Category: medicine

this week i have been in the outpatient and casualty departments in the kijabe hospital, shadowing a really cool american doctor who speaks fluent somali, arabic, and about seven other languages. and when he’s not there, shadowing a family practice resident who is in the u.s. airforce. and when he’s not there a very goofy clinical officer (kenyan equivalent of a physician’s assistant) who wants to emigrate to canada. i think that this emergency department-style medicine is my favorite kind, because there is lots of interaction with patients (and their families), there’s lots of variety, and you never know what’s going to happen next.

the other day a lady came in who we finally found out had aids even though she told us she didn’t tell us at first. (it directly related to the nature and urgency of her problem). but her husband didn’t know she was positive, and she refused to tell him (in the west someone could be and has been charged with attempted murder for such stubbornness). anyway, she finally agreed that the only way she would accept treatment (and if she didn’t get treatment she would probably die the next day because she had meningitis) was if the doctor called her husband in and “nonchalantly suggested” that they both be tested for hiv, so that the truth could come out without the husband knowing the wife had previously known about her status. well, when the husband was told this it did not go over well – he gritted his teeth and got a look on his face that suggested he was going to strangle his wife the minute they left the office, if not the doctor before that. it was kinda intense. speaking of aids, there was this woman who came in who was negative but has a positive husband who she really wants to have a child with. she wanted to know the best days of her cycle for conception. what should the doctor say to that? in other news, there was a radiologist here from montana that i got to hang out with a bit. he ultrasounded me for about two hours one day, demonstrating to the ultrasound techs how to find every organ possible. turns out i have a large spleen.

i also got to go back to joytown, the home for disabled kids. this time dr. bransford was giving a tour to a group that is going on a medical missions trip to sudan. that is the main reason he goes there, but whenever we are there he sits down with the therapists for a couple hours and brings in child after child to try to figure out what is wrong with them. there are only a couple therapists there, taking care of 300 kids who in the west would probably have one-on-one care. unfortunately one of the byproducts of this relative lack of care is that a lot of the kids with paralysis die needlessly from kidney failure because their bladders aren’t being managed properly. these kids (some as young as five) are being taught to catheterize themselves on a regular basis. imagine trying to learn to catheterize yourself at age five. i’ve also been making some cushions out of old foam mattresses, plastic shopping bags and tape to put on the hard schoolroom chairs so these kids don’t get sores that get infected and then kill them. perhaps the craziest thing about the whole setup is that its a pediatric neurosurgeon who goes there every now and then to give tours that has to notice something obvious like that before anything gets done.

last week was a busy one. i spent most of it in the operating room. dr. bransford operated late into the night a couple times, and all day saturday too. there are just so many kids coming in with spina bifida and hydrocephalus. i got to “scrub in,” which means i put on the sterile gown and gloves and passed instruments, suctioned oozing blood, etc. i also watched a couple other neat surgeries, like the resection of a huge (like one foot long huge) testicular tumor. one night i stayed up almost until the sun came up watching about the most epic surgery ever. this somali guy had come in with a tumor about the size of a football in the middle of his head and neck. so the kenyan plastic surgeon here decided to take ‘er out. he had to peel back the guy’s entire face, and dissect everything below it down around the carotid artery (it was suspended in mid air) all the way to the spinal bones in the back of the guy’s neck. it basically took all day and all night. that was definitely one of those “wow” moments – to see basically everything between the neck and brain completely gone, and then put back together again. the surgeon kept sending me up to the reference room to find out what artery he was likely come upon next! there was also an ear nose and throat team here repairing cleft lips, so i got to watch them do those surgeries for a day, which was really interesting too.

one day i went to a home for disabled children in a place called thika with dr. bransford and a group of visiting american southern ladies. it is called joytown, and it was alot of fun. i argued with some of the ladies about politics (they started it). joytown is run by an ngo that dr. bransford started. there are hundreds of children there who have all kinds of severe physical and cognitive developmental problems; it is quite the place. actually a lot of the kids with problems resulting from hydrocephalus and spina bifida here at the hospital end up there after they are discharged, so it was interesting to see the track that life takes for many of them. to be honest, normally i’m not all that inclined to spend time with developmentally delayed kids, but i had about the most fun i’ve had in a long time with them there. i sat down in a wheelchair and started wheeling around with them, and then a bunch of them decided to push me around the entire place in my wheelchair, and next thing i knew an hour had gone by!

