There goes another week

Frustrations….

Working in medical settings in the third world inevitably necessitates a change in expectations. In the West, we generally do anything and everything that is necessary for the patient to live, with regard to cost and resources only after the fact. In places like rural Costa Rica, remote northern India, or most parts of sub-Saharan Africa, thought must be given to these considerations beforehand. When someone is dying on the ward and has begun to lose cardiac and respiratory function, we often call a “code “ in the US. This involves a team of nurses, physicians, and technicians who immediately attend to the patient. This often involves intubation (place a breathing tube, typically attached to a ventilator). Code situations or pre-emptive intubation (for the patient who is going downhill and has foreseeable respiratory failure) frequently result in stabilization and the patient may be moved to the intensive care unit (ICU) for more specialized care with continuous drips of various medicines and aggressive ventilator management. At the Moi Teaching and Referral Hospital, one of the largest institutions in Kenya, there are five ICU beds with ventilators. These are generally reserved for post-operative patients who need monitoring until anesthesia wears off. Only very rarely may they be used for patients on the wards, and only in cases with immediately resolvable issues (such as acute poisoning, where after a brief ICU stay with dialysis a patient might be expected to make a full, or close to full, recovery). With any other patients who are “coding” or close to coding because of an underlying process with a more dismal prognosis, the standard of care is not to code.

All of the above is to say simply that patients here often die much sooner than you would expect coming from the West. There was a morning last week when Serena, the Purdue pharmacy student on the same team with me, and I arrived for rounds only to discover that three of our patients on our census of 15 or so had passed away during the previous night. We were shocked. The most upsetting part of it was that no one seemed to know how or when they had passed away. All the team knew was that the beds were now stripped and sanitized, ready for new blankets to be put down, which meant either they had been discharge or had died. Since we hadn't discharged them, we knew they must have died, which the nurses confirmed. We couldn't believe how little gravity and attention was placed on the departure of three people from this Earth.

Sadly, they all died from conditions that should be easily managed and treated in the US. The anger and frustration that arises from these situations is tough to describe. In contrast, the Kenyan medical students and physicians take it all in stride. This blase attitude is not due to lack of compassion, but rather that you simply become accustomed to the facts of the system over time. If the rate of death on the inpatient service is always that high, you simply know that you cannot save everyone, that you are not God, and that you can only do what you can within the limits of the system. Death becomes part of life. It would be impossible to base your emotional and psychological well-being on the health of and survival of each and every patient; you would end up destroying your own mental health and your ability to take care of the next patient. So, you care as much as you can , you do as much as you can, and you work to improve the system. The rest you accept begrudgingly as things you cannot change, at least not immediately. After all, we are not the final arbiters.

However, even here, some of the deaths ought to be preventable. The nurses are completely overwhelmed, taking care of 10-15 patients each. (In the US, the average would be more in the 4-6 range, or fewer in the ICU). That being said, one of our patients who died last week had been on service for four days with hypertensive urgency (uncontrolled blood pressure). He was only intermittently receiving his medications even in the hospital. We complained to the nurse, tried to emphasize how important BP control was with him since he was having symptoms from it. When we came in the day after he died, we saw that he had not received his BP meds again the previous day. Whether he stroked and died because of that failure, or whether it was some other cause, we'll never know, but the disappointment and anger over such a preventable passing lasted all day...until the next admission of a sick patient needing our help. And it starts all over again. Do what you can. Change what you can change. Accept what is beyond your control. Trust in God.

(One of the reassuring considerations when events like this happen is to think that a mere 20 years ago, there was no hospital in existence here at all. The progress that has been made has been exception. Obviously there is a long way still to go. It's for that reason that people like the Mamlins and their Kenyan counterparts work on a daily basis to make those infrastructural changes that will be necessary to improve outcomes in a sustainable way. Imagine what further change might occur in the next 20 years!)


Natural history….

Partly because of the lack of preventative care and the lack of resources here, we as medical learners have the opportunity to see and to learn what is called the “natural history” of disease processes. This term refers to the way in which a disease progresses, from onset to endpoint, without any intervention or treatment. The endpoint can be resolution of illness without sequelae (long-lasting repercussions); it can be some sort of permanent impairment; it can be temporary resolution with later recurrence; or it can be death.

We don’t often see the full natural history of most diseases in the US, because we intervene and treat and alter the course of history for that particular illness. Here, however, we’ve had many opportunities to see much more of the natural history of diseases like HIV, Tb, meningitis, rheumatic fever, heart failure, cancer, etc, than you would see at home. While it is sad and sometimes horrific to see this natural history before your eyes, it also serves as a strong education by sharpening our mental images of how diseases typically progress. Having now heard the unmistakable murmur of profound mitral valve stenosis (the valve controlling blood flow between the left atrium and left ventricle in the heart) caused by rheumatic fever in several patients, I know that I won’t miss this finding back in the US, rare though it may be. Having now seen several patients with disseminated Kaposi’s sarcoma (and AIDS-defining malignancy), I know I won’t miss those lesions in a previously undiagnosed ER patient in the US. The same goes for the natural history of malaria, Tb, meningitis, etc. Seeing and understanding the full scope of the disease process here should mean (I hope) that I will be able to more easily recognize the early stages of these diseases back home.


