Coming Home

Good-byes are always bitter-sweet.

After spending four weeks here in Kapsowar, Marta and I are going home to Kansas! Today we said good-bye to the nursing students and various staff, as well as to the missionary doctors here. We'll be leaving Grace behind, as she has two more weeks here, so please pray for her; we heard that the hostel had been broken into twice in the past. Among our several last-minute errands, Marta donated blood and took a picture of her negative disease screening results. I think my Asian-ness has rubbed off on her and have created a photo-monster :)

The last few days kind of got lost in being distracted by various things and a slight regret of not getting certain things done earlier. Such is life, and I'm reminded of what Moses said in Psalm 90, "Teach us to number our days aright, that we may gain a heart of wisdom." Time management is ever a lesson of mine.

There are many things we haven't had a chance to put on this blog, and there are many pictures yet to be uploaded. We will have to do that after we get back to the high-speed internet in the States. A trip like this doesn't leave one without reflections and contemplations, so there may be more sharing and thoughts after we go home. I can't wait to share with you the lessons I've learned and the stories of what happened here, but seeing that I'm starting inpatient rotation on Tuesday, the reflections may come out very slowly.... we'll see.

Thank you again for your prayers. It rained and turned cold the last couple of days. As I'm typing this, it's about 3 hours before we're supposed to be leaving Kapsowar, but there is some concern about the roads being too muddy for travel. I know many people are praying for us, so I will learn to trust in God to bring us home.

I look forward to seeing y'all soon!

Love,
Katy

Two in One

                Two weeks in one!  I took a vacation from writing last week as I took my turn at not feeling well.  Last week I decided to see what a week in the life of surgery entails.  Dr. Rhodes just arrived back, so the number of surgery cases increased dramatically.  (Within a day, patients knew Daktari Rhodes was back, and were coming in search of him!)  The first day was mostly burn contractures examined under anesthesia.  In the afternoon we excised a ginormous hip mass, and ended up chipping away part of the head of the femur.  The next day there was an equally large mass protruding from the shoulder.  With the shoulder, the bone just melted away with the mass, and no chipping was needed!  It is amazing these masses get so big.  We also did several laceration repairs and incised and drained multiple abscesses (many of which were TB).  Unfortunately the pathology of the hip mass and shoulder mass are still pending.

                One early morning I was called in to assist with a cesarean section.  We opted for the emergency method of opening, and for a first time section (ie no prior scar or scar tissue, I don’t know why we do anything else!  Into baby in 3 minutes or less!  Mom and baby did well, but my night of night sweats caught up to me and sweat was beading off of me as if it was pouring outside.  I filled out the post op documents while Kyle closed the skin subcuticularly, and I didn’t mind the chance to get out of the gown and gloves and try to dry up.  The rest of the week was pretty much a blur of cool, clammy sweats and feeling dizzy and extremely weak.

                This week I started Medicine and have been in charge of the women’s ward and seeing more outpatients.  Some of the highlight patients: a 40 year old severe asthmatic who requires 5 L and despite neb treatments, steroids, antibiotics and aminophylline, we can’t get her chest cleared up; and the 70 something year old lady who is also an asthmatic and saturates 60-90% on 5 L of oxygen (the maximum possible) who one day had absolutely no air movement bilaterally, who is also on aminophylline and every possible medication for asthma available!  One patient came in with “conversive disorder” a misspelling/misunderstanding likely of conversion disorder – a physical manifestation of some emotional pain or distress, who upon further investigation has had 12 episodes of passing out after experiencing palpitations, who has an amazing murmur and I suspect all of her passing out is not due to a psychologic illness rather, aortic stenosis!  She will go into the next major town 2 hours a way for an echo for further evaluation.  The patient I did the LP on, who was found to have cryptococcal meningitis had a clear LP 2 weeks later, and Amphoterecin finally arrived.  After writing a page of precautionary orders, the patient was started, and tolerated the test dose, ands subsequent doses.  I had to laugh – the medication is sensitive to the sun, so the nurses wrapped the IV fluids, and all the tubing leading down to the patient, in black plastic bags!  Managing diabetes with insulin, but without any way to check daily, or 4 time daily blood sugars is definitely a new experience!

