The week in snaps

This is a nice kite I got in the mail from my friend Molly last week. Much nicer than the prison kites. And this week, we'd have to replace "head" with "lower extremity." People with foot, knee, and hip pain have been limping in all week. So I went on a bit of x-ray binge. After being so conservative with x-ray ordering in my last clinic (since my patients usually were paying for all of their expenses out of pocket), it's nice to have that diagnostic tool available...plus it makes me feel like I am "doing something" for their pain other than just ordering ibuprofen, giving them sheets of exercises, and handing them tissues when they are in tears due to pain. Occasionally, the x-rays are actually helpful.

I spend a fair bit of time thinking about freedom since I've been working in a correctional facility. On my way out of work, I walk through the parking lot to my car. Just 50 feet away, the inmates are returning their living units. It kind of amazes me that a simple chain linked fence separates me from all of the prisoners. Not because I feel threatened, but just because of thinking in terms of probability. I often wonder about my chances of being on the other side of that fence.

Working in prison makes me feel very grateful to have a nice family, a good education, and a La Quinta to come home to at night. This month, I have appreciated the fine Christmas decorations in my hotel.



Maybe I should have put up some garland in the prison clinic? One offender told me it was her first Christmas away from her kids, and she cries when she hears Jingle Bells. Some people have "an old number," that is, their department of corrections number has 5 digits instead of 6 and starts in the 50,000's. Some of those folks have spent their lives in and out of prison, while others have been locked up for a long time. One delightfully cheerful and funny patient today told me she been in was diagnosed with hypertension when she got to prison. When I asked her how long she'd be in, she replied 22 years! That's a lot of prison Christmases.



This beautiful tree would have fit right in at my tacky Holiday party last weekend!



Matt and I with our ice sculpture.

Can I take your order?

I've always thought I learned a lot about my current career during my days as a young waitress at Bob Evans. Basically, people don't like to be kept waiting, they appreciate when you are nice to them and they expect you to get them what they want. I used to have nightmares about having tables of people that I forgot about. On occasion, I have similar dreams about patients being left in the exam room while I run late. Ironically, now I spend lots of time counseling about the side effects of the products I used to push: country fried steak and french silk pie. I may not wear a blue apron and dowdy clip-on tie anymore, but I still have to provide plenty of customer service. And as a chocolate heart, I can find it hard to say no to things that seem like no big deal "on the streets."

Stuff for which people have requested I write medical orders:
A snack
A release from wearing her bra (she had shingles...and bras are required by the department of corrections...although wearing two bras does not require an order)
A lower bunk bed
A release from a previous lower bunk bed restriction
An extra pillow and blanket (for a prison aerobic teacher with an injured meniscus)
To cancel her "Pueblo healthy living diet" and then to reorder the diet (by the same offender in the same week)
An order to move back to a living unit close to the "chow hall" (for her bad arthritis)
An order to prohibit working more than 4 hrs/day
An order to get rid of the fruit cocktail on a diabetic food tray
An EKG for my boss who was having chest pain

Lockdowns and Shakedowns

I enjoyed a lighter patient load at prison this week due in part to the usual stuff--patients canceling or no-showing, for which they are charged $3. However, a few patients were also cancelled as a result of a lockdown on Wednesday afternoon. Apparently when fights break out or there is some sort of mayhem, the "shift commander" (boss of daily operations) issues a lockdown, and the offenders must stay where ever they are until it is clear. In this instance, two women from unit 2 got into a brawl. I guess there was quite a weight class differential because when they brought up the ladies for an "anatomical" (full body nursing assessment in the medical clinic), the lightweight was missing a chunk of hair and had some abrasions, while the heavyweight contender didn't have a scratch. I hear of a few catfights in the women's prison, but the serious fights happen in the men's prison. These can have fatal outcomes.

When prisoners break rules or get in trouble, depending on the seriousness of the offense, they are brought to the "seg" unit. In this area, they are in their cells for 23 hrs/day. I made a trip to seg in my first week at prison to accompany our nurse practitioner as she gave a breast cancer awareness and self breast exam lecture. (Nevermind that teaching self breast exams is a USPSTF category "D"...the prisoners seem to really enjoy health education.) Anyway, imagine about 20 prisoners trying to watch this talk while looking through the 5 inch wide windows on their cell doors. I had to walk around with the self breast exam poster to each of their cells so they could take a quick look. The seg cells do have a small window to the outside world, which I think would preserve my sanity. Often as I leave the prison at night, I see prisoners in the medication line adjacent to seg signing to their friends who are locked up.

By some stroke of luck, I am on a list serve for a men's prison and get emails with the daily "incident report." These contain reports by officers detailing a wide range of topics --from unruly prisoner behavior to malfunctioning equipment on the campus. These objective descriptions can be quite hysterical at times. ("I, Officer H, witnessed offender #(insert 5-6 digit number here) place a brick of cheese in the kitchen on the underside of a metal cart. I later asked him what was in his pocket and located the brick of cheese.") Many of the reports have to do with illegal tattoo equipment seized during searches and shakedowns. I am still trying to learn what a "shakedown" is, but I think it is a cell search after a piece of contraband is found. Apparently, you can dismantle a radio and use it as a tattooing machine. Don't expect me to come home for Christmas with "prison doc" with a heart around it on my bicep.

Pleasantville

I had a very pleasant day at the prison today. It's amazing what having a few motivated, reasonable patients on my schedule will do for my job satisfaction. Instead of copping an attitude when I declined her request for "bottom bunk restriction," my anorexic patient with a history of a controlled seizure disorder actually thanked me for my "thorough evaluation." (DOC has pretty strict criteria regarding who can have a lower bunk because EVERYONE wants one. She didn't qualify.) I also had a good visit with an diabetic amputee whose sugars are much improved since tweaking her insulin regimen almost weekly over the past 2 months. She also said she was feeling much happier as a result of achieving better diabetes control, so that was encouraging. In the afternoon, I saw a few ladies who were eager to manage their hypertension and high cholesterol. One lady excitedly told me she had lost 40 pounds and recently had gotten her cosmetology license, both of which had improved her confidence. (I REALLY need a hair cut, but don't think I'm ready to have the inmates tend my tresses...yet)

To top things off, I found out about 6 of my requests for specialist consults or imaging studies had been approved (including a few MRIs I didn't think had a chance). It's like a Christmas miracle!

Could that breakfast burrito with Pueblo green chili have been just the ticket to start my day off right? FYI the chili is both a pepper and a type of stew/gravy used to smother sandwiches ("sloppers"), recently featured on Food Wars. I can't say they look pretty, but the taste is growing on me.

http://www.youtube.com/watch?v=h49_G5JWejc

Livin' La Vida Pueblo

While working in Pueblo four days a week might not have been exactly what I had in mind for my first job in Colorado, I am enjoying it. Who wouldn't love a piping hot Belgian waffle every morning? And who wouldn't want to drive 2 hrs south on Monday morning at 5:30 am to enjoy one? Ok, probably next to no one. The delightful waffles are the high point of the Pueblo breakfast as the case may be. Tomorrow is "Dress Down and Breakfast Burrito Day," and you can be sure I have pre-ordered my breakfast burrito. They apparently come with something called "Pueblo green chili," a local treat I am eager to try. I asked someone how the prison guards could dress down and was informed they can wear jeans with their prison uniform shirts. (Furthermore, I got a mass email stating, "you may dress down but you still must act like a professional." Thanks for the clarification.) I will be sticking to dress clothes.


My evenings in Pueblo are simple, but I really haven't gotten too bored. Between trips to Target and the Dollar Tree, the treadmill, knitting projects, The Girl Who Kicked the Hornet's Nest, and dinners with a few new nurse friends, I have managed to stay occupied. One night I came upon this sign outside the La Quinta conference room:


I peeked in the class room and saw a big "Join the NRA Today!" poster. Although I didn't attend that time, you never know after a few more months in Pueblo...A nurse reminded me last week that "this is a red state." I reminded her that I moved to the blue part.

Pueblo's major employers historically were the steel mill and the state mental hospital, formerly known as Colorado State Insane Asylum, established in 1879. A city of about 100,000, Pueblo boasts a downtown River Walk and two Walmarts! If that wasn't exciting enough, I am pleased to let you know it is located in a "banana belt," which is a region that enjoys warmer weather than the surrounding area, especially in winter, apparently. Today was sunny and 50, so I believe it's true.

I'll take two tickets to paradise....I mean Pueblo.

