Christmas in Kenya 2011

My first year making homemade Christmas cookies! 

My cooking partner....

My new breakfast creation: Apple Spice Pancakes with Powdered Sugar on top!  Yum!

The Snowman Cake I made to go along with the Christmas cookies for my Intern Christmas Party... He has Mentos buttons, a candy bar smile, M&M eyes, a carrot nose and dum dum arms. 

Presents under the tree.  They were only there for 8 hours - they were otherwise hidden from Teddy in the spare bedroom.  The presents were warm fleece scarves and candy for the interns.  We also played games and had "prizes" for the winners. 

 

A Kenyan fried fish dish that one of the interns brought to the Christmas party I hosted.....one of my favorite Kenyan dishes
so far!

 

Teddy taking a long winter's nap during the Christmas party....

All my interns gathered for the "Christmas Bash."

Top Ten Ways You Know You Are Celebrating Christmas In Kenya

10. Your holiday plans were cancelled due to a matatu strike.
9. You are instructed to bring your own plate and silverware to the neighborhood holiday party.
8. All the cars on the road have a live chicken on top.
7. There are cows in your front yard and they are NOT part of your Nativity scene.
6. Its 70 degrees and raining.
5. You bought your kid's new puppy from a guy selling them at a traffic stop.
4. You bought a new skirt for your daughter the same time you bought the puppy! (different vendor, of course.)
3. In the Kenyan version of the Savior’s Birth, the 3 Wise Men came from “Not Far.”
2. Your kids put out ugali and sukuma for Santa

And the #1 Way You Know You Are Celebrating Christmas in Kenya…..

1. You wake up to the sound of your neighbor killing a goat.

Merry Christmas!

Annual Report

As I am celebrating the end of my first year on the field, I am excited to say that I feel like it has been a productive one.  The learning curve has been incredibly steep, but the OB team has grown and improved in many ways.

I am so thankful for the way that I have been embraced and welcomed into the OB department.  I am much indebted to the many people who have helped make this year possible: nurses, visiting doctors and students, donors, prayer partners -  so many that I cannot even name you all, but your assistance and support has meant more than I can ever say.

Resources
Finding and keeping resources is a challenge at any mission hospital.  One of our challenges this past year has been supplies: vacuums, protective eyewear and masks, nitrazine paper, a fetal heart doppler and other useful tools that tend to "walk" off.

Thanks to our nursing supervisor, we were able to secure a locker outside the OB theatre and stock it with supplies brought by our very generous visitors.  Now, we are better able to alocate and locate our supplies.  The interns share a doppler and have been very responsible with its upkeep (of course, I did threaten to disembowel them if it got lost!).  They also now have access to protective eyewear for surgery (very important in our high HIV population). 

For those of you who have generously donated to my Project Fund - I have used some of those funds to restock equipment for the nurses and interns: new blood pressure cuffs, stethoscopes and batteries for equipment, cytotec for inductions of labor, personal hand sanitizers (great when doing wound dressing changes as soap is not always readily available).

Protocol
When I first arrived at Tenwek, I was often told to refer to the "OB Protocol" Book.  It took me a few weeks to find this epic book and when I did find it, I was vastly underwhelmed.  It was a softback book, bound in old newspaper, with mainly information, but few actual guidelines inside.  In order to standardize care, and decrease maternal morbidity and mortality, a effort was begun to update - and create - hospital protocols. 

We now have standard protocols for: Preterm Labor, Rh isoimmunization, Pre- and Post-Op Antibiotics, Miscarriages, Vaginal Delivery after C Section and Operative Delivery.  The protocols were a joint effort between OB doctors and OB nurses.  Several more are currently under way, but this endeavor has greatly improved communication among caregivers and has hopefully helped to decrease our wound infection rates.

Our OB clinic - MCH - has  also asked for practice guidelines regarding common occurences just to ensure that practice is consistent among all the providers/interns. 

Education
Education has become a huge part of my ministry here at Tenwek.  In August, I purchased pocket textbooks for the interns; the books became so popular several interns have asked to buy their own copy.

In addition to teaching/group rounds, I have tried to implement quizzes during the OB rotation.  Each rotation also now holds the tradition of having a "suture party," where interns - past and present, gather at my house for a tutorial on proper knot tying technique and instrument handling.  Afterwards, we have dessert and tea!

A few fond memories from the past year:

We miss you, Dr A!

Teaching rounds with interns, visiting PA students and OB nurse.

After rounds, chai time. (Thanks for the photo, Dr P!)

Thanks to all visitors and patient-family members who have given blood for
my patients!

Merry Christmas to those who "graduated" from Tenwek...
(Study hard!)

On the way to L&D.....

