I had an excellent getaway in Freetown. Spoiled myself and visited with friends old and new. I like trying to read the signs in Crio.
When I left you, we were in the middle of Migori Town, surrounded by protestors, with the patient in the back, on our way to the Catholic hospital of her family’s choice. We made it to the hospital just fine and again, a gurney was brought after we convinced the registrar she needed to be admitted. She was unloaded from the ambulance onto the hospital’s gurney, and taken to the Observation Unit. After 20 minutes or so of waiting out on the porch (I got to hold the newborn baby girl who slept the whole time!), a nurse came out and said we had to go talk to the Clinical Officer. This is an even more highly trained clinician than the nurses, who provide almost all care here, and was clearly the Clinician-In-Charge of the entire facility that day. She told us, the patient’s mother and I, that while they agreed that the patient needed surgery, the Medical Officer on duty that day was stuck an hour away in Kisii and could not get through to the hospital due to—you guessed it–the protests!
The driver had a quick discussion with the mother and patient, and after a phone call to the first hospital to make sure they could do the surgery, we did the whole thing in reverse. The patient was bundled onto the gurney and then into our ambulance, we went back to town and through the young men protesting, (after only one failed detour down a narrow dirt street trying to find a “back” way to the other hospital), and made it finally to the original hospital we started with. After getting the patient settled into a bed in the maternity ward, the driver found the medical officer who was prepared to do the surgery. He assured us he was hoping to get started within the hour, and we left the patient’s mother talking to the administration about how she was going to pay for a unit of blood, should it be necessary. (The patient’s father was already on the road, coming to Migori Town.)
By now it was after 2 pm. The driver and I went back downtown to see if the post office was by any chance open—I knew there was a package there waiting for me to pay customs fees—and it was almost as if nothing had happened. Businesses along the main route had opened their shutters, the sidewalk vendors were again laying their wares out and removing the tarps they had placed over them, and cars again lined the streets and moved through the traffic of buses and motorbikes.
We got the package, went shopping and ran other errands, and picked up the our passenger who was also ready to return to Matoso. Along the bumpy road back, we ate bananas the driver had bought, and bread I got at the supermarket, and drank Fanta Passions in silence.
I was not scared for our safety (other than concerns that the patient would need a real medic and care on the way), but I was really, really glad to get home!
(This is not our ambulance but it is very similar. Older, four wheel drive Toyota, but we don’t have fancy shades on the back windows.)
One week ago we had a lady in the Maternity wing who had delivered a baby the night before. When the nurse checked on her in the morning, there was bleeding that was more than normal, and the nurse diagnosed a cervical tear. Because we have no surgeon or operating theater, it was necessary to transport her to the nearest town with a hospital where she could have surgery.
I volunteered to accompany the patient, because hospitals like it if patients show up with a medical professional, not just the driver. Because it was a relatively busy Friday morning, I knew that I could be spared much more easily than one of the nurses. I cannot speak the language here well enough to see patients on my own, and so someone always has to translate. The woman’s mother came in the front seat, holding the newborn baby girl. They sat between the driver and another staff-member who just took advantage of the free transport to Migori.
I knew I was not going to be acting like a medic in the ambulance. For one thing, the ambulance is not set up even to hold a gurney. There is a bar on the right side of the back of the vehicle that at one time may have supported or attached to a gurney, but it is seriously deformed and non-functional . The way the ambulance works now is this: The 20 liter gasoline and water cans (two each) are pushed far forward, up against the backs of the front seats. The forward bench seat is collapsed against the left side, and the spare tire which normally lays on the floor of the ambulance gets tied to the left side with the tire helping hold the seat up. The remaining bench seat is where I sat, and a mattress was placed on the floor for the patient.(Largest rectangle below.)
A wire has been forced between the roof of the vehicle and one of the supports that holds up the roof. This is where the IV bag can hang. (Star shape below.) The wire would be in the perfect position for someone sitting on the forward bench to be able to hold the IV bottle still, but it is out of my reach from the back seat. I have one spare IV bottle and I brought a box of latex gloves and another IV needle and tubing in case the IV fails on the way. These are the only supplies.
