Change of Plans....

So, it appears that I’ll be ending my “African Adventure” a little early this time around…..The upcoming Referendum, which is basically a vote to implement a new Kenyan Constitution, is creating some concern about a possible repeat of the 2008 election which ended in civil unrest for several months. The “Yes” Camp, which includes the government and most of the media support here in Kenya are neck and neck with the “No” Camp, which includes the conservative majority. For the last couple of weeks you can spot supporters of either camp by the hat they are wearing. Red hats are “No” voters, while Green hats are voting “Yes”. It seems to be a very close race, which as everyone knows means the Losing party will be that much more upset. Fortunately, the majority of people are presuming that Tenwek will not be affected following the vote and that there is a really small chance of a recurrence of the 2008 violence. However, following that 08’ election, some people were apparently stuck in Kenya for several months before the violence calmed down enough to get home. Thus, since I would only be here another week following the vote, I (with Rachel’s FULL support) decided to move my flight up a couple of days to get out of Nairobi before the vote. So, long story short, I’ll be coming home in a week!
It is bittersweet because I miss everyone at home but also am enjoying Tenewk so much. Livingston, which is the GuestHouse Manager who was here for both of our trips in the 90’s, made Hon’s Eggless “Wacky Cake” for everyone the other night. I had a piece and it was pretty good. Unfortunately though, I still like his "salty chips" better (sorry Ray). Oh, and the guys of the guesthouse made a pack last week to not shave until we leave; so the GuestHouse is full of a bunch of scraggly looking guys….unfortunately, my “beard” leaves much to be desired. I’m sure I’ll shave it before anyone in the States gets to see it (Don’t let Daddy worry). My friend and next door roommate, Robbie, left this morning. He is 4th year med student at Emory and I was very sad to see him go. We were both on the Medicine Ward together and he always had a nice pot of coffee to share every morning before we left for rounds. I guess I’ll have to figure out the right Kenyan Coffee proportions for the remainder of my trip. Robbie, if you're reading this; don't worry, I wasn't JUST your friend because you made good coffee, you also shared your English Muffins too....just kidding. I am currently fighting a brutal cold that has my eyes and nose watering all day; everytime I pull my stethoscope out of my pocket about 10 used tissues fall out…..really gross. But, that is what I get for playing with every cute Kenyan kid that I pass in the hospital. I just can’t help but pick each one up and toss them into the air. I’m sure all of their parents think I’m crazy, but the children love it. Sometimes when I’m really busy, I have to go around the other side of the Chapel so I don’t pass the Pediatric ward and have 15 little kids running (and wheeling) out to me to play. Their smiles are so fun though and it makes me smile to see them so happy despite most of their terrible conditions.
As far as the medical stuff goes, I’m still learning a lot. I’ve now done about 5-6 lumbar punctures; enough so that I can keep a steady hand when I’m entering the spinal space. The interns here are so good at doing LP's (b/c of all of the bacterial meningitis) that they could probably do it blind. Thus, they are more than happy to let me try whenever one needs to be done. I’ve also got to practice a lot of Arterial Blood Gases (ABG’s). I started off pretty good at those, but I’ve missed my last couple and needed Doug to help me out. Everyone is really patient here and lets me try as much as I want to. Today I had to give up on one ABG after trying twice on this “hysterical” patient. Although she was sick, she was pretty funny. She was singing and kept trying to hug me and dance while I was trying to stick her radial artery. We think she has some kind of encephalopathy (Hypertensive or Uremic). I just kept saying “Asanti”, which means Thank-you and she would calm down long enough for me to try again. But finally I gave up since she was constantly dancing and I wasn’t getting anywhere. Unlike the first half of my trip, this last week has seen a bunch more lives being saved than lost. It always is nice to be able to help someone who comes in so sick just by finding the right medicine that will do it for them. They are so thankful and appreciative even though all we did was provide them with a medication that is completely free at all Wal-Marts across the U.S. Anyway, before I get sucked into talking about all the medical stuff I'll stop b/c I only got a few hours of sleep last night sicne I was on call so I think I’ll wrap this blog up and take to my bed. I can’t wait to see everyone soon, I should be getting home on a Tuesday night. See yall soon.

