The ICU

Some of you may be aware of my dislike for the Intensive Care Unit (ICU) in the States. I am not a big fan of the high intensity with multiple patients on the brink of death. I have discovered that I probably wouldn't mind the ICU here - it is NOT high intensity.


I had my first real encounter with the ICU team this week when I wanted them to come see a patient on our team. The patient arrived on our team around 10 AM as we were going about our morning rounds. We stopped to assess the new patient because he looked quite sick. After a quick examination we found that his extremities were cold, he had no peripheral pulses, and we were unable to get a blood pressure or oxygen saturation. He was on oxygen and was clearly having difficulty with his breathing.

It was clear that this patient was not adequately perfusing his organs and he would quickly die if we did not get him to the ICU with some type of pressor support. On rounds we discussed this and the plan was to call the ICU and cardiology to come see him. After we saw the patient I noticed that no one was calling the ICU or cardiology. I asked my intern and he said he would call after rounds (rounds are an average of 3 hours long). I told him the patient wouldn't survive that long, so I called both consults myself.

I was pleasantly surprised when cardiology showed up 20 minutes later to see the patient. They agreed that he needed to be transfered but thought it might be too late to help him. I continued to wait for the ICU team to arrive. The patient died at 1pm and the ICU team showed up to see him around 3pm.

I was extremely frustrated with this but I learned that the ICU works a bit differently here. They take all the consults they recieve and go around seeing the patients. They may have 1-2 beds available so they try to find the patients they feel might have a chance at surviving. The others they turn down and the patients remain on the wards to be managed.

I guess my patient did not fit into their "possible recovery" category as he was unable to survive long enough for them to come see him. There is absolutely no urgency here in patient care.

The Street Children of Eldoret

There is a large population of street children living in Eldoret. The total number is unknown because they are very difficult to track, but the estimation is over 2,000 children. Some of the children live on the streets during the day and go home at night but many live completely on the street with no home to return to at night. These children are often forced to leave their homes because of lack of food or violence toward them in the home. On the streets they can make their own money and have freedom from those who may harm them at home. They form communities on the streets with the older children assuming leadership over the younger children. The age range is broad with some of the younger children being 4-5 years old. Many of the older children living the streets are killed by police.

On Saturday morning several of us went to an outreach for the street children. The outreach is put on by Tumanini House (with means Hope in Swahilli). This home is a day center for the street children where they can come and shower, eat, and participate in different types of education. The people at Tumanini are working hard to help the children find a way to get off the streets by teaching them a trade and getting them back into schools.

There is a huge problem with substance abuse among the street children. Nearly all of the children are addicted to sniffing glue. It was hard to watch as we played soccer with them on Saturday because as they played they would have the glue bottle in their mouth sniffing.

It was a neat experience but overwhelming to see the needs of these children. Tumanini is definetly a place that is trying to make a difference in their lives. If you want to read more about the Tumanini center check out their website: www.tumaninicenter.org.

Neema House

Neema house is a home for children located in Eldoret, only a five minute drive from where I am living. Yesterday afternoon I had the opportunity to spend several hours playing with the children. It was so much fun!

Neema house is home to 39 children at this time, 29 of them are HIV positive. It was started by an amazing couple who wanted to provide a home for abandoned children. They have also built a primary school on their property for the children to attend. It is a amazing place and I am eager to go back and play with the kids some more. I think I will stop by on Saturday for a few hours! I am sure to have more adorable pictures :)

Pellagra

Sorry if my pictures gross you out, but I wanted to share this amazing case with you. This man has a disease called Pellagra. Pellagra is caused by a deficiency in Vitamin B3 (Niacin). Patients with pellagra usually have a diet that is rich in unprocessed corn. It can also occur in alcoholics due to malnutrition. The treatment is very simple, you just have to give the patients a vitamin. Ofcourse we ran out of oral Vitamin B Complex today in the hospital so my patient has not been recieving his mediations.

If Pellagra is left untreated it will result in progressive dementia and ultimately death. Pellagra is a very preventable and treatable disease.

Lack of Supervision

The day to day routine at the hospital is alway different depending on who shows up. Some days we have a huge crowd with 10 medical students, two interns, 1 registrar, 1 attending, and myself. Other days it has been only me and the intern rounding on 50 patients. It is actually more fun and interesting the fewer number of people because it allows me to be more involved in patient care.

