Final Countdown

This week begins my final full week in Kenya. With a heavy heart I think of leaving this place of beautiful people, culture and such a strong sense of community. I am truly grateful for my time here, but I do miss my home, family, and friends. This week I continued to have great experiences, though many of them were related to saying goodbyes. Tirajeh headed out on Friday (to the coast to continue her work with a non-profit in Mombasa) and two of the leaders in many of the projects I have had the privilege of working on, Astrid and Laura, headed to the US on short notice to speak about a grant project in D.C.

On Monday I got another opportunity to see clinical medicine at AMPATH by attending Tumor Board and the Oncology clinic. Dr. Abuodha, who recently finished his intern year and is practicing in the oncology clinic at MTRH (pic of the front of the building below), led a group discussion about three interesting clinical cases with others in the healthcare team. He discussed a case of lower extremity fibrosarcoma, scalp sarcoma and recurrent osteosarcoma. Each case was discussed and treatment options and a plan was developed with everyone's input. The tumor board was a stark reminder of the reality of cancer in this developing country; late diagnoses plague the population here with poor health outcomes and education about treatment and the realities of cancer is something that must be addressed. People here, due to lack of access to health care and poor health education, often seek the healing power of "herbalists" before seeking "professional" medical care, delaying diagnosis and worsening their prospects for treatment. Another unfortunate reality is that at the rural health centers people are not referred in a timely manner and this too leads to poor outcomes. The physicians at the Tumor Board discussed such challenges and admitted that country wide education needed to be made a priority.

MTRH

I then went to clinic and spent the morning alongside Dr. Abuodha seeing patients (the clinical room is pictured below). We saw 6 patients, discussed their treatment plans, and I watched as physical exams were performed to check on the status of spleens, livers and lymph nodes. As a young physician Dr. Abuodha did a great job explaining to patients the realities of their disease, the course of treatment and their individual prognoses. One patient sticks out in my mind as she was born the same year as I and suffered from breast cancer. The cancer was identified when it had progressed to stage 3 and the young woman had just recovered from the mastectomy of her right breast. Her chest had healed well from the surgery and so she and the doctor began to go over the next steps in her treatment plan. It was clear to me that she was scared about the diagnosis and plan but was also very interested in finding out how she could work with the healthcare team to beat the disease. She spoke of her interest in a family and having children, something that hit close to home as I prepare for an upcoming marriage with hopes of having children one day as well. After discussing the treatment options she determined that she was ready to begin chemo that day. She was inspirational and her strength and resolve was undeniable.

oncology room

Monday afternoon I worked to get the video for the grant together and took it to Laura so she could make the final cut. It was a fun project and I look forward to seeing what happens with the grant!

Monday evening Astrid and Laura hosted a dinner for the Kenyan team, the University of Toronto students and IU students who worked on a number of the projects together this summer, as a sort of send off (since they both left on Tuesday for the US). We ate Indian food and spent a while reflecting on our experiences and how certain aspects of the projects that everyone was a part of surprised each of the team members. It was a great dinner and we took lots of pictures to commemorate our time here (first: the Canadian Contingent, second: the IU Contingent, third: the whole group).

Astrids 1

Astrids 2

Astrids 3

Tuesday I attended morning report, which was again led by Dr. Kussin from Duke. He talked of some of the work he is doing alongside the microbiology lab at MTRH. They are working to categorize the types of microbes that are responsible for most of the infections in the hospital (specifically the ICU). It was interesting to hear about the types of infections commonly seen and also to learn what drugs showed the best curative profile for each of the microbes. The rest of the day was spent getting some slides together for the "Fireside chat" which Tirajeh and I gave on Thursday evening about our experiences here in Eldoret and around Kenya. It was nice to get to do a bit of reflection about all I have gotten to see and be a part of since my arrival.

Tuesday evening Tirajeh, Kelsey and I went to Justice's (one of the folks from Kenya who we have all worked with) house for dinner. He and his sisters (pictured below) made a feast (also below). We had ugali, cooked green bananas (matoke), githeri, noodles, groundnut sauce, tomato/onion salad (kachumbari), and lots of other foods. We had a great time talking, eating and learning about each other's future plans. We then headed off to club "Spree" for Karaoke with some of the Pharmacy folks from Purdue and a couple of people from Duke (see picture below). A number of "great" songs were sung, Justice and I gave a rendition of a rap song by R. Kelley called "Remix to Ignition", which was pretty well received :). It was fun getting out and singing and a nice send off for the Purdue folks who left on Thursday.

Justice and sis

Justice dinner

spree1

Wednesday Tirajeh and I met up to do a little planning on the Fireside chat front and I spent some time listening to and picking some music that will hopefully accompany part of the video for Lydia's grant. In the afternoon I set up what will likely be our final installment of Ultimate frisbee here in Kenya. We had a great turnout (6 on 6) and we were granted cool weather with a smattering of raindrops. It was a lot of fun and we finally stopped as the drips turned into a downpour. A group of us from the game headed straight to "group dinner" which was held at Sanjeel (a great local Indian restaurant). There was far too much food as usual so we took a bunch of the leftovers to the gaurds at IU House. A number of new students arrived during the day and they joined up for their first group function.

