow down because the dust on the ground was so deep that we would get stuck if we drove too slow. when we got to the “village” (3 houses), the maasai folks let all their goats out of the pens, and we watched/”herded” them for a while. then we drank some chai (tea) that was made from the fresh goats milk. almost as good as chai with cows milk. we then selected a goat. when they kill it they hold it down, basically dissect its entire neck while its still alive, and then cut its corotid artery and collect the blood (to drink fresh). then they hang it from a tree and open er up. when they found the kidneys the little children got all excited and immediately ate them raw! we roasted the meat over a tiny little fire (some of it got cooked) and ate it in its entirety. well, us and the millions of flies, and all the random maasai folks that showed up after they must have smelled the dead goat. either that or someone called them on their cell phones, which they all remarkably seem to have tucked under their robes somewhere. needless to say, we ingested a lot of protein, and undoubtedly a lot of other random creepy crawlers that live in raw meat too. what couldn’t be roasted, like the lungs and stomach (including far more than necessary of its partially digested contents), were thrown into a pot to be boiled and then we ate that too. this meat eating saga lasted the entire day, and it was truly epic. and considering that the only side effect was above average toilet paper use for the next few days, it was definitely worth it!

next day we took a matatu (small van that serves as public transportation) into nairobi. they are extremely overcrowded - people sitting on laps, in the 8 inch wide "isles", etc.. and hanging off the back bumper too. each matatu has a name - like "jawbreaker", "the last ride you'll ever take" and "jesus of nazareth is the king of kings and lord of lords". they are known for being almost entirely responsible for kenya's position at the top of the list of road accident deaths per capita - all the doctors in the hospital have stories of times when there were matatu accidents and the casualty was flooding with dozens of trauma cases in the middle of the night - presumably these dozens were all stuffed into (or on top of) one matatu when it crashed. but actually the trip wasn't too stressful - in fact i think i'm going to start using them as much as possible! we went with a kenyan intern who took us to the craft market downtown. we were solicited for our money (which i don't even have) so much and so heavily that i almost lost my mind. this is one thing i don't like about it here - have they never seen a white person before? (i know they have). has it ever crossed their mind that i might be more likely to buy their stuff if i could actually look at it rather than their frantic face 3 inches from mine, making sure again and again that i understand they they have the best deal in the city (which they most assuredly don't). and then when you try to leave they grab your arm and you literally have to run faster than them and never go back. forgive me, i rant. we then went to a restaurant called the carnivore, which serves crocodile and ostrich meat, but unfortunately their grill was closed so we ate burgers. we would have stayed until it opened later on, but apparently there is a significant risk of getting carjacked after dark on the road down to kijabe, so we wanted to catch the last matatu home before sunset.

tiny babies and huge giraffes

the last few days I have been in the nursery, which is a nice place to be! most of the babies there were born premature. the biggest thing for the babies seems to be increasing their food intake at the right rate - a lot of them have to be fed through ng tubes because they haven’t developed their sucking reflex yet. we can test for this reflex by putting our little finger in their mouth! also, a big problem for many of them is hyperbilirubinemia, which, long but physiologically fascinating story short, is treated by putting the baby under uv light. so the whole room is full of all these tiny babies in their incubators of sorts being bathed in blue uv light. the only drawback of the nursery is that they keep it very warm for the babies, but it’s a little too warm for an adult after you've been in there for a couple hours. the best part is that whenever there is a c-section they call us and we get to go and when the baby gets out, stimulate it and make sure its crying, and cut its umbilical cord off. I have also spent the last few evenings (as opposed to all-nighters) in the emergency room, which continues to be exhilarating in the fullest sense of the word.