We set out, and it is a very bad road for at least 30 minutes. We go up multiple hills, and down into their accompanying valleys. At the bottom of the valleys there is often a bridge over whatever water or waterway is there. The valleys seem the worst—the place where the dirt road meets the concrete of the bridge is often extremely rough, and the bridge is likely to be pot-holed especially at the beginning and end. But the hills are challenging , too, and very rocky where the rain has washed the dirt away. Of course, the loose mattress, and the patient, tends to slide a bit when the ambulance is going up or down.
The driver drives as fast as possible, as the trip takes an hour on a good day, and we want to get to the hospital. I am perched on the back bench, and the IV is swinging wildly. For a while, the staff passenger in the front seat stabilizes the IV bottle, but eventually she probably gets tired of reaching backwards and she lets go of the bottle. I try to hold onto the IV line, but not pull the line out of the bottle. The patient is bumping along on the bottom of the car, and I have to stretch my legs over her to brace myself and stay on my bench. Then I notice that the tire is wobbling quite a bit, and the rope holding it upright on the left side is beginning to loosen. Since it will fall right on the patient if it falls, I try to hold it still with my elbow. Sometime as all of this is going on, the IV begins to leak, and it is flinging IV solution all over the back of the ambulance and the patient. I have to ask the passenger to unhook the bottle from the wire and hand it to me, and I am able to force the canula back into the bottle as it was just loose, not all the way out. I decide to hold on to the bottle rather than re-hang it.
I check the patient’s pulse, as I cannot speak her language and she has her eyes closed. The road is way too bumpy to see if she is breathing. It is really the only way I can even slightly monitor her. God alone knows what I would have done if her pulse was weak or something worse. Now, holding the IV bottle and the tire, I notice the tire is even looser. I finally tell the driver to stop, and he comes back and ties the tire much more securely. I change the IV bottle to the fresh one and we are on our way again.
When we finally get to the tarmac we pick up speed and race through the small centers along the road. It is Friday, and there are some protestors out waving greenery in each of the centers. They are supporters of Raila Odinga, the candidate in opposition to the ruling Jubilee Party and President Uhuru Kenyata. They are peaceful, and we also notice more and more vehicles are now sporting greenery on their hoods or grills.
The driver is very familiar with the road, and knows which speed bumps he can go over fast, and which ones will break the axle. As we approach the edge of Migori, we drop our passenger at the main road into town, and we take a back road to the private hospital the driver knows—the closest one.
We arrive and the driver and I go in to see about getting the patient admitted. The registrar agrees to take her, and several staff members come out to get her. They load her onto a gurney and take her in. There is a conversation now between the driver and the mother, and they figure out that the driver forgot to discuss the destination with the patient and her family. They want to go to the Catholic hospital on the other side of Migori. So the patient is transferred back to the ambulance and off we go.
It is about noon as we enter Migori Town, and we are driving in the center approaching the bridge over the river that winds through town. It seems that all the vehicles are now festooned with greenery. There are lots of young men walking cheerfully up the street toward us, loud and happy-looking. Suddenly a loud noise startles me, and people start telling us to turn around. I cannot see what made the noise, but people are running in all directions. The driver starts to turn the ambulance, but someone relents, tells us to turn the siren on, and waves us through. The young men carry a cardboard box in the shape of a coffin, and they pass it over the ambulance. I don’t know until later that they are hoping that one of the members of the IEBC (the Electoral Commission) will step down, and that this represents his coffin, with him in it I am sure.
To be continued in Ambulance, Part Two.
The semi-annual, regular dental visits that I have maintained all of my adult life was sacrificed to my hurried preparations to get to Kenya. The date for it fell a few days after my flight from SFO, and I just didn’t arrange to change the appointment. Thus, now that I have been in Kenya for almost 5 months, my teeth were really feeling dirty.
