The last 48 hours have been extremely busy.
Yesterday morning started with Dr. Allibhoy picking me up at 07:15. We headed to the hospital and hit rounds. His training is in Family Medicine but also in Cardiology, as here, FM can serve as a springboard to that further subspecialization. Rounds were very similar to that in the U.S: walking rounds, with a crew of about 10 - 15. We started in the open-air ICU, seeing all four patients (capacity). All four were HIV-positive, with three of them having CD4 counts less than 50. Three were intubated with active TB. One had arrested (died/coded) on his presentation to the ER, but had been resuscitated by the nursing staff. Each patient was on a different antibiotic regimen for different empirical reasons, most on four or more. Dr. Allibhoy has a wide-range of experience, admitting all kinds of patients for over 25 years at this hospital. He's actually the "resident doctor," meaning he's one of the primary admitting doctors here at the Aga Khan Hospital, the private hospital.
We then started to accumulate the crowd for rounds further down the hall in the wards. We amassed four from the Nutrition Department, one Physiologist (Physical Therapist), one counselor, and one physician-in-training. The physician-in-training was essentially serving as an Intern/Resident, but she she is simply gaining experience before heading on to Residency next year. Each ward (room) had about four - six beds, one flat-screen TV with the British Premier League on, and was served by about three nurses. The nurses would help on rounds, giving Dr. Allibhoy the run-down of what'd happened the night before. The nutritionists would give input, the counselor (her badge said she was from the Pathology Department) would get assignments, and the physician-in-training would keep tabs of her assignments to complete after rounds. We hit two other wards seeing everything from alcohol withdrawal, an upper GI bleed, cryptococcal meningitis, and dehydration from diarrhea. We last went to the isolation room, with two patients being treated for active TB. One with a classic x-ray to learn from.
So, Dr. Allibhoy had rounded on roughly 15 patients by 09:00 and then we headed to clinic where he proceeded to see about 20 - 30 before we stopped for lunch at 13:30. He saw hypertention, diabetes, prior strokes, prior heart attacks (treated here with thrombolytics, as they don't have capabilities to cath and stent people here in Kisumu), and bronchitis. This guy is busy.
We saw two interesting patients here. The first needed a CT of the head, his son was told the price of the CT (full price, no co-pay), he was asked if they could afford it, he said they could, and then went on for the CT (about $90). The second older woman needed to be admitted for further work-up and observation - she definitely needed to stay in the hospital THAT NIGHT, but the son had to go to the family and round up the money to pay before she could be admitted. Again, this is the private hospital, but still pretty sobering seeing patients actually take into account the full price of services (VERY different from the U.S.). Plus, there are no EMTALA laws here, demanding they admit the sick elderly woman if she can't pay...
Mom showed up to the hospital at 09:00 at met up with the counselor, and was able to see some patients with her, even helping to counsel the alcoholic along with her. More on that down below I'm sure.
What an eye-opening day at the hospital.
The lunch-hour of course didn't start until we were greeted by the friendly pharmaceutical rep from Nairobi. He comes out every six - eight weeks and brought with him some ads for an Omeprazole patented drug (the new fancy pill coating, of course) and the Augmentin-alike, with different names. He didn't bring a free lunch for the staff though, so Mom let him know that's how to do it next time. GREAT - my own mother enabling these drug reps. How wonderful.
The evening ended with me attending a lecture at the hospital given by a Critical Care doc (Intensivist) from Nairobi - he'd trained in New Orleans and Toronoto, and gave us the run-down on Hospital Acquired Infections. This was mostly stuff beaten into my head throughout residency, and this hospital is working on their protocols to prevent HAI's such as UTI's and VAP's. I introduced myself afterwards, and we talked about the Family Medicine program they're starting at Aga Khan University in Nairobi!
I finally scooped Mom up in a tuk-tuk to head out for "oriental" (NOT the preferred nomenclature, but the name of the restaurant) food, which was amazing and the only restaurant recommended by my Attending. The power was only out for about 5 minutes of the meal, and ended with a quick tuk-tuk ride home.
This morning we headed back out to the clinic in Masara. We saw only a few patients, seeing a tooth abscess (a.k.a. osteomyelitis of the jaw) to be fixed on Monday at the Aga Khan Hospital by a surgeon from the public hospital, but I gave him some Clindamycin and Ibuprofen to help in the mean-time. We also helped a young woman requesting a Depo-Medrol injection. Yes, the clinic does an amazing job with Family Planning services, providing Depo-Medrol injections for less than $1 and OCP's for those who so desire. The clinic is also offering Diphtheria, Hepatitis B, Hib, Tetanus, Measles, and Polio vaccines to children and mothers - free of charge thanks to the government. Unbelievable the range of services this clinic has grown to provide to the area.
This morning also brought our first intro to Brenda, the community health worker / social worker / counselor that Dr. Bonyo's crew has come to know in the last few months. She described some amazing projects, educating the local secondary school about Sexually Transmitted Infections (STI's) and stressing to the currently pregnant HIV-positive mothers (about 17 in the area) the importance of getting to the hospital for their delivery, along with taking the HAART during the pregnancy. At the hospital they apparently get AZT orally during labor in an attempt to prevent transmission to the baby. The delivery at the district hospital in Ahero, if they actually go for the delivery, costs the equivalent of about $5, and Brenda says she'll even pay if they need her to! Compare THAT to costs in the U.S!
