Saturday, June 30, 2012
Kisumu, Kenya
The seven of us are currently enjoying a relaxing weekend on Lake Victoria. The beauty of this place is indescribable, so here are a few measly photos to try and help you get the picture...
Friday, June 29, 2012
Wednesday, June 27, 2012
Tuesday, June 26, 2012
Waiting (for the baby) to Exhale
I stood there scrubbing my palms in a circular fashion, the bar soap gripped tightly in-between. Each stroke was cautiously undertaken, as I was unsure of my technique. The instructions taped on the wall informed me of my next move: first the palms, then the backside of the hand, then the fingers. Had it not been for these instructions on the wall, I surely would have attempted to emulate what I had seen on tv. Dr. Peter Benton from ER meets East Africa...or at least that's how it played out in my head.
My surgical career began that day with a few short words: "So, you'll assist me on the c/s?" Rajiv, a 2nd generation Kenyan with a surely-Indian background, had been my mentor for the past two days. He was the perfect go-between for myself and the brash, quizzing consultant. Rajiv thought quickly and his answers came with, quite seemingly, no effort at all. His willingness to indulge my curiosity was the reason I stayed near his side. I knew nothing about Obstetrics, and prior to this week, was terrified of Gynecology. Watching one vaginal delivery cured me of my fear, however. I wondered why it had been built up so in my mind.
With my arms bent and palms facing my chest, I backed out of the scrub room, and into the theater. The daunting task of donning sterile gloves with semi-dry hands ensued. I fumbled through the entire process, both times failing to realize that sterile gloves are handed. This was not the case for any other latex glove I had worn. Had it not been for Malia's guidance, I might never have made it to the table. Rajiv noticed I wasn't wearing my surgical cap (where did mine go to?), and quickly gestured to an assistant to fetch one. I made him explain the instructions to me twice, fearing that somehow this baby wouldn't come out in one piece if my forceps weren't arranged just so.
"The key to it is not freaking out," Rotich, the other intern, murmured into my ear. Easy for you to say.
Eye contact was made, a slight "So, we begin" from Rajiv, and we're off. Outer skin, muscles, fascia all stand no chance against the surgical steel. Despite their tenderness to the blade, each layer is carefully breached. Pools of blood form in the pockets made by the incision--I was warned that suction is not routinely used in c-sections in Kitale District Hospital--and my initial shock at the sight was quickly spurned: "Be more aggressive with the gauze, and help him blunt dissect," Rotich said over my shoulder. Hearing the words "blunt dissect" in an African accent was nothing new for me: Dr. Paul at school loved this technique. You should check out his book if you get a chance.
The procedure ticked on, until the uterus was reached and the last incision made. The c-section gained exigency when intrauterine fetal distress had been noted by the examining physician earlier in the maternity ward. This is all done by fetoscopes, not doptone like in the states. The baby was also lying transverse in the mother's belly, making the procedure much tougher than a routine c-section. Once the uterine wall was crossed, the pace of Rajiv's movements hastened: once cut, the uterus begins to contract, making extraction of the baby much more difficult as time progresses. He struggled to get a hold on the child's head. His frustration, and my anxiety mounted with every passing second. "Press downward on her uterus," he commanded." I did. "With all your weight. Don't hold back." The change in his tone alerted me that this had crossed over into a dangerous situation for both mother and child. There I stood, pressing my hand into and downward on her belly, all my weight on top of this woman. Still no grip, still no child. This continued for an eternity, so it seemed, until one final push from me and a secured grip from Rajiv brought the baby out into the chilled air of the operating room.
I had been informed that the clamping and cutting of the cord was my chief responsibility once the baby was out, and it was to be done closer to the mother than the baby, to allow for injection of resuscitating medication for reviving of the child. When the baby appeared, I saw why. The cord was wrapped around his neck twice. No time for freaking out, I thought. I clamped and cut quickly, then returned my attention back to the mother. She was bleeding quite excessively from the forceful tearing of her uterus and abdominal wall. Rajiv began suturing, I, blotting. This went on for nearly 4 minutes without any noise from the table across the room, where a team had assembled to revive the child. I periodically locked eyes with Malia, who sat peering over their shoulders trying to view the baby. Just as I began to think that this, my first surgical procedure, was going to end in fetal demise, the cry came.