After the group dinner Tirajeh and I headed to Jordan and Abi's home for a final debriefing and reflection of our time here (as Tirajeh left on Friday morning). It was really nice to again reflect on what we had done and are currently doing here. We ate homemade apple crisp with ice cream, which was a great treat. We spent a long time talking and laughing about all we had done and gave Jordan our perspective about the program and our specific projects; with the hopes of helping make the experience equally rewarding for next years scholars. It was a really nice way to wrap things up and we took a group photo to commemorate our final little get-together (see below). 

Jordan/TJ/Me/Abi

Thursday I spent the day finishing up my part of the presentation for the Fireside chat and met with Tirajeh to run through the finished product one more time. I then took a trip into town to pick up a thank you present for Anita. I went by the Sally Test Center and played with Lydia for a while and gave Anita her gift. It was so nice getting to work with her over these past 8 weeks and her patience and ability to make all of the children at the Sally Test Center more comfortable through OT and PT services is something that will stick with me for the rest of my life.

Thursday evening Tirajeh and I gave our Fireside Chat discussing all of the things we did while we were in Eldoret and the surrounding areas. It was very well received and it was the perfect send off for Tirajeh (she finished the presentation with her "Reflection Rap" about her time in Kenya; it was really good :).

Friday morning I ran a number of errands and did some work to finish up some small projects I had been working on. In the early evening a group from IU House (Sonak, Colin, Phil, Peter, and Me) met up with the Moi University basketball team for a scrimmage. It was a great game. A picture of the group guys we played with and against is below.

basketball

 Saturday a group from the Canadian contingent organized a trip to Kakamega Rainforest. I tagged along and got to see some of the natural beauty that Western Kenya has to offer. The Rainforest is home to 45% of the Kenyan butterfly population hosting 488 different species. There are also 4 kinds of monkeys (Blue, Redtail, Colobus, and Baboons) and 410 bird species located within its border. We saw three different kinds of monkeys, numerous birds and a great many butterflies. We hiked up to a hilltop viewpoint and snapped a number of photos. Unfortunately for the hilltop a local who was cutting down some grass some 2 days earlier dropped a cigarette and set a portion of the hilltop ablaze. The fire stopped at the lower hiking path, but the top of the hill was pretty badly burned. It was a unique, albeit a bit sad, scene but the surrounding rainforest seen from the viewpoint was spectacular. After a 4-5 hour hike we headed back to Rondo Resort and ate a picnic lunch before heading back to Eldoret. On the ride home we passed numerous tea plantations, which are a major source of income for people in these areas. (Pictures from the hike below)

Kakamega 1

 Kakamega 2

Kakamega 3

Sunday was a day spent eating meals with Kenya friends. Amy, Kelsey, Justice, Mungai and I ate lunch at "The Well" and shared stories of our time and work here. Sunday evening I went to dinner with my COBES team as well as my next-door neighbor from the Hostel. We ate at a restaurant called "The Noble" and again had great food and conversations. The week seemed like one long goodbye but was very nice.

On Monday the 29th I spent the morning at the diabetes clinic working to get data from each of the Type 1 diabetic patient's charts so I could plot growth curves for each of them. I printed off the growth curves, utilizing WHO standard curves, and began plotting them for each patient so we can track their growth and development at each visit. I then headed over to the Sally Test Center to visit with Lydia and Anita. (pictures of Sally Test Center below)

Sally Test 1

Sally Test 2

In the evening a small group from IU, Purdue and Toronto headed to the "Pizza Bistro", a local restaurant and had some delicious pizza (pizza and group pictured below).

PB1

PB2

PB3

Tuesday I finished up the work on the growth curves for the 62 patients in the Type 1 diabetes clinic as well as finished up my written reflection about my time here. I have plans to head to Karaoke with a number of folks from IU House tonight and will pack my bags for my return flight tomorrow morning.

During my time here I have gained a detailed perspective on healthcare in a developing country and so much more than I could have imagined when I left home eight and a half weeks ago. Getting to know this country and its people has been the experience of a lifetime. I pray that I can take all that I have experienced and learned and use it as I continue to pursue excellence in the practice of medicine.

Gratefully,

Bryce McKee

Posted at 20:16

"Grant"ed another week in Kenya

The seventh week in Kenya brought with it a new opportunity; a chance to work with a team to write a grant. Dr. Laura Ruhl and Dr. Jordan Huskins (two of the Team Leaders here) proposed the idea of applying for some funding to expand the work that we are doing with Lydia. The hope is help establish a neurodevelopmental clinic here and work with a number of children with communication challenges through the use of AAC (Augmentative and Alternative Communication) tools. This week brought with it additional opportunities to attend lectures on interesting medical topics, hang out with Kenyan friends and an informative "fireside" chat about maternal and neonatal mortality.

 On Monday morning I met with Jordan and Laura and discussed the plan for setting up the grant proposal and a timetable for getting the information together. I spent the rest of the day working on a lit review regarding the use off AAC technologies generally and studies specifically done here in Kenya and around Sub-Saharan Africa. This was my first experience working on a grant and I quickly realized how challenging such a project can be. I emailed Megan Shanley (the OT in New Mexico who has been integral in leading our work with Lydia) to ask if she had any resources regarding AAC technology and she sent a great list of pertinent articles. Monday evening a group of us played a few games basketball at IU House before dinner, which was a great relief after a long day of reading and writing. After dinner one of the guards, who is also a personal trainer, led a group session ab workout, which nearly killed everyone involved :).

