We received some saddening news upon arrival to the clinic that our child with malaria had died at 3am this morning. Malaria is a terrible illness in this part of the country; however, if it is caught early it can be treated with anti-malarial medication. Our child presented with fulminant cerebral malaria, scleral icterus, and an extremely high fever. Our clinical suspicion was that this baby had been sick for a long time and was not brought to the clinic soon enough. Unfortunately, poor familial dynamics, economic problems, and some neglect likely played a role. The mother and family were distraught but according to a nurse at the clinic, the family accepted the situation and brought the body home for proper burial. We learned that small graves behind Kenyan houses were common.
On the opposite end of the spectrum, we experienced the miracle of birth today as well. Upon arrival, a 16-year-old female was fully dilated and was having regular contractions. She, however, was extremely non-corporative–not responding to commands and rolling on the floor. The pain was unbearable and resulted in her being more comfortable delivering on a mattress on the floor. Several of us held her legs, one supported her head, and more women were encouraging her to push from above. It was organized chaos. After two hours of pushing without pain medication, it was becoming clear that the baby needed to be born. The mother was exhausted and pushing became a battle, but she was informed that if she did not push the baby would surely die.
Many of us have seen live vaginal births before, but this was far different than anything we had seen in the United States. There was no nearby operating room to transfer the patient if the pelvis was too small or the passenger was too big. The mother’s vitals were not monitored in real-time, and the fetal heart rate was listened for by a small rubber device instead of a real-time monitor. The room was absent of family members–the mother was en route but was over 3 hours away and the father was not present. The patient was also not receiving pain medication nor was it an option. It was the purest form of childbirth many of us had seen, and we realized that women of Kenya and healthcare providers deserve great respect. While women and partners in the United States tour OBGYN departments to see which places have the most comfortable private beds and greatest sunlight entering the rooms, these women just hope that their birth is without complications. We must be grateful for this luxury in the United States and applaud the healthcare providers in Kenya for working diligently with what they have. In the end, a healthy baby girl was born and will stay for the next 48 hours.
Outside of the OBGYN room, clinic these last few days has been very hectic. We saw another case of mycobacterium ulcerans, diagnosed additional cases of malaria, and determined two more women were pregnant today. The high number of Kenyans coming to our clinic is secondary to the doctor’s strike that is occurring in the country. Doctors are on strike due to monetary reasons and the upcoming election. Mama Pilista Medical Clinic is the only clinic in the area that is still taking patients, so even though resources are somewhat-limited, the patients are provided with excellent care during this tough time. It is important to note though that any referrals or hospital transfers are limited–making severe cases harder to treat.
It has already been a whirlwind of a week and it is only Wednesday! We wanted to end this post by just reviewing who our team consists of as several people have inquired.
-Two Internal Medicine Doctors–one who practices outpatient and one who practices inpatient
-Two Family Practice Doctors (including Dr Bonyo)
-One hostel building volunteer
-One donation/organizing clinic volunteer
-One fourth year KCU med student
-Two third year KCU med students
-Two second year KCU med students
-Group of 15 Lao/English translators
-Clinic coordinator and clinical officers/clinical nursing staff (10)
Today started with rounds, which included our sick male patient with pneumonia being managed with antibiotics and fluids, our child and young female with malaria, our two non-dilated pregnant women with abdominal pain and UTI, and our readmission for generalized fatigue and pneumonia. Rounds at the hospital are conducted by the medical providers who stay with the patients overnight and include some friendly “pimping” of the student doctors. For those not in the medical field, this involves asking questions of students to keep them engaged, thinking, and prepared for intern year. At the end of the day, wrong or right, we are all still a team and all still learning.
In clinic we saw many interesting cases, including a pretty severe case of herpes simplex virus on the bottom lip. The history included appearance and ulceration that started two weeks prior, and physical exam pointed away from squamous cell cancer (no lymphadenopathy, no lip palpable mass, no indolent course of presentation) and more toward HSV. We also completed numerous knee injections.
Several people also completed sexual education at the clinic. We taught a group of ten 18-22 year old students about family planning, access, and communication. They asked fantastic questions and seemed very engaged. The class was a mix of males and females and the goal was to increase communication between the two genders regarding this topic as well as to educate.
We do want to end this discussion with a particularly saddening story that occurred today. We were faced with a seizing 1-year-old the moment we got to the clinic. The boy had been having a tonic clonic generalized seizure for over 45 minutes and was extremely ill. He was tested for malaria, which returned positive, and we immediately gave him acetaminophen and IM/rectal diazepam. Unfortunately, starting an IV proved to be extremely difficult as the boy’s veins were collapsed secondary to hypovolemia. Several attempts were made in all extremities as well as his external jugular vein. After thirty minutes, a peripheral IV was eventually gotten and fluids started. The process was agonizing. Minutes of seizing turned into over an hour. After this hectic process, he was still breathing but remained rigid without pupillary or reflex responsiveness. Many times we experience pure hell as providers. Here was this 1-year-old child with his whole life ahead of him. Had he had been born in the United States he would have presented by ambulance in less than five minutes and gotten rapid intraosseous access. He also would not have presented with the illness of malaria. It’s unfair, unfortunate, and sickening. But it’s the reality and without the clinic many more children with malaria would not be diagnosed and not be treated. We left the clinic today without knowing if the boy would survive the night, and can only hope that the cerebral damage is not extensive. The best possible care was provided to this infant in a resource-limited setting. And, we must remember to keep our heads up because there are other patients tomorrow that need our care.