"That is a good outcome for us," Rajiv said, noting my wayward gaze, "but we must focus on this woman, for she is our responsibility."
My surgical career began that day with a few short words: "So, you'll assist me on the c/s?" Rajiv, a 2nd generation Kenyan with a surely-Indian background, had been my mentor for the past two days. He was the perfect go-between for myself and the brash, quizzing consultant. Rajiv thought quickly and his answers came with, quite seemingly, no effort at all. His willingness to indulge my curiosity was the reason I stayed near his side. I knew nothing about Obstetrics, and prior to this week, was terrified of Gynecology. Watching one vaginal delivery cured me of my fear, however. I wondered why it had been built up so in my mind.
With my arms bent and palms facing my chest, I backed out of the scrub room, and into the theater. The daunting task of donning sterile gloves with semi-dry hands ensued. I fumbled through the entire process, both times failing to realize that sterile gloves are handed. This was not the case for any other latex glove I had worn. Had it not been for Malia's guidance, I might never have made it to the table. Rajiv noticed I wasn't wearing my surgical cap (where did mine go to?), and quickly gestured to an assistant to fetch one. I made him explain the instructions to me twice, fearing that somehow this baby wouldn't come out in one piece if my forceps weren't arranged just so.
"The key to it is not freaking out," Rotich, the other intern, murmured into my ear. Easy for you to say.
Eye contact was made, a slight "So, we begin" from Rajiv, and we're off. Outer skin, muscles, fascia all stand no chance against the surgical steel. Despite their tenderness to the blade, each layer is carefully breached. Pools of blood form in the pockets made by the incision--I was warned that suction is not routinely used in c-sections in Kitale District Hospital--and my initial shock at the sight was quickly spurned: "Be more aggressive with the gauze, and help him blunt dissect," Rotich said over my shoulder. Hearing the words "blunt dissect" in an African accent was nothing new for me: Dr. Paul at school loved this technique. You should check out his book if you get a chance.
The procedure ticked on, until the uterus was reached and the last incision made. The c-section gained exigency when intrauterine fetal distress had been noted by the examining physician earlier in the maternity ward. This is all done by fetoscopes, not doptone like in the states. The baby was also lying transverse in the mother's belly, making the procedure much tougher than a routine c-section. Once the uterine wall was crossed, the pace of Rajiv's movements hastened: once cut, the uterus begins to contract, making extraction of the baby much more difficult as time progresses. He struggled to get a hold on the child's head. His frustration, and my anxiety mounted with every passing second. "Press downward on her uterus," he commanded." I did. "With all your weight. Don't hold back." The change in his tone alerted me that this had crossed over into a dangerous situation for both mother and child. There I stood, pressing my hand into and downward on her belly, all my weight on top of this woman. Still no grip, still no child. This continued for an eternity, so it seemed, until one final push from me and a secured grip from Rajiv brought the baby out into the chilled air of the operating room.
I had been informed that the clamping and cutting of the cord was my chief responsibility once the baby was out, and it was to be done closer to the mother than the baby, to allow for injection of resuscitating medication for reviving of the child. When the baby appeared, I saw why. The cord was wrapped around his neck twice. No time for freaking out, I thought. I clamped and cut quickly, then returned my attention back to the mother. She was bleeding quite excessively from the forceful tearing of her uterus and abdominal wall. Rajiv began suturing, I, blotting. This went on for nearly 4 minutes without any noise from the table across the room, where a team had assembled to revive the child. I periodically locked eyes with Malia, who sat peering over their shoulders trying to view the baby. Just as I began to think that this, my first surgical procedure, was going to end in fetal demise, the cry came.
"That is a good outcome for us," Rajiv said, noting my wayward gaze, "but we must focus on this woman, for she is our responsibility."