                One sad story, a young woman came in after a self inflicted ingestion of an insecticide.  We set up gastric lavage and believed it was a relatively recent ingestion given the thick yellow substance that was pumped out.  Charcoal was given even though the time of ingestion was not known.  The patient was identified only by, Unknown African Female, and even her neighbors who brought her in couldn’t give us her name.  She was never alert, but after seeing a few kinds recover from such poisonings within a week I had hope for her recovery.  She was receiving atropine every 5 minutes!  I returned the next day, and the bed was empty.  She had died within 4 hours of arrival.  More bad news, she was reportedly 30 some weeks pregnant.  By the time the doctor was called that she was doing poorly, he couldn’t find heart tones and so there was no need for a stat c-section.  According to local custom, the baby would need to be removed, and so we did a post-mortem c-section to retrieve the baby.  After making the initial incision, the intestines, now full of air came pushing through the incision.  After fishing around for a bit, Kyle was able to locate the uterus, less than fist sized and in its non-gravid location.  If the woman was pregnant, she was in the first month or two of pregnancy!  That was the end.  The pathologists were left to close the incision, and we went to talk to the family members gathered outside.  Very sad.  I am thankful there was not the tragic death of a viable baby, in addition to this young woman’s untimely death.

                Managing outpatients is often a challenge in terms of requiring a translator, but, so refreshing in that sometimes all that is required is an rx for Tylenol or ibuprofen!  

Mature audiences only:               

I asked to borrow a book on female circumcision, aka, female genital mutilation due to the severity.  This book is written about the Marakwet people who are the people that live here, and Kapsowar, this community, is even mentioned.  It is supposed to be accurate, but I have my doubts.  Supposedly, women asked for the procedure!  According to this book I’m reading, written by a local man who studied divinity in the US, and then returned back to Kenya, who interviewed many women and compiled this research, those who are uncircumcised, both men and women, are considered childish.  Circumcised men would have parties and slaughter goats, and not bring any of the meat back to the “children”/uncircumcised.  So, the women got together and came up with the idea of female circumcision.  I don’t buy it.  He goes on to say that young girls have to make the decision themselves and get the approval of “instructors.”  If the stars are aligned, the crops are plentiful, and the instructors approve, the process can continue.  There is a night of getting drunk, and the girls are asked many times if they are going to go through with it, and the gorey details are not spared.  On the day of the process, sometimes stinging nettles are used to help anesthetize the area.  Sometimes the clitoris is cut out, but as with many of the patients I’ve seen here, the mons pubis and labia minor and majora are removed too!  The girls are instructed to be stoic and not to show any emotion.  It reflects poorly on their family, community, nation…if they cry, and they are ridiculed for it.  They are called cry-babies and can only marry the boys who cry at their circumcisions.  For the first two weeks, the girls are spoon fed as they recover.  After that, they start to learn about how to be good mothers, care for babies, clean, satisfy men, etc.  They are at a seclusion house for 4-5 months, before returning to their families, and as their can only be one circumcised women in a household (ie, the girl’s mom), usually given in marriage quite soon after returning.  Really – how does cutting off some foreskin compare to dismembering a female?  As of now, the Christian church and doctors and others have announced their opposition, but it is still carried out.  Most of the young pregnant females have had it done.  It is awkward to talk about even among female nurses and students because some have had it done, and so many have varying opinions of it. 

A Different Beat

This week Marta is on surgery and I’m on medicine.

Rounding is not quite the same as St Joe Medicine back home. The nursing students are taking their clinical assessments this week, so my first day trying to round on patients started out with serious-looking faces wondering why I was interrupting them. In the meanwhile, since my Kenyan preceptor tells me to meet him at 9:30am but doesn’t show up until 10:20am, I’ve learned to sit and relax and enjoy the scenery surrounding the female medical ward. It has been quite entertaining to watch the white pillar of smoke puff out of the kitchen just down the slope from the female ward, to greet the random persons going to and fro on the hospital compound, to follow the three cats that patrol the hospital, all the while trying to keep an eye out for my preceptor. (I know, this sounds like I have too much time on my hands….I guess I do.) Eventually I’d decide it’s time to start rounding, and I would approach the nurses and students huddled in the office. It is such a strange feeling to have all eyes on you, expecting you to say something substantial and educational, but that’s the position I’ve found myself in, when they help me interpret each patient interaction. In fact, I’ve been pleasantly surprised by how much I could teach the students, and even the nurses. I’m still trying to gauge what their knowledge base is, but sometimes I’m surprised by their appreciation for even just explaining the difference between Tylenol and ibuprofen, what I mean when I say we need to wean a patient off oxygen, and why we ask the questions we ask of post-C-section moms. When my preceptor comes as I finish my rounds, we would talk about the patients and he’d take the opportunity to teach various topics. He is quite laid back and easygoing, but he is very smart, and who can blame him for starting the day late with only 3 patients on the ward, as was the case today?

