Home again, home again....

I arrived safely home Friday night after a long, but uneventful trans-Atlantic trek. No big mushroom cloud of ash was going to stop us....we just skirted the burping volcano adding a mere hour to the 24 hours of total travel from Tenwek to Denver. The best part of the whole two month adventure was Tim's open arms and big smile at the end of the international terminal runway when I got through customs--it is great to be home!

Things I have learned....

--Kenya (and its people) is a beautiful, rugged, tenacious place
--The medical and surgical need is huge and often overwhelming at times
--The staff at Tenwek are gracious, hard-working, and patient with the visiting staff as we bumble through learning a new system in very foreign surroundings
--Caterpillars are truly evil creatures that bite, sting, and attack hands and feet and cause significant loss of limb all over Kenya
--Mt Kenya is a very high, cold, beautiful mountain
--You don't need half the 'stuff' you think you do including more than two outfits for two months, CT scans, or ice cream (well, maybe I did die a little inside after seven weeks without ice cream)
--Almost anything can be accomplished in the OR with a 3-0 vicryl
--With just a little 'decontamination' and Cydex, practically everything can be reused including pleuravacs, bovies, bowel staplers, tru-cut biopsy needles, and ventilator circuits
--An African safari is a must do, once-in-a-lifetime event for every human being on the planet
--There is no place like home

Thank you for all of your support and prayers over the last two months. I am truly blessed to have such an infallible and steadfast group of family and friends--you all made this wonderful adventure possible.

One day in the life...

Here is one day in the life of an American ‘muzungu’ (white-girl) surgeon in Kenya…

Up at 5:30am to make some tea and eat a piece of fresh daily banana bread.

Walk up to the hospital for 6am devotions with the surgery team before making rounds on male and female surgical wards, ICU, and pediatric ward. This is similar to home and includes addressing diet, pain, management, and changing dressings on woundcare patients.

Make rounds with the consultants (attendings, bosses, big cheeses) at 7am. We have the interns and first year residents present overnight events, vital signs, exam, and plan for the day. Xrays are reviewed and teaching points are made.

Conference at 8am which includes Grand Rounds, Morbidity & Mortality, Morning Report, Chapter Club, or physician devotions depending on the day. These conferences cross specialties so the pediatric team is there with the OBGYNs and the surgeons, etc. It allows for some multidisciplinary teaching and learning experiences.

Theater (OR) cases start around 830-9ish depending on the day and the case. My busy OR day last week included:
--A palliative below Knee amputation for a large skin cancer
--A keloid scar excision for a 2 yo boy
--An exploratory abdominal surgery in a man who had had a colon resection a week earlier but was not progressing--we found an anastomotic leak and he needed a diverting ostomy
--Biopsy of a soft tissue muscle tumor in a 14 yo boy who will likely need additional procedures based on the pathology results--these take three weeks to get back from nearby Kijabe Mission hospital
--Incision and drainage of an abscess for a patient with Ludwig’s Angina, an infection in the neck originating from a rotten tooth
--Removal of a 15cm benign fatty tumor from a 40 yo lady’s shoulder
--Appendectomy

Evening rounds at 6pm with the intern on call to check on the patients and make sure tasks were completed for the day.

Home to the guesthouse for dinner at 730 with local Kenyan food of Chipati (fried flatbread), sumkumuwiki (shredded cooked kale with spices), rice, and roasted vegetables with beef.

Back to the hospital to make sure patients admitted for surgery the next day are appropriately prepared, blood is ready if needed, and labs are drawn.

Bed by 10pm after some email, Skype, or blogging.

The missionaries at Tenwek

The people that work and live around here are the real heart of this hospital. Tenwek has a variety of missionary volunteers including physicians, nurses, engineers, social workers, teachers, and laboratory support staff. Each Tuesday, Thursday and Sunday, us short-timers are invited over for a meal at the long-timers houses. Each has a unique path they took to Tenwek and will share these stories with us over lunch or dinner.

