In my mind I'm a Kenyan

While running the Indianapolis mini-marathon a few years ago, another runner was wearing a shirt that caught my eye and made me smile. 

If only I could run like a Kenyan.  If I want to even try, Eldoret is the place to be.  Eldoret has produced more championship long-distance runners than any other town in the world.  Located in the Kenya Highlands at an altitude of 6840 feet, it has become a mecca for runners from around the world to train.  This has inspired several of my friends and colleagues, who have signed up to run the Kilimanjaro Half-Marathon.  As a result of peer pressure, I have signed up as well.  

I have been running with a Kenyan friend.  She used to be a marathoner but was forced to take a couple of years off due to health-related issues.  She is running again and pushing me along in the process.  On my days off, she recommended that we run twice a day...I had to draw the line there.  While I don't have enough time to adequately train for the half-marathon (5 weeks away), it will be good to give it a shot.  I can always run/walk and am mentally prepared to be last across the finish line.  If all else fails, I can default to the 5K.  While my running partner is determined to make me a Kenyan, I am sure it will only be in my mind.

A Partner In Crime

Monday was an encouraging day.  I have been discouraged in casualty without anyone who seemingly cares or has the power to help make improvements.  On Monday, things began to look up.  Simiyu, a trauma surgeon, showed up while I was rounding on our observation patients.  Simiyu is an enthusiastic teacher and clinician who used to be the head of casualty.  He had made significant improvements (yes, it used to be worse) but due to hospital politics, was let go from his clinical duties.  He still teaches emergency medicine, trauma and disaster preparedness for the medical students both here and in Nairobi.  Anyhow, I had a meeting with him during my last visit in July to discuss the department and get any advice about working there.  I really appreciated his excitement, encouragment, and ideas for change.  I was sad that he was no longer working in casualty, especially since I was lacking a Kenyan counterpart and knowing that he would be an excellent partner committed to education and patient care.

Unbeknownst to me during my time at home, he worked it out with the hospital director to work in casualty again.  He has worked out his schedule so that he will be here for my entire six months.  It is such a relief and answer to prayer to have a Kenyan counterpart active in the department, working together to improve care.  I also met with the chief medical officer on Monday and established a series of lectures I will be giving to all of the medical and clinical officers in casualty.  A great day and a step forward.

I left the hospital overwhelmed by God's goodness, knowing that He was working things out.  So thankful for the complete sovereignty, infinite wisdom, and perfect love of God - He is worthy of our trust! 

Shopping Adventures

Shopping is always an adventure here.  Last time I was here, I searched for protective eyewear for procedures and intubations in Casualty.  At the supermarket, they presented me with several options to choose from:  goggles, tinted glasses, a snorkeling mask, and a gas mask (I apologize that I couldn't find the picture of this presentation).  Of course you all know I wanted to go with the gas mask, but didn't need anything else other than my white skin to make me stand out.  This is just an example of the diversity of products one can find in Eldoret.  Dad, they even have "Diabetic Jam" here for you...there's no reason now that you shouldn't be getting on a plane to visit. 

This weekend, I made a trip to town for groceries.  For produce, the best stop is the local outdoor markets.  It's the cheapest and freshest.

 

For everything else, it's off to the supermarket...Nakumatt.  Although I am not a big shopper, I find the place intriguing.  Of particular interest this visit were the small shopping carts.  They have rows of them outside.  I haven't quite figured out why.

I have come up with a few speculations:
   a.  Kenyan's are short.
   b.  Small carts keep you from spending too much money.
   c.  Children do the shopping here.
   d.  This is the intermediate step between the regular cart and the evolution of the basket.

So, definitely choice (a) isn't it.  I haven't noticed an abundance of children shopping.  Any other thoughts...I'm going with (d) for now.

Back in Kenya...Preparing for Battle

I have arrived back in Kenya and am getting adjusted to life here again.  I have moved into Hilltop, a set of homes near the IU House where the "long-termers" associated with the IU-Kenya partnershp stay.  The best part is having some space to myself, including my own bathroom.  Yay, the simple things in life! 