                On Tuesday I went with Laura (wife of Dr. Rhodes, the surgeon) to the Children’s Home for a quick visit. The walk was about 40 minutes through the mountainous uneven red dusty roads, frequently shared by grazing sheep and wandering cattle. On our way there Laura shared with me they’ve had some problems with caretakers or board members taking the money or goods that were meant for the children, so now they mainly focus on investing in the children’s education, which no one can take from them.  A field separated Children’s Home and the primary school house some of the children attend. As we climbed over the fence to go toward the Children’s Home, a group of children readily ran up to us and cried, “Candy! Candy!” Several of them touched my hair and clothes, but all slowly retreated back to the school when they realized we meant it when we said, “Hakuna candy (no candy)”. The Children’s Home we came upon was more bare than I had imagined, but they had separate rooms, outdoor shower stalls, and latrines for boys and girls. The children cook their own food, and they have a field behind the Home with maize, cabbage, a couple of other local vegetables, as well as chicken, sheep, and cows.  A highlight for me was seeing the boys’ room because that’s where an Ashley original still graces one of the walls. I took a picture of your painting, Ashley! J

                On our way back from the Children’s Home, several groups of school-age children met us on the way because it was lunch time, and apparently school was out. The children flocked to us and followed us as we walked on, giggling and laughing, all the while calling out, “How are you? What’s your name? How are you? What’s your name?” Laura later said she tries not to encourage them, for although some are genuinely curious and excited to see foreigners, others are just being rude. My mind flashed back to a memory of being at the cultural center with a few of my classmates back in Taiwan. We were probably in fourth grade at the time, and I can’t remember why we were at the cultural center, but we noticed a Caucasian gentleman by the windows. Someone said we should go say hi, but none of us were brave enough to actually initiate contact. After some prodding and pushing and embarrassed laughter, one of the boys went up to him and said something like “Hello” or “How are you”, before we had a brief, kind of awkward, not really fully understood conversations, ending in silly giggles on our part. I now have much sympathy and empathy for that poor gentleman, who was just minding his own business…. J I guess what goes around does come around.

                While I was on call one night this week, we did a Cesarean section on a lady named Dorothy. I had to laugh because the Swahili word for baby is mtoto. What does this remind you Kansans of? We operated on Dorothy and mToto!!

                A little update on previous notes. The mom who was carrying twins went into labor and delivered by Cesarean section one of the two twins. The other twin had unfortunately died in utero. The surviving baby is now in the nursery, slowly growing. Please continue to pray for them.

                Thank you for all of your prayers for me. I am now well and free from chest or belly pain. I am also not taking any prophylaxis for malaria, according to the advice of three doctors and one medical student here. It would be very ironic if I were to get malaria now, but seeing this is a low-risk zone, I think I’ll be okay.

New Experiences

Katy’s Long Novella

I had my best birthday ever.  Thanks to God, I’ve had many memorable birthdays throughout the years, but I haven’t had an all-day celebration until I came to Kenya! 

            My 29^th year started out with Marta making delicious and beautiful German pancakes (the one that puffs up on the edges of the pan and is fluffy and delectable!) served with powdered sugar for breakfast.  (Normally, it would be served with powdered sugar and lemon juice, but the green skinned fruit I insisted was a lemon, was in fact, as Marta said, an orange, so we had powdered sugar and orange juice!)   I finally called my grandparents in Taiwan since I’ve been here, as well as talked to my mom again. Marta and I walked to town in hopes of getting some key ingredients for our dinner party at the Jones’ next door. We found the local market but could only find seed potatoes and not potatoes for eating, but we did find some carrots and mangoes. On our way back we stopped by a general store and got the only tub of margarine they had to get off the shelf, out from underneath and behind several  bottles, and dust it off for us (we later found many tubs of various sizes at a different store, but oh, well, we were supporting the less frequented little stores). We checked out at least three butchery shops, but everyone was either not there or not open. We later found out they only butcher cattle on certain days, and when I asked, “And you only have chicken on Tuesdays and Thursdays?” One local student nurse said to me, “This is Africa!” Oh, right J We did see one chicken along the road, and Marta invited him home for dinner.  I don’t know if the bird noted the double entendre, but he continued on his own way.  By God’s grace we found potatoes before we got home, but Marta thinks they had even more eyes and would have been better for planting than the ones they wouldn’t sell us at the market.