Today I was a little more involved in patient care than I prefered. Last month the intern I worked with was awesome. She knew what she was doing and just asked me for my opinion on certain issues. We have two new interns this week, one who is very strong and one who is extremely weak. Somehow today about half way through the rounds the registrar and good intern had to go to a meeting and I was instructed to "take over rounds." It was me, the weak intern, and 2 third year medical students. Talk about overhwelming. We had at least 40 patients on our service, about 10 of them were new admissions from the night before.

In the first 15 minutes of being the "attending" on my rounds today we had 4 patient that were completely unresponsive and one man with an acute abdomen. One unresponsive patient has cryptococcal meningitis and was actively seizing during rounds. Another man was in clear respiratory distress with an oxygen saturation of 68% (normal is 98%). Another patient I am concerned has TB meningitis (which I have seen twice in my life). The guy with the acute abdomen had severe rebound tenderness, guarding, and peritoneal signs.

I felt very helpless and overwhelmed today, but I was definately participating in patient care. None of the patients died during rounds or before I left for the day, which I thought was an accomplishment. I know I am getting use to the wards but I would prefer a little more supervision.

Giraffes, The Rift Valley, and The Rainforest

Our rainforest guide taking a break on the river.


Gillian and I enjoying the view of the rainforest.

Beth, Jaime, Sarah, and I overlooking the Great Rift Valley.

My buddy giraffe at Kruger Farms.

Sorry for the lack of blog posts, the internet has not been working ver well at the IU house. It has been working on and off for the past hour so I am trying to get some pictures and stories up for you to read. There is so much to write about it is hard to put these experiences into words on a blog. I am trying the best I can and hope you enjoy it. Hopefully, the internet will cooperate better with me and I can write more.

This past weekend we took two day trips which were both a lot of fun. On Saturday we went to a place called Kruger farm. This is a large farm owned by a South African family. When Eldoret was expanding the giraffes in the area were being killed for their meat and hides. They transported a family of giraffes over to Kruger farm to protect them from poachers. So you can walk the farm and look for family of giraffes. We found them after about an hour hike. There was a family of about 15 and they let us get within 10-15 feet and take lots of pictures.

After our visit to Kruger farms we drove to The Great Rift Valley where we ate at an awesome restaurant that overlooked the valley. We had a wonderful dinner and enjoyed the view.

On Sunday we took a group for a hike in the Rainforest. Kakamega forest is the only remaining rainforest in Kenya. We hired a guide who took us on a four hour hike through the rainforest. It was beautiful! We were very glad to have the guide because we would have been lost in about 5 minutes. Plus he pointed out all the cool birds, monkeys, butterflies, and plant life.

Another weekend full of adventure. My plan was to just stay at IU house and relax but I couldn't pass it up when people asked me if I wanted to join them. I hope you enjoy the pictures!!

Avoidance

For all of you who know me you know I have an interest and passion for end of life/palliative care. It is something I feel very strongly about and work hard to make sure my patients and families are comfortable at the end of life.


Due to my interest in end of life care I have had many frustration on the wards. I have discovered that as a patient dies here very little attention is given to the patient. There is one patient on our team who was admitted last Monday with altered mental status. He quickly declined and now is completely unresponsive, has bed sores from being unable to move, and started having seizures. On Wed, Thurs, and Fri of last week I was the only person to see this patient. The rest of the team skipped over him during rounds despite my reminding them. This patient is still alive, which is truly amazing, and recieves very little attention if any at all. Nothing is being done to make him comfortable.


A similar situation occured last week. We had a patient that presented with an intestinal obstruction and was found to have a large mass in his abdomen. We were planning on doing a CT scan of his abdomen but he quickly went downhill, we were not sure why. On our morning rounds the patient had agonal respirations (a sign of immiment death) and there was nothing else for us to do. The attending physican (head doctor) and I had the following conversation....


"Dr. Lupov, do you think there is anything else we can do for this patient?" Attending


"No. I think our focus should be to keep him comfortable." Me


"I agree. Our plan should be to keep him comfortable." Attending. After saying this he walks away and moves on to the next patient.