Call nights in Africa

Sorry its been a while since my last “blog” but I’ve been trying to stay as busy as possible to keep from missing Ray and everyone else at home. But, don’t worry, I have plenty of friends here that are really nice. Dolly and her husband Vince even found the British Open on the satellite TV so I could watch Tiger after they heard I was sad I was missing it! Dolly even made a huge thing of popcorn for everyone. (The TV is a projection screen that is set up in the basement floor of the new addition on the guesthouse. It usually is used for movies only, but they bought a two month TV deal so that everyone could watch the World Cup). Hon, you will appreciate this……I wasn’t sure if I mentioned it last time, but a new couple came in last week and the husband will be the Resident with me for the next month. His name is Doug Johnson, and he is a resident in Internal Medicine at Duke. His wife, Sarah, is with him and is a physical therapist. Its interesting b/c he went to Med School at UAB and his parents live down the street from us in Bluff Park! His Dad is a Pulmonologist at UAB. He also is good friends with Tim Heacock from our yearly NC beach trip. Its crazy to go all the way across the world and be working with someone who lives less than 5 minutes from where I grew up (and now live) in Bluff Park. Anyway, since my last blog, I have taken call a few more times and had several new patients admitted to me on the ward. On Friday, my call started with a comatose 31-week pregnant patient who came in after apparent seizure activity. Since she was not HTN, didn’t have protein in her urine, and had normal platelets and Liver Function Tests, the OB team didn’t believe she had Eclampsia or HELLP syndrome and so they admitted her to us?? By the time I got there they were already admitting her to the ICU b/c her pupils were blows. According to the OB team, first priority was the mother b/c nobody knew how long she had been seizing and the baby’s prognosis was already extremely poor. Anyway, right when she arrived in the ICU she stopped breathing! The worst part was, that she stopped breathing right in front of me and none of my upper levels had arrived yet. Luckily there were two nurses there to help me, as I started chest compressions and they began to bag her. A few minutes later the Kenyan intern, Damaris, came in and we intubated the patient and got ready for the defibrillator. She initially regained her pulse and was stable for about 30 minutes until crashing again. This time the CPR code lasted for about 45 minutes (I was completely soaked with sweat by the end of the code from doing chest compressions…..and Rachel knows that I don’t sweat that much normally!) before my Attending said that we had done all we could do…..she and her baby had passed. It’s very hard not to get discouraged and frustrated having these kinds of results so often here, and I’m quickly learning how fortunate we are in the States to have the kind of care we have. In Kenya, most patients do not seek any kind of medical care until the last unbearable moment. In this patient’s case, she didn’t seek care until her family found her comatose and her baby had most probably already passed. But I guess, if we had to walk 3 hours on dirt roads to receive medical care, similar results would occur in the U.S.. Another sad tradition in Kenya is to never bury a deceased baby and mom together. Thus, the morgue had to remove the baby so the two could be buried next to each other. I’m just glad I didn’t have to be there for that part…too sad. But fortunately, even though I have experienced a lot of deaths, there are far more stories where patient’s have been saved and sent home! On Monday, I had a previously healthy 25 year old guy come in who was fine the week before but during a hospitalization at another hospital he developed seizures, tremors, confusion, multiple lower extremity joint pain, and ascending weakness. They didn’t know what to do, so they sent him to Tenwek. Even though his wife said he was walking normally last week, by the time I was examining him he was paralyzed from his toes to his hips. He also had a severe intentional tremor and was so confused all he could stutter was, “I think I should be fine soon.” With no past medical records (or any records at all) a lot of the time we have to treat empirically w/o having the exact diagnosis. In this patients case, his differential consisted of Guillan-Barre (classic for ascending weakness), Transverse Myelitis (usually seen in MS and needs MRI to dx), Lupus (need ANA or anti-smith antibody titers to dx, which we don’t have), Lyme disease, TB meningitis, cerebral malaria, polio, typhoid fever, and bacterial meningitis. Since diagnostic and treatment resources are limited, we had to really have faith that the treatment we choose is most likely to cover the disease at hand. The first thing we started him on was IV steroids to hopefully stop any autoimmune/inflammatory/infectious process causing his weakness. Then we began daily IV ceftriaxone (to cover deadly meningitis), RHZE (TB treatment), and a dose of quinine. He was so nice and scared, which made me want to help him so much more. Luckily, two days later I finally got him to move his big toe!! Then later that day he was using his Plantar Flexor muscles (like stepping on the accelerator). Yesterday, he was able to pick both legs off of his bed! With his LE strength improvements, also came improvements in his tremor and confusion. Today he stood up for the first time in 2 weeks and was speaking almost back to normal. The exact diagnosis is unknown, but I believe the most likely dx was Transverse myelitis, which can be caused by a host of viruses.