The road was quite muddy and sticky because it has been raining almost non-stop for three days, and their soil is a little bit more of clay consistency, being a deep brick red.

Once we were home Marta then made cinnamon buns from scratch, but there wasn’t enough sun or heat to make the dough rise properly, so I pulled out my hair dryer, but the valiant attempt only lasted a couple minutes before we decided to put it in the preheated oven. We made curry for dinner, and with only one package of chicken drumsticks left from Eldoret and no chicken to be bought in town, I came up with the brilliant and messy idea to de-skin and then de-meat the drumsticks…. Marta laughed at me, but I think the end result was tasty. Marta was quite a baker and made a chocolate cake for me from Duncan Hines, Grace put the Betty Crocker frosting over it, and Marta wrote out in home-made icing, “Siku njema ya kuzaliwa, Katy”, which we hope says, “Happy Birthday, Katy”

                We hauled all the food we had prepared next door. The Jones’ had a Happy Birthday banner up, with balloons and candles for decoration. Ces, a surgery post-residency fellow, joined us. I got presents from two of the little guys, including homemade cards. It was pretty special. After dinner we had coffee and a movie, a relaxing way to end a wonderful day spent with new (and old) friends.

                Okay, now for the parts you really want to know about.  J

                I’d like to share with you that we went with Kyle last Tuesday evening to a nearby village to show the Jesus video in their native language (Mariquet). We rode in Kyle’s SUV with the equipment, and the two older children (6 and 4) came along. Once outside of the school, we put up a white sheet for a screen and set up the projector, speaker, generator, and amplifier. About 50 people, mostly children, were already there, but by the time we started, I think there was well over 200 in the crowd. A lady from church led a few songs in Swahili, and then we realized we forgot the cord for the amplifier!!! While waiting for someone to get it from the hospital, we decided to have Grace and me hand out cookies to the audience. That was when things got out of hand. 

                I’m sure everyone has seen news footage of hungry people crowding around aid workers in refugee camps, but it’s the very first time I’ve in the position of seeing all these outstretched hands. The first couple of children I handed the cookies to were really hesitant and timid in taking them from me, but before long I was surrounded, and as the evening was setting in, a shield of palms was all I could see in the dim light. A local pastor tried to have them form a line but was not successful. I tried to make sure the little hands below get cookies, too, while trying to hold the box close and high, as some bigger hands were either snatching them from others’ hands or trying to get into the box. I soon found Grace by my side, calling out for order and closing my box for me. Later I found out the reason she was riled up was because several adults jammed their hands in her box of cookies, and took as many as they could grasp, wasting many in the process, and leaving her with nothing.  Kyle finally took my box away because it was getting frustrating, and I saw him giving cookies to the little ones who stayed around the projector and didn’t have a chance at the crowding.

I overheard people say that some children are “tricky” and would come back for seconds, but I feel like that’s just being children yet to learn how to look after others. At any rate, it was not the intended effect, and what we thought was a nice treat to share with the people there turned out to reflect more ugly and selfish human nature. I felt like it was a little degrading to have caused their shoving and crowding and trying to get more for themselves without regard for the little ones beside them, but I didn’t expect that, and all this for something they didn’t need. It would have been nice to have the cookies, but it wasn’t like the essential food and water. It would have been even more unbearable for me had I been the aid worker distributing to a famine-stricken land. I tried to tell them there’s enough (and there were enough if people didn’t take seconds or fourths), but it probably also has to do with the issue of trust. They didn’t know me; why should they believe what I was saying and not try to gather as much as they could for themselves while they were near the cookie box?

It really made me think of why we were there. As upsetting and surprising as something like this was, we saw that it was precisely this broken state of human relationships why Jesus had to come and save us from our depravity. He had to come to show how good God is, and how life can be good when we have been restored to our intended relationship with God, through the sacrifice of Jesus’ death on the cross. Without that, we cannot love others, we cannot trust God, and we’ll always think we’re in want. Even after we’ve become God’s children, how often do we hold on to God’s riches and not think about others’ needs because we feel like we won’t have enough if God gives to others, too? How much do I trust God when He says He is enough for me, no matter what happens?

