Home, Sweet Home....

So, it's been nearly a week since we touched down and I'm finally getting around to writing my final thoughts. My apologies. Apparently, as I have found to my dismay this week, traveler's diarrhea is not exclusive to the trip there. Thank God (and Bayer Pharmaceuticals) for Cipro. I'm pretty much back to my usual state of health (minus a few pounds, it seems) and figured it was as good a time as any to post a few parting thoughts...

By week six, I'll be honest, I was ready to head back. Not out of any kind of ill-will or negative experiences, but rather out of inevitability and good ol' fashioned homesickness. The trip for me was an overwhelming success and I felt as if I had laid some significant groundwork for any future trips I could make during my career. My eyes were opened, as I had hoped they would be, and my heart took to Kenya in ways I didn't think it would. It was an experience I wish more people in our profession would undertake and I personally would love to take part in helping future students and physicians reach this part of the world.

We spent our last weekend shuttling back and forth from Kikuyu to Karen and Nairobi in search of last-minute souvenirs, cultural events, and, of course, food. We spent Saturday exploring the Karen Blixen Museum and Karen Blixen Coffee Garden, then walking to Karen Center to hit the Rusty Nail one last time. That place is just incredible. We met the owner, Clive, who is the son of British expats and was born and raised in Kenya. He bought the Rusty Nail along with his sister and they've run it since the late 70's. Fascinating story. He got us caught up on all the Kenyan politics, past, prestent, and future. I really can't wait until I can go back and eat there again...it was seriously that good.

Sunday and Monday (thanks to Kenyan Labor Day!) were spent in Nairobi. We caught a play at the local arts center entitled "The Burning of the Rags" that was absolutely fascinating. I won't go into details about the plot, but I found it refreshing to see the universality of themes we take for granted in the US: big city thinking vs. the village way of life, the double standard women bare for their indiscretions, generation gaps, and women's rights. It was billed as a comedy, and it was for the most part, but it got pretty serious by the end and concluded with a lady, who I presumed to be Death, leading the spirits of two dead characters onto the stage and delivering an ominous message about regrets and unrequited love. Quality stuff. I could see this off-Broadway somewhere in Brooklyn, easily.

My final rotation at the hospital was with the medicine team, which meant rounding, rounding, and more rounding. Now, if I had written this post right after I had finished the rotation a week ago, I could probably provide more details on interesting cases. But all that sticks out in my mind at this point was that our legendary patient, Mr. Uremic Frost, at one point refused to come out from under his covers because people were telling him that the food was dirty and that he wasn't going to get better if we kept looking at him. This poor gentleman was admitted just before we had arrived with a chief complaint of "open wound on the toe". Since his admission, he had been diagnosed with uremic frost that turned out to be non-uremic, developed a mysterious bowel obstruction that, upon exploratory laporatomy by Dr. Kavaludi, yielded nothing but gas, developed open bed sores on both heels, and finaly had a psychotic break that made communication with him pretty much impossible. It's that final problem, it turns out, that will probably be the straw that breaks the team's back since phychiatry is still a pretty tough service to come by in Kenya. It is pretty much administered out of one hospital in the whole country, and unfortunately it has the reputation of Kings County's G-Building...multiplied by a factor of 50 or so. Then again, the odds of Mr. Uremic Frost getting out of the hospital any time soon is pretty slim considering the bill he's accrued. Have I mentioned the fact that bills must be paid in full before a person can leave the hospital in Kenya? It's an amazing system that seems to work surprisingly well at PCEA Kikuyu Hospital. Imagine trying to implement that in the US. They'd have to relocate Kings County and Downstate to Ryker's Island just to accomodate the extra capacity. Which system is better, though? One seems perfectly logical in that you pay for what you receive, as with everything else in life. The other is more along the lines of the altruistic medicine we all claim to love in our med school essays, but that end up costing us 1/3 of our GDP in healthcare costs. I guess the jury's still out on that one.

Slowly, but surely, I packed every evening during the last week. Tuesday night found us at Maureen's (surgical resident) apartment eating the best Kenyan of the entire trip, hands down. We ate until we couldn't eat any more. The walk home in the dark and the mud was hilarious, though, sadly, it ended up costing me a pair of shoes. I like to think that somewhere, right now, some big-footed Kenyan is plodding around in a pair of size 14 Kenneth Cole Reaction bowlers and loving them as much as I loved them.

We ended the clerkship with a lunch outing with Dr. Kavaludi in the town of Wida. We had a lively discussion about politics, medicine, vegetarianism, and how the elective could be improved for future groups heading there next year. He expressed his ultimate goal in having an exchange program for residents and attendings, in addition to students, between PCEA Kikuyu and Downstate. Logistically, it sounds like a nightmare to negotiate between visas, salaries, and accomodations. But logically, if we're ever going to make strides in spreading medical knowledge and practices globally, then immersion seems like one of the most direct and exciting ways to go about doing it. After seeing first hand, I'm a believer.

