Something just broke

An epilogue, or epi-blog, as the case may be…

When we last left our intrepid traveler, she was en route to London by way of a brief and altogether unmemorable stay in Nairobi. After being fleeced by the taxi driver that picked her up from the airport, she spent the day napping, watching bad movies, and carefully guarding her belongings. There was little else to do, as the hotel was in the outskirts of town and not conducive to walking around.

Early this morning, she rose and begrudgingly took the same taxi, relying on the old wisdom of the devil you know being better than the devil you don’t. After a little over-priced last-minute souvenir shopping, she headed to her assigned gate, suffered two additional security checks, including an unpacking of the carefully engineered space-occupying masterpiece that was her carry-on. She was called to board, whereupon she notified the world of her movement.

Imagine then, her surprise when the huddled masses were shepherded out of the jetway and back into the lounge. Without the same pressures as the other passengers (i.e. screaming, hungry, bored children), she relaxed with her laptop. Unaware of the time that had elapsed until her laptop battery was abruptly depleted, she soon realized that it had been two hours without a word of explanation from the airline.

The captain had the unhappy task of eventually informing the somewhat irate crowd, many of whom had been monitoring the busy worker bees hovering around the craft, that an engine part had malfunctioned – an engine part that was not to be had in Nairobi, but that would have to be flown in from London on the evening flight. Timid flight attendants followed behind with paltry offerings of snacks as the travelers made their way to reclaim luggage and join the queue for hotel assignments.

Nervously, she watched as her suitcase was loaded onto the rack on top of the bus taking her to the city center of Nairobi and to the gilded halls of the Hilton. Food, beer, heated swimming pool, air conditioning, and a hot bath went a long way to dispelling our traveler’s anguish at the delay. Another bus awaits her in the morning, where two Virgin Atlantic planes should be ready to wing their way to London.

And they all lived happily ever after. 

Because I knew you, I have been changed...

It is, perhaps, fitting that the sky of Kisumu is gray and gloomy today, if only to match the pall overtaking my mood. I won’t be forced to watch the sun sparkle across Lake Victoria as we climb into the sky. The magnificent greens of the valleys and hills are but a muted pewter and not the brilliant emeralds of my memories.
Walking across the tarmac, I am thinking back on the trepidation that filled my steps the last time I was here. It seems almost laughable now. Alone, nervous, and hesistant, I gathered my strength and piled myself and my belongings into what I hoped and prayed was a legitimate taxi bound for the now infamous Sooper Guest House, all the while wondering exactly what I had embarked upon.

That first night, I stared at the ceiling through the soon-to-be familiar pores of netting, and despite two days of traveling with bare snatches of sleep stolen in economy class seats, my mind wouldn’t let my body rest. Racing from thought to thought, I saw myself struggling with patients that didn’t understand me, with responsibilities I didn’t feel confident to shoulder, with surgeons that would either expect too little or too much from me. Having spent the most recent portion of my training traveling through various subspecialties, I feared the possibility of clumsiness with general surgery. Had I only known that my bigger nemesis would be my complete lack of knowledge of orthopaedics, how much more fitful would have been my eventual sleep.

On the first full day, exploring the town, I smiled blankly when offered ugali or chapatti with my meal, squirming at the sight of the whole smoked tilapia and not even understanding the diction, choosing nothing to accompany my timid roast chicken rather than the unknown. It was not long before I was rolling the white maize polenta between my fingers with my lunch of fish and cabbage and snacking on the flat bread with my mid-morning tea.

Like the meals, patterns became established, and once my jetlag was abolished, the routine became comfortable. A bumpy ride in the little yellow tuk tuk, past the raw wooden stalls lining the roads, dodging bikes, motorcycles and matatus to arrive at the hospital compound. Swinging myself over the wooden railing and into the changing rooms, to emerge in scrubs and boots to work either with hurried abandon or at an anesthetist’s leisure. Tea and mandazi, lunch and ugali, a mad dash back into civilian clothes for an afternoon soda in between cases before summoning my little yellow tuk tuk again. Dinner, perhaps a beer, equally as relaxing with new found friends or alone with my thoughts.

There were memorable and happy deviations. Visiting a village, playing with its children, being welcomed into homes and conversations. Watching the efforts on behalf of one woman’s memory making very real changes in people’s lives and attitudes. Venturing forth, relying on the hospitality of almost perfect strangers to explore beyond my little coastal town.

My perspective on medicine shifted, in ways I couldn’t even begin to anticipate. I had developed certain frustrations with American medicine, in that it often seems our resources aren’t necessarily dedicated to maximizing good quality patient-years. There are inequalities in care, but it’s generally a difference between good and better. Not so here, the difference is between good and none, between life and death. I’ve lost patients for lack of monitoring, for lack of labs, for lack of available anaesthetist. Every medication, every operation, every thing that is done here has purpose and is needed. It may make my frustrations and irritations worse when I return home, but my hope is that it will give me the resolve to be honest about the type of surgeon I want to be.

In short, some amazing people gave me their friendship; patients gave me their trust. Chance, fate, or God gave me so many wonderful new experiences. My heart is so rich and full of the gifts I have received that it becomes easier to forget the not-so-happy memories.

With childlike fascination, I press my forehead to the window pane beside me, unblinkingly scanning the ground until the sun warms my face, the clouds are beneath my feet, and the dirt and dust of Kisumu have melted away.

Kenya has enchanted me – I will return…

Best to take the moment present as a present for the moment...

Though today could have been a difficult one, I was given the opportunity to realize how much my visit here was appreciated. Without exception, every single person to whom I said my goodbyes today asked, “When are you coming back?” My heart swelled with gratitude for the experience.


The day started by meeting with Dr. Juliana, the hospital administrator. We spoke about my time here, giving feedback on what I feel are their more immediate and attainable needs. Hopefully, I’ll have the chance to coordinate with the surgical team that is coming in February. Interestingly, it was at this “exit interview” that I learned that I had performed a hernia repair on her uncle. Strong show of faith in her hospital. She remarked that he was amused at the thought of a male Kenyan surgeon working side-by-side with a female Mzungu surgeon. Luckily, he recovered nicely.

After that, I ventured into the main theatre, where I was chastised for not informing them of my departure in advance. They missed a chance for a party and they love an excuse to have a party.

Wandered the wards to touch base with the interns and to check on the baby I had operated on the day before.

Rapenda and Kariuki, the men's ward interns

Muchela, the women and children's ward intern

Took my last ride in Mike's tuk tuk. He put up with so much from me. Having to turn around to stop and buy things on the side of the road. Being on call for whatever random hour I got done at the hospital. And perhaps his biggest struggle as a Kenyan, picking me up on time in the mornings. ;-)

A final lunch with the MCI team at a swanky guest house called Le Savanna, joined by the pediatric surgeon I worked with so often. Not sure if I had mentioned it before, but as part of the public health initiatives here, hand-washing has become a strict pre-meal ritual. And I mean ritual. It’s either fingerbowls or hot towels or a waiter carrying an ewer of hot water and a pump bottle of soap. Today’s method, however, was new. Hot water was poured into ceramic jugs near the tables, and we all left the table to wash.