After things settled down and the movie started; people’s attention was captivated. I wondered how many people in the audience had ever seen a movie like this before? I thought of my mom telling me stories of how when she was little, she would, with other neighborhood children, crowd outside someone’s window to look in at the rare black and white TV around. Being rainy season we started to feel some drops on our faces, but Hudson and I prayed, Kyle later said he was praying, and I was sure many prayed, that God would hold the rain and not cause a downpour, so people can finish the movie and hear the message in their mother tongue. It did just that; praise the Lord that despite occasional drizzle, no one left, and the movie was shown in its entirety. We went home tired but very happy.  [Marta here.  I was talking with a local pastor at the back of the crowd.  It was at the time the movie was playing a scene with a blind man receiving his sight.  The pastor said that in English, or Swahili, you hear the words, of a blind man receiving his sight, but in his own “mother tongue” he could hear the desperation, even before the action of the sight being restored.]

I wasn’t feeling well that day, but I was glad to have gone to the movie showing and had the experience and conversations I had. I hope by God’s strength I was graceful in my interactions, and I pray many there heard the message in their hearts.

The reason I wasn’t feeling well was, after deliberation among five healthcare providers, reflux disease exacerbated by doxycycline, which I was taking for malaria prevention. It was atypical reflux, though, as it first presented by waking me up in the middle of the night with chest pain. The chest pain persisted the next day, which was the day we showed the Jesus video, but it also included gassy upper stomach pain. Then it started to hurt when I drank hot water. The next day, taking anything, including water, began to cause pain. Breathing became painful, too. I started to feel feverish and weak and had muscle aches; when I woke up to Kyle’s phone call about a pediatric pneumonia admission, I found myself drenched in sweat. After learning from his wife, Vanessa, that I wasn’t feeling well, he had pity on me and went to see the patient himself. The next morning, he found Tecta (Protonix) for me to take, and thank God I’ve been getting better since then, just in time for my birthday cake.

What I learned from this was that it’s very hard to do missionary medicine, or anything at all, when one’s not feeling well. The devil plays mind tricks on you and there’s just gloomy thoughts all around. Thank you all for your prayers, and I’m thankful that when I was the most defeated on Friday, God heard our prayers and gave me a wonderful day, by His strength. Rounding went smoothly, then I got to do a few more ultrasounds; induced a couple of patients—one for post dates and one for intrauterine growth restriction; and did a cesarean section.

Okay, that’s a very long post. I just wanted to cover all the major points of this week. Thank you for reading!!

Marta’s:

After all that, what more is there to add?  Katy always seems to be busier than I.  When she was on Peds the first week she did several admissions a day; I had 2 all week I was on!  On OB she has been inducing patients like crazy! 

The other doctor, a Kenyan, had a few days off, so I saw all the Peds patients, Katy took care of OB, Kyle did men’s and women’s wards, and I saw many of the outpatients.  There were some hospital follow-up patients who had recovered and I simply had to provide reassurance, and refills if needed. 

The saddest case was a 7 year old girl who came in with her mom.  The day before, she didn’t go home from school for lunch.  She was abducted by a man working for her grandmother, who took her to his house, both parties were without underclothes.  What he did, I can only imagine, she will never forget.  Thankfully the examination did not reveal irreparable damage, but only abrasions.  After she was released from his bed, she went home, and hid under a counter, which is where her mom found her the next morning, with a tear stained face, and mud all over her legs.  Her mom came back the next day for us to fill out the official police report form.  It was extensive, 4 pages long.  Her mother added she was doing well, and that her incontinence of urine was improving.  Kyle did the initial exam and documentation, although I was there, but when her mom came back, I was doing the visit, so I was able to add my two cents.  I don’t know that anyone ever feels comfortable in these situations, but I wanted her to know that her daughter would need lots of extra love, support, and patience, and I told her mother that.  I had Kyle come up to sign all of the documentation that I had done on the police report, because I didn’t want the case to be thrown out on account of the fact that I had filled out the report but was no longer there.

Katy Again (No…not her again~~!)

After a restful weekend not on call, we’ll be starting medicine and surgery, so stay tuned for more happenings at Kapsowar….

Life on the Wards in Kapsowar

Marta’s New Week

                It hasn’t been so long, so this will be much shorter.

