The nurses at the Lalmba Clinic in Matoso, a tiny rural fishing center on Lake Victoria, deliver approximately 100 babies per year. So far, in the second year since opening the maternity suite in December of 2016, we are very fortunate that all of the babies have been spared HIV infection. This is quite remarkable since approximately 25% of the mothers are persons living with HIV (PLHIV). (The infection in Kenya affects young women disproportionately, and our region is part of Migori County, one of the counties with a high rate of infection.)
Because the region is so poor, and also because it can be considered bad luck to plan for a baby to survive delivery and infancy, some mothers arrive at the clinic with little more than the clothes they are wearing. In the past, the clinic was on such a shoe-string budget that there was no provision for cloths to dry the babies at birth, and it was impossible to supply the mothers with blankets to wrap the babies for their journey home. Usually the woman had a shuka, or shawl, of thin cotton, but not always. The nurses disliked it when they had to send the baby wrapped in rags or bits of the mother’s clothing, especially as transport to the woman’s home usually involves riding a motorbike on our dirt roads. And I disliked trying to dry the newborn with edges of the maternity bed sheets, while the new mother rested on them!
I managed to find some baby blankets in the local used-clothing market and bought all they had, but they had all run out by the time I left Matoso in May. Tamara, my colleague in Public Health here, found a few in the market in my absence, and convinced Lalmba to budget for towels and blankets in the future.
When people read of the sparsely-clad babies in The Independent, the weekly paper for Livermore and Pleasanton, CA, there was an outpouring of support for them. People donated blankets their children had outgrown or that they found at thrift stores and garage sales. Several people bought sheets, swaddling cloths, and towels and delivered them to my door personally, or shipped them to my house.
And a very special group of quilters in Roseville, CA, responded with dozens of homemade blankets of the softest cotton flannel in beautiful patterns and colors.
For two weeks it seemed that we got deliveries daily, or even multiple times per day. Some were sent to Colorado for eventual delivery by people from Lalmba’s headquarters. (Someone from Colorado visits here each quarter during the year.)
One hundred and twenty blankets, cloths, and towels fit in my luggage on my return to Kenya in August! The nurses assure me these will last for one year, and they have already designed a system to make sure that each new baby goes home with a new blanket. The towels are stocked in the delivery room so each baby can be dried off with a clean, warm and dry cloth—not paper towels as was sometimes the case.
Hundreds more blankets are in my basement at home, ready to be shipped gradually to Colorado or carried back to Kenya . Thanks to the generosity of so many, the babies of this little corner of the world will be warm and dry for years to come. Thanks to all who made it happen—you know who you are.
One dozen really nice penlight flashlights with clips. I am lost without one clipped to my pants pocket for looking down throats, looking at a rash in an unlighted exam room, lighting the path to my house on cloudy/moonless nights, reading the tiny labels or looking for something in the barn-like storeroom which has only the light from the open door. Mine take AA batteries, which is great because those are available here. (AAA batteries, not so much.) The clip is necessary or it would fall out of my pocket more easily on the motorbike/matatu/ambulance rides on these incredibly bumpy roads. I brought a headlamp which is handy for some examinations, but is usually lost deep in my back-pack, and is too uncomfortable and awkward to carry all the time.
My own stethoscope, opthalmoscope/otoscope, and reflex hammer. Duh, I’m a doctor and the ones available here are crap. Sorry, there is really no nice way to say it. Should have brought (SHB): my own BP machine with batteries and good quality thermometers. (these are available, but are usually in a locked room or all the way at the other end of the building, or broken, when you really need them.)
Nail scissors. Toenail clippers. SHB: Better quality clippers. Mine broke after about 9 months, and I have not seen any here, though I confess I have not looked. Doing what I can with the scissors.
Dental Floss, extra contact lenses, cases, glasses. SHB: one year supply of floss and both cleaning and wetting solutions. Just bring one floss per month and 4 bottles each of solution–it may be the only year of your life that you actually throw each bottle away after 90 days, as instructed!
Hair-cutting scissors and comb. SHB : one year’s supply of “product”–my Hard Up gel, and two bottles of nice shampoo. You really can tell the difference between that and the two liter jugs of what is called shampoo here.
International voltage adapter/surge protector with two USB ports, and socket for American grounded plug. SHB: At least two of them. The one I brought is wearing out and is temperamental about when it decides to charge. Though I found a new Samsung rapid charger with two ports in Nairobi, and it works great. Pulling the adapters out of the socket seems to do the most damage, so if you can leave them in place and just plug the USB end of the cord into them they will last longer.