One group is three couples who arrived about four months ago. There are four physicians--an ophthalmologist and an OB/GYN who are married, a surgeon, and a internist, both who have non-medical wives. They met in medical school and became friends while attending the same church. They all just finished their respective residencies and wanted to travel overseas together as a group. Tenwek was the only mission hospital that could handle four doctors at once for their two-year commitment. They live communally, living in a triplex, sharing a car, a washer and dryer, and childcare responsibilities. Eventually, they want to set up surgical services at a hospital somewhere that has less physician density than Tenwek.

Another couple, who are both family medicine trained, run the Casualty department and have been here about 18 months. They have two daughters who have adapted to Kenyan life without pause. Most of the families here have young children and they are communally home-schooled until about 8th grade when they go off to Rift Valley Academy, a boarding school that mostly has missionary kids (MKs) and some local East African kids. There are probably 30 kids around the compound at any given time who play, learn, and grow up together.

The guy with the most time here currently is Russ White, a general and thoracic trained surgeon from Brown University. His wife, Beth, and their five children have been here for almost fifteen years and have served in a variety of ways from medical director to residency program coordinator to endoscopist to hospital administrator. They are planning on going back to the US for 6-9 months furlough this summer to be on faculty at Brown and raise support for the next 4 years.

The individual stories and unique calling to the mission field could fill many more pages of space. Although not all of us are destined to serve long-term, the opportunity to be a relief team member for short-term service is a real blessing for everyone involved. People who come over for a month or two help with the overwhelming workload including call, preparing conferences and lectures for the residents and students, and allowing the long-term doctors to have some much needed time off. When I arrived with a group of other residents including pediatrics, medicine, and neurology, over half the long-term staff left for a two week conference on the coast. The two Kenyan chief surgical residents have been on their required anesthesia and endoscopy rotations since I have been available to cover the surgical service. Short-term visiting staff also allows for specialty services like neurosurgery, joint replacements, pediatric surgery, and open heart surgery---the Vanderbilt team will be arriving next week just after I leave. All of these individuals, both career and visiting volunteers, create a dynamic and comprehensive medical staff at Tenwek that I am fortunate to be a small part of.

Kenyan Medicine

There are all sorts of similarities between medicine in Kenya and the United States. For one, people bring their loved ones to the hospital in search of help, pain relief, answers. Doctors, nurses, and techs work hard, long hours to diagnose medical diseases, give medications, and sometimes even perform surgery to fix some ailment. The overall premise is the same but the route to get there is curiously different.

In rural Kenya, patients will travel for hundreds of miles to reach Tenwek. Although they pay out of pocket for the services they receive, the reputation of this mission hospital is that it is one of the best places to come for surgery, orthopaedic issues, trauma, obstetrics, and pediatrics. The nursing care is thorough and the doctors are actually available which is a stark contrast to many District, or government run, hospitals, where the physicians abandon their assigned post to work in their more lucrative private practices.

At Tenwek, the patients often arrive through Casualty, the US equivalent of the Emergency Department. It is a tiny room with seven gurneys, minimal equipment and supplies. At any given time, there are at least double that number of patients and each of them bring along 2-5 family members. It is barely controlled chaos to say the least and works essentially as our ER at home….like a triage center for admission. To give an example, today in Casualty, there was a women who died due to esophageal cancer whom I placed a tracheostomy tube in a week ago to help her breath easier, a ten year old boy who was mauled by a lion, two boda-boda (read: moped retrofitted to carry up to five people) accident patients with open fractures, and a partial finger amputation from a panga (read: bush-style machete).

The surgery service admits all general adult and pediatric surgery, trauma, ortho, urology, neurosurgery, and burns. Most go to the male or female surgical ward, two open rooms with 18 beds each, but often hold many more patients than that. You guessed it….they double up. Complete strangers, grown men and women, sharing twin hospital beds. And adding to the overwhelming humanity is all the family who bring the patients food, do their laundry, perform their physical therapy, and get them out of bed every day. Presiding over this whole enterprise is four nurses….not four for each ward….four total. They give all the meds (if we have them available), take vital signs (once a day), keep track of drain outputs (maybe), and help changes wound dressings. Their job is daunting and often impossible. It is no surprise with the advanced patient disease and lack of monitoring that, on average, one patient per day dies on the surgical ward.