dr. and mrs. bransford have been gone to the usa to receive an award from the ama (american medical association) entitled “excellence in international medicine.” yes, that is an impressive award. only one physician receives this award each year. if anyone deserves it, it would be dr. bransford. another doctor and his wife moved in to the house to keep the two junior bransfords and myself company. they like very much to cook elaborate meals, which is fantastic. the man is an ob/gyn, and i have been shadowing him all week at the hospital – i’ve been learning a lot. gynecology involves a lot of clinic time inspecting a lot of… you guessed it. also a lot of counseling women on how to get pregnant. also, we have spent a lot of time in the operating room – laparoscopies, tumor and fibroid removals, hysterectomies, and an ectopic pregnancy removal (read blood, blood and more blood. the fetus implanted itself in the fallopian tube and the placenta vigorously attached itself to every organ within reach). also things like the results of female genital mutilation and spontaneous abortions that are happening right then and there. it gets pretty intense sometimes. it can be really rough being a woman in kenya. for example, there is a girl here who was forced into marriage when she was 14. she immediately got pregnant, but when she gave birth the baby died and she got a fistula (urine and stool were coming out the wrong hole). thus her husband abandoned her. so she went to live with her brother, who decided that she wasn’t worth feeding, so she became extremely malnourished. to top it all off, when she came in to have her issue repaired (which it turns out was far easier said than done) it was found that her husband had given her hiv. she’s not even 18 yet. very sad.

the other day i got to watch a baby get delivered for the first time! it was extremely exhilarating, and i was just watching! that first baby had a huge head and left a trail of destruction on its way out that required many stitches to repair. by now i’ve had the chance to see more deliveries – in fact in one single one hour stretch there were no less than five! in other news, i got really sick but thankfully recovered in about a day, took a matatu into nairobi and got lost for most of the day (but it was the good kind of lost), and got the most terrible back pain i have ever had from twisting it playing basketball as well as bouncing around in the matatu. the trip back from nairobi was so crowded that this elderly man who had clearly been smoking far too much pot in the recent past had to legit sit on my lap the whole trip home. i think he enjoyed his “trip” a little more than i did mine. not to complain though – the babies definitely made this week one of the best yet!

last week i did rounds with dr. bransford. (the doctor [aka superman] i am staying with) in the early mornings, which I have been doing every week, and then rounds with peter and the pediatrics team, and worked on my research. we also learned a lot about diabetes in africa. the director of a major international diabetes organization came and gave a lecture on that topic. it is becoming a lot more common because more and more people are switching to a western style diet. there is also an obesity epidemic looming in africa, because for many it is culturally desirable to be large (it implies your husband is capable of providing). in this culture it is also considered completely strange to be seen exercising, a fact that i am constantly reminded of by the quizzical stares everyone gives me when i go on my daily run. interestingly, africans are actually more prone to obesity and diabetes than are caucasians when all other factors are constant. the diabetes expert suggested this was because caucasians were the first in history to begin consuming lactose/dairy products, allowing them to consume more calories. this allowed for a gradual selection of genes that made them less calorie efficient. interestingly there is a third form of diabetes in the developing world which has been (creatively) named type III diabetes. it is caused by malnourishment. in other health news, they found some e-coli in the kijabe water source. someone came rushing into the house to tell us not to drink the water – immediately after i had just chugged about a liter of it after a long run. we all felt a little sick for a few days.

other highlights have included a visit from my cousin who i shall not name, who lives in a country which i shall not name, lest government officials from said country google “name of said country” “and” “jesus,” find that both exist in this blog, and hunt my cousin down. i wouldn’t want that. i also had a harvard and oxford educated doctor roommate one night in the bransford’s loft where i sleep. i hoped some of his intelligence would emanate in my direction as we slept, but the fact that i am writing this sentence right now probably proves that it didn’t. the hospital has also been hosting weekly seminars on islam, and it has been very interesting to compare the african-christian perspectives on islam with the arab-muslim and other perspectives i got in the middle east when i was studying there. this week peter and isaac left. they were the medical students that i spent basically every waking hour of the the last month with – in casualty, pediatrics, various trips to maasailand and nairobi, and playing copious amounts of settlers of catan and basketball with. i’m going to miss you guys.

