Sunrise View on Motigo

Four of us ran up Motigo this morning to catch the sunrise.  It was a little tricky running up in the dark with only a flashlight.  But amazingly, we all made it safely without any ankle sprains or fractures, or encounters with motobikes.  The view from the top was amazing.  Next time we'll have to plan a trip up for star gazing.

Psalm 148:1, 3-6, 13.  Praise the Lord from the heavens, praise him in the heights above.  Praise him, sun and moon, praise him, all you shining stars.  Praise him, you highest heavens and you waters above the skies. Let them praise the name of the Lord, for he commanded and they were created.  He set them in place for ever and ever; he gave a decree that will never pass away.  Let them praise the name of the Lord, for his name alone is exalted; his splendor is above the earth and the heavens.

Teamwork and Community

I have been really impressed by the teamwork among the doctors at Tenwek.  Not only among the individual services, but between services as well. It is very easy to get a surgical consultation for a patient and we as pediatricians often co-manage surgery patients.  It has been fun getting to know everyone around the hospital.  We all meet together for morning report and participate in the teaching cases, whether the discussion is pertinent to our particular service or not.  It has been kind of nice reviewing medicine cases, OB cases, and surgery cases that I learned about in medical school but have not seen or managed since then.  Morning report is different every day and involves either a morbidity/mortality presentation by one of the services, a case presentation by a post-call intern, a grand rounds presentation involving a case presentation and review of the diagnosis, or a lecture by a visiting consultant.  One day a week we have a group devotion and there is always daily prayer at the beginning or end of each morning report.  So it's nice to be able to start the day off learning and praying together and then consult each other throughout the day as needed.  And if I don't get my questions answered during the day, I can always ask them over dinner! 

Thankfully, for the visiting doctors, the community spirit does not end at work.  We get to eat meals together, relax together, and share stories together.  It has been very therapeutic to discuss our experiences of the hospital and the new culture around the dinner table.  Recently the dinner discussions have centered around surgery, since we have a majority of surgeons in the current visiting staff group. But any topic is really fair game.  Then, after dinner, there is always someone up for playing Settlers of Catan, cards, or some other fun game until we're all exhausted and ready for bed.  We've also had smores around campfires and jogged up to the top of the mountain to view the sunrise together.  And Friday night is movie night, although I haven't been able to attend yet.  We're never bored with so many people around.  And new friends can come in handy, like when you need someone to remove a tick on your back.  (Who thought Kenya would have ticks- but apparently they can transmit a rickettsial illness like RMSF called African tick bite fever. Good thing I'm already on doxy!)  The ability to experience daily life at Tenwek with other young, energetic, Christian physicians has been really wonderful and a much needed change from the more limited social schedule at home.

The other group of people I interact with is the long term missionary doctors.  We have a rotating schedule of lunches at different missionary homes every day.  It is so interesting to hear their stories of how they arrived here, how long they have been here, and what they do during their daily activities at Tenwek.  These physicians are amazing and have left well-established and potentially lucrative careers at home to work here.  They are raising their families here and home school the kids together as a group.  They are so passionate about their work here and their calling to this area.  One night last week I was invited to eat dinner with one of the post-residency doctors assigned here for two years.  She is moving to Burundi after these two years are completed.  It was really helpful to talk with her about different fellowships, career options, and what she sees as beneficial skills and knowledge for working in third world hospitals.  Who knows, maybe I'll have some direction by the time I get back to the states! That's the goal and the prayer, anyway.

Here are some miscellaneous pictures taken around the hospital.  Several of them are courtesy of one of the other visiting residents from Pittsburg.


A large poster on the wards to remind the nurses and doctors of the definitions and symptoms of certain illnesses, just in case they forget.  This poster lists the symptoms of acute flacid paralysis, measles, and neonatal tetanus.

All charts are clipboards with papers, some have covers and some don't.  This is the chart for the patient in ICU bed 1.



 

The lab results get placed in the back of the chart once they arrive on the floor (may be a day after they are drawn).  They are glued to the paper so that at least once they arrive, they are not lost. 

    

A patient's medical record from Kericho Hospital, a local referral hospital.  Referral hospitals and district hospitals have the same reputation here that they have in the US- we always have to question the diagnosis and management.  Patients are given discharge summaries and expected to carry them with them to followup appointments.  These books, or something similar, are also brought to every well child visit to document vaccines, growth and development. 

 

Talking to the interns about the 'double bubble' sign on a patient's xray during chai time before ward rounds.