Tuesday I wrapped up the lit review and began the process of answering questions for the grant proposal. In the evening a group of us headed back to the Eldy Sports Club for our second session of Ultimate Frisbee. It was a lot of fun, though we had a slightly smaller crew (about 10). Tuesday evening Jordan and his wife Abi had Vinny (a fourth year from IUSM) and me over for dinner to discuss our time here in Eldoret working with MTRH and AMPATH. They made lasagna, garlic bread and banana bread for dessert. It was nice to be able to reflect on our time here and to hear how Jordan and Abi have come to make this place their home over the last year. They talked about how the constant influx of volunteers, students and health care providers to IU House and this partnership continually energizes them in their often-challenging work.

Wednesday I finished the initial draft of the grant proposal and sent it off to the rest of the team for revision. I also finished up a few other small projects (including the final update of the Tylenol/Brufen dosing sheet). Afterwards I headed over to Sally Test to hang out with Lydia for a while and helped answer a few questions that Anita had regarding adding words and pictures to the IPad. Lydia continues to make huge strides in both the use of her AAC device as a true communication medium as well as rapidly expanding her vocabulary. While I was visiting the Sally Test Center on this particular day at least 2 healthcare workers came by just to say hi to her and see her use the AAC device. One nurse saying that Lydia "is a constant source of inspiration" and that her use of the IPad is "truly amazing". These AAC tools that have been granted to Lydia for communication have shown me what value they hold for those with neurodevelopmental issues as well as reinforcing why access to such resources are vital for this population. She has the ability to interact and control her environment in a way that would just not be possible without such access.

Thursday morning I attended morning report, which was led by an ICU/Pulmonologist from Duke, Dr. Peter Kussin. He presented a clinical case and we were asked to come up with a set of differential diagnoses and then work through the case to determine the true cause of the problem. We eventually determined that the patient of interest suffered from acute pancreatitis. It was fun to get to work through the case with other medical students and pharmacists. I then spent some time in Sally Test recording footage of Lydia for a video that is to accompany the written grant. I filmed her working with the IPad, eating and demonstrating her fine motor control. For lunch Vinny and I went to a local eatery called Sizzler Cafe for "burrito Thursday"; it was delicious. Our afternoon lecture was given by Jordan and we learned all about Leshmaniasis, caused by the bite of a sand fly infecting the host with small protozoa. In the evening the "fireside chat" was led by Laura and Astrid addressing maternal and neonatal mortality. We discussed why maternal mortality is such an important global health issue. A study done on the effects of a paternal death in the family (in a resource limited setting) showed that it altered very little about the lifestyle/education/health of the children and the family unit as a whole, while a maternal death negatively influenced all three parts of this family dynamic indicating why reducing maternal morbidity is such an important issue. We were introduced to the "Three Delays" that result in poor health outcomes for pregnant mothers in developing countries. The delays include: delay in the decision to seek health care, delay in reaching care, and the delay in receiving adequate care. This costs numerous women their lives and these delays present a problem for the rural population as a whole. We then discussed what we thought were the most important interventions that could be undertaken to improve both maternal and neonatal outcomes. It was a thought provoking discussion and was motivating to hear how some of these issues are being tackled by those on the ground here in Kenya as well as where this type of work is headed in the future.

Friday was spent again in the Sally Test Center filming both Lydia and Anita for our video. Anita provided excellent insight into the challenges of working with children with neurodevelopmental delays like cerebral palsy (see picture of Anita and Lydia below).

 Lydia and Anita

For lunch Tirajeh and I took out two of the 6th year students, Dennis and Carole, who had assisted us with the Physician-Patient Communication course (picture of the motley crew below). These two students provided invaluable insight into how we could alter the class to allow the 5th year students travelling this year to get the most out of their experience. We ate at Sanjeel, a wonderful Indian restaurant, in downtown Eldoret. Carole gave Tirajeh and I a really nice thank you card and we discussed plans to meet up again in the future.

Sanjeel

Friday afternoon the group that will be working as a team to facilitate the grant, if it is awarded, met via skype to review the proposal and get the details for the plan ironed out. Dr. Oyungu (a Kenyan pediatrician interested in starting the neurodevelopmental clinic), Dr. Greg Wilson (developmental pediatrician at IUSM), Dr. Jordan Huskins, Dr. Laura Ruhl, Anita, Sarah Ellen, Megan Shanley and I all talked through our plan. Following the planning portion of the meeting Anita, Megan, Sarah Ellen and I went through the normal clinical discussion about how things were going with Lydia. We were all very encouraged by her rapid progress over the past 6 weeks and we discussed how meetings could continue to be arranged once I leave the country. Megan and Anita plan to meet twice a month to help support one another in their work. It is nice to know that things will continue to move forward for Lydia as I phase out of my time here. We checked Lydia's word list on the IPad and she is now up to 123 words (she was at 20 about 4 weeks ago) with no signs of slowing down!

