Still More to Learn in Week Six

I can't believe this is already week 6 of my trip.  This is the last week the current group of interns are on pediatrics before they switch services.  And all the long term doctors are preparing to leave for a retreat in the next 1.5 weeks.  I hope I've learned enough about the Kenyan pediatric protocols to teach the new interns how to care for the patients and manage the patients myself while everyone is away!

Today, I saw a 24 week old stillborn infant with anencephaly (absence of a brain), open spinal cord, and large oomphalocele.  It was definitely the most depressing thing I've seen so far.  Apparently there are a lot of pregnancies here that result in anencephalic fetuses.  And there's a fair amount of spina bifida as well.  Last week I attended the resuscitation of a full term infant with large hydrocephalus, bilateral club feet, and an open lumbar myelomeningocele.  When I asked the OB's why neural tube defects are so common, they listed several possible reasons.  One, dietary folate deficiency is common.  Two, many pregnancies are not planned so women do not take folate supplementation prior to conception.  Three, many women do not come for prenatal care to receive folate supplements.  Finally, the women who have a history of anecephalic pregnancies are not aware or not motivated to take the megadoses of folate recommended to prevent repeat spinal column defects.

I learned today that risus sardonicus is the term for the facial muscle spasms that occur in tetanus.  We had a patient with grade II tetanus who presented with risus sardonicus, but I didn't get to see it because he improved rapidly with diazepam and was sent home after a few days in the hospital.  I'm also learning that caterpillars can be dangerous and lead to limb amputations.  Now that the rainy season has arrived, there are numerous hairy caterpillars crawling around.  Their spines are poisonous and a sting from their spines can lead to secondary infections that may require amputation if the infection is severe.  The surgeons are potentially amputating 5 patients' hands this week due to caterpillar stings!

We are celebrating another birthday tonight with chocolate cake and nutella frosting- delicious.  We had home-made brownies with reeses pieces over the weekend, but the Kenyan housekeepers threw the leftover brownies away- I don't think they understood what they were doing!

A Kenyan spacer for inhaler medications- originally a coke bottle.  When asked where I'm from, everyone can relate when I say, "Atlanta, the home of coca-cola."

One of the malnourished patients who has been discharged but is at the hospital until her family can pay the bill to leave.  With this system, we actually observe patients improve even after discharge (or readmit them if they stay long enought to get sick from the other patients).

Ophthalmologist doing ROP exams in the NICU.

A Kenyan breastpump.

Cephas and Lando's last week on the pediatric service.

Dan's birthday dinner at the guest house with Todd, Heather, Rachel, Patty, Annette, and Roche.

Day Trip to Nakuru

After hearing about all the animals and flamingos in Nakuru Park, a few of us decided to take a day trip to Nakuru this weekend.  Although I wasn't post-call like the last time I went on safari, I had been on call Thursday night and then was invited to a pizza dinner and game night at my attending's house Friday night.  So the 6am start time for our trip felt really early, but was necessary to travel there and back in one day.  It was a three hour car ride and we passed some of the same large tea plantations I saw on the way to Uganda.  Nakuru is actually one of the largest cities in Kenya, after Nairobi, Mombasa, and Kisumu.  We arrived at Nakuru Park before most of the other tourists and started our 3.5 hour mini-safari.  Although we didn't see any big game this time, we did see some beautiful birds including flamingos, pelicans, storks, and others.  The flamingos used to be very numerous in the lake, but pollution or climate change has altered the lake to the extent that many flamingos have migrated elsewhere.  We saw some flamingos, but not the hundreds that used to be there in the past.  But the trip was still fun because we actually got out of the car to walk around and the animals were closer to us than at the Mara safari.

We ate lunch at a nice restaurant in Nakuru after leaving the park; we actually ran into three people at lunch who were also traveling from Tenwek!  Then we ventured outside of the city in search of the Menengai crater.  After driving down a few wrong roads, and discovering that the correct roads only half existed due to gapping trenches created by heavy rains, we finally found the crater.  It's actually an extinct volcano, and I'm told it's the largest above ground caldera, 2,300 meters above sea level.  We arrived just before the afternoon storms, so we couldn't stay very long.  Thankfully, we made it down to the bottom before the torrents started; we didn't want the partially existing roads to become nonexistant while we were riding on them.  After the rains stopped on the way back to Bomet, we saw a beautiful rainbow. 

