Man vs Matatu

"Man vs Matatu" sounds like it might make a great new TV show.  Instead I have come to dread these all too frequent encounters.  This episode would star my friend Eli after being challenged by a matatu (a mini bus that serves as the main public transportation in Kenya).

Eli and his eldest daughter

The Matatu

Eli, also known as Eli Kubwa (Swahili for Big Eli), is our favorite guard that is stationed six days a week at the gate outside our home.  He is one of the all-stars in our weekly dodgeball and wiffle ball games.  More than anything, I love our daily conversations and the continual lessons he gives me in Swahili. 

Friday night, I was out with friends when I received a call from Sonak (Pharmacist) and Laura (Med/Peds physician), both living here long term.  They were with Eli in Casualty still waiting to be seen; the medical officer had left for dinner.  He was complaining of severe abdominal, back and hip pain.  So back to Casualty I go to care for our trusty guard.

As soon as I walked into the room, I heard Eli calling for me..."Nyumba" (Swahili for House).  He was lying on a stretcher covered in dirt with multiple abrasions on his head and extremities.  I joked with him in Swahili as I began to examine him.  I agreed with Laura's assessement and began the process of starting an IV, drawing blood, ordering films, and getting him pain medication.  The x-rays were normal.  With his continued pain, I wanted to get an abdominal/pelvis CT. 

Little did I know what I was asking for with the CT.  Sadly, the technicians for radiology are not in the hospital during the evening/overnight hours.  There is always someone on call, but they are difficult to get to come to the hospital.  Thankfully, the technician returned my page, but then began to argue with me about not being able to do the CT.  He first asked if the patient had his bowel prep. I tried to explain that for a trauma patient, he only needs IV contrast; no bowel prep is necessary.  This argument went on for a while.  After we agreed on IV contrast only, he then said we couldn't do it because he needed two people, one to push the IV contrast and another to run the scan.  Easy fix I said, I'll push the IV contrast while he runs the scan.  He then stated that there's no radiologist to read the scan at night so we can't do it.  No problem, I can read the CT.  Back and forth we went.  Finally, he said he wouldn't come unless I got approval from his boss.  Fine, I'll talk to the boss.  So another page and conversation later, I got the approval to do the CT.  Still not sure if and when this guy was coming, Sonak and Laura drove to the private hospital to see if they had CT available at night.  It was the same situation there so I decided to keep him in Casualty. 

Not much later, I was pleasantly surprised to see the radiology technician.  We worked out the payment issues for the CT (patients are required to pay before they can get any test) and took Eli for his scan.  Thankfully, the scan looked pretty good with only a few injuries, a couple stable lumbar fractures and an acetabular fracture.  I thanked the technician for his work and went back to Casualty to get Eli admitted with some pain medicine and an orthopedics consult.  Sure that I had upset enough of the hospital staff for the night, we went home.  Another adventure...Oh Casualty, how you challenge me. 

I rounded on Eli the next morning.  Although still in pain, he looked much better and was in good spirits.  He was able to be released from the hospital that next evening with ortho follow-up.  Although sad that he won't be around for a while as he recovers, I am thankful he is doing well and that the matatu didn't win.

Tumaini

Tumaini (Swahili for hope) is a drop in center for street kids in Eldoret.  The organization is dedicated to empowering and serving street children here, and ultimately giving them hope. These children roam the streets all day in search of food, money, and friendship. Some are orphaned, but most come from families too poor to provide for their children.  Living on the street often leads to malnutrition, which inhibits their growth and development and puts them at risk for a myriad of infectious diseases. Substance abuse is nearly ubiquitous among the street children.  You will find many of them walking around with a bottle of glue hanging from their mouth, huffing to get high and suppress their hunger.  They are frequently harassed or abused by community members and even by the police. However, most of the street children are not inherently delinquents or criminals; they are just seeking love, care, and support...what all of us want. These street children are missing their opportunity for education, vulnerable to violence and disease, and without access to health care or other social services. They have been denied their rights as children by the demands of living a life of survival on the streets.

Thankfully, Tumaini works to provide a safe environment and positive role models for these children.  On Saturday mornings, a handful of us go to the outreach events, hoping to build relationships with the children.  Most of the mornings consist of games of soccer, which the boys love.  Noticing that the girls often don't come, we are planning to have more activities for them next week, such as crafts, jump roping, and nail painting.   Last Saturday, another physician and I held a clinic in the barracks where many of the street children stay.  Most of my encounters included a pregnancy test and lots of counseling.  Despite leaving with a headache from inhaling glue all day in the closed tent, we are planning to have frequent Saturday clinics for them.  Serving these kids has been an enjoyable part of the week.

Here are a few pics of the kids...