Friday morning, 4:50am my alarm went off and so began the long trek home. It was 9:50pm on Thursday night in the US. In the end, I stayed awake for 26 straight hours before finally resting my head on my pillow back home in the Bronx. That accounted for three different X-ray checkpoints in Kenyatta National Airport, waiting another hour before our flight actually left, one 8 hour flight to London that included 4 movies, a brief layover with bathroom break, another flight of approximately 7 hours that had 3 movies, the endless wait for baggage at JFK, a welcome home pizza party at my sister's house, and a drive back to the Bronx at around 10pm. I slept like a rock, to say the least.

Oddly enough, I was up bright and early at 7am sharp and ready to reacquaint myself with driving on the right side of roads that didn't have the appearance of having been imported from Baghdad. Jetlag is a funny phenomenon.

In the end, sadly, it starts to all feel like a dream. It's incredible how quickly the mind can just start to fragment, store, and reshuffle memories, especially those that are particularly unique. An hour into my ER shift at County on Monday, and it was as if I had never left. It's as if 6 weeks in an incredible land halfway across the globe is no match for four years of the stained tiled walls and gothic architecture of Kings County Hospital. Sad, really. But thankfully, I have all these entries, my own journal I kept, and the nearly 3,000 pictures we all managed to take to keep my memories fresh whenever I find myself forgetting what the hostel looked like or the names of the residents we met. I truly can't wait to find myself back there sometime in the future, in a role that actually permits me to strategize and help more effectively. I wish those students who are going next year the best of luck and I hope they can use some of these entries to their advantage when they finally start planning their journey.

I will be posting a grand presentation of pictures soon, so please check back often.

And for those of you who'd like to follow me along as I enter the next adventure in life as an intern in Ob/Gyn, feel free to pass by whenever you get a chance and throw in your two cents....

Cheers!
Jerry.

Signing off from Kenya...

Well, folks, it looks like this will be my last communication from the great nation of Kenya. Nancy, Judith and I made one last trip into Kikuyu town to get some music, buy something to bring with us to Maureen's house tonight, and hit the ATM before heading out Friday morning. Tomorrow is a half day for us, as we've set up to meet with Dr. Kavaludi as a "debriefing" for our experience here, and then I have to figure out how to repack my stuff to avoid having to buy an extra ticket for my luggage.

It has been an amazing trip and I can't wait to come back someday. I'll be arriving in NYC on Friday night around 8:45pm via British Airways.

Keep checking back, though, as I'll be keeping this blog going even when I get back. I still have roughly 600 pictures on film that I need to get developed, so check back often!

Thanks for sticking with me!

Cheers!

Some pictures from Mombasa...

Hey, two days in a row of updates! It only took me five weeks to get conistent...this isn't a very lengthy post, though, so you can breathe a sigh of relief. We spent the day in Nairobi souvenir shopping and seeing the US Embassy Memorial Park. Very well-done memorial, in my opinion. Makes you wonder how things could have been different if we had paid more attention to it when it happened.

Here are some pictures from our trip to Mombasa last weekend.
http://www1.snapfish.com/thumbnailshare/AlbumID=41603762/a=6248780_6248780/t_=6248780

I apologize for Snapfish making you have to register to see them. It's the only way I can do it right now. When I get back to the states, I'm going to figure out a way to share them all without making anyone register...

Four more days, and a wake up to go!

Rounding third....

…and heading home soon.

As I write this, there are six days left in our whirlwind African adventure. Three of those days are a three day weekend, thanks to the Kenyan version of Labor Day this Monday. I’m telling you, one of the biggest incentives to moving here is the prospect of only working one full week a month, maybe two. Apparently, in October there are so many holidays that you work about two weeks TOTAL from what I’ve heard. This weekend is dedicated to exploring the town of Karen and seeing the home and the grounds that inspired Out of Africa. We’re also making a return trip to the Rusty Nail, the restaurant from my Week 1 post that I never got around to reviewing. This time, I’ll try to write a few words about it.

Our trip to Mombasa last week was exactly the relaxing break I was looking for. It was basically air conditioning, bad movies on TV, the pool, the bar in the pool, the bar by the ocean, the bar at the restaurant, and a day of hustle and bustle in Mombasa proper. The city definitely had a different feel to it than Nairobi. Like most port cities, you could find influences from numerous different cultures in the architecture, commerce, and way of life; specifically to Mombasa, the influx of immigrants from India and the Middle East combined with the European conquests throughout the centuries created a environment I had never experienced before in my life. Honestly, it was both comforting, since it was closest to what I’m used to having now lived in major port cities for the past 10 years, and discomforting given the heightened tensions these days between these prevailing cultures and ours. It’s hard not to think of the 2002 bombing of the Paradise Hotel when you’re actually staying in a similar type of establishment designed specifically for Westerners and well-off Middle Easterners. Then again, you can’t let that get in the way of interacting and facing matters face to face; and more importantly, you can’t let that in the way of enjoying a once-in-a-lifetime experience. At no times did I really feel in danger, and looking back I probably could have loosened up a bit more towards the end of the day in Mombasa when we were being shuttled around by a group of parking attendants who not only manned the parking spots and picked who could park there (i.e. vans full of muzungos with money) but also became personal escorts to the fabric shops we wanted to go to. If you know me, you know how much I love being pushed and pulled around. Ultimately, though, everyone got what they wanted out of the trip.