If you would like to financially support my ministry at Tenwek Hospital:

Please send your gift to:  World Medical Mission

                                          PO Box 3000

                                          Boone, NC 28607

                                         

Please specify Acct #003897





The Twelve Days of A Tenwek Christmas

The last few weeks have been super busy, so I thought I would condense all the news into a festive, but compact blog:

Twelve Months in Kenya:  Happy One-Year anniversary to me!

Sorry, I just really like this picture of me and the worm.

Eleven episodes of The Glades: I like this show.  The medical side is weak, but the sarcasm is strong.

Ten Pints Transfusing:  I've blogged many times about the ongoing blood shortage in Kenya.  At first, I tried to solve the problem myself:

Then I learned the blood types of others and stalked them shamelessly:


Now, I have taken on a new and bold strategy:  I am requiring all elective hysterectemies to bring 3 family members in to donate one pint of blood each before being admited for surgery.  And finally, it works!  One week, we took in so much blood, we were able to give 3 units to a needy surgery patient.  Let's hope my blood nazi system continues to work!

Nine Days on Strike: Since December 5, all government-paid physicians in Kenya have been on strike, protesting for better medical benefits (definitely needed), better medical supplies to district hospitals (definitely) and more pay (join the club).  Since that time, all patients have been re-rounted to private ($$$) or mission (that's me!) facilities.  We are seeing a lot more transports, and have decreased our elective surgeries in response.

Eight Crying Babies:  (Okay, just an excuse to put in a cute baby picture here!)


Triplets that I had to deliver vaginally: 2 breech and one cephalic.  All 3 feeding and
growing well in the NICU!



Seven Attempts to Get this Picture:

Merry Christmas from Teddy!

Six Bad Placentas: Over the past 3 months, I've had 1 velamentous cord insertion, 1 choriocarcinoma, 1 acreta, 2 incretas and 1 percreta!

Placental Increta

Velametous cord insertion from triplet delivery

Placental Percreta

Five Inches of RAAAIIIINNN!  Sorry - I got nothing else.  Theme blogs are hard.  I don't see me doing this again.

Four Hours Decorating:


Three days in Nairobi:  A few weeks ago, I travelled to attend the annual Christmas fair in Nairobi.  It is basically a huge, Christmas flea-market.  Unfortunately, this year it was preceeded by a LOT of rain, so this was the sight that greeted us!  I spent the day shopping in the mud and muck - but found some good deals nevertheless and had an other wise relaxing weekend!
 

Two Docs Operating:  My Co-Post-resident has decided to join me for a few weeks here at Tenwek.  Though she is a general surgeon, I managed to steal her away for a few cases..... 

And me with a Christmas Tree:

Stone

Just when I thought I had seen the weirdest that Kenya had to offer....
.....just when I thought my cast list could NOT possibly get more interesting..
...just when I thought I could not get more heartbroken on behalf of a patient......

She came to see me in the office.

The history was very hard to get.  A C section two weeks ago for premature rupture of membranes at 30 weeks.  She waited in a district hospital for two days for a doctor who knew how to do a C section.  Complaints of weeks of pelvic pain and leaking fluid before that. 

I was completely unable to do an exam in the office because she was so uncomfortable.  I suspected she had a vesico-vaginal fistula because of the copious amount of urine that was leaking, so I admitted her to do an exam under anesthesia.

To add to the ambiguity of the situation, I learned that she had presented a few days earlier to the outpatient department when this xray was taken:

After brainstorming with OtherDoc and deciding this might be a bladder stone, I consulted a visiting urologist and asked him to be on stand-by for the exam under anesthesia.

I was putting on my gloves when I heard the surgery resident say, "Dr. Huber, the stone is sitting in the vagina."

Whoa.  Back the truck up.  She has a stone in the vagina?  True, she wouldn't let me touch her in the office yesterday, but...seriously?

I examined her bottom and there it was....a shining white globe the size of my fist.  Dumbfounded - the first thing I thought was - let me go get my forceps and I'll pull it out that way!  On closer examination, the round mass was actually attached by a thin septum to a mass inside the bladder.  A vesiculo-vaginal stone? 

So, I called for one of the long term surgeons and asked the question that everyone dreams of hearing their surgeon say: "Do you think it would be okay if I just pulled this out?"

In the end, I did break the connecting septum and pull out the two pieces of stone.  And this is where it gets strange.

By this time, word had gotten around that something "interesting" was happening in Room 3, so scrub techs, rsidents, visiting staff and the visiting urologist - at least 15 people - had migrated in to see what was going on.  Amidst the crowd, the long term surgeon and I worked to get the large pieces of stone out of the young girl's vagina.  Just as it was twisting to come out, we all saw something....a plastic blue something. 

"There's something in there!"

It was some type of foreign body encrusted inside the stone.  Now, I admit - I was a little freaked out at this point.  And also happy that the patient did not understand english.