Another success story included a woman who came in the other day after being gored by a cow’s horn! It was a very serious puncture and so she was rushed to surgery. A fellow resident in the Guesthouse, Vince from NY, was the Surgeon on call who opened her up and reported that the cow’s horn had punctured her intestines in an “accordion-like” distribution, producing 5 holes in need of closure. During the procedure, Vince pulled out a tapeworm that was over 50 feet long! Talk about an incidental finding!
Other than that I’ve had a few more interesting cases, which include an extremely nice 50 year old male with osteomylitis, a 20 year old boy with (what we think is..) Osler-Weber Rendu disease (a rare Autosomal dominant disease where some of your blood vessels don’t form correctly and you have recurrent nose bleeds, AVMs, and other bleeds). This kid had a hemoglobin of 3.0 (normal is >13.5) and was walking around w/o complaining. In U.S. we freak out if Hgb is <7. I also had a case of Infective Endocarditis, which is an infection that spreads to the valves of the heart, and requires 4-6 weeks of antibiotics to cure (the patient even had the classic splinter hemorrhages of his fingernails). Another patient had a spontaneous pneumothorax that we believe was caused by TB. His CXR and physical exam were crazy. The collapsed lung had pulled his entire mediastinum (which contains the heart) over to the right side of his chest. Thus, to listen to his heart, you have to place the stethoscope over the right chest. Very cool! My last patient was a 70 year old man who presented with several weeks of “severe sickness” and anuria (no urine output). On lab check, his Creatinine was elevated to over 35 (normal is 1.0). Again, in US we freak if it is over 5. It turns out he had such a large prostate he couldn’t pass any urine and so he got bilateral hydronephrosis and damage to both kidneys. We finally got a catheter through the obstruction and drained a ton of urine. He immediately looked at us like we had just cured cancer and hopped out of bed feeling like a new man! He was so thankful, but he didn’t realize that all we did was catheterize him and drain his urine. We sent him home later with some BPH meds.
Saturday afternoon was nice because most of the young people (including myself) were off and we had a chance to hang out. We played a lot of ping pong and a new game called Walley-Ball, which is volleyball played inside a racket-ball court. It was a lot of fun. Then we watched the british open, and I crashed around 9:30 since I only got 3-4 hours of sleep the night before (call=night). I went to Church this morning and got home and had 9 missed calls from Rachel! I was so worried. I finally got through and discovered that our House Alarm had gone off around 4:15 in the AM while she was asleep. She called my house and my Dad ran over to check everything out and convinced her it was safe to leave the room. Probably a false alarm….but of course something like that happens while I’m over here in Africa. Anyway, I’m glad she’s o.k. Well, my computer is about to die so I will end this ever-long “Blog”. Hon, I hope your happy because I just realized this dad-gum blog is like 2.5 pages! Well, I miss everyone and look forward to seeing you soon. Anna, tell Janie-Bird I said hello.

Missing Rachel

Well, I finally figured out how to access the blog without Rachel's help. As most of you know by now, Rachel made it safely back home to Bluff Park leaving me all alone here in Kenya. After dropping her off at the airport, I thought I was doing pretty good until I got back to our cozy little room and saw her empty little backpack sitting on her side of the bed. I can't believe its already been two weeks. It seems like it was just yesterday that Mr. and Mrs. Vinson were knocking on our back door in Bluff Park to drive us to the airport. I am SO glad we got Rachel home safely, and without even getting sick once (that is much more of an accomplishment than you realize). Anyway, to get my mind off Ray's departure I decided to take her advice and be extra social around the Guesthouse. So the day after she left me and 5 other young med students made the 4 hour round-trip hike to the top of the mountain surrounding Tenwek. The views from the top were beautiful. Although most of the others probably didn't think so, the most fun part was that about half of the way up the clouds rolled in and completely drenched us! We had absolutely no where to take cover and so we finally gave up and continued up in our soaked clothes. That night the two long term missionaries that stay at the Guesthouse threw a World Cup Final party and cooked cupckakes and brownies for everyone (and popcorn for me). It was a good game but was hard to stay up for since it didn't end until midnight over here. The next day was a busy day in the Hospital because I was on call. My cryptococcal meningitis patient finally received his last dose of Amphotericin B. This was an accomplishment b/c half way through his treatment the entire region ran out of AMpho B and it took an entire week for the replacement to get shipped in. Lunch was awesome at the Stanfields house; we had Chicken Pot Pie, Homemade biscuits, and green beans (don't worry Hon and Ray, it didn't have eggs)! After lunch things got pretty busy. Our Tetanus patient (who has severe case of "Lock