i thought i’d write a little bit about the research I’m doing, as some of you might be interested. only read if you are. we are looking at the incidence of post-operative infection in children who have had a shunt inserted for the treatment of hydrocephalus. hydrocephalus is caused by a blockage of the normal circulation of the cerebrospinal fluid (csf; the clear fluid that bathes your brain and spinal cord) – it causes increased pressure on the brain which must be relieved. a hole is drilled in the skull, and another one made into the peritoneum (the abdominal cavity in which all your organs reside). a tube is then shoved under the skin, with the help of a blunt metal stick, from hole to hole. one end of the tube ends up in a ventricle of the brain, while the other end drains the excess csf into the peritoneum, where it is resorbed by the body. this is called a ventriculoperitoneal shunt (vps). a doctor who was here before me compiled a bunch of information into a spreadsheet, so we thought it would be rather easy to just figure out how many of the patients had developed shunt infections after their surgery. we decided to define shunt infections as csf infections exclusively, because other infections such as wound infections can be caused by a number of factors other than surgery. we also decided not to include patients who have had spina bifida as well, because these patients all would have had another surgery to close the meningocele (neural sack) on their back, which greatly exposes the csf, leading to much greater chance of infection. normally there wouldn’t be very many cases of spina bifida in relation to hydrocephalus, but because kijabe is a pediatric neural referral center, about half of the hydrocephalus cases here also have had spina bifida. most kids with spina bifida end up getting hydrocephalus – this could be because they have were born with (congenital) central nervous system issues, or because their csf is exposed to infection (because of the defect on their back), which can cause hydrocephalus.

the data includes about 300 cases. what we didn’t realize until after i had written up the paper and everything was that about half of the patients had insufficient follow-up, which we decided should be at least nine months after their surgery. you can’t really say that you have an infection rate of x% if you don’t even have any information for half of the patients. any critic would just say that it is possible that all the patients that were unaccounted for had shunt infections. and this is probably more likely to be the case in africa than in the west. in the west someone would take their child to the hospital if they got sick after an operation. but because many of the children here live sometimes days journeys from the hospital and often have no means of transportation or financial resources, combined with the fact that there are large families living at home who would have to be neglected if the parents had to make the long trip to the hospital, if the child gets an infection they often sadly die and the hospital never finds out. of course, probably most of the patients who don’t come back for follow-up are doing fine, but we have no way of definitively knowing that. there can also be a stigma associated with hydrocephalus here that causes parents to neglect these kids – there are even stories of communities burying alive children with hydrocephalus during times of drought to try to appease their animist gods.

so i had to go about trying to gather more information on these patients. i searched a nascent electronic database that the hospital has, and found some extra information. then i had to pull the charts from the medical records room for those cases who still had insufficient follow-up and look through those for more information that may have been missed. then, i made up a little questionnaire form with some questions about the patient and their phone number, if i could find it, and had nurses call the family to see if the child is still alive and if they have ever gotten a shunt infection. everything seems to be a logistical challenge in africa though. for some reason that i do not understand many of the kids don’t share their parent’s last name. a lot of the patient’s records didn’t have phone numbers. many of the ones that did didn’t work, because most people in kenya just use cell phones, and there is a lot of number turnover. also, there was post-election violence here a few years ago and many people were displaced from their homes so are not able to be contacted because they still live in internally displaced people (idp) camps or have resettled somewhere else. additionally, many of the people who come to the kijabe hospital are somali refugees and don’t speak kiswahili, or have moved back to somalia where they can’t be reached. many of the kenyans are from remote areas and belong to tribes that don’t speak kiswahili. i probably would have called it quits there, but dr. bransford wanted to find more of the patients. the more we find the more viable the results will be. so, we split up all the files of the ones we couldn’t get ahold of into tribes and towns throughout the country, and are trying to get a loose coalition of chaplains throughout the country who are associated with the hospital to go out into their communities and find these people. hopefully this works, although you can probably imagine the difficulties inherent in trying to get someone to get someone else to conscript some other people to go find some other people and ask them some questions… in africa. we’ll see how it goes.

edit: sadly i never did end up publishing this data, but the data showed a rate of infection comparable with some studies in the west, which is pretty good for a hospital in sub-saharan africa!

yesterday was an exhilarating day. i went with some doctors and medical students to a rural clinic about an hour away on very bumpy roads. many of the patients didn’t even speak kiswahili, so their concerns had to be translated into that and then into english. luckily there weren’t too many patients to see and we had all day, so there was no rush. it was great because we talked out every case in depth. the clinic was a little dispensary out in the middle of nowhere, and they only had a few drugs there, so that was all that could be prescribed. most people wouldn’t have the means to travel anywhere else for healthcare. so invariably what ends up happening is that the few types of medicine there are just end up getting prescribed for almost everything, mostly just to treat the symptoms rather than the cause of the problem; this is called “jungle medicine” and unfortunately its the best that many africans have access. they served us lunch there too which was delicious. then my two med student friends from chicago and i went over to a school that was there and dozens of little kids immediately vacated their classrooms (who knew where the teachers were), and crowded around us cheering and obviously about as excited as kids can get, presumably because we were not locals and and wearing white doctor coats. so we hung out there for a while.