After some maneuvering the mass came out in several pieces:

The vaginal "stone"

Vaginal "stone": The whiter area on top (in the middle) is where it was attached
to the bladder stone.

Stone chipped away to reveal the foreign body - bottle cap - within

Baby Bottle Cap: Contraception? Preservation of virginity?  To protect
a pregnancy?  Punishment?

While everyone else marvelled over these events, the urologist and I did another exam.  There were 3 vesico-vaginal fistulas, the most distal one being only 1 cm from the urethral opening.  There was a large fistula opening where the connecting "septum" had been, but overall the tissue looked quite healthy.

A blue baby bottle top....placed in the vagina...that eroded into the anterior vagina, causing mutliple vesico-vaginal fistulas and eventualy was encased into a bladder/vagina stone.

As astounded by the situation as I was, I was more so astounded by the cruelty of these circumstances.  After multiple conversations with the girl and her family, I am no closer to understanding how that bottle top came to be inside her than I was that day in the operating room.  I only know that her life and possibly - her livilihood- are forever altered. It will be weeks before she is able to undergo surgery to repair her fistulas and it will require multiple surgeries.  Money and the overall poor prognosis will be roadblocks to her receiving a "cure".  It is all very crazy and senseless.

And why was it put there?  This was a young, reportedly unmarried girl who had just delivered via C section two weeks prior.  Obviously this foreign body had been there some time - but how long?  And for what reason?  The girl did mention that she was told she was leaking urine and needed a C section - both because of some sort of obstruction.  At least that part of the history makes sense now. 

These are the patients that are my struggle.  Especially at this time of year, when I am torn - already with the melancholoy of missing family and friends.  I miss Thanksgiving, the glitter of Christmas decorations and I even miss Black Friday.  How guilty I feel - to know I am wishing for commericialism when I am caring for a girl who may soon be a social pariah because of her medical condition.  This world - a place of sickness and unexplained cruelty draws me in with the sweet addiction of seeing new things and helping the hopeless...but it also turns me away with the many frustrations of never knowing....why? 

This is a strange story and I'm sorry to end it on a sad note.  But sometimes I am sad and angry and frustrated for my patients.  Behind the sensational stories, I know the people who have lived these tales.  But by sharing their story - and mine-  I hope you will join me in praying for faith and the maintenance of hope.

And a certain woman, which had an issue of blood twelve years, And had suffered many things of many physicians, and had spent all that she had, and was nothing bettered, but rather grew worse.  When she had heard of Jesus, she came in the press behind, and touched his garment. For she said, If I may touch but his clothes, I shall be whole. And straightway the fountain of her blood was dried up; and she felt in her body that she was healed of that plague....... And he said unto her, Daughter, thy faith hath made thee whole; go in peace, and be whole of thy plague.   Mark 5:25-34

It's Complicated

Life is complicated no matter where you live.  Sometimes its one big complication, a series of mini-problems or a waiting room full of patients with all their complications - but irregardless - life is definitely complicated.

Some of you may remember my blog from October "Not Far," in which I included the story of visiting my gardner and his family.  On this trip - I got to meet the cow that supplies my milk.  Recently, I learned that the cow was stolen.  Well, not really stolen - rather repossessed by a relative.  Turns out, my gardner was borrowing the cow from his grandma - who has recently decided to sell it to another relative - who has now repo'ed it from my gardner and now he - nor I - have milk. 

In the meantime, I am also a little caught up in the social complexities of my patients' lives.

I have a patient who is s/p a hysterectomy after a placental percreta.  Her uterus was ruptured, there was placenta in the abdomen and she lost 3 liters of blood while I frantically did the fastest hysterectomy of my life. She is not married but has three children - ages 3 to 12.  She lives 4 hours away and her children are home alone - the eldest caring for the younger ones, while we care for their mum.  She has no phone and presumably has not spoken to the children in ~ 2 weeks!  When I questioned her about this situation, she assured me that if there was any problem, the neighbors could look in on the children. 

Another patient just had her second admission this pregnancy for self-poisoning.  She is only 20 weeks pregnant and I suspect she is trying to abort the pregnancy. 

A couple came to see me recently for reproductive couseling.  She is HIV positive and he is not.  They want to know how they can safely have children.

The list goes on and on.....

It makes me think of Matthew 9:36...."But when he saw the crowds, he was moved with compassion, because they fainted, and were scattered abroad, as sheep with no shepherd."

I humbly admit that there are days when I am not entirely "moved with compassion" though.  Some days there is a great deal of frustration and self-pity.

Seriously? Who borrows a cow?
How can a parent seem so nonchalant about leaving their kids home alone for weeks?
Suicide and abortion are against the law - just call the police.
If one more person ask me for anything - I. will. scream. 
The patients aren't prepared on time for the OR, my case got bumped, I'm hungry, my back hurts.....

