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ktkski2017-blog · 7 years

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Life in Chogoria

February 6, 2017

Today was day 7 in a row of working at PCEA Chogoria Hospital. For the previous six days Dr. Clark and I have been rounding on the men’s ward (the males and females are split between two inpatient wards – the other wards include surgery, pediatrics, OB/GYN, and private). Over the weekend the coverage reduces and procedures, discharges are somewhat on hold – which makes inpatient medicine with sick people very challenging. We have had several deaths on the men’s side that have been challenging to bear – in Traverse City I have only had one patient pass away on my service and he was very ill in the ICU and opted for comfort measures. Since being in Chogoria there have been six within the last 7days. I take them very personally and a dark place in your mind wonders "is it because of me?” – but then I remind myself how much I advocate for these patients during the day and just how sick they are. We had one guy with a hemorrhagic stroke who had expansion of his bleed due to resistant hypertension – in a ward where the blood pressure cuff works 50% of the time and there is a delay of hours to days when a new medicine order is put in, and where we do not have access to percutaneous intervention. Another patient had severe nephrotic syndrome with recurrent ascites filling his abdomen that was resistant to treatment. He passed away from respiratory failure prior to being placed on dialysis because the machines had been broken for a while and the technician/specialist who could initiate dialysis wasn’t due to arrive for a few more days – he was in his twenties. However - undergoing dialysis is not comfortable. Patients often feel sick when they get dialysis and it usually lasts up 4hours every other day - for the rest of your life - which is ultimately shortened anyways due to the severity of disease required to consider even initiating dialysis. If he had survived long enough to get dialysis, it is quite possible that it would have been an unpleasant and still very much shortened life. Another twenty something year old was emaciated from HIV and the lab technician missed drawing his labs for three days despite reminders and pointing out the patient. I have noticed that patients with known HIV that has progressed to illness and malnutrition tend to get less attentive care from nursing and ancillary services like xray and laboratory. In a system where it is not common for very ill people to not get labs drawn for a few days, this can certainly accelerate patient mortality. However, if you calculate a patient’s prognosis (expected life outcome) due to the severity of their HIV illness, even with top notch medical care you may not extend their lifespan more than a few months or a year once they have become so ill. So perhaps it ends up being the kinder end to pass away with an acute illness rather than drag on living in a hospital for 12 more months with such poor quality of life. It certainly depends on your outlook on life because this can look suspiciously like neglect and bias against those with HIV. In Kenya the idea of Do Not Resuscitate does not work, because culturally this looks like neglect. Palliative care has similar negative connotations in the US and Kenya however is perhaps less welcome in Kenya – in the US I think if more people were educated in what it truly means there would be little resistance whereas here in Kenya, if people were more educated on it they would still resist it.

While the patient deaths and hospital inefficiency challenges have been difficult (albeit not unexpected), I have had some really great experiences too. I really enjoyed working with Janet and Musa while on men’s inpatient ward. We created a nice team of collaboration and were all engaged with the patients and patient care. There was no oppressive hierarchy – we were all contributing to improve patent wellness. We went out to dinner at Lenana’s with the clinical officers and visiting medical students on Thursday night and had an interesting discussion regarding strikes and protests internationally, prompted by a new national nursing strike in Kenya on top of the already going physician and university strike. The food was lacking (and this was the second time we went to Lenana’s and they had run out of food) but this might be biased by the fact that we asked for pilau w vegetables and received chicken rice with cabbage. We returned for lunch the following day (we had heard their lunch menu typically was more robust) and I was not disappointed with a mashed root vegetable with spinach-like greens. They also have fresh squeezed tropical fruits (sooo good). On Saturday afternoon we hiked the ravine behind our apartment compound to look for a waterfall. Due to the drought we found some boulders and mosquito breeding cesspools, but the view at the top of the boulder pile/head of the ravine was beautiful as we got our first glimpse of Mount Kenya in the background. Chogoria rests in the foothills of the mountain so it is hard to see it with the intervening hills. We had to shower after the walk back on the dusty red dirt road. On Sunday evening we lounged for several hours in Dr. Clark’s backyard, picking vegetables and herbs, reading on her swing, basking in the sunlight (slathered in SPF 30), and she made us dinner that we ate on her front porch with a dessert of papaya, passionfruit, lime, and freshly picked mint. We then played cards until the sun went down while listening to the a capella singing of the several surrounding girls’ schools. We have also been eating significant amounts of tropical fruit (perhaps spurred on by reports of winter storms and below-freezing temperatures back home). Today I had half a mango for breakfast (with yogurt) and probably one third of a yellow pineapple for dessert. Not to mention my avocado grilled cheese I also had today and the taste/trial of horny melon that we had prior to dinner (I think it wasn’t ripe yet – unless it’s supposed to taste like a sour cucumber). Jen picked a papaya from the tree behind Dr. Clark’s backyard and we have our eyes on the avocado tree and neighboring mango trees.