Lumino Reading light. I’ve mentioned it before but I can’t emphasize it enough.
Radio. I was advised to bring a short-wave radio, and I did. Mine is very nice, but the instructions have not helped me pre-set the stations, and it has about a million stations so it is really hard to scan or seek to find something. I finally, after about 6 months, learned the setting for the station that carries the BBC at about dinnertime, so I can just type in the setting and see if anything is on, in English. And Joyce can listen to the local am or fm Dholuo station. I likely would not bring this again, but it might be fine for a more tech-savvy ex-pat or someone who really needs background noise.
Wash-cloth. Towels are here in abundance, but for some reason not wash-cloths. And when you are taking cold-water showers, it somehow feels a little better to at least start with a wet washcloth than just stepping straight into the cold water. For Christmas, I was given a wonderful, soft, incredibly absorbent and quick-drying wash-cloth. (I know, all those descriptors mean it is likely made entirely from petroleum products, micro-particles and/or tubules, and will have a 1000-year half-life.) It is one of the greatest gifts of all time! If you can find one, definitely bring it to Africa.
Reading glasses, especially if you use anything more than 1.5 magnification. You can find 1.0 and 1.5 fairly easily, but nothing else. For those I suppose you have to go to an optometrist. In a city. Far away.
Several items of “technical” clothing: I’m really glad I brought two long-sleeved shirts with insect repellent that lasts through 70 washes. I don’t need and usually can’t wear them during the day, but can put them on after dusk to minimize the DEET I have to apply. I brought about 5 pairs of light-weight multi-pocketed pants which have been great. Next time I will likely break loose the wallet for the ones that have the 70 washes of insect repellent, because spraying these with permethrin every 6 washes is not something I am too good at. I did not bring many “regular” clothes, having been assured there are lots of used clothes here, and that turned out to be true. Still, I did bring one pair of jeans which are good for Nairobi where it is less hot, and for traveling. My sleeveless cotton tops are good for lounging around on the weekends, or layering with a light cotton shirt for the clinic. I brought two long-sleeved tee shirts. I really only needed one.
My supportive Keen walking sandals. Three pair were almost enough. The flip-flops available here hurt my feet. SHB: A couple of pairs of comfortable thong sandals to wear around the house. I got one pair in a care package and they were completely trashed in 6 months. They might have lasted longer had I refrained from gardening in them and wearing them outside.
iPad and Netflix. Luxury, not necessity.
Pure Should Have Brought:
A couple of bars of nice soap.
Hot sauce. McCormick Bacon Flavored Bits*. Dark chocolate, if you have a fridge/freezer in Africa. A box of packets of your preferred artificial sweetener. Spice teabags. (I include these items mainly to stress the importance of bringing that one flavor or spice that you will really crave if you cannot get.) Forget about things like saltines or French bread or those delicious little nut-crackers. They will get stale faster than you can eat them in this climate, even if wrapped, sealed, and irradiated.
Retractable ball-point pens with clips on the actual pen, not on the detachable top. (See penlight discussion above.) One can buy pens like this in the cities, but out here in the country you can only find very cheap pens with a cap. The good things is they are cheap–10 shillings, about 10 cents–but they don’t last long, or they stain my clothing, and I lose them too fast. One cannot possibly bring too many of these–if you don’t use them all you can leave them as gifts.
Pencils with erasers. I am sure these are available somewhere… A couple of dozen is not unreasonable. Again, good gifts.
*Avocado sandwiches just are NOT the same without them.
I was in Nairobi after the Grand Tour of Masai Mara, and was a little disoriented from lack of sleep that first day back after dropping travelers off at the airport the night before. I was so happy to find a full-service DHL office near the Intercontinental Hotel, and they helped me to prepare a box of souvenirs to send home. I wouldn’t have to store them in Nairobi or schlep them home to Matoso in my smaller luggage. (I sent my big suitcase with my safari-mates, loaded with the heaviest carvings for under the plane.)I sent off everything, about one hundred dollars’ worth of cloth, small carvings, and miscellaneous stuff, and happily paid the 34000 shillings, thinking I had paid $34.00. I was wondering why no-one had told me about this great option to mailing or carrying stuff home!
