Friday Clinic

I woke up with the idyllic rooster call and sunshine peeped through the window of my mud hut. It was Friday and just one more clinic day stood between me and a relaxing weekend. I stepped outside, took a deep breath of fresh Kenyan air and I saw Paulette sitting near my hut, enjoying her breakfast.

“Don’t look to your right,” she says.

“Okay, I won’t…. why?”  My curiosity got the best of me.

“They’re slaughtering a cow right outside your hut.”

Aside from my rough start to the morning, I was excited to experience another day of clinic outside of Bungoma, Kenya. Dr. Keith Scott announced to us that some of us needed to leave for clinic early. I volunteered and piled into a vehicle with the other early birds and we took off for clinic which was located one hour away.

Our final destination was a small mud-building with a tin roof. We found out that it was the village’s church. A lady and a gaggle of small children meandered out of the church to see what was going on. As we poured out of the vehicle, some of the little kids acted a bit terrified of us. I even heard some of them crying. I guess they don’t see wzungu, whites, very often.

We checked out the building and realized it was just too small for our clinic and there was no shade outside so we couldn’t work outdoors, either.  Some of the locals told us of a better location just a little way down the dirt road. I grabbed my belongings and Marcy helped me pass candy out to the children as we headed to our next location.

A man led us to a green yard with a nice house and a canopy of trees. We were told that this house belonged to the pastor of the church.  We began setting up our clinic stations and the pharmacy.  I found a nice shady patch, grabbed a translator and was ready to get clinic started.

My first patient was a 3 year old boy. I recognized him as one of the children from the small church. He had a patch of impetigo on his upper lip.  His little nose was running onto the impetigo and he had flies crawling on his face. I grabbed wet wipes, Hibiclens and triple antibiotic ointment and got to work. The little boy stood there, quietly, while I scrubbed his face. I even cleaned the parts of his face that weren’t affected since I didn’t want flies to walk over the impetigo. When I was done, I gave him some candy and toys and sent him on his way.

My next few patients were a smattering of the usual: osteoarthritis, GERD, untreated hypertension. A mom brought in a 5 year old girl for tinea capitis (tinea = ring worm, capitis = of the head). The little girl’s younger brother was so scared of me that he buried his face in his mom’s chest and wouldn’t even look at me. I tried to offer him some candy so that he might not be afraid, but he was hanging on to his mom for dear life.

The LSU medical team began wrapping up clinic a bit earlier than usual since many people were leaving for the United States the next day and needed to pack. Right when I was about to start getting my things together, a mother walks up with her four young children. My translator, Ellah, who is also a Kenyan physician, gave me a pleading look that said, “Please don’t leave me!”, so I asked Mary Katherine and Mama Joyce if it was okay for me to stay behind. They said it was fine, and thus began the most overwhelming afternoon of my life.

Once all of the LSU wzungu left the clinic, the only medically trained people left were Ellah and Edward (Kenyan physicians), Karen (Kenyan nurse) and myself. Ellah eventually found another interpreter for me so that she could start her own clinic station and we could get through the patients more efficiently.

I still had to examine and manage the mom and her four children that arrived at my station. The first child I examined was an 8-year-old boy who had a history of complex partial seizures ever since he had meningitis when he was 2 years old. We cannot treat chronic seizure disorders from our clinics since we cannot follow-up with our patients, so I explained to the mother that she needed to take her son to a hospital or clinic so that he could be treated and followed for his disorder. As good measure, I decided to listen to the boy’s heart. I was startled when I heard a systolic murmur. It was loud and clear. Panic ran through me: I could hear Dr. Kiel’s voice in my head, asking me what might be causing this boy’s heart murmur. Unfortunately, my mind was blank. I also didn’t have any American doctors to consult anymore since they had long since left clinic. I started to get more history on the boy including his activity levels and any history of syncope. I felt horrible that there was nothing I could do for him at clinic (even if the American doctors were still there), and I knew that if we were in the US, we’d get an echocardiogram on this patient to find the cause of the murmur. Unfortunately, we were not in the US and this family had very little money. So I told the mom that she needed to have a doctor listen to his heart when they take him to get his seizure disorder worked up.

Next, I listened to the boy’s younger sister. The mom said the little girl had a history of asthma-like symptoms. As I was listening to her lungs, the little girl laughed a lot. I was glad that a child was not terrified of me for once.  Her lungs sounded great, which made me happy since I didn’t want to add any more problems to this mother’s load.