Making a run for it

An excerpt from a prison staff email:

"Exercising on your lunch hour can offer many health benefits and is a wonderful way to eliminate stress. If your chosen exercise is running, then please notify the Main Entry staff BEFORE you run out of the parking lot and onto the roadway. Seeing someone running out of the parking lot tends to cause stress on the staff members who are manning the armed posts."

I think I'll save my running for the La Quinta treadmill after work.

Wearing Thin

Perhaps it is the six weeks of driving to Pueblo and lugging my stuff in and out of the hotel or maybe it's the ever growing number of chronic pain patients on my schedule, but this week is wearing on me. I'm seeing about 14 patients a day, which pales in comparison to the 22+ I'll see if I take a job in a Denver community health center. The bottomless basket of charts "to review" is a welcome relief from the patient visits at the end of the day. And tomorrow I have to see my least favorite patient: a 40 something yr old who is convinced something is seriously wrong with her and derails all of my attempts to take a history with her tangential thought processes. I am just waiting for her to file a grievance against me and call her lawyer (which I heard she has done in the past).

Depending on your view of musculoskeletal medicine, the prison population is either a treasure trove or your worst nightmare. (For me, more of a nightmare.) There are very limited means to treat chronic pain here, so I end up telling everyone to exercise, lose weight, and take NSAIDs. Luxuries like PT, massage, accupuncture, and pools are not an option. (Even social support is hard to come by.) Occasionally it seems like a brace would be helpful, but the inmates have to buy these from "canteen" with the money they earn working in prison. Often, they say can't afford what I recommend and it's usually true because I can see how much money is in their account (one funny difference compared to medicine "on the outs.")

There are a wide range of jobs in prison including "porters" who clean the offices, cooks in the kitchen, harvesters on the "farm crew," and the "pusher" who pushes the wheelchair of a diabetic with an amputation, plus many more. Nearly all of the MRIs and outside consults I have requested to orthopedists or podiatrists have been denied by the prison insurance company. Which leaves me with, as I recall hearing in medical school, "the most powerful tool in modern medicine...the human hand." (Being an osteopath would be extremely helpful!)

Today I attempted a knee injection and a ganglion cyst aspiration. Hopefully they'll fare better than the lady whose trochanteric bursa I injected a few weeks ago. She had no improvement and was tearful and frustrated yesterday. I think I absorbed all of her frustration right into my trapezius. Six weeks in prison have left me feeling like I have fibromyalgia. At least I can soak in the La Quinta hot tub and sleep on a decent mattress, so I'm grateful for that.

Just one more day of work this week and then I'm off to "headquarters" in Colorado Springs for a provider meeting on Thursday.

Fountain of Youthful Offenders

Once a month, a batch of new teens/young adults arrive at our prison to start the Youthful Offender System (YOS), a program that focuses on education. Completion of this several year, multi-phase program will shorten the prison sentence for offenders age 13-21. (The vast majority of the inmates in my prison are women, but some youth and adult males are in a separate area of the prison for a short term.) The first month of YOS is a boot camp, and day one of boot camp includes a military-like welcome and subsequent parade through the medical, dental and psychiatry clinics. My boss warned me that "there would be a lot of yelling in clinic" when the youth came for their medical exams. I would never have made it in the military.

Just after noon, seven teenage boys in yellow jumpsuits enter the clinic scooting along the hallway walls with canteens over their heads while drill sergeants yell and, at times taunt them. Meanwhile, one woman with a video camera follows them around documenting everything. (My only guess is that this is to ensure the tough love/breaking in is humane and follows some kind of standard?) My job is to basically do a sports physical on the youth to ensure they are cleared for the physically rigorous boot camp, all the while trying to keep a straight face when they answer "ma'am, yes ma'am!" and "ma'am, no ma'am!" to my medical questions. I had one kid today say "ma'am, no ma'am to 8 question in a row, and when I tried to ask an open ended question, he said "ma'am, none ma'am!" (Another funny moment: me "have you seen your tongue? does it always looked like that?" Youthful Offender "ma'am, yes ma'am!" It was the strangest tongue I've ever seen!)

All the ma'am responses drive me a little crazy, and I gave one of the drill sergeants a dirty look for scolding one of my patients when he just answered "yes." And don't be the kid who says "ma'am, no sir" to a drill sergeant, because that does not go over well.

Coming up tomorrow, there will be a multidisciplinary debriefing and potluck, where the staff discuss each offender's medical, psychosocial, education, legal, and gang background before the youth go to the yard for their "exercises." The debriefing last month broke my heart. Most of the kids never even had a chance. Hopefully, they can get through YOS and get their lives on track. And until they do, I will keep tending to the broken noses and busted up lips from the fights that break out at the main YOS campus down the hill.

Kites and other Prisonisms

When you have to go through a metal detector and three electrically bolted doors to get to work, you know you're in prison.

I am quickly becoming acquainted with the fascinating culture of the correctional system...and trying not to break any rules I don't know about. Today I got scolded by one of the nurses for telling a patient when her consultation with the GI doctor was scheduled. What I should have told her was that her appointment would be "very soon." (Like that's a satisfying answer to someone who can't even swallow liquids without choking and regurgitating...) Apparently, if the inmates know when their outside appointments are, it could be an escape risk and "you could get fired for that sort of thing." Being a contractor, I didn't get to partake in the month long "academy" that all correctional employees go through. This where they learn the cardinal rules of prison, like not telling inmates when their appointments are, while reading books called Games Prisoners Play. Employees also take a pressure point training class so they can subdue a threatening inmate with a single finger to the Mandibular Angle, or other sensitive areas. (I also saw an email for an "interesting" Spontaneous Knife class...I can only imagine the pearls they pick up there!)

But until I become a real DOC employee, I have to learn my prison survival skills on the fly.

Other prison idiosyncrasies include:
-Officers checking to make sure all the car doors in the parking lot are locked several times a day...otherwise they will lock them for you. Another escape prevention precaution I guess...

-Walking to the clinic in the morning and and hearing "Offender so and so, please report for your 7:30 cosmetology appointment" over the PA. (Need a manicure at a discount at sunrise? There's a cosmetology school in prison, and acrylic nails are very popular among the medical staff.)

-Having to ask permission from an insurance company for every imaging study or specialist consultation...and the answer is usually is no. (I have a template for my appeal letter :)

One of most charming prisonisms is the newly created communication system where inmates write their appointment and refill requests on a small piece of paper called a kite, which the nurses have to log daily. Sometimes I have to review the kites and "kite them back." Have a dental problem? Better kite dental. Want a refill on your psych meds? Kite mental health. (Did I mention medical and mental health are totally separate in prison? No psych here for me.) Then at the end of the visit, I have to "close the kite out" in the computer tracking system. I love how kite is both a noun and a verb, and a major pain to the nurses. I think it's very poetic to think of the inmates writing and sending kites. They could at least make them diamond shaped.

More prisonisms, including lockdowns and excerpts from the hilarious prison emails I receive, coming soon.

The Baader-Meinhof Phenomenon

Since I started working in prison, I have become highly attuned to stories of prisons and prisoners on the radio and in the news. On my daily drive, my ears perk up for any NPR story on the prisoners of Guantanamo...China...South America. Seems like prison stories are everywhere, even inundating me on my [fabulous] 3 day weekends...or maybe it's the Baader-Meinhof phenomenon. Ever learn a new word or topic (usually obscure) and then start noticing it all around you? (Like when I went to the Nuggets v. Suns game last weekend and noticed the Suns' point guard Steve Nash...then Monday I heard his name in the lyrics of a Nelly Furtado song...oh, Canadians...) Anyway, you think it must be an amazing coincidence that the new information is suddenly everywhere! How did you never notice it before?! (One theory is that the brain has a bias for recognizing recently acquired information and patterns, termed the "recency effect.")

Such has been my experience since working in prison. And not always in a good way.

I really try to avoid knowing the legal history of my patients. It seldom has anything to do with why they are in my exam room, and I don't want it affecting how I treat them. I think a lot of the women may be there on drug charges, but others have convictions for sexual offenses and murder. Anyway, imagine my surprise while reading the newspaper last weekend to find a big article about of of my patients. Cringe. Then moments later, there was story on tv about a prisoner who escaped from Colorado Department of Corrections 7 times, which I had heard about briefly at work. The tv story described him building a huge copper ladder and climbing over the electrically charged "kill fence" before being apprehended by the escape recovery team.