if you are so inclined, you could pray for some people. anabel is a little girl who got burns over most of her body from boiling water. peter is a little guy who came into the e.r. last night (after being hit by a truck) and hasn’t become conscious yet. and there is a baby in the nursery whose mother is only 13 years old - she was raped by a family member :(

in other news, on friday night I went with peter and isaac to a classic african pentcostal worship service at the hospital chapel. then we went for tea at one of the kenyan intern’s place - turns out he is a undercover celebrity in the kenyan christian music scene, and does concerts around the country when he’s not on call. very nice (to be pronounced with borat accent, just for fun :) ) music videos! then on saturday we went to lake naivasha, which is about an hour up the road. we got a guy to come pick us up with his car, but when we saw it we wondered if it was going to make it. sure enough, as soon as the driver sat down, his entire seat broke off and fell into my lap. so eventually we stopped on the side of the road and get someone to weld the seat back on before carrying on. we went to this wildlife preserve called crescent island - although its not really an island because lake naivasha has basically dried up because kenya is experiencing a drought right now. anyways, there were giraffes, wildebeast, zebras and antelopes all over, and we could walk amongst them and even chase them (to try to get as close as possible)! perhaps nothing is more exciting than running right behind a giraffe - their legs are so long and they gallop so gracefully that it literally seems like everything is in slow motion!! you have to try it i guess. i climbed into an aardvark hole but I needed help getting out because I got stuck. we spent most of the time looking for a python but it was obviously hiding in the one place on the island we didn’t look. it was a good day. we’ve also been playing copious amounts of basketball just up the road at the rift valley academy boarding school (which, as some of you may know, is where my mother grew up and also was a teacher for many years!). from there one can look out over the great rift valley - truly a beautiful sight.

rural clinic

yesterday was an exhilarating day. i went with some doctors and medical students to a rural clinic about an hour away on very bumpy roads. many of the patients didn't even speak kiswahili, so their concerns had to be translated into that and then into english. luckily there weren't that many to see and we had all day, so there was no rush. it was great because we talked out every case in depth. the clinic was a little dispensory out in the middle of nowhere, and they only had a few drugs there, so thats all that could be prescribed. most people wouldn't have the means to travel anywhere else for healthcare. so invariably what ends up happening is that the few types of medicine there are just end up getting prescribed for almost everything, mostly just to treat the symptoms rather than the cause of the problem; this is called "jungle medicine" and unfortunately its the best that most africans get. they served us lunch there too which was delicious. then my two med student friends from chicago and i went over to this school that was there and dozens of little kids immediately vacated their classrooms (who knew where the teachers were), and crowded around us cheering and obviously about as excited as kids can get, presumably because we were white and and wearing white doctor coats. so we hung out there for a while.

that night one of the med students was to man the e.r. all night, so i stayed up with him. exhilarating. it was quite busy and all kinds of stuff happened. i learned how to take a complete history and i handled one young man who came into the e.r. from start to end! (it wasn't too serious). i even wrote him a "doctor's note" (he had no idea i wasn't a doctor :) ). we also got called to confirm a death on the ward; i got to peel back the guy's cold, stiff eyelids to see if he was really dead by seeing how his pupils reacted to light. then later we actually watched a lady die :( lots of interesting people seem to arrive in the middle of the night, like a masai woman with the huge necklaces, ear loop thingies and uncovered breasts who casually sauntered in with a baby with a huge growth on its head after walking for who knows how long to get here. and a case of hemorroids that was bad enough to warrant a visit to the emergency room in the middle of the night. i think i'm going to spend more time in the e.r.!

other than that there have been a slew of surgeries relating to an appendage unique to males that i have been watching during the day, some of them a whole lot more invasive than one might ever want to imagine. on saturday i went into nairobi with the doctor i am staying with's son and some of his friends and ate some delectable njera b'wat (if you don't know what i'm talking about you should find your local ethiopian restaurant and patronize it asap!) also, i am doing some research for the doctor regarding infection rates after hydrocephalus shunt insertions. the whole research dealio is a bit tedious to say the least, but hopefully if successful it will stoke my medical school applications a little bit. more importantly, it may also help the organization that provides the surgeries to convince the governments of neighboring countries that they should allow them in because their post-operative infection rates are so low, as currently there are a lot of kids suffering more than they need to in some east african countries because they aren't getting the operations they need.