Chai time for the nurses and nursing students on the wards.

One of the nurses in the ICU taking care of our patient with hepatosplenomegaly, thrombocytopenia, anemia, respiratory distress, and coagulopathy of unknown etiology. He died after three days of hospitalization without a definitive diagnosis; we were considering severe malaria even though the malaria smear was negative.

Rounding on the burn patient in the ICU with the respiratory therapist and the long-term pediatrician.  This picture was staged, by the way.

Ann, the 'head nurse' in charge of NICU, accepting a donation of hand made hats and blankets for the NICU babies.

Becky and Emily, two other visiting residents, both from Pittsburg. Becky is ED and Emily is Med/Peds.

One of the discharged patients waiting to pay the bill to go home.  I wish I had a before picture because the change was dramatic.  He was admitted with anasarca due to nephrotic syndrome.  He diuresed enough fluids to drop 2-3 kg during the hospitalization.  He still found a way to fit a spoon with rice and beans into his mouth even when his face was extremely swollen.  He has a much easier time eating now.  :).  Lunch on the wards for the patients is always rice and beans.

A very malnourished 6 year old eating lunch on the wards. 

Three girls we met outside the hospital; I gave them my remaining mendazi so they agreed to have their picture taken.  All the school children are required to have short, cropped hair.  Most of them have shaved heads.  I'm guessing it is to prevent lice, but I'm not completely sure.  It's interesting to see so many bald girls running around in dresses.

Baby Names in Kenya and Other Miscellaneous Topics

For all my pregnant friends, here are the top nursery baby names at Tenwek.  There are at least 2 or 3 patients with the same name in the nursery or on the floor at any given time. I'm not sure how the nurses and staff keep the patients straight.
Boy: Kiplangat                                                 Girl:  Cherono
        Kimutai                                                            Cherotich
        Kibet                                                               Chebet
        Kipkemoi                                                         Chepkemoi
        Kiptoo                                                             Chepto

And at least half the people have the last name of Langot.  These names are Kipsigis language names.
If you didn't guess, the prefix Kip- or Ki- indicates males and the prefix Che- indicates females.  This makes it a little easier to identify the sex of the child, especially when all the kids stay bundled and wrapped up in so many blankets on the wards.   At some point in life, the children drop names, add names, adopt family names, or change to 'English/Christian' names. So there are mothers whose names are Betty, Beatrice, Susan, Lucy, Mary, Faith, etc.  And in the nursery, babies are identified as 'Chebet, baby of Betty,' with out any last names. 

I have been amazed at how many pediatric surgical cases I have seen in the NICU over the last three weeks.  There have been cases of necrotizing enterocolitis with free air under the diaphragm (usually we try to catch it in the states before there is perforation if we can), nec totalis, midgut volvulus, annular pancrease, ano-rectal malformation or recto-vaginal fistula, jejunal atresia, and Cystic adenoidmatous malformation of the lung (CCAM).  There are no pediatric surgeons here or pediatric anesthesiologists, for that matter. Just general surgeons without extra training in thoracic surgery or pediatric surgery who do amazing things with these small babies.  Of course, the mortality rate is high.  The patients with nec totalis, free air under the diaphragm, and midgut volvulus all died. But they did a pneumonectomy on the infant with CCAM in the left lung and he is currently doing very well.  And the anesthetist was telling me he has not been in pediatric cases in 20 years and he did not have any of the usual monitoring equipment that he would use in the states, but the patient still did well!

The other common non-surgical NICU admissions are the usual preterm delivery (typically not more preterm than 26 weeks), hyperbilirubinemia, sepsis, RDS, birth asphyxia / HIE, and HIV or syphilis exposed.  There was one infant born with the most severe hydrops fetalis I have seen yet. His ascites probably weighed more than his head and body combined.  The OB's had such trouble delivering him that they accidentally ripped off his umbilical cord.  So there was not even a cord available to try to find a heart rate.  But he was basically dead on arrival and not viable for resuscitation. We think it was due to Rh incompatibility since mom was Rh negative and had not received Rhogam after the previous pregnancy.  I've discovered that many women do not receive Rhogam, even if they are Rh negative, mostly because it is too expensive for them to purchase but also probably because they don't understand the importance of it or they are not aware that it is needed.  So it is definitely not routinely given like in the states. 