And now that you know about Baader-Meinhof, you will probably notice it. Everywhere.

http://www.9news.com/news/article.aspx?storyid=165313&catid=339

Chocolate Heart

Prisoners have been known to be manipulative in the medical clinic, and I have been known to be on the naive, trusting side of the spectrum. (While on rounds as an intern, I presented a patient with the history of being chased all night by "meth heads." Incidentally, his legs looked like they were covered in tree bark. This tale caused my program director's mustache to twitch into a sly smirk during my presentation...Later, when the patient claimed the meth heads pulled up to his hospital window in a tanker truck and that the nurses were in a meth ring, I became suspicious.)

In prison they call my type the "chocolate heart," chocolate for short, or "don't go all chocolatey on us!" The last doc in my position was the opposite of chocolate, and I don't mean vanilla. Perhaps sour grape?

In medicine, the doctor who gives out the narcotics is the "candy man." Fortunately for me, there isn't a lot of candy to give out in prison. No one is on chronic narcotics, and even drugs like neurontin require approval by special committee. (Apparently, there are all kinds of meds you can get high on, and all sorts of ways to procure your meds, despite having an officer shine a flash light in your mouth after you swallow.) Of course, many inmates have "burning, tingling nerve pain" and it's hard for this chocolate heart to separate the wheat from the chaff. I'll just go back to eating tootsie rolls in my office.

Bringing it back

I've been inspired lately by the resurrected blogs of my residency pals and my ample free time in Pueblo hotel rooms to bring the Kenya blog back. This time there won't be any accompanying slides shows of cute animals...I work in a prison and cameras aren't allowed. Let me summarize the past few months and then we'll get back to prison.

I finished residency in June and was off all of July. Post graduation, I enjoyed a fabulous cruise with my family to Alaska (complete with several nights in the cruise dance club--Skywalkers--with my sisters, Matt and even Granny!) I also spent a lovely week in Mexico with Alyson (want to try the best guacamole and salsa ever in Puerto Vallarta? look me up...) Finally, I managed to pass the boards, check out some fab hikes with The Hiking Club, and having happy hour prn before starting work as a faculty for my residency in August. When I wasn't fending off the questions of super smart residents, I was tackling items on my Seattle to do list like full moon kayaking, enjoying the Seattle arts scene, and taking a few last laps around Green Lake.

At the end of September, Chelsea, Matt, & I shoved all my worldly possessions into a 6x7x8 "Relocube" and drove to Denver. All that stuff about 300+ days of sunshine is true! I acclimated well to the gray skies and mizzle of Seattle, but the sunny rays sure are nice! No more "I-should-go-outside-since-it's the only-sunny-day-all-week-but-would-rather-sleep-in" Seattle guilt --it's always gloriously sunny in Denver!

October brought a month of unemployment, interviews, and travel while trying to settle in to my new digs. My Seattle treehouse has been replaced with a 3rd floor Congress Park "penthouse" (Being on the 3rd floor and having a dishwasher are the main luxuries...storage and quiet are not the penthouse's forte...I may re-dub it the "Icebox" until my heat is fixed and my Raynaud's improves.) Which about catches us up to the present day: Room 316, La Quinta, Pueblo, CO.

Yes, Pueblo is 2 hrs south of Denver, and I recently moved cross country to be closer to Matt. However, I'm doing locums work (which has the flexibility I wanted), have a 4 day work week, and actually am really enjoying correctional medicine at the women's prison. More to come about life beyond the razor wire fence...just don't bring in a camera or cell phone!

Kwaheri!

Just wanted to give you the scoop on the safari and wrap up the blog since I'm back from Kenya. We departed from Kijabe last Monday and set out for the Masai Mara with our driver, Michael. Along the way, we passed many waving children and a lot of Maasai shepherds. The last 1 1/2 hrs of the journey were on a rugged dirt road. After about 5 hrs, we arrived at the Sopa Lodge in the Masai Mara National Reserve (http://www.sopalodges.com/masai-mara/home.html). The lodge was fabulous and highlights included a beautiful pool, sumptuous buffet (loved the Indian food and our waiter, Jacktone), spacious cabanas decorated in rustic safari style, and evening animal feedings of the bush baby, hyena, mongoose (mongeese?), and wild pigs. The Mara is sunny and hot in contrast to the sunny but cool Kijabe days.

At about 6:30 in the morning, the Wazungu all gather in front of the hotel to climb aboard matching white touring vans with pop-up tops. We went on 4 game drives and enjoyed the vistas of the Mara. We knew the game drive was about the get interesting when Michael would get a hot tip on the radio and would bee-line off the road toward a collection of Wazungu Wagons. One such occurrence revealed a mama giraffe pacing around a tree. Michael said, "the meat is in the tree," and tried to point out where a leopard had killed a baby giraffe and drug it up the tree. We saw no evidence of this the first day, just a grieving giraffe looking for her lost baby. The following day we were able to spot the crafty leopard as well as the giraffe in the branches. The animal kingdom can be brutal. Leopards are hard to find, so we were grateful that we spied one. We made up a grading system of animal viewings with levels 1-6. Seeing a donkey or sheep grazing on the side of the highway is a level 1, while a baboon or a dikdik is a level 2. A giraffe in a tree is a level 6 ("rare animal behavior and unusual sightings") for sure.

We also got to see 3 lionesses strolling around with 7 bouncing baby lion cubs. I have a great video of the lion family sunning themselves on some rocks until they are on the move when bunch of elephants approach. The herds of elephants were truly incredible. We also saw a few wildebeests and zebras, although Michael pointed out that these animals were "confused" and missed the migration to Tanzania a few months ago. We were only eluded by the cheetah.

The long trip back to Nairobi was a hot blur of bumpy roads and city traffic. We had about 5 hrs in the Jomo Kenyatta Airport to spend the rest of our schillings shopping for curios. The flights back were relatively uneventful. We spent about 3 hrs in the early morning in Heathrow. I had a "flat white" at an Italian coffee shop in the airport and then spent Matt's last 5 quid on a tiny wallet at Cath Kidston, which appeared to be Vera Bradley's British cousin. The Continental in flight entertainment en route to Houston was amazing! Where else can you watch Motorcycle Diaries, Beyond Borders, and The September Issue in one sitting? Unfortunately, my cell phone did not make the last flight to Seattle and is currently hanging out in Houston with a gate agent named Jamie. (She managed to call the last number I dialed, "Mom Work Cell," but the exact whereabouts of my cell phone remain a mystery...)

Although still jet-lagged, I am adjusting little by little to pacific time zone. (I slept for about 16 hrs the first night I got back!) Hopefully I can return to Africa and specifically to Kijabe someday. I will miss the peaceful routine of rural life and the equatorial sunshine. I also really enjoyed the supportive, friendly culture of Kijabe and the lack of egos in medicine. However, I will miss the relationships I made in Kenya the most. I am so grateful for the warm hospitality of the Kenyans and the missionaries.

Asante sana for reading my blog and for your support. Your comments and emails helped me feel connected while I was away. Kwaheri for now!

That's so Kenyan

I can’t believe this is my last day in Kijabe. This is such a neat community, and I am sad to leave. For our last day, we woke up early to go on an adventure to Mt. Longonot with Doug Trotter. Mt Longonot, a volcanic crater which last erupted around 1860, is designated as “senile” not “extinct.” You can see steam vents at a few places. We hiked up to the crater rim, passing a few giraffe on the way, and walked the loop around. The views of the Rift Valley were stunning. We had smashed peanut butter sandwiches at the highest point on the ridge. We also had a contest up there to see who had the lowest pulse oximetry reading. Two medical students from Chicago, who just arrived yesterday, clocked in around 91%, but I was 95%. The hike took us at 5 ½ hrs, and I think we may have walked 8-10 miles. We never saw another person for the first 4 ½ hrs of the hike, but there were droves of people heading up as we descended. I preferred hiking up in the cool morning air.

For some reason, all Kenyan national park workers were green camouflage uniforms, resembling the military. Yesterday at the Hell’s Gate gorge, a camouflaged man told us where to park our bikes, where to sit for lunch, and then took us in a small back room to pay for our hike. I thought we were going to get interrogated.

Another interesting thing about Kenyans is their greetings. If you say “hi” to a Kenyan, he very well may respond, “I’m fine” despite not being asked how he is. Other common greetings are hi hi, hi to you, jambo, and habari (hi, how are you). Our guide yesterday just kept saying pole, pole to us, which Matt and Ben thought meant hurry up, but actually means sorry. He said pole a lot when we were walking barefoot on rock shards.