Sunday, June 24, 2012
Improvisation
I spent my first week--an abbreviated, four-day week--working in the OB/GYN ward. The moment I walked into the room, my new lab coat still creased from the packaging, all eyes were on me. Patients were packed into a 20X30 concrete room, holding 10 beds, with 2 patients per bed. The day before, we had toured the private hospital adjacent to the area in which we will work for the duration of our stay here. It was noticeably absent of patients. That side costs extra we were told, explaining the paucity of inhabitants. There are plenty of sick people to fill the rooms, but healthcare is a business here as it is anywhere else.
Having little experience in hospitals of any kind, I felt quite awkward standing around with my hands in my pockets. I announced my presence to the day nurse in charge, and she promptly sat me in front of a mound of patient charts. "Read these," she said, and then returned to her work changing bed sheets, a chore that required a mass exodus of patients from the room until her task was complete. This happened every morning, I learned; the head nurse was the shepherd, the patients the sheep. By the time I had scanned through the charts, the menial task was complete.
The first thing you see is the sheer number of patients that occupy the room. After that initial shock subsides, you sink into a state of acute observance. Soon, the slight breeze coming through the windows causes the gentle swaying of the nets above each bed, and you take note of the women just outside drying laundry on the dew-crested side yard. Thermoses of tea and loaves of bread fill the cabinets beside the patient beds, and some have taken to their morning routine, eating and drinking. Perhaps it's my presence or that of pain and illness that stifles much of the idle chatter--everyone seems to be merely existing, surviving. No different than in any other hospital, I imagine.
A tall, verk dark-skinned physician ("daktari" in kiswahili) approached me: "I am Dr. Mawalwi, the chief medical officer for this ward," he said with the bass of a bullfrog. The people speak softly here, almost inaudible to my western ear, but the deepness of his voice did much in the way of transmitting the message. Soon, we alighted to the theater (the OR in Africa) after our brief exchange: there was a woman with a massive spleen that needed surgical excision.
It was there we met the consultant, another tall Kenyan wth a booming voice. He had the air of a surgeon, confidence to a fault, and a belly that revealed a lifestyle different from most in this country. From gaunt to skinny, you don't see much in the way of overweight people here. In Africa, it's malaria, in America, it's Type II Diabetes. As for the consultant, he had traversed the 5 years of medical school, the year of internship, and had practiced privately many years before he began his consultantship. This was the pinnacle of the medical hierarchy in Africa, being a consultant.
The patient arrived about an hour after we had left the ward, and at this time, I had caught up with Malia, my classmate who was rotating in maternity ward. Our separate designations, OB/GYN and Maternity, beared much resemblance in responsibility, so we stuck together for the week. I enjoy her personality, and was happy to have a companion for this our first week. We enjoyed a cup of tea while we waited for the surgical theater to be prepped. Tea here is a thrice-daily occurrence. They take it solely with milk, thus bearing the name, chai na maziwa.
During our wait, Dr. Rajiv, a medical intern in OB/GYN, began operating in the side theater on a routine c-section. I had never seen such a procedure before, and was amazed at how quickly it transpired, from first cut to the appearance of the child. At some point, you realize that you're cut out for the medical profession; the large grins beneath our scrub masks surely marked this point for both Malia and myself. Little did we know that we'd be assisting on one of these procedures before the day concluded. Who knew holding a once-gravid uterus would be such a poignant experience?
***Graphic Description Ahead***
With the main theater open and Malia assisting with the c-section, I examined the belly of the patient with the large spleen. It was palpable all the way to the midline, and descended near her belly button. She looked pregnant, her belly encompassing nearly twice her pelvic width. Her liver seemed enlarged, and present well below her diaphragm. Still, the consultant kept calling it an ovarian malignancy. How could this be, I wondered? It would need to be rougly the size of a basketball in order to distend her abdomen to that extent. Plus, the splenic involvement was puzzling. Was this a blood cancer, a metastasis? As it turned out my approximation was wrong: the right ovary was larger than a basketball, and the enlarged spleen turned out to be her left ovary. It was slightly smaller, but no less impressive. Roughly 15 lbs of ovary sat on the surgical table beside the bed, with a uterus the size of small change purse sitting in juxtaposition. This girl, no older than 20, already with two children, would never bear another. Her chemotherapy would begin soon after, but these two massive organs would be the last thing to pass from her belly. I wondered if she would survive, I wondered how long she had been carrying that burden.