Hiding in the tree yelling "Nyumba" (Swahili for House - my new nickname)



They love to perform

 

I am enjoying getting to know these kids, learning about life through their eyes.  My hope is that even if just for a moment, these outreaches would give them a chance to claim back some of their childhood - to play, be carefree, and feel loved.  May they get a glimpse of God's unconditional love that provides the greatest hope and will never abandon them.

David vs Goliath

Last week in Casualty, I had the privilege of taking care of a man named David.  Wasting away from AIDS and TB, this weak and frail man has a difficult battle ahead of him. A husband and father of three, he became very ill from his disease and was unable to work, leaving him and his family without food or shelter.  He was brought to me in Casualty to be cared for while the program found shelter, mattresses, and food for his family. 

When David arrived to Casualty, he was very sick.  His blood pressure almost unrecordable with lots of difficulty breathing.  During my exam, he started crying, fearful that he was going to die.  My eyes watered, trying to hold back tears while praying silently in my head for God's healing hand upon him.  He had a tension pneumothorax, likely from his tuberculosis.  After performing a needle decompression and starting an IV, I took him to minor theatre to place a chest tube.  He tolerated the procedure well and began to show improvement in his breathing. 

I have visited David on the wards this week, watching him slowly improve.  His breathing is much better.  His medical team has been discussing taking out the chest tube.  Today, he had a repeat chest x-ray which David asked his wife to take it to me in Casualty to review.  He wants me to take out his chest tube so he can go home.  I wish it were that simple.

I have tried to encourage him to eat as he continues to waste away.  I even made arrangements for him to get some ugali, a staple starch in the Kenyan diet thought to make you strong.  It's a cornmeal mush, cooked to the consistency of a thick dough. One eats with it by forming a piece into a small ball in your hand, indenting it with your thumb, and then using it to scoop up your greens or stew.  It isn't too bad, but sits like a brick in my stomach.  Regardless, I hope he continues to gain strength so that he might have more good years with his wife and children (ages 14, 6, and 3).  For David, the battle will be tough and the disease is certainly a relentless Goliath; however, I am thankful that with Christ, there is always victory. 

"Therefore we do not lose heart.  Though outwardly we are wasting away, yet inwardly we are being renewed day by day.  For our light and momentary troubles are achieving for us an eternal glory that far outweighs them all.  So we fix our eyes not on what is seen, but on what is unseen, since what is seen is temporary, and what is unseen is eternal."  2 Cor 4:16-18.

Out of Medicine

The local newspaper advertised that we are out of medicine.  For the last couple of weeks, we have been low on medications in the hospital.  We are now out of all IV and oral antibiotics along with many other medicines.  What?!?  How can this be, especially at a large referral hospital for Western Kenya?

There are so many problems within our system, corruption that extends throughout all levels of the hospital and government.  Everyone blaming each other for the problem.  There are concerns that the money distributed by the Ministry of Health is being used for things other than medicines.  Others argue that the Ministry of Health isn't giving us enough money for medicine.  The newspaper article discusses how suppliers are threatening to stop deliveries of medicines to MTRH due to lack of payment:  "Health Gap International, points out how medical suppliers had threatened to stop deliveries to the Moi Teaching and Referral Hospital over a Sh75 million debt. It says funds from the Treasury are not adequate to cater for the needs of the referral facility.  Some suppliers had stopped deliveries due to non-payment, a move that does not augur well for a referral hospital”  Not sure how we're supposed to care for patients without medicines.

One report in the article blames medical personnel for the problem stating, "The patients accused nurses and other medical personnel of hoarding the drugs and secretly supplying them to private pharmacies, a practice they cited as a key contributor to the shortage of drugs."  Sadly there is truth to this statement as well.  Some hospital personnel will sell the medicines to pharmacies or private offices to make money.  If you go to the pharmacies in town, you may receive a medicine with MTRH stamped on it, identifying it as medicine that belongs to the hospital. 

So now what?  In several other resource-limited settings, patients receive scripts for medicines to buy and bring to the hospital for their treatment.  One pharmacy tech actually did this and things didn't go well for him.  He was pulled into the director's office and asked why he told a patient we didn't have medicine here.  He was then fired.  Now, no one will write scripts for patients to bring their own medicines.  I'm investigating developing my own stash of medicine...a pocket pyxis.  I'll add it to the other supplies/equipment that I haul to work every day since things mysteriously disappear if left at the hospital. 

In the meantime, what about the patients?  Amidst all the bickering and finger-pointing, it's the patients that suffer.  They come to the hospital trusting that we will do our best to care for them.  How is that possible without life-saving medicines?  Do you send them somewhere else?  If so, where?  I thought we were supposed to be the referral center.