The next day I had to take an Uber back to DHL, from my beloved Flora Hostel (no more Intercontinental for me), hauling the rest of the souvenirs and a couple things I figured I didn’t need any more, just to lighten the load a little more. This time, after finding the right size box, wrapping the Masai knife and other pointed objects really well, padding them carefully with fabric and shukas and preparing the detailed list of contents and values, the total came to about $300.00 dollars! I totally freaked, told the lady (who had also helped me the day before), “That’s impossible!”, and tried to explain that the larger box yesterday had only cost $34.00 to send. She patiently found the reciept from the day before, and showed me that in fact, I had paid thirty four thousand shillings, not thirty four hundred. The cost to send those souvenirs home had been $340.00. I felt rather dashed and for a moment, like quite a schmuck! Now I am just happy that I was too brain-dead to know how much it was actually costing, so my load will be lighter and it is too late for regrets–it’s enough to enjoy the luxury, and to be grateful that this is not life and death for me, as it would be for some.
Postscript: I actually started this post on April 9, so these events are a month old now. I still have the souvenirs from the second box, to bring home under “my” airplane. Now I know why people cheerfully pay the $50 or more excess luggage fee!
My thoughts are increasingly focused on two months from now, when I leave Kenya after spending a year here. There is so much left to do!
Hire a nurse for the expansion of treatment of HIV at Ochuna, and wherever else we need them.
Make sure all the nurses are licensed in Kenya. Some were hired a year ago and have not yet gotten their Kenya license—I think it is because it costs them money to do so, and no one has put much pressure on them thus far.
Meet with the Kenya Ministry of Health and get them to agree that we can treat all HIV positive clients on site with anti-retroviral drugs (ARVs), TB prevention, and prophylaxis of opportunistic infection. (Currently our mandate from MOH only includes treating pregnant mothers who come to us for antenatal care and are then found to be positive, their children and partners found to be positive at our site.)
Hire a “mentor mother” who will be in the well child clinic so that all our duties to the mother won’t be forgotten as we take care of the babies: moms need Vitamin A, sometimes tetanus or Rhogam, post-natal assessments at defined times after delivery, support in the areas of nutrition and breastfeeding.
Make sure somebody feels comfortable assessing the patients with high viral loads (the virus is HIV, and approximately 12.5% of our clients are infected), making sure they get counseled and re-tested if they are adhering to treatment, and switching them to another regimen if needed.
Familiarize the nurses and clinical officers with the system that exists for clinical consultations for complicated HIV cases. This is something I just became aware of in 2018, quite by chance, and I have not yet succeeded in actually getting an answer from them. I have learned how to contact them, how to submit a clinical summary, and several contact phone numbers and e-mails for the county and the national levels. We will undoubtedly need more assistance on cases beyond the two I have submitted so far.
Finish my contributions to re-writing the clinical guidelines for Kenya—a huge project which the folks back in the states are helping me with, thank goodness.
Keep my trees and flowers alive for another two months, and with any luck, figure out who will take care of them when I am gone. I hope the new Agriculture In-Charge will take them on, but she has quite a full plate with the shamba of vegetables for the children’s home, and the “public” parts of the grounds. My plants are mostly in the expat portion of the compound. I now have a small papaya tree, and lots of papaya seedlings, an avocado tree, a loquat tree, some passion fruit vines, multiple philodendrons, two mango trees (volunteers) and several shade trees, the names of which no one knows the English translations for.
The other really exciting thing is that I am having my first friends come visit me! We are going on safari to the Masaai Mara, and I am so excited.
Rechargeable reading light–this Lumino light is by far the best thing I brought!
Unfortunately I lost the charging cord recently, and it is now too dim to use. I ordered another one and it is coming soon!
In the meantime I found a little lamp here that works well on my bedside table. I have to sort of aim it properly and position my book just right inside the mosquito net, and I can read in bed–one of the joys in life, in my opinion.
Small pen-light torches–brought 12! good job. I always have one clipped to my right front pocket, along with my pen, and I use it multiple times a day–in the clinic, but also in the cookhouse or to see into dark corners or to guide my way when I walk in the dark.
Keen sandals–brought three pairs. Should have brought a few more pairs of SmartWool footie socks–I don’t know what they are really called, but the ones that just fit around the moccasin line of your foot and make plastic sandals more comfortable.
Yubi power adapter and surge protector–mine has two 2 USB ports and a socket for a grounded plug. This is incredibly useful, and I could have used 2 of them here.
Brought my unlocked old i-phone and it works great. I just buy another sim card if I go to another country for more than a day or two.