"Without imaging, there is no way to accurately predict what we're going to find when we go in sometimes. Surgery in Africa, you'll learn, it's all about improvisation," the consultant intoned.
Having little experience in hospitals of any kind, I felt quite awkward standing around with my hands in my pockets. I announced my presence to the day nurse in charge, and she promptly sat me in front of a mound of patient charts. "Read these," she said, and then returned to her work changing bed sheets, a chore that required a mass exodus of patients from the room until her task was complete. This happened every morning, I learned; the head nurse was the shepherd, the patients the sheep. By the time I had scanned through the charts, the menial task was complete.
The first thing you see is the sheer number of patients that occupy the room. After that initial shock subsides, you sink into a state of acute observance. Soon, the slight breeze coming through the windows causes the gentle swaying of the nets above each bed, and you take note of the women just outside drying laundry on the dew-crested side yard. Thermoses of tea and loaves of bread fill the cabinets beside the patient beds, and some have taken to their morning routine, eating and drinking. Perhaps it's my presence or that of pain and illness that stifles much of the idle chatter--everyone seems to be merely existing, surviving. No different than in any other hospital, I imagine.
A tall, verk dark-skinned physician ("daktari" in kiswahili) approached me: "I am Dr. Mawalwi, the chief medical officer for this ward," he said with the bass of a bullfrog. The people speak softly here, almost inaudible to my western ear, but the deepness of his voice did much in the way of transmitting the message. Soon, we alighted to the theater (the OR in Africa) after our brief exchange: there was a woman with a massive spleen that needed surgical excision.
It was there we met the consultant, another tall Kenyan wth a booming voice. He had the air of a surgeon, confidence to a fault, and a belly that revealed a lifestyle different from most in this country. From gaunt to skinny, you don't see much in the way of overweight people here. In Africa, it's malaria, in America, it's Type II Diabetes. As for the consultant, he had traversed the 5 years of medical school, the year of internship, and had practiced privately many years before he began his consultantship. This was the pinnacle of the medical hierarchy in Africa, being a consultant.
The patient arrived about an hour after we had left the ward, and at this time, I had caught up with Malia, my classmate who was rotating in maternity ward. Our separate designations, OB/GYN and Maternity, beared much resemblance in responsibility, so we stuck together for the week. I enjoy her personality, and was happy to have a companion for this our first week. We enjoyed a cup of tea while we waited for the surgical theater to be prepped. Tea here is a thrice-daily occurrence. They take it solely with milk, thus bearing the name, chai na maziwa.
During our wait, Dr. Rajiv, a medical intern in OB/GYN, began operating in the side theater on a routine c-section. I had never seen such a procedure before, and was amazed at how quickly it transpired, from first cut to the appearance of the child. At some point, you realize that you're cut out for the medical profession; the large grins beneath our scrub masks surely marked this point for both Malia and myself. Little did we know that we'd be assisting on one of these procedures before the day concluded. Who knew holding a once-gravid uterus would be such a poignant experience?
***Graphic Description Ahead***
With the main theater open and Malia assisting with the c-section, I examined the belly of the patient with the large spleen. It was palpable all the way to the midline, and descended near her belly button. She looked pregnant, her belly encompassing nearly twice her pelvic width. Her liver seemed enlarged, and present well below her diaphragm. Still, the consultant kept calling it an ovarian malignancy. How could this be, I wondered? It would need to be rougly the size of a basketball in order to distend her abdomen to that extent. Plus, the splenic involvement was puzzling. Was this a blood cancer, a metastasis? As it turned out my approximation was wrong: the right ovary was larger than a basketball, and the enlarged spleen turned out to be her left ovary. It was slightly smaller, but no less impressive. Roughly 15 lbs of ovary sat on the surgical table beside the bed, with a uterus the size of small change purse sitting in juxtaposition. This girl, no older than 20, already with two children, would never bear another. Her chemotherapy would begin soon after, but these two massive organs would be the last thing to pass from her belly. I wondered if she would survive, I wondered how long she had been carrying that burden.
