Do I get a commission???

It's been so busy at the clinic that there usually are 15-20 people waiting outside.  Yesterday a guy rolls up around noon on his bicycle and starts selling food to those waiting.  At 4:15 there were 10 babies yet to be seen with 5 pending lab patients still left.  Everyone would need a malaria test as they all had coughs - for some reason cough is a very common symptom of malaria.  Each patient takes a minimum of 5 minutes to evaluate and then the lab is another 40 minutes to draw, stain the slide, let it dry, and then view under microscope. Then 10 more minutes to hand out meds and explain them.  No way we'd be done until after 8:00pm.  Triage down the line:  "What's the problem?"  "cough, cold, fever for 3 days", "come back tomorrow".  I did see two that were pretty sick and sent the rest away knowing that they all have malaria.  Each day I tell people to come in the morning but they still come late afternoon.  They all want lab tests regardless of the 99% chance it will be malaria (I think I've only had 1 negative result so far).

I'm thinking I should get a commission from the guy selling food or maybe set up my own food stand on the side.

Oh Sunny what have you done to me?

The "good mechanical condition" Chinese made pick-up, Sunny, decides to lose electrical power coming down a long hill.  I coast to an intersection of main roads where there are a few shops and lots of people hanging out to make the Matatu transfer.  I try to act like I'm just using my cell phone and there is no problem but after a while I have no choice to exit Sunny and see what I can do.  I'm surrounded by a number of guys soon after.  I quickly use my 10 words of Kimeru so to seem like a local but, of course, I'm whiter than the color of my vehicle.  A good thing about driving a piece of crap is that it appears you have no money.  A peek under the hood shows a loose cable to the battery and is resolved in a life sparing 10 minutes.  Of course, everyone who looked under the hood wants some schillings for their assistance.  I toss a 100 schilling note ($1.25) and tell them to split it.  Off I go.

Sunny and I started off so well.  Fickle girl.

Me and Sunny

Decided on another weekend get away.  A friend in the village says I shouldn't pay for a car as he has an extra and is in good mechanical condition.  Great I say, how about noon on Friday?  Well, 12:45 rolls around (which is early for a noon appointment) and in comes about a 40 year old small white pick-up by the brand of Sunny - I think Yugo took over this brand and improved it.  I figure what the hell, I can't hurt it.  I squeeze into the front seat with my knees wrapped around the steering wheel and head hitting the roof.  Now, everything is left hand drive here so it's even more challenging trying to pump the brakes (are brakes part of the mechanical system?  I should ask my friend), downshift and stay on the left side of the road without running into anything.  Fortunately, the river lodge I'm going to is only 70 kms away and the road is decent and I can average 40-50 kph without fearing a catastrophe.

This weekend is certainly going to be an adventure.  If you don't hear from me in a couple days, send out a search party on the road from Meru to Timau.  :-)

Malaria sucks

So, most of the time malaria is easier than treating a cold.  Quick test, some tylenol and antimalarial medicines and you are on you way.  The last couple days really have sucked with sick kids from malaria.  I come back to the clinic from lunch and find mom holding a 3 year old in her arms that only responds to painful stimuli but starting to arouse.  He's been sick for a day and had a seizure about 30 minutes before.  His temp is only 38.9C but this is after the seizure and expected to be lower after the muscle activity.  He is sick and needs to go to the hospital but what to do before he goes.  His gag is good enough to get oral tylenol down but what if he has another seizure.  The saline IV drips I bought last time are gone and could do just an IV but reluctant to give any IV meds if he is being carried down the road.  Maybe I could give some IM diazepam to possibly prevent seizures on the way but there's no way to monitor him.  Does he have just a febrile seizure that happened because of rapid rise fever or perhaps cerebral malaria?  Perhaps both.  Shitty choices to make.  I give him the tylenol and tell the parent to get him to the hospital as quick as they can.

Most of the time this is fun, sometimes not so much.

Disparity

Today I saw many sick children but one stands out.  A 9 year old boy that had been abandoned by his mother and left with some extended family member.  I could tell when he entered he was in serious condition.  In the ER, a code would have been called and rapid transfer to a children's center would have been done immediately.  He had been sick for about a week but it was obvious that malnutrition was a big problem as he was emaciated and weighing 19 kgs.  His respiratory rate was over 50 at rest and initial temperature 40+ C with a heart rate of 160.