I went to look for sesame seeds at the duka the other day. I have probably never purchased sesame seeds in my life, but wanted to add them to a dish. The man who does the purchasing asked me, “are they submerged in water? Are they pickles?” I wasn’t able find any, but he assured me he would bring some back from Nairobi, as they could be a big hit with the missionaries.

Kenyans also take their tea time very seriously. Every day at 11, everyone stops working to drink tea and have a snack. (I had the Kenyan trifecta of snacks recently - mondazi, samosa, and chapati). The only time in Kenya is tea time. Sometimes you can get roped in to having tea and there is no escape. Yesterday, I went to go quickly meet Tembu’s fiancé Violet, but it turned in to a tea party. Usually, this would have been wonderful, but I was already late to leave for Hell’s Gate. I did have a good time at tea, but at the expense of getting home an hour late. This didn’t seem to worry the Kenyans whatsoever.

Time for a shower and some blood letting, then dinner at Mama Chiku’s “hotel for delicious foods.” We are off to the Masai Mara tomorrow for our big safari, but I will miss Kijabe town!

Full Circle

Today was my last day of work, and the time in Kijabe has gone so fast. This was a week full of parties. Wednesday, we had the interns over for taco night. They had no idea what tacos were, and Karen got confused and asked if we were going to eat tequila. There is no alcohol in Kijabe, so I was thrown off by her asking. It took me a minute to figure out she really meant tacos. We served soft and hard shell tacos, guacamole, beans, rice, and no bake cookies. The singing started at the stroke of midnight, Aurelie’s 31st birthday. They sang an awesome version of happy birthday, and they sounded amazing! I taped it on my camera and hope to post it on the blog when I get back. The interns stayed until almost 1 am, much to the dismay of the couple living beneath us.

Thursday we celebrated Aurelie’s birthday some more with homemade pizza and chocolate cake. I had to improvise the red plate, but I think she had a memorable 31st.

Friday night, the interns had us all over for a Kenyan feast. Pulei (an intern) made ugale (typical Kenyan bread-like fluffy substance), sucuma wiki (spinach and kale), chapati, chicken, pilau, and chai. It was delish. Dinner was followed by a dance party where we watched African music videos and tried to copy their moves. Charles, one of the interns, played DJ, and we danced to a very eclectic set, including “Breathless” by Faith Hill, “18 til I die” by Bryan Adams (shout out to my mom – It’s her favorite song!), Elvis, and Rhianna. The interns are super fun, and I will really miss them. It has been fun to bond with them in their first month in Kijabe.

I feel like I have come full circle with a few patients in Kijabe. I admitted a preeclamptic woman name Jane on of my first days in clinic. We have been observing her over the last 3 weeks for signs of worsening preeclampsia, and last Wednesday her blood pressure shot up to 200/130. Her gestational age was 30 weeks, 4 days, which isn’t terrible for Kijabe, although we had hoped for 32 weeks. We tried to induce Jane’s labor, but I got a call Thursday night that she was having brisk vaginal bleeding. My attending and I took her to the theatre for a crash c-section. Her baby was vigorous and is just using CPAP…I really hope she will make it. I have really enjoyed taking care of Jane over the last 3 weeks, and I feel good about seeing her pregnancy to the end. Pray for baby Mercy!

Another patient, Gladys, came in last week preterm premature rupture of membranes at 20 weeks gestation. She had no amniotic fluid on ultrasound, and we counseled her that the baby would not live. She was discharged, but returned today with pain and bleeding. She was able to deliver the fetus, who had died in utero, but was having pretty significant bleeding. Her placenta had sheared off the amniotic membranes due to infection and there was a lot of material in the uterus. Tembu and I took her to theatre for a d and c. I think she will be ok despite hemorrhage and infection. Matt and Ben donated some blood last week so maybe it will go to Gladys. I’m hoping to donate after we climb Mt. Longonot tomorrow. I’ll save my red blood cells until then.

After rounds today, Matt, Aurelie, Ben and I went to the, as it turns out, aptly named Hell’s Gate National Park. The park has huge rock towers and canyons. We rented mountain bikes and took the 9 km road to the gorge and the Central Tower. We set out at the hottest time of the time of the day, so most of the animals were hiding in the shade while we pedaled to the gorge. It turns out that I really don’t like mountain biking and particularly riding through sand-like dirt. I was happy to be off the bike when we finally got to the gorge. A Maasai guide then led us on a hike through the gorge. It was nice enough until we started hiking through a canyon to get to a cave. At one point early in the hike, the canyon was blocked off with water. The guide suggested we take off our shoes and walk through the water. He left his shoes on the bank and continued walking through the canyon barefoot. I’m not sure if it was because his English was limited or if we are just completely idiotic, but we left our shoes too, thinking we didn’t have much further to walk. However, we walked for about 30 more minutes barefoot over dagger-like pebbles, obsidian chips, and dirt. I had the misfortune of stepping on a thorn, which was imbedded into the ball of my foot. (Thankfully, I got my Tdap vaccine a few months ago. Matt and Ben got tetantus boosters at the hospital last week ---only 80 cents each). I couldn’t believe we were doing actually walking barefoot, yet we still continued scrambling through the canyon. I guess our guide missed the powerpoint slide about delicate Wazungu feet in his new guide orientation. When we were well past our breaking point, our guide told us there was 1 more minute until the cave, so we pressed on. The “cave” turned out to be pretty much a dead end in the canyon, so we took a picture and made the painful journey back to our shoes. We ditched the bikes and took a taxi from the gorge to the main gate. Through the tinted taxi window, we saw zebra, buffalo, and giraffe grazing, so it might actually have been nice to bike out, despite my dislike for mountain biking. Tonight’s evening activity is scouring the tropical medicine book for all of the diseases we might have contracted through the soil and water. Tomorrow’s activities include consulting with our infectious disease specialist neighbor and buying some antihelminthics from hospital pharmacy. I hope I can ascend Mt. Longonot despite my sore puncture wound!

Top Kenya Baby Names

Faith
Grace
Mercy
Immaculate
Precious
Mary
Anne
Susan
Jane
Joyce
Esther
John
Wanjiku
Wanjiru

I met a set of newborn twins yesterday named Sharon and Elvis. Sharon was named after my attending, but I’m not sure about Elvis. I am told he is not popular here. A visiting doctor from Pennsylvania told me there was a baby the other day named Ringtone, but I am convinced that baby was actually named Newton. Then there are our favorite names from the peds ward – Innerbelle and Alabel. I also met a baby named Trivia yesterday. There are many Ruths and Peters, but interesting baby names abound.

Matt's Guest Entry: US saying: “Hammer looking for a nail,” Kenyan saying: “Machete looking anything”

Hello Julie’s followers, this is Matt writing and today I’m providing a guest blog entry about what I’ve been up to the past few days (Mon-Wed) while Julie has been working in the hospital. In summary, Ben (Aurelie’s husband) and I have met a wonderful man named John Njane who provides mentoring, shelter, and training for “street boys” in order to give them opportunities and have better lives - we’ve spent the past three days doing various home improvements alongside the street boys and this has been a truly wonderful experience, providing an authentic insight into Kenyan culture that I would have otherwise missed, but I’m getting ahead of myself…

Sunday evening, following dinner, Julie called a missionary woman who is the head of welcoming and familiarizing new doctors to Kijabe, to inquire about volunteer/service opportunities that Ben and I might participate in during our week in Kijabe. It was arranged that we would meet with a man (John Njane – pronounced “John Johnny”) who runs a ministry that provides services for “street boys” (kids living on the street, who don’t go to school, and whose outlook is bleak) and orphans. Without knowing much more, the missionary arranged for Ben and me to meet John Njane the following morning to build a fence at his house (where there are five street boys living with him).

At 7:30 am on Monday morning, John (who is also a mechanic) arrived on a dirt bike/motorcycle (or a “piki piki” as they are commonly called in Swahili). John asked if Ben or I had any experience riding piki’s, at which point we both indicated that our experience level was very limited, but were also confident that we could ride a piki without much trouble. Ben and I later confessed to one another that by “a little” experience on a piki, we really meant “none.” Nonetheless, the three of us rode about 5 miles up to John’s home on two pikis (Honda dirt bikes) via a steep, rocky, rutted, red dirt road - Ben driving a piki while I rode on the back on John’s bike.