We made it back in time to attend the goodbye party for one of the missionaries who has been here for six months.  Most of the people in the guesthouse have left this week or will be leaving next week, so it's going to be a little less exciting around here until the next group of visitors arrives.  It's fun to meet so many people from all over the US and form friendships that can continue longterm, but it's sad when they have to leave.

Beautiful fluorescent blue bird.

Storks.

Pelicans.

Zebras.

Flamingos.

Baboon.

Very colorful lizard- probably one of the coolest sightings of the day.  I enjoyed watching him warn us away by bobbing his torso up and down.

View of the area around Lake Nakuru.

Lake Nakuru.

The toilets in the park advising us to 'Please observe cleanliness.'

Giraffe.

Small waterfall in the park.

These rhinos did not like the camera and ran away from us quickly.

Lemurs.



Directional sign at the top of the crater's edge.   



Menengai crater.

Tea plantation; the tea fields spread over at least 10kilometers and were originally planted by the British in the early 1900's.

Rainbow after the storm.

Pet Camelions and Call Night

Eating lunch with Missionary Kids is always interesting- they have a completely different perspective on Kenya, America, and life in general.  Yesterday I had lunch at the home of a general surgeon and his wife.  They have two girls ages 5 and 2.  The 5 year old loves animals but wants to be an ophthalmologist when she grows up.  She has a pet frog, a pet camelion, and wants a pet dog, but currently is pretending that a rock is her pet dog (she even drags the rock around with a leash!).  When she moves to Burundi in a few years, she is planning to have a goat, a cow, a rooster, a chicken, and any other animal permitted by her parents.  At lunch yesterday, she presented her pet camelion to me at the dinner table- and by presented I mean she basically stuck it in my face- and asked if I wanted to watch it eat.  So we took the camelion outside and searched for flies.  Once we spotted a fly, we slowly crept towards it, taking care not to scare it away.  Then we put the camelion about 6 inches in front of the fly and watched it focus in on the fly with its eyes.  Then the excitement started- the camelion suddenly extended its long tongue to catch the fly and bring it back to its mouth.  It was very entertaining!  We fed it three flies before we were satisfied.  I should mention that this camelion is pregnant and will likely have 10 or more babies if it's anything like their last pregnant camelion!

Yesterday's call night included monitoring a young girl on Bipap for worsening pneumonia.  Her saturations were dropping and I thought I was going to have to intubate her overnight.  I called the respiratory therapist to assist me in setting up the ventilator.  When she arrived, she discovered that the oxygen delivery to the hospital was malfunctioning and the patient was actually only getting a fraction of the oxygen that we thought she was getting.  So we didn't have to intubate the patient after all, just fix the oxygen delivery problem!  Of course, that required contacting maintanence in the middle of the night, bagging the patient for the hour or more that it took to correct the problem, then discussing with the medical supervisors why no alarms sounded for the low oxygen.  Thankfully she is continuing to improve.  I have seen only 2-3 patients discharged from the hospital after requiring an ICU stay, hopefully she will be one of them.

Yesterday's afternoon rainstorm was pretty intense and even included large hailstones! I still haven't gotten used to the intense rainstorms that come and go every afternoon.  But the foliage is so much greener and alive after the rain, and thankfully the electricity goes off less often after the rain provides water for the electricity generator.

Xray of a 5 year old girl with bilateral hilar lymphadenopathy likely due to TB.  She has protein energy malnutrition and is not gaining weight well even on high calorie feeds in the hospital.  After discussing with the nutritionist, we sent her home on special uji feeds, a form of millet porridge that the kids actually like to drink.

Using a home Bipap machine and adult-sized mask to provide Bipap to an ICU patient.

One of the best parts of NICU rounds is holding the babies!  These are two of the quads who turned 40 weeks gestation this week.  Instead of being told to come back later to examine the babies, I can examine and even hold any baby I want during the day.