Merciline, Ben, Dr. Ongong'a, and Beldina

Surprisingly, I have managed to pack everything into the small amount of luggage I brought with me. Hopefully, it will all still meet the weight restrictions for Kenya Airways and Virgin Atlantic!

We attempted to celebrate one last sunset at Kiboko Bay, but the weather didn’t cooperate, and there’s no reason to fight the mosquitos without the payoff. We ended up instead at The Clarice (no fava beans or chianti... anyone?), the luxury guest house we had last visited on the night of the ::grumble:: burglary. Couldn’t leave Africa without a drink (or two) of Amarula.

I am spending my evening as I have spent so many, writing my blog, looking at photos, having a drink with Beldina. Later, I will sequester myself in my mosquito net, armed with flashlight and Nook. Why should tonight be different from any other?

Promised Beldina's son, C.J., that we would have breakfast together in the morning. I would say that six-year olds get attached pretty quickly, but this thirty-five year old is just as attached. He was so proud of his first day as a Year Two today.

Tomorrow, my last blog. An attempt to wrap-up this amazing month. Thanks for sticking with me…

Everybody's got the right to be happy...

Time is ticking away! Did my 45th and likely final case today. Then went souvenir shopping.


It seems silly to mention in this land of want and sacrifice, but do you know how much it killed me to miss the Emmy Awards????? I am addicted to awards shows, and not only for the fashion like some of my friends. I genuinely enjoy the bits and the speeches. If only my computer weren’t so riddled with viruses that I can’t see YouTube… Grrrrr.

Oh, and since I temporarily have unlimited internet, I attempted to access Netflix. Guess what? Can’t stream outside the US. Bummer.

Let’s see. I did promise at some point to give a quick peek at Kenyan history. This is going to be an exercise in seeing how much I retain from reading the newspaper three days ago… ;-)

Despite the timeless landscapes and rich, enduring heritage, Kenya is a fairly young country. A product of colonial expansion, the British held on to the country, for its plentiful agricultural resources until the people demanded liberation in the form of a band of rebel fighters called the Mau Mau. Though the Mau Mau was technically defeated and its leaders were forced to live in hiding in the forests, it advanced the cause of independence (the populace was straining under frank segregation in education and opportunity). The country was turned over by Governor MacDonald to the government of the nation’s first president Jomo Kenyatta in December of 1963, amid much pomp and circumstance.

Despite the takeover, the new government left many of the British political systems in place. There seems to be some element of discordance at this point, as a portion of the country reveres Jomo Kenyatta and credits him with strong leadership that allowed Kenya to come forward as an independent nation. Others feel that his party had little to do with the fight for independence, and it was simply a matter of trading one autocracy for another. To be sure, the executive branch in this government is strong, as there have only been three presidents in the 47-year history of this independent nation.

Government has been very centralized, which has led to opportunities for corruption. Many Kenyans blame their woes on this idea of “Nairobi” whether that means the central government or the governors is unclear.

However, after years of debate and revision, the country finally passed a new consititution. Among other things, it decentralizes the government. What I have found most interesting is the range of expectations this change brings. For some, it means building new offices; for others, employment opportunities cleaning those offices. For even fewer, it means taking control of community projects, being able to control local income and revenue without watching it all go into unknown pockets in Nairobi.

It was an amazing time to be in the country, listening to the fervor of a people empowered.

That’s it for Stephanie’s History Corner. Only one more blog from Kisumu!!!!

On the soft green elliptical grass

After having attended two vastly different churches the past two weeks, I decided to see if my church could continue to provide the same constancy of ritual, of community, that I've always clung to in times of trouble. With hope for finding the familiar, I headed this morning to St. Joseph's Catholic Church in the Milimani suburb of Kisumu.

The exterior of the church, a meeting ground for the community

While much of the service was obviously similar, there were many Kenyan touches. Perhaps things are different in different churches, but I was raised in a church where the ushers were always the men of the church or the youth. Here, it was the women elders, collectively called  "The Mothers", that clearly ran the church, from seating, to offertory baskets, to presentation of the gifts. There were two young schoolgirls that were ever present in the aisle of the church, and they performed choreography to many of the recitations and responses sung during the mass.

The songs were amazing, with rich harmonies, complete with the uniquely African noise that can only be described as ululating. Unfortunately the music was often over-accompanied by what I've always referred to (my sisters will back me up on this) Fletcher Organ Company music. There used to be a piano and keyboard company that sold instruments in the malls in central Florida, and there was always some synthesized rhumba beat emanating from the store. Anyone remember that? I did attempt to record some of the music, but I'll have to play with it before I can post it properly.

The first mass was celebrated in Kisumu in 1902, as the railroad approached town, a number of the workers were Catholic and traveled with a catechist. The diocese was made official, and St. Joseph's was established in December of 1903.The church holds masses in Kiswahili, English and Luo, one of the tribal languages (of which, Kenya has 42!)

The Mary shrine

There were some changes in the mass, what I presume to be optional portions of the service. And, my search continues for a parish that actually recites the Apostle's  Nicene Creed. I think the more I recognize that I miss it, the more I realize that it is that portion of the mass that has always spoken to me. A unified group of people speaking firmly and strongly about their beliefs. I know that communion should be the most important part of the mass, but professing that belief really centers me as a Catholic. Some portions of the mass that I've always considered reserved for the celebrant, i.e. through him, with him... are recited in unison. And what seems like a deliberate change may or may not have a specific meaning (Steven? help me out here) in that they say "... shed for you and for many, so that sins may be forgiven..." instead of "...shed for you and for all..."

I took it as a positive sign that the communion hymn was one of my favorites, "Bread of Life". I know it's not exactly unique, but it was the version and tune that I remember from childhood.

So, yes, a bastion of familiarity in this crazy, wonderful country. Very glad I chose to go.

This is the morning report

So much to talk about, I have to squeeze two days into one blog, since I’m running out of time ;)


Thanks to those who commented, emailed, or facebook’d about the trials of yesterday’s blog. I shall chalk it up to life experience and move on…

Determined not to let the robbery ruin my last weekend in Kenya, I proceeded with the plans that were already in place, namely a bus ride to Nakuru. It was a wonderful day to be in Kenya, even if we were far away from Nairobi, as the patriotic fervor stirred up by the signing of the new constitution was infectious. But, I’ll leave Kenyan history and politics for tomorrow’s blog. Today, I want to tell you about my continuous wonder at the constant surprises in this country.

In a previous conversation, I was gently chided by a fellow traveler for having flown to Kisumu. According to him, the only way to really appreciate the splendor that is Kenya is to travel on the ground, and after this bus trip, I’m inclined to agree. The bus itself wasn’t anything special, except that I could get from western Kenya to central Kenya for ~$8. And that was the luxury line.