Market Fresh Chicken

Sunday included a trip to the market...this time to buy a live chicken for dinner.  We received tips from a Kenyan friend on how to pick out a good one.  Look for a fat chicken.  You must feel all over the chicken for good meat - the neck, the breasts, the butt.  The chicken must also be "active" which portrays good health.  After a few tips, we were ready to check out some chickens.  I can't say that I handled these birds with much grace.  One pecked at my hand which caused me to let go of her wings.  She then flapped around until someone else grabbed her.  I'd say that's an active one. 

Checking out the chicken

Daria displaying our chicken of choice


Once we picked one out, we watched them kill and depluck our chicken.  I struggled a little with the slitting of the throat, but once she stopped moving, it wasn't so bad.  It didn't look too difficult so I am determined to do it myself sometime.

Deplucking

Now ready to remove the guts.



Not much longer and we were headed home with our first "live-but-now-dead-market-purchased" chicken.  It's amazing how much space those feathers take up.  The chicken wasn't nearly as big; nothing like chickens we buy at home.  Still we were happy with our purchase.  Once home, Daria and I prepared dinner for everyone...beer can chicken, rosemary & garlic potatoes, and avocado/tomato/cucumber salad.



Before going in the oven

Yay!  Everything turned out wonderfully.  Sorry there's no after picture; we ate it all so quickly...very tasty.  A great dinner with friends before the middle-of-the-night Super Bowl viewing.  Go Packers!

Time for Ice Cream

Indiana University's partnership with Kenya provides a medical exchange for students and residents to rotate on the wards here.  For most trainees, it is their first experience practicing medicine in a resource-limited setting.  And even for the more seasoned travelers, there are still difficult and overwhelming days.  I often find myself on the listening end of many of these bad days, trying to provide some validation, insight, and encouragment to frustrated residents.  After a rough week on the wards, one of our pediatrics residents was over it all, ready to go home.  Sometimes words just won't suffice.  At this point, I knew it was time....time for some ice cream!


Yum...Strawberry Milkshakes!

Of course, I have already scoped out the town for the best treats.  For milkshakes, it's the Sizzler.  Nothing like a little taste of home to make the day better.  Bring on tomorrow!

"Casual"ty

Casual:  "without serious intention; careless or offhand; seeming or tending to be indifferent to what is happening." 

Emergency:  "A serious situation or occurrence that happens unexpectedly and demands immediate action; a condition of urgent need for action or assistance"

I am not sure that it is possible to marry these two ideas as they seem to directly oppose each other, but something needs to change in my department, appropriately named "Casualty".   The saying throughout other departments is that "they are too casual in Casualty."  While I believe this attitude is widespread across the hospital, my goal is to at least make some improvements in our department. 

The week brought many frustrations in this area.  There certainly is no sense of urgency in this culture.  No vital sign is alarming.  No lab is stat.  No medicine is critical.  To me, all of this says:  no patient, no life is important.  As is customary when I arrive to work, I usually find a few patients in desperate need of attention.  I found this chart on the desk:

No one seemingly aware of who this patient is, where he/she is, or that there is anything terribly wrong with those numbers on the page.  Already, the patient had been sitting somewhere for 30 minutes without any intervention. Granted nearly every patient here is terribly sick...cachectic and wasting away from AIDS, has a decreased level of consciousness, is actively bleeding, or has bones where they shouldn't be...I would be pleased with some hint of awareness or concern regarding the degree of illness in Casualty. 

I found this patient sitting in the waiting room, a young woman weak and pale.  It became clear after my examination that she was in shock from a septic abortion.  In the Kenyan culture, women often have little control over their sexual lives which leads to many unwanted pregnancies.  Once pregnant, everything rests completely on the woman's shoulders as the sole individual responsible for the care of the child.  Often in times of desperation, women will go to unskilled traditional providers to try to end their pregnancy which is very unsafe and often fatal as was for this woman. 

While I worked quickly to get her fluids and antibiotics, she needed more.  The lab wouldn't answer the phone to come do a point of care hemoglobin as well as the tests to get her blood for transfusion.  The nurse then sat down as if we had done all we could do.  After asking her to run the blood down to the lab, I just got a blank stare in return.  I also asked if we could call the OB/GYN to come see the patient and take her to the operating room.  The medical officer stated that usually we don't call anyone; she will just go to the ward where the team will review her case and then take her to the operating room.  Knowing how the wards work here, I know that is not true...maybe the patient will be seen later today or maybe in the morning during rounds.  She needed immediate attention and operative treatment.  I called the ward, but all the doctors were at lunch.  Despite trying to page them, no one answered.   While I don't know if the outcome would have been any different, it is hard not to feel as if we failed this patient.

I left angry, frustrated, and tired.  Some days I just want to take a poll to see why people are even in this line of work.  If I knew why they do what they do, I would at least have a source of motivation for them.  I want to push them in a way that they will respond, a way that is a little more emergent and a little less casual.