The biggest task of the week was getting adjusted to the time difference, leaving me with many wakeful nights.  Despite wanting to sleep during the day, I ventured to the hospital to work in Casualty and get started on my research.  Of course, I found a few implemented projects from my time in July to have gone back to their usual state of disorganization.  The emergency area was also missing more valuable equipment as people love to walk away with anything and everything.  So after a week of little sleep and frustrations in Casualty, I am taking the weekend to rest and prepare for the steps ahead as the task of developing emergency medicine here seems overwhelmingly great.  I was reminded of Ted Loder's Guerillas of Grace: Prayers for the Battle:

Heavenly Father,
grant me an ease
to breathe deeply of this moment,
this light,
this miracle of now.
Beneath the din and fury
of great movements
and harsh news
and ugent crises,
make me attentive still
to good news,
to small occasions,
and the grace of what is possible
for me to be,
to do,
to give,
to receive,
that I may miss neither my neighbor's gift
nor my enemy's need.

Thankful that I can rest in God, knowing that all things are possible with Him.  May I make the most of this opportunity:  to grow in my relationship with God, to provide the best medical care possible with limited resources, and to improve emergency care for the people of Kenya.

 

Bye for Now...

"There is peace all over Kenya and that is more important than the referendum." Most people are excited about the passage of the constitution this past Wednesday. The transition of this country to a democratically ruled state is a slow, laborious process that has cost many lives along the way. Thankfully, none was lost with the referendum as many were extra cautious given the horrific events of the inter-tribal warfare that occurred after the presidential election. Everyone is anticipating that the constitution will bring about unity for this nation that currently operates on such strong tribal loyalties. One can hope that the changes that have just been voted into effect will be able to staunch the gross corruption and money-hoarding that continues at the highest levels of government. Fortunately, the attempts on the part of the prime minister of Kenya to raise his yearly salary to three times that of President Obama’s have been eliminated. My biggest hope is that the constitutional amendments will further empower the women in Kenya who lead the most difficult and oppressed lives here.

During the voting, we made the most of the lockdown. Games of basketball, wiffle ball, and dodgeball were organized. Sonak (pharmacist here full time), Monica (another pharmacist), Erin (OB/GYN/global health fellow from Duke), and I then made some home-made ice cream (chocolate cookies & cream and pineapple sorbet) - yummy!! The four of us rocked it out on rock band and watched a couple of movies on Sonak's TV. Erin was skeptical of rock-band so it was funny when we couldn't tear her away from the microphone. Great for me (and everyone else) since my singing is horrible. =) It was a great time....and an enjoyable taste of home.

Three of us took a little escape in a matatu to Naiberi River & Campsite Resort today, located about 20 km from Eldoret. The journey, as always, was quite the experience. A matatu is a small, narrow van that provides much of the transportation for the people of Kenya. It has seating for 12, but that is just a suggestion. By the time we were loaded up to head toward Naiberi, we had 23 people in this matatu. For a portion of the trip, I had someone sitting in my lap. I think having this many people in the van actually might prove to be safer, serving as some type of restraint system as you can't really move at all. There aren't much in the way of road rules, or at least ones that are enforced. Although a police officer pulled us over at one point, a small payment put us back on our way. Oh, but not before he tapped on the front window at a 2 year old boy sitting on another man's lap in the front seat. The boy scooted back a bit and we got a thumbs up. I felt so much better, phew....now he's safe?!?! Aside from the car trip, Naiberi is a nice resort that I will frequent when I come back for sure at a mere $3 entry for the day.

This week I have spent some clinical time in the children's emergency area. Most of the sick kids, except trauma, are sent to this area for triage and care. As soon as I took my first step in the door, I was led to my own desk with a chair and my first patient. Amazingly, my Swahili has come a long way, enabling me to get a pretty decent history for most children. I need some help with the details, but usually get the main complaints. The children here are gorgeous....and their smiles light up the room. They are usually dressed in 3 or 4 outfits with at least one snowsuit covering it all, making the physical exam quite an exercise. Like most Kenyans, the children speak so softly and often look down when talking, making it difficult for my deaf ears to hear. Many of the children will sneak up close to me and hold my hand...it is then that I know what they really want. If I listen closely, I can hear the word - "sweeties." Sadly, I failed at having a supply of candy...not a very good mzungu (literally means aimless wanderer, but a term used for any white person).

The remainder of the week was spent in meetings with the several key people, including the Director and Dean of the Medical School, regarding the improvement of casualty and building a collaboration with IU's EM program. All of the meetings went well which was a much needed encouragement. Thank you for your prayers. It has been a good way to wrap up my time here.  Now I have lots of work to get done at home in preparation for my return in January.