Work, Water, Worms, Wilms, and Wonderful American Food

Well, I was on call this weekend for 48 hour straight.  Although it could have been potentially very brutal and busy, it was actually not bad at all. As the only pediatric consultant in the hospital, I rounded with the interns on the pediatric wards and the nursery.  Two interns were off, one intern left postcall after rounding on the wards, and one intern was on call. Saturday was calm until around 4am when I was called to resuscitate a sick infant in casualty who needed fluids, antibiotics and admission to the ICU for septic shock, acute renal failure, and severe dehydration. Sunday rounding was a little crazier because there were 45 babies in the NICU and many of them were very sick.  I diagnosed a baby with congenital heart disease on Sunday (and admitted another patient with CHD on Friday- only because I had been thinking there were not many cases of CHD here). Of course, they have to be referred to Nairobi because there are no pediatric cardiologists here.  The worst part of rounding in the NICU Sunday was being there during three feeding sessions with the mothers; it is very hot and very challenging to examine the babies when all the mothers come.  I didn't finish in the NICU until almost 7pm! Thankfully there was only one delivery at 6:30am, but unfortunately that baby died later in the day likely due to early GBS sepsis. 

Since I wasn't traveling this weekend, and there were fewer pages on call than expected, I actually had time to enjoy socializing with the other visiting residents.  Unfortunately, the current group of visitors is leaving soon.  But new people are always coming in.  Friday night we watched the African Queen and Saturday night we watched the Lion King, although it was not as exciting as I remembered. Sunday evening we had a fire and a birthday party for one of the visitors.

The food this weekend has also been very good.  After being here a month, there are some foods that I've started to miss from home.  I miss spicy Mexican food and frosted mini-wheats cereal with skim milk.  I plan on having both when I get back to the States. :)   The long term missionaries celebrated St. Patrick's Day on Friday with a potluck dinner that included fantastic American food and desserts.  Saturday, I was invited to lunch with one of the doctors and he introduced us to 5-minute Artisan bread, which I will have to attempt to make when I get back to Durham.  Saturday night dinner consisted of home made pizza! It was definitely much better than the 'pizza' the guest house cook makes, which includes beans and chili as the pizza sauce. This pizza was made with fresh pineapple, bell peppers, bacon, onions, mozarella cheese and tomato paste.  The dessert pizza was even better; we compiled all the sweet things we could find around the guest house to put on the pizza.  This included nutella, peanut butter, cinnamon, chocolate chips, and pineapple.  Although it may sound like a strange combination, it was really yummy.  Sunday night we had cake and ice cream during the birthday party. And Monday night we had poppyseed chicken and cinnamon rolls.  Definitely a good weekend for eating 'real food,' although there were a few meals with chipati, rice, and beef stew, too.

According to the locals, winter weather has arrived.  Everyone is wearing jackets.  Rainy season has also started and the rains are very unpredictable, as far as I can tell.  They say the rain typically comes in the afternoon between 1-3pm, but it has rained in the evening, in the early mornings, at lunch, and all day long.  I've tried to be prepared by taking my umbrella to the hospital, but inevitably I either have my umbrella when I don't need it or leave my umbrella at home when there is torrential rain.  I have had to run home in the rain due to not having my umbrella.  The rainy season makes running a little more challenging because it is hard to predict when there will be an hour free of rain in which to run. And the rain creates paths of mud with large mud puddles that make for a very slippery terrain and create very heavily caked, muddy shoes.  But I managed to run up Motigo this morning in the mud without too many problems.

A few more strange sightings around the hospital:

-a girl with heavy shoes that weigh more than she does and go 'clomp, clomp' when she walks down the hall

-a mother leaning over the bed to breastfeed her crying infant while we are attempting to place a foley catheter to obtain urine

-ROP exams being performed in the NICU by a retinal specialist

-starting chemotherapy in Africa on a Wilms tumor patient

Now for some medical cases and graphic medical pictures!