What was so inviting was that the terrain is so unflinchingly verdant. The green never stops. Even the wide depressions on the sides of the road were tumbling with wildflowers and weeds, interrupted periodically by a neat, methodical garden plot of cabbage or maize. The trees would vary as we climbed in elevation, and at one point the flat-topped canopy trees gave way to slender coniferous species until I could imagine I was on the Garden State Parkway. Eventually, we crossed into the land of tea plantations, and the peculiar yellow-green of the tea bushes would stretch in wide swaths over the rolling plains. In the distance, you could always find the white rectangles of the worker’s brick row houses and the tall metal central plant. Crossing through the Rift Valley area, the roadside shrubs and trees would suddenly thin out and you find yourself staring down into a valley with trees so dense and vegetation so lush you could swear humans had never set foot into it, only to see a woman come out of the darkness with a bucket of water on her head. And not ten minutes later, a flat meadow full of sheep, with the shepherd relaxing roadside with a hunk of sugar cane in his mouth. I spent the entire four hours with my forehead pressed to the window.

At last, we came to Nakuru. To begin with, for those who know me, the thought of staying with the family of a friend of a friend is a little (a lot) outside my comfort zone, but this whole trip is about shaking up my life, yes?

Kahenya and his fiancée, Laura, met me at the bus station and whisked me away to one of Nakuru’s nicer restaurants for lunch. It happened to be Ethiopian, so yummy. Afterward, we headed to Menengai crater, a dormant volcano (I think?) that is not far from their home. Except for the many km of switchbacks that it takes to get to the top rim of the crater. I’m not really sure what I was expecting, some small divot a couple of hundred yards wide, perhaps. Certainly not the spectacle I ended up seeing. Pictures don’t do it justice (not the first or last time I will say that). There are also many little areas in the base of the crater that emit a fine white line of smoke. Presumably little geothermal vents that the government is trying to find a way to harness as an energy source. The local tribe, the Kikuyu, Kenya’s largest, have traditionally felt that the crater harbor devils. That the steam spouts are where the devils are digging. It was the only explanation for why cattle grazing in the area would disappear in the treacherous soil. The rocks in the area are pumice and subsequently very light, and the temperature gradient between the rim and the floor causes a strong upward breeze. As a child, Kahenya recalled stories about people trying to throw rocks into the crater and, because of the gusts, being told that the devils were throwing them back.

Kahenya and Laura

The devils are digging...

After winding our way back down the treacherous road, I met Kahenya’s parents, watched some of the constitution celebrations, ate dinner and headed to bed early. It had been a long day, particularly after the late night/early morning I’d had the night before.

The next day (today), after breakfast, Kahenya, Laura and I headed into town. There is a Kenya Wildlife Bus that tours Lake Nakuru National Park, and it leaves from the Kenya Railway station at 9. Supposedly. We stayed there (and thank goodness they stayed with me) from 8:45 to 10:15, and there was nary a bus in sight. Laura finally gave up and told Kahenya just to take me into the park. She ran off to run her errands. He and I got to the park and were told that there was no bus today. Yikes. He agreed to be my safari driver, a choice he had reason to regret later. ;-)

Our safari truck, a.k.a. Kahenya's mom's gardening truck

The park was incredible, and we only toured one half of it. The side of the lake that we journey was marshland with small copses of trees and grassland. The other side, as he told me, is more traditional grassland savannah. His main accomplishment of the day is that we didn’t get stuck, and mine? Well, you’ll see mine in a little bit.

Lake Nakuru is renowned for its birdwatching, but since I know little of birds and do not have a fancy camera, I was just looking for the main highlights. Had I known how extensive the park was, I’d have insisted on coming when it opened and not leaving until it closed!

The lake itself looks like it’s rimmed in pink, with throngs of flamingoes clamoring over one another all along its vast shoreline. He took me through the marshy roads and around the baboons, and I was snapping pictures left and right. Zebra, water buffalo, water bucks, a couple of different types of antelope, baboons, hyenas, every thing I saw.

But, my goal, my raison d’etre was to see the rhino. And we found him, and he was amazing. The sun came out from the clouds, he stood up in profile, there were birds lined on his back and the flamingos were flying behind him. And my camera decided to stop working. Lens error! LENS ERROR! I wanted to cry. I was crushed. I played with it for about 10 minutes, desperate to make it work. It was that Kahenya realized he had a crazy Mzungu in his truck. I simply told him that we had to go back to town for me to buy a disposable camera. That’s all there was to it. I had to get this picture. He looked at me like I was nuts, which to be honest I probably am. I promised him that if he did that, then that was all we had to do, he didn’t have to show me any more of the park, just help me get the picture of the rhino. We had to persuade the gate guards to let us have an exemption to leave and return, and luckily Laura had her camera with her, so we caught up with her to get it and raced back to the spot. He had moved a little, but not far. And was now surrounded by a herd of water buffalo. Apparently, I was risking life and limb, because at one point Kahenya very calmly dropped his voice and ordered me to get back in the truck. The rhino was at my back and had started moving closer. Once we were out of the area, he told me that they can charge at 50 km/hr. Glad he didn’t tell me that before…

Look, Zoe! A nino!

Aunt Steph doesn't know it, but the nino is getting closer...

Gentleman that he is, he continued to take me around the park, at least up to the Baboon Cliff Lookout. And thank goodness he did, it’s on a high point overlooking the lake and the view was spectacular.

Love the reflection of the clouds in the lake

We did Ethiopian again for lunch (the other Nakuru restaurant was closed…) and I journeyed back to Kisumu. So glad I ventured forth from my little city in the west.

That's my new philosophy

Initially, the title of this blog was “No good deed goes unpunished”, but after somber reflection, I adopted a more forgiving lyric. It is with great hesitation that I include this chapter of my Kisumu adventures, knowing that many of you might be alarmed as you watch the tale unfold. I beg you to read the blog through to its conclusion and remember that a good reporter tells the whole story.

When last I left you, I was enjoying Beldina’s hospitality, laughing and eating Oreos with a cold glass of milk. A rare treat, trust me. However, when Beldina took me back to the guest house, things went awry.

My room had been burglarized in my absence. There were subtle but obvious signs that someone had rustled with my stuff, the least of which the drawer in which my valuables were locked had been stripped open. I grabbed everything valuable that they didn’t take and went back downstairs to report to the lobby receptionist, calling Beldina with my free hand as I made my way down. She turned around and came back and told me to call the owner, which I did. The men in the lobby were helpful in some ways and less so in others. Firstly, they immediately had a suspect, in that they were already suspicious of the man that had checked into the room next to mine. Helpful, sort of. They went upstairs with me, which is when we realized the balcony door was open and that the window screen next to that door’s lock had been bent backward to allow a wrist access. Then they told me that I had to go to the police station to file a report. As if I had the means and/or the desire to wander Kisumu near midnight to find the police station. Less helpful. Once they realized I was on the phone with the owner, they became a little more helpful. Beldina and the owner arrived at the same time, and we went back up to the room, where the owner and his wife proceeded to chastise me about the fact that I left valuables in the room. Because that’s exactly what I needed. Beldina started hinting about the fact that she was going to end her relationship with the guest house, and they suddenly became a little more gracious, though only barely. My recollections of most of this are hazy at best as I was in a haze, feeling violated, overwhelmed, and stupid all at the same time. They recognized that they rented a room to someone against their policies (without an ID/passport), but still wouldn’t accept any hint of culpability. We all left en masse to the police station.