Today I learned how to place a central line in a pediatric patient.  Not a useful skill for back home unless I am going to work in the ICU, but fun none the less.  But placing a central line Kenyan style is a little different than what I've seen in the states.  First, you have to search for about 30-45 minutes to actually find a central line that is pediatric size.  Then you have to ask a nurse to get suture and a blade from the OR. One everything is set up, you have to give the patient valium IM since there is currently no IV line (hence why you are placing the central line).  Now, there are no disposable sterile gowns, only cloth gowns that are reusable.  They are three sizes to big so you opt not to wear one.  The sterile gloves are about 10 sizes too big, but there is no option there; you have to wear them and make the best of it.  But it creates some issues trying to grab small objects with large gloves.  So after setting everything up, you notice that the sterile drape has no hole in it- but it is in the central line kit- so I'm not sure what they intended it to be used for.  But after remembering your impressive snowflake making skills in school, you expertly fold the sterile drap and cut a hole in the center.  Of course the Kenyans have no idea what you're doing because they've never made paper snow flakes, much less experienced snow.  The procedure is fairly straight forward except for accidentally finding the femoral artery first instead of the femoral vein; but thankfully the femoral vein is found on the second try.  The guidewire is threaded in, the dilator works well (after using a blade to nick the skin a little), and the double lumen catheter is inserted.  Now you just have to suture it in place.  Too bad there are no sterile needledrivers.  So you just push the needle through the skin carefully (remember you have huge gloves on and it's hard to grasp anything) and then make the knots.  Once the catheter is ready to be connected to the IVF, you realize that the Kenyans have not used this type of IV connector before and their 'giving set' does not fit exactly.  On the first attempt to fit the rubber giving set into the IV connector, it goes in and starts running, but then pops out right away under high pressure.  The second attempt is a little smoother but you realize that either the nurse is going to have to stand there and vigilantly watch this (and potentially hold it in place) all day or you're going to have to find some tape to hold it together.  Finally, an hour after the start of the procedure (and two hours into rounds), you are done and the patient can get IV fluids.

The patient that we placed a central line in today is a 6 year old who was caught in a house fire that dad started.  There was another house fire over the weekend in which an 8 year old boy attempted to rescue his younger siblings and sustained severely burns (45% BSA).  He died after a few days in the hospital.  Then there was a 1 year old admitted today who has severe burns from a kerosine lamp falling on him and igniting his clothes on fire.  It is dangerous not having electricity and relying on fires for light!! And there are some very sad social situations here, just like in the states.  I haven't taken care of any burn patients at Duke since UNC has a large burn center, so this is a new experience for me. Hopefully there won't be many more; I think we've seen plenty recently. 

I'm planning to go on safari this weekend, so hopefully there will be some great animal pictures coming soon!

These are pictures of the medicine formulary used at Tenwek.  If you look closely, you'll notice that the cover is a little unusual.

The list of medications available at Tenwek.  Supposedly up to date as of 2010, but not completely up to date since the available medications change depending on donations from visitors and use of the supply of standard medications.  Notice anything unusual about the cover of the medicine formulary?

It's an xray!  That's right, all xrays here are film- not digital- and I guess some of them get reused as formulary covers.  10 shillings to whoever can figure out what the lesion is on the xray (if there even is one). :)  The interesting thing is that outside of radiology, there are limited numbers of reading light boxes.  So we tend to read the film xrays by holding them up to the overhead lights! What a way to diagnose subtle lesions!

Weekend Adventure Number Two: The True Kenyan Experience

Since Tenwek has such a large American community, the visiting staff don't always get to experience living a true Kenyan lifestyle.  So one of the visiting students and I traveled to Kilgoris for the weekend to visit a friend of a friend of a friend. We left Saturday midday (after another good run to Motigo) and carpooled with one of the Kenyan surgery residents who was going to visit friends in Kilgoris.  We thought we were going to be riding with another surgery resident who has a car, but it turns out the car was not working so we hired a private driver.  Of course, this was after waiting 2 hours for the surgery resident to show up.  The private driver was a lady, so she picked up a 'muscle man' to ride with us for the trip in case the car broke down. We drove the two hours to Kilgoris and arrived without problems.  Kilgoris is on the edge of the Masai land and if you walk far enough outside the city, you will run into lions and zebras and other animals. So I'm told. We didn't have time to check it out, unfortunately.

We arrived and met Titus and his family including his wife Ann, and his children Hope, Revive (boy), Charisma (boy), Lillian and one other girl away at school.  Hope is actually from Tanzania but was 'adopted' by the family.  Titus is a pastor at Treasure Center Charismatic/Pentecostal church. Ann works part time with Compassion International-sponsored children locally.  They rent a house in an area with many other houses and farm animals.  There were chicks, chickens, cows, dogs, puppies, donkeys, and of course, roosters.  The Masai are known for their large herds of cattle.  We were told that Titus' family had 6 cows but that some were stolen; I'm not sure where he keeps them.  Often families will have 50-100 cows.