Friday evening I went out with a few students (Kisilu, Emmanuel, and I are pictured below) from the Hostel to a local club called 411. We hung out, talked and danced for quite a while. It was nice to get to see the medical students relaxed and enjoying themselves after a long week.

411

Saturday morning Laura, Dr. Oyungu and I met at the Sally Test Center to film additional parts of the grant video. When we arrived Dr. Oyungu and Laura (who hadn't seen Lydia much since April) got a chance to meet with Lydia and see what she was capable of with the IPad. She really impressed them both with how much she could do and how well she could communicate her wants and the needs with the AAC device. We hung out with her and a few of the other Sally Test kids for a little while and then went outside by the playground to film. It was a productive session and we now feel like we have all of the footage we need to put our video together.

Saturday evening we had a cookout that was organized by Phil (a ND MBA student, pictured below with Joe another ND MBA working at AMPATH). We ate heartily and afterwards I played a few games of "ZEBRA" (as opposed to the American version of HORSE w/ a basketball) with Elly, Spencer, and Josh. It was a nice evening and I headed to bed relatively early to make up for my late night and lack of sleep from the night before.

Cookout

Sunday I downloaded all of the videos that we had shot on Saturday with the hopes of getting our video for the grant together. A group of 8 of us then headed out to Eldy Sports Club for Ultimate Frisbee Edition #3 :). It was a great time, though playing with only 4 players per side led to rapid exhaustion for most of us. It was nice to get out and enjoy the warm weather and was a nice way to break up the day. Sunday evening we had a full house for dinner at IU House and afterwards a group of 7 of us did round 2 of Sammy's ab workout.

The time here feels like it is slipping away, but each week continues to bring new surprises and great experiences. I hope this blog finds you making the most of your time wherever in the world you are. Thanks for reading!

Asanteni,

Bryce

Posted at 19:50

Groundnuts and Chai

This week brought with it continued work with Lydia, a trip to the far western edge of Kenya, another visit with a Kenyan family, and unfortunately an untimely illness.

On Monday I spent the morning in the Sally Test center with the little girl with CP, Lydia. I worked with Anita to program some new words into her IPad. We added the faces of all of the employees at the Sally Test center into her word list and Lydia was immediately able to identify everyone with the IPad. There was another pretty cool moment on Monday with her as well. While I was outside with Lydia we added the words "up" and "down" to the IPad. I then pressed "up" and picked Lydia up and placed her on my shoulders. Next I pressed "down" and set her on the ground. We did this a couple times and she really seemed to get the concept. About an hour later, while I listened to Tirajeh give her second Sally Test Talk, Lydia came over to me and made the sign for "IPad" and then took my hand and led me outside. She grabbed the IPad and then pressed the word "up" and lifted her arms so I would pick her up. It was awesome! The purpose of the IPad is to replace her voice and this was a PERFECT example of getting her to use it to communicate.

Monday evening we had our final Patient-Doctor class. Sarah Ellen Mamlin led a large part of the class emphasizing the importance of working with "special" patient populations (specifically the pediatric population). We got into small groups and practiced talking to children and going over scenarios with a pediatric doll (picture below). After the small groups the students got to act out some of the scenarios in front of the class and we talked about what they did well and what ways to make small improvements in communication. It was a great way to round out the class. At the end of the class Tirajeh and I presented the 6th year students with a gift of our appreciation (pulse oximeters that a doctor in the States who Tirajeh knows donated). We took a picture with our 6th year class leaders and it is attached below.

Class week 3

Class reps

Early Tuesday morning I left the Hostel with Tirajeh, Kelsey (from U of T) and a Kenyan team that was headed to Port Victoria. I was scheduled to meet up with Amy (also from U of T) and Caro (her Kenyan counterpart) in Teso, a region that borders Uganda. When we arrived in Malaba I met another driver, Mangai, and we drove out to a site where Amy and Caro were working called Angurai (a rural clinic). They were working on collecting data about the Group Care programs that have been up and running since February. Group Care empowers women in the community through education about how to prepare for all of the things that come with pregnancy and how to care for those children after delivery. The women in the groups are all paired together by their EDD (estimated date of delivery) and get to know one another as they progress through their pregnancy and into life with the child. Over the next two and a half days at 5 different facilities (Angurai, Malaba, Akichelesit, Kocholya, and Moding) we recorded the gestational age at birth for all of the deliveries, looked at the number of ANC (ante-natal care) visits that each women in the groups attended and collected a few other relevant statistics. It was very interesting getting to see what Group Care was all about and how things work in the rural clinics. Here are a couple pictures from the clinic sites and a shot of Amy and I with our driver Mangai.

Rural clinic 1

Rural 2

Mangai, amy and I

We stayed in a nice hotel in Malaba and one early morning Amy and I took a run on Uganda road. The morning was beautiful and the weather was perfect. We also took one evening to swing by the border crossing between Uganda and Kenya (a few pictures attached, trucks set to cross the border and a train track that leads to Uganda :).