Imagine a small city, with barely enough street lamps to keep the main thoroughfares illuminated. The streets are mostly deserted, as it is the eve of a great National Holiday, the birth of a new Kenya, a historic event on par with the celebrations of the independence it gained from Great Britain in 1963. The car slows as we near an ominous gathering of men in the street, fortunately it turns out to be located in front of the District Commissioner’s home and a security presence is strong. The gravel crunches as we turn onto a small back street. Broken and vandalized vans line the darkened street, and were my driver any other than the companion I have, I would be insisting we head back to civilization. The police station is neither well-marked nor well-maintained. We pull off the gravel road into the dusty soil of the station’s lot. Boda bodas and tuk tuks fill most available spaces, waiting for the off chance to transport the officers anywhere they may need to go. The station is little more than a holding cell with a small cement antechamber in which two officers while away the night. The first sits behind a desk with a massive paper ledger, into which he records the details of my situation. The second stays at the door with a gun stretched across his lap. Numbly, I stay in the broken chair he offers me, facing a metal door with a small square hole, curiously painted bright blue. As Beldina and the guest house owner provide local information and provide a little pressure in the form of Beldina’s contact with the head of Kisumu Crime, I realize that I’m staring at the town jail, and the disembodied voices yelling in Swahili (or perhaps Luo, I can’t tell) are the prisoners. A fact that becomes more real when I lift my arm from the desk and see the title of the ledger beneath me, “Cell Register”. Not exactly where I ever expected I would be in the early morning hours of a Kisumu morning.

We returned to the guest house, where I prepared to pack up and move rooms. All sense of safety had fled from me, and even with a group of people behind me, my heart started racing as I opened the door to my room. I couldn’t get out of there fast enough, and despite the fact that the hotel staff was trying to help, I got tremendously disturbed that they were touching my things. So much anger building inside until I wanted to scream, but I didn’t. We moved me down to a room right next to reception, and the owner left. I sat there with Beldina on the verge of falling apart. My heart was still pounding, and Beldina, reading me more acutely than I realized, called the owner and forced me to talk with him. It was on the phone with him that I finally started to lose it. Without Beldina within earshot to appease, he began again with his lecture on the error of my ways. First was anger at his failure to acknowledge that his staff already had suspicions about this guy, who should never have been allowed in the guest house. What good are all his locks and buzzers (we have to ask to be let in and out of the reception area) if he doesn’t pay attention to the clientele he admits? Then I flat out got scared, and couldn’t keep the tremor out of my voice. I told him I couldn’t spend another night at the guest house, I felt completely violated and couldn’t accept the fact that the chief suspect still had a key to the guest house. I also added that because of the theft I wasn’t in any position to pay any of the bill that I had already accrued. He made me sign the bill I had accrued, to which I added my own comments. He professes that he will submit an insurance claim for the items that were taken, but that he refuses to be responsible for the cash.

We were both sufficiently shaken up at that time that Beldina didn’t want to stop the car until we got back to her home, where I will be installed until I leave Kisumu. My anger was red hot last night, and spread over everyone. I was angry at Kenya, angry at myself, angry at a God whom I thought should protect people trying to do good things.

When I finally got my hastily packed belongings back into some order in Beldina’s guest room, it was near 2:30 before I was able to lie down to sleep. And as I fought with the mosquito that got trapped inside the net with me, I did a fair amount of soul searching. In truth, the things I had lost were just that, things. I had my health, I had my life. It could have been so much worse. Money flows in and out of my life, and though I have struggled with it, I’ve never been so destitute that I felt I needed to resort to criminal activity to survive. I have clean clothes on my back, a roof over my head and a generous layer of fat to remind me of my nutritional excesses. Perhaps my God was watching over me and kept me safe from bodily harm. This man, this thief, took away some of my sense of security, but he’s the not the first to have done that. He stole very little of anything irreplaceable. And he’s more than welcome to the Broadway audios on my iPod and the photos, videos and phone numbers on my American cell phone. He neglected to steal the power cords, and as I haven’t seen any in Kenya, he can enjoy them while they last.

And so, I’ve decided to be thankful for the things I do still have:
For the souvenirs that he didn’t feel were important enough to take.
For the passport that he was generous enough to leave.
For the fact that he didn’t recognize was a Nook was, and I still have my primary form of solitary recreation.
For the split decision to take my laptop and camera with me to Beldina’s house.
For the many friends and family that will, of course, send me their phone numbers again… (via facebook and email)
For Beldina’s friendship and her ability to see beyond my anger, urging me to stop and reflect.
For the wonderful memories of this trip that I will not allow to be tainted by this individual act.
For perspective and forgiveness.

And that’s my new philosophy.

Tempus fugit

Tick tock, tick tock, times goes by...

Yet another day in the theatre of New Nyanza. When I arrived, I mistakenly changed into scrubs right away, since I knew that the head surgeon had requested for two cases to be put on for the morning. Appropriately attired (ridiculous white boots and all), I perused the board in vain, as no cases had yet been submitted. Full of ire, I raced back to the changing room, returned to my civilian clothes and prepared to go let loose on some intern. I extracted myself from my operating gear and headed to the ward, where not a single intern was to be found. Miracle of miracles, when I returned, fuming and frustrated, the cases had been magically listed.

With a huff, I changed back and dug in for the wait. And, predictably enough, the wait was long. ;-) Didn't start my first case until 11 am. Again, I thank providence and Dawn for the wisdom of bringing the Nook with me. I also thank Alexandre Dumas pere for writing four volumes of the story of the Three Musketeers. Prior to this trip I wasn't aware of the other three books of the series... I embark upon the 4th and final volume tomorrow.

Did my two cases and waited patiently for the third. The same baby that I described in my dressing down of the interns yesterday had not yet resolved his intestinal obstruction and needed to go to the operating room. However, things being how they are, only one anaesthetist is qualified to manage a 4 month old infant, and he was not scheudled ot be at NNPGH today. I waited in good faith for three hours for his arrival, then informed the gentleman who styles himself a pediatric surgeon that he would have to do the case.
(P.S. I did take pictures of one case today, but trust me when I tell you that the general public does not want to see a degloving injury of the lower leg)

On to the evening.

I enjoy Guinness. It is a taste I developed gradually over the course of a period in my life that is not to be mentioned here. I have enjoyed Guinness in Ireland, in England, in Irish pubs in New York, DC, and Orlando. I've even enjoyed Guinness in an Irish pub in the heart of Rome. I've even managed to sample some the "discarded" Guinness recipes at a bar in Dublin. What I didn't expect was to find a brand of Guinness brewed and bottled in Kenya, called Guinness Foreign Extra. It was a pleasant surprise, and the best of the bottled Guinness I have every tried. (Guinness on draft in a place with a clean nitrogen push system is still the best...)

After that delightful discovery, I joined Beldina and her family for dinner and companionable chatter over drinks. Just hanging out. Having a grand ol' time. Her son C.J. just went to bed, which is probably a sign that I should be heading back to Sooper soon. Busy day of travel tomorrow. I may or may not be able to post tomorrow night... For those of you who are inclined to worry, don't. ;-)

How the other half…

How the other half…

Shall I bore you with yet another description of Major Ward Rounds? Though I will say, the age of political correctness and constructive criticism has robbed senior residents and attending physicians in the United States from getting truly creative with their instructional methods with deficient interns. Though the sarcastic and selective emphasis of “daktari” is eerily similar to the familiar, “So what are you going to do… doctor?” heard by interns all over the US.