"Wait...do you have IV Morphine or Ativan? What can we give this patient to make him comfortable? He clearly looks like he is in pain and has a lot of air hunger." Me


"Giving those drugs is euthanasia and that is illegal in Kenya." Attending


"I disagree. We can keep patients comfortable without expediating there death." Me


"If you give that man Morphine and he dies, the family will say you killed him." Attending. At this point he stopped talking to me and moved on to the next patient.


How incredibly frustrating and sad. It has been so hard for me to watch numerous people on the wards die with absolutley no effort to keep them comfortable. I have not given morphine to a single patient since I have been here (and I have seen a lot of people die).


After talk about this with several people I have calmed down a little (not all the way) and realized that the Kenyan doctors' attitudes is likely a defense mechanism. Due to limited resources there is little to nothing to do for these patients. It is easier to avoid the patient then face the reality that the patient is dying and there is nothing you can do.


I hope palliative care/hospice can take hold here in Kenyan and change this attitude. Every person deserves dignity at the end of life and I believe it the physicans duty to make sure that happens. It has been hard to me to keep my mouth shut, because I don't think it is something I can change now. It will take time and many people to implement this changes. Maybe I can be a part of it in the future.

The Living Room

HIV clinic in Turbo.


The Living Room Hospice Center

When I visited the small clinic last week I met a lady named Juli. She has lived in Kenya for 7 years. She initally came with an NGO and decided to stay on to open a Hospice center for dying patients in rural Kenya. She has been doing Hospice for several years out of a small home that could hold only 10 patients. She was able to raise the funds and opened a new Hospice center two weeks ago. I had the chance to visit the center today and was amazed at what she is doing.

The patients she cares for are the ones that everyone else gives up on. They are the patients with no family, no home, and no place to go. They have a beautiful facility with 14 acres of land. If you want to learn more about what Juli is doing check out her website - livingroominternational.org.

I have a very strong interest in palliative/hospice care and it was encouraging to see that someone is aggressively trying to implement end of life care here in Kenya. It has been one of my biggest frustrations to see dying patients on the wards recieve little to no care. Part of this is due to resources (lack of pain medications) and partly due to lack of education as doctors and nurses do not know how to care for the dying patient.

There was a young girl at Juli's center named Chepchumba who is 8 years old and weighs 13 pounds (there is a picture of Chepchumba on Juli's website). She showed up to Juli's center 8 weeks ago and they were not sure if she would survive if they attempted to feed her. She is currently doing well and has gained two pounds. There was another young girl who arrived yesterday who is 5 years old and weighs 10 lbs. The degree of malnutrition was unbelievable.

p.s. Katherine - Juli is opening up a school to train better quality Kenyan nurses....I see a future trip for you :)

My pale skin does not get along with the hot Kenyan sun!!

Do you see that giraffe behind me? AWESOME!!


The hippos can actually be pretty dangerous, but they were all sleeping when we drove by.


Beth and Jody at our "rustic" campsite.

Hiking the gorge at Hell's Gate.

I had a very adventurous weekend which including biking, camping, hiking, and boating. We started the weekend biking through Hell's Gate which is a national park with a variety of wildlife. We biked to a gorge and hiked down into the gorge, it was beautiful. We spent the night at a rather "rustic" campsite.

The next day we took a boat trip out on Lake Navasha and saw the hippos and lots of different birds which inhabit the lake. The boat took us out to an island where the movie Out of Africa was filmed. When the movie was made they shipped in all the animals. They shipped out all the dangerous animals after the movie was filmed (for example lions) and now people are allowed to walk around the island and get pretty darn close to the animals. My favorite part was getting about 10 feet from a giraffe enjoying his lunch.

Our final destination of the weekend was Mount Logonot. This mountain was an old volcano that has a large crater in the middle that you can hike around. I found out I am quite out of shape. The top of the moutain was 9,180 ft, my lungs protested the whole way up. It was beautiful but it was HOT!! The combination of hiking up the moutain at the peak heat of the day, my pale white skin, and walking on black lava rocks results in a pretty nasty sunburn despite copious amounts of sunscreen. My skin and the Kenyan sun do not get along well. The humorous part is always to see where you missed putting sunscreen - the back of my hands, my toes, my hair line, and the back of my knees. Lets just say I have some funny sunburn lines!

So the adventure did not end there....On the way home we ran out of gas on the side of the road and had to call for some help. When we arrived home to the IU house they were roasting a goat to celebrate the IU students graduation from medical school.

