Packing Up the Skirts and Saying Goodbye

I cannot believe that eight weeks has passed so quickly.  But then again, I was very busy working and traveling.  My last few days were filled with 'lasts' and goodbyes.  Three of the interns invited me over for dinner Tuesday night. They cooked a very nice Ugandan meal of mashed bananas, rice, meat, salad, and custard for dessert. Then we sat around having 'girl talk' for a few hours- it felt like hanging out with my friends at home and was a very welcome evening of relaxing.  Unfortunately, I was on call and had to answer several pages but I was thankful that it worked out for me to have dinner with them before I left.

My last call night was quite busy until around 1am.  During the day, I gave chemo one last time to the Wilms tumor patient and wished his family good luck with the rest of his long chemotherapy regimen.  In the evening, I set up the EKG machine in casualty for a patient with syncope (a pretty major feat); although all the leads were not completely clear, I could read it well enough to tell there was no QT prolongation or heartblock.  Then we admitted a patient with what appeared to be toxic ingestion of a plant or weed with anticholinergic properties.  She had dilated, unresponsive pupils and was making strange grasping movements of her hands towards some kind of visual halluciation she was experiencing.  She calmed with some benzos and thankfully was much improved the next morning, although she still had not voided.  One of the 900g NICU babies died overnight and we had a few deliveries to attend. But I was thankful to get some sleep since I knew the travel itinerary for the next few days was going to be strenuous.

My last morning involved a tearful goodbye to the nurses, interns, longterm doctors, and visiting staff.  I couldn't adequately express what a joy and privilege it had been to work alongside them for two months.  I know it seems like two months is nothing compared to the years that they spend working there, but friendships form quickly when there is a common purpose and a dependence on others for guidance in an unfamiliar environment.  One of the most touching moments of my trip came after I stopped by the NICU to tell two of the interns goodbye.  One of the mothers, whose son had recently been discharged from the NICU, greeted me in the hallway with the typical handshake.  When she learned that I was leaving, she grasped my hand even more firmly and proceeded to walk down the corridors from the NICU past the ICU, down the sidewalk, to the pediatric wards with me, chatting the entire time.  In Kenyan culture, holding hands is a sign of friendship, and I was humbled that she considered me a friend.  Everyday in the NICU she greeted me with a smile and asked how her son was doing.  Even when we were closely monitoring his newly diagnosed PDA to make sure it was not symptomatic, she was calm and joyful.  I watched her patiently wait for two long months for her son to be ready for discharge.  Thankfully, her son was one of the fortunate ones who was able to go home and she was grateful for the care we provided.

I enjoyed one last run in Kenya through the fields and dirt roads around the hospital.  It was a perfect last adventure as we ended up climbing over wooden fences, hissing cows out of our path to the side of the road, running past traditional mudded homes, and asking directions from random children playing in the fields.  Only in Kenya can I feel safe enough to get lost on a run and enjoy it!

We had no troubles traveling from Bomet to Nairobi.  We saw some zebras and baboons along the road, but no giraffes.  We stopped by a souvenir stand along the Rift Valley for the other passenger to buy something he had forgotten on the previous trip.  I needed to spend some shillings and found something I liked as well.  The shop had very high prices, intended for people to bargain down.  I think I bargained well, but when I went to pay, the owner tried to use a much lower exchange rate than the going rate in Bomet.  When I pointed this out to him, I think he finally realized that I was not a gullible tourist and he was not going to be able to make a killing on my sale. I probably still paid a little too much for the item that I bought, but not nearly what he was hoping I would buy it for. 

We ran into some rush hour traffic in Nairobi.  We attempted to avoid the traffic by driving down side streets instead of the main highways for part of the trip.  This allowed me to see the government referral hospital, Kenyatta National Hospital, as well as the outside of the president's house.  Our driver was shocked that Americans have access to the White House and can go on tours and visit without an 'official appointment'.  Their equivalent of the White House stands behind locked gates and barbed wire fences and is only accessible to people with appointments for official business. 