“D____, you tell me that M____ is in theatre, that R____ is in theatre, and that you are busy running the ward. But you don’t know these patients, what are you running? Are you patrolling the corridor? Maybe we should take your white coat and give you a security uniform. We have people to patrol the corridor. Don’t tell me you’re working when all you’re doing is running back and forth looking busy.”

“So, M____, you think this woman has PID, did you do a PV [per vagina, bimanual exam]?” “No, she is on her menses.” “And you cannot take care of her properly because she is on her menses? Are you a doctor or a Jewish rabbi? Do you think to yourself: ‘This lady is clean, I will examine her. This lady is unclean, I cannot touch her.’ How can you diagnose PID without a PV!” [I have no clue about the accuracy of his theology, but he’s pretty funny.]

Then when examining a baby who clearly has an umbilical hernia, but was being seen to r/o intussusception.
Intern: “The abdomen was soft with no abnormalities noted.”
Surgeon: “Did you examine this baby?”
Intern: “Yes”
Surgeon: “Is there something wrong with your eyes, do you need to get closer to the baby?”
Intern: “No”
Surgeon: “And there’s no abnormality with this baby’s belly?”
Intern: [stares blankly at the naked child on the bed in front of us all]
Surgeon: “Touch his belly.”
Intern: [gently brushes his finger over the top of the hernia]
Surgeon: “Don’t lie to me. I can tell you’ve never examined this baby. I can tell you don’t know what a hernia is. Don’t read to me what other people write. I know how to read.”
Intern: [stammers a bit]
Surgeon: “And what about the PR? Exactly. You didn’t do one. If you’re not going to put your finger up theirs, you may as well put your head up yours.”

And my favorite of the day: “There is supposed to be a difference between parrots talking and humans talking. You know that? Humans are supposed to realize that the sounds have meaning. You are a bunch of parrots!”

No operating for me today. Left early (after six hours of rounds!) to do some souvenir shopping and make arrangements for my weekend. But I have figured out that in the 12 days in theatre I have had, I have done 40 cases, 11 of them on my own. Not bad. Three theatre days left.

Tonight was a treat. Most of the time I have spent with Beldina has been in the village or doing her infamous “windshield tours” of some of the slums in and around Kisumu. She is so passionate about the work that needs to be done here that it’s infectious. That is to say, I didn’t mind a single minute of it, I can’t say I enjoyed – who can enjoy witnessing such poverty! – but I was enlightened by seeing some of the areas. In contrast to that, however, tonight we dined like the Kisumu elite do, in the relatively wealthy neighborhood of Milimani. The first clue was the cars in the parking lot. The simple fact that there were cars, not a bunch of Mzungus being dropped off by taxis and tuk-tuks. Secondly, the cars were of a certain class of German import. ;)

When we walked into the dining areas (inside, veranda and outside courtyard) it was like walking into my imagination. This was the linen-ensconced, lantern-lit Africa that I had been envisioning. Dark wicker chairs with deep burnt orange seats surrounded rich wood tables under draped canopies of tan fabric. Candles flickered from behind hurricane glass on each individual table. The courtyard was strewn with these private huts, just far enough away from each other to hear murmurings of conversations in the African rolling Rs of their vaguely British accented English, interspersed, as always, with Swahili.

And they weren’t out of steak.

Until tomorrow…

I’m a stranger in the strangest of lands

Despite my valiant efforts at wiping away yesterday’s bitterness and starting anew, the events of today chipped away at my sunny, if artificial, brightness before tea time. When tackling an elective list of twelve cases, it’s probably best to start the first operation before 10 am, no?

I’m still not convinced I’ve even figured out what the hold-up was. But, I profess only a mild indignation at the late beginning, as I was not looking forward to the orthopaedics festival that was planned. I mean no disrespect to my friends who have chosen this career, but there’s a reason I didn’t choose it. The last two weeks have been enough ortho to sate my lust for power tools for quite some time.

Again, despite having conversations about allowing me to run a second room with the non-ortho cases, none of the anesthetists felt the need to communicate with the rest of the staff and no one would go get my patients from the wards! Without the strength to fight another uphill battle, I took it all in stride, read a little bit, sipped my tea, nibbled my mandazi. Fortunately after about an hour, there was a very complex cancer surgery being done by the maxillofacial surgeon, and so I quietly strolled into his theatre and watched him for a while.

Finally, I was deemed worthy of a patient, and they brought her from the ward. I went to the surgeon’s room to tell them I would be starting soon and was promised the assistance of the intern as soon as they were done with the hardware portion of the case they were doing.

My case? A woman with suspected pancreas cancer with an obstructed biliary system and elevated bilirubin. My task? A cholecystojejunostomy (connecting a loop of small intestine to the gallbladder to relieve the obstruction). Don’t ask me if I’ve ever done one before. I’d have to lie. My preference was to do a more complicated reconstruction, but I was told “just bring up a loop, two-layer closure, okay?” So, I think I stepped up to the plate and used my surgical reasoning to do the job correctly. It might have been easier had I not been flummoxed by two things: (a) the intern never showed up and (2) my assistant was a student scrub nurse who had never scrubbed before. Did I mention I also wasn’t allowed to have cautery because of the complex cancer case I had been watching so faithfully earlier?

Finally finished with that around 5:45, when I am told that there is an elective patient that’s been waiting all day, can’t I just do a quick breast mass excision? Well, sure, except there are lesions in both breasts, and they are the size of a small pea and difficult to feel. Add to that, no one apparently heard the surgeon tell me that, because 45 minutes later, the anaesthetists are preparing to leave when I look at them with no small amount of incredulity. They forgot. Forgot. FOR...GOT! Perhaps I starting acting a little childish at this point, muttering under my breath and dully beating my head against the wall... The woman probably won't even notice that I did teeny tiny incisions near her nipples so that the scars won't be noticeable. P-a-i-n-f-u-l.

My little tuk-tuk didn’t drop me off at the guest house until 8:30pm, and I decided to go to a restaurant nearby because I’m craving steak. I’m calmly sipping my beer when the waitress returns to inform me… out of steak.

So ends another day of frustration. I’m so disenchanted with the OR right now, I hope for a few good days to end on a strong note.

Plans still aren’t definite for the weekend (my last one in Kenya!), so I’m not sure what I’m doing. I thought I did, but things change as they usually do.

Oh, and in case you’re wondering what it is I’ve been eating for lunch at the hospital… Ugali is a form of white corn meal cooked to something thicker than grits consistency. If Bobby Flay were here, he’d cut it into rectangles, grill it, and call it Kenyan polenta. The cabbage is cabbage, and the fish is smoked tilapia from Lake Victoria.

The queen insists on quiet

Today's title is because I was feeling a little diva-ish, and threw around a little subtle sarcastic attitude, which I'm sure was almost completely lost on my audience....

It was an interesting day, and I’m not sure why. I think, perhaps, I forgot where I was and slipped back into New York mode. I was mildly irritated by almost everything today and let myself get frustrated in the operating room. To start my day, I was informed that I would not be assisting with the one interesting case of the day. It was done in one of those oh-so-sly-can’t-say-no kind of ways. In an effort to get more cases done, wouldn’t I like to have my own room and do solo cases today? Of course, I agreed. Anything I could do to help the patients get the procedures they needed.