Uganda 1

Uganda 2

On Wednesday evening we were invited to have dinner with a local minister, Moses, and his family. Moses got to know Caro because he is a leader in the community and had previously worked on women's health issues. It was only after his work talking to the local communities that the group care program was able to make its way out to this remote location. Amy, Mangai, Caro and I set out to their property at about 6:30pm. When we arrived we were informed that the families youngest daughter, Tresia (2.5 years old) had never seen a white person before. She was exceedingly apprehensive about getting anywhere near me. She seemed to take to Amy much more easily. Before dinner we sat outside and had groundnuts, sweet potatoes and chai (see picture). The appetizers were delicious. The sweet potatoes were so sweet it was hard to believe it wasn't sugar cane.

 Groundnuts and Chai

For dinner Leah, Moses wife, prepared ugali wimbi, managu (a local vegetable) with cowpea leaves, fried egg and rice. We ate and ate, but didn't seem to make a dent in the large meal. We ate together and talked about how everyone ended up in a place that allowed this meeting to happen (see picture of dinner). It was a wonderful dinner and afterwards we talked about life in Kenya, the US and Canada and at the end of the evening Caro asked if I would take a few pictures of the family (see below, Leah seated on the right, husband behind and their two daughters between Leah and I; Caro, Amy are in the back). I happily snapped a few pictures and I told them I would get them developed and send copies back with Amy next week. The dinner and evening was another wonderful example of Kenyan hospitality. Moses got to know Caro because he is a leader in the community and had previously worked on women's health issues. I told Moses that I hoped to visit again when I come back to Kenya in a few years, perhaps his youngest daughter will warm up to me by then.

Dinner Moses 2

Dinner Moses

Thursday we finished the last of the data collection and headed back to Eldoret. It was a great trip out to the field and I was again grateful for the ability to get to talk to a leader at the community level and see what a difference such a person can make in shaping how healthcare is delivered in rural areas.

Thursday afternoon Amy and I went to get pictures developed from our week in the field (copies were made for Moses and his family to be delivered next week and for our driver Mangai) and from our trip as a whole to help create a reflection piece we were asked to put together by some of our advisers here. Amy chose to make a collage, using a number of the pictures from the rural clinics, of a pregnant mother as her work focuses on maternity and maternal heath care (see below).

Pregnancy

I picked some photos that I thought summed up a number of my experiences here and placed them around the edge of a piece of cardboard and wrote a small poem about the photos (the finished project is below with the poem to follow).

Reflection

The poem is entitled "To Be A Kenyan You Must Be Strong" (a sentence Mangai said on many occasions this past week):

In Kenya so much about the people and culture

is grounded in strength: family, faith, friendship and food.

The groundnuts, viazi, chicken curry and chai power

the women as they carry great weight on their heads and backs,

  the children to run around the track at Iten and families

to build homes from sticks and mud.

With limited technology surgeons save lives and

mosquito nets prevent infection.

The trees grow for hundreds of years and the grasslands

give the giraffes the strength to run the countryside.

In a learning center a small girl with cerebral palsy

begins to speak with the assistance of an IPad.

Small clinics empower community members to teach

one another through group care and chaumas.

On the train track that runs through life in Kenya

all of its members are connected through their strength.

On Friday morning I awoke to what I imagined would be another day of work. I was greeted with a fever that ended up sticking around the better part of 24 hours. It was untimely in the worst of ways, as I was supposed to leave Friday evening for a weekend trip to Niavasha. Instead I spent 20 of the following 24 hours sleeping off the fever. I woke up Saturday morning feeling back to near normal so I feel pretty lucky. Many of the travelers from IU house have been far less fortunate, acquiring GI bugs that put them out of commission for three or four days, so I will take a 24 hour fever with almost no other side effects any day of the week.

I took it pretty easy for the rest of the weekend until Sunday evening when we hosted our Patient-Doctor class at a local eatery for nyama chama (grilled meat), ugali, kale, rice, beans and a tomato dish. We enjoyed our meal together and spoke about what they learned from the class and where we could improve. We also just learned about where each student was headed and what their apprehensions were. It was a great way to end the class and the students all seemed to be very happy with what they had learned through the course. Tirajeh is working to connect students from each program to the Kenyan alumni that participated in those same programs so they have additional contacts. Pictures from the celebration are included here.

Members 1

Members 2

Members 3

Members 4

This week, as each before, was not exactly what I had planned but was just what I needed to stay energized about the work I am doing. I am continually humbled by the opportunity and grateful for each moment here and each new person I meet. Have a wonderful week.

Asante sana,
Bryce

 

Posted at 05:05

Kenyan Family

As the end has come and gone to my fifth week in Kenya I find it hard to fathom how quickly my time here has seemed to pass and there is some sadness in knowing that this trip is rapidly coming to a close. This week was filled with Canadian and US holiday celebrations, observation of pediatric surgery, continued work on existing projects and a great experience getting to know the family of a Kenyan colleague.