Overall, a very adventurous weekend. I slept very well last night. My skin and muscles are still recovering from the hike up the mountain. I hope you enjoy the pictures!!

Clinic Experience

The market! It is packed with thousands of people selling anything you can think of. It is a little overwhelming because people are all around you and it is hard to move.


This guy sold us some fruit and he was super eager to be in a picture - he even posed.


This is how they fill in pot holes in Kenya - with dirt. The problem is that the cars drive over the newly filled holes and the dirt becomes a cloud of dust and the hole remains.

This is my foot covered in the dust of Kenya. All the "sidewalks" here are dirt paths and it is so dry there is a lways a cloud of dust in the air. By the end of the day you have to shower and wash off the layer of Kenyan dust that has accumulated on your skin.

Today I had the chance to go out to a smaller HIV clinic with one of the American doctors who has been here for 12 years. It was a great experience. AMPATH has set up 55 clinics around Western Kenya to provide HIV care. The clinic I went to today was about 1 hour from Eldoret in a town called Turbo.

I saw about 8 patients with Dr. Mamalin, and it was an eye opening experience. First, it was amazing how many patients were at the clinic. It made me realize that HIV is a pandemic in Kenya. The small clinic that I visited is currently serving 7,000 HIV positive patients. They come in every 1-6 months depending on how good they are doing and are able to get their medications, see the doctor, and get labs drawn for free.

My eyes were also opened to the devastation of tuberculosis in Africa. Of the 8 HIV patient we saw 3 of them has tuberculosis. I was shocked to meet one lady that was dying from TB, she was probably my height and weighed 60-70 lbs. She was the most emanciated person I have ever seen.

The wonderful thing was to see how the doctors and support staff are fighting for the patients. They are not giving up on them and they are working to try and get them the care they need to survive these awful illnesses. I was just blown away by what AMPATH has established here. Even though there is still a long way to go it was neat to see how the organization is making a difference in the lives of individual people.

Short Supply

We ran out of Potassium today - so they wrote an order for two bananas with every meal!


A husband feeding his sick wife.



The entrance to the Hospital.


Jody and I standing at the entrace to Moi Hospital.

I have quickly discovered that they run out of medications here and it varies day to day what is available. They do not inform the team when the antibiotics run out they just put N/A on the treatment sheet or sometimes they keep checking that the patient is getting the medication. So you can think your patient is getting antibiotics when in reality they are not.

Today they ran out of potassium replacement. One of the patients on Beth's team had a very low potassium and really need replacement. So the above picture shows and order they wrote for the patient to have two ripe bananas with every meal. We thought this was pretty humerous.

One thing I am learning is that if you want to make sure a patient is getting a medication you need to physically walk to the pharmacy and ask them if that medication is in stock. We are constantly changing patient's antibiotics around based on what is available. It is really hard to keep up with the treatment plan.

The other interesting thing I observed today is that patient's hang around for several days after they have been discharged. I think this is due to a combination of factors. Number one is the patients can't leave until they pay their bill. Number two they have to wait for someone to come get them. We have patients that have been discharged and just sit there for days/weeks. We just walk by them on rounds and say "they are discharged" and no further discussion.

Tonight is dinner out for everyone. We go to a restaurant in town every Wednesday night. The food here is good but it is nice to go out and get some more variety. Last week we went to a delicious Indian restaurant. I think tonight is Chinese or Italian!

I hope all is well back in States. I miss you all very much. Thanks for following along on my blog.

Helpless

Over the weekend two patients on the male ward died with severe anemia. Just to give you a reference range the normal hemoglobin is >14 in men. In residency the lowest hemoglobin I have seen is 4.5. The two patients that died over the weekend had hemoglobins of 2.5. My roommate Beth had a patient today that presented with a hemoglobin of 1.8. How is that compatible with life? The sad thing was the two men that died over weekend were only 16 and 18 years old.

So I discovered last Friday that there is a massive blood shortage in Kenya right now. The country gets most of its blood from school aged children and they were on vacation for the month of April. So currently in the hospial you cannot get blood unless you have a family member that can donate for you. To top it off last week the blood bank ran out of agents to cross match the blood and had to send all the blood (even the family donated blood) to Nairobi for cross matching. So even if the family donated it would take 2-3 days to get a unit of blood. This explains why my two patients died from severe anemia over the weekend.