His little plan backfired, though, when he cancelled the patient he had asked me to do. They were scrambling to determine which case to start next, and the intern was nowhere to be found, so I ended up assisting in the interesting pediatric case, after all. Hah! (An anorectoplasty, if you're interested) While we were working in there, he asked them to bring me a case from the ward that needed an urgent amputation. He hadn’t answered his phone, he hadn’t received a message, there were no smoke signals in the sky, he just happened to be keeping this lovely (and might I say smelly) wet gangrene case as a surprise treat. I left about thirty minutes later to check the status of the case, and the patient was still in the pre-op area. I calmly explained, yet once again, that I was doing the case, no, there was no need to wait for the surgeon to finish. He was going to continue his elective cases while I did this one in another room. (Left hand meet right hand, aarrghh).

Finally, the patient was taken to theatre. Knowing I had AFAT (Anesthesia F-around time, another global constant) to deal with, I changed clothes quickly to run to the canteen for a mandazi to have with tea. Got back, changed, had tea, and the patient still hadn’t gotten her spinal anaesthetic yet! I went and sat in the room to hurry things along, and still it took another 30 minutes. So, then I scrubbed. I was left alone with a student anaesthetist and a student scrub nurse. Despite the fact that he had been puttering around with instruments for half an hour, he wasn’t ready for me to prep. There was no chlorhexidine, there was no betadine, there were no sponge sticks. The patient hadn’t been hooked up to cautery, there was no cautery instrument, he didn’t have scalpels on the tray. I think that might have been the first time I let go of any of the anger that was building when I said, “You know, this would only take 20 minutes if anyone would actually let me get started.”

Finally got the case done. Not only was it my first without a power saw, apparently their amputation saw has been in need to sharpening for months. My right upper arm is a little sore. ;-)

Then, Dr. Slick (I felt very used by this attending today, might have been part of the overall mood) pulls this one. “Let’s get this last case started, I’ll harvest the skin graft, you can prepare the graft sites.” Fantastic. No worries. Until he shaved off some skin and said, “Ok, just get that tacked on. Have a great night, see you later.”

Now, in the US, this might not seem like such a big deal. You slap the skin on, grab a skin stapler and secure the thing. Five minutes tops. Maybe six, if you’re worried about being hyperperfect and trimming edges. (Who me?) Well, you guessed it, no such thing as skin stapling in Kisumu. Every place that would have required a two-second staple, now required a much more time and labor intensive 4-0 chromic stitch. Cut to an hour later, and I was finally done securing graft to six separate recipient sites. Add to that an intern that I had to keep reminding to cut my suture, and an anaesthetist who pretended not to hear me when I asked to have the table raised higher but kept bugging me to finish because he was out of ketamine (it was well within the patient’s safety to switch to halothane, but that requires manual ventilation by the anaesthetist).

So, yes, perhaps not a stellar day, but I am doing my best to wash away the bitterness and start anew tomorrow. And a sincere apology to my non-medical friends who probably really don’t want to hear me whine about stuff like this. But, hey, you can always go back to yesterday and look at the zebras again… ;-)

Oh, and just for giggles. There's a snack product here called "the Big Stix", essentially Kenya's answer to Chee-tos. But the subtitle is the best. "Knobbly stiks of corn"...

Follow the fold...

Another relaxing Sunday spent in the summer winds of Kisumu, though it started earlier than I had hoped as I inexplicable awoke before sunrise! While on the phone the night previous (or yesternight, as it is referred to here), I had run out of Safaricom shillings and needed to go into town to buy more, since I was expecting Beldina to call when she was downstairs to pick me up for church (I mentioned this yesterday…have you been reading?) Thinking I would be oh-so-coordinated, I got completely ready for church and headed into town, hoping to buy airtime and get a decent cup of coffee at the Kenshop Internet Café – it’s also an inexpensive internet option if I’m just checking facebook or email, too cumbersome for photos or posting though. Alas, not much is open early on a Sunday morning in Kisumu, a lesson I apparently didn’t learn well enough last week. I returned to the guest house to partake of the breakfast they offered there. Confusion reigned supreme when I decided I needed some milk. I tried to order the special with coffee and milk. “So, I bring you white tea?” Thanks, but try again, I was trying to get a cup of coffee and a cup of milk. “So, I bring you white coffee?” Again, no, and I had to use to gestures to indicate two separate drinking vessels, one with coffee, one with milk. And before you ask, this wasn’t a language thing. She spoke perfect English. It was more a cultural thing, but how large a cultural thing I didn’t realize until she brought me hot water, instant coffee and a cup of warm milk. The instant coffee I was expecting, hence the reference to the decent cup of coffee at the Kenshop. What I failed to remember is that no one drinks cold milk here. Aaarrgh. Beldina was as frustrated as I was when I told her the story ;)


With my stomach full of increasingly milky coffee, I headed to church. Wow, what a difference a week makes. Beldina now attends the Christ Church of Kisumu, and other than a belief in Jesus Christ, the two churches couldn’t be more dissimilar. We walked in during the music section, which I later found out is called the Worship. Very Sandi Patti-esque. [I was trying to think of some other singers of 70s-80s contemporary Christian music and realized I couldn’t]. The pastor of the church is an American who brought his family to Kisumu in 1995; some of the children have returned for college, but his oldest daughter leads the Worship and has a fairly riff-y gospel voice for such a white girl ;-).

Of course, they make visitors stand and be recognized, you must know how I loved that. The offering is done very publicly – no pass-the-basket for these folks – the baskets are at the front of the church and everyone has to leave their seat to contribute, and don’t pretend people aren’t watching. Today’s sermon (not sure if that’s the right phrase) was about building strong relationships with God and with each other. A simple enough concept, but a theme that got drummed to death for about an hour and a half. It gave me time to sit and reflect on faith and spirituality and my grasp on the concepts. Fairly soul-searching stuff, and not entirely appropriate for this blog, but I did spend some time jotting in my personal journal. Oh, which reminds me, people were taking notes during the sermon! At the conclusion of church, Beldina introduced me to everyone we ran into. One of her church members is head nurse at Kisumu District Hospital, and plans were started for me to observe some operations there, perhaps this week.

We went to lunch, where we lamented that no one in Kisumu has figured out what a hamburger really is. Then, she dropped me off at Impala Park Sanctuary. Only a brief description, and then some photos. Probably more to be posted on Facebook later. First, the reason I wanted to go to the park: during my boat ride two weeks ago we saw a clearing through to the shore, and there were people strolling about with impala grazing around them. The guide books had warned that it was not such a fantastic “zoo” with animals in small cages, etc. But, given the free roaming impala, I was willing to give it a chance. [By the way, Beldina confirmed that it has only been recently that they have enlarged the animal enclosures, and that it was truly sad as recently as last year. Haunting memories of the Anchorage Zoo, circa 2001]

Immediately upon entering the park, the impala are everywhere, and generally not too skittish when it comes to the people in the park. You can get as close as about four feet before they scamper off. They also have some monkeys that have free reign of the park. I saw one little family group playing around me while I was sitting by the shore reading and resting my aching feet (sandals + walking rocky trails = not a good time).