Goal zero solar charger and storage unit–was a good idea but only worked part of the time, and then I could no longer charge phone from it. Not quite sure what the issue is, but the storage unit is a very good flashlight, so it’s all good.
Dental floss-should have brought more. Bring one package per month. Toothbrushes are available, but they seem to all be hard, or at best medium. No soft ones. I brought my electric toothbrush but it refuses to charge so I could only use it for a few days. Same thing happened in Sierra Leone, so don’t bother.
DEET- containing insect repellent. One needs plenty, and it is not available here in rural Kenya.
Permethrin impregnated shirts. Next time, bring the pants, too. I spray mine periodically, but having the ones that last for 72 washes would have gotten me through the whole year.
Things I should have brought:
Mobile hotspot with sim card, removable. I was given one after arriving, but it really is a lifesaver here.
A fan–paper or plastic, non electric. I don’t know why, but they are not seen here often. I bought one in Sierra Leone from a woman at the craft market. She wasn’t selling it–it was her own!
More discreet panties–not thongs. Everyone hear wears long knit shorts (omg they look hot, but at least keep your thighs from sticking together) under their skirts, and of course all clothes are used–matumba!
Solar-recharging lights/torches. But you can buy some here. Batteries are a pain in the neck.
Shampoo-hard to get good quality. I’m keeping my hair short so two bottles should be enough.
Prepare computer ahead of time-load software, movies, books or music. You pay by the minute to download anything here, so all those Amazon Prime or Netflix videos are being paid for twice. Mostly I do without, but it was really painful to fly across the continent with nothing to watch, and only one book.
Bring some thumb drives for work.
Computer should have had Bluetooth, and/or better sound. I bought (later) a nice Bluetooth speaker, but my computer doesn’t connect! Oh, well, I use it with my iPad.
Parmesan cheese, bacon bits, decaffeinated tea and coffee–any little things which keep and that you really like. You cannot get good cheese here, though we have finally found real butter. Don’t bother with bringing crackers unless you are okay with eating them all in the first week or two–I really miss them but they get stale so fast, even if the package is unopened.
I’m sure there are many more things I should note down, but maybe there will be a Part 2 to this blog!
I spent the day attending patients in the remote clinic in Ochuna. It is a much smaller site than Matoso, and is not open for emergencies or deliveries. It is less than 5 km from the border with Tanzania, and many of our patients come to us from very rural areas of Tanzania. Malaria is even more common than it is here for some reason–probably poverty, poor nutrition, and maybe fewer mosquito nets.
It takes 45-60 minutes to get to Ochuna, and today I rode a motorbike with another staff member who helps at Ochuna frequently. He does data gathering, registration of patients, immunizations, dispensing in the pharmacy, –and driving, obviously! On the way, we saw men from the Rural Electrification part of the government installing electric lines in the village of Othoo. Imagine, all of this part of western Migori County (and much of Kenya, I’m sure,) has no electricity, no water system, no trash pick up.We are truly living in the wild, wild west. And just because they were putting in lines does not convince me we will have electricity soon. Poles and wires have been in place in Ochuna for two years, but the transformers all failed, apparently. So they sit.
For the first half of the day hours, from 9:30 until 1 pm, I saw patients with Mary, the nurse. We saw a bad scrotal abscess in a three-year old that probably started with the itchy rash of scabies. (Scabies is also rampant in Ochuna and our patients in Tanzania.) One family of a mother, her 4 girls ranging from 5 to 11, and her one year-old son–all the kids had scabies, and the mother and one of the daughters had malaria, as well. We saw a girl who fell down yesterday and felt a foreign body in her knee. Mary pulled out a splinter 2 cm long! We saw one child, about 2 years old, who had such severe malaria that we immediately referred her to a hospital. (Fever measured 38 degrees C, respiratory rate 60-80/minute, lethargic and dehydrated.) Mary suspected they would not take the child for lack of money, and there is no ambulance in Ochuna, so we also gave the treatment for malaria so the mother can at least try to give at home. I suspect the child will not survive the next 12 hours, but only God knows.
From 2-4:15 I saw patients with one of the medical assistants translating for me. Many of our patients were sick with malaria or just fever, but we saw one child with dysentery (bloody diarrhea). She got zinc tablets, ORS, Bactrim antibiotic, and Whitfield’s ointment for her scalp fungus. Many of the ladies came for their depo-provera shots, and Mary put in some long-term implants. We talked about PReP (pre-exposure prophylaxis of HIV) with one woman, not so much for her but for her husband, who is negative, because the first wife is positive. Mary knows the husband, whom she says will not come to the clinic for testing or treatment, but I was glad we got to discuss it with the second wife. Luo family culture is very complicated sometimes, with its odd blend of acceptance of sexuality as part of life (often resulting in early sexual intercourse–especially for girls–and multiple partners throughout life as far as I can tell), polygamous marriage, and Christianity with its attendant shame and secrecy.
