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!