Jaw) started seizing and gasping for breaths. The resident and I were the first ones there, so I got to "schock" him, while Doug administered CPR. Unfortunately, the patient needed immediate intubation because his Tetanus had caused him to have Larnyngeal spasms, but this was impossible because his Jaw muscle was "locked" up. Its impossible to get his mouth open far enough to even get a straw through. We were about to perform an emergency tracheostomy when his pulse finally disappeared and after 10 minutes of coding him, he passed away. It was really sad, he was only 26 years old. Apparently mortality from Tetanus is fairly common around here and we were told that the Massai's will intentionally knock out their front teeth so that they can be fed through a straw in case they develop "lock jaw" like our patient. Its so funny how the Kenyans tell these stories so "matter of factly" like its no big deal to knock out your front teeth to have insurance against future "lock jaw". By the time we were pronouning this patient, we were frantically rushed up one floor to a patient with TB and alcoholic DTs who was also seizing and not breathing. We ran up there and I bagged him while others did Chest compressions. We finally got him intubated (no "lock jaw" thankfully) and I continued pumping air into his lungs while we administered other drugs to try and get his Oxygen saturation up. But of course this is Africa so something has to go wrong. Whenever we tried to swap the patient to the ventilator his O2 sats dropped into the deadly low zone. Long story short the 3 ventilators in the whole ICU were malfunctioning at the same time, so we had to move the entire ICU down to two floors to the surgery recovery room to keep our patient (and three others) alive. As were were leaving the ICU, I hung a piece of paper on the door saying, "ICU moved down to Surgery Recovery Room". Very official of course. The rest of the night went slightly better, and I am currently trying to figure out a case of ascending paralysis (thats not Guillan-Barre). Unfortunately, diagnosing diseases in Kenya is so much harder b/c we don't have 10% of the available tests we have in the U.S. Well, I just wanted to see if I could post a blog and didn't realize how long it was getting. Sorry for anyone who reads this and gets bored by the medical stuff (Alex and Susan probablty quit reading after the first 3 sentences). Thanks to everyone for your prayers and hopefully I'll have some pictures to add soon (I'll have to ask Rachel how to do that). How do you end these things anyway??

Final Days at Tenwek

I guess I haven't written since Monday. Monday seems like ages ago, and yet, I feel like this week has flown by. I have one more full day here at Tenwek and I think that I feel a bit numb. I don't want to think about leaving this place, the people, and especially Wiley. The past few days I have sort of been in a routine here at Tenwek. Each morning I wake up and make coffee and then everyone in the guesthouse eats breakfast together, which usually consists of cereal or toasted banana bread. My midmorning has consisted of different activities. On Tuesday, I had chai at Mrs. Manchester's house. She is one of the long term missionaries and she has tea every week for the wives/family of doctors that have come to Tenwek. I knew most of the women that were living in the guesthouse, but it was a great way to meet some of the long term missionary wives that are not in the medical field. We talked about the hospital and how long she has been in Africa. We talked a little bit about the new constitution that is about to be voted on. That seems to be a hot topic here right now. I think the vote for the consitution will be on August 4th. Hopefully it will be peaceful. I think the main sources of conflict are over the topics of abortion, land rights and recognizing the muslim courts. I am not educated enough on the subject to even summarize the issue, but there are several good articles that come up if you google the subject. Anyway, another morning I went on a walk around Tenwek with Carolyn. We did several loops around the hospital grounds. It was the perfect weather for a walk. I got a little winded walking up some of the hills. I kept telling myself that it was the altitude, but that might have been wishful thinking. Another morning I had chai with the house help. I found out that it is rude to decline an offer to have chai (of course, I discovered this after I had already declined it once before), so I have had a lot of chai while i have been here. Around 11am each day Taylor and I would go to the nursery. We were able to be of more help this week since there were 30 babies born over the weekend. I was able to hold several babies that were crying in an attempt to calm them down. While the babies were so cute and I enjoyed this task, I learned early on that wearing old clothes is a must. None of the babies had diapers on, so the first time I held a baby it used the bathroom on me! I guess i shouldn't complain though. Taylor's baby did more than use the bathroom on her, so I felt like I got out of there pretty lucky! All kidding aside, the nursery was definitely one of the highlights of my week. I really enjoyed meeting all of the nurses up there. I felt like I wasn't much help, but they were so welcoming and appreciative of what we did.