We rode home again on the motorbike, taking about an hour and arriving back in Matoso hot, sticky and dusty. Time for a welcome cold shower!
I am busy, and happily so. The Vice President of Lalmba came to visit for a week so we were busy with meetings and staff interviews to hire a public health specialist and an agriculturist–both new positions.
The VP complimented the work I have done so far to beautify some parts of the compound. I have shrubs growing in clay pots, philodendron under a tree where formerly grew only weeds and spiderwebs, and several fruit and shade trees started. (Avocado, loquot, mango and shade trees I do not know the names of.)
And that’s just my after-work work!
I feel like I am finally getting in the rhythm of being an ex-pat Medical Director. Here is my week, which I feel is fairly representative:
Sunday: walked with the Public Health Director to neighboring farm belonging to a local community organization. Her goal was to view the shamba and advise the group members in how to get the water pump they would like. We met one of the organization members on his personal shamba, which was lush with oranges, papaya and other crops. I talked with him about my problems with growing trees, and he presented me with a beautiful papaya fruit and we arranged for him to come and plant a papaya tree at Lalmba.
Monday: worked on the rewrite of the Medical Guidelines specific to Lalmba in Kenya. These were last written in 2008 and must be updated and harmonized with our current formulary of drugs.
Tuesday: spent too much time completing business related to my health insurance back in the United States. This project involved forms to fill and sign, then e-mail to my partner Jack, who had to print and send with a check to the company. All vastly more complicated than it should be in this day and age, but I am grateful that after my health insurance coverage, which was suspended for many months, it has finally been re-activated. Thanks, Jack! I consulted with a teacher at a nearby vocational school who was concerned that one of the students, a twenty-year old man, seemed to return from each break spent at home with symptoms of a sexually transmitted infection. I assured her that it appeared to have been treated appropriately, and that no, that particular infection did not “stay in his body forever.” I told her that his partner at home likely needs treatment!
Wednesday: Normally I help document immunizations in the Well-Child clinic, but today we had a visitor from Palladium. They are the folks that have developed KenyaEMR, our EMR. While he was here, we did a “regular data quality check.” We got excellent scores for completeness of everything except some scores for tuberculosis. It turns out it was good I was there, because I was able to convince the rest of the team (all non-clinicians) that the EMR did not give us a chance to gather all the information they were looking for. We were recording everything we could, but the tools we were given were faulty. In the end, the guy from Palladium had to go back to his team and tell them they must solve this problem. That felt like a big victory.
Thursday: I went to Ochuna, our remote site, as I try to do every Thursday. As I arrived, Mary told me that she had two patients for me to see. One was a 47 year-old woman who had been brought in by her much older co-wife (the husband died a long time ago) and other relatives because she was confused on Wednesday, and unable to walk and talk Thursday morning. After much conversation they were finally able to make me understand that the woman had actually been sick for at least a year and a half, having to do with a mass in her abdomen, and had been given no long-term medications or diagnosis at the time she was seen at the referral hospital. Of course, they had left any medical documents they might have had (one is normally given some kind of referral letter from your local clinic to the referral hospital, and a letter from the referral hospital back to your subsequent care-givers) at home. Sure enough, she had a firm mass in the abdomen which was NOT her spleen, and which was quite obvious to even the untrained eye. Our conclusion was that she had some kind of neoplasm. She seemed to feel a little more normal after we gave her a liter of fluids intravenously, and got up and walked, and talked with her family. We recommended that she go back to the referral hospital for diagnosis and treatment, but the family took her home. There was no money for a hospital.
The second patient was someone I had seen a month or so before with a swollen left foot and pain in the left groin. It looked like he had an infection in the foot so we gave him antibiotics. He came back because while his foot was less swollen, now his entire left lower limb was swollen from ankle to groin and felt tough and “woody”, and he had bumps and pain in the groin. Mary suspected a dramatic and fairly classic case of very rapid onset Kaposi’s Sarcoma which usually accompanies AIDS, and I agreed. He came from Tanzania where he is living, but his home is in Kenya, so we recommended he go to the county hospital in Homa Bay, our neighboring county. Homa Bay County has the highest incidence of HIV in Kenya, and there are specialists from Medecins Sans Frontieres (MSF, Doctors Without Borders) there. We hope they may be able to offer him some kind of treatment, because we had none to offer.