We attempted a tour of town but it started raining torrentially.  We had already walked 5 minutes away from home so we had to wait out the rain under a store awning.  We did make it to town after Titus called a friend to pick us up.  We saw his church and he gave us a tour of the town.  I bought a wrap like the one that all the women wear to carry their babies on their backs or as a skirt.  This one in particular was made in Tanzania and had a Swahili proverb on it that says something like 'Gossiping is bad.'  The other wraps we looked at had sayings like 'The mother knows the pain of childbirth' and 'You should fear the teeth of the lion but not the people's words.'  We had a fantastic dinner of home-made chipati, beef stew, potatoes, pinto beans, and fruit.  Ann is known for her homemade chipati and it was definitely the best I've had yet.  We had to take chai, of course, prior to dinner.

Titus' house had a central living room furnished with several couches and chairs all covered in blue with lace covers.  The walls were decorated with printouts of Christian encouragements and Bible verses from Titus' time as a computer teacher.  There was a bedroom with two beds to the side.  The front entrance opened up into a small room used as a kitchen.  There was no stove; they cooked over coals.  There was another room with some bunk beds.  Attached to the side of the house was a 'shower' where you pour water over yourself to wash. There was another room attached to the side that had a bed and was used for cooking as well.  There was a chicken coop outside.  The bathroom to the house was outside but they would not show it to me because they thought it was not nice enough.  The bathroom that we used was all the way up the hill up a dirt path past 5 or 6 more houses, chickens, cows, etc.  The picture is below.  As you can see, it is a shed with 3 stalls, two holes in the ground, and only one door.  As I mentioned in my blog about rafting the Nile, it is quite an experience trying to use a hole in the ground.  And there was no sink in the house.  We used a basin with a cup of warm water poured over our hands and a bar of soap to wash our hands before eating.  I think they went out of their way to make sure they offered us a way to wash our hands and bought toilet paper for the occasion.  The bathroom by the church was made of slabs of wood complete with holes in the floor and on the sides. As my friend clarified for me, we were experiencing life in the African 'bush.'  But this family was very hospitable and very welcoming, as I've found most Kenyans to be.  We brought them groceries as a thank you gift.

There was no electricity, so when the sun set at 7pm, we ate dinner and continued our conversations by the light of a kerosine lamp and flashlight.  Of course, this was the one time when I didn't pack my flashlight!  The lack of electricity definitely made it nice and dark for sleeping, although the beds that dipped in the middle and lacked pillows left something to be desired. The roosters started crowing around 3am and didn't stop until after the sun rose.  We had home-made ndazis for breakfast, then walked the 1-2 miles down the road to town for church.  Titus said that church started at 9am (and lasted til noon) but we didn't leave the house until 9am. When we arrived about 9:30am, there were only 2 or 3 people there.  They slowly trickled in later and eventually there were about 30-35 people including all the kids.  Titus had asked us to give a 'talk'.  So the church service consisted of lots of singing, us sharing, lots more singing, lots of dancing, an offering, and the main sermon.  All in all about 3 hours.  We joined in the dancing; these songs lasted 10-15 minutes at a time and they danced the entire time.  It got really hot in there!  The main soloist was a Kenyan runner and runs the 3000meter steeplechase in 9 minutes and some odd seconds and will likely be on the national team.  My first real Kenyan runner, but I didn't get to run with her!

There were not enough seats in church for all the kids so I shared my seat with a cute 2 or 3 year old who seemed to be fasciated by me as if she had never seen a white person.  She kept touching my skin and counting the freckles on my arm.  Very interesting.  The kids seemed to spend more time staring at me than my traveling companion, although I'm not sure why.  We actually did see two other white people in town, but they were the only two other white people the entire trip.  We were invited to the neighbor's house for coke and fanta afterwards while we were waiting on the matatu (Kenyan bus) to take us back to Bomet.  The cokes come in glass bottles and the bottles have to be returned, so there is no 'on the go' bottles. 

