Saturday, August 4, 2007

Up Country

August 3, 2007

Yesterday I left Mike to run the service and left on a four-wheel-drive hospital ambulance to cover the weekly trip to a community “dispensary” two of the 5 that Kijabe staff visits on a monthly basis to act as the consult for the nurse or pharmacist that runs the medical clinic.

The medicine was interesting, but the non medical aspects of the journey will probably last in my memory longer. Our driver’s name was Paul. He has been driving this vehicle for the past 10 + years and he was nervous. The past few days it has been raining which means the beautiful rolling hills of red clay covered with brilliant green tea plants of the Kikuyu land turn into slops so slick I mentioned the concept of chains for the tires during one of several stops to push the truck out of the hill. Even though running is something I have unfortunately done none of here yet, I am glad that my body is “fit” as I gained significant respect from my male co-travelers as I pushed the truck in my skirt and wimpy dress shoes while the other “ladies” stayed inside. I had a well thought out plan: when the “consultant” came all the way and had no idea what was going on with the patient, “at least” they would say “she can help us get out of the mud.”

It was still a long time after we arrived at the dispensary before I got to try out my ability to be a consultant. First came the traditional Kenyan breakfast: chai, white bread with Blue Bonnet, and a hard-boiled egg which we shared in a room made of tin walls and a wooden plywood roof with indulgent relaxation and light conversation. From there we went to another room with concrete walls painted white and decorated with evangelistic HIV awareness posters and scripture verses. For the next 20 minutes we had a church service complete with Kikuu praise songs, a short sermon about how Christ came to heal the sick in conjunction with bringing his message of “good news” and how grateful they were that God had brought us (myself, a Kenyan intern, a medical student from Australia and two dental hygienists) to their village, followed by prayer. We were given a tour of the dispensary, the lab, the examination room, a description of the procedures of the dispensary, and all that they had to offer patients. It was only then that I asked quietly and as politely as possible “are there patients for us to see?”
“There are two here and the rest are coming.” Apparently the sight of the ambulance passing through the village is sign that we are available and the patients need time to trave. “The young always come first, the oldest and sickest may not make it today because of the rain.”
“Do you know where the oldest and sickest are? Can we go to them?” My question was somehow hilarious, received with prolonged laughing by the pastor, the driver and the pharmacist.

We saw our two patients, the dental hygienists did a tooth extraction and by 1 pm we were back in the truck to the second of two villages on the schedule for the day.
The second clinic was slightly larger. We were served a large meal, had chatty conversation and then saw our seven or eight patients who had been waiting for us. Again I was struck by disease progression here. We saw a 65 year old female with 3 years of bloody stools, occasionally black, with weight loss and mild abdominal pain. At first it struck me as unfortunate that guiac cards were unavailable and there was no ability to due a hct, but when I felt a 3 cm mass in her right lower abdomen, those tests seemed ridiculously unnecessary. Fortunately she could easily get a colonoscopy at Kijabe if she could find someone to take her there.

We saw an eleven year old for evaluation of murmur who had a history of recurrent pharyngitis, and arthralgias. We suspected rheumatic heart disease requiring her to have monthly penicillin injections for prophylaxis. As I pursued the differential diagnosis and looked up treatment regimen and prognosis for this case that felt quite unusual to me, the Kenyan intern was moving on to the next case… bread and butter for her. We saw physiologic jaundice and probable early HIV neuritis.

Our trip home was uneventful, peaceful, full of more reflection as I watched the rolling hills pass by, the children waving, and the sun come out from behind the clouds. We bounced along to the Kenyan praise music playing on the radio.

I will never have a day like this again.

When I came home, Bill and Liam were playing with the wooden train… besides the big red plastic bat and a fire engine, they are the only toys Liam has. I am not sure if this reality is more difficult for Bill or for Liam.

Bill and Liam have been helping in the OR storage room folding sterile packets and learning Swahili from the “vegetable ladies.” Bill has also been busy planning their upcoming Safari this weekend when I am on call. He has been an incredible support, had maintained a remarkable attitude and actually seemed interested in what I am doing in the hospital. Movie nights with Mike, Jordan, and Daniel have been good. Yesterday Mike implored us to watch one of his favorites about the characters from Star Trek being captured by aliens and taken into space on their ship… he and Daniel have seen it more than five times. Now I have seen it once… the first movie I have seen in about 6 months…humm…prioities?
And the next morning Mike was teaching me about intercranial bleeds, Glasgow Coma Scores, and craniotomies.

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