The next sibling, was a baby over a year old. Her lungs sounded terrible. I could hear wheezes and mucus all over her lung fields. The baby didn’t look toxic, which was a good sign. I discussed the case with Ellah and she suggested we give the baby amoxicillin and a shot of rocephin to cover most causes of pneumonia in a patient her age. I ran to the pharmacy and Karen helped me mix up the amoxil. I started looking around the table for the rocephin, but I could not find any sterile water or glucose to mix with the rocephin in order for us to administer it intramuscularly. That meant the baby would only get amoxicillin. We had also run out of albuterol and all other inhaled medications meaning we couldn’t offer the baby any immediate breathing relief.  The best we could do was crush up some salbutamol and mix it in water to give the baby. It wasn’t anything I’d do in the US, but I was desperate to make her feel better and keep her out of the hospital.

At this point, many other patients had arrived and registered to be seen by a doctor. I think they may have been telling this woman things in Swahili because she told me that she wanted to withdraw the fourth child from being seen. I made sure she got a refund for that child. The mom grabbed her children and left quickly after I educated her on warning signs that the baby might be experiencing a respiratory emergency. Even if the baby did need to go to the hospital, I am not sure the mom would be able to find transportation there.

The rest of the afternoon was a bit of a blur. I knew I had to see many patients and I had to see them quickly. I also had to depend on my brain, my books and my stethoscope (my otoscope and ophthalmoscope ran out of batteries earlier).  I also did not have my attending doctors to consult when I was not sure of what to do. Luckily, most of my patients were pretty much complaining of musculoskeletal problems, GERD, headaches and other very common ailments that I could manage.

One older woman had a very deformed ankle that she came to clinic for.  She told me (okay, she told the interpreter who then told me) that she had broken a bone in her leg last year and was in the hospital for 3 months while it set. It was obvious that the bone was not set correctly as it was now grossly deformed. The woman was in so much pain and could no longer work due to her leg. I asked Ellah what this woman’s options were in Kenya. Ellah said that all we could do was treat her pain. If we were in the US, this lady would be having orthopedic surgery. It made me so frustrated that there was not more we could do for this woman.

The three of us somehow managed to see all of the patients. Ellah congratulated me on my hard work and I told her that I was worried I did not do a great job. She told me that we were not only treating the patients physically, but also psychologically since we listen to their problems and we show them that we care about what they need.

I thanked Ellah for her kind words and felt a little bit better about my afternoon. Mama Joyce thanked me repeatedly and told me that I was very brave for staying at clinic without the rest of the LSU team.  I finally felt like I actually may have made a larger contribution than I initially realized and felt good about the work I did. I heard thunder in the distance and was glad clinic was over so we wouldn’t have to be in the rain. A single rain drop fell on the side of my face. I wiped it off with my hand.

It was a bird dropping. 

- Allison Cormier

February 8, 2013

WHITE WATER RAFTING/DEATH FLASHES BEFORE OUR EYES

            White Water Rafting on the Nile - sounds fun. Adventurous. Life changing. Peaceful even. It all started out pretty positive.  We missed the 16foot waterfall and ironically, it was all downhill from there.  Olow, our Ugandan native raft guide, led us on the “wild side” of the first rapid where we were flipped immediately in what we thought would be the time of our lives.  While previously flipping sounded fun and adventurous, it was in actuality death defying and terrifying.  Chancy, picture this, is being bobbed like an apple, trapped like a rat under the raft.  While she says she was under for a whole minute, it was probably more like 10-20 seconds.  She looked like a wet rag doll when we pulled her limp body back into the safety of the raft.  White as a ghost.  Silent as a monk.  Chancy’s silence was an ominous sign. She was pretty ter-ri-fied.  I had also been under the raft but pulled myself out from it and was tossed about as we rode the rest of the rapids out.  Thankfully, Olow was by my side to calm the panic attack that was happening.  These rapids were like nothing I’ve ever seen.  Honestly, after that first flip, Chancy and I considered switching to the safe raft. (Thankfully, we didn’t because in hindsight we had a great time and live to tell about it). 