Interestingly, it is not socially acceptable to talk about death and terminal illness in Kenyan culture. Death/die/dying/dead are all avoided words. How do you convey the obvious, you ask? Some of the best culturally acceptable sayings include “the patient went mute” or “they stopped taking chai”. Chai is Kenyan tea that is drunk throughout the day on the order of 10-15 cups per person—when a Kenyan does not take Chai, it is a marker for severe illness, and often, as we see too frequently here, even death.

Despite the differences, the art of medicine in Kenya and the US still strives to achieve the same goal…to heal and comfort the sick. I feel honored and privileged to be a small part of such an impressive hospital that ministers to the whole patient in both body and spirit.

Poor Prognosis and Timely Saves

The most difficult thing about working on the surgical team is the number of people that we are unable to help. We usually have at least one person die everyday on the service. The entire pediatric and adult surgical service has between 50-60 patients, so a death everyday is an alarmingly high percentage. I have seen more children and young adults die here in the past four weeks than during my entire four years as a surgical resident in the U.S. Many of these patients die of endemic disease like TB and malaria, but there are also plenty of children who die from simple things like dehydration and burns or adults who die from delayed care and traumas. By the time the patients arrive to the hospital, many of them are too ill to recover.

In clinic today I saw Nancy, a 32 year old woman who delivered her second child three weeks ago. Unfortunately, she was diagnosed with esophageal cancer while in her second trimester of pregnancy after she developed problems swallowing. The tumor had already spread to other parts of her body so she has no chance of undergoing a surgery to cure her disease. She had a stent placed in her narrowed esophagus to allow her to eat, but the stent is now collapsing as the tumor continues to grow. She came in to talk about options for her to receive nutrition so she can continue to breastfeed for the few weeks she has left. I talked to her about the possibility of placing a feeding tube in her intestine so she can give herself pureed food beyond where the esophagus is obstructed.

The unique thing about healthcare in Kenya and at Tenwek is that patients must pre-pay for their admissions, surgeries, x-ray studies, and medications. Although it is a fraction of the cost we see in the US, it is a substantial amount for people living on a few dollars per day. After reviewing all these details with her, she decided to return to her village to attempt to ‘raise the funds’ as they call it, before possible surgery next week to place the feeding tube. She is a strong, stoic lady who is mature beyond her years, yet is willing to have surgery at the end of her life to help her baby have the best chance of success even after she is gone.

Thankfully, not all of the stories are sad. We have had two 20 year old young adults come in over the last two days with bowel perforations. One was due to a stomach ulcer and one was due to a volvulus (twisting of the bowel). Both had been transferred from District, ie. government, hospitals because their families felt they were getting sicker. Both patients arrived in Casualty (fancy colonial term for ER, but unfortunately it is the same dreadful place it is in the US), had the problems diagnosed quickly, were taken to the operation room for repair, and are recovering well. Just a few more hours or days and they both would have likely died from their very manageable surgical problems. These are the people and stories that keep me going.

Please remember to pray for these patients and for their families. It is a blessing for us to care for such kind and grateful patients.

Safari

No trip to Africa would be complete if it didn’t come with a few elephants and lions so this weekend we journeyed to Fairmont Mara Safari Club on the edge of the famous Masai Mara Game Reserve. The Tenwek hospital coordinators have arranged a deeply discounted rate at this five-star resort for their visiting staff to go for the weekend so our motley crew of a pediatrician, internist, neurologist, two surgeons, wives, toddlers, and car seats made the trek across the African plains.

It started with a long, dusty, hot car journey over dirt ‘roads’ on Friday morning. Although it is only 60 Km, the trip took 3.5 hours. We arrived for lunch and were greeted with cool, eucalyptus-scented washcloths and fresh mango juice. After a delicious lunch of pumpkin curry and grilled snapper, we jumped aboard our personal open-air safari jeep and set out across the vast grasslands. After an impressive blown tire and a team change that the best pit team would be proud of, we saw elephants, gazelles, giraffes, cape buffalo, zebras, lions, and warthogs. The scenery was spectacular and quite surreal in stark contrast to our usual surroundings at the hospital. We came home for an excellent dinner of lamb chops and grilled vegetables before heading off to our tent—a luxurious canvas room with marble bathroom and private veranda.

