Tuesday, May 24, 2011

The General Specialist

A young woman (early 30s) who was taken to OR for unresolving pelvic mass....

Classic studding of pelvic TB on the mesentery of the small bowel.

Bilateral pyosalphinx (blunted tubes, filled with pus) on either side of a uterus covered with the TB "studding"


Massive fibroid arising from the fundus of the uterus (the pelvic mass!)


A few days later....  a 24 year old G1P1 with abdominal ascites and a abdominal/pelvic mass...

It was a 30 cm ovarian tumor (Sertoli-Leydig)....

I did the surgery aided by a 3rd year general surgery resident visiting from the US...

 
The finished product!


One of the challenges - and joys! - of this job is that I get to do so many cases that I would not get to do in the US.  Here I am the MFM, the oncologist, the intensivist ....and the *sigh* .... reproductive specialist.  Today, I tackled my first myomectomy - it was a fundal fibroid that measured 15cmx10cm.  Luckily, it was  a very smooth case and the patient mantained her uterus! 

Please remember me as I struggle to adapt to these new challenges: that I would have grace under pressure, the courage to try something new and the wisdom to know when not to!

And finally.....my favorite work in progess....

 Teddy, the cat in the (night) hat!  ha ha ha

Sunday, May 22, 2011

Extreme Home MakeOver

I have been working very hard over the past few months to create a comfortable "nest" for myself and Teddy here in Kenya.  Thanks to my awesome cousin and mom in the US and many visitors here at Tenwek, I have been able to "import" a few things from the US to make the house look nice.  In addition, I have been carefully combing Nairobi for clearance deals on households goods!


 I hit the local Masai markets for artwork and found some good stuff.  The Kenyan gentleman who helps me with yard work has taken great pride in trying to bring some of the "greenery" of the outdoors, to me indoors.  Also, flowers are a major export item here in Kenya, so luckily they are both abundant and very inexpensive!  Of course, all flowers have to be protected from hungry kitties....



 Curtains and tablecloths can be hard to find here unless you have them custom made.  So, some of mine are a little lacking in the "exact fit" department.  But all in all, I think it looks pretty good!

This is a traditional wrap that I bought in Sudan.  Ladies wear them over their dresses or skirts.  I liked mine so much I attached it to a piece of rope (attached it with 3-0 monocryl hee hee)  and hung it on the wall. 

 I was able to get some imported bedding from home to soften up my super firm Kenyan mattress.  Plus, I found some happy fabric to decorate my storage container side table!  I also printed out some favorite photos, put them in plastic protective sheets and hung them over the bed.  (The walls are concrete, so hanging anything is always a bit of a challenge)

 More finds from the Masai Market: picture frames, soapstone decorative plate and a carved wooden elephant...

 The "business center" where Teddy sits and watches the birds in the mornings...

And of course, lots of pictures from HOME!


Thursday, May 19, 2011

A Story....

Here is a story of HIV.
A 21 year old married female with three children.  She just delivered her youngest by repeat C section two weeks ago.  She was re-admitted yesterday because of a wound infection.  I am not posting pictures due to the sensitive nature of her situation.
She was diagnosed with HIV in 2009.
She is not taking anti-retroviral medication and neither is her newborn baby.
Her other two children have never been tested or treated for maternal exposure to HIV.  Their chances of transmission are ~ 45% without the treatment. 
Her husband does not know about her diagnosis.  He is her second husband.  She was very vague about what happened to her first husband.  Only that he is “not around.”  In Kenya, widows are “inherited” by brothers of the husband.  Is her new husband her former brother- in- law?  Are they even married?  Not sure.   
Nevertheless, this man provides for her and the child from her first husband and his two subsequent children.  She does not take the treatment for HIV because he might find out about her disease.  If he finds out, he will kick her and her children out of the house.  They will have no food or shelter, she says.  He will blame her for bringing this sickness to his house.  As a woman she can own no land.  And she has 3 children to support with very little education herself.  So she lives in secret, her children at risk, all for the price of shelter, food and pride. 
Please pray for this woman and some many others like her who live under the yoke of fear.  Also, please pray for me as I struggle to find some way to help and encourage them.