that night one of the med students was to man the e.r. all night, so i stayed up with him. exhilarating. it was quite busy and all kinds of stuff happened. i learned how to take a complete history and i handled one young man who came into the e.r. from start to end! (it wasn’t too serious). we also got called to confirm a death on the ward. then later we actually watched a lady die 🙁 lots of interesting people seem to arrive in the middle of the night, like a masai woman with the huge necklaces, ear loop thingies and uncovered breasts who casually sauntered in with a baby with a huge growth on its head after walking for who knows how long to get here. and a case of hemorrhoids that was legitimately bad enough to warrant a visit to the emergency room in the middle of the night. i think i’m going to spend more time in the e.r.!

other than that there have been a slew of surgeries relating to an appendage unique to males that i have been watching during the day, some of them a whole lot more invasive than one might ever want to imagine. on saturday i went into nairobi with dr. bransford’s son and some of his friends and ate some delectable njera b’wat (if you don’t know what i’m talking about you should find your local ethiopian restaurant and patronize it asap!). also, i am doing some research for the doctor regarding infection rates after hydrocephalus shunt insertions. the whole research dealio is a bit tedious to say the least, but hopefully if successful it will stoke my medical school applications a little bit. more importantly, it may also help the organization that provides the surgeries to convince the governments of neighboring countries that they should allow them access because their post-operative infection rates are so low, as currently there are a lot of kids suffering more than they need to in some east african countries because they aren’t getting the operations they need.

i’m in kenya now, and have been kept very busy at the kijabe hospital! i’m staying with a pediatric neurosurgeon who is a old friend of my mom, and it has been great! i’ll be here for the next three months, learning as much as i can about medicine. every day we head down to the hospital at 6:30 am, and do the rounds of the patients he will be operating on that day (often about ten patients – he’s an extremely busy man!). most of the kids have spina bifida, hydrocephalus or both. spina bifida is when the neural tube fails to properly close during fetal development, allowing the spinal cord to grow abnormally and often outside of the body, often resulting in some or a lot of paralysis. and hydrocephalus is when the cerebrospinal fluid that lubricates the brain and spinal cord is blocked from circulating properly, putting a lot of pressure on the brain, which causes problems. and because baby’s cranial bones are so soft, this pressure causes their entire skull to expand, often to extreme extremes, especially if they aren’t brought for help soon enough. very sad. so, the doctor i am with does surgeries to deal with these problems, although when the presentation is late, often damage control is the best outcome that can be hoped for. i have been in the operating room watching a lot of these and helping out when i can. also, thankfully the hospital is rather relaxed in terms of letting me get involved where i can, so i have watched some other surgeries and with cleaning some gnarly wounds, abscesses and burns, etc. their are about a trillion acronyms or more in the medical world, so it has obviously been a huge learning curve sometimes even following what is going on for me as a mere undergrad. but it is very gratifying when one of the acronyms, disorders, procedures or drugs that i have managed to remember is used in conversation. i’m really looking forward to learning more and eventually becoming a doctor who knows what he is doing.

the hospital is a training hospital – both for kenyan medical students and a few fourth year american medical students who are doing an international rotation. so i have spent considerable time with them as well, lately on the pediatric (kids) team. they do rounds of their ward every morning with an attending doctor, looking at each of their patients and talking out the latest information on the status of the kids and treatment plans, and they have been kind enough to let me join them. it is nice because even though they are obviously a lot further along than i am they are still learning. they also share some interesting info (they are all really nice people). for example, i just learned that rickets (soft bones in kids) never used to be a problem in kenya, though now it is. it has finally been discovered that the cause of this is that the government has been promoting a type of mixed grain flour that actually reacts with breastmilk in such a way that kids don’t get enough calcium, which can cause rickets. in this context the moral of the story is to make sure to tell the mothers with kids with stunted development who come into this maternal care clinic which is onsite (another place i have been hanging out with some of the interns) that they should avoid this type of flour even though the government tells them it is the healthiest (it actually is once the kid is done breastfeeding). fascinating. all the kenyans (at the hospital) speak english, although sometimes their accents are so foreign to me that i think they are speaking swahili, which is always a little embarrassing if they happened to be talking to me. just takes some getting used to. there is also a free kenyan lunch four days a week for the interns that i have been going to, followed by a technical lecture on a medical issue of note. needless to say my brain hurts a little from all the stimulus, as well as my feet from being on them all day basically without ever sitting down. but i’m getting used to it, and enjoying it thoroughly. honestly its like i’ve landed on a totally different planet, and have to learn a new language and way of doing things. but such is the beauty of life!