The most striking new project she has working revolves around keeping teenage girls in school. Many, due to the embarrassing experience of having a period with no sanitary towels (pads), simply skip school for that one week each month. Because of this, many are held back, and then simply drop out of school. From what I've read, educated women make smarter decisions regarding numbers of kids they have, protection used during sexual intercourse, and of course, and have more resources to work and provide for themselves (thus, not relying on their men for support). They don't have pads due mostly to cost, and this seems like a small way that rich-country folk like us can help out. More on that over the next couple weeks, I'm sure.
The clinic experience today also allowed Mom to hand out more coloring books and lolli-pops to the kids. One of the ladies older than Mom (yes, older than Mom!) was even reading (yes, reading!) her own coloring book! It's for her grandchild... Overall, the kids are loving the coloring, and not to worry all you haters, we've got toothpaste and toothbrushes for after their done enjoying their lollies. One of the little 1.5-year-olds at the clinic, who happened to be running around naked today, starts yelling crying when I simply make eye-contact with him. I rounded the corner this afternoon, and he was walking towards me, we met eyes, and he ran off screaming. Not sure what it is about this mzungu...
This afternoon Brenda helped us buy Mom some cloth at the market for skirts/blouses (I guess) and those will get tailored sometime this week. Tonight, we plan to hit up the Imperial Hotel for a sunset Tusker, and then dinner with Josh and Brenda - then hopefully a little dancing to some Bongo + Luo jams. Poa Vipi!
These few days have sparked a lot of thought - how humbling.
More from Mom:
Yesterday, Trav and I spent much of the day at the Aga Khan hospital (private). I made rounds with the psychological counselor (aka social worker) and we saw 3 patients. The lst man was awaiting test results to determine if he had AIDS. The counselor would find out the results and be the one to tell him that afternoon. The 2nd patient was a man admitted for alcoholic withdrawal and she asked me to lead the session. I was surprised but went for it. I learned that there are very few social services available for alcoholics--no AA or rehab programs (at least not in Kisumu; apparently there is AA in Nairobi). The young man seemed motivated to be sober so we talked about ways he could achieve that including finding a "sponsor" (new concept to counselor) who could support his sobriety. I won't go into details here but it's amazing how interested the counselor was in seeing me work with patients. Plus she asked me to document our meeting with this patient in the chart which would never happen in the U.S. Trav and I were both given free access to the hospital not required to wear nametags or sign in. When Trav tried to take a picture of the outside of the hospital, a security guard said that wasn't allowed. Security is very important here. Anyway, back to my story. We next met everyone in her dept. which is the Pathology Dept/Lab which was interesting. While in an area where the counselor's purse was stored, I met a woman who had given blood. After introducing myself and she heard what I did, she stated that she was a college teacher and there was a social work program there and would I come and do a lecture. I agreed and we exchanged names and phone numbers. And then to tea--which is served here with milk. Tea is grown locally and quite delicious. I met even more folks and then we saw our last patient a woman with stage 4 cervival cancer. This will not be treated and she was awaiting a bed in a hospice. She also has AIDS which many patients do. She was depressed and again the counselor wanted me to talk with her. The counselor has not had a lot of formal training so was quite eager to learn. I'm hoping to meet a trained social worker and work out a field placement for a Social Work student from UT.
After rounds, I connected with Trav and the Dr. he'd been with all morning and we were served lunch made by the dr's wife in the dr's office as he doesn't have time to get out. It was quite delicious--some type of sandwich with chicken and spices that had been fried and then we had little rice cake type cups which we filled with Kasava (like scalloped potatoes). After a 30 minute break, the dr. was ready to return to work and I returned to our hotel and proceeded to fall into a deep sleep for 2 hours. Jet lag is catching up with me I think. Trav returned early but then went back to the hospital for a lecture at 7. He was home by 8:30 and we headed out to an Asian restaurant where I had hot and sour vegetable soup with vegetable fried rice. The electricity went off for a few minutes which made dining interesting but it was restored and all went well. We went back to the hotel and both fell asleep early as we were to be ready at 8 a.m. this morning to return to the clinic.
We arrived at the clinic about 9:30 or so and I spent the morning with Brenda, the social worker connected with the clinic. She is starting a lot of very needed projects. She's had 2 years of education which included social work, project management, community development and public health. She works with orphans (getting sponsors for their educations and other needs), pregnant women who have AIDS trying to convince them to deliver their babies in a hospital so that the baby can be treated and not get AIDS hopefully (clinic pays for the deliveries) and with new mothers helping them learn about breastfeeding. Many mothers have AIDS and need special encouragement and instruction for breastfeeding. She was very enthusiastic and engaging and is only 24 yrs old. She grew up in Kisumu and just began working with the Bonyo clinic this year. She has some big goals and will send me more information as her program unfolds. Oh, she also does lots of family planning and STD counseling. After talking with her, I spent much of my time playing with the children since there is no school on Sat. for primary age kids. We'd brought lollies and they were quite excited about this. We left the clinic about 2 and were dropped off at a market accompanied by Brenda. She helped me pick out some fabrics that her tailor will use to sew some skirts and a blouse or 2. We then walked through a huge market through a big downtown park to another shopping area and that's where we are now! It was great to get some exercise. Tonight we're going to meet some folks for drinks at sunset at the Imperial Hotel. Now that sounds like a grand plan to me!! Lots of love to you all! All is well with us here. We are sleeping and eating well.
Asante sana for all your support and prayers. Much love.