On Monday morning I worked on some of my projects and then got to head to the Sally Test Center to watch Tirajeh give her first Sally Test Talk. She talked about drug compliance and had great audience participation. It is rewarding to see the parents come to listen and engage in the discussion about how to help care for their children. Monday evening brought with it round two of the Patient-Physician class. It was a great class. The sixth year students led most of the class skits and discussions and it was really rewarding to see how well the class was received. At the end of the class there was a panel discussion where the students travelling abroad this year were given free reign to ask any questions they wanted to the sixth year students who went abroad the year before (see picture below). Interestingly the returning students mentioned things that were challenging to get used to that would never have crossed my mind; for example: "the sun sets/rises at all different times of the day" (here at the equator the daylight lasts from about 6am-6pm every day of the year) and "you can't cross a highway on foot, no one slows down for you" (here people cross every street on foot and cars often yield the right of way at some point). Our final class will be held on Monday the 8th of July with a dinner party on the following Monday. Helping lead the class has been a huge highlight to an already wonderful trip.

class 2a

Monday evening was the "official" celebration of Canada day, complete with the traditional dish of poutine (fries with brown gravy and cheese curds). The food was great and the Canadian contingent here seemed quite pleased with the turnout.

Tuesday I took the day away from my usual work and shadowed a Kenyan and American pediatric surgery team. A physician, Fred Rescorla (interestingly the same doctor who interviewed me for medical school a little over a year ago), and Troy (who just finished fellowship at Riley in pediatric surgery) from IU worked alongside a Kenyan physician, Dr. Tenge. In the morning I watched as two sections of bowel were reattached in a child who had been born with an imperforate anus (no external opening for the colon exists at birth). Two sections of bowel had been opened to the external environment at birth providing an exit for stool (colostomy fistula) and a drain for the lower part of the colon that had a blind pouch (mucous fistula). These two fistulas were reattached after a rectum had been surgically created. It was a very interesting surgery and Dr. Rescorla took me outside afterwards and showed me a PowerPoint presentation highlighting the different types of repairs that could be made in such cases. In the afternoon I observed the final part of a surgery on a small boy who suffers from Hirschsprung's disease. In this disease part of the large intestine is not innervated and so the stool doesn't move through the bowel appropriately and leads to impaction. The part of the intestine that is not innervated is removed and then the "good bowel" is then attached to a small section of the rectum in a procedure called a Duhamel. Observing the surgery was really interesting and seeing the team work fluidly together after just a short introduction was inspiring (a picture of Dr. Rescorla, Dr. Tenge and me below).

Surgery

Wednesday I went with a group of students to the immigration office to get our alien registration forms submitted. I am officially an alien and didn't have to travel to outer space :). At breakfast before we left a doctor from Mount Sinai asked if I knew my blood type; normal breakfast conversation here I suppose. When I said yes and that I was O+ he asked if I would be willing to donate a unit of blood for a patient in the critical care unit with extensive bleeding, so after we got our alien registrations I went to the Blood Transfusion Center and donated. It was nice to actually know who my blood was going to and a great chance to donate blood since I won't be eligible for 1 year after I return to the States (because Kenya is labeled a "malaria zone"). In the afternoon I went with Dr. Rescorla's wife and son, Michelle and Grant, to Neema House. It is an orphanage and school that takes in children infected or affected by HIV/AIDS or that are abandoned. About half of the students there live on site while the other half come to school daily from the surrounding area (98 in total). The school teaches student from 4 years of age (preschool) through the end of primary school (8th grade). We spent about an hour playing futbol and hanging out with the children and toured the school. It is very cool place, started by a husband and wife team, Joshua and Miriam Mbithi, in 2008. 

Thursday morning I went into the diabetes clinic at to finish up some data collection for the COBES project I am working on with some fourth year Kenyan students. I spent the rest of the afternoon entering the data into a spreadsheet and working some more on the diabetes carb counting sheet we are putting together as a resource for the type 1 patients. It was a productive morning and early afternoon and I felt like I really made some headway on the diabetes project front.

Thursday evening was a 4th of July blowout. We played cornhole and basketball and had a huge potluck dinner. In true American style there was far to much food to be eaten and everyone left a bit bloated but happy and content.  

4th of July

4th part 2

Friday morning I toured the RFP (revolving fund pharmacy) with Imran (an Eldoret native), and learned how such pharmacies enable AMPATH and rural/district hospitals to ensure that they have a constant drug supply. The initial startup investment (from donors/drug companies/private sponsors) is used to purchase a supply of drugs (mostly cardiac meds, antibiotics, pain relievers, GI meds, etc.) that patients can then purchase for an amount a few shillings over cost. In this way the RFPs never run out of drugs and don't have to rely on a governmental supply chain to keep them in stock. The small profit made from the drugs can then fund future pharmacies and/or employees to keep the pharmacy running. It is important to note that these drugs are much cheaper at the RFP than at any Chemist in town so it is a great deal for the patients and provides constant access to drugs that are vital for many of the patients. Imran gave me a list of the most commonly used drugs at the RPFs with the hopes that I, along with Kenyan pharmacy students, can develop some helpful "drug cards" (detailing dosing and proper administration practices) to hand out to patients when they receive their meds.

Friday afternoon I spent a few hours playing with Lydia and working with her on the IPad. Anita (her primary caregiver at Sally Test), Sarah Ellen, and I had a skype call with the OT in New Mexico that we have been working with to discuss how utilization of the device is improving and to get ideas about how to make the device even more effective. Since our last meeting two weeks ago Lydia's vocabulary (on the IPad) has increased from around 20 words to over 65! It is quite amazing to see her rapid progress and gives us all hope that this program might translate well to other patients with similar needs.