Here the difficult part comes.  It's apparent this child needs to go to hospital but he hasn't been well cared for in the past and questionable if the adult will take him and pay for treatment.  I've seen it before so my approach is to evaluate, start treatment, give the full course of medications (in case they don't go to the hospital), and hope the child makes it to the hospital.  I treat him with max dose of tylenol, ibuprofen, and start the antimalarial meds and amoxicilllin while waiting the results of the lab for typhoid and malaria.

After about an hour, he is positive for malaria and negative for typhoid but his heart rate, respiratory rate, and temp remains unchanged.  Tough little guy but he is sick as hell.  I emphasis to the adult he needs to go to the hospital and cannot tolerate walking 10km in the sun.  I give her the medications in case she decides to go home instead.

The disparity is here.  Her reason to bring him to the clinic was that her well nourished 4 year old daughter (who weighed almost as much as he did) had a cold.  I guess it is admirable that she would even take him in but it is tough to see the terrible life he must endure.

A day in the life of ......................

Typical day:

0430:  Chicken makes obnoxious chicken noises and wakes me.

0440:  Chicken goes back to sleep and I toss and turn.

0528:  Fall back to sleep

0530:  Wake to the mulching machine used to grind vegetation to feed the cows.  I like the rhythmic sound of the machine.  Chicken makes chicken noise.  Hate the chicken.

0545:  Attempt to disentangle myself from the mosquito net and climb down from the top bunk of the bunk bed.  Hope the bed, which is designed for 120 pound Kenyans, doesn't collapse as I drop off the edge.

0550:  Bathroom events.  Hope the water tank is full otherwise cold bucket shower is in order.

0615:  Try to access the internet as morning is best time.

0700:  Served breakfast - something new everyday but always with strong tea mixed with 50% rich and fresh milk.

0800:  Off to the clinic through the shambas.

0810:  Arrive clinic usually to find it like an earthquake happened.  Kenyans like to wait instead of cleaning at the end of the day.  Put all the medicine bottles back and tighten lids that Ruth left all over the desk from the previous day.  Mop floors if we have water.

0815:  See patients

1300:  Walk home to have lunch waiting for me.  Again, a variety of foods but always fresh.

1400:  Return to clinic.  See patients.

1630:  Stop seeing new patients and tell those waiting to come back tomorrow.  Nobody leaves.  Finish up pending patients.

1700:  Leave clinic with people waiting outside in disbelief I am leaving.  Tell them "tono arojo" or see you tomorrow.  Take a quick peek to see if anyone looks like they are dying.  The staff works long hours and if I stay, they stay.  The nurse makes just over $100 per month for 6 day week and no holiday.  I figure they should go home at 5:00pm.

1715:  Sometimes hang out and relax or sometimes take the 3 km hike down to the tarmac and relax at Black Africa.  I have to admit I was first reluctant to go into a building called "Black Africa" being the only Muzungu around.  It's sort of a bar/restaurant where people from the neighboring towns go to have a beer or choma (bbq goat usually).  The people there are very friendly and I'm a big hit as I usually leave a 50 cent tip.

1900ish:  Walk back up the hill and wait for the peering eyes from the bushes whisper "muzungu, muzungu".  I usually roar at the kids and they scream and run away.  It's lost some of the affect since I do it a couple times a week now.  I'm still warned not to walk back up the hill as it could be dangerous but everyone knows I work at the clinic and it is doubtful anything would happen with so many eyes watching.

2000:  Served dinner at home despite tell them I'll be eating at BA.  Pick at a few bites while watching "in the name of love".  My family can't speak a lick of English but just love the Mexican soap opera dubbed by Japanese into English.

2100:  Try to crawl back into the top bunk without any collapse.  Read.  Hope the chicken has a heart attack while sleeping.

Code Brown - where the hell did that elephant come from?

I took the opportunity to escape for the weekend and rented a car and drove to a mountain lodge on the southern slopes of Mt. Kenya.  Beautiful place built during the colonial times and since have added some cottages.  It sits on sloping hills that come down to a clearing where, on occasion, the elephants partake in the salt lick and then drink from at one time was a swimming pool but now turned watering hole.  I was fortunate the first night to watch a herd of about 25 with 5-6 babies come from the dense forest and spend about 2 hours just 200 feet away from the lodge.  At night the jungle comes alive with all the night life and is eerily loud.  No electricity so it is pitch dark and I've never seen stars like are in Africa when the moon is dark and no lights are on - just incredible.