We made it to the airport with plenty of time to spare.  The customs and security process was surpisingly simple.  The lady checking me in was nice enough to ask if I wanted to receive my luggage in Amsterdam as opposed to having them checked through to the US.  Thankfully the airport had a 'fast food' restaurant with decent enough food and quick service to allow us to eat before our flight.  I arrived in Amsterdam tired, having not slept much on the flight, but ready for my next adventure and the option to wear skirts or pants of my choosing!

As this is likely my last blog post, I want to thank the people who made this trip possible:  World Medical Mission, Samaritan's Purse, Duke's Hubert-Yeargan Center for Global Health, and Duke Pediatric Residency Program.  And many thanks to my church family and friends from home who supported my trip and prayed for me while I was away.  I hope the blog provided insight into Kenyan culture and created an interest in medical missions.  Although I'm back home for now, there are longterm missionaries hard at work around Africa who still need prayers and support.  And I hope to return someday.  Until then...thanks for reading!

Helen and another lady help clean the guesthouse and Livingston is the guesthouse cook.  He always wears a white coat while he cooks, usually from one of the departed visitors.

Working in the NICU- I spent many long, hot afternoons here.

Caroline, one of the new pediatric interns.

One of the pediatric patients.

Flower outside the guesthouse that I enjoyed everyday.

Beautiful interesting tree outside the nursing school with small red flowers.



Map of Africa detailing the Great Rift Valley that runs from north to south.

Coke's worldwide advertising extends even to the remote areas of Kenya.



Community Health Vaccine Clinic

Monday I decided to join the community health team at a vaccination clinic about 15 minutes outside of Bomet.  The Tenwek Community Health program has several different components including vaccinations for children, prenatal visits for pregnant women, family planning clinics, HIV/AIDS education and antiretroviral treatment, and water purification programs that include education about prevention of diarrheal diseases. 

In the Kipsigis culture, vaccinations are a high priority because the families understand that they protect their children from illnesses (in contrast to many Americans who voluntarily refuse vaccines).  And since the vaccines only cost the patients 20 shillings each, a few cents, it is truely a bargain.  The government provides the vaccines for the clinics.  Interestingly enough, they also provide birth control in the form of pills and the Depo injection for the family planning clinics.  The community health workers told me that the Kipsigis tribe would have overtaken the other tribes in sheer numbers if they did not have access to the family planning birth control options. But of course, birth control is typically not offered until a woman has at least one child, since children are so highly prized and the culture encourages all women to bear children.  There are many single mothers with children- one single mother got more than she bargained for when she delivered triplets last week! They are currently doing well in the nursery, but who knows how they will do at home if the mother is not able to provide for them and the father is not around.

Today's vaccine clinic was relatively slow, with only about 70 women and children being seen in 2.5 hours; on busy clinic days, they may see more than one hundred women and children.  At the peak of the clinic, there were about 25 women inside a small room and 10-15 waiting outside in the grass.  The community health workers have a well-organized system and very efficiently weigh the child, take a history of feeding and any symptoms of illness, then administer vaccines and vitamin A based on the age of the child.  There were also a few older children that came to the clinic to receive the tetanus vaccine.  And while the vaccine clinic was going on in one room, a smaller back room was used to examine pregnant women. Since these community health workers are not physicians, any serious issues that arise during clinic are referred to the doctors at Tenwek. 

This particular clinic occurs the second Monday of every month at an African Gospel Church.  The pastor was there to greet us and host us during the clinic.  Since I was new, and not very useful in clinic without the ability to speak Swahili, he offered to introduce me to his family and show me his house.  He has a large shamba with tea fields and corn fields.  He also has two wives, 17 children, and lots of grandchildren.  I think I was supposed to be impressed by this.  Our conversation was somewhat limited by his English and my limited Swahili, but he got the point across that he was very proud of his family. His grandchildren were very excited to meet me and somehow I provided entertainment for them just by being there and walking around their land.  His first house had two rooms with the larger room's walls decorated in newspaper pages.  The use of newspaper as wallpaper is similar to the paper printouts used as decorations in the house in Kilgoris. But these walls were completely covered from ceiling to floor by newspapers.  So I guess that's one way to remember important events- just read the wall!  The second house was barely decorated at all, I'm not sure why the difference in the two.  The kitchen was a separate building all together; it was made of a cement type material in a circular shape and had an open fire pit inside as well as space for preparing the food.  He made a point to introduce me to every member of his family, including the ones out in the fields picking tea.  They wanted me to take pictures of them in the tea fields, which I was happy to do. 