I found two sources of dental care near here. At Saint Camilla’s Hospital in Migori, Brother Bonaventure assured me by phone that they had a dentist who would enjoy seeing me because “He is like you.” I assume he is also an expat, or at least a white man. (You know, we all look alike so we must also enjoy each other. No, really, I am sure it is true. Tamara is 16 years younger than I and has longer hair, but we get called each other’s names all the time. When we are together, we are also asked if we are sisters. It is quite amusing, most of the time.) The second place I was told to go was Aga Kahn Hospital in Kisumu, a branch of the premier hospital in Nairobi. There, I was told, I could be confident that the equipment would be properly clean and the care professional.
I ended up at Jaramogi Oginga Odinga Teaching and Referral Hospital. I thought I was at Aga Kahn, because that is where I asked to go, and that the name had been changed to a less colonial sounding name. However, after I got home I found that Aga Kahn is on the other side of town, and that the driver had taken me to the wrong place. As you can see, the physical plant is adequate, with lots of old but well-maintained buildings, corridors outside but under metal roofs, and benches or chairs in the many waiting halls, both inside and out. The outside in front reminds me of the Stanford Medical Center in Palo Alto—I think.
While there, I did manage to get my teeth cleaned, but it was the roughest teeth cleaning I have ever had. Probably, I now realize, because it must have been a student using the tools and spraying water all over my face! But at least the suction only went down my throat once, and it didn’t get far because I have a well-developed gag reflex. Happily, my teeth are all intact and my mouth no longer hurts. Next cleaning in another 8 months when I get back to the USA. But I bet that one costs a lot more than 1000 shillings! (about $10.00.)
The fundis (a fundi is someone who can fix or make things. It is a great Kiswahili word to me…) were up on the steel roof replacing some panels with holes in them, and painting the roof with aluminum paint. They made this great ladder specifically for this job. They explained to me that they have two types of eucalyptus that they cut down to make this ladder. One is for the long pieces, and it does not split easily. The cross pieces are a different type that is more prone to splitting, so they like to wrap the nails around those when they are small enough.
They cut down the trees and trimmed off the branches, and then cut and shaped them to make the ladder with just a panga. This is a big knife, but I am not as skilled as these guys are in using it. It is truly impressive.
This ladder, made on site with materials close at hand and simple tools, is one of the things I love about Africa. People are so resourceful and inventive. So many times, if they do not have something, they either know they can live well without it, or they make it themselves. (This does not work with drugs, however. Uncle Sam, Unicef, WHO, etc., keep sending those drugs here!)
The gardener witnessed me wielding my panga, and paid me a lovely complement. He said, “Good, Dr. Ball, now you can be a panga-boy!” For those of you who know my record with knives, you can stop cringing now. So far, in several days of chopping down invasive vines around the compound’s perimeter, I have only cut one fingernail. And not even all the way through!
Who knew you could make really good ice cream by just throwing the ingredients in the freezer? We don’t have cream, so technically it was ice milk, but it was really good, nevertheless. The ice cream container is back in the freezer, ready for another recipe this weekend. Since it will be thoroughly cold, perhaps it will make the ice cream while we stir it this time.
Joyce tells me there are people who make butter from their fresh cows milk. She asked if I wanted some butter, and of course I said yes, so I imagine she will find some and bring it next week. She finds all kinds of stuff for us: currently we are enjoying papaya, pineapple, watermelon, oranges, sweet small bananas, and avocado. Vegies new this week are green beans and carrots obtained in Migori.
I guess it all depends on what you are used to. We Americans keep being surprised by our Kenyan co-workers and how they bundle up when the weather is on the cool end of the range. The range is pretty small, relative to say, Reno, where the weather can be 50 degrees different between night and day. It is almost always between 60 and 90 here. Here’s the thermometer on the morning of one day last week:
On this day, Tamara and I showed up to work at 8 am in our usual short sleeves and long pants or long skirt. It had rained a little bit and was still dripping lightly, but nothing to get excited about. But our morning parade which is usually under the trees in the center of the compound, had been relocated to the porch in front of the lab. And our friends were dressed quite differently than we were!