The overnight train ride to and from Mombasa was an experience I think everyone should do at least once in their life; but only one way, to be honest. The trains and the train stations were straight out of 1955. In some respects, they were pretty well-maintained; let me stress some. We reserved First Class accommodations, which gave us a bunk bed for two in a private cabin with a sink, closet, and bedding. We also were provided dinner and breakfast in the restaurant car. To me, this was one of the highlights. It was a scene straight out of a Humphrey Bogart film, with dinner served in courses and strangers having to sit with one another and make conversation. All that was missing was a murder mystery and chase scene on the top of the train. Probably the most unsettling part was passing through some of the most desolate areas in the middle of the night, then coming to a stop and hearing kids in the dark asking for a shilling. Otherwise, I slept pretty well (all things considered) and saw the most stars in the sky than I have ever seen in my life.

This past work week (if you can call it a week) I spent at the Eye Unit. I’ll admit, it was probably lowest on my list desired rotations since I just never really had any interest in ophthalmology. The half-Wednesday I started I was in the clinic, which, much like the ortho clinic last week, is just a non-stop solid barrage of patients from 9am-5pm, with a one hour break for lunch. Unlike the ortho clinic, this goes on 5 days a week in the Eye Unit. The volume is unreal, though the pathology wasn’t shockingly different from what we’d see in the states. It was pretty much a cataract-removing-glaucoma-fixing factory, which is desparately needed anywhere.

Thursday was spent in theater all day. I had never seen ophthamologic surgery to this point in my med school career, so at minimum it was fascinating for most of the day. The saddest case I saw was a two year old boy who had to have his left eye removed completely because of a retinoblastoma. I had never seen a human eye extracted before (well, intentionally anyways...trauma surgery saw its share of dangling eye balls) and it was pretty gruesome. It was replaced with a small orb that basically looked like a child's marble and then the muscles and fat were used to sew up the gaping hole. The next step is having pathology examine the optic nerve to see if the tumor had spread any further than the eye ball. If so, it means chemotherapy and/or radiation at Kenyatta Hospital, aka The Kings County Hospital of Kenya. Otherwise, I saw so many cataract lens replacements that I'm fairly sure that if given the chance, I could perform one myself on some poor, unsuspecting soul.

Friday was a blend of clinic and theater as I spent the day with the attending who was on-call. The most interesting thing I saw was a corneal repair. I don't know how those guys work with such small, nearly-invisible stitches under a microscope. At least the abdomen after a c-section gives me a bit of a target to work with....

In the evening we visited the home of the minister who presides over the Presbyterian Church. For the first time since coming here, we felt as if we finally got a glimpse into the homelife of a Kenyan. Thus far, it's been hostels and hotels the whole time. It was really nice to feel at home...

Speaking of which, it's only 6 short days left. If you have any souvenir requests, get them to me ASAP. So far, I am bringing back so much coffee that I will most likely have to declare myself a business and pay an import tax.

I've edited my Week 4 pictures and added captions! I'll be adding more Pictures tomorrow!!

See you all soon!

Week 4 pictures...

Why Scott would love Kenya…

Hello my loyal readers…well, at least both of you who are still out there. I am writing from the town of Kikambala, on the east coast of Kenya, approximately 20km north of Mombasa. After a grueling three day work week shortened by two national holidays (Easter Monday and a surprise Day of Prayer on Friday in memory of 14 government officials killed in a plane crash on April 10th) we decided to holiday at the Royal Reserve Safari and Beach Club, thanks (big THANKS!) to Meredith’s parent’s RCI timeshare for a few days. With time suddenly flying by and our time drawing short, we figured it was time to get our feet wet in the Indian Ocean…or in one of the two pools at the resort, at least.

Before I get to that, let me breakdown my work week, which may have been short in duration but long in experience. As some of you may have judged by the title of this post, I spent the week at the Kikuyu Orthopedic Rehab center. As to why I think our own Scott Stanat, future orthopod extraordinaire, would love it…well, let’s just say they’ve got an endless supply of knee and hips replacements, freaky fractures from all sorts of crazy Kenyan car accidents and thug attacks, and pathologic bone disorders I’m still trying to find a clue as to what they are….and they are more than willing to let any muzungo hop in and lend a hand. If Scott were here, Meredith and I doubt they would let him leave.

The first thing that struck me about the center was that they are somewhat more updated than what I’ve seen up the hill at the hospital so far. Having been built sometime in the early 90’s, it actually looks like a hospital that could easily be found somewhere in the States, in contrast to the main hospital up the hill that could easily be found in another time period all together in the America. We rounded at 8am and would go to theater immediately afterwards until 5 or 6pm.

On Tuesday, the day started off with a wicked distal fracture of the tibia in a gentleman who had been in a car accident back in December. At the time, he had just received a cast and sent on his way. Why he hadn’t sought help in the past 3 months despite not being able to put any weight on it was beyond me, but here he was with an ankle fractured in three places and pieces of his tibia floating everywhere. As with every surgery at the center, the team begins with a prayer. Upon opening the leg it was pretty obvious that this was going to take a lot longer than they thought it would. First, the fibula had to be intentionally fractured to allow for the tibia to be properly aligned. Then, all the poorly formed calluses from nearly 4 months of improperly aligned healing had to be broken, shaved, and practically gnawed off just to get a decent fit between all the floating pieces. From that point on, I’ll admit my lack of orthopedic knowledge fails me, and all I can really describe was a lot of hole drilling, screw placing, foot twisting, and long metal rods being shoved into places where bone marrow once resided. Three and a half hours later, the gentleman was on his way to recovery with a halfway decent joint that may actually function once again. With what they had to work with, both in the leg and on the sterile trays, these surgeons were practically miracle workers.