When we arrived at John’s home, we were introduced and warmly welcomed by the street boys (Steven, Steven, Mark, Anthony, and George who were ~13-15 years old, with the exception of a little Mark ~9 years old). John (29 years old) had recently moved to this new 3-room home with his wife, daughter, his wife’s young cousin (a 13 year old girl who helps with the daughter), and the five street boys. The house is extremely modest - I would estimate it to be 600 square feet. It has an outdoor latrine and no indoor water, though it does have some “luxuries” for amongst other homes in the area – which include i) a solar panel to power one small fluorescent light in each room (similar size to a desk lamp), ii) a large (10’ diameter, 6’ high), concrete, water storage tank that collects rainwater via PVC pipe affixed to the corrugated metal roof, and iii) a car battery connected by jumper cables to power a mini DVD player (we watched 15 minutes of Rush Hour 2 over lunch during out third day of working – John loves Jackie Chan and thinks Chris Tucker is hysterical… so do I!). Also, when they found out I was half Chinese, the boys thought I looked like Jackie Chan… but they all also thought Ben and I looked like brothers, go figure…

The five street boys living with were chosen from a larger group of street boys living in the nearby city nearby or Maii Maihu, which Ben and I refer to as either “Sin City” or “Sodom, Gomorrah, and Maii Maihu” – as it appears to be run rampant with unsavory characters, drugs, prostitution, and poverty (as opposed to Kijabe where we’re staying, which is owned by the mission and more akin to a wholesome Utah town).

At any rate we began building a new hybrid barbed wire/wooden fence using very limited amounts of tools and supplies (i.e. reusing boards, reusing bent and rusty nails, and using a machete for both digging post holes and “sawing/hacking” wood). It is amazing what you can do with a limited supply of tools when that is all you have available. Over the three days that Ben and I have spent working at John’s, we’ve both managed to get a little sunburned, have built several sections of fence, gates, a clothesline, done some work to make an improved and safer walkway to the latrine, and been welcomed into a Kenyan home for several wonderful, lunches consisting of Kenyan fare ( i) rice and vegetables, ii) ugali and sukumi wiki (corn paste/”bread” that is used to pick up and eat a spinach/kale mixture, and iii) maize and beans).

Today John is working at his mechanic job, so Ben and I may get a late start but are looking forward to another day working alongside the Kenyan street boys…

Black Cloud

Warning to the growing number of pregnant readers: this blog, like nearly all of my entries, contains graphic material regarding pregnancy. If you need to skip it, you can stay tuned for top 10 Kenya baby names on 1/28/09!

This week the maternity week has had a black cloud over it. We haven’t had any maternal deaths all month, and yesterday there were 2. Both women suffered complications of pregnancy and both were transferred after being treated at the same outside hospital. Anne delivered twins about 2 weeks ago, but developed post partum hemorrhage due to retained placenta. Apparently she was taken to the theatre for surgery and lost 3L of blood. She then developed seizures. She was in a coma when she was transferred to Kijabe. She had been in the ICU for a week and a CT in Nairobi showed massive anoxic brain injury. Somehow she got transferred to the labor unit yesterday. Most of the women in that room are in labor, newly delivered, or being closely observed for some pregnancy complication, so I’m sure it was difficult for the other patients to see her suffering. The beds are separated by a thin curtain, if that. It was probably even harder for Anne’s family to be surrounded by happy post natal moms. We had a family meeting last night and told the family that comfort care was appropriate. She died last night at 7:20 pm. One of her twins also died, but the family was going to pick up the healthy twin from the nursery today. She had two other children at home as well.

Another lady was admitted last week with suspected pelvic abscess after a d & c for a miscarriage. In the theater, she was found to have a necrotic uterus and bowel and lost a lot of blood during the operation. She went to the ICU and developed pneumothoraces. One of the attendings thinks she might have had choriocarcinoma due to the appearance of her vocal cords (apparently it can metastasize there). She left the ICU in a beige cylinder. A

16 yr old pregnant Maasai woman came in to clinic yesterday with dehydration, fever, and “fainting.” Last night she had several eclamptic seizures and got a crash c-section this morning. I think her baby is 2.2kgs and doing well so far. I have enjoyed seeing so many Maasai people in the maternity ward.

Another woman, who had a radical hysterectomy yesterday for invasive cervical cancer, did not make any urine over night. Fluid boluses, lasix, and a catheter change did not help. My attending asked me to get her an IVP (intravenous pyelogram) to see if a ureter had been injured during the procedure. A physician has to go to I push the contrast, so I went. Mysteriously, none of her collecting system contained contrast after 20 minutes. We’re not exactly sure what happened to her kidneys, but she probably has intrinsic renal failure related to the surgery or anesthesia. She is now in the ICU and may need to go to Nairobi tomorrow for dialysis.

I hope the black cloud passes soon! We could use a silver lining on maternity.

It Came from the Abdomen

Matt and Ben made it safely to Kijabe on Friday in good condition ---no confiscations by security or last name misspellings and minimal jet lag. It sounds like they had a great layover in London, complete with a ride on the tube, bangers and mash, and visiting the guards at Buckingham Palace. Matt studied abroad in London in college and enjoyed the return visit. I’ve never been to the UK and really wish we had a layover on the way home. I’ll just have to keep dreaming of fish, chips, and those double decker buses.

I’ve been on call this weekend with two of my favorite interns, Karen and Obonyo, although it hasn’t been too busy…yet. Yesterday we took my patient Immaculate to the theater for an exploratory laparatomy. She was admitted 1 month post partum with vomiting and abdominal pain and swelling after a supposedly normal vaginal delivery. I got to open her abdomen and found a large, loculated cystic mass stuck on the uterus. We drained about 2 L of pus from the abscess and removed some crazy looking debris. Her intestines were encased in her upper abdomen by a weird membrane. We called in the general surgeon to have a look, but he recommended leaving the bowel alone. She got to keep her uterus and hopefully antibiotics will help her continue to recover. Prior to her surgery, we advised her to round up some blood donors since she was anemic. (If you need blood in Kijabe, you need to BYOD- bring your own donors.) It is a struggle for most people to find one or two blood donors. Immaculate’s sister said they had a “bus load” of 20 blood donors including 10 who had her blood type. I was touched by her family’s generosity.

I also got to do a c-section for a lady had poor progress of labor. Her baby turned out to be occiput posterior, and the CS went well. It is funny to find random babies under the warmers alone in the delivery room long after the delivery or CS. I got to bring that baby to her mom, and she was really cute with her.

The Rift Valley Academy had their “senior store” yesterday, which is a fundraiser for the senior class trip to Mombasa. They have a big bbq and sell these amazing homemade iced donuts. We also watched one of the students asked a girl to the junior-senior banquet, the RVA version of prom. This girl was directed to run through a line of people collecting roses until she reached the end where the guy was waiting with a pizza that said “BQ?” in peppermints. Very sweet and random…but she said yes!

I also had another amusing trip to the market yesterday. As soon as I approached the market, 4 ladies who had been sitting outside ran in to staff their tables, bringing the total to 9 produce ladies. I had just been to the market the day before and didn’t really want to buy something from everyone. I tried to stall by visiting the craftsman in the back selling curios. (He came to our house once with a bag full of crafts, saying he was a craftsman, and wearing a “Craftsman” hat.) However, the ladies weren’t deterred. I told one lady I needed “the best watermelon.” Instantly, three ladies each grabbed a watermelon and proclaimed it the best. One offered to cut it for me right there and prove it was ripe. It turned out to be a very nice watermelon, and we enjoyed it in a fruit salad at our dinner party with the neighbors last night. The Trotters came over for dessert and brought Aurelie an early birthday cake. We will need to have another party on Thursday for the big 31!

Mtoto!

The last few days in Kijabe have been action packed. My patient Sarah did end up having an ectopic or possibly heterotopic pregnancy (pregnancies in the tube and uterus--the twinning rate here is 1/20!). I got to do her d & c and ex-lap on Tuesday. She ended up having 2 tubes, so may have had a salpingostomy with her first ectopic. Her recovery went well, and she left today in good spirits, although she was disappointed I didn’t get to meet her mother. Yesterday I got to deliver a cute healthy baby named David. I admitted his mother from clinic also on Tuesday for induction. The nurses told her to stop yelling and start pushing. There are no epidurals here so laboring women are often screaming, although some are very stoic. I was walking recently through the labor ward and a woman yelled out “Mtoto!” (Baby!) I grabbed some gloves to help delivery her cute baby girl, Elizabeth, right in her bed.