Submitted by Julie Ronecker
Today at clinic we were exposed to a variety of very serious illnesses. A dermatologist who graduated from our school joined us on the same day we saw a massive ankle infection with exposed tendons, subcuta
neous tissue, and overlying infection. Without a biopsy or culture, our best guess was Mycobacterium ulcerans. The woman had recently been scratched by a cat and the resulting skin infection was quite impressive. She underwent wound debridement, was given antibiotics that would penetrate the skin, and was informed about the need for further surgical debridement. Additionally, we saw a child who was 8-years-old and diagnosed previously with
sickle cell anemia. She was extremely ill, clutching her abdomen, and with cough and fever. On physical exam, she had splenomegaly to below her belly button (approximately 10cm below the costal line) and scleral icterus. Fortunately, her hemoglobin was 7.6, which for chronic sickle cell anemia is fairly normal. We discussed the need for her to get check up visits regularly and for careful monitoring of her hemoglobin yearly.
However, the mom brought up a good point: Would these extra check-up visits cost money? Unfortunately, regular visits like this could be costly and thus it was decided to watch her closely, bring her in during the acute crises, and keep her away from contact sports. She was sent home on an antibiotic and counseled for the eventual need to be placed on a medication such as hydroxyurea.
We were also able to do several ultrasounds on women at various stages of pregnancy. The women loved to see their babies’ beating hearts and bodies within their uteruses. It brought such joy to them! We also continued to do knee injections and shoulder injections for patients with severe osteoarthritis. The most important part about a successful knee injection is when resistance is hit to move the needle into a different spot and aspirate to ensure injection within the synovial fluid. Steroidal injections are extremely effective and can help reduce the degenerative bone destruction occurring within the joint. It is important not to do more than one injection in a three-month period for risk of tendinopathy, tissue tenderness, and tearing secondary to weakness.
We also did several successful teeth extractions secondary to either infected or dead teeth. Patients were sent home on adequate pain medication to compensate for the painful procedure. We also diagnosed several new HIV cases and these individuals underwent counseling and began ARV medication treatment. ARVs are provided by the government of Kenya and the clinic has approximately 220 active patients that they track and follow.
At the end of the day, we were able to meet a young boy who Bonyo saved as a child. The 8-year-old was born to two HIV+ parents and within the first year of life experienced extreme failure to thrive. This kid would have died if not for Bonyo donating milk from a cow to feed the child for a year during the crucial stages of growth. Breastfeeding in HIV+ women is contraindicated for risk of transmission to the baby, thus, it is necessary to find an alternative source. Cows milk can be a safe and effective way to help kids with failure to thrive who cannot breastfeed. The child is now 8-years-old and enrolled at a local elementary school, but still visits the clinic regularly to visit Bonyo.
Submitted by Julie Ronecker
Today we had a chance to visit Kit Mikayi, a local rock within the village that stood for “Rock of the First Wife.” Our tour guide was very passionate and told us a wonderful narrative that introduced us to their culture.
The history behind the rock began during a very dry season without rain. In order to get rain, the people of the village were told to sacrifice 1 goat and 2 chickens. The male village leader would stab a goat onto the rock and blood would be shed on its face, and they would open both chickens and do the same. The goat and chickens would then be eaten as they prayed to their god for rain. The next day, the rain would come and the people of the village would have a plentiful harvest.
We also learned about traditional living arrangements in the village, consisting of one male house at the center. Distributed next to the house were his wives’ houses where the children would also stay. The culture was traditionally polygamous and this is true of several families to this day. Within each house was straw beds, water jugs, rock grinders to grind spices, plates and bowels, and medicinal equipment. One of the most interesting component of their culture was members of their village between the ages of 15-18 would have their bottom 6 teeth removed. The purpose of this was to assist in providing food and nutrients to villagers if they were sick and could not chew. The medicine was ground and dissolved into hot water and swallowed through a large spoon-like device that fit through the gap created from the six missing teeth. To us, this may seem aesthetically unappealing, painful, or unattractive, but the utility of this speaks volumes.