Wednesday I saw my first ever total knee replacement. It was performed by a surgeon that everyone simply called The Professor. Word is he trained many of the current attendings working at the center and he continues to teach at the University of Nairobi Medical School in the mornings and operates in the afternoon. I’ve decided that one of my lifelong goals now is to be known simply as The Professor at some point in my career. No last name, no first name…just The Professor. I know what you’re thinking…I’ve read one too many comic books and it’s finally rotted my brain. Now, I can’t honestly argue to the contrary that this is probably a contributing factor, but mostly I see it as one of the highest honors a person can attain in any profession, but even moreso in medicine since so much of our profession depends on knowledge being passed down orally and by observation. One of the residents that The Professor was operating with had never done a knee replacement before, so he pretty much became a living, breathing, drilling textbook of orthopedics as they hammered and cemented into place a brand new shiny knee joint.

Thursday was clinic day. In the US, from what I’ve seen thus far, clinic days are usually a half day affair one day a week in which residents present to attendings in an orderly, pressure-free environment. At the ortho clinic, 135 patients walked through the door over the course of an entire day; and that’s only Thursday clinic. They do the same thing on Mondays, too. It was a seemingly endless parade of stiff knees, sciatica, swollen joints, cast removals, funny-walking kids, osteoarthritis, and injuries from all sorts of weird and whacky circumstances. I followed an attending around the whole time and by the end I felt like I needed some sort of orthopedic support for my feet, knees, and back. One patient that stands out was a 55 year old woman who had a swollen arm, from shoulder to fingers, and occasional fevers over the past 4 years whose X-ray showed horribly deformed bones from the humerus to the tips of her first four fingers. The only possible contributing history was a fall she sustained when she was a young girl. No one in the room had a quick answer. Why it just affected the arm and nowhere else at all was beyond us. Geoff and I talked about it afterwards and we think it was probably a TB infection isolated to the arm that just has wreaked havoc all these years as she’s grown. It is definitely a radiograph fit for textbooks.

As I mentioned earlier, Friday’s scheduled surgeries were all canceled in observance of the Day of Prayer called by President Kibaki in rememberance of the 14 people, 6 of which were Ministers of Parliament, that died in a plane crash a few weeks back. We rounded in the morning and then I headed back to the hostel to pack for Mombasa. Our train was leaving at 7pm and we would be riding overnight in a sleeper car, with dinner and breakfast provided. More on the train ride and Mombasa to follow….

10 more days!

Weekend in Nairobi...

HAPPY EASTER to all of you celebrating today! And to my family, HAPPY PALM SUNDAY!

We spent this weekend in Nairobi, which allowed folks to attend all the church activities they needed while others had to opportunity to go out and do other things. We stayed one night at the Kenyan Comfort Inn (our new favorite cheap hotel in Nairobi) and then one fabulously posh night at the Stanley Hotel. After an afternoon at the pool yesterday, a few of us spent a chunk of the night with a touch of gastrointestinal distress...oh well. Bound to happen at some point. At least we had a variety of TV options to keep us occupied.

I'm back to 100% now. Heading back to Kikuyu in a couple of minutes. Tomorrow I think we are doing a day trip to Lake Nakuru where all the rhinos hide out. These four day weekends are rough....

Here are some random pics from Week 3 of my Kenyan adventure....

http://www.snapfish.com/thumbnailshare/AlbumID=40688255/a=6248780_6248780/t_=6248780

Love to you all! I'll try to update throughout the week....

Land of Extremes...

Disclaimer: This will probably end up being a pretty long post, so be prepared. I’m pre-writing it on Meredith’s laptop so I don’t have to worry about time-constraints or connection speeds, so I apologize for any meandering that may occur. I’m not sure the best way to organize this entry, so I think I’ll start chronologically and go from there.

First off, here is a link to my Week 2 Snapfish pictures: http://www.snapfish.com/thumbnailshare/AlbumID=40092925/a=6248780_6248780/t_=6248780

On to more exciting stuff:

Our safari weekend in Maasai Mara was beyond description. The pictures I’ve posted on Snapfish (http://www.snapfish.com/thumbnailshare/AlbumID=40630025/a=6248780_6248780/t_=6248780 ) do it no justice, but hopefully you’ll get an idea of the fun we had. I don’t have many digital photos because I used my manual Minolta with telephoto lens mostly so that I could get closer, more detailed shots. Those I have to wait until I get back to the States to see. Meredith and Nancy, however, have a TON of digitals, so you can go to their Snapfish albums to see more when they get a chance to upload them tomorrow.

The adventure began with the ride to the reserve, with our expert driver/guide Sam navigating some of the worst roads I have ever seen in my life. We spent half the time driving off-road in the shoulder of the highway because the potholes were so bad. It took about 5 hours to get to Maasai Mara, with two strategic “bathroom breaks” at roadside souvenir shops that exist merely to haggle with mizungos (white folk) like us for such “hand carved” items as six foot giraffe statues, endless rows of ebony buffalos, and soapstone candlesticks. They’ll also barter for such items as ballpoint pens, Advil, the shoes on your feet and the shirt off your back.