Getting to the lodge is a bit difficult the last 5 kms as it is dirt, steep, full of holes and rocks.  On the way back home I was in my tinny little toyota trying to avoid getting high centered or stuck in a hole.  I come around a corner and on the road about 70 feet in front of me is a full grown elephant and a juvenile.  The pucker factor increased dramatically when a quick math calculation revealed that I could reverse at 2 mph and the elephant could charge at about 30.  Hmmmm, this really sucks.  I've been on safari before and I've seen the guide rev the Land Rover engine to get them moving.  I give this a try in my 90cc engine.  I could have farted louder.  Should I honk the horn?  Nah, this would probably just piss them off and result in a worse situation.  I just sit tight and after about 10 minutes they finally move on and I pass without incident.

As frightening as this situation was, it wasn't nearly as dangerous as the drive down.  Just north of where I am a crop called "mira" is grown.  It's a bush and when chewed, causes a stimulant with mild hallucinatory effects.  You can tell the guys who chew mira as their eyes are buggering out, blink about once every two minutes, talk a mile a minute, and constantly cram more leaves in their mouth.  This is a lucrative crop and is exported to the Arab countries.  So, these stoned guys load a pick-up truck to about 20 feet tall and head to Nairobi down the treacherous road.  Usually on the wrong side of the road, going 150kph, horn blaring, eyes wide, green crap dripping from their mouth.  Appraently the mira drivers are well known to cause many accidents.  Give me the elephant any day over these lunatics.

I'm a lucky bastard.  I wonder how many lives I have left?

Frustration

My last visit I spent much of the time explaining to Ruth about appropriate antibiotic use.  It's terribly overused here and now that the Chinese have given the Kenyan government 40 billion doses of amoxicillin (of which about 40,000 are at our clinic) it is even more difficult to control.  Anyone who has a cough or thinks about coughing gets antibiotics and usually for a course that wouldn't be effective anyway.

So, I see a patient that appears to have a viral upper respiratory infection but needs to be tested for malaria.  I need to leave so tell Ruth to give the patient some tylenol and treat for malaria if positive.  Patient comes back 2 days later wanting more amoxicillin for their family as they have run out.  I check the card (every patient gets their visit recorded on a 3x5 card) and see that Ruth has given the patient antibiotics.  I ask her why and she says the patient has a cough.  rrrrrrrrrr Sometimes I feel more frustrated than a 13 year old boy surrounded by 16 year old girls.

Taking a holiday - rented a car and going to a mountain lodge to sit around and watch the elephants.

Monday - almost the same as home ....... except

Monday is a busy day, probably the busiest day of the week.  Today I saw about 30 patients and 23 of them were positive for malaria.  Of the 23, 21 were children under the age of 6.  It's almost like seeing kids with URIs -  a few tablets and off you go.  There are some that you can tell even before the exam begins that they are sick and it is uncertain about their outcome.  These I worry about.  It's probably only one or two a day but still very concerning.  I tell them to come back in a few days but rarely see them again - do they survive?  I'm not sure.  Sometimes I suggest the hospital for further treatment but I can see it in the mother's eyes that they cannot afford such a luxury..........

Sometimes Kenya makes me sad.

 The typical response to the Muzungu factor.

The New Girl and Toilet Seat Etiquette

Where I am staying is pretty comfortable for most people in this area but it is still very rustic by U.S. standards.  My family hires a live-in girl to help with the cleaning, cooking, etc.  When I was here before the girl was very shy and avoided me but we eventually became friends and she was of great help.  Upon my return the previous girl had been replaced by someone who gave me the "eye" when I first arrived like "who the hell is this white guy and how much extra work will I have to do?".  The living situation is that I am in the main house, the parents in their own area, and the house girl stays in a closet/bedroom.  Now, from my past experience, the house girl has her own place to shower and toilet and the main house is for my use unless visitors come.  Last time the toilet seat was broken and I sort of fixed it so that it worked as a "sitter".  Upon arrival it was off in the corner.  I fixed it again but the next day off in the corner again.  Hmmmm, I wonder why since I'm the only one sitting here?  I take out the leatherman tool and affix it properly so it can't be removed but one hinge is still questionable - fixed.  I get up one morning rather tired and sit down to find the seat up.  I know I left it down and I've heard strange noises at night and flushing so I'm suspecting she is using the toilet so she doesn't have to go outside but doesn't like the seat down and sits on the rim.  First time I've run across a girl who wants the seat up!  Never could figure girls out.

Life stops at 8:00 pm or WTF?