The matatus run on Kenyan time which means that although we booked a ticket at 1pm, the matatus didn't leave until 2pm so we walked around and tried to find something to snack on.  We found roasted peanuts, which are actually very good here and are not salted, making them even better.  The matatus are notorious for packing as many people in as they can, ignoring the fact that they only have 10 seats. Thankfully, this trip they did not take on extra passengers so we had a comfortable ride with actual seat belts.  We arrived in Bomet and took motobikes the remaining 4 miles to Tenwek.  Just like matatus, the motobikes also aim to fit as many people on the back as possible.  So I rode the majority of the way as the only passenger, but then another Kenyan jumped on the back for the last mile.  I kind of felt like an oreo, smushed between two Kenyans.  No pictures of that experience, sorry. 

But we made it back to Tenwek safetly and I got to take a much needed clean, hot shower.  All in all, a good weekend experiencing Kenyan culture outside of Tenwek and worshiping with some new friends who welcomed us with open arms.  And I think I gained a greater appreciation for the circumstances of my patients so I can relate to them better.

The livingroom

Revive and Charisma, in 5th and 6th grade; huge Arsenal soccer fans- we listened to the Arsenal vs Southerland game Saturday night on the radio.  They followed the game by identifying the players on a poster calendar.

Hope in the kitchen after making chipati.  The room with bunk beds is behind her.

The outside of the house.  To the left is the 'shower,' the extra bedroom/kitchen, and the chicken coop.

The main bedroom with two beds and clothes hanging all over the walls.

Making mendazis in the side kitchen.  It tastes like funnel cake without the powdered sugar.

Frying the mendazis in cooking oil over the hot coals.

The choo (bathroom).  A 3 minute walk up the dirt path by all the other houses and farm animals.  Kenyans call it short call and long call instead of #1 or #2. 

The view from the choo.  Hopefully no one is milking the cows or feeding the chickens while you are using the choo.

Titus, Ann and their family and me.

A district hospital in Kilgaris.

The town of Kilgaris.

Motobikes lined up in Kilgaris waiting for passengers.

The church; they are hoping to evetually move to a different location but currently are working on finishing this building by adding windows and a concrete floor.

Inside the church; the open windows on the right are covered by lace; the windows on the left are just open.

All the kids sitting around; I'm giving my talk.

Titus was my translator from English to Swahili.  He gave his sermon in English and had someone else translate into Swahili.  It was funny because the translator walked back and forth across the front of the church with Titus as Titus moved during his energetic sermon. 

Dancing during worship; the lady in the brown suit is the runner.  At one point, one of the girls in front was doing moves from the macarena; I'm not sure how worshipful that is but maybe she didn't know what it was. Most of the songs were in Swahili, although they would usually sing a few verses in English for us.

Participating in the dancing at church.  Attempting to keep up with the rhythm. 

Waiting for the matatu.

Safely back at Tenwek.

Hospital Happenings and Call Number Four

The Kenyan/British medical terms are rather interesting and take a little time to get used to.  They have terms like 'hotness of body' for 'warm to touch' and 'liquor' for 'vaginal discharge.' They also say 'fair general condition' instead of 'well appearing, no acute distress' and 'flaring of the alae nasai' for 'nasal flaring.' And I think 'crepitations' means wheezing, although it may very well mean crackles; most kids have both.

Another interesting contrast between US medicine and Kenyan medicine is that in the US, we have to bring patients back for weight checks and conduct motivational interviewing in an attempt to help the patient lose weight by decreasing intake of sweets, sodas, fast food, etc.  In Kenya, with so much malnutrition, they have to bring patients back for weight checks and conduct motivational (or whatever style) interviewing in an attempt to have the patient increase food intake to gain weight.  So, for example, if you and the mother agree that the patient will drink one glass of milk per day (instead of the 0 glasses of milk he was drinking previously) and you ensure followup in one week, then the patient can be discharged from the hospital.

Also, the medication bottles for code drugs are provided in different measurements that I'm used to in the US.  I have to remember odd conversions like 84mg is 1meq. This is difficult to calculate in the middle of a code situation.  The reporting of lab values is different too.  So for bilirubin, I have to divide by 17:  bilirubin of 78 should not concern me because it's really just 4.5. A glucose of 3.5 is normal (multiple by 18 = 63) and a creatinine of 100 may also be within normal limits (divided by 88). So it takes some adjustment to a new system and initially I found myself concerned about what seemed to be an outrageous number until I remembered the conversions.

Call number four: another crazy day. We had a child decompensate during rounds and require attention.  We had 3 back to back c-sections that were slightly urgent for one but elective for the other two yet we did not have enough equipment for all of them since there was limited time to sterile the reusable equipment. And at one point we were expecting two infants at once in two different locations and I had the only laryngoscope yet it turned out to be my intern who needed to use it for her resuscitation. 