Daily Dilemma

As illness has made its way through the IU compound, I have been struck with a bad cold and some GI distress.  Our guard at the gate of the IU House, Michael, is the sweetest, most smiley man ever - I know, just the type of guy to scare people away.  (Of note, the bag he carries to work is a kid's bag with barbies on it - makes me smile).  Anyhow, he always provides me with encouragement every day as I venture to the hospital; today, he suggested I start taking medicine for malaria so I can be "active" again. 

Despite not feeling well, I went to the hospital as I want to make the most of my short time here.  Within minutes of arriving, the Casualty Room filled with patients and went from being calm to chaos.  My toughest issue of the day quickly shifted from bathroom access to resource allocation:  Which one of these patients should or will get the ICU care with only one bed available.

1.  An unfortunate gentleman, a security guard for a school, who was assaulted on Sunday.  He had been taken to an outside district hospital and kept there until Tuesday when he was sent to us.  He had a GCS of 8 (GCS is just a general measure of the conscious state of a person with the worst score being 3 and the best being 15).  He also wouldn't move his left side at all.  With obvious deformities to his face and skull, he went to the CT scanner where we found an impressive depressed skull fracture, epidural hematoma, and intraparenchymal hemorrhage (bad blood in his brain). 

2.  A 17 year old boy with some heart problem who came in with copious froth coming from his mouth and nose, no pulse and taking his last shallow breath.  The obvious source being heart failure.  He had gone to bed complaining of chest pain and trouble breathing, but never woke up.  The poor sister had tears streaming down her cheeks, telling me she had just lost her mom and dad recently and couldn't lose him too.

3.  A young man with newly diagnosed HIV who was also unresponsive with labored respirations.  He was sent from a district hospital for "r/o stroke or meningitis".  No family or friends were around to give any other history.

4.  A 35 year old man who hit 4 others on a motorbike with his car.  He tried to take off after hitting them, but a mob of people chased him down, pulled him from the car and beat him badly.

5.  An 8 year old male motorbike passenger with an obvious head injury and extremity injuries.  Moaning and localizing to pain.

6.  A 22 year old female passenger on the motorbike with a GCS of 4.  She was unresponsive, posturing with an obvious head injury.

7.  A 30 year old female passenger on the motorbike was complaining of chest pain, trouble breathing, belly pain and had an obvious femur fracture.

All lined up in this small room.  I didn't have vitals on any of them.  It is difficult to manage this many patients here since the doctors are expected to do everything...evaluate the patient, start IVs, lab draws, write out order sheets, etc.  Also, until the family registers, they don't have a number that we can use to get medicines or tests.  I sent my medical student down to the pharmacy to grab antibiotics and steroids for the HIV patient (although the pharmacy only had one of the four medications I requested) and mannitol for one of the head injury patients; thankfully, they gave it to him without a patient name or number.  We did our best to resuscitate these patients but with little success in this system.  The ICU medical officer had come down to evaluate the patients.  I would have intubated any number of these patients along the way, but there were no ICU beds available.  We negotiated moving one of the patients from the ICU to the wards, but now what?  Who do you choose to get the ICU bed?

How do you decide?  Whose life is more important than another?  The young?  The non-HIV patient?  Families standing over their brother, sister, child with looks of fear on their faces, scared of losing yet another loved one.  How can I say in one breath to one family that we will do everything we can and in the next breath, tell the others that there is nothing more to offer, knowing that outcomes could be different given another time and place.  Who would you choose?  Why should you have to?

These decisions are more frequent than I would like.  Medicine here then becomes about picking which patients might have a chance and focusing resources there.  We have a limited supply of antibiotics and other life-saving medications.  The government has not distributed funds for the upcoming year so we are currently running very low on many medicines.  Each day I have to check with pharmacy to see what antibiotics are available.  With only several vials of an antibiotic, do you just treat until you run out, give one dose and see if there is a response before deciding on more, or save it for only those who show promise of recovery?