Today we went to Chapel in the morning (every Monday this is a time for the hospital to make announcements and introduce new people). Although the prayer was appx 10minutes long I did stay focused long enough to hear the sermon – there was mention of Trump and his ridiculousness name calling this “so-called judge” and fear mongering in the context of Kenya’s election coming up later this year. The message was focused on putting God first during this challenging time however the guy lost me when he started mentioning the evils of homosexuality and taking religion out of schools. Instead of rotating on the men’s ward today I followed Jason for the morning in the NICU and on pediatrics.

In the NICU incubator is a 35day old infant who was born between 24-26week estimated gestational age by spontaneous vaginal delivery. Today is the day we are going to see how he does outside of the incubator as he is now 1.7kg.

On pediatrics we had to inform a mom that her 11month old had end-stage liver disease. The patient had evidently presented with hepatitis and diagnosis of biliary atresia approximately 6months ago and was referred to Nairobi for a stent placement (to drain the blocked duct) – however when the surgeon opened the abdomen it was obvious that the liver had suffered too much damage so they had to close the abdomen without placing the stent. Since that time the family has been home, however the mother re-presented to Chogoria due to worsening jaundice and poor feeding. The poor baby had ascites, venous congestion with veins criss-crossing the abdomen, jaundice, and was small for her age. The process of explaining the disease and need for palliative care to the mother was challenging to begin with but almost impossible when there was a language barrier. The clinical officer tried however I am unsure whether the empathy was well transmitted.

Another 6year old kiddo who has mysterious systemic lymph node swelling, low platelet counts, hemoglobin, and no obvious derangement on peripheral smear was scheduled for a bone marrow aspiration today. Provi – a US trained physician who was raised in Kenya as a young child – showed such care for him as she carried his small frame from the pediatric ward to the minor theatre (operating room) and held him tight while he had his IV placed. He did so well with the bone marrow aspiration; we did sedate him with ketamine but prior to that he lay calmly on the operating table next to his dad, gingerly holding his new IV site. He has the thickest eyelashes I have seen so far while in Kenya.

Afterwards I rounded with Provi, Lena, and Eric on female medical ward, so I spent the morning getting to know the new group of patients. I was again impressed with Provi’s compassion with patients – it really helps when you are able to speak the same language and you have such good bedside manner. I couldn’t help but duck over to the men’s ward a few times today to check on the status of our more ill patients and wave/smile hello, habari to a few others. This is when I heard of the passing of one of our mystery illness patient’s. He had been encephalopathic for several days after previously being able to chat with us and developing renal failure after we diuresed him from heart failure exacerbation. He likely had severe sepsis from an unknown source, likely meningitis, however the empiric antibiotics we started were not sufficient to overcome his illness. A point-of-care cardiac ultrasound performed earlier today showed a barely pumping heart. We actually received some lab results back on him after he had passed away – he had an INR of 50 suggesting systemic coagulopathy. We were unable to perform a CT scan of his brain to rule out stroke versus infection as he was not on the national insurance plan and his family had not come to visit him so we had no one to pay for it – in Kenya you pay for the procedure or imaging prior to it being performed. If you cannot pay, you cannot get the procedure.

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