After the clinic finished, the community health workers wanted to take lunch in Silibwet.  So we stopped at a hotel (restaurant) and ate a quick lunch before arriving back at Tenwek.  It was only slightly strange that I was the only white person and the only female among the customers, but I had my ndazi while they had their stew and ugali, and we had a good lunch.  They were nice to let me tag along on their clinic day and I was very glad to see the children receiving vaccines. 

The 'clinic' before the women and children arrive.

The clinic after the women and children arrive- the children on the left are waiting for vaccines.

The women on the right are waiting to have their child's weight plotted on the growth chart.

Waiting in line outside to be weighed.

The scale.

Weighing a child.

The outside of the 'clinic' and our vehicle.

The pastor's grandchildren outside their home.

These children thought I was extremely funny- I'm not sure if they had seen a white person before.

Some of the children in the tea fields.

More of the family in the tea fields and the pastor on the right.

Visiting the Nursing School

Friday I had an opportunity to visit the nursing school at Tenwek.  Tenwek has a very reputable nursing school for Kenyan students.  I've interacted with some of the nursing students in the hospital and many of the nurses currently working at Tenwek were trained there.  It is a 3.5 year training program that prepares them to be midwives, general nurses, and community health nurses. The students live in apartments on the hospital grounds during their training. I didn't realize that everyday when I look out the windows in the nursery, the buildings that I see are the nursing school and the apartments.  Most of the nurses here have been great to work with, and a few of them commented that I should come back for 2 years next time, because 2 months is not long enough!

The student nurses wearing their new scrub caps.  The second student on the left always seems to have some question for me about my orders in the NICU and patient management.  They tend to address me as 'Chancey' since first and last names are used interchangeably here.

The nursing school building, completed in 2000.

The nursing school library.

The mannequins used as practice patients. Many of the items used at the school are donated from missionaries.  Apparently the white mannequin arrived first and the students felt that it did not provide appropriate training since they would be taking care of black patients. So the school had to seek out a black mannequin for the students.  The only clinical difference I've encountered here is the challenge in detecting cyanosis and erythema in dark skinned patients, and I don't think the mannequins are able to display those exam findings!

Beyond the nursing school, the patients have an area where they can wash clothes and hang them to dry.  I always see the mothers coming and going with baskets of clothes, it took me a while to realize they were doing laundry outside the hospital.

Laundry time for the patient's families.

This is the file room at the hospital where all the patient charts are stored. 

I asked for a deceased patient's chart and I was surprised that she could find it so quickly in the many stacks of papers.  They have some kind of filing system, but I imagine they will soon run out of space given how full the room is already.

Delivering Bad News

As I resident, I have to practice delivering bad news to families.  Every year, we are sent into a room with fake parents to practice telling them their child has cancer; it's always the same set of actors and a similar story.  I never really enjoyed the exercise, but I guess it was helpful.  I anticipate having to deliver bad news in the bone marrow unit next year.  But this past week has provided more than enough experience in delivering bad news.  I think I can safely tell my program director that I don't need any more practice!

With the long term missionaries gone, another visiting doctor and I have been in charge of the pediatric ward, ICU, clinic, nursery, and the new interns.  I was hoping things would be calm while everyone was gone, but it has been very busy.  Not only have we had sick patients, but we have had more procedures in one week than is typical.  I've done 4 paracentesis this week (compared to none in the US), helped the interns with several LP's, intubated one live baby, instructed the interns in how to intubate a baby who died, and placed an IO in one baby and coded or semi-coded several babies.  I've told a mother that she's Hepatitis C positive and infected with syphilis, explained to a family that their child with end-stage HIV was not going to survive, and discussed extubating a patient who was likely brain dead with a family who probably didn't understand much of the conversation.