Today I got to spend a lot of time in the theater. The nurses grabbed me to help with a retained placenta for a woman who had PPROM’ed at 26 weeks. That placenta was not coming out without a fight. My attending ended up pulling out tatters of shredded placenta. I got to do her d & c. I think the baby came out looking like a 30 weeker, so maybe he will be ok. Then, I removed a mass from another woman’s c-section scar, which sounded like an endometrioma but didn’t look like much. I also go to help with an urgent c-section on a 38 yr old woman who had no amniotic fluid. It was a bit of a scene – the patient was having a weird reaction to the anesthesia, the blood pressure cuff stopped working, and then the scrub tech knocked over all of the sterile instruments. My attending got the baby out very quickly. The patient was a first time "mum," and she was thrilled. Baby Samuel is doing well. Later, I attempted a LEEP today for CIN II, but somehow broke 2 loops in the process. I don’t like to blame the tools, but procedures here seem to take longer and have more unexpected complications than they do at home. It is rare that I get to spend this much time in the theater, so I had a really good day.

The pathology here is pretty shocking. Probably 30% of the people I see in clinic get admitted to the hospital. Yesterday, I admitted a 25 yr old woman named Immaculate who was 26 days post partum from a normal delivery at another hospital. She had been sick with abdominal swelling and pain and fever since post partum day #2. After a 10 day admission elsewhere, she came to Kijabe since she was not improving. (Kijabe Hospital has the reputation for being affordable and trustworthy). The patient was febrile, tachycardic, anemic, and had a boggy tender uterus and a distended abdomen. Her ultrasound showed a large cystic septated mass coming off of her uterus and free fluid in the pelvis. There is nothing good going on in that abdomen. She will likely go to theater soon and hopefully will not end up with a hysterectomy.

I also saw a woman in clinic who was 23 weeks pregnant and had bleeding for a week. Her ultrasound revealed a molar pregnancy. I had to tell her that she had no baby in her uterus and needed urgent surgery. Despite having a really good nurse help us communicate in Swahili, the patient left against medical advice. I couldn't tell if she didn't believe me, but she kept laughing even though I stressed the gravity of the situation. Get some O negative ready...

Another woman came in last night because she had been told she had a 20 week fetal demise. She came to Kijabe for confirmation. I did an ultrasound tonight and told her it was true. I am out of kleenexes from telling people bad news.

Last night I went to one of the interns’ house for dinner. The interns eat together nearly every night. We had mashed potatoes, cabbage, and some delicious mixture called “green grams.” They are so supportive of each other. We are hoping to have them over next week for taco night. I tried to explain tacos to my team, and Tembu (the family medicine resident from Nairobi) said, “I am pretty sure it is a jumbo sandwich.”

Matt and Ben arrive tomorrow, so Aurelie and I are excited. My favorite driver (recommended by Vy and Alyson) is picking them up in Nairobi. We hear they made it to London!

Joy and Sorrow

In the clinic today, the clinical officer (like a PA) asked me to review the “file” of a 50 yr old woman with HIV and infertility, who had traveled several hours for the visit. She works as a primary school teacher and stated she and her husband are lonely. They have 2 adult children, age 25 and 26, but their daughter lives in Tanzania. My patient found out about her “ISS” (immune suppressive syndrome – they don’t say HIV or AIDS much here due to stigma) in December. Her husband also has ISS, but has been sick with TB since August. He has a CD4 count of 12. She also had a history of a blocked fallopian tube seen on hysterosalpingogram 2 yrs ago. I think there is pretty much no way she is ever going to conceive again, which she actually seemed to take pretty well. I performed a quick VIA of her cervix and hope to see her in gyn clinic next week for a biopsy.

My last patient of the day was Sarah, a 34 yr old lady with 6 weeks of vaginal bleeding, intermittent abdominal pain, a positive pregnancy test, and an ultrasound that showed an normal, empty uterus with right ovarian cystic mass. She has one teenager and very much wanted another child. I am on call tonight and was worried that we would need to take her to the theater for removal of an ectopic pregnancy, especially after she told me she had an ectopic in 2005. However, on exam she had no abdominal tenderness and appeared to be actively miscarrying. I had never actually seen POCs until today. She was very relieved to find she could keep her only remaining fallopian tube, which prompted her to say “I love you!” to me. It was very sweet.

There are 7 beds in 2 rows in the labor part of maternity ward where they keep the most active patients. I have not yet been able to figure out why they are numbered M 01, M01 extra, M02, M03, M04, M05, and M corner. I also like that instead of ordering patients to be NPO (to not eat), they order them to be “starved” (although that might just be my British attending). The Kenyans also call scut work “donkey work.”

The interns here are total troopers. They are on call every 4th night for the entire year and work 1 weekend a month…which means potentially a 60 hr call shift from Saturday through clinic on Monday afternoon. No work hour restrictions here. I have never heard anyone complain about anything. If they choose to do a residency after their internship year, they have to pay to do it.

We'll see how the rest of the call night #2 goes. I'll be waiting for my page to go off, and also anxious about what I might be missing something if I don't get paged.

Hungry, Hungry Hippos

I was off work this weekend and got to spend some time exploring Kijabe and the surrounding area. (The tourist blogs will soon give way to more medical blogging as I start a 2 week stretch of work tomorrow. But for now, the travel writing…) Yesterday I hung out with the Trotters for a while and went to the duka (small grocery store) and produce market. I didn’t buy something from every lady this time since they had a lot of traffic – hopefully I didn’t make any enemies. We then had lunch at the Trotters’ house and walked the perimeter of the Rift Valley Academy, a school mainly for missionary kids whose parents are stationed all over Africa. About 500 students attend there, grades K-12. We were entertained by a few colobus monkeys and baboons during our stroll. The school is up on a hill and has an amazing view of the Rift Valley. It was very serene. I also ended the night at the Trottter’s house for game night. Aurelie was on call all weekend, so the Kathy and Doug are my new best friends. The anesthesiology residents and a physical therapist from Kansas joined us for a competitive and fun game of Taboo.

The weather here has been lovely – sunny and 70s during the day, but cool and super windy at night. I have been getting enough Vitamin D to last me through the rest of Seattle winter.

Today, Tracy, an anesthesiology resident from Vanderbilt, and I went to Crescent Island at Lake Naivasha, about an hour from Kijabe. Scenes from the movie “Out of Africa” were filmed there. Apparently all of the animals were imported to the island for the movie and have flourished. It is one of the only game parks where you can walk among the animals, as you usually you are confined to your land cruiser. A British couple now owns the island. Our animated guide Mumo showed us around- first stop was the hippos. We crept through the brush and Mumo went first, in case they attacked. Just as we were approaching, a small antelope ran out of the bushes, which scared us half to death. Hippos can be very aggressive, and hippo bites are not an uncommon chief complaint at the hospital. (The “white lady” who owns the island had a hippo skull on her porch and it looked like a t-rex!) Anyway, there was a family of about 12 hippos in the water. In case a hippo charges, Mumo recommended running in a zigzag pattern uphill or hiding behind a bush, and then darting in another direction. There are also a few buffalo on the island, which have large curled horns. If they attack, you should climb a tree. However, they have an excellent sense of smell so you stay up there for a while or they will smell you and come after you. Another option to escape buffalo is “lying on the ground.” I guess it is better to be crushed than gored? We kept our distance.

Mumo also informed us that giraffes have a 1 yr gestation and can kill a lion with a swift kick. (I could go on with Mumo stories for a long time…and will.) If a giraffe is about to “drop a baby” and it is threatened, Mumo says it will run away for 3-4 hrs with the baby giraffe "hanging out of it." We did not witness this theory in action, but we did see a family of giraffes with two 1 month old babies. Amazing! I am definitely getting carried away with my new camera. Herds of running wildebeest also made for exciting videos. There are also a few pythons on the island, but we did not meet them nor learn how to flee from their clutches [shiver].

Next we went to the Lake Naivasha Country Club for a “nice lunch.” (People in Kenya are always telling us where we can find a “nice lunch.”) The country club is actually a hotel and restaurant on a beautiful piece of land across the lake from Crescent Island. We were made “honorary country club members” since we are volunteering in the hospital. Lunch was served on a verdant lawn where we sat in whicker chairs. We really liked our driver, John, and invited him to join us. Instead of the chicken salad and watercress sandwiches I had envisioned, we were served curry soup, cucumber salad, fish, french fries, cooked spinach, pasta, dessert, and tea. It was a very “nice lunch” and a real treat!

There is a public Kenyan beach by the country club, so we walked there after lunch to view more hippos – but this was a “friendly” hippo family accustomed to people. More national geographic picture taking ensued until we could capture a hip with its huge jaws open.