The animals in the enclosures seem well-tended, enough so that I wasn’t hit with overwhelming remorse at having patronized the place. They have African buffalo, jackals, cheetahs, lions, hyenas, baboons, and some kind of antelope I haven’t identified. The park could use a little work on its signage.

After doing my best to angle all my shots so that the animals didn’t seem caged, I decided to follow the trail along the shore. Now, while I did know that the park was under 1 sq km, I neglected to work out that since it was only about 1/2 km in width, that would make it almost 4 km in length… I persevered, and it was worth it, as I found little hidden gems of landscapes that I really enjoyed.

Then, I encountered probably my biggest “wow” moment of the trip so far. Walking back toward the entrance, my head was down texting Beldina to come pick me up when I heard a scuffle, not unlike a small group of horses, in front of me. I raised my head and dropped my phone, eyes wide open as I groped for my camera. They had free-ranging zebra in the park! A small group of five. I followed them for a bit, and then as suddenly as they entered the main path, they left it again. P.S. I had to go back to get my phone. ;)

I leave you with a not-quite sunset picture, but I liked the framing of the sun. Nothing like a long trip to acquaint you with all the features of your camera…

And the wind starts to blow...

Too bad Toto wasn’t with me today, I didn’t have a chance to pass the rains in Africa, they were all around me! Luckily, the last few annoyingly stubborn wet socks had finally dried just as the first drops were falling.


Are you still there? Didn’t drop dead of shock? Yes, I did laundry today. Kenyan style. Though it has taken the better part of a week for me to prepare myself for the ordeal, I did do some pre-planning and bought the requisite plastic bucket and washing powder earlier in the week, knowing that I wanted to start before the Ukwala was open. What I didn’t examine carefully enough was the instructions on the packet of powder, which were in Swahili. Thankfully, following the pictograms, I was able to discern that I should let the clothes soak for an hour before hand scrubbing. What a great opportunity to work on my ever-browning skin! Now, I had watched many Kenyan women wash clothes – the relatives of the patients in the hospital that did laundry in the courtyard, the young women in the village, and the women at the guest house. Never did I anticipate how badly my lower back (which is far older than my chronological age, thank you, Walt Disney Entertainment!) would handle the bending over and scrubbing. But, what are ibuprofen and Tusker for, after all? ;)

A Kisumu washer/dryer combo...

Of course, because I couldn’t estimate the size of the bucket I would need, I ended up having to do two loads. More time up on the roof, reading in the sun. While I was up there, one of the young men of the guest house was washing the towels and sheets. Smart people that they are, they have a built in cement block sink, and they literally stomp around wine-press style to get all the sheets and things submerged in the soapy water! The wind really picked up, which meant a quicker drying time, but it also meant that after an hour of getting up and down to put things back on the line, I ran to the store to get pegs (clothes pins). Of course, I was in a tank top and shorts, so that necessitated changing into a T-shirt and pants. (No shoulders or knees showing, please). However, at the end of it all, I now have enough clothes to last the rest of the trip.

Beldina had agreed earlier in the week to take me out into the country today to get a picture at the Equator. So, of course, it turned out to be on the day of the only rain storm since I’ve been here. She picked me up when it was still “little bitty stinging rain”, and we made it out to the marker before the heavens opened up with “big ol' fat rain” [Forrest Gump, anyone?] The marker was placed by the Lions Club of Kisumu, probably when they got tired of all the tourists asking where it was.

If you look to the left behind me, there's a village kid wondering why the crazy Mzungu is getting her picture taken, and the Atlas pose was Beldina's idea ;-)

The area we went through was beautiful, something about the terrain, it’s very rocky and green, all at the same time. Beldina says there is a large stone area similar to Stonehenge nearby, but we didn’t have time to see it. All I have to say about the trip back is that Kenyan roads – frightening to begin with – are much scarier in blinding rain.

Scary clouds...

We stopped at the local “mall”, Mega City, the scene of a very recent true story of lost backpacks and check fraud that Beldina was telling me about. Was hopeful that this larger store would have a better selection of Kenyan wine, which was somewhat true. I shall continue my faithful tasting of Kenyan products, boxed or not…

After visiting Beldina’s childhood church last Sunday, she has invited me to attend her current church in Kisumu tomorrow morning. And then I’ll just have to see what the day brings… and write about it for all of you ;-)

Tutaonana!

Pretending he's beside me

It was yet another day in the hospital, operating like a mad woman. When I got to theatre in the morning, there were 18 cases scheduled! Luckily for my Friday evening (and perhaps not so lucky for the patients), the interns had failed to prepare a number of them for theatre. Labs hadn’t been done, blood hadn’t been prepared, and so a reasonable amount of them ending up getting cancelled. In the overall scheme of things, not the preferred choice, but at least I am home at 8pm and not still at the hospital. ;-)

Me and Dr. Raburu, head of surgery at New Nyanza PGH

Learned first-hand of some more differences between Kenyan healthcare and American healthcare:

If you think there is a blood shortage in the United States (and there is, that’s why there are so many pleas for blood drives!), you can’t even begin to imagine the blood shortage here. For elective cases, the patients undergo preparation for auto transfusion. They will be bled once a week for three weeks (banked whole blood is only good that long), and if the operation is delayed, they are transfused one of the expiring units and then bled again the next day! Two cases today got cancelled because the interns hadn’t bled the patient pre-operatively.

Ok, ladies. Let’s spend a minute or so to discuss breast cancer. We all have the pink logos everywhere, we all do our self breast-exams (we do, don’t we?), we give to Susan G. Komen or the AVON walk or whatever charity is out there, because it’s breast cancer. It hits close to home. 1 in every 7 American women will have breast cancer at some point in their lives. The good news is that between early screenings, early excision and improved chemotherapy regimens, it’s not always a death sentence.

I was prepared for the fact that there is no early screening. Mammograms are expensive, and women are much more worried about feeding their children. I knew that cancer here tended to present at much later stages because of this. Today, I did a mastectomy on one such woman. She had a large mass that had broken through the skin and obviously hard lymph nodes in her armpit (T4N3Mx, for those medical among you). We did a palliative mastectomy and selective lymph node excision. Why? There is no chemotherapy in Kisumu, no occupational therapy to help reduced chances of arm swelling after a complete lymph node dissection, no radiation therapy. These were all facts I was willing and able to understand knowing what I do about the area.

What I wasn’t prepared for, despite thinking that I was a culturally sensitive doctor, was listening to the senior surgeon tell me why these women don’t see the inside of a theatre until this point. The first is understandable. There are superstitions and traditions that many of the Kenyan tribes have about the female breast. The removal of such is traumatic and spiritually offensive. Even if a woman is seen with a small palpable mass and excision is recommended, she will likely disappear until it grows through the skin and then she will come to the surgeon “because she is smelly”. Even that, knowing that it is the patient herself that is making those decisions, within her cultural context, is acceptable to me. Painful, but acceptable.

Less acceptable is the fact that sometimes these women will be diagnosed and the husband and/or father will not allow the woman to undergo the recommended treatment, even if her life is on the line. The senior surgeon today told me of at least one case where the woman came with a small “curable” lesion two years ago and is now dying. If he has at least one story like that to share, imagine how many are out there. That situation, despite it being within the male/female cultural context, is not acceptable to me.