NICU surgical cases from this weekend:

1. 2 week old male presenting with abdominal distension and left scrotal swelling that started 8 hours prior to presentation.  He was a full term infant born via SVD with normal stooling and urination. His parents are farmers and mom's serologies are negative.  He was being fed herbal medications daily.  He has no history of omphalitis. On admission, he was crying in distress and had a very tense abdomen and mild tachypnea without retractions.  An xray of the abdomen showed no dilated loops of bowel, no obstruction, no free air, and no obvious fluid collections.  An abdominal ultrasound showed normal anatomy without ascites.  His admission labs included blood gas 7.514/16.5/58/13.3/-10.  WBC 3.9, repeated 27.4 (N 100). Hgbl 14.1/hct 36. Plts 26, repeated 98.  His urinalysis showed dark urine, ph 5.0, WBC 1-2, RBC 10-20, bacteria 4+.  He was taken to the OR the next day for ex-lap.  The surgeons found thick pus throughout the abdomen with fibrous caking. There was no perforation of bowel but there were dilated loops of small bowel secondary to ileus.  He was diagnosed with primary peritonitis of unknown etiology and started on antibiotics.  He is currently doing well. 

2. 3 week old preterm infant being fed herbs and breastmilk at home who developed 3 days of abdominal swelling and yellow vomiting. He was passing stools.  His admission exam was significant for tense abdomen, tachypnea, and no stool in the rectal vault.  His xray showed distended loops of bowel.  An ex-lap showed distension of the cecum due to a collection of herbs and cecal necrosis. He underwent cecal resection and anastomosis of the remaining bowel.  He is currently doing well breastfeeding.  Apparently part of Kenyan culture includes bathing infants in herb water and then giving them the same herb water to drink! 

3. Preschool child presented with abdominal distension and small bowel obstruction.  He was taken for ex-lap and found to have worms obstructing the bowels!  See below for graphic pictures.  Most of the children on the wards are dewormed during admission, especially those that pass worms in their stool, vomit worms, or have severe malnutrition.  I'm told that children are also routinely dewormed a few times a year as an outpatient.  Better to deworm frequently than to have bowel obstruction!  I may even consider taking medicine to deworm myself before leaving, just in case. 

4. We have had two patients with Wilms tumor in the past 5 days.  The first patient presented to casualty with huge abdominal distension, but was stable enough to be referred for an outpatient ultrasound and surgical followup.  The ultrasound confirmed a large right kidney mass and he was taken to the OR for resection yesterday. The turmor was the size of a small soccer ball and his IVC was removed from the renal veins to the liver due to the location of the tumor.  We are actually going to start chemotherapy on him tomorrow!  The other child presented with massive abdominal distension but was not stable enough to have surgery and he passed away. 

Enlarged ileum filled with worms.

Squeezing the worms out!

A bowl full of Ascaris worms.

A Tenwek ambulance.  Ambulances are not used often because of the huge expense incurred by the patient for transportation via ambulance.  We attempt to stabilize patients prior to referral then send them via private car (or less desirable, public matatu transportation) to Nairobi or Eldoret for consultation. 

The schedule board listing all the surgical cases scheduled for Monday 3/21.  The surgeons are always very busy.

The hot, sauna like NICU becomes even more crowded with the nursing students rotating through.

The nursing students rotating through the pediatric wards learning how to measure middle upper arm circumference to evaluate malnutrition.  We had several shining examples of malnutrition to show them!

Examining a patient during rounds with Cindy.



A 2 year old that presented to casualty with a huge abdominal mass, thought to be malignancy.

After ultrasound confirmed Wilms tumor, surgery removed a soccer ball sized tumor involving his right kidney.  We are going to start chemotherapy tomorrow!



An aerial view of Tenwek.



Strange Sightings Around the Hospital

- 40 pairs of red or blue flip flops in a bin by the nursery door so the barefoot mothers can come in and wear flipflops while breastfeeding their babies
-10 extra nursing students in the NICU making for a very crowded, hot room with 5 nurses, 10 nursing students, 5 doctors, 30 mothers, and 35 babies
- a 7 month old infant weighing only 2 kilograms!
- red, cloudy peritoneal ascities fluid in a boy with possible TB peritonitis
- an intern wearing Halloween scrubs because she thought they were fun; she had never even heard of Halloween
- Kenyan Christian music videos blaring loudly on the wards while we are trying to round and examine patients
- bribing the interns with ink pens in order to pay attention to my lecture today
- diffuse pustular rash on a 10 day old infant born at home
- rapid deterioration of an infant with progressive bullous hemorrhagic lesions as well as circular purpuric palpable lesions progressing to vesicles of unclear etiology (no biopsy available)
- two entire hospital days without a working CBC machine; but interns still order CBCs just in case the reagent arrives before the anticipated date
- resuscitating an infant on a table or on a medicine cart because the only warmer available is in use by a surgical patient
- celebrating match day around a fire roasting marshmellows despite the 55-60 degree weather :)