We then spent some time hiking in and around the rock formation. Under the rock was a small space that our tour guide informed us was a place to pray, relax, and offer promises. For the women in the community, they would walk underneath the rock, pray to the altar, dance, and touch the rock. They would promise to stay with their husbands through anything–starvation, sadness, childbirth, and arguments. The underground area was also home to dozens of small bats, and a lot of us were thinking about Histoplasmosis and Rabies because we just took our board exams.
When we climbed to the top, we were able to see a fantastic view of the village–complete with goats relaxing on rocks, villagers lounging below, and a landscape mixed with lakes and greenery. When we got back to the base, a traditional group of village women performed a dance for us and sent us on our way. The song and dance was representative of female empowerment, which a lot of us were happy to see in a male-dominated village.
Our next stop was to the equator line, where we stood at both the southern and northern hemispheres sequentially. We saw that the leaf spun counterclockwise and clockwise in each hemisphere respectively, and we were also able to balance an egg at the equator. If anyone happens to know the science behind this please do share–many of our group members are skeptical.
We have especially enjoyed this weekend and are now more informed medical providers. Part of being a good physician is learning about the area and being culturally-sensitive when providing medical care. For example, knowing that some members of the community believe in polygamy helps us test for multiple partners for sexually transmitted diseases instead of just one wife. Knowing that missing 6 bottom teeth in this village is culturally normal helps us not worry about vitamin C deficiency. Knowing that women carry large basins of water on their heads and babies on their backs gives insight into why joint pain, somatic spinal dysfunctions, and lumbar strains are common chief complaints. And, knowing that animals are sometimes sacrificed gives insight into potential exposure to blood-borne pathogens. On rotations in the United States we are familiar with the culture so the predominant goal of our clerkships is learning the medicine; however, when we come to Kenya, we must learn both the culture and the medicine as both are intrinsically linked in diagnosis, treatment, and management.
Saturday was spent resting and recovering from our week at clinic. Recovery days are important on medical mission trips so that we can return refreshed and rejuvenated to best help our patients. We are expecting to see close to 60-75 patients on Monday after a long weekend. Several of these patients will be follow-ups and the rest new patients. But first, a little recap of Saturday!
We got to experience Kisumu culture today on a relaxing walk through the city. Street artists were selling their clothing, shoes, handmade objects, and art. A lot of us compared it to a mini-version of downtown Kansas City; people were driving, walking, and biking while exchanging quick greetings to each other. We are learning a few greetings in Swahili such as “hamjambo” and “sasa.” It is important to note that Swahili is the main language spoken in Kenya, but each individual village speaks another language. The language in the town that we work in is Lao, and we use translators to translate between patient and physician. Essentially, this means that Kenyans are almost always multilingual–at least a village language, Swahili, and English (due to English being taught in school starting in kindergarten). It really goes a long way and shows respect when visitors try to use greetings.
We had a late lunch at a coffee shop, where some of us ordered more traditional American cuisine like burgers and soup and others ordered quesadillas and beans/rice. Though we are loving the food at the hotel, it’s always nice for a change.
Our evening was spent getting drinks at a hilltop restaurant next to Lake Victoria. Lake Victoria, according to one of our group members, is the second largest freshwater lake in the world. It was home to many creatures–hippos, birds, fish, Naegleria fowleri and other amoebas. We were able to see a hippo lift its head above the water and blow freshwater through its nostrils. It was quite possibly the coolest creature we were able to see, until one of us humans fell in (just kidding!).
Today at clinic we saw a variety of cases that were interesting, and valued the fact that we could send for labs and receive results immediately. For example, one patient was having bloody diarrhea and we sent for a rapid s. typhi test which came back positive, and another patient was having an opportunistic infection and was tested for HIV and found to be positive. The fact that Mama Pilista clinic has a lab with rapid results allows for more specific and successful diagnosis and treatments. On the other hand, one patient and her child who came in with thrush did not want to be tested for HIV. This is a common occurrence because of the stigma and sadness associated with potential positive results. At the end of the day, we must respect the patient’s autonomy. In other cases, physical symptoms outweigh the cost of having to test. A woman came in with pelvic inflammatory disease–pelvic tenderness, green discharge, back pain–and instead of doing a pelvic exam the best approach and standard of care for the village was to simply treat for PID.
Two of our medical students saw their first live vaginal birth. The woman gave birth without pain management and only experienced extreme pain once the episiotomy was placed. These anterolateral cuts help reduce bleeding trauma for the mother and facilitate a smoother labor. When the baby was born, the students remarked how calm the room was but how beautiful the process was. The mom and baby will be kept at least 48 hours for post-partum complications.
One of our members worked on the hostel today–fixing the door frames and working on final changes to the main entryway. The purpose of this hostel will be to house volunteers during medical mission trips and allow for them to be closer to the clinic. This will allow for more time to be spent at the clinic and less time communing from Kisumu. If interested in donating, the approximate cost is $50,000 and can be donated online.
As a group we are all feeling a bit nauseated. We will be taking the day off tomorrow to recover and return on Sunday refreshed and revived!