The rest of the day we saw our usual scabies and malaria, as well as other routine cases. I also saw a nine year old girl with pain in the left chest and ronchi on just that one side. She had recently been hospitalized and was on some unknown medications, but again, they had left all paperwork at home so we really had no way to tell if she just had resolving pneumonia or something more serious. We advised they complete the course of medicine for another week, and return if she was still ill at that time. And this time, bring all the paperwork!
Friday I was back in Matoso and was called to help counsel the family of an HIV positive eleven-year old girl. She is one of our approximately 30 clients who are failing in the treatment of HIV and therefore have a “high viral load.” She usually comes to the clinic alone, but on this day she came with her mother. (Everyone in the clinic and our area seems to agree that the mother is “not mentally fit” but cannot tell me what makes her so.) We talked with them, but I noticed that the baby the mother was carrying on her back looked pretty tiny and wizened. I unwrapped him, weighed and measured him, and found that he was severely malnourished: 10 months old, 3.7 kg, 47 cm tall, with an upper arm circumference (MUAC) of 9 cm. (normal for child under 1 is >12.5cm, if I remember correctly.) He had thrush, and mom admitted he was breastfeeding but not getting much. Much of the morning was spent getting him treated and referring the family to relief, our program in Matoso for children or elders who need extra nutritional supplementation. It is likely that the mother of these children is not taking medication for her HIV. As the children are not orphans, and the mother declines or is unable to accept treatment, it seems there is nothing we can do for this desperately sad situation.
Highs and lows, and sometimes pushing rocks uphill. That’s my life in Kenya!
Banded groundling dragonflies flutter their short lives away with barely-there percussion in my shadow as I gather the valuable leavings of the cows. Why don’t we call it scat, as in the leavings of raccoons? Is it too boring to earn the jazz name, composed as it is of grass and leaves, barely touched in the journey through mouths, stomachs, mouths again and gut? It may not have variety of content, but it is a gallery of different forms: rosettes of flat and lacy fiber, soft, glossy stacks teeming with larvae and their attendants, or dried pucks of shellacked and hollow rind? And don’t forget the mounds of half-termite-hill, half scorned and uneaten dung—left perhaps from day-before-yesterday?—that will add ready-made soil to the concert of compost.
Today started like any other Saturday: I woke up at seven and puttered around making banana pancakes and eating them for breakfast. Then I wandered up to take an armful of books that the current ex-pats have either already read, or don’t want to read, to the library. The clinic is open only for emergencies and maternity on the weekend, so it is usually quiet. One nurse is on call for the entire weekend, and handles everything. Only occasionally do they call another nurse to help them. Today, there were 25-30 people standing around inside and outside the clinic, and the project director was in the crowd. He explained that the nurse on call was in the procedure room with a patient. They had had to latch the door to the procedure room, from the inside, to keep all these people from walking in and out of the room as they were working. The project director said I should go in, so I knocked and the folks inside let me in.
The patient was a man who was bleeding profusely from multiple lacerations of one thigh and leg. His friend was holding the injured leg in the air as the two medical folks were attending to the patient. There was a puddle of blood on the floor, and the nurse was struggling to suture the first laceration on the top and back of the thigh, about 6 inches long. The skin was torn loose off of the front of the thigh, leaving a triangular area of muscle exposed that was probably 6 inches long and three inches wide, with a large flap of skin hanging down. There were three other lacerations on the back of the thigh and behind the knee that were somewhat shorter, but deeper.
Later, I found out that he was a fisherman who had been swimming out to his boat. On the way, when he was in deep water, he met a hippopotamus, and that is what tore up his leg! I was told that it was very good that the water was so deep, because that meant that even the hippo could not get his feet on the bottom of the lake. The thirty or so people at the clinic were friends and family, waiting for him to be treated and wanting to take him home.
We dressed his wound with some new bandaging materials donated to us from Kenya Relief. I don’t know what we would have done without the long gauze strips and the Coban we used to wrap the leg, because the only alternative would have been 4 x 4 gauze with yards of tape. Partnering with Kenya Relief was great for us, and for our patient. You can look them up here to see the kind of work they do: https://kenyarelief.org/