Every day is a reminder of the frailty of human life; it is so apparent everywhere.  Although death may be more common here, especially among young people, it doesn't make it any less painful for these families.  Their cries and tear-stained faces leave an impression in my mind.  For the sister of the young boy who died from his heart failure, I wanted to give anything to make the outcome different, to make it better for her; all I could do was hold her while she cried.  It is days like today that make me just want to go home.  Then, I see the faces of these families, the sister, and know that for them, I must keep working. 

"Teach us to number our days, that we might gain a heart of wisdom.  Satisfy us in the morning with your unfailing love that we may rejoice and be glad all our days."  Psalm 90:12,14

Walking Far, Walking Together

"If you want to walk fast, walk alone.  If you want to walk far, walk together."

This African proverb really resonates with me as I begin this collaboration.  As an American and an Emergency Medicine physician, I want things to happen quickly and efficiently.  I find myself restless when things are slow.  As I have spent this past week in casualty, God is teaching me patience.  I am learning that if I am to be committed to this partnership and development of their department, I have to redefine my goals and expectations in preparation for a long journey.  

After one week of working in Casualty, it is clear that it in order to make any changes, I am going to need the help of administration.  Joe Mamlin (the founder and heart behind the IU program here) is going to introduce me to the director of the hospital and dean of the medical school this week.  The Dean has a reputation of being a very nice man; I look forward to discussions about teaching medical students basic concepts in emergency medicine.  The Director, on the other hand, has the reputation of being a very arrogant man with his own agenda.  I am hopeful that I can match my agenda with his and win over some of his influence.  We had a morbidity and mortality conference this past week - 20% of patients admitted to the wards die.  The average length of stay for the male and female wards is 8 and 9 days respectively.  The Minister of Health wants the hospital to decrease this to 7 days.  I know that I can help make a difference in all of these numbers by instituting a few protocols in our Causalty Room.  We have lots of patients with serious infections such as meningitis and sepsis who don't get antibiotics for many hours after being seen, bleeding patients with hemoglobins as low as 2.5 that don't get blood for hours (and they argue about giving fluids for volume as it will dilute their hemoglobin?), and the list of scenerios goes on.  By helping him achieve some of his goals and provide better patient care, I am hopeful that he will help me out with staffing of the Casualty Room.  I learned that the medical officers (my most experienced physicians having completed an intern year) are rotated to different areas of the hospital every 3-4 months despite their interest.  I have been told by several that this is because the Director doesn't want anyone to get good at what they do, allowing him to keep them under his thumb.  While I hope this isn't true, I pray that he will be open to allowing people to stay in Casualty for longer periods of time so that I might provide more effective teaching and emergency medicine training to the medical officers in that area.  I remain optimistic that we will have a great meeting that will be the beginning of a relationship that will help facilitate the development of this program and provide better patient care.

After my week at work, I spent a great weekend here in town relaxing.  Some friends (Marc, Erin, & Monica) and I had planned to make dinner on Saturday for Joe and Sarah Ellen Mamlin.  What we had originally planned to be a small dinner turned into quite the party.  Several "VIPs" arrived into town on Saturday morning.  One is a two-time grammy award winning opera singer who is here for a few weeks to perform a concert and observe (she has asked to spend a half day with me in casualty - wondering if we can give all of our patient care in musical format - picture a mix between the shows Glee and House). Anyhow, since the Mamlins' are entertaining them, we ended up cooking dinner for everyone.  Sarah Ellen really wanted us to roast some chickens for dinner.   So, our preparation consisted of watching the Julia Child's episode on "How to Roast a Chicken" while we cooked.  Many of you know how my chicken baking turned out in Zambia, so you can imagine that I was a bit nervous regarding this dinner now that we had quite the guest list.  Everything turned out wonderful, making for a great night of food and company.  So much fun!!  Joe has asked us to make food for them every night...for him, I would consider it.       