My week went like this:
Day 1 with new interns: Oriented the new interns to peds- which means explaining all the tedious math we do to dose medications and give IV fluids, and introducing them to the foreign world of premature infants in the nursery.  I helped an intern do her first lumbar puncture on a pediatric patient.  I consulted on a patient outside the ER after the clinic has closed. The clinic intern very diligently obtained an EKG from ICU which means that she set up the leads and did it herself after reading the instructions on the machine! Only lead I was readable, but I thought it was consistent with atrial enlargement. And the patient had a new murmur, which typically means rheumatic heart disease. This was confirmed by echo the next day; he had mitral stenosis. 

Day 2:  A patient with end stage HIV/AIDS died after lunch.  This occured while we were simultaneously trying to do a lumbar puncture on another girl, go to delivery resuscitations, do OB consults, discharge a patient home because his sister just died and his parents needed to leave, and give chemotherapy to the Wilm's tumor patient who had been waiting all morning for his lab results.  Needless to say, it was a little crazy and we started afternoon rounds very late.  In the evening, I did a paracentesis on the baby with hepatic insufficiency and ascites. Then I found out mom had hepatitis C in addition to syphilis. This patient died later in the week and I had to spend time explaining to the mother then the father the circumstances surrounding his death, which included a lot of 'I think this is what happened' since there are limited diagnostic tests available.

Day 3 on call: I arrived at hospital to find the family practice doctor attempting access on an unresponsive child on the floor.  Since we were unsuccessful with IV access, we attempted IO access.  The IO's here are the old-fashioned kind where you have to push and grind the needle in.  My first attempt I went into soft tissue. My second attempt I went into bone, but the line did not flush.  A surgery resident came to help us obtain central access and she repositioned the IO into a better space, but by then fluid was leaking out of the first hole I had created.  So we attempted access in the second leg, but an IV had already infiltrated there previously. The IO went into the bone and we used it for 30-45 minutes before the leg swelling worsened.  Attempting to bolus fluids here is a challenge because they use the 'drip method' where fluids are hung on a nail and drip in as fast as they can.  Squeezing the bag only results in fluid leaking out the needle that has been inserted as a pop-off valve.  So I got sprayed more than once while attempting to bolus fluids.  Another option is to extract 40-50 ml of fluid at a time and push it in through the line, but this also is very slow and tedious.  We 'coded' the child for several hours, but the codes here are often done with less intensity than in the US.  This child received lots of fluids, dextrose, code drugs, antibiotics, etc.  But the surgery resident was placing a central subclavian line as the patient was becoming bradycardic.  So my compressions were one- handed under the sterile dressing.  We had two new interns observing and multiple other curious nurses peeking in through the door, while all of us were working in a space the size of a large closet.  The patient made it through the day but coded again overnight. We had already decided that given her underlying hydrocephalus and newly placed VP shunt, we were not going to intubate her.  So she died and I had to deliver more bad news to this family.  

The rest of the morning consisted of rounding on very stable patients and sending them home, then finding several very sick ICU-worthy patients who were on the floor because there was no room in ICU, and attempting to improve their management without a true diagnosis.  One of them actually did get better with the management I suggested for his hepatic encephalopathy, but we diagnosed hepatitis B and had to discuss this new chronic illness with his family. And since he likely acquired it perinatally, we had to suggest the parents also get tested.

Day 4, postcall, was no different. There were more critically ill patients.  We were called during lunch to assess a patient with respiratory arrest in casualty. I attempted to intubate but was only successful in passing a 3.0 tube, not the 4.0 tube required for the patient's size.  The surgery resident who assisted with the IO came to assist with the intubation.  While this was all going on during lunch, I was supposed to be giving a lecture to the interns. So I missed lunch, showed up 20 minutes late to the lecture, then went back to ICU to set the ventilator for this patient who had been intubated and bagged in casualty.  The patient's story was very strange; he had been sick with TB or pneumonia-like symptoms for a while, but then was getting better. He was running and playing the morning of presentation when he suddenly cried out in pain and had a change in mental status.  His lumbar puncture was very bloody with high protein count and we were potentially thinking TB meningitis. But his story was more consistent with an intracranial bleed, although he had no known risk factors and there is no imaging study available to diagnose it.  Although we ventilated him overnight, he did not improve; he was unresponsive to any stimulation and had fixed and dilated pupils.  So I spent a long time on Day 5 discussing the prognosis with the family and the fact that he was probably already brain dead but we were keeping him alive with the ventilator.  They agreed to extubate him.  The only request they had was that a photograph be taken of him.  He was two years old and they did not have any pictures to remember him by. There was no available hospital staff with a camera so I took the family picture.  The mother did not want to hold the child because she was fearful, so the father held him.  Unfortunately, soon after we extubated him, he stopped breathing and died.  We were able to allow the interns to practice intubating him, since it's a skill they'll need to learn if the rest of their rotation is anything like this week.