Emily doing a paracentesis

The very cloudy red (nonclearing) ascitic fluid

Large pustular rash on a 10 day old infant born at home

Skin lesions on an infant who died; hemorrhagic bullae

Same infant with palpable circular purpuric nodules on legs

Nodules turned into small bullous lesions

Safari Weekend

After taking call Friday night and running up Motigo to see the sunrise Saturday morning, four of us left Tenwek for our weekend safari.  Safari is the term Kenyans use for any trip, but this safari was the typical American idea of a safari, complete with wild animals, great food, and beautiful landscapes.  We traveled 2 hours south to the Masai Mara in the Great Rift Valley.  According to http://www.game-reserve.com/kenya_masai-mara.html, 'There are four main types of topography in the Mara: Ngama Hills to the east with sandy soil and leafy bushes where black rhinos live; Oloolo Escarpment forming the western boundary and rising to a magnificant plateau; Mara Triangle bordering the Mara River with lush grassland and acacia woodlands supporting masses of game especially migrating wildebeest; Central Plains forming the largest part of the reserve, with scattered bushes and boulders on rolling grasslands favored by the plains game.' This large plain continues through Tanzania as the Serengeti.

Saturday, on our way to the Mara, we passed a very large open air market.  Women set up wooden stands to sell all kinds of fruits, vegetables, and clothes.  The goods for sale are transported to market by mule or donkey.  So the most interesting part of the market for me was seeing around 50 donkeys tied to posts or fences along the dirt street!  Access to the Mara is down a VERY rocky road, it felt like we were being jerked around the entire trip.  We passed HUGE aloe plants and cacti.  We also passed some Masai huts and small villages. The amazing thing is that the Masai herd their goats and cows in the same land where the wild animals live.  And they live near the zebras, cheetahs, giraffes, and other animals without any  problems.

We stayed at a very nice resort called the Fairmont.  Most visitors to Tenwek stay at this location, although there are many other nice locations.  http://www.fairmont.com/marasafariclub.  We were greated by a woman offering us mango juice and warm towels to wash our hands after driving down the dusty dirt road.  The mango juice tasted so fresh!  Someone delivered our bags to our tents while we checked in.  The tents are permanent structures with a bathroom, shower, and bed inside.  We ate lunch by the pool; there were so many delicious food choices, we tried everything.  The rest of the meals during the weekend were excellent; we enjoyed Indian curries, french toast, chocolate desserts, lamb, fish, ostrich and other foods that are not available in rural Kenya.

Our first game ride was Saturday afternoon.  Our driver's name was Sammy and he was experienced in finding the animals.  Our group of four was joined by a group of three - one woman from Canada and two American women working at another mission hospital in Kijabe, Kenya.  We traveled around in an all terrain vehicle that had a detached roof to allow us to view everything outside the vehicle, 360 degrees.  On the first ride, we saw giraffes, zebras, lots of gazelles and antelopes, water bucks, wildebeest, elephants, lions, and the cheetah.  The cheetah was probably the coolest find on that trip; we saw a mother and her cub.  We wanted them to run, but they would not - probably because there were three safari trucks surrounding them.  We were able to get quite close to the animals without them indicating that we were intruding or annoying them.  They seemed to be used to people gawking at them all day.  There were lots of baby animals including baby zebras, giraffes, elephants, wildebeest, and lion cubs.  The mothers were protective of the babies and would move closer to them as we approached.  Seeing the animals in their native environment- sharing the same grassland, eating side by side-was pretty amazing.  And watching the wildebeest babies running so fast across the plains as they were playing by their mothers, watching the giraffes walk with their awkward gait, and the lioness clean the baby lion cubs as they roll around in the grass was quite impressive.  We were very content and happy at the success of our first game drive.