Success

 I appreciate everyones' prayers and encouragement.  I do have a special prayer request for the next week regarding political affairs occuring in Kenya right now.  So, when I arrived to Eldoret, there was red carpet on the tarmac and a crowd of people around the fences of the airport.  While I would love to believe I am that admired, I knew President Kibaki had just arrived as our plane was parked next to the Kenyan equivalent of Air Force One.  He is making his way around the country to promote the proposed Kenyan Constitution that is to be voted on August 4th.  Just as controversial as his presidency especially in the Rift Valley (where I am located), so is the constitution.  The constitution is much like the American constitution and most educated Kenyan's and Americans are in favor of the document.   However, the Kalenjin and Luo tribes (located in the Eldoret area) are not in favor, also not big fans of the president as they believe he won by electoral manipulation - hence the post-election violence in 2008.  Given the tensions from the past, many are cautious about the upcoming vote on the Constitution, which is predicted to pass.  So, please pray for a peaceful response to the voting on August 4th.  I think the country is more prepared now than after the election.  President Kibaki is sending an army of Kenyan military men to Eldoret in hopes of ensuring peace as the passage of the constitution will be his legacy.  We will be prepared for possible evacuation but most (Kenyans and Americans) don't think it will be necessary.  I think we will be staying in the IU compound for a few days following the vote to be cautious.  At lunch on Sunday, Joe Mamlin was telling me they are meeting with the US Embassy this week to discuss our security in case a war breaks out.  I'm not quite sure what my face looked like while he said this, but he smiled at me, put his hand on my shoulder and said "Don't worry, we'll protect you."  So, no worries...and truly, I am completely at peace resting in the hand of an Almighty God. 

I appreciate all of you walking with me on this journey.  It is true that walking together allows me to walk much farther than I would by myself.  Thank you!

"Walk in a manner worthy of the calling to which you have been called, with all humility and gentleness, with patience, bearing with one another in love."  Eph 4:1-2

The Kenyan Adventure Begins

So here we go again…

What am I up to now?  Well, I recently finished my five year residency in emergency medicine and pediatrics.  Yeah, I am done...or so I thought.  As many of you know, I love traveling and international medicine.  Throughout the years, I have taken several medical trips and knew that God was leading me to serve in this capacity.  Not surprisingly, God is good at making everything fall into place.  Looking for a job that would allow me to incorporate international medicine, I was approached by one of the directors of the IU-Kenya program regarding developing the emergency department at the hospital in Eldoret, Kenya.  The AMPATH (Academic Model for Providing Access to Healthcare) program is an incredible partnership (nominated for a Nobel Peace Prize) that Indiana University has with Moi University Teaching and Referral Hospital to provide healthcare for the people of Western Kenya.   After several discussions with the chair of the Emergency Medicine Department at IU, I am now creating my own international emergency medicine fellowship at IU, working to develop the Emergency Department here in Eldoret and develop an international elective for the EM residents. The timing was perfect to be finishing residency and have this opportunity open up to me with the support of the IU School of Medicine and EM Department. 

This is the path that brings me to my current location, Eldoret, Kenya  I am here for a month to observe and learn about the Casualty Room (ER) in the hospital before coming back for a longer stay to really work on the development of the department.  It truly is one room and a bit of a disaster.  There is only one bed, although it may hold two or three patients at a time.  Others will be brought in on a gurney or placed in a wheelchair in the one room.  Once no more bodies can fit, they are lined up outside the room.  By mid-morning, the waiting area is already full, making for a long day.  


Welcome to Casualty



I started seeing patients today with the medical officer (doctor who has finished an intern year only) and began to venture out on my own once we were behind.  The language is my biggest barrier, but hoping to get much better with my daily Swahili lessons.  I am taking a medical student tomorrow who will also serve as an interpreter.  I am hoping it goes better than today.  My last patient of the day was someone I dug out from the stack of patients in the waiting room.  The triage nurse just brings the charts of new patients in and lays them down by time of arrival.  While looking through them, I found a woman who had an unobtainable blood pressure, febrile, no pulse recorded, hypoxic and tachypneic.  I walked outside and asked the nurse where this patient was, wanting to see her right away.  After asking around, we located this patient who was indeed in septic shock.  Before we could begin any therapy, she decided that she did not want to stay in the hospital and was adamant to leave as she had a young child at home.  I told her that if she left, she would die.  Everyone else, including the medical officer, started laughing.  Angry, I looked at him and asked "why are you laughing?  She will die if she leaves; this is serious."  He replied, "Yes it is dangerous, but she doesn't want to stay."  My response, "Dangerous?!?  She will die.  She has to know that is the reality if she leaves."  Still no one else seemed concerned and despite my arguments, she left...my heart sank.  I have found that it is not uncommon for people to laugh as they are uncomfortable wanting to avoid the subject of death, even though it is very common here.   The end of day one working in Casualty and I already had my first one.  Here's to tomorrow...a new day.