I had observed before that what felt cold to people here did not feel cold to me, but this was the first time that I remembered the thermometer I found in Nairobi for the lab, and had my phone handy. Also, after almost 5 months here I feel comfortable laughing and joking with the wonderful staff about our differences. And laugh we did!
Someone asked me this, because I was only talking about my work gardening and pulling weeds on the grounds, learning Dholuo, and sightseeing or fighting with the bureaucracy in Nairobi.
Yes, I am doing a little medicine. I am currently studying malaria, trying to really understand the life cycle, why it is important, how the drugs work and their pharmacology, and the host factors or treatment refinements that may change how the disease responds to treatment. Every time I read the 2015 World Health Organization (WHO) Guidelines for the Treatment of Malaria, I learn something new or see something in more depth. Amazing how motivating it is to have daily reminders of the seriousness and incredible prevalence of this disease!
Then I try to create an engaging, interesting conversation with the staff, who have all seen much more malaria than I, and transmit the current global standards for diagnosis, treatment, and prevention of resistance. That’s the hard part–overcoming months or years of the habits of professionals–and helping them change the way they practice. I have to remind myself regularly that practice changes often take decades to implement fully, and they aren’t going to happen in a year just because some ex-pat describes the ideal a few times!
What a great day today. The day began with a great discussion of a case study I prepared –a conglomerate of many malaria patients I have seen since my arrival in Kenya. We had a lively discussion of the case, and everyone participated: nurses, lab, pharmacy, reception and even the Information Technologist. There were real differences in how people interpreted the facts of the case, and even differences of professional opinion. Everyone was respectful of each other, and everyone with patient contact contributed. I think we aired some very good issues, talked about best practices and how to best implement the guidelines, even down to some discussion of where to best treat the patient, when to ask the lab to come to the patient rather than sending the patient to the lab, and how to prepare tablets that get crushed and administered to children. (During regular hours we can ask the pharmacy to prepare, and when we are on-call, after hours, the nurse can crush and mix with drinking water right in the holding room.)
Next, I saw some patients with one of the nurses, and one was a child with a positive blood smear for malaria. It turns out that she had been to another facility and had been given oral anti-malarials just two weeks ago. The family decided that she had actually been bewitched, and so she did not complete the medications. Instead, they took her to the herbalist who gave her remedies, but of course the child stayed sick. The mom even told us the child had vomited, in an apparent attempt to get an injection. Turns out the child was eating okay and last threw up three days ago. The mom said the child was “afraid” of the oral medicine, so we asked why. Turns out, the whole family had the impression that an injection was better for malaria than oral medication. Since I had just reviewed the treatment of malaria, I was able to describe the actions of the oral medicine, how quickly it entered the blood stream (peaking within 2 hours), and the benefits of using the combination pill rather than the single drug injection.
I was also confident that we were treating recurrent malaria due to inadequate treatment, rather than treatment failure which would require other drugs. Two weeks is too soon for someone to have a positive blood smear (visible parasites in the blood cells) if they have been adequately treated. After the three day treatment is complete there is a period of time, 4 or 5 days, in which one is somewhat protected from re-infection by a new mosquito bite. Then, there is a period of time, 7 to 9 days, after the bite, when the malaria parasites are hiding in the human liver and not causing any problems. During this time they are not visible in the blood smear.
In the end, the mother agreed that the oral medication sounded good, and felt that she could explain it to the father in a way that would also convince him. They left happy even though we did not give her a shot, and I was fairly sure that this time the child would finish her medication and eradicate the parasites in the blood—at least temporarily!
This part of Africa is called “hyperendemic” for malaria, and we are even more prone to get it being in a lakeside area. This means that malaria is always present in the population, is present in high numbers, and is highly transmissible—lots of the mosquitoes are infected. The mosquitoes here prefer human blood, and they live a long time in the mild climate. This corner of Kenya, the lakeside west, near the border of Tanzania, must be the best kind of environment for the mosquitoes that carry the Plasmodium falciparum parasites. P. falciparum is responsible for the most serious and deadly form of malaria, and is the most common cause of malaria here.