::steps down off soap box::

On a different note, I learned that there is an immeasurable difference between watching/assisting on a case dozens of times and being alone in the room to do it on your own with an intern that has no clue what you’re doing or anything about the patient (because he hasn’t read the chart AT ALL). We get a fair amount of surgical autonomy at Columbia, but there’s always someone in the room that can help, and the resident assisting you has some knowledge of the procedure at hand.

Maybe you’re thinking… but, Steph, you’ve been telling us about all these solo procedures. And the answer is, yes, I have. But those have been things I am confident that I can perform. This? This was a colostomy in a 3 week old baby girl. Conjuring up all the confidence I could, I just thought, “What would Abbey do?” ;-)

This weekend will be some non-medical things, so hopefully some cool pictures and thoughts to write about. A break from all this daktari stuff…

Two weeks of operating completed! Only 6 theatre days left! A short operating week next week as Friday was declared a National holiday for the president and ministers take new oaths of office under the referendum that was passed the day I arrive. Then only a partial week before I head to Nairobi, London and ultimately NYC!

Going by too fast…

My arm is complete again!

Today was completely a medical day. No fun trips out and about. No time to sit and reminisce about the myriad of things that I’ve seen here. Ok, that’s not exactly true. I did have some time in between cases, but I’m reading a Thomas Hardy novel that I hadn’t heard of before, and the sentences captivate me. In sheer length alone! But conjuring up deep thoughts and trying to sort out the meaning of it all is not a task to be cobbled together with spare minutes. That’s a full day’s reflection. Perhaps I shall have to reflect by the shores of Kiboko Bay this weekend… ;-)

When I first arrived in theatre today, the intern began telling me about a blunt trauma case. A young man knocked down by a motorcycle trying to cross the street. He was haemodynamically stable and his exam was notable for some left-sided abdominal tenderness. The first thought that flitted through my mind, typical American that I am, get a CT scan and we can probably watch him in the ICU. Silly me, forgetting where I am.

Instead, we took him to theatre. Where, I, with a grand total of 2 splenectomies under my belt, took out his spleen. (Yay! Three!) And it was a simple laceration, Grade II at the most. He could have kept his spleen and not gotten a huge midline incision were conditions a little (a lot) different here.

In theatre, I was a little disappointed. The intern that is on call this week (and hence has theatre privileges for any emergencies) is one of the interns that stands out in her class. She knows her patients and performs well on rounds. I’m not sure if that makes her really good, or if she looks good by comparison. I know I’m expecting a lot of an intern, but she does not have great hands or eyes or common sense. I did two cases with her today (more on the other later), and despite gentle instruction, there was no improvement or even a morsel of understanding as to what I needed her to do to assist me!

On to emergency case #2, a woman transferred in from a district hospital with multiple pathologic fractures(pathologic = due to a disease process, not necessarily trauma) and a large bowel obstruction. Because of the report of the abdominal x-ray, concern was raised for over distension and perforation. First, I’m trying to teach the interns (not just me, but the surgeons here) to re-examine and re-evaluate the patients that come from the lower levels of the health system here. The way the national system works makes it unclear if a physician has actually seen the patient as many sub-district centers are staffed by clinical officers, whose training is variable and difficult to define. Secondly, the abdominal xray was clearly showing dilated small bowel, not large, and risk of rupture is much, much less (if not completely infinitesimal). She was comfortable with a tube decompressing her stomach and after an enema with some results (if you know what I mean). Back in the good ol’ US of A, we’d have gotten a CT scan, which would have shown what it took a foot-long incision to show me: a non-obstructed dilated small bowel, likely just an ileus (a discoordination of the bowels, usually because of pain medicine).

When I left theatre after that case, I was told there was another. A three year-old girl that had been struck by a motorcycle trying to cross the road. The staff told me that it would be about an hour, so I changed back into civilian clothes and went to the hospital canteen to get outside for a moment or two.

Upon my return, all seems ready to go. The child is on the table and the anaesthetist is ready to put her to sleep. I ask the nurses to inform the surgeon that we’re starting. Despite the fact that he let me do the other two on my own, I wasn’t really comfortable with doing a pediatric case on my own, particularly a splenectomy, which is what I was anticipating.

Wonder of wonders, he didn’t know about the child. The intern that booked the case never told anyone, just stuck a sheet of paper on the theatre board. AND, felt that he had covered his tracks by documenting in his note. “Prepare for theatre, unable to reach consulting surgeon by phone.” The surgeon (who happens to be head of the department of surgery) was running the monthly department meeting and so sent his colleague in to do the case. After the conversation I had with that surgeon, I am very happy that I am not the intern that booked that case. He might need his spleen taken out soon!

This case turned out to be less disappointing than the others, because while the others could have been managed non-operatively, this child had a complete fracture of the spleen and it needed to be removed.

It may seem to you (if you’re medically inclined at all, or even just curious) that there is a lot of spleen injury in Kenya. What I learned today is that the various infectious diseases that are endemic here, particularly malaria, cause enlargement of the spleen. Additionally, there can be fibrosis and adhesions that would be unexpected in a Western population. It becomes a bigger and more tethered target and gets injured even with low energy impact. And that, ladies and gents, is your East African fact o’ the day.

My last four cases have been exploratory laparotomies, watch tomorrow end up being a whole lot of ortho just to balance it all out!

G’night all!

Sooper Trouper...

When heading up to the terrace to resume my daily habit of watching the sunset, I encountered a trio of friends staying here at the Sooper Guest House. Given my usual introvert self, I did not seek out, but did ultimately join them when asked.

Turns out that they are three music teachers from the UK, here on extended jobs teaching at schools in Nairobi. They are here in West Kenya doing a mini tour as their choirs just performed at the National Music Festival in Kakamega.

James has been here the longest, going on five years, and runs the music department at a national school about an hour outside Nairobi. Rob finishes his two year stint at the end of this calendar year, and Georgina is only about eight months into hers.

All in all, a pleasant evening, and it was strange to hear Kiswahili spoken with a British accent, as James did at dinner. Personally, it was great just to listen to them talk about music. Though, I will say, Rob is pretty knowledgeable about Kenyan politics and history and we talked a lot about tribal conflict and the government corruption. It’s much safer talking politics about someone else’s country ;-)

Did another solo case today. During Major Ward Rounds, the head nurse took me to see a new arrival from casualty. The guy had classic story for obstruction, but no hernias, and his abdomen really wasn’t all that distended. I presented him to the consultant on call for the day, and he let me take the patient to theatre. It was an obstruction, from a weird congenital band. Hopefully, all will end well. Particularly, since I found out that they are documenting my presence on rounds…

Don't you just love the boots and apron?

Heard another “yell at the interns” session today. Though, I would have yelled at them, too. There was a patient admitted on the 13th that no one had seen since then. Granted Ward 2 has 67 patients (3 interns) and Ward 1 is just as bad.

Tomorrow I have the option to assist with some Gyn cases or just hang around waiting for emergencies. Depends on whether my book is any good or not ;-)

Toodles!