                Today I tried a custard apple for the first time.  The outside is green and it looks like a cross between a pineapple and a pinecone.   Inside, there was a creamy, sweet fruit, with seeds big enough to just pick out.  It was 20 schillings, so about 20 cents.  Katy was excited to find it, and it was a nice treat!

                I have taken over the pediatric ward from Katy this week.  She was collecting patients, and holding on to them!  My last few days have been filled with multiple dismissals per day, and lots, surprisingly that comes with a fair amount of paperwork, even in Africa!   There is a one page form, which is shorter than my usual dictations, that summarizes the diagnoses, hospital course, and discharge meds.  A separate card is for the patient and had the diagnoses and meds.  

                I did have one new admission for severe malaria this morning, and one for ingestion of insecticide yesterday.  Kids don’t usually ingest too much insecticide as it tastes and smells so foul, but this guy got somewhere between 5 and 75 ml!  Yesterday afternoon he seemed pretty stable on admission with clear lungs, reactive pupils, and general fussiness from all the poking and prodding.  This morning he was obtunded, pupils were pin-point, lung sounds were coarse and crackly throughout and he was drooling.  I was amazed how well just one dose of atropine worked, and was expecting to have to give it every 15 minutes, but the first dose held for at least a few hours!

                I was helping out in the outpatient department today, and saw two patients this afternoon.  That is quite a difference from the 12 I was seeing to try to squeeze in all my frequent fliers before being absent for this month!  The first had abdominal pain and knee pain, both were chronic.  He had been treated empirically for H. Pylori on the last visit in September, and his abdominal pain resolved with that.  I simply refilled his omeprazole and offered him a knee replacement for the crepitus and arthritis in his knees.  Just kidding…no such thing.  But, in the end he said he had had the pain for years and didn’t care for any medication for the pain.  What a difference to be on another continent!  No narcotic seeking behavior! 

The second patient had three complaints: chest pain, localized to the left side wall for 24 hours, no change with exertion, position or deep inspiration, this was the second time she’s had the pain, and the last time was a year ago.  There is some associated shortness of breath.  We don’t have an EKG machine that I can tell and given her age and risk factors she would have been a shoe-in for a heart catheterization to rule out/for reassurance.  Instead, I offered her an aspirin a day, which she declined.  She said that her diagnosis was that she was going to get pneumonia, but didn’t have any symptoms yet.  She was afebrile, had no cough, lungs were clear on exam and had no aegophany.  I even offered to write, against my own doubts, a script for amoxicillin in case she did develop symptoms of pneumonia, so as to save her the clinic fees again, but she declined.  (See, no med drug, antibiotic, or narcotic seeking!)  Her second complaint was feeling hot x 2 years, LMP 2 years ago, menopausal for the last 2 years…  I am not aware of any hormone replacement therapy available, so I reassured her she was afebrile and she seemed ok with that.  The third complaint was pain in the knees, ankles and feet.  Again, there was marked crepitus bilaterally.  I looked through the medication formulary and found the only injectable steroid was dexamethasone, and there was some cousin of lidocaine.  I offered her a joint injection, but she declined based on cost.  For the steroids and lidocaine, it would have cost 350 schillings, or about $3.50, but she had only brought 200 schillings with her.   I felt as if the encounter dragged on considerably, and I have much more empathy for anyone who has to use an interpreter on a regular basis (and makes me very thankful for being able to speak directly with my Spanish speaking patients!)  At the end of the visit, the patient asked, if she were to come back the next day, would I be there.  In my mind I’m thinking that she is thinking, “Who is this crazy white girl, maybe doctor?  She wants to give me aspirin and I don’t want it.  She wants to reassure me she doesn’t think my chest pain is because of my heart, but she still insists aspirin may have protective properties.  She is convincing me I don’t have pneumonia, but what if I get it tomorrow?  Why doesn’t she want to take my blood?  She could test for typhoid or malaria, but I have no symptoms, she could check for pneumonia, I’m sure.  Why won’t she take my blood?  Why is this the longest time I’ve ever been in a doctor’s appointment?  I wonder if this girl knows what she is doing?”  In reality, she said she appreciated the way I interacted with her, and she would come back tomorrow afternoon for the joint injection, if she could get the money.  

Katy’s Days

It’s my turn this week to learn obstetric ultrasounds, and today I promptly asked my preceptor to confirm a twin gestation that he said was “straightforward singleton”. Okay, so I need more practice. After that, I did get a real twin gestation and practiced measuring dates on two babies for the price of one!