Days 6 and 7: I was on call this weekend and we were very busy.  Saturday, we saw several patients in casualty with enlarged hearts.  One had heart failure from rheumatic heart disease; he had the largest heart on CXR that I have ever seen- it filled the entire chest and there was barely room for lung tissue.  We did a paracentesis to relieve some of the pressure from his ascites and gave him some lasix but did not admit him because there was really not much else we could do for his heart failure.  We suggested that he go on hospice.  Rheumatic heart disease is killing so many children here, it is unbelievable.  Another child had an enlarged heart likely due to high output cardiac failure from severe anemia.  Another child had a cyanotic congenital heart lesion and was still doing well unrepaired at age 6-7!  His clubbing of the nails and fingers was more severe than any I've seen.  He was stable enough not to admit, though. 

There were several deaths in the NICU including one VLBW micropremie, HIV exposed. Unfortunately, this mother has had multiple OB complications and many of her children have died.  I felt so bad for her.  But as I called the chaplain to talk with her after her baby's death, I also asked the chaplain to talk with the mother of the other micropremie who has been unstable.  The second mother accepted Christ after talking with the chaplain.  We transferred one baby to ICU who was in respiratory failure but the mother did not have enough money to intubate the child and ventilate him, so the child died.  His heart stopped, he was not breathing, he was cool, and he had no pulse.  After having the conversation with the mother about whether or not to ventilate him, I had to tell her that he had died.  I left to go finish rounds and the nurse called me 20 minutes later to say that the patient was breathing again and had a heart rate!  They were about to take him to the morgue when they noticed!  I can only say that it was a miracle.  I am treating him for pneumonia, but he is HIV exposed and I do not have his HIV PCR results to know if he is positive or negative. So he could have some opportunistic infection that I am not adequately treating.  But at the moment, he is doing well.  All I can say is that for many of these children, they get better in spite of my limited knowledge and ability and the limited resources here- there are definitely miracles happening.
 
Amongst a week of craziness, I laughed when I saw a Masai father on the wards with his long earlobes slung over his upper ears.  It made me think of the children's song
'Do your ears hang low? Do they wobble to and fro? Can you tie them in a knot? Can you tie them in a bow? Can you throw them o'er your shoulder Like a Continental Soldier? Do your ears hang low?'

The family who requested a photo of their son.

The one month old with massive abdominal ascites, hepatosplenomegaly, exposed to syphilis and hepatitis C who later died.

Random Events

I know I'm behind in posting blogs, but it's been a really hectic week on the pediatric service.  Stay tuned for details in the next blog post. 

It's rainy season and yes, there are heavy afternoon showers.  But one storm recently was more powerful than anything the area has seen in a long time.  It was a very intense 20 minute rain storm with winds so strong that many trees and power lines were knocked down.  One crashed down on the souvenior stand outside the hospital. Another hit the roof of a house.  Some of the missionaries were without power for a day or two.  I'm told this storm caused more damage than the area has seen in many years.  But what was more impressive than the storm's strength, was the rapid response of the workers to clean up the debris, replace the power lines, repair roofs, and chop down trees that were damaged.  They also decided to chop down trees that were not damaged, but were near houses or powerlines and could potentially fall in a future storm.  Visitors will not recognize the area  the next time they come because so many trees have been chopped down. So now there's an ample supply of wood for whatever project someone comes up with!

Heavy rains during the storm.

The winds made the rain fall almost sideways.