We got a preview of our weekend at one point when we looked to our right and just saw a giraffe casually eating from a tree about 50 yards from the road. Then came the zebra herd just hanging out. And just when we thought the car ride would never end, we rolled up to the gates of the Sarova Mara Resort, buried in the bush just a few miles within the park entrance. It was completely NOT what we were expecting. For $65 a night we figured we’d get your basic travelers’ hotel designed for you to go out all day on safari and be too tired when you get back to care about what the place looks like. Instead, we found ourselves in a four star resort complete with pool, a bar with a fireplace, an incredible buffet-style restaurant, and picturesque grounds that would put most American catering halls to shame. Our individual rooms were actually luxury tents that mirrored most luxury hotel rooms in terms of amenities, except for having no walls. The attached bathroom was the nicest bathroom I have seen since coming to Kenya. If you’re up for a unique honeymoon experience, this is the place you want to go.

After arriving around 2pm, Sam gave us the opportunity to freshen up, settle in, and grab lunch before heading out for an afternoon drive. It had begun to rain, but that didn’t seem to affect the animals too much. Right off the bat, we came up on a group of female lions lounging around by the side of the road. Next came a family of elephants out for an afternoon stroll. A little further down the road we found a pride of gazelles and then a group of giraffes munching on the high trees by the road. No matter how many times you’ve seen these creatures on TV, in the zoo, or at the circus, nothing compares to seeing them in their natural surroundings. It’s simply majestic. Of course, it takes a bit of willing suspension of disbelief considering that you’re standing in a minivan taking pictures from out of a retractable roof along with all the other tourists that gather at a particular spot once word spreads of an animal sighting. It’s actually amusing to watch the animals simply try to pay us no mind. You just can’t help but feel like you’re a Far Side cartoon waiting to happen.

We got back to the resort exhausted and starved. The buffet dinner didn’t disappoint. Afterwards we were treated to some traditional dancing by some Masai tribesman. The Masai are the dominant tribe in the south-central region of Kenya along the border with Tanzania. You’ve probably seen them on postcards or documentaries about Africa. They wear bright red fabric to ward off lions and are famous for their nomadic lifestyle and mastery of cattle herding and selling. In fact, one Masai told us about their belief that all cows belong to the Masai, which helps drive their way of life. It also fuels some pretty nasty disputes with other tribes, apparently. It got us to thinking…what could we claim all of and start herding for ourselves ? We came down to a few finalists: motorcycles, airplanes, computer operating systems, and donkeys.

The rest of the weekend saw us finding 3 of the “Big 5”: Lions, Water Buffalo, and Elephants. We didn’t get to see Rhinos or Leopards, but we DID see a beautiful Cheetah up in a tree, so we decided it was an honorary member of the Big 5. The scenery alone was absolutely incredible, with a sky so vast and endless even the elephants seemed dwarfed at times. We also got to see a Masai village firsthand, complete with a cow dung covered center where all the cattle are kept at night, huts made of dried elephant dung, and more flies than I care to ever see again. It was a bit “Colonial Williamsburg” in terms of staged presentation, but still interesting to experience as a tourist. I also got pretty good sunburn on both arms by standing up all day taking pictures from the retractable roof opening. Small price to pay…trust me. By the time we got back Sunday evening, I was burnt and ready for bed.

Monday morning I started Surgery with Dr. Kavaludi, the Medical Officer in Charge and the person responsible for us during the elective. Rounds began at 9am with the intern, Maureen, where we were seeing the usual cases of broken bones, gunshot wounds, car accident victims, mugging injuries, and diabetic feet. Then we came across a little girl named Hannah; nine years old, obviously sick, and with what appeared to be gangrene ascending both her legs. She had never been in the hospital before in her life. According to the mother, about a month ago, a classmate pushed her and Hannah fell in such a way that she hit both her feet on her desk. There was no apparent injury, no cuts, no broken bones, except for persistent pain and eventual discoloration. The feet became cold to touch, and that is when her parents began bringing her around to various hospitals and clinics. At each one, apparently, they were told the same thing: the girl is developing gangrene and needed amputation to avoid any further systemic problems. Each time, the parents sought a second opinion.

By the time she reached us, she was responsive only to pain and had a fever of nearly 102^o. The gangrene in the right leg had reached the level of her knee, while on the left it had reached her ankle. On examination, both feet were ice cold and the toes on the right foot were simply stiff, black projections coming out of the foot. No pulses cold be felt in either foot, and all the way up to the knee on the right. To top it all off, she was severely anemic (4mg/dL) and had a white blood cell count of 100mg/dL, which on first glance points to a full blown horrendous infection. To this point in my medical career, I had seen anything like this. Maureen and I rushed to report this to Dr. Kavaludi, and with only about 30 seconds of history, he wanted the girl in the operation room within the next 30 minutes. The mother was at the end of her rope and could seem Hannah could no longer take what was happening to her, so she consented to the surgery.