The post-game drive nights consisted of excellent dinners, fun conversations, and spades.  Although the weekend was relaxing because we were not at work, I was exhausted from staying up late chatting and playing cards and then getting up before sunrise to go on the pre-breakfast game rides.  We were served an early morning drink of our choice at our room by one of the staff (hot chocolate, tea, or coffee) before heading out to the game drives.  The sunrises were beautiful, especially the second morning when the clouds were not covering the sky and we could see the sun coming over the hills behind the acacia trees. The giraffes love to eat the acacia trees and actually prune them to look like the classic umbrella shape.   I've fondly started them Simba tree as a tribute to the Lion King.  The driver told me the real name, but it sounded something 'balanitis tree' (medical condition) in his accent, so I'll stick with the name I gave them. 

There were storms every afternoon before our game rides, which I think helped the animals come out to eat the freshly watered grasses.  We also had some rain during our second afternoon game ride; the storm clouds were pretty dark and fierce so I was expecting more of a storm than we experienced.  I also really wanted to see a rainbow over the Mara, but that didn't happen. We saw some ostriches, baboons, warthogs, secretary birds, dik diks, hyenas, and vultures, plus all the same animals we had seen the first day.  We drove through a different part of the Mara every day, although it ooked very similar with lots of rocky terrain, patches of acacia trees and brush, and fields of open grassland.  Although there are worn paths that the jeeps typically follow, we drove off the road many times in search of animals.  There was no place that we could not go!

The second afternoon we drove to an area where we could actually get out of the jeep and walk down a dirt path to see the rhinos.  The rhinos are endangered due to poaching so there are rangers that monitor their location and safety during the day.  They lead them into a pen at night.  It was interesting because this was the closest we had gotten to any animal and definitely the first time we were allowed outside of the vehicle.  The ranger used a stick to move the rhinos away if they came too close to us.  It was probably one of the coolest parts of the ride.

Although all of the rides were fun and exciting, the other unique part of the trip was seeing the elusive leopard.  He did not show up until the very end of the ride on the last day.  We had searched carefully by every clump of bush and group of trees, but they are camouflaged so well by the brush.  The leopard that we did see was just sitting by the road as we were headed back to the campsite.  We had barely a second to take a picture before he crossed the road and went back into hiding in the woods.  We drove around and waited for him to come back out, but he never did.  I think we were the only group that saw him that weekend! 

Our campsite was located along a river where the hippos live.  We spent quite a bit of time watching the hippos.  Amazingly we saw them sleeping on the shore just as often as we saw them lounging in the water.  Although we saw a few nashing of teeth when one hippo irritated another, there were no displays of full outright fighting.  I was amazed by how sharp there teeth are and how large their mouths are - and they eat only grass all day!  We also saw a very large crocodile swimming in the river by the campsite; I'm not sure what happens when the crocodile and the hippos cross paths- we didn't witness any interactions.

It was a very fun and enjoyable weekend and a wonderful way to experience God's creation.  We returned to some much-needed rain at Tenwek.  After two impressive thunderstorms, we ventured out for a 7+ mile run through a very muddy path to the nearest town of Bomet and then back up the hilly road all the way to the hospital.  There are some challenging but exhilarating runs here!  We met a few children who ran with us and many adults who laughed at us. But it was fun. Here are some safari pictures to enjoy.  The rest are uploaded onto facebook.

A Masai man stopped us to ask for a ride.  Since we helped him with the ride, he allowed us to take his picture without asking for money.

Our group in front of the jeep that we used for safari trips.  You can see how the roof is separated from the body of the jeep to allow us to stay inside but still see everything outside.

The crocodile swimming in the river by the campsite.

The hippos lounging on the beach and in the water by the campsite.  We learned that oxpeckers (birds) live with animals to eat the ticks off their back, but they also drink blood and pus from the hippos and keep their wounds open.

The Masai giraffes.

Wildebeest.

The cheetah and her cub.

The zebras.

An acacia tree.

The lioness and her cubs.

Elephants.

All the animals eating grass together.

Rhinos.



Vulters in an acacia tree early in the morning.

Sunrise on the Mara.