Saturday started with a wake-up call by Salim, our personal room attendant, who brought coffee, tea, hot chocolate, and shortbread biscuits. We were out in the jeeps by 6:30 for our pre-breakfast drive where we came across a fresh leopard kill 20ft high in a tree. We also saw a walk of giraffes and a breeding group of Thompson gazelles. Breakfast was made-to-order omelets and fresh pastries with lots of local fresh fruit. I then traded my safari clothes for a bathing suit and lounged at the pool while the rest of the group headed out to a local Masai village to experience some African culture. Lunch was followed by another afternoon game drive where we saw a cheetah mom with her newborn kitten and rhinos! Dinner was an authentic African barbecue before heading back to the tents for a much needed shower and sleep.

Our last drive was Sunday morning where we happened upon lions basking in the sun, hyenas, and ostriches as well as the now ‘ordinary’ herds of elephants, giraffes, and gazelles. Breakfast, packing, and home from whence we came. Now I just need to get in my 17 mile marathon-training run before dinner and bed. Back to the hospital in the morning where I have a whole day of cases in the OR with our visiting pediatric and neurosurgeons before being on-call tomorrow night. Never a dull moment over here in Kenya!

Tenwek Hospital

I made the three hour drive to Tenwek from Nairobi safely and on nice, new roads. The grounds are stunning, my room is spare, but clean with everything I need, including a hot shower, sometimes :)

Africa is a very different place to work. The hospital at Tenwek is a 300 bed hospital, but the size of the hospital is much smaller than one would expect. Most of the beds are together in one of several large rooms and line the walls on either side. There are male and female surgical wards with 18 beds each, although patients will often share, sleeping head to foot. The nursery consists of one large room with 3 “modern” warmers, several wooden bassinets with phototherapy lights, and multiple small wooden or metal bassinets. Most patients receive food and supplies from their family members. Milk, chai tea, and purified water are distributed on a cart twice a day that rounds through the wards.

One of the first things that you notice is that most of the hospital is actually open to the outside. There are no doors separating the wards from the hallways and hospital grounds. You can see the disinfected vent and oxygen tubing drying in the sun on the way in the door of the ICU. Nothing goes to waste here. Everything from pleuravacs to bovie pencils are 'decontaminated' in bleach between patients and re-used after drying. All of the IV fluids that patients receive are in glass bottles and there are no pumps to titrate fluid, meds, or Ensure tubefeeds.

This week, Jeremy and I did an ex-lap and attempted liver resection for a 9cm tumor but it was growing into too many adjacent structures. We did two thyroidectomies for massive, airway compressing goiters and removed a 5 pound leiomyosarcoma from a thigh. I put a silo on a preterm baby with gastroschesis who unfortunately did not survive due to respiratory failure and malnutrition. Next week, I have bilateral nasal polypectomies, a 6cm urachal cyst resection, and a thyroidectomy with radical neck dissection.

Here is the short list of crazy, never-see-it-again diseases that I have come across so far…..

--Typhoid with bowel perforation – this boy died today
--Esophageal cancer in 20 and 30 year olds
--All types of meningitis (meningococcal, TB, cryptococcal, viral)
--Lots and lots of malaria
--Small bowel obstruction from worm balls
--Rheumatic heart disease in a 14 year old girl
--Meningomyelocele in a 6 month old
--Milliary TB in a 6 month pregnant woman - both baby and mom did not make it

The list will grow each day as the pathology is overwhelming and unbelievable at times. The Kenyan people are gracious, stoic, and so grateful even though we often can not do anything except send them home with hospice. I appreciate this opportunity to help in a small way as well as gain a different appreciation for our system at home.

Mt Kenya and beyond....

Yes, we slogged our way up Mt Kenya through prehistoric forests and misty mountain tops, although the magical experience was definitely magnified by the fact we had porters lugging our backpacks up the hill.

The adventure began when Rusha and Guy Lev, friends from medical school who have been living in Uganda, flew into Nairobi a few days after I arrived. We rustled up a mountain guide on the recommendation of a Swiss guy and visited the only outdoor store in all of East Africa run by a French guy before hopping on a matatu (read: squished public transport minivan) for the four hour journey to Nanyuki, ie. base camp.