Friday, May 6, 2011

AIDS in Africa

I didn't think much about AIDS before I moved to Kenya. 

It was the stuff Lifetime Teen Choice Movies and board questions were made of. 

There was the occasional patient - referred to the infectious disease specialist.  

Now, I think about it every day. I have to.  On any given day, I typically have one or more patients on the ward with HIV.  Sometimes they are pregnant, sometimes not.  Sometimes on meds, sometimes not.  Sometimes its a new diagnosis......are they in PEPFAR...are they breastfeeding.....


So, in response, I have found myself reading more and more about HIV. 

·    Africa accounts for 14% of the population of the world
·    Sub-Saharan Africa accounts for 68% of all HIV infected adults, 90% of HIV infected children and 76% of AIDS deaths.
·    Southern Africa (Botswana, Lesothu, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe) has the highest prevalence of HIV; Swaziland being the greatest at 26% of the adult population (age 15-49 years).
·    Proposed reasons why Southern and East Africa have higher HIV than other regions:  lower rates of circumcision, greater gender inequality and regular concurrent sexual partners.  (**Notice I did NOT list promiscuity, more sexual partners, the unavailability of condoms or lack of religion.)
From Manson's Tropical Diseases, 22nd Edition

And I'm finding the best reading isn't in the textbooks.  I am becoming fascinated with the culture and fight against and how much medical school did not teach me.  In her book, The Invisible Cure, public health specialist/molecular biologist, Helen Epstein disspells some of the myths regarding AIDS in Africa.  Epstein became involved in AIDS research when she was commissioned to Uganda to help with research for a potential AIDS vaccine.  Her observations and research is not only a good read, with lots of I-know-that-feeling! moments for anyone who has ever tried to do anything in a third world country, but it has also started to make me realize that maybe that there are a lot more layers of complexity to treating AIDS in Africa than I ever imagined. 

I am including some of my favorite quotes below - at the risk of pulling a Jim Carrey movie trailer trick and revealing all the good parts - I assure you that this book is worth the time to read it!  Oh, and the sarcastic, not very useful comments in parenthesis are just mine....


 From Helen Epstein's, The Invisible Cure: Africa, the West and the Fight Against AIDS

I learned early on that the most successful AIDS projects tended to be conceived and run by Africans themselves or by missionaries and aid workers with long experience in Africa – in other words, by people who really knew the culture.    (American paternalism, exit stage left, thank you very much!)
There would be power cuts and water shortages and broken toilets and stuck doors and cars that started only when you kicked them.  Most of the time, someone would find a way of rigging things to avert disaster.  
I began to feel as though I had landed in a fairy tale where everyone is evasive and ignores appointments.  (HA HA HA)
Much of the stigma and confusion surrounding AIDS has to do with its common association with perceived “irresponsible” or “immoral” sexual behavior.”   (This is an obvious statement - but it has far-reaching implications: denial of diagnosis, delay of testing, even not the reluctance to reveal test results on the part of both patient and caregiver alike.  And many times, the patients I see, are not "high risk" - they have had one or two sexial partners, no history of drug use or transfusion, and they are pregnant.)
Urging African people to abstain or be faithful has its limitations too, because most people are faithful already, if not to one person, then to two or three.
The greatest error the researchers made was to assume that any poor person can just go out and start a business.  Many of them just can’t do it on their own.
Distributing even relatively simple drug regimens on a large scale basis in Africa poses formidable obstacles. Many African health facilities lack trained and motivated staff,adequate management and administrative capacity, and sufficient supply of medicines, vehicles, refrigerators, lab reagents, and other basic equipment. Some lack water, electricity and even intact buildings.
…20 percent of African women who tested positive for HIV experienced some sort of negative outcome if their husband or boyfriend found out.