Last Sunday after church I attempted to bask in the sun like my patients do.  Unfortunately, given the heat of the midday equator sun, I only managed to lay out for about 15 minutes.  But it was nice while it lasted!

Last Sunday's lunch was with Gladys, the guesthouse coordinator.  Her children don't speak much English, but they are always playing and running around the guesthouse.  This is a picture of Gladys' daughter, who is very cute and photogenic.

One of the orthopedic doctors who arrived a few weeks ago brought a lot of handmade dresses for the pediatric patients.  I'm sure the group of ladies who made the dresses intended them to be worn by the little girls, but the mothers wanted their little boys to have a dress, too.  So I spent one afternoon handing out the dresses to the patients and their families.  Everyone chose the brightest colored dress in the stack.  A few days later I actually saw a patient wearing the dress, so I thought I'd take a picture.  Notice she's wearing the dress over her regular clothes.  This girl survived a RTA (road traffic accident) and had an open skull fracture and exposed brain tissue.  She was in the ICU for a while, required a dural flap, but is now doing well and planning to go home soon.

Before Peter (anesthesiology) and Roche left, a South African couple currently living in Canada, I took them up to Motigo to see the sunrise.  They thought I was crazy to run up the mountain in the dark, but after they got to the top and saw the sunrise, they agreed that it was worth it.  These photos are from Peter's camera.  They were very fun to hang out with and invited me over for dinner before they left.  Peter was amazed to meet someone shorter than his wife.

Jeff, Roche and me at the top of Motigo.

Peter, Roche, Jeff, and me on Motigo.

Work mule carrying a load down the hill to Motigo.

Curious child along the route.

Story from Motigo: Peter and I ran up the mountain ahead of Roche and Jeff.  I failed to give Roche and Jeff complete directions and thought I had time to show Peter the top of the hill then go back down to the road to get Roche and Jeff.  But they were not as far behind us as I thought and so they passed the turnoff and I had to go searching for them.  Thankfully, I had been taught a useful phrase in Swahili during my trip to Uganda (in case I got separated from the guys): mzungu wapi?  Where are the white people?  So I asked a man along the road and he directed me to the runners.  They were impressed with my Swahili and decided to store that phrase for future reference.
On the way back down the mountain, Roche and I ran ahead of the Peter and Jeff.  Roche didn't want to wait for them at the turnoff, so she creatively made an arrow to direct them to the bridge over the dam so they wouldn't get lost.

Hill by the dam.

River feeding the dam during rainy season.

Bomet sells everything you need circa 1995

Three of us went to Bomet Saturday morning to explore the market and the town.  It's the closest town to Tenwek but it's definitely not an exciting town by American or Kenyan standards.  It was fun to wander around, though.  The open air market is close to the matatu station, so drivers thought we were interested in taking a trip somewhere, because what white person in their right mind would want to spend a day shopping in Bomet?  So we were offered multiple trips to Kericho, and gracefully declined all of them.   Our shopping experience included visiting dukas (little stalls) that were selling luggage, toiletries, sweets, mens shirts, cosmetics, socks, and other various items, including Titanic movie posters from the late 1990's.  There was even an entire store full of VHS videos.  In addition to little stalls, there were also people set up along the side of the street selling things.  One woman was selling warm winter sweaters; the irony is that she was using an umbrella to shade her from the very hot sunny day.

There were multiple hair salons around the marketplace.  Apparently Saturday is the day for hairdressing.  We got an impromptu lesson on African hair braiding from a very nice hairdresser.  And we answered many questions from her about haircare for mzungus!  She seemed amazed that we have to wash our hair several times a week and that we never put oil in our hair.  She declined a request to braid our hair stating that it was too thin and wouldn't hold well.  This entire 15 minute exchange occurred while she was braiding a girl's hair. She allowed us to take pictures of the hair but really only wanted us to see the finished product, which she said would take another 30 minutes.  Unfortunately, we didn't make it back there to see it.

We bought some produce from the produce stands.  The fruits and vegetables are so cheap and so fresh.  Mangos and avocados are especially cheap and really delicious here.  I found an explanation of some of the typical Kenyan foods that I thought I would share to explain what I eat on a regular basis in addition to the fresh fruits.

