mzungus in mombasa

i had a funtastic weekend in mombasa! caught the night bus (8 hours) down on thursday night with a guy named kevan that i met last weekend and kent, his kiwi roommate from the orphanage they volunteer at. wandered around the river road area of nairobi a bit before we left - i can see why some people are scared to go out at night in nairobi! we missed (through no fault of our own) the bus we were supposed to take at 9:30pm, so we had to buy new tickets for a bus at 12:30am. but we got there, and after a great ferry and a little more matatu riding than it turns out was necessary, found the idyllic diani beach and the girls, sonja and ali. found a hotel room a matatu ride from the beach for $12 a night, and us 3 guys shared a room by putting the mattresses together on the floor. basically spent 3 days on the beach which was glorious. 3 study abroad students from the midwest came for a couple days too, as did a couple peace corp volunteers and some christian law student volunteers from the uk. good times. also lots of male bonding in our room because it was very necessary to have someone else thoroughly rub aloe into our sunburned backs. one day we went snorkeling out on the reef. eventually found out that kent was a christian too so that was cool! then on monday we headed into mombasa town and got a bit of a tour from the friendly peace core workers who live in the area, and then just wandered around. its a very interesting city - very muslim, always very hot and humid, rich history, etc.. where else would you find a fort jesus, pentacostal churches, mosques, animists, and jain and hindu temples within extremely close proximity? i liked it. we went to a coffee shop in the old city where they serve coffee with all kinds of delectable spices in it. a few different times.

barely caught another night bus back on monday night, and then went to the boy's orphanage tuesday morning in a suburb of nairobi called waithaka, just to see where they spend their time. they hang out with preschoolers all day - who are really cute. all in all, i don't see how the weekend could have been any better! back to the hospital tomorrow!

from kibera to githunguri

i have spent this week with the aidsrelief team, who are a special medical unit fighting valiantly to fight hiv/aids in the kijabe catchment area. they provide free antiretroviral therapy (arvs) and various symptomatic treatment free of charge to all hiv positive people who want it - courtesy of pepfar- the president(of the united states)'s emergency plan for aids relief. so i have been learning a lot about cd4 count trends, viral loads, the various antiretroviral regimens, protocol for switching to second line therapy, etc. etc. 2 days i spent in their clinic in the hospital - doing rounds of the aids patients who are in the hospital at the time and then clinics. and then i went to 2 rural clinics in places called gilgil and githunguri, where the clinicians go to the people's towns for their follow up appointments. because one of the worst things that can happen is that people will start taking arvs and then be inconsistent - and the virus easily develops mutations to the drugs - and they spread it - and next thing you know the drugs won't work on anyone anymore. so the biggest challenge is keeping people adherent to their regimens. its such a big deal that there are people hired to go around to patients homes and make sure they are taking their meds. remarkably, even though the drugs are the cheaper ones available, many people can live their entire lives on them and never come down with aids.

last weekend, i got to go into nairobi and stay with my aunt who lives there for a couple nights. it was a lot of fun. on sunday we went to nairobi baptist church (huge and basically western despite the lack of mzungus [white people]) and then got some chinese food. and on saturday i hung out with some fellow canadians! two nurses who are volunteering at an internally displaced people (idp) camp, and a guy who is working at an orphanage. we went to the famous kibera, the second largest slum in the world after soweto south africa, and got a tour from a really cool kenyan guy who lives there. he is spearheading a large number of development projects there, and earns his money by organizing the filming of various documentaries and films such as the constant gardener. it was very interesting just to walk around in the slum - the kids in there certainly weren't suffering for lack of happiness! conditions were pretty bad though, as you can probably imagine. the worst problem is the lack of garbage and sewage disposal, so those 2 things in particular tend to pile up all over the place. then we went to the giraffe centre - a place where one can get up close and personal with a special breed of giraffe that is almost extinct. if you put some grass in your mouth the giraffe will kiss you! it was fun. then we went to a japanese restaurant for some pretty good sushi. this weekend i am going with the same peeps to mombasa on the coast (indian ocean), so it should be a great weekend!

outpatients; more joy at joytown

this week i have been in the outpatient and casualty departments shadowing a really cool american doctor who speaks fluent somali, arabic, and about 7 other languages. and when he's not there a family practice resident who's in the u.s. airforce. and when he's not there a very goofy clinical officer (kenyan equivalent of a physician's assistant) who wants to emmigrate to canada. i think that this is my favorite kind of medicine because there is lots of interaction with patients (and their families), there's lots of variety, and you never know what's going to happen next. sometimes the doctor has to do things that they aren't trained to do. like the other day a lady came in who we finally found out had aids even though she told us she didn't tell us at first. (it directly related to the nature and urgency of her problem). but her husband didn't know she was positive, and she refused to tell him (in the west someone could be and has been charged with attempted murder for such stubbornness). anyway, she finally agreed that the only way she would accept treatment (and if she didn't get treatment she would probably die the next day because she had meningitis) was if the doctor called her husband in and "nonchalantly suggested" that they both be tested for hiv, so that the truth could come out without the husband knowing the wife had previously known about her status. well, when the husband was told this it did not go over well - he gritted his teeth and got a look on his face that suggested he was going to strangle his wife the minute they left the office, if not the doctor before that. it was kinda intense. speaking of aids, there was this woman who came in who was negative but has a positive husband who she really wants to have a child with. she wanted to know the best days of her cycle for conception. what should the doctor say to that? in other news, there was a radiologist here from montana that i got to hang out with a bit. he ultrasounded me for about 2 hours one day, demonstrating to the ultrasound techs how to find every organ possible. turns out i have a large spleen.