To add a new twist to the story, when Maureen and I went to the laboratory to pick up more blood for transfusion, the lab technician brought to our attention the peripheral smear made from Hannah’s original blood sample. It seemed what was recorded as a granulocytosis by the cell cytometer was actually a proliferation of band-like cells that resembled lymphocytes, indicating that on top of a toxicemia due to the gangrene she was probably suffering from some sort of leukemia as well, which would help explain her apparent tendency to thrombus formation.

This is pretty much the medical definition of a train wreck.

I’ll spare you the details of the surgery itself, but let me just say I actually snagged Meredith from the c-section she was observing in the next room just because I wanted someone there with me. I have seen amputations in the past, both voluntary for medical reasons and involuntary due to trauma, but nothing prepared me for the sight of a nine year old girl losing one leg above the knee and another just below. And the worst part is that it was just the beginning for her. This newly diagnosed leukemia was probably going to lead her down yet another tortuous path of hospitals and clinics.

Unfortunately (or, perhaps fortunately, depending on your point of view) the next morning when I went to check on her, I was told she had passed away during the night. Apparently, she had never woken up from the anesthesia and she finally went into respiratory distress at around 1am. This was, by far, one of the worst medical situations I have ever been a part of. From the age of the patient and the seemingly benign nature of her injury to the probable preventability with early intervention, this case just made no sense and will stick with me for a very long time.

So I hope this post makes up for my lack of content this past week. Being in Nairobi, I’ll probably be able to post a little more this weekend…hopefully this post hasn’t made you all sick of me!

Miss you all. 20 more days to go….

Another quick update....

I had hoped to have a grand update with pictures, but this internet connection in Kikuyu is killing me and it would take me all night to load even 1/10th of my pictures. I think Meredith may be posting a few pictures over at her blog, so scroll down and find the link to it. Tomorrow we are going to a better cafe with somewhat of a better connection, and I'm going to pre-write my post tonight. There is so much to say. The weekend safari was easily one of the top 5 most incredible things I have ever done or seen. Honestly, if I were to go home tomorrow, I think I would be satisfied. Then, back at work, I witnessed one of the top 5 most horrendous and sad things in my life. I will tell you all about it tomorrow...right now, I'm going to just leave you in suspense. Everything else, meanwhile, is fine and the whole group is in tact. We are gearing up for a FOUR DAY weekend this weekend since Good Friday and Easter Monday are both national holidays in Kenya! Rough life, I know.

More to follow.

-Jerry.

Quick update...

So we've taken a mile and a half stroll into Kikuyu Town with our new friend Russell, who is an internal medicine resident from Milwaukee who just arrived two days ago to work at the hospital for two weeks. He's been to Western Kenya before and seems pretty down with flow of the place. Today was our last day of work for the week and we leave bright and early tomorrow for Masai Mara for our safari. Not sure when I'll be able to update next, but I'll definitely have pictures to show. It's been tricky uploading pictures because of the slow internet connections we've run into at the internet cafes.

Nothing much to report since my long winded post yesterday...

Gotta head out before the sun goes down. I'll be in touch soon!

-Jerry.

It's not all fun and games...

Okay, so I’m reading over my blog thus far and apparently I’ve given off the vibe that we’ve flown halfway across the planet for vacation. So let me talk a bit about what we do with the majority of our day….

We all wake up around 6am to get ready for breakfast, which is served at 7am in the dining hall/ballroom. The food is pretty good for a hostel, with a decent amount of variety from day to day….we get really excited when they put out the beef sausage. The best part about the meal is that it’s prepared and served by some of the nicest folks you’ll ever meet. After breakfast, we head back to the hostel and finish getting ready for the work day.

After the 15 minute hike up the up the hill to the hospital, we all split up and go our separate ways. (Actually, whoever is rotating through orthopedics gets a break from the hill since the rehab center and ortho operating rooms are just next door to the hostel…currently, that’s Nancy). I’m still in Maternity/Pediatrics, and will be switching on Monday to either the Eye Unit or Orthopedics. I spend the morning rounding with a team of residents and an attending on women currently in labor or being induced, post-partum mothers and their newborns, gynecologic/surgical patients, and pediatric patients below the age of 5 years old. It’s definitely more of a primary care field than what we practice in the states. In the US, we basically catch the babies and pass them off, sometimes literally, to the pediatricians. From that point on, unless a boy is getting circumcised, we don’t have anything to do with the newborn.

Pretty much every morning after rounds there has been a c-section that needed to be done, either for failure to progress leading to fetal distress or as an elective procedure to reduce the chance of mother-to-baby transmission of HIV. What I’ve observed during those surgeries has both horrified and amazed me, sometimes at the same time. I’ve included some pictures from the operating room (or “theater” as they call it) so you get an idea, first and foremost, of the environment they work in. I’ve learned that sterilization is a relative state that probably exists somewhere between the reusable and rewashable hand scrubbers, surgical gowns, and patient drapes I see here and the completely disposable and ultra-wasteful use of surgical supplies in the U.S.