Each day at 1pm Wiley and I would eat lunch together along with the other people staying in the guesthouse. One day we ate in the canteen at the hospital, another time we ate at the guesthouse and then two days we were able to eat lunch at some of the full time missionary and staff houses. I really enjoyed those lunches because we were able to get a better perspective of what it is like to be in missions full time and to learn more about the hospital. One of the families that we ate with have been here for 8 months and will be at Tenwek for 2 years. They are planning to open up a teaching hospital with two other families at Tenwek somewhere else in Africa after their two years here.
In the afternoons on Tues, Wed, and Thursday I was able to go to a nearby orphanage with several other girls at Tenwek. The orphanage was called Umojo Children's Home and houses about 40 children of all ages. The time that I was able to spend at the orphanage was definitely the highlight of the trip. As soon as we pulled up to the orphanage the kids bombarded the car. They were so excited to have visitors that were there to spend time with them. The first day that we were there, we brought jump ropes and hoola hoops which they loved. We didn't bring enough for everyone, so we had to get creative with some games we could play. I had to pull games we played in elementary school from the recesses of my memory. Ring around the Rosy was a huge success. We played that at least 20 times. I tried
duck duck goose, but I couldn't really communicate the rules of the game very well. They would all just chase me whenever I said "goose ".
I have included some pictures of the children at the orphanage. I tried to import a video but I don't think it worked. The second and third day it rained, so we were forced to go inside and we made bracelets and colored. It turned out to be such a blessing, because we were able to really get to talk to some of the older children who sometimes get overlooked when playing games outside because the younger children get more of the attention. I talked with Joy, Mercy and Susan. They each spoke very good English and were 14 years old. Mercy was so inquisitive. She wanted to know everything about the US and the states that we came from. She said that she wants to be a pilot when she grows up. They all shared their favorite bible verses with us which they each had memorized and we were able to share ours with them. At the end of our time with them each day they would sing songs for us and would then ask us to sing a song as well. We weren't really prepared for that the first day, but we quickly learned that it would be routine for us to at least sing one song. I definitely enjoyed the time that I spent with these children, but I also greatly enjoyed getting to meet Joseph, the founder of the orphanage. He is such an amazing person. I was so encouraged by him because he was evidence of God at work in this world. He is just an ordinary person that saw a need and met it. There were so many obstacles in his way and so many reasons why he shouldn't take care of those children, but he was obedient to God's call and has seen God take care of him and these children over the past 7 years. It is amazing that 40 children now have hope for the future because Joseph was obedient. I was also encouraged ny how much Joseph depended on and trusted in God to provide for the orphanage. I was reminded about how often I deceive myself in thinking that I am in control and struggle with self sufficiency. I was sad to leave the orphanage, but I hope and trust that Thursday was not the last time that I would see Joseph and the children.
On Friday morning I really had no plans for the day. I thought I would pack and update the blog, but Patsy came to my room and asked if I would like to see a surgery. I had never seen one before, so I said yes. Her husband is an orthopedic surgeon, so we were able to watch one of his surgeries. I was not sure how I was going to react. I have never really seen someone cut open before and I was nervous that I might faint. I have never fainted either so I didn't know what I would feel like if that was about to happen. Thankfully I was okay though. The operation was to put a metal plate into someone's broken arm. We stayed in surgery for about 20 minutes and then headed back to the guesthouse. I was telling Taylor a out my experience and while we were talking her dad walked up and told us he would be performing a c section at 2pm if we wanted to watch. Since i was pretty confident i wouldn't faint I said yes. It end up being more like 5pm before the c section occurred because he had to perform a surgery to tie someone's tubes. We were able to watch that surgery as well which was interesting. I was more focused on the patient than the actual surgery. They only gave her local anesthesia for that surgery which stressed me out. She looked so scared and i could certainly sympathize, since i have a lot of experience in being afraid. I tried to hold her hand throughout the surgery, but I'm not surer if she really liked me doing that. Thankfully it was over quickly. The c section was awesome as well. The mother had been pregnant 5 times before and none of the babies had survived, so it made this delivery extra special. I felt like clapping or crying when we heard the babies first cry. I will say that they are pretty rough with the baby when they are pulling it out! I am about to post this bc i am about to board the plane. I will try to update more later.