Saturday I finished up work on the "final" draft of the diabetes carb counting sheet and also wrapped up the brufen/paracetamol dosing card (both with revisions pending). A group of us then headed out to the Eldoret Sports Club and played two long games of Ultimate Frisbee! It was awesome and just as we left a huge storm hit, complete with a rainbow and some hail (pictures below).

Ultimate 1

Ultimate 2

Ultimate 3 Rainbow

Sunday will definitely go down as one of, if not my favorite, days in Kenya. I spent the day with one of my 4th year Kenyan colleagues, Nicholas Kisilu (the two of us below at his parents house). We attended mass at his home church and then headed off to a barbershop to get his haircut. We then grabbed a cab to head to his family's home in Eldoret. We spent the cab ride there talking about his life growing up in Kenya and about how he ended up in medical school. He graduated from high school and then began volunteering and eventually working with the AMPATH pharmacy team. When the diabetes program got underway and the home glucose-monitoring program began he was there. Eventually his work led him into medical school. When we arrived at his family's home his parents, three of his sisters, and two of his nieces greeted us warmly. We sat in the living room and discussed how we met and his father asked numerous questions about how the United States and Kenya differed. His family was incredibly warm and made me as comfortable as possible. We ate lunch together (mchuzi mboga-vegetable stew with rice and chapati). It was delicious and we continued to get to know each other as we ate. At the end of the meal we went out and took some pictures of the family (picture below) and then Nicholas, his mother and I headed back into town. It was so nice getting to know what life in Kenya is like for a student who is in a similar program as I. His family's interest and excitement about his success was palpable. 

Kisilu and Me

Kisilu's family

Sunday evening ended with a meal at the hostel. Kisilu prepared ugali, nyama n'gombe and managu (a local vegetable that he had been trying to get me to eat for a while). It was a great end to a wonderful day. I am so grateful that I am getting to know my Kenyan counterparts in a way that allows for long-term friendships to develop. Today was truly a great day.

This experience is certainly one that will remain fresh in my mind for months, years and decades to come and will hopefully bring with it a lasting connection to a land I am coming to know and learning to love.

Asante sana,

Bryce 

   

  

Posted at 20:47

Half way home, but far from gone

This weeks' end marks the halfway point in my time here in Eldoret. It is hard to believe I have been in Kenya for four weeks already. It seems like just days ago that I boarded the airplane in Indianapolis and headed off for a big adventure in Kenya. The past four weeks have brought with them so many opportunities to learn and so much time to experience the culture of community that exists between those involved with the IU/Moi partnership. I spent much of this week as I have spent the previous three; working on projects, attending some lectures, seeing different clinical relationships and district hospitals and hanging out with my Kenyan counterparts.

On Monday I again had the opportunity to speak at the Sally Test Center hosting my second "Sally Test Talk". I spoke to the parents in the wards about the importance of identifying strep infections early, getting the proper antibiotic treatment and how proper treatment can prevent rheumatic fever and it's complications. In Kenya when patients present to physicians with a fever and sore throat the first diagnosis that comes to mind is often malaria. This is a safe bet in a place (Africa) where it is estimated that the average child has between 1.6 and 5.4 malarial infections a year. This is counter to what happens in the US, as physician/patient there can attest to; presenting with a fever and sore throat inevitably leads to a throat swab and culture to check for a strep infection. In Kenya a missed diagnosis of strep can lead to untoward complications; namely rheumatic fever. This can subsequently lead to rheumatic heart disease (destruction of heart valves, most often the mitral valve) or other cerebral side effects. We carefully discussed the criteria for evaluating strep infections and what medications (namely penicillin) were recommended for treatment so such disastrous post-infection side affects can be avoided. The parents were again very receptive to this information and asked a number of very good questions. I was fortunate to have Jordan Huskins, our peds team leader, in attendance to help field a few of the more difficult and medically oriented questions. At the end of the talk we went over how to appropriately dose paracetamol and brufen for fever/pain relief. This talk, just like the first, was a great experience and certainly one of the highlights of my time here thus far.

Monday evening I led our first Patient-Doctor Communication class (picture below) with the help of six 6th year students who travelled abroad last year (the class addresses topics relevant to the 5th year Kenyan students who will be travelling abroad for rotations in the coming year). We discussed appropriate bedside manner and talked extensively about the importance of nurturing a good patient-physician relationship and how that can improve care. We demonstrated a good patient interview and a bad patient interview in two skits where I acted as the patient and two 6th year students acted as the health care providers. We then broke up into groups and discussed how these two skits differed and how the bad skit could/should have been improved. It seemed like the students enjoyed the class and a lively discussions ensued. Next weeks class will cover medical mistakes, professionalism, sensitive topics (like sexuality, substance abuse, etc.), and then a panel discussion with the 6th year student's fielding questions about their experiences in their rotations through schools in the US/Canada last year.