            The second rapid we debated for about 30 minutes whether to take “the chicken line” (as Olow so detestably called it), the class 4 rapid or the class 5 rapid.  Well after much debate and trepidation, we requested the class 4.  Kyla, in her bossy little cute self, says says “LETS DO THE FIVE!!!” and pokes her oar at Chancy and stares her down saying “Chancy?” Chancy, not fully recovered from vomiting the Nile says - “No, Kyla.  I don’t wanna die again.”  Little did Kyla know, I was right behind Chancy shaking my head and wanting to go on a raft called “Kindergarten” – wishing it actually existed. We think we make it through.  We hear cheers and applause from the other 1% rafters in the background.  Well whatdya know? We flip again on the last rapid.  It’s another rollercoaster of death.  “PADDLES FORWARDS TEAMS, PADDLES FORWARDS! PADDLE HARD! PADDLE HARD! HOLD, HOLD!” …and we’re in the water again.  Meanwhile, while we are sucking on the Nile like fish, the other rafts went down the class 5 and came out dry and smiling.  That’s when we nicknamed ourselves “the unlucky 99%” because obviously we were not in the thriving 1%.  We got dragged throughout the water like ragdolls, pulled back into the boat, and we are exhausted, defeated, whipped.  We realize after we get back in the boat that Matt has ripped his pants from Kingdom Come. He was concerned that people saw more than they bargained for – Marcy assured him that everyone definitely did. We have met our match.  Chancy has now lost her left contact and cannot see. She was walking around like a pirate. I guess it was better that way – ignorance is bliss.

            We paddle to the next rapid where we have to walk around it on land since it’s a class 6.  (Yes, they have even more terrifying rapids than what we experienced). So as we are paddling to land, Olow is just a screaming at us to “PADDLE HARD, TEAM! PADDLE HARD! HARDER, HARDER!” Obviously I think we are headed straight for the class 6 and I am paddling my little heart out by this time.  The thought of a class 6 makes me sweat even now.  I’m freaking out.  I can hear it in the background calling me to my death.

            We reach land.  We get to walk near the class 6.  It’s terrible.  It’s as long as a football field and as scary as walking into a gladiator ring where you know you have a 50/50 chance of dying.  I won’t even get too close to it in fear of falling in. 

            We have one more rapid before lunch.  I’m the last to get back in the boat.  My hands are trembling.  We are immediately launched into the end of the class 6 rapid where it turns into a class 5.  We make it through!  This one was called “grave.” Surprise.  Surprise.  We rename ourselves the 1% due to our new found success.  Kyla is over there on the other side of the raft rowing like a champ.  She needs a 10 ft clearance just to get her stroke in.   

            Lunch: The pathway to lunch is up the hill where they have prepared a feast of chipatees (a fried flat bread), and a spread much like make your own tacos.  They have passionfruit juice at the end.  Once I got my glass,  I noticed there was dirt floating around in it.  I figured if the rapid didn’t kill me, this surely couldn’t.  I drank 2 glasses.  I looked over and everyone seemed to be having a great lunch.  Chancy looked a little road hard and hung up wet, but the break was really nice. 

            Back to the water: We somehow make it through the next series of rapids without flipping.  Making it through is so fun and exciting.  We ride the waves instead of drowning in them. 

            We knew it was too good to last.  At the very end, we flip yet again.  By this time, we’re used to it, or as used to it as we could get.  He asked us if we wanted to go big or go home.  We wanted to go home. Olow told us the last one is like 50/50. Half a chance we could flip, half a chance we won’t.  Stirling later says he was sending out positive energy that we would make it.  Well I was in the back of the raft countering that with my negative, pessimistic energy.  I knew it wasn’t  50/50, but more like 99/1 and that we were on the 99% of that .  It was over and under for us.  I’ve got my eyes closed the whole time until I open them and realize we are a good 10 feet perpendicular to the rapids. I hear Jason coming in hot above me and chancy.  He is literally catapulted off the raft, leaping over us, 10 feet in the air, stride in a runners sprint.  We’re hitting the water, and he’s not even gotten wet yet.  We rode the rest of the rapid out and stayed in the water for a good ways just floating until we got to the end. At this time, Andrew decided to be our tour guide and pointed out some interesting wild life on the river banks. Without his narration – our peaceful floating would not have been the same.  

            At the end, they cooked us kabobs and had cold beer for us.  They put together a slide show of each of the different groups’ pictures.  I’m not being biased when I say all of the groups are smiling and waving in their pictures while our group has the look of utter terror as we plunge to our death.  Kudos to Stirling, Matt, Jason and Andrew who went along with us and our nervousness.  (but in all honesty, I think they used us as a scapegoat because they too were terrified deep down inside).  It was a great day! If I was asked again to go the next day, I would say absolutely not.  But in a year, I might consider riding the rapids again.