On the way out, Tracy bought a 3 ft wooden carved giraffe in the gift shop. I bought a pair of bone earrings (that I can not make myself, Yiota!) Here is the text of a sign in the gift shop, "Polite Notice. We regret that in the unfortunate event of an item being broken or damaged whilst viewing, we shall have to ask you to pay for it. By Management." Kenyans are so polite. You break it, you buy it!

No trip to Kenya is complete without a bit of car trouble, right? We got a flat tire on the way home, but our driver swiftly fixed it and we were on our way back to Kijabe.

The power has been out for a while, so I’m typing by candlelight. Hope someone switches on the generator soon…

(Almost) Total Eclipse of the Sun

It’s hard to believe I’ve finished my first full week of work. The time is going by very fast here, and I feel pretty settled into Kijabe life. There weren’t a lot of surgical cases this week, but rounding and clinic kept me busy. Gynecology clinic is on Fridays, and I think 90% of the patients I saw today came in complaining of fibroids. Most were asymptomatic, but the patients had been told that a hysterectomy would help their neck/bone/leg pain- doubtful. Many other patients complained of infertility. I saw one woman at the end of the day who was not well- hypotensive, tachycardic, and complaining of 6 weeks of vaginal bleeding. She wasn’t pregnant, and her exam was more consistent with pelvic inflammatory disease. I was a little alarmed that she had sat in the waiting room for several hours with such bad vital signs. I’m anxious to check on her in the morning.

They perform a lot of neurosurgery at Kijabe – particularly on kids with hydrocephalus and spina bifida. The lack of folic acid in women of child bearing age is a widespread problem. Currently, there are some visiting neurosurgeons from Wisconsin, so people are traveling very far for neurosurgery consultations. Yesterday a mother brought her newborn in who had anencephaly. The poor little guy had protruding brain tissue and a very small cranium. Not even the neurosurgeons could help him. Today we admitted a term mom who was told she might be having twins, but her baby actually had hydrocephalus. We ultrasounded her, and asked the neurosurgeon if there was enough normal brain tissue for the baby to live. He thought so, and we did her c-section tonight. The baby was breech with a very, very large head as well as a myelomeningocele. He will get a VP shunt within 24 hrs to relieve the pressure in his head, but will have a very difficult road. At least the mom has 3 healthy kids at home.

Everyone take several breaks during the work day to “take tea.” The head maternity nurse told Pauline yesterday that she should buy them all mondazis (fried doughnuts). It must be universal that to keep the nurses happy, you should bring them snacks. We figured out that we needed about 20 mondazis for everyone. (The Kenyan family medicine resident Tembu told us “better order 21, because I can take two.”) I am surprised by the fact that there are male OB nurses here as I have never met a male ob nurse in the States. The nurses here are all trained as midwives. You can spot all the nursing students becasue they women wear blue sweater vests and skirts and the guys wear short white lab coats.

Today there was an annular solar eclipse, and everyone was outside looking at the sun through x-ray films. The eclipse was awesome – also very funny to see all of Kenyans peering through random x-rays. I hope I didn’t burn my retinas!

Theatre to Market

By virtue of being the only one dressed in scrubs yesterday, I got to have my debut in the theatre to be the primary for 2 c-sections. The procedures went well and the babies were healthy. One of the moms had several prior fetal demises, so she was very happy and named the baby Gift. We either misunderstood her or she changed the name, because today the baby was named Precious. I also go to do 2 dilation and curettages – one woman with a retained IUD and another with post menopausal bleeding. The OBs do the big cases, and one was particularly sad – a 26 yr old woman with ovarian cancer who got a hysterectomy.

I was on call last night but had a little down time in the evening since we do home call here. I went to the vegetable market up the street to buy some ingredients in hopes of making yellow curry. There are about 8 women with little tables selling the exact same thing, and I’ve heard they get upset if you don’t buy something from everyone. They are very persistent. If you don’t want a pineapple, how about plums? Take home these mangos! You can’t buy 2 peppers – 3 is a better number! I ended up with WAY too much stuff, and at the last minute another vendor sat down at her table – 2 more oranges in the bag. I spent about $5 for nice potatoes, passion fruit, peppers, potatoes, oranges, cilantro, tomatoes mangos, and green beans. Two women selling tortillas and English muffins out of a bag stopped me on the way home, but I was out of schillings. Shortly after I started to prepare the veggies, I got called by my intern Pauline about a woman with slow progress of labor.

The hospital is a quick 5 minute walk from my apartment. I reviewed the non-stress test (NST) with Pauline and it looked fine, so we let the lady labor a little longer. However, she got stuck at 8 cm and went to c-section last night. Pauline got to do it, and I went home to bed. It was a quiet call for me, but Aurelie was up most of the night with kids in respiratory distress.

I really enjoy working with the interns, and Pauline in particular. We chatted last night about our families, medical school, and life as a Kenyan intern. Today Pauline showed me the staff break room and we had some “drinking chocolate” (hot chocolate). (Aurelie and I tried to buy drinking chocolate because we liked the name, but actually bought “strawberry drinking chocolate” by mistake). The hospital staff take a break around 11 or so for chai tea and some kind of snack like mondazis (doughnuts) or chapati.

I get a kick out of the Kenyan idiosyncrasies. Many of the patients complain of “hotness of body” (fever). Additionally, the hospital has suggestion boxes all over it – in the waiting room, in front of the IT department, outside the pharmacy, by the lab…I wonder if anyone makes suggestions. There are several signs in front of the hospital that say “polite notice...” Kenyans also really like to shake hands.

Fetal monitoring during labor is also quite different here. My attending asked me to teach the Kenyan resident today about fetal heart tracing. It’s hard to read an NST when the contractions patterns aren’t recorded and the printers work inconsistently. We planned to review the NST for a mom with possible preeclampsia and premature rupture of membranes, who was somewhere between 37 and 44 weeks gestation. While waiting for the tracing to print, we heard a few decelerations down to 60 beats per minute (not maternal.) We finally go the NST going…deep decelerations in the absence of labor. The Kenyan resident did her c-section with me as his assistant. Thankfully, the baby boy was vigorous and 2.8 kg.

The evenings are quiet in Kijabe. Sunset is at 6:30 and we usually cook, use the computer, read, knit and go to bed. Tomorrow we are having dinner with our neighbors, Phil and Carrie, from Minnesota. There are also anesthesia residents here from Vanderbilt and several eager beaver med students from Wake Forest and a military med school. The place is overrun with visiting Wazungus!

Daily Grind

Today started with a surgical conference on trauma and senior staff chapel, which is a like a mini-worship service. Then we had teaching rounds where the interns, Kenyan family medicine resident, the attending and I rounded on many of the ob patients together. The patients are in big rooms of about 8 beds each separated by thin curtains. My intern Pauline and I usually round on the post-surgical patients. Many of the patients are new each day so it’s a mystery to figure out what’s going on. It usually involves me looking for a baby in the mom’s bed and trying to decipher the paper chart (“file”) notes. (“Ok, so there’s no baby, probably not a c-section…hmmm, she doesn’t look pregnant… [flip through the chart some more]…aha! Ruptured ectopic pregnancy post salpingectomy!”) The ladies are far more gracious than I would be after sleeping in a room with 7 women and crying babies.

We have a few preeclamptic women in the 6 bed labor ward. I went with Sharon today to perform an ultrasound one of them who had with severe preeclampsia at 30 weeks gestation. The findings were not good -scant amniotic fluid (“licor”) and reverse end diastolic flow. My attending, Sharon, ordered a non-stress test which prompted a stat c-section. Unfortunately, the baby’s lungs were not mature enough, and he didn’t live despite a good attempt at resuscitation. Premature deliveries and fetal demises occur daily here.

I spent the afternoon in the maternal child health clinic. I’ve already said it’s chaotic, but in a very small space with about 10 exam rooms, there are 8-10 nursing students, several women carrying cute babies on their backs, a gaggle of medical students and residents, 5 geriatric men waiting with walking sticks, and a head nurse or two managing the cacophony. Exam rooms are scarce, and I have to throw some elbows to claim one. Once I’m in the room with the patient, the exam room door will be opened by various nursing students no less than 5 times. If I lock the door to perform a pelvic exam, incessant knocking will disrupt the visit until some essential supply can be removed from my room. Nonetheless, I am starting to grow very fond of the nursing students who often help interpret my Swahili visits. I would be even more lost without them. Thank goodness they know Naegle’s rule to calculate pregnancy due dates since I don’t have a due date calculator on my pocket PC. Sharon gave me a pregnancy wheel today, which is made of metal and 12 inches in diameter. (They usually fit in your pocket!) I am thinking of wearing it as a necklace.