Patient-Doctor class

Tuesday morning I attended morning report where we heard about a case of GBS (Guillain-Barre Syndrome) and it's presentation in a young boy on the wards. It was interesting to hear how the disease was managed here in Kenya juxtaposed to how we would treat it in the States. The boy ended up recovering with little medical intervention here, but things could have ended up much worse. Later in the day I attended a talk on malaria, presented by Jordan Huskins. We played team jeopardy based on some of the readings and got to test our knowledge about this disease state that is found so ubiquitously in Africa.

Wednesday I attended the monthly mortality and morbidity talk for the pediatric group in the hospital. In these meetings the deaths for the month in each pediatric ward as well as the newborn unit and sick child clinic are reviewed. The physicians and students talk about specific cases to try to understand what health care procedures or protocols need to be put into place so that patients have the chance for the best health outcomes. It was an interesting look at how care is delivered and how care protocols need to be constantly evaluated and improved. In the afternoon I spent time skyping with one of the team leaders who is temporarily back in the States, Laura Ruhl, who I am working on a number of projects with; we set up my schedule for the upcoming weeks and reviewed some of the things I have done on projects thus far.

Thursday I again attended morning report where we watched a movie about pneumonia and how it wreaks havoc on children in poverty stricken areas around the world. We then talked a bit about the importance of identifying pneumonia and how important early detection can be in terms of patient outcome. After the morning report I headed to Diabetes clinic with Dr. Apondi were we saw three Type 1 patients for follow-up. We worked with the same girl we had seen the week before who was struggling with some food security issues. She seemed to managing a bit better and finding a more regular source of food, which was encouraging. In the afternoon I attended a talk about diabetes in SSA (sub-Saharan Africa). It was led by a pharmacist from Purdue, Sonak, who essentially helped set up all of the clinical work that is going on at AMPATH/Moi and at the district hospitals that relates to diabetes care and management. It was great to see someone so fired up about treating patients.

Thursday evening I attended the "fireside chat" about Women's Rights and Human Trafficking. It was an interesting discussion about a topic which was not all that well informed about. The presentation was loosely based on some of the stories in a book called "Half the Sky". We broke up into small groups and discussed how we would approach one particular difficult situation and then came back together to find out the real outcomes of each of the scenarios we were discussing. The talk was informative and brought front and center the reality that human trafficking is a huge global business and needs to be aggressively pursued for elimination by national and international bodies.

On Friday I went with Sonak, the Purdue pharmacist mentioned above, to Webuye district hospital (picture of the front of the building below) to observe the Diabetes outreach work that is being done in the catchment area. The team of pharmacists and "home glucose monitoring" staff along with a few Kenyan physicians saw about 40-50 diabetic patients (and a few anti-coagulation patients) in about 4 hours. They reviewed their meds, checked hemoglobin A1C's and rapid blood sugars, and did a physical exam to make sure that the patient's diabetes was under control. The "home glucose monitoring" program is a recent development here. Patients monitor their blood sugars 3 times a day using handheld glucometers and are called once a week by the health workers to check to see how well the disease management is going. Based on the rapid blood sugar numbers that the health care workers record the physicians managing the patients can quickly look at their results and make adjustments to their dosing schedules as needed. Most of the patients are well controlled and the compliance is quite remarkable. I am continually impressed by the commitment of the patients living in very isolated regions to manage such a difficult chronic disease.

Webuye hospital

Friday evening two of the University of Toronto students, Amy and Kelsey, three Kenyan students who live in the hostel and I went to dinner together at a local restaurant called Klique. We shared some local dishes (pictured below are chicken curry and a local cooked tilapia) and had great conversations. It was a nice way to end the week and we plan to continue these weekly Friday meals with our Kenyan counterparts.

Kilque dinner 1Klique dinner 2

I began Saturday with a 5 mile run and put a load of laundry in while it was quiet around IU House (I am quite the partier I know :). I then went to lunch with a number of folks from the IU House at a local restaurant called Bandaptai (picture of everyone and their dishes below). We then went on a hunt for some souvenirs and got to see a number of the local markets. It was a great day just spending some time getting to know Eldoret a bit better and locating the places to come back to to pick up gifts before I leave Kenya.

bandaptai

Sunday I went to a celebration of Canada Day (a day early) with many of the Canadians who call Kenya home (I think I got them all in the photo below). We went to a local farm called Kaptagat where a couple named Paula (Canadian) and Ash live. After we ate far too much food we took a nature walk around their property and saw "Big Daddy", a tree that is 1000 years old (also pictured below). We also caught a few glimpses of some Colobus monkeys that live on the property (they have a very "skunk-like" coloring pattern and didn't like all the attention we were giving them so they hid in the canopy). The five-acre property is beautiful, as it is positioned at the top of a hill and leads down to a rushing stream. They grow bananas, passion fruit, avocados, and sugar cane to name just a few of their crops.

CanadiansBig Daddy

In the evening I met with the 6th year medical students who are helping me teach the Patient-Doctor communication class. We discussed how we would run the class on Monday and looked for ways to incorporate some of their ideas about important topics to cover into the class.

All in all it was another busy and rewarding week. I look forward to the second half of my time here and know that this is a community I will continually be grateful to have gotten to know and become a small part of.

Asante sana,

Bryce 

Posted at 20:24

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