It is hard because you just feel helpless. I went to the blood bank and provided them with the names of my patients and asked how quickly they could get blood. They told me it probably wouldn't be until Monday due to the lack of reagents. I asked if there was any way to speed it up and they said no. So that is where it ended. There was nothing else I could do.

I think there will be a lot more helpless moments to come over the course of the next six weeks. I am trying to focus on the things I can do and the ways I can help.

More pictures!!!

Half my body is in the northern hemisphere and half my body is in the southern hemisphere...kind of crazy!!


I was about 10 ft from this guy. (I was in the car)



This is a hyena - I thought they were pretty ugly.



This giraffe walked right in front of our car, stopped, and looked at us to pose for a nice picture.



It is baby season and there were little animals all over the place. The cutest of these being the baby monkeys.

Lake Nakuru

Baboon sitting on someone's car wanting the food inside. They were pretty aggressive and really liked human food.


My roommate Beth and I overlooking Lake Nakuru.



African Buffalo - these guys are mean. They get mad when you drive by and charge the car.

White rhinos taking a nap in the shade.

The vervet monkey. He looks cute but he is a bit on the annoying side. One of these monkey jumped on top of our van and was trying to get in and get food. It was quite scary!

In Kenya they have a saying "The Big Five" - which are the five animals deemed the most dangerous in Kenya that people try to see on Safari. Well , I went on my first safari this weekend and saw four of the Big Five. So the big five include: elephants, lions, rhinos, buffalo, and leopards. We saw everything at Lake Nakuru except elephants (because there are no elephants at Lake Nakuru).

It was truly an amazing, beautiful experience. It is hard to put into words. We left Saturday morning and drove two hours to Lake Nakuru National Park. We had a safari van, where the top opens up and you can stand up to see animals and take good pictures. We spent a total of 5 hours on Saturday and 3 hours on Sunday driving around the park seeing amazing animals. The park was huge and centered around a beautiful lake. We stayed at a resort lodge within the park. Overall, it was an incredible weekend. I hope you enjoy some of these pictures.

Here is the list of animals we saw this weekend: lions, leopard, black-backed jackel, spotted hyena, vervet monkey, yellow baboons, white rhinoceros, plains zebras, african buffalos, warthogs, giraffes, common eland, impala, waterbuck, gazelles, marabou stork, great white pelican, flamingo, southern groun hornbill, common ostrich, helmeted guineafowl, and long-tailed windowbird. These are the animals we could identify in my travel book!

Things are a little different here.

On rounds today the head doctor (consultant) showed up along with about 10 medical students. We were completing our rounds on about 40 patients and we arrived at one of the last patients in the back corner. There was a nurse/tech trying to put an IV in the patient and he had an oxygen mask on his face. No one knew anything about the patient because he had come in earlier in the morning and no one had seen him yet. The intern picked up the file and started talking about the patient. After a few seconds several of us realized that the patient was not breathing. The consultant checked his pulse and the patient had passed way. I was just shocked that no one had any idea who this patient was and why was he one of the last patients we rounded on that day.

We also had an interesting case of what we think is Gullian Barre Syndrome. This gentleman has had a 1-2 week history of ascending paralysis. He now is unable to move his legs at all. The weakness has moved into his arms and he is starting to have some difficulty with his breathing. So we called the ICU in the morning. They have 5 ventilators in our hospital and they are very selective about who can use them. Fortunately this man was transferred to the ICU because Gullian Barre is reversible and you just have to let it run it course. Very interesting case that I will have to follow-up on. I am interested to see if he actually gets intubated.

I did my first lumbar punture today on a patient. Lumbar puntures here are a WHOLE lot easier because the patients are so skinny and you can actually feel their spine. This guy has severe neck stiffness and was not responding very well. The Medical student tried first and was unable to do it, so I gave it a try and GOT IT....I was pretty excited. Ofcourse the fluid came out so slow I had to sit there for about 30 mins watching it drip one drop at a time. We had to label the sample with small pieces of paper taped to the bottles and carry across the hospital to the lab to make sure it got done.