Still Alive - Hannah Scott and Chancy Gulotta

A Second Home

From Thursday (we're trying to catch up now that we have internet!!):

For the first time since we have arrived in Kenya, I slept pretty soundly through the night. I only woke up once around 3 AM when it had begun to storm around. I’m hoping by next week, I’ll be able to sleep a full night even with any combination of animal sounds, monsoons, or people pumping water before dawn. It’s troublesome getting up before the sun because really – what can you do? I am also developing a personal vendetta against the rooster outside who insists on crowing every 5-6 minutes starting at 4:37 AM and the geckos that sound like a broken beeper that doesn’t turn off.

We ate our breakfasts and had our morning disease presentation in the gazebo this morning. It was a little muggy and cloudy outside, but the temperature is still quite nice. The gazebo is actually more like a giant hut, replete with giant thatched roof, concrete floors, and mismatched furniture. We all huddle together around the table and eat our PB & banana sandwiches and drink chai.  A few people have brought some mini speakers so we tend to have music playing the background at times, which also kind of brings a little bit of the US to our African experience.

Clinic today was in a village called Masango. It was “near” in Africa terms, which means over one hour away. On the drive over, Masango seems to be a more developed and populated area than some of the other places we have been. There were lots of shops and gas stations along the way. The roads were generally well-paved and we saw lots of schools (with playgrounds!). Wherever we seem to go, people – 99% of the time hordes of children – come running out to wave at us and yell, “Muzungu!” (def: foreigner) or “How are you!” (not an actual question; usually said in lieu of hello). I feel as my arms will fall off, but I cannot in good conscience, willingly not wave back to a child.

When we arrived to our destination site, we were in one little building so many of us had to set up tables and chairs outside. Shortly after arriving, this wizened old lady named Judith came inside. She said hello to all of us as she clasped our hands individually and kissed them, thanking God and us for being there today. She is a tiny little lady with a huge smile and some missing teeth, but so much energy and sweetness. She brought out a drum and rounded up some children to sing a welcome song for us. Both she and Ann, one of our favorite translators, led the song. It was a wonderful opening to the day.

Kenyans are some of the most welcoming people I have encountered in the world. In many different cities and villages all over we have met people who have tried their hardest to make Kenya a second home to us, whether it was at the hotel outside of Nairobi or here at Icodei. They have gone out of their way to make our weeks here as comfortable as possible, whether it is cooking us meat, when meat is quite a luxury, or whether it is putting a light bulb in our room so that we can see in the dark.  Bishop Ruben and Mama Betty have truly become surrogate parents to us all!

As has been the case, surprisingly enough, we encountered lots of chronic diseases today, like reflux and angina. Lots of back pain. I remember taking a course in college where we read an article issued by WHO about the changing face of disease in developing countries – and how chronic diseases that we associate with the Western world are rising in incidence and even sometimes surpass classic tropical diseases. There are a lot of people who smoke and eat a lot more unhealthy foods (yay intercontinental trade), so a lot of what we are seeing are patients with problems very similar to what we see back in Louisiana. One patient of note that I saw today was a lady presenting with left sided burning and tingling pain that apparently started one year before when she had neck surgery. It seems like the surgeons must have injured a nerve at the time, but no one has seen or treated her pain. Unfortunately, we are limited with what medicines we have and had to give her the name of an affordable medicine that she could hopefully find at the local chemist (pharmacy). This is what seems to be the most frustrating aspect of this trip: knowing all the resources we have in the world to diagnose disease and the medicines to treat them, but then operating in a resource-scare area, with only my brain and stethoscope to try to figure it all out. That’s a battle in itself. 

- Monika Kumar

Little Girl Blessed

Tuesday Clinic

The first time we met Blessed we thought she was dead. Her mother brought her into clinic and sat down on the bench next to our group and patiently waited her turn. Her seven-week-old baby, Blessed, was wrapped in numerous layers on her lap. She patiently waved over our translator, Ellah a Kenyan physician who was helping translate for us. Ellah calmly looks over to us and states, “It’s an emergency.” Side note: all Kenyans seem to speak impossibly soft and are difficult for loud Americans to hear.