We had some admissions and ward issues, but the worst part of the night was the code that happened in casualty.  A 6 year old boy came in after a week of gastroenteritis and dehydration. Apparently he was in poor condition when dad brought him but he decompensated quickly and we were coding him before he had even been fully evaluated by the CO.  So in a busy casualty room with many other patients, two nurses, the intern, and I are coding this child.  All of the medications are in a different concentration (as mentioned above) and based on the heart tracing using the defibrillator paddles, he is in PEA.  After 15-20 minutes of resuscitation, one of the nurses just stops bagging and excuses herself to continue caring for other patients.  We continue on for another 10-15 minutes then call the code and notify the parents.  Not 10 minutes afterwards, another child is lethargic with oxygen saturation recordings of 6.  There is no available oxygen port because the one next to his bed is being used by an adult.  So we carry him quickly to the only available oxygen port in casualty- the one near the bed of the child who has just passed away.  So the two children are sharing a bed- the recently deceased child and the child that requires oxygen.  It was very strange and somewhat disturbing. 

Then we later get called for abdominal distension in a NICU patient with cholestatic jaundice.  His total bilirubin is over 600 = 35! (half conjugated) but there are limited serologic, genetic, and metabolic tests available.  He decompensates over the next 12 hours and then finally dies after an ex-lap shows midgut volvulus and gangraneous bowel.  (I've been amazed at the number of surgical cases that present in the NICU; and the cases of NEC that we have seen have been so advanced, perforation is very frequent.)  The baby's mother was so encouraging through the whole ordeal with an amazingly strong faith in God and his provision even during this time.  And she even gave me a hug for taking care of her baby after he died.  I wanted to cry.  Another NICU baby also died that night, somewhat expected but no less difficult to break the bad news to the mother. So that makes a total of 3 deaths within my 24 hours of call; not a good night for peds.  And we're sending two home on hospice tomorrow.  But there are also many patients who are getting better and we get to discharge them home in better condition than when they came in. 

Here are the final pictures of the hospital (and some other random pictures).

Wednesday is hospital cafeteria lunch day.  Today I ordered somosas (fried with beef), chipate, and suma wiki (the green stuff)

One of the outpatient clinic rooms

Eric and Moses.  Moses recently finished the Tenwek internship year and Eric is a Family Practice post-residency missionary who was working with me on pediatrics initially. 

The hand washing sink and towel.  There are sinks all over the hospital with signs reminding people to change the towel every two hours or when extremely wet.  Somehow they are always extremely wet.

The 'spirits' used to clean stethoscopes and equipment.  Not called alcohol.  They are cotton balls and some kind of antiseptic.

Patients in Casualty, the Kenyan term for emergency room.

The other half of the casualty room.  There are about 6-8 beds but somehow they fit many more people in here during busy times. And the waiting bench overflows outside.

The code cart in casualty, conviently pushed behind other equipment.  There is no EKG in casualty, only in the ICU. So the code cart is the only means of tracing heart rhythms.

The IV fluids.

Bible verse written on the wall in casualty.

A pediatric surgical patient who I am not taking care of but who greets me with a big smile every time he sees me.  We shake hands and I draw on his cast and he smiles again.  No need to learn Swahili here, we are already friends.

Two patients in traction for leg fractures.  They seem to tolerate it well and spend the day talking, coloring, and eating.

A Maasai woman with her child.  The Maasai are known for their colorful wraps and beaded accessories.  She also has large holes in her earlobes per the Maasai tradition.  Some older women somehow wrap beads around the lower skin of the earlobe.  I'm told they create the hole by making a cut in the earlobe then placing a corn cob in the hole.  Choose the corn cob based on the size of the hole you want!  So beaded bracelets, beaded necklaces, beaded 'earrings' and for the infants, a beaded waist band.  The waistband tells them how much the child is growing since as his belly gets larger the waistband gets tighter until they have to cut it off.

The fourth pediatric intern, Lando, rounding in the nursery.

A chart outside the nursery explaining what to feed a child at different ages and what milestones and weight the child should achieve.

It's kind of funny but also sad that they have to put 'remember to feed your child three times a day' on the poster.

The source for heating the warmers in the nursery: lightbulbs on a built in shelf under the box.  The more warmth you need, the more lightbulbs you turn on.

There are lots of multiples in this area of Kenya.  We currently have 3 sets of twins and one set of quadruplets (one quad died).  And we only have about 30 patients.