I’m on call tomorrow with Pauline and hoping to be a part of the OB action.

Wazungus on Safari

Saturday morning after rounding in the hospital, Aurelie and I were picked up in an antique looking pea green land cruiser and were whisked away to Lake Nakuru, a national park about 2 hrs from Kijabe. I enjoyed seeing the Kenyan countryside with its endless fruit stands (each selling little towers of potatoes), amusing signage (“beach hotel” nowhere near the beach), and many Kenyan children wearing knit ski hats. We even saw our first zebras right off the highway. Highway travel in Kenya can be harrowing. At any given time, about 50% of the cars are passing on the wrong side of the road which makes for an armrest-gripping, palm-sweating experience.

We arrived at Lake Nakuru to the greeting of “bye wazungus!” from two litte Kenyan boys. Wazungu means "white people" in Swahili (or possibly "British or Europeans" per the Swahili phrase book). While several species are endangered at Lake Nakuru, there is no shortage of wazungus. Shortly after we were greeted at the game lodge by security guards (with herbal hot towels and passion fruit juice), a deluge of wazungus descended. Swarms of older wazungus sporting khaki canvas zip off pants with matching mesh vests checked in after we did. The combined power of all their telephotos lenses could likely view the outer solar system. I must admit that this is pretty much the pot calling the kettle black since Aurelie and I were nearly matching outfits -khaki roll up pants, fleece jackets, and brightly colored sneakers. (We are keeping a tally on the number of times we get asked if we’re sisters…2 so far.) REI could definitely shoot their next catalogue at the Sarova Lion Hill Game Lodge.

The evening’s activities included a short “game drive” through the park scouting animals – buffalo, antelope, baboons, warthogs, and waterbuck. Then the lodge put on some traditional Kenyan dancing at sunset. We sat in the front row and were invited to the stage by the Maasai warriors (despite agreeing that we were NOT going up there). I tried to mirror my dance partner, and, sadly, our moves looked something like a cross between the chicken dance and a do-si-do. It was quite entertaining to look out on the fleece and khaki crowd shaking it with the Maasai, although some of the wazungus were really good! For dinner, we had an extravagant buffet with Kenyan barbeque, Indian food, tropical fruit, and endless desserts. A Kenyan guitarist wearing a camouflaged Seattle sombrero and tye-dyed hippie shirt serenaded us at dinner with Beatles (Let it be) and John Denver (Country Road) tunes. (No Jack Johnson as requested by the table next to us). We retired to a lovely bungalow with mosquito netting draped about the beds.

At 6:30am when the animals are supposed to be active, we left for another game drive. The rhinos (both black and white) were plentiful, if a bit sleepy. Also saw a lot of interesting birds – guinea hens, eagles, storks. After breakfast, we went on another game drive ---about 5 hrs of driving! I think our driver Joe was determined to find a lion for us, but no such luck. I really enjoyed the greater and lesser flamingos. Lesser flamingos are less pink. Just when I thought the game drive was over and we weren’t going to see any giraffes, two long necked Rothschild’s giraffes appeared. The giraffes and rhinos seem almost mythical. Between the giraffes and the zebras, I have a whole new respect for animal print. I, like many wazungus, am a sucker for charismatic marcofauna. Even the dikdik –a “tiny hare-like antelope” was charming! Looking forward to big cats, hippos, and elephants when we go to the Mara at the end of the month! (Would love to post pictures and videos of animals walking/muching, but didn't bring my camera cord!)

Being in Africa is like living in another world where we don’t need to eat or sleep. I sleep maybe 4 hrs/night and wake up (unfortunately) several hrs before work. Not sure if it’s still jet lag or my chronic insomnia. I’m not tired during the day but then feel like I’ve pulled an all-nighter by about 8 pm. We also eat a light breakfast, work through lunch, feel ravenously hungry at dinner, and then are satisfied by a small amount of food. Maybe it’s the altitude? Hopefully after another week in Kijabe, we’ll have adjusted.

More Tales from the Maternity Ward to come with my first call on Tuesday!

Thrown to the Zebras

I have survived my first 2 days of work. Yesterday started off well with a lecture about HIV and a tour of the hospital (about 265 beds including Men’s & Womens wards, pediatric ward, ICU, maternity ward, and an outpatient clinic that sees 100,000 patients/year). However, then the medical director left me with my new attending who told me I probably wouldn’t have the chance to be in the theatre (operating room) all month since the Kenyan interns and residents are new and need to learn. I likely won’t be doing many deliveries either since the midwives do them here. January here is like July in the States, when all the interns are new (and traditionally the worst time to be a patient!) I was really bummed at the prospect of not being able to do any procedures all month. Hopefully, I’ll be able to find a way to get to use my skills. I heard Alyson “vacuum in her pocket” Feigenbaum was very useful in November!

I then was asked to help the Kenyan intern with her rounds. She is nearly as clueless as I am since she’s about 4 days into her internship. We spent about 8 hrs in the maternal child health clinic (MCH), which is quite chaotic. It is run mostly by nursing students as there is a nursing school in Kijabe. My mom would be happy because it is a 3.5 yr program – no condensed programs here! My intern is named Pauline, and she is great (and was surprised that we don’t have much malaria in the States). I thought it was very cute that instead of asking pregnant women “have you felt your baby move?” she asked “is your child playing?” Prenatal care here is completely perplexing. The women get 4 visits (maybe) and I’m still trying to figure out what labs (“investigations”) they order. Everyone gets “fansidar” (malaria prophylaxis), and no one tests for Group B Strep.

Today I was in the MCH for a few hours and admitted a woman with preeclampsia. Thankfully, her ultrasound suggested she was 28 weeks pregnant instead of her calculated 22 weeks. I was in the gynecology clinic for the rest of the day. I think my hands might peel off from the obscene amount of hand gel I’m using. Sinks with actual soap are hard to find.

I got to see the delivery room today, which has 2 beds. In one bed was a mother who just delivered a 4300 g baby, which is big in the States and HUGE by Kenyan standards. In the bed next to her was a 25 week gestation woman who was miscarrying. My attending ruptured her amniotic membranes and the baby was born within minutes. Babies need to be about 30-32 weeks to survive here, and this one only weighed 700g. They attempted resuscitation, but it clearly was not going well. He was quite a contrast to his neighbor. It was very sad to watch that baby struggle, although he probably would not have lived in the States either due to meconium and chorioamnionitis.

On a lighter note, Aurelie (the other resident I am with in Kenya) and I are going on an excursion this weekend to Lake Nakuru, where there is a game preserve. They have rhinos and are famous for bird watching – apparently there are lots of flamingos. We have only worked 2 days, but it will be nice to have some time to explore before our first call shifts next week.

So all in all, despite a rocky first day, things are looking up.

Getting there is half the fun

After a long 2 days of traveling, we arrived in Nairobi last evening. We flew from Seattle to Houston to Amsterdam to Nairobi. The trip went very well, and the only casualties were my knitting needles and scissors, which were seized by security in Amsterdam. Somehow the small pocket I knife I had in my carry-on accidentally made it through TSA and Amsterdam just fine. Thankfully, they did not find my bamboo needles holding together my first baby hat for Baby Terp. I may have to borrow Aurelie’s straight needles or keep making baby ear bands :) Not bad at all considering my ticket was for Julie Phistlethwaite. We even sat by a retired family doctor missionary on the flight to Nairobi. He was from Minnesota who had worked in Liberia for many years. Nairobi is nothing the Casablanca-like image I had of it.

We stayed at the Mayfield Inn in Nairobi last and a driver named Davis picked us up this morning to take us to the grocery and to Kijabe where we’ll be working. His 1 year old daughter Cindy was diagnosed with malaria and tonsillitis yesterday, so she and his wife made the trip with us so she could be seen in the hospital. Maybe she’ll be Aurelie’s patient on the pediatric ward tomorrow, as she looked a little listless.

The weather here has been rainy, so we feel right at home. We are staying on the top floor in a complex of 6 apartments. Our big picture window has a beautiful view of the Rift Valley. Tonight we have a dinner date with Doug and Kathy Trotter. Doug is a family doctor here from Washington. Kathy just took us on a tour of the town and to buy produce at the market. Hopefully we’ll be able to eat the veggies since the sterilizing solution we bought appears to be for “baby bottles and equipment.”

We start work tomorrow morning, and I think I’ll be on the obstetric service. I’m nervous, excited, and looking forward to settling into a routine in Kijabe. So far everyone has been very kind and welcoming. Karibu Kenya!