Unwinding....

I get the feeling we'll be traveling and trying to explore other parts of Kenya almost every weekend here. To this end, we took two SUVs and drove down a couple of thousand feet in elevation to the rainforest on Saturday morning. The area we camped at is called Kakamega Rainforest. It's a protected reserve of what used to be a forest that was continuous all the way from Kenya through the Congo. This huge swath of rainforest has been hacked up and carved up over the past century by British colonialists and local communities such that only a few small pockets remain. Kakamega is one of those pockets.

Keith's photo, experimenting with his camera settings. Kakamega is full of flowering plants.

After two hours on the bouncy, pothole-ridden Kenyan "highways," we made a turn off onto a dirt road that led into the forest. After another 20 minutes or so of jostling along the road through the increasingly dense foliage, with large broad-leaved trees stretching above the road and Kenyan men riding by on bicycles and women carrying cut logs for firewood on their heads, we finally arrived at a small clearing near some traditional thatched-roof houses.

A view from inside the banda. Phil, the side of Benson's head, and Keith.

We stayed in similar, but much larger, thatched huts called "bandas" at the edge of the forest. Each banda had a couple of beds with mosquito netting overhead. All of the cracks and openings between the walls and the roof were covered with wire mesh to keep out mosquitos. The floors were cement covered over by dirt. No electricity or water, but quite comfortable.

Keith, sitting atop a lookout tower for the biologists who work in the forest. You can see forest to your left and a large clearing in the center.

There were 13 of us in attendance (me, Keith, Nadine, Andy, Don and his wife Crystal, the five pharmacy students, Phil the resident from Brown, and Benson, one of the Kenyans who lives/works at the IU house). So, quite a crowd. We had four bandas, and they each surrounded a central meeting/eating area. We did two hikes, one when we first arrived and another at 5 AM to climb up to a hill top that overlooks the whole forest where we could see the sunrise (although it was a bit cloudy, and thus we didn't see much of the sunrise...but it was still an amazing view and it was nice to be up and out before dawn!). The forest was thick and dense. It reminded me of the rainforest in Costa Rica, although it was less humid here, as we were still at roughly 5000 ft.

One of the many monkeys near our camp.

We saw all kinds of varieties of plants and trees. Additionally, the rainforest is host to 200 of the 400 butterfly species in Kenya, so we saw a number of them, many brightly colored, others darker and closer in nature to the black swallowtail that's common in Indiana. One of the best parts was the monkeys! They were everywhere. There were three different species we saw, each of which were pretty different (four if you count the baboons we saw during the morning walk).

Walking through the forest. Much greener than Eldoret!

On Day 2 we had an episode with some of the blue monkeys, who descended from the trees to steal a loaf of bread from us.

Andy, Nadine, me, and Keith, all standing within a tree that's been strangled by another tree

We also went briefly into a bat cave in the side of the hilltop that we climbed on a walk at sunrise. I was expecting dormant small bats attached to the ceiling of a large cavernous cave, as you tend to find in southern Indiana. I was wrong. These bats were huge, the cave was small and narrow, and there were anything but dormant. Given my distaste for bats flying close to one's head, I didn't last long before I had to leave, but it was definitely an experience.

Phil, cooking up his masterpiece over the fire. Veggies on the left, chicken on the right.

For dinner, Phil cooked an amazing meal of carrots, potatoes, onions, and chicken, wrapped up in tin foil, seasoned well, with some white wine added to the veggies and some Tusker (the Kenyan national beer) added to the chicken. It made for a delicious meal. After the meal, we sat around by the fire and listened to Benson tell us about how to avoid being eaten by predators in Kenya. I wish I could approximate his high-pitched, colorful voice with his Kenyan accent, but I really can't describe it except to say that his stories were enthralling, especially after he'd had a couple of Tuskers.

Tasty meal, eaten with a leatherman, complimented by a Tusker

In the afternoon on Day 2, it poured on us (I guess there's a reason it's called a rainforest), so we just sat around and waited to be picked up.

Looking down on the rainforest from atop a hill (the highest in the area) after our sunrise hike on Day 2

That's it for now. I'm off to go enjoy some fresh sheep meat (the result of a basketball tournament, I'll write more about it later this week) and move my things down to the hostel, as Nadine and I are swapping locales today.

One of a hundred bats in the small, narrow cave.

Cheers!