Thelathini na moja

1/27/2010-1/28/2010
Day 20-21

There comes a time for every blogger when the entries must become sparse. Time is accelerating in our last week here in Kijabe, and days are packed full of activities. To recap the 27th: I rounded out my call night with about 3 hours of sleep (the usual) interrupted by a stat page from the intern at 3:30 am to tell me that Angel was decompensating. She actually made it through the night, much to our surprise, but has been discharged home essentially on comfort care since there is nothing else we can do for her.

The day of the 27th was a blur of exhaustion. We had a few more new admissions. One is a 2 year old girl who was scalded by boiling water. She has burns over at least 17% of her body (let me just take this time to send a shout out to all the Seattle Children’s Hospital residents who create the survival guide. That thing has been nearly as valuable as my N-95 mask.). Another admission is a bounce back of a 2 year old boy with heart failure we discharged about a week ago. He is back with respiratory distress, in failure again. In the time since his last admission, he even had a consultation with a cardiologist in Nairobi (very extravagant and unusual for our patients). Of course we didn’t have the records from his consultation, but after a few phone calls we got a hold of someone in the cardiology clinic in Nairobi (anyone who needs any sort of specialist or a CT or MRI has to go to Nairobi, if you hadn’t deduced that). All they could tell us was that he has a dilated cardiomyopathy (which we figured), and they started him on coumadin, digoxin, and a beta blocker. We had already started him on lasix. That is a lot of medication for one little guy. And a bit scary to prescribe digoxin given there is no way to monitor drug levels in these parts. And Coumadin?!

I managed to get an hour nap in after clinic from 5 pm to 6 pm. Then it was all hands on deck in our kitchen to prepare for our Mexican fiesta with the Kenyan interns. We told the interns the party started at 7:30 pm and they all arrived right on time at 8 pm. The evening was a total hit. We started out with home made tortilla chips (well, we baked tortillas in the oven. The tortillas were made by a woman in Kijabe named Rachel) and guacamole (made by Ben and Matt). The Kenyans were pleased by the guacamole and remarked on how sweet it tasted. As I have mentioned before, the Kenyan palate is much less complex than ours, and few things are actually sweet tasting (aside from the chai which has added sugar). Then it was time for a taco making demonstration by Julie. All 12 of us piled into the kitchen to watch Julie load her flour and corn tacos full of meat and toppings. The Kenyans seemed very dubious about the hard shell tacos and all opted for the flour tortillas for the first round (flour tortillas look somewhat like chapatti, which is a Kenyan staple). The rolling of the tacos was a bit of a challenge, since most piled the tortillas too full of toppings. It was very amusing to watch our friends attempt to eat with their hands. We took lots of pictures. By the time the second round came about, the Kenyans were feeling a bit more adventurous and opted for the hard shells. Both taco types were very well received.

After dessert (no bake chocolate cookies that turned out very sticky) we sat around talking for hours. Just like our dinner parties at home, it didn’t take long for the men and women to form separate conversation groups. From the snippets that floated over to our side of the table, I gathered that the men’s topics included politics (American and Kenyan), cars, and casinos (there are some in Kenya, both Ben and Matt were pleased to find out). The ladies, on the other hand, discussed marriage, childbearing, and African vs Wazungu hair. I revealed that I secretly want to have braids just like all of them, and they revealed they are secretly jealous of our feathery hair that can be washed daily.

At the stroke of midnight, the Kenyans burst into an African version of Happy Birthday. The lyrics went something like this: “Happy birthday Cabou! May you have many many more, may you make a very good wife….” It was glorious, though hard to capture in words. I would post the video on my blog if it weren’t for the atrocious internet connection (getting slower by the day). Our friends left a little before 1 am. Needless to say, after my call night of 3 hours of sleep, the 4 I got last night weren’t the most restful. But it was well worth it. We are going to the interns’ place for a Kenyan feast on Friday. We are loving the cultural exchange.