i also got to go back to joytown, the home for disabled kids. this time dr. b. was giving a tour to a group that is going on a medical missions trip to sudan. thats the main reason he goes there, but whenever we are there he sits down with the therapists for a couple hours and brings in child after child to try to figure out what is wrong with them. there are only a couple therapists there, taking care of 300 kids who in the west would probably have 1-on-1 care. unfortunately one of the byproducts of this is that a lot of the kids with paralysis die needlessly from kidney failure because their bladders aren't being managed properly. these kids (some as young as 5) are being taught to catheterize themselves on a regular basis. imagine trying to learn to catheterize yourself at age 5. i've also been making some cushions out of old foam mattresses, plastic shopping bags and tape to put on the hard schoolroom chairs so these kids don't get sores that get infected and then kill them. perhaps the craziest thing about the whole setup is that its a pediatric neurosurgeon who goes there every now and then to give tours that has to notice something obvious like that before anything gets done.

mentally compromised kids and tumor resections

last week was a busy one. i spent most of it in the operating room. dr. b. operated late into the night a couple times, and all day saturday too. there are just so many kids coming in with spina bifida and hydrocephalus. i got to "scrub in", which means i put on the sterile gown and gloves and passed instruments, suctioned oozing blood, etc. etc. i also watched a couple other neat surgeries, like the resection of a huge (like 1 foot long huge) testicular tumor. one night i stayed up almost until the sun came up watching about the most epic sugery ever. this somali guy had come in with a tumor about the size of a football in the middle of his head and neck. so the kenyan plastic surgeon here decided to take er out. he had to peel back the guy's entire face, and dissect everything below it down around the carotid artery (it was suspended in mid air) all the way to the spinal bones in the back of the guy's neck. it basically took all day and all night. that was definitely one of those "wow" moments - to see basically everything between the neck and brain completely gone, and then put back together again. the surgeon kept sending me up to the reference room to find out what artery he was likely come upon next! there was also an ear nose and throat team here repairing cleft lips, so i got to watch them do those surgeries for a day, which was really interesting too.

one day i went to a home for disabled children in a place called thika with dr. b. and a group of visiting american southern ladies. its called joytown, and it was alot of fun. i argued with some of the ladies about politics (they started it). joytown is run by an ngo that dr. b. started. there are hundreds of children there who have all kinds of severe physical and mental problems; its quite the place. actually a lot of the kids with problems resulting from hydrocephalus and spina bifida here at the hospital end up there, so it was interesting to see the track that life takes for many of them. to be honest, normally i'm not all that inclined to spend time with mentally challenged kids, but i had about the most fun i've had in a long time with them there. i sat down in a wheelchair and started wheeling around with them, and then a bunch of them decided to push me around the entire place in my wheelchair, and next thing i knew an hour had gone by!

ob/gyn!

dr. and mrs. b. have been gone to the usa to receive an award from the ama (american medical association) entitled “excellence in international medicine”. yes, that is very impressive. only one physician receives this award each year. if anyone deserves it, it would be dr. b. another doctor and his wife moved in to the house to keep the 2 junior b.s and myself company. they like very much to cook elaborate meals, which is fantastic. the man is an ob/gyn, and i have been shadowing him all week at the hospital - i’ve been learning a lot. gynecology involves a lot of clinic time inspecting a lot of… you guessed it. also a lot of counseling women on how to get pregnant. also, we have spent a lot of time in the operating room - laparoscopies, tumor and fibroid removals, hysterectomies, and an ectopic pregnancy removal (read blood, blood and more blood. the fetus implanted itself in the fallopian tube and the placenta vigorously attached itself to every organ within reach). also things like the results of female genital mutilation and spontaneous abortions that are happening right then and there. it gets pretty intense sometimes. it can be really rough being a woman in kenya. for example, there is a girl here who was forced into marriage when she was 14. she immediately got pregnant, but when she gave birth the baby died and she got a fistula (urine and stool were coming out the wrong hole). thus her husband abandoned her. so she went to live with her brother, who decided that she wasn’t worth feeding, so she became extremely malnourished. to top it all off, when she came in to have her issue repaired (which it turns out was far easier said than done) it was found that her husband had given her hiv. she’s not even 18 yet. very sad.

the other day i got to watch a baby get delivered for the first time! it was extremely exhilarating, and i was just watching! i’m just glad i’m not a woman so i don’t have to dread the experience, especially since that first baby had a huge head and left a trail of destruction on its way out that required many stitches to repair. by now i’ve had the chance to see more deliveries - in fact in one 1 hour stretch there were no less than 5! in other news, i got really sick but thankfully recovered in about a day, took a matatu into nairobi and got lost for most of the day (but it was the good kind of lost), and got the most terrible back pain i have ever had from twisting it playing basketball as well as bouncing around in the matatu. the trip back from nairobi was so crowded that this elderly man who had clearly been smoking far too much pot in the recent past had to legit sit on my lap the whole trip home. i think he enjoyed his “trip” a little more than i did mine. not to complain though - the babies definitely made this week one of the best yet!

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.