Ugali - I didn't have ugali until I went to Nakuru last week, but it is definitely a Kenyan favorite and staple part of the diet.  It is a semi-hard cake made of maize (corn) flour or millet flour.  I don't know what everyone has been raving about, it was very bland.  Apparently if you ask patients at the hospital, they will say they haven't eaten in days despite the hospital food they're provided because they have not had any ugali.  And I was told by one of the ICU nurses that only real Kenyan women cook and eat ugali. So I guess I'm not authentically Kenyan, then, because I don't desire to cook or eat any more ugali.

Sukuma Wiki - a vegetable stew made of leafy green vegetables, mainly collards or kale. It is served with many Kenyan meals. The word ´sukuma wiki´ means ´to stretch the week,´ implying that sukuma wiki is a food used to stretch the meals to last for the entire week. 

Chapati - a round, flat unleavened bread cooked on a griddle to a soft brown color.  It is often served with meat stew and vegetables.  I asked the lady in charge of the guest house to give me and one of the guest house cooks a lesson in preparing chapati.  It is really good and I enjoy eating it with many different dishes.

Pilau - rice flavored with Indian spices. It is a common dish served during Kenyan parties, celebrations and festive seasons.  I've only had it once or twice, but it is more flavorful than the white rice that is typically served with meals.  Rice is definitely a staple in the diet and eaten all the time.

Irio - potatoes mashed with beans and peas or maize and pumpkin leaves, then sautéed with onions and served with either beef stew or vegetables.  I had irio last week at a restaurant in Nakuru.  I actually liked it; it was definitely much better than the ugali.
Maandazi - deep fried dough (similar to doughnuts- or funnel cakes without the powdered sugar) served for breakfast with tea or coffee, late afternoon snack with tea, or anytime really.  We have maandazis with chai before rounds at least once a week at the hospital.

Samosa - a deep-fried, square-shaped, meat-filled dough that is served as a snack or appetizer.  We were discussing whether or not one of the Kenyan doctors would make samosas for us; one girl recommended putting apples, sugar, and cinnamon inside instead of the meat.  She wanted to make a dessert samosa, then realized that McDonalds had already claimed that idea in the fried apple pie!

Uji - porridge traditionally made from fermented millet, corn flour mix or a mixture of millet flour, maize meal and powdered milk. Because of its high nutritional value, uji is a popular drink prepared for infants, adolescents, nursing mothers and those who are sick.  See below for a woman actually selling cups of uji during market day.

Market stall in Bomet.  All the produce is fresh and delicious.  I bought a large avocado for 10 shillings (12 cents)!

The butcher's shop with a fresh leg of something hanging in the back.

There were several fabric and textile stores.

We received a lesson in African hair braiding from one of the salon owners.  They sew fibers into their own hair to make these elaborate braiding designs.  The hair cannot be washed or get wet or the braiding will be ruined. When they are ready to change the hair style, they cut the attachments of the fake hair, unbraid their real hair, and wash it with water then lather with oil.  Hair braiding is quite an elaborate process that can take several hours.  But it was the thing to do on Saturday; we saw several busy salons.

A woman selling cups of uji.  We use special uji all the time at the hospital for the malnourished children. I didn't realize people sold it by the cupful in town.  Kenyan's consider a 'full' cup to be at the brim, almost overflowing, as evidenced by these very full cups.

Shopping for skirts at the market.  They display what they have; if you don't see what you need, you are out of luck.  If you are wondering what will fit, the lady in charge will select some items then hold them up to you to estimate fit.  There are no dressing rooms, although I did manage to try on a dress over my shirt and skirt at a different shop.

Dried minnows.  I'm not sure who eats these delicacies, but I also saw them being sold in Kilgoris.  One of the missionaries bought some for her cat, but even the cat refused to eat them! 

Buckets of coal for sale.  Coal is one of the major forms of energy used here.  There were at least 50 buckets of coal for sale lined up along the road.  The buckets are overflowing, so I'm not sure how people manage to carry them home, especially if they plan to carry them on their heads or via donkey!

The grocery store has good ice cream (by Kenyan standards).  It alse has an entire section devoted to thermoses for keeping chai (tea) warm.