This morning (the 28th) I stumbled out of bed, rounded on my kids early, and hopped into an “ambulance” (more like an off road vehicle with no backseat) and headed to a rural clinic. I know what you’re thinking: isn’t Kijabe a rural clinic? But no, Kijabe is more like the tertiary care center of Kenya. There are many satellite clinics (or “dispensaries” as they are called here) that the Kijabe docs serve on a rotating schedule every month. I went with Janet, one of the interns, Steven, a nutritionist that I’ve worked with a lot on pediatrics, and our attending. The clinic is in a town called Mukeu, which is about 45 minutes drive from Kijabe on a pot-hole ridden red dirt road.

First I should backtrack and mention I was told to be ready for the driver at 8:30 am sharp outside the hospital. It was a good thing I was ready then, since the driver rolled in at 9:30 am. We arrived in Mukeu around 10:30 am and then stood around chatting with the clinic workers as the patients looked on from their spots on the grass. Then we “took tea” for about 30 minutes as the patients continued to wait without complaint. Then the clinic nurse addressed the patients as a group (who had all gathered on benches by this time), and we introduced ourselves. Both Swahili and English had to be interpreted into Kikuyu, which is the tribal tongue spoken by most of the patients. After introductions, a minister gave a sermon for about 20 minutes. Then it was time to get to work. Most of the clinic space is outdoors. There is a large grassy area with grazing sheep, chickens, and cows. The clinic building itself is brick with about 4 rooms (2 for medical patients, 1 for VCT (aka STI/HIV) testing, and 1 for the cashier who collects money and dispenses the medications. I saw about 10 patients, who each filed in one by one, clutching a small notebook (more like a paper composition booklet that has been ripped to about 1/3 the proper size). This is their own chart, which they bring each time. Each page contains the date (if you are lucky), perhaps a diagnosis, and the plan for the visit. Sometimes the page would say something like “Cough. Give Amoxicillin, Flagyl, Albendazole, return in 2 weeks.”

I had heard that the clinic was mainly for chronic illness maintenance such as hypertension and diabetes. My first two patients didn’t quite fit the mold: a 44 year old woman with hemoptysis (coughing up blood), fever, tachycardia. She definitely needed more than we could provide (no imaging available, no inpatient services). She got a concoction of antimicrobial agents and I referred her for x-ray with strict instructions to come to Kijabe if she wasn’t better soon. The next patient was a 5 month old with fever, respiratory distress, who also got some antibiotics and strict warning signs (hard to follow since most people can’t get to Kijabe easily).

The rest of the patients were a bit more straightforward. I saw a number of blood pressure follow up visits (so easy when there are only 3 meds to choose from), 2 abscesses (I and D’d using a sterile needle and Kleenex both of which I happened to have in my pocket), osteoarthritis, and a patient who was told he needed 7 tetanus shots after an injury (he was back for his second round and luckily I thwarted that plan).

Around 2:30 or 3 pm we were finished seeing the patients and took lunch (chapatti, rice, some stew with unidentifiable meat from an animal I’m quite certain was grazing there earlier that morning). After a stop at the clinic “choo” (translation: hole in the floor that serves as a toilet), we then drove back to Kijabe. Along the route back, we stopped at a produce market which involved rolling into the market and having 25 people swarm the car, pry open the windows, and shove produce at us (I nearly got an eye poked out by a few ears of corn). My Wazungu face was yet again a spectacle. The Kenyans bargained for produce (which is apparently much cheaper everywhere outside of Kijabe) and we returned with about 6 giant trash bags full of cabbage, carrots, potatoes, and beans at our feet. I got 4 ears of corn for 40 shillings. Bargain basement!

Now I am back home witnessing preparation for a grand birthday celebration. Ben is busy in the kitchen making cakes (I say multiple cakes because a few burned in the process – darned altitude and an oven with no temperature gauge!) and pizza from scratch. It is a very impressive effort from Ben after a big day of donating blood at the hospital. Talk about community service! Ben, Matt, Julie and I plan to have a low key birthday bash to ring in number thelathini na moja (you’ll have to look that one up to find out how old I am… which according to the Kenyan interns is practically geriatric.). It has definitely been an amazingly memorable birthday and a great way to wind down our time here. Stay tuned for the last few entries from this tired but very happy blogger.