So on a lighter, non-hospital note the weather here is awesome. It has rained a few times but it is mostly sunny and in the 70s. I am going on a safari this weekend to Nakuro National Park which is know for rhinos, hippos, and flamingos. So I am sure I will have some great pictures. I will try and post some more pictures soon.

First Day in the Hospital

An overwhelming day...I think that sums it up. But I will share a few more details with you :) So to start I went to bed last night at 8:30 pm (with the help of a Tylenol PM) and slept until 7am. I had breakfest which included cereal with warm milk out of a bag. It actually wasn't too bad. I met up with my group and headed to the hospital around 9am.


The hospital is actually nicer (no cleaner) than I expected. It is quite large with a lot of different sections and a variety of services. I am on the general medicine ward. The medicine wards are spilt into two - female and male. I am currently on the male side. There are 60 beds on each side and there are two people in each bed. There are two teams per side - so that equals 60 patients per team. For my fellow residents in the USA - WAY OVER CAP :)


So the team leader is called the Registrar (he comes a couple of times a week) and we have two interns who pretty much do all the work. There is an attending, but they do not come very often from what I hear. Then there are a variety of medical students that come every now and then. Finally, there is me and a 4th year medical student from Indiana.


We rounded from 9am until 1pm. We walked from bed to bed and talked about (we didn't talk to the patients) and occasionally examined a patient. I quickly discovered that the are many limitations to medications you can order and labs/radiology you can get. A quick example...we have a patient that has rheumatic heart disease and suspected endocarditis (infection of the heart valve). They have been treating him for 4 weeks for endocarditis. On rounds I asked what bacteria they were treating. I discovered they cannot order blood culture and they were just treating him empirically for 6 weeks of IV antibiotics.


The other big difference here is that the patient has to pay for everything. You have to record every pair of gloves you use and they will be billed for it at the end of their hospital stay. They are not allowed to be discharged until they have paid their bill. They have guards at the doors to make sure the patients don't leave until they pay. If they can't pay then they don't get the procedure. We had a guy today with suspected gastrointestinal bleeding, he was vomiting up blood. He needed and endoscopy which costs $45. He is unable to pay for it at this time so he is going to go home and try to raise the money in his home town and get the procedure done as an outpatient. You really have to think about every little thing you order or use because the patient has to find a way to pay for it. Another patient has metastatic cancer and the Oncologist wanted us to order a CT scan of the abdomen. The Registrar said no because he knew the family had trouble affording food for their family.


Sorry if this seems a little depressing. If you read this blog you might have to get use to some sad stories. Hopefully there will be some success stories I can share too.

An overwhelming day, but I really liked it. I am going to hit the text books before bed to try and learn about all the crazy diseases my patients have.

Far Far Away!

I am really far away from home. I can tell this because I have been travelling for the past two days. I don't think I could get on another airplane even if I had to right now. But the good news is several hours ago I safely arrived in Eldoret, Kenya. Things are kindof a blur right now because I am so worn out. The combination of jet lag and just plain lack of sleep is catching up with me. Overall, my trip went as well as it could have. No big hiccups and I made it to my final destination.

The IU house is very nice. I just finished unpacking all of my stuff and I think a nap is in my near future. I think I will be getting a tour of the hospital later today.

Sorry this is so short, I just wanted to let you all know that I am here. The pictures above show the Eldoret airport and the plane that I took from Nairobi to Eldoret. Hope all is well back home. I miss everyone! Will write more soon.

Landed in Amsterdam

I have landed in Amsterdam and I am waiting for my plane to Nairobi. I still have about four hours of waiting. I discovered you can get 30 minutes of free wireless internet so I thought I would throw a quick note up on my blog. So far the trip is going well. I am bit on the tired side, and not really looking forward to getting back on another plane for 9 hours. I can't complain because every thing has gone smoothly thus far.

I was excited to see a Starbucks at the Amsterdam airport. So I ordered my classic Vanilla Soy Chai (which does not have any coffee in it), I guess a Vanilla Soy Chai in Europe is different because mine sure tastes like coffee. Oh well...I can probably use a little extra caffeine.

I think the best part about airports is people watching. It is amazing the diversity you see and all the languages you hear if you just stop and listen.

Well I miss you all already! Thanks for following me on my blog. I will write again soon from Kenya!

Ivan: I watched the movie Black Swan on the airplane, it was really dark and strange. Just thought I would let you know :)