After we convinced our guide, Dickson, that we normally carry our own backpacks, cook our own food, and read our own maps, he reluctantly agreed to our terms--we did not want the big caravan of support people that normally accompany these treks, often 4 Kenyans to one paying customer! We only wanted one porter for each of the three of us to carry our bags, which were relatively light at less than 30 lbs each, and we would do all the rest.

The first day was mostly travel from Nairobi, park entrance logistics, and an easy 6 mile hike to the first hut. The accommodations are basic, but give protection from the torrential rains in the afternoon and evening and definitely beat a wet Bivy sack. The next day we made significant elevation gain to where we staged our summit attempt at 3am. With headlights and rain coats, we hiked to Point Lenana, the top elevation for non-technical assents. We made it for a chilly sunrise before hiking down 6000 feet and 20 miles to our next hut. Here we had a hot shower after the water was heated with firewood in a 50 gallon drum! The last morning, we did a 20 mile hike out to the small village of Chogoria through rain forests and lush tea plantations. We saw monkeys and African buffalo and lots of elephant poop, but no sightings of the mammoth beasts themselves.

If the internet connection was better, I would post some of the stunning photos, but no luck. Will share when I get home :)

"that is very African..."

So I arrived safely and without incident....except for the ride through the dark streets of Nairobi by the Mwanzia sisters, the youngest of whom was the proud owner of a sparkly new wedding dress from David's Bridal?!? Let me start from the beginning...

The flight was long and fairly painless, despite the threat of strikes from the British Airways cabin crews. I knew I would be arriving into Nairobi late and had arranged for a ride from the airport to the guest house where I was staying. Unfortunately, the only friendly faces with a big sign for 'Dr. Sarah Judkins' belonged to Karutha and her sister and they were not at the airport in the middle of the night to shuttle a mzungu doctor to her hotel....they wanted their sister's wedding dress and the mother-of-the-bride gown. I was asked to carry over a wedding dress, amidst bovie pads and eye drops, for a friend of a friend who knew someone else...I had room so I said yes to this trans-Atlantic dress shuttle and a big box magically arrived at my house in Denver two days before I left from a friend of a friend in Pennsylvania. As we sorted through each of my five bags in the middle of the airport to find their dresses, we realized there was nobody else there to pick me up. Considering the karma points I had just racked up, they volunteered to drive me into town. Imagine my surprise when we found the place in the dark, off a dirt street, and they weren't even expecting me....that is very African!

The Mennonite Guest house is wonderful. It is a secluded oasis in the city with lovely gardens and clean, basic accommodations. It is a Nairobi hub for missionaries from all over Kenya when they need to come to the city for supplies, visitors, or meetings. It was a warm, welcoming place in the middle of the controlled chaos that a city of 7 million people produces. After a day of relaxing and repacking, I set off to meet my friends, Guy and Rusha Lev, for our attempted assault on Mt Kenya. Let the adventure begin....

Last supper

Still not packed, still procrastinating. Things I need to do before I leave...

1) pack
2) run 14 miles for marathon training
3) shovel snow
4) plant all the peonies and dahlias I bought in Costco-sized portions last week
5) make Posole soup for last supper
6) sleep
7) make 2 months supply of trail mix for Tim
8) finish gallstone pancreatitis research project

Obviously, not in this order, but I completed #1, 2, 5, and 7. I guess 50% isn't so bad....

Getting ready....

The preparation and packing that goes into one of these expeditions is impressive.....or at least I make it that way. Between cooking food for Tim (burrito mountain above) and last minute massive changes to the itinerary (climbing Mt Kenya before I start at Tenwek Hospital-Yikes) I seem to create all sorts of turbulence. I have been trying to balance sleeping between busy night shifts and running errands during the day to check off my ever-growing pre-travel list. Yellow-fever vaccine....check. Cash for travel, $100 bills, 2006 mint or newer to take advantage of best exchange rates in Nairobi....check. Dried mangos from my aunt and powdered Gatorade for marathon training from my best friend....check. Packed for my two month adventure....not even close. To be continued.....