It's probably a good thing I wasn't a disciple, because I probably would have told the crowd: "Sorry, you need to leave and come back on Monday because that's when the Saviour has clinic."

In all seriousness, being in Kenya has made me vastly aware of how easy it is to either
1) become so emotionally overwhelmed by someone's suffering that your own judgement is affected, or
2) to become to tired, frustrated or cynical that you become completely de-sensitized to the suffering of others. 

Please remember me in prayer as I seek this balance in work life and home life.  It would be my prayer that I remain somewhere in the middle - compassionate, objective and totally in love with the idea of helping others.

On a completely unrelated note.......even my cleaning has gotten "complicated"..... now I know why this bathroom cleaner was on sale....it makes my toilet overflow with bubbles with every flush!

Transport

Transport: (According to Merriam-Webster) 1. v. To carry away or convey from one place to another. 2. n. Goods (or people) in the process of being received.

When I was in residency, I knew this word as the noun.  "We are getting a transport."  Any day teetering on the edge of goodness would be quickly pushed into chaos by this sentence.  It made everyone cranky: nurses, residents, attendings.  Especially if there were three transports.  Or unstable transports.  Or transports that had complications.

When I was working locums in rural Ohio, I learned this word as a verb.  "We need to transport this patient."  Suddenly, I was on the other side of the equation - being the physician who realized that she did not have the facilities to care for whatever condition the patient had.  Crankiness turned to anxiety in these days - getting the patient transported quickly, knowing I was responsible until she reached the next hospital, did I move fast enough? should I have caught it sooner?  did the other hospital hate me?

In Kenya, I am again on the receiving end of transports.  The big difference here is that transports are mostly concerned with the medical aspect and not so much with the legal.  In fact, if you - as the receiving hospital - say - "Sorry, we don't have an open beds in our ICU," you are likely to be told - "Sorry, the transport has already left."  There is also a common belief that once that patient leaves the facility - out of sight, out of mind!  Hence, I have received more than one transport that ends up receiving chest compressions within 5 minutes of them being at Tenwek.

Other popular reasons for transport:
       - no gauze, no IVfluids, no magnesium in stock (preeclampsia), no blood in blood bank
       - patient having difficulty breathing, patient can't be extubated after surgery (needs ICU care)
       - no anesthetist, on call doctor can't be reached, surgeon busy with other cases
      - failed induction of labor, needs C section - have had two of these patients who were actually not pregnant, but just had fibroids

Many of these district hospitals lack the medical training to take care of ob/gyn patients.  In addition, the patients who come to hospitals can often go from alittle complicated to  "needs ICU" in a short time. 

Take this patient:  a 34 year old multiparous patient who underwent a C section 2 weeks ago for cord prolapse at a district hospital.  Then 1 week ago, se developed a wound infection.  She went back to the same district hospital and had an exploratory laporatomy with a wash out.  Then she was hospitalized for daily dressing changes.  This past weekend, the hospital called saying that the family was requesting that the patient be transported to Tenwek for ICU care and dressing changes.  Unfortunately, at the time, we had no beds, so I declined the transport - but in typical Kenyan fashion, the hospital sent her anyway.  But it was a good thing they did....

When the patient arrived, the doctor on call took her immediately for ex lap because there was copious amount of pus draining from the incision site.  He paged me when he found a necrotic uterus and pelvis abscess:

Yucky necrotic uterus: I am pointing at the round ligament.

I began the very difficult task of debriding the necrotic tissues and doing a hysterectomy.  Luckily, I was able to at least "feel" the ureters and stay well out of their way.  Unfortunately, I can not even describe how badly this case smelled.  Then, just after we had close the abdomen, cleaned her up and began to move her to a clean bed....I spotted this.....coming out of her...uh...posterior area....

AAAAGGGGHHHH!  I hate worms!!!

Me and the worm

A bottom (low fundal) view of the necrotic uterus.



In the end, she went to the ICU on broad spectrum antibiotics - and albendazole.  She is still septic and will need lots of prayer, support (and washouts!) to get her through this.  Please keep her and our Gyne team in your prayers as we try to care for her. 

And to all my fellow medical co-workers: I am hoping that tomorrow will be a transport- free (both noun and verb) day for all of us!

Pictures - Work & Play

Interns doing a C section together.

 

Our recovery room in the main theatre looking clean and nice for a visit from the Minister of Health.

 

Sharing stories at the Samaritan's Purse retreat in September...

 

Visiting the Geddi Ruins with a fellow post resident.

 

End of the Rotation Party at my casa...

The success of any party in Kenya is directly portional to the number of shoes

you have inside your door!

A little "friendly" competition!

Chocolate chip cookies are a hit in any country....