So, everything comes to a stop in Kenya at 8:00 pm.  There is this Mexican soap opera called "in the name of love" that is shown at that time and apparently can't be missed.  The funny part is that it is in Spanish that is dubbed to English by Japanese speakers.  English is fairly well understood in Kenya if spoken very slowly and clearly thus the dubbing is at about 50% of the speed normal English speakers would use and there is a 20 year old girl with Japanese accent for the 80 year old grandmother.  So it goes like:  Oh .......... please .............Erica ............ do..............not ...........waste.........your..........life..........on............Juan........Pedro........Santos.............Guiterraz

You can't get a beer, a taxi, or a life saving injection between 800 - 900pm.

Ok - I watch too.

The Speed of Kenya - pole pole

Kenya has surprising good technology in some respects.  Everyone has a cell phone and reception is available in most of the country.  Money is transferred from one cell phone to another thus eliminating the need to visit town or wait in long lines or use banks to a large extent.  Internet is another story.  I write this blog on a USB modem that connects to the internet via cell phone reception.  The Safaricom service comes with an ability to monitor the speed of the upload and download.  It appears my average speed is about 32kps - yes, that is a "k" and not a "m".  I'd like to attach photos to the blog but might have to wait until I get home.

Pole pole is kiswahili for slow slow and describes the lifestyle.  It couldn't be more true for the internet here.

Sex for 20 bob in a matatu

First, a bob is the equivalent of a penny in U.S. currency of 100 units per dollar or schilling in Kenyan currency.  Twenty bob is about twenty-five cents.  Second, a matatu is a van used for transport between towns.  It has seating for 12 but most often carries closer to 25 or more.  Often sitting in each others' laps or some other awkward and sweaty position.  This, combined with the frequent bumps in the road, results in a rather unique experience.

Sunday - Fire, Brimstone, and 800mg of Ibuprofen

Ok, so the clinic is sponsored by the MCK (Methodist Church of Kenya) and it is expected to attend church services on Sunday and especially so if you are the only muzungo in town.  I've learned from past experience it usually is wise to premedicate yourself with some anelgesic to best survive the three hour experience.  It is pretty much fire and brimstone service with amplified technology at an OSHA violating, ear damaging level.  Most of what I was praying for during the service was the electricity would go out and my tinnitus would subside, and that my heat exhaustion wouldn't become heat stroke.  Fortunately, the service would be interrupted by the occasional need to collect money, sell a chicken, or to sing a song and a short respite would be allowed.  I'm planning on a short trip next weekend.

Kenyan voices

My most favorite part being here is the walk to the clinic in the morning.  The area is rural and made up of shambas (small farms).  I walk down a trail bordered by coffee bushes, banana trees, and many other crops.  On the way to the clinic I pass by the primary and secondary schools where about 400 girls attend.  In the mornings they are all together and singing and clapping to African songs.  This never fails to bring a smile to my face and a feeling of contentment. 

Life at the clinic and communication differences - or please, just the facts

The staff and the patients are very nice but there certainly are some cultural difference.  Ruth, the RN, helps with the translation during the exam.  Now I'm a sort of "just the facts" type of guy and generally prefer to skip all the extraneous stuff but life is different here in Kenya.  Here's an example of a typical interview:

Me:  What's brings you to the clinc?

Pt:  After 2-3 minutes of communication to Ruth, "a cough".

Me:  Is that all?

Pt:  2 more minutes, "yes".

Me:  Do you take any medicines?

Pt:  2 more minutes, "yes"

Me:  What are they?

Pt:  2 minutes, "Amox"

Me:  When was your last dose?

Pt:  2 minutes, "three months ago"

and so on.

Conclusion of exam and treatment and sending the patient home:

Pt:  "I have a headache and pain in my joints"

Me:  (eyes rolling) Really, what part of "is that all" wasn't clear?  Lets test you for malaria and start over.

Kimeru language has words for yes and no but they are rarely used.  Everything is a story here.

Back to Africa or the return of the big, fat, white chicken

I guess the title needs some explaining.  At the conclusion of my last trip to Ukuu I was presented with a big, fat, white chicken (seems ironically fitting) that was expected to accompany me on the return to the United States.  I left it under the care of my host family which it is now waiting for me.  Given that it lives 4 feet outside my bedroom window and likes to remind me of it is still here at 400am, I think it's time to serve it up for dinner soon.  I'll try to post before and after photos.

If you haven't read the previous post about Ukuu, I'm back at the clinic for 5-6 weeks during January and February 2011.