After Ellah states that it’s an emergency, we come over and see this tiny infant looking blankly into the air. After a few agonizing seconds, she blinks. Feeling her forehead, she is burning up. Dr. Walter Scott, a pediatrician was called over. He states that she is having a seizure and feeling her head quickly determines it’s a febrile seizure.  While we spend time worrying about how to stop the seizure, he’s worrying about the cause of the seizure. Her mother begins to unwrap the multiple layers that surround the child, which seems to grow smaller the more clothing/blankets she takes off. Finally, we see her thin body and are able to examine her. Her pulse is racing and she is using accessory muscles to breath. Wheezing is heard over her chest. She probably has pneumonia and needs more than we are able to give her. Dr. Scott immediately orders a shot of antibiotics to give to her before we transport her to the hospital.

            The shot is brought over and her leg looks too small to give a shot. It is so thin. Blessed’s mother states that she has been feeling like this for one month and has been seen and treated at the local hospital without improvement. She couldn’t afford to go back. Three of us got into the van to bring her to the local hospital while Ellah stayed behind but called the hospital and told them to expect us.

            We arrived at the hospital and men with guns opened the gates to the parking lot. We got off the bus and followed our translator to a room full of five women who were completely confused by our presence. The nurses here are on strike.  Evidently, a different civil service group goes on strike every week according to the locals. We then go to the ER check in and jump to the front of the line. Robert was there and said he had just gotten off the phone with Ellah and was waiting for us. He briefly looked at the child, did an exam, and spoke with the mother (Lillian) and decided to admit the child for work up and treatment for possible pneumonia. We tried to pay ahead of time but we told to wait until discharge. Robert was told numerous times to take good care of Lillian and baby Blessed and that we would pay.

            We haven’t been able to get back to the hospital to check on baby Blessed and pay the hospital bill, but Mama Joyce, the medical coordinator here, has been in contact with Lillian. We hope to check up on them soon and see the progress Blessed has made. This is just one example of the times when you feel like you really made a difference. We hope to have many more in our remaining 2 weeks of clinic. 

Anna Craig

Learning to Improvise

Our first day in clinic was Tuesday outside of Bungoma, Kenya. Our bus ride was only about 30 minutes to this particular clinic where we ended up seeing 138 patients!! Our medical team right now consists of 19 medical students, 1 cRNA, and 2 attending physicians. We work in teams of 2 medical students + a translator. Once we see a patient and develop a plan, we will present it to our attending…just as we do in the States. 

Although we see tropical diseases that we would rarely, if ever, see in the U.S., we still see back pain, constipation, ear infections, pneumonia, etc that we see back home. The consensus is that we’ve learned a tremendous amount about medicine, each other, and ourselves in just one week.

As you can imagine, treating patients in a Developing country requires a fair amount of improvisation. We have all had some frustrating moments with patients when we want to do so much more…in the U.S. we would send them for a much needed surgery. But we’ll blog more about those cases later!

On Tuesday, I happened to be seated closest to the door, which made my lap the perfect target for a mother to place her seizing child. I was working with Ashley that day and we were already seeing another patient, so it took me by surprise when I suddenly had a small child in my lap who was convulsing. I took the 4-yr-old Kenyan girl to the front of our clinic where we have the medications and where I could have a few more experienced hands/eyes on deck.  I kept her in my lap, but tried to keep her on her side while we administered medical care. She stopped seizing within about 30 seconds. Her temperature was 104.0 and we began to hunt for the source of the infection. She had coarse breath sounds and was moving very little air. Although we would have loved to admit her to the hospital and give her a full work-up, our resources were limited. We administered IV antibiotics, gave her acetaminophen, watched her for a while, sent her home with antibiotics and begged her mother to take her to the Bungoma District Hospital.  In these situations we always wish we could do more, wish we had more equipment with us to provide better medical care. Each year we think of ways to improve what we’re doing in Kenya. Ways we can set up a Global Health program with our friends at Icodei that will change medicine in Kenya. We’ve got a long way to go, but we certainly are trying!

It’s not just clinic tables/equipment that require improvisation. After my patient with the febrile seizures was treated, I required a new pair of pants. (At the end of her seizure, she released her bowels on my scrub bottoms).  No one thought to bring an extra pair of pants, but fortunately Matt H. allowed me to use his jacket as a skirt. Fun times. Pictures to come!

Mary Katherine