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.

Last Sunday at Bethesda Church

Today was my last Sunday at the Tenwek Hospital church.  Next Sunday I'll be on call at the hospital and the following Sunday I'll be traveling home.  It seems unreal that in two weeks I'll be back in the US.  We've been preparing for Easter and today was Lord's supper.  There are some pictures below of the praise and worship team at the church, made up of missionary and Kenyan doctors.  It has been wonderful to worship with both the Americans and Kenyans in a very multi-cultural service. 

Prayer requests:
1. The long term missionaries are leaving this week for retreat and vacation.  Pray that they will have safe travels to the coast and that they will have sweet fellowship, relaxing time with their families, and will be rejuvenated for the work ahead.
2. One of the missionary families is planning to adopt 1-2 more Kenyan children from an orphanage; they already have two Kenyan children.  Pray that the process will go smoothly and that they will be approved by the adoption board.  They are hoping to find out by the end of the month.
3. Pray for the doctors and staff who will be working at the hospital while the long term missionaries are gone.  Pray that things will be calm and that we will be able to carry on the work of the hospital well.
4. Pray for a very sick child on the pediatric wards with HIV and complications for her infection.

Yesterday I woke up from a nap to an afternoon rain storm.  The sun was still shining, and there was a beautiful rainbow across the sky.  With so much rain everyday, I knew there would eventually be a rainbow.  It didn't last long, but it was pretty.  Before church today I ran to the neighboring town of Silibwet, a four mile run across dirt paths, paved roads, cow pastures, and a huge 400-500 meter steep hill full of mud puddles and slippery rocks.  I'm so going to miss these runs!  I'm already getting nostalgic for the gorgeous mornings with perfect running weather.  This morning the sky was vividly blue without any clouds and the bright green fields contrasted so nicely.  I felt like I'd stepped into a beautiful landscape painting.  I'm going to miss the friendly kids who yell 'I am fine' as I run by even before I've even said hello.  That must be the first English phrase they learn.  And today, I actually saw someone I knew in the small town of Silibwet, one of the ladies who works in the kitchen at the guesthouse.  It felt like meeting someone at Kroger, expect in the middle of Kenya! 

Worship team including Lando on guitar, Agneta on drums, Jason on guitar, and Erik on piano.

Heather and another lady singing; kids participate in the worship team, too.

The little boy was so cute trying to play the guitar.

The Lord's Supper table.

Where did all the patients go?

This has been a rather slow week in the hospital, which is a nice break from the large census and critically ill patients that we've had over the last month.  Apparently now that the rains have started, all of the families are planting their crops.  These families have spent any money they might have used for medical care on the seeds and items necessary to plant their fields.  And since planting requires a lot of work and a lot of people, there is limited time to travel anywhere, including the hospital.  So currently there are far fewer patients than the initial 3 weeks I was here when we were overflowing with patients and patients had to share beds.  Now there are empty beds; even the discharged- but still in the hospital because they haven't paid -patients are finally going home.  And women must be choosing to have their babies at home because even the the nursery has fewer patients and there have been fewer delivery resuscitations.

We are also discharging patients home, including the quads who were discharged from the nursery this week.  The mother will return to her village outside of Nakuru where the entire village will be waiting to welcome her home with the babies.  They will likely slaughter a goat in celebration.  These villages take pride in their animals and slaughtering a goat or cow signifies a very large celebration.  One of the interns' families slaughtered a cow in celebration of her medical school graduation, and they slaughter a goat every year for Christmas.

When a patient cannot pay for the hospital stay, we send them to the legal officer to discuss their finances.  One mother told me that it would only be possible for her to pay the remaining hospital bill if we gave her a 7 month grace period so that she can go home, plant her crops, harvest the crops, sell the crops, and then pay the hospital.  I guess living in an agrarian society means that repayment of debt depends on the rains and can be delayed for half a year or more!  She ended up selling a piece of land in order to pay the hospital fees.  But that involved a long process including travel to two or three different locations, spending several days trying to sell the land, and then returning with the money.  Selling land, cows, crops, or other items is a common means of paying the hospital bill. It's kind of interesting; on rounds we always have to stop and ask, what kind of resources does this family have?  Will they feed their child goat's milk or cow's milk? Will they have access to eggs or meat as protein sources if they are a new diabetic, or will they just provide milk and potatoes?  Are they going to go to a 'healer' who will make traditional marks on them or give them herbs or other traditional medicines to heal their illness or did we educate them well enough?  Apparently there are 'healers' out there who claim to be able to heal HIV.  In face, when we stopped in Kisumu on the way to Uganda, we saw a poster on an office building listing patients' praises for the healer's ability to cure their HIV, take them off their antiretrovirals, etc.  Some of what the healers do is benign, but they can be dangerous, especially in the area of HIV treatment.

This week was spiritual emphasis week at Tenwek.  The president of the World Gospel Mission flew in from the US for the occasion.   He preached Sunday at the hospital church as well as at evening services Monday through Friday.  I was able to attend a few services.  The first was a more American style service with English songs and a defined end point.  The second was a more typical Kenyan service with a 6 woman choir, songs in Swahili, and multiple speakers thanking the president for his presence this week.  When a Kenyan gets up to speak at any gathering, he typically says, 'I don't have much to say,' but what he really means is, 'I'm going to speak for a long time.'  But the services have been a nice end to my days and a chance to refocus on the spiritual work at the hospital.

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.