The next thing that blew me away was the speed at which they perform the c-sections. First off, the mothers are all put under general anesthesia here. It was explained to me that culturally women here do not particularly enjoy the idea of being awake with just spinal anesthesia. Apparently, they prefer to simply go to sleep and wake up and find the baby out and the wound sewn up as opposed to experiencing all the pulling and commotion associated with the operation. With that being said, the general anesthesia they use, primarily nitrous oxide and halothane, works its way quickly into the mother’s circulation and, ultimately, into the placenta and the baby’s circulation. Therefore, in order to avoid a floppy baby or possibly respiratory distress upon delivery, the baby needs to be extracted quickly. So far, I have seen an average time of about 6-7 minutes from the time mom goes under and the knife hits the skin to when the baby is pulled out; No bovies to cauterize any bleeders and no extra care to create a bladder flap. No fuss, no muss.

Oh, and did I mention that those performing the surgeries were an intern (for one intern, it was his 5th ever…for another, it was her first) and the scrub nurse, who is the senior surgeon in the room. The attending wanders in and out from his spot in the lounge periodically to check the clock and to see if there are any complications arising. Otherwise, it’s trial by fire for the intern. And thus far, I have been utterly amazed at the skill and incredible poise they’ve shown. When I first learned that it was my intern’s 5th c-section ever, my jaw hit the ground. I had to make sure he didn’t say “50th”. All the babies have come out happy and healthy and most mothers are discharged in 2-3 days barring any complications, of which there is only one that seems to be brewing at the moment involving possible bladder trauma and potential fistula formation. Of course, given the spotty follow up and return rate, it’s hard to quantify the true post-operative complication rates for such things as infection, infertility, incontinence, and fistulas.

This post is long enough, so I’ll save my story about the 19 year old girl and her “criminal abortion” for my next post. It’s a sad story, but with the way things are going in the US with our current administration and its Supreme Court, it’s a story that could become pretty relevant once again in our neck of the woods.

I hope I’ve given those of you who thought I was just frolicking out in the sun, working on my tan, and sipping mango juice all day a bit more perspective on why I’m out here. It’s hard work, I tell you.

Now, I’ve got to go the store and pick up a few things for our safari this weekend. More pictures to follow!

Cheers!

Nairobi...the city of safari-peddlers and meat.

We are ready to head out of Nairobi in about an hour, so I thought I'd post some of my musings and observations. My impression of the city waxed and waned between dissappointed and exhilirated often during our short stay here. The first hotel we stayed in (The Embassy) was pretty much the type of seedy roach motel you'd see in a movie about seedy roach motels. But for $10 per person, we were willing to give it a shot, even though I could hear our hearts collectively sink as Big T pulled up to it. Since it was dark by the time we got into town, we decided to stay in and check out the "Bar and Restaurant" in the hotel. Aside from the Tusker beer I drank in rapid succession in hopes of improving my horrified disposition (I'm reminded of a funny t-shirt I once saw that read: Beer! Making Ugly People Beautiful for over 100 Years!), this place made me feel like jumping out of the window overlooking the run-down "City Market" across the street. When our order finally arrived about an hour (and three beers) later, it was about 10% accurate, with the kitchen staff apparently deciding that our choices were either not appropriate, or simly did not exist in reality (re: Googly Burgers...despite explicit advertising to the contrary, they do NOT exist...trust me). Things did not improve as Geoff and I ventured to our crack den and found that we would be sharing our room with an army of baby roaches living in our bathroom. To top it all off, the walls were so thin and beds so rickety, that when the couple next door showed up around 4am we felt as if we had inherited two roommates on their honeymoon. I slept for a grand total of an hour and twenty minutes.

The next day Geoff and I proposed to the group that we switch hotels. After a search in our travel guides, we settled on the Kenya Comfort Hotel just around the corner. It was just about the same price, but man was it absolutely WONDERFUL! It had been recently renovated and it's kept up perfectly. Our moods instantly improved. We went about wandering the city, getting targeted and harassed by every safari salesman in Nairobi. It was at this point I realized the beacon I must be in this art of the world. Meredith has taken to calling me "Sore Thumb" because of how I stick out. We researched safaris and had lunch at the Thorn Tree Cafe in The Stanley Hotel, where Ernest Hemingway often ate and wrote. It was a wonderful meal, though to be honest it kind of felt like we were hiding with the imperialist. A subtle reminder were the guards out front that checked every car that entered the hotel roundabout with mirrors in order to make sure none had a bomb strapped to them. Sadly, the American Embassy bombing came to mind often during my stay here....in some ways, the underlying tensions are still palpable, despite the overwhelming amount of smiles and friendly demeanors we've encountered so far.

We then ventured to the National Museum north of the city, only to find that it was closed for renovation. From there, we went to a suburb call the Westlands, which basically spells out the split personality of Kenya I've talked about since arriving. First, we spent a few hours wandering a fully Westernized mall, complete with a food court, ATMs, clean bathrooms, and all kinds of clothing and department stores. Apparently, this is where you'll also find all of the white folks, Indians, and other non-Africans hanging out. Step outside the guarded parking lot, and directly across the street you'll find a shanty-town of shops and lean-to's full of poor shopowners literally begging for you to buy something. We caused a mini-riot by crossing the street...five well-off Americans surrounded by dozens of men and women pulling them into stores and offering "half-price" for "hand made" jewelry, masks, prints, pots, and hundreds of other useless treasures. The bargaining is intense, and they use every kind of pressure tactic known to man. You can usually get them down to 80-90% of their opening price, but it takes a lot of work and a little bit of cold-heartedness considering the circumstances. It was an eye-opening experience, and one that I'm not sure I want to do again any time soon.