"Without imaging, there is no way to accurately predict what we're going to find when we go in sometimes. Surgery in Africa, you'll learn, it's all about improvisation," the consultant intoned.
Thursday, June 21, 2012
I don't know if I could have ever prepared myself for what I'd find here... There are more sights and smells and experiences than I could have ever imagined. Our small group of wazungu create quite a spectacle here in Kitale. The population is pretty homogeneous and 5 white people (+ 1 classified as "mwafrika!" walking around in a group is an uncommon sight. On our first day here we all took a post-supper stroll through one neighborhood and you'd have thought one of us was the Pied Piper from the number of children following us down the road.
Most roads here are unpaved, just hard packed dirt which can get interesting after a late afternoon rain shower, which has so far been a daily occurrence, much like summertime in Memphis or Atlanta. But the weather is beautiful, there are cool breezes and sunny mornings, and the town is surrounded by trees and hills and beautiful scenery.
We are only in our third day at Kitale District Hospital but already none of us lack for novel and exciting stories and experiences. I'll let everyone relate many of those on their own, but I'll go ahead and tell you I got to scrub in and assist with a C-section on my very first day! I got to help deliver the baby and cut the umbilical cord and everything. So I'd say we're off to a great start.
Tutaonana (later)!
Most roads here are unpaved, just hard packed dirt which can get interesting after a late afternoon rain shower, which has so far been a daily occurrence, much like summertime in Memphis or Atlanta. But the weather is beautiful, there are cool breezes and sunny mornings, and the town is surrounded by trees and hills and beautiful scenery.
We are only in our third day at Kitale District Hospital but already none of us lack for novel and exciting stories and experiences. I'll let everyone relate many of those on their own, but I'll go ahead and tell you I got to scrub in and assist with a C-section on my very first day! I got to help deliver the baby and cut the umbilical cord and everything. So I'd say we're off to a great start.
Tutaonana (later)!
Sunday, June 17, 2012
How are YOU?
Trains, planes, and matatus...this is the way to Kitale. We arrived shortly after 2:30 pm (7:30 am EST) yesterday, and were greeted in typical Kenyan fashion: warm hugs, a hearty "caribou sana," and yet another delicious meal...we ate the world's best mango yesterday. Fact.
Today, we're running errands and getting settled in our new home, a beautiful farm just outside the city. Tomorrow, we begin our work in Kitale District Hospital. We're eager to begin, and it is our hope that we'll be able to give you a tiny sliver of what we're experiencing through this forum. I can guarantee you that this medium won't capture the enormous beauty of this country and the people that live here. Yet, we'll still try. Until then, we say kwaheri and hope to speak with you soon. SS
Today, we're running errands and getting settled in our new home, a beautiful farm just outside the city. Tomorrow, we begin our work in Kitale District Hospital. We're eager to begin, and it is our hope that we'll be able to give you a tiny sliver of what we're experiencing through this forum. I can guarantee you that this medium won't capture the enormous beauty of this country and the people that live here. Yet, we'll still try. Until then, we say kwaheri and hope to speak with you soon. SS
Thursday, June 7, 2012
Well, with my first post, I'll announce that I'm finished tinkering with the layout of the blog. It only took me 3 hours to get that picture loaded and looking right. Alas, a web programmer I am not.
Sorry if you checked in to find an enormous photo covering the entire site...I was "in the weeds" there for a bit, if you know what I mean. SS
Sorry if you checked in to find an enormous photo covering the entire site...I was "in the weeds" there for a bit, if you know what I mean. SS
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