Cesarean section is very different in Africa in the sense that the field is a little bit more bloody, seeing there are no electrocautery set up, and you only get five lap sponges the whole case. FIVE. Marta and I have been alternating to be the primary with our preceptor. Most of the uncomplicated vaginal deliveries here are done by nurses and nursing students, since there is a nursing college on site. When they get in trouble, as in the case of a retained placenta yesterday, they’d call in the daktari. After manual extraction of the placenta in fragments, IV and IM oxytocin to contract the uterus, and bimanual massage, there was still a lot of vaginal bleeding, so we requested help from the surgeons for a potential hysterectomy to save her life. Thankfully, we established hemostasis enough and examination under generalized anesthesia allowed us to identify and repair several lacerations.

One hospital phenomenon that’s especially worth mentioning is that a patient of mine left this morning (Wednesday), but she was discharged on Monday! Yup, if you can’t pay the bill, you have to stay in the hospital and wait until someone pays your bill, whether it’s family member, or in her case a Children’s Fund. I can’t imagine how this practice would pan out in the States.

Since we’ve been here, we’ve seen many premature births. Kyle attributes some of that to heavy duty manual labor, which makes me wonder about my recommendations to my early second trimester moms who want to start leave of absence (FMLA) right then for belly pain and back pain, since I’d tell them, “In many countries, women work up until the day they deliver, so there is no medical indications for you to start staying at home now.” The youngest estimated about 22 weeks gestation age (5 ½ months), and there was nothing we could do for the baby girl, except to keep her comfortable and let the native nurses ask mom, in their culturally acceptable way, whether she’d want to see the baby before she died.

Yesterday was a bittersweet day (UPSETTING CONTENT, not for the faint of heart). One first time pregnant mom came in for “three days of abdominal pain.” As I asked more questions, the shocking truth came out. She was about 24 weeks pregnant, and right before she got pregnant she was diagnosed and treated for Typhoid fever and amoebiasis. She has also been having nausea, vomiting, and poor appetite, so last week she went to Eldoret for an abortion. She later revealed that she chose abortion because she was a single primary school teacher, and the man became distant when she told him she was expecting. The more horrifying fact is that she went to someone who “gave her some drugs and put something in her uterus,” which is likely to induce abortion. On my ultrasound I didn’t see a foreign body, but I did find twins (really, there were two). At this time my preceptor came in and heard the story. A father of four young children, he was visibly upset by whoever’s performing abortions on twins, not to mention abortion is illegal in Kenya! Kyle spoke rather directly with her, and she expressed remorse, stating this was why she came to the hospital yesterday.  Kyle did the sterile vaginal exam, on which the cervix was visually closed, but there was frank pus and blood in the vault. She was then admitted to get intravenous antibiotics, while the gram stain showed gonorrhea. Thankfully, ferning was negative, so she didn’t break her water, yet, and she has some time to get steroids for maturing babies’ lungs.  A little bit later, Marta went to check on maternity ward while I was in a C-section and found out more to the story, which I’ll put in her own words:

“   A short time later as Katy was finishing a cesarean section, I went down to see that everything was under control on maternity, and a nurse told me, another nurse had felt a syringe in the patients vagina.  I’m not entirely sure she was being checked at such an early time, but I donned my sterile gloves and as I had the patient open her legs for the exam, a 6 cm long piece of plastic was protruding from the introitus!  Her SVE was 4 cm dilated, very thin, and +1 station, but the presenting part was something other than head as both twins are breech.  I was sure the patient would have delivered overnight last night, but she is still currently pregnant tonight, and still receiving steroids to help their lungs mature!  The patient is remorseful, and knows she did the wrong thing so caring for her and the babies is easier.  I’m not sure what we would do if she hadn’t changed her mind. “

So please pray for this mom, who is in such a difficult dilemma and both physical and emotional pain. And pray for the babies, who may have a chance of surviving if we can get the steroids in and mom’s infection under control. I can’t believe what they used to induce abortion, and I’m thankful the mom came when she did, and that the babies are still beating their hearts and going strong. One of the student nurses was so upset by what happened, but I told her this is one of the reasons we’re here, to catch people when they’re in trouble and help them turn around, to reassure them of the forgiveness in Christ, when they realized they’ve done wrong and want to make things right.

Sorry to end things on a sad note… The next one will be more cheerful, I hope. Just an FYI, I’ve killed 3 mosquitoes while writing this note.