Continuing with the imperialist view of Nairobi, we dined at a restaurant called Carnivore in the southwest region of Nairobi. I cannot even begin to explain the meat we had. I think Meredith has a good breakdown on her blog, so I'll just throw in some broad descriptions. The meal is basically described as a war between you and the kitchen. The weapon is food. The kitchen is literally trying to kill you with food. So they give you a little flag on your table and when you've had enough, you are supposed to tip your flag as a sign of surrender. Until they see that flag fall, the Meat Servers (or as I like to call them, the foot soldiers in the Kitchen's Army) will continuously bring huge skewers filled with every type of meat known to man and drop it on your plate, regardless of your condition or amount of food still on your plate. Then, when the flag finally falls, and you think that you've cheated death by stopping the meat parade, they come at you with deserts ranging from ice cream to cheescake to warm pineapple pie. It was only by the grace of God that we did not break the axle of the cab we all squeezed into afterwards. All of this, with wine, dawa, and bottled water, for about $50 per person. In Manhattan, that meal and experience is EASILY $80-$100 per person....and there is no way you would have gotten ostrich, camel, and crocodile!

Alright, Big T will be here any minute and I want to get one more Tusker before heading back to our dry quarters...check out my Snapfish photo album in the mean time:

http://www.snapfish.com/thumbnailshare/AlbumID=39913895/a=6248780/t_=6248780

Here's Nancy's too:

http://www.kodakgallery.com/Slideshow.jsp?mode=fromshare&Uc=64i7mowj.5giw7lfn&Uy=-kvbc5b&Upost_signin=Slideshow.jsp%3Fmode%3Dfromshare&Ux=0&UV=598054253426_548132831107

Miss you and Love you all...

Day 4 update...

Check out the link up top to get an idea of where we're working! Our accomodations are ridiculously posh, located on a postcard-worthy campus complete with a garden, mess hall, and scenic walk to work. Breakfast is served at 7am, and we mosey on to work around 9am. Currently, we've been split up - I'm in Maternity (surprise, surprise), where I do more pediatrics than Ob it seems, Meredith's in Peds where she seems to do more medicine than pediatrics, Geoff is (eventually) in the Eye Unit, Judith's in Surgury with our director, and Nancy's down the hill at the Ortho clinic, aka Femur-Fracture Central. Everyone seems to be getting out pretty early, except me, of course. But we rotate, so everyone will get to feel my pain eventually. Today I saw an emergency C-section performed by the intern (it was his FIFTH one ever) and the scrub nurse (who doubled as the attending surgeon). The Maternity Medical Officer (the real attending) would poke his head in occasionally whenever his newspaper got boring. The surgery was an absolute success, with the intern making it look like it was his 500th c-section. Honestly, I don't know whether to be amazed or horrified by what I saw...but you know what, it got the job done and both mother and baby boy are fine.

Tonight (Thursday) we've headed down to the suburb of Karen (named after Karen Blixen, the author of "Out of Africa") to run some errands and grab dinner at a highly recommended restaurant: The Rusty Nail (review to follow). We have to walk about 1/4 of a mile to get there from the center of town where I'm currently typing, and we have to do it before dark falls, so I'm signing off for now....Enjoy some pictures while you can!

The eagles have landed...

...and so far, no international incidents! We are well, our accomodations are outstanding, and everyone here is so nice and welcoming! Pictures to follow....hope all of you are well!

Meredith's Adventures in Kenya

Here is Meredith's blog!

Meredith's Adventures in Kenya

Meeting our boss....

Here's the Kenya-bound group meeting with Dr. Kavaludi, our boss and preceptor at PCEA Hospital, at Downstate on March 13th. Front row (L to R): Meredith, Nancy, Judith. Back Row (L to R): Me, Dr. Kavaludi, Dr. Imperato, and Geoff. I wonder if Geoff and I could win some money in two-on-two basketball pick-up games while we're over there... 

Where to begin?

Okay, so like most people in my age bracket, I had sworn off the whole "blog" phenomenon. I mean, seriously...did we really need one more version of an internet soapbox? Between chat rooms, message boards, myspace.com, and the endless number of personal websites dedicated to countless worlds of one, it makes you wonder whether people even had opinions prior to 1993 or so. When I was a kid, I remember trying to be as cool as Doogie Howser by starting a computerized diary on my Commodore 128. Now, I guess one just puts it on the internet, and it's a blog. How self-important of us.

(You're waiting for the part where I take back all I've said and embrace this fantastic new form of human communication, aren't you?)

Well, I guess it starts with Kenya. With my impending trip this Sunday with a group of fellow 4th year medical students to PCEA Kikuyu Hospital outside of Nairobi, I began brainstorming ways to keep in touch with a large group of folks without having to flood email boxes with photos and blabbering. Instead, people can just click a link and view my photos and read my blabbering without worrying themselves to death about disk space quotas, e-mail etiquette, and feeling pressure to reply knowing how fragile my ego is.

Perfect!

So I hope you enjoy your visits here. When I get back from Kenya, maybe this can turn into my own little residency diary full of baby-catching, sleep deprivation, and political musings....exciting, eh?