La fin

For my last day in the hospital I thought observing surgeries would be a nice chill way to end my trip, but alas, there were about 30 people waiting in minor as I walked by and I ended up staying there for 9 hours.  It seemed to be a pretty typical morning with redressing, suture removal, catheter changes, etc. and I was feeling content about going out this way. The afternoon brought its own excitements however and it was probably for the best that I never made it up to the main theatre. A man came in with a huge growth on his head (I never heard the diagnosis) and we were put in the awkward position of redressing it and letting him keep the growth because the doctor’s weren’t sure what to do with him. Then a mechanic came in with his finger dangling off, followed by a man who had been literally stabbed in the back.  Following these two came a “wagon pusher” (his words) who had been run over by a Matatu (van used for inner city transportation) and it was here that the passage about Jesus washing feet took on a whole new meaning for me. This guy runs all day with a wagon full of fruit behind him, with no shoes and then he came promptly into minor with foot wounds. So there I am cleaning this gentleman’s feet for 45 minutes and I think I may have removed about 10 years of asphalt. He seemed pleased with the result and his wounds were not as extensive as we all thought.

The highlight of today was George. Last night, a few of my fellow students did a night shift in the hospital and became well acquainted with this man’s injuries. From what I can gather he came in very confused, face and clothes covered in blood, and explained to all of them that he had been attacked by hooligans who robbed him. Upon examination George presented with four knife wounds to the head and one to the wrist. I received a text from Joel this morning to look out for this guy and just as I thought I was going home for the day in saunters George. I get to do the stitches on his head wounds and have to do them in a hurry because of the amount of blood that he is still losing. While he is on the table we are chatting and he wants to reassure that even though he was attacked by thugs, “change is coming”. I ask him politely that if he feels like he is going to die then he should tell me and I’ll stop what I’m doing to save his life. He laughs even though I am completely sincere and once the head wounds are all closed I feel better about him not dying. The doctor then comes in and reattaches the tendons that had been severed by the knife which should restore George’s hand function.

I left the hospital with George’s promise that the Lord is going to bless me and I feel like today has been the perfect last day in the hospital. I got to see a lot of things and do a lot of things and mostly I really feel like I helped somebody. I’m looking forward to a career where these days are not so few and far between, and I’m looking forward to what the Lord has in store, because I think we all know by now, its more than I could ever dream of.

This guy just came in for dressing and then his thumb fell off.

the growth

A dangley finger

George's wounds

                                                                       Sutures!

                                                                     fixed tendons!

             

25

Earlier in the week I made a point to contact one of the doctors in the millennium theatre to see if it was possible for a few of us to join him as he performed some C-sections.  Today was our appointed day and we were had the privilege of watching several operations. We came in on the first when the baby had already been taken out and we realized that she did not survive. We went in to the OR to watch the rest of the surgery and it became increasingly apparent that the mother needed to have a hysterectomy as the walls of her uterus were paper thin. She is a diabetic who has already had 3 stillborns. The physician called for assistance and mama’s uterus was removed. All of this took place while she was under full anesthesia. My prayers are for 32 year old mama Florence, who will wake up to find that she does not have a child and she does not have a uterus.

After this instance the doctor pulled the 3 of us aside to explain. He said that the mother was experiencing something called Plancenta Previa (sp?) which means that the placenta has blocked the birth canal and the baby cannot makes it way out. When labor begins the mother will bleed and that is when she usually comes into the ER. He also explained the complications of a diabetic pregnancy, including having a very large baby due to the glucose imbalance in the mother’s system. He explained that she had not had any prenatal care and that she had not come to the clinic when she first started to bleed. He explained that when the after-birth was being removed from the uterus some of the uterine wall came out with it and that is why the entire uterus had to be removed.

The next two cases that we saw were much more encouraging in that both mama and baby made it through the procedure. The first was a very quick process lasting maybe 10 minutes and a healthy baby girl came into the world making her little baby cries. The next one was interesting because once the little boy had been removed from the uterus, the doctors pulled the uterus completely out to suture up the incision and it was about the organ was about the size of pee-wee football. The three of us stood gaping in wonder at how a woman’s body can adjust to accommodate a baby in so many ways.

Because I had seen a C-section earlier in the week I think the initial shock from the situation had subsided and I was really able to think about the process in a different way this time around. Mostly I just kept catching myself placing both hands on my torso in amazement of what my body is capable of. Often girls my age begrudge the fact that we are the ones equipped for childbirth while men just sit happily by, but today I realized how powerful this experience can be. Don’t get me wrong, it is still disturbing and terrifying that an entire human being can be grown inside of me, but it also strangely empowering to know that your body has the strength to handle this situation. Call it feminism if you will, but I was feeling pretty impressive (albeit hesitant) as we left the operating room.

The entire situation has solidified the feeling that I always get when I get this acquainted with the human body: we are made by a God who knows exactly what we need.

This evening we returned for a short night shift and I got to suture another head injury. This one was on a small boy, Samuel, who was a character and was really brave about the whole procedure. Things got theatrical when my assistant, Homayon, had a bit of a slip up when applying the local anesthetic and managed to spray us both in the face with it. We immediately rush to the sink (fortunately there was running water today) and neither of us have had any repercussions from the incident. It was quite the spectacle for two sutures but we managed to get Samuel sutured and dressed.

                                                                       Opening

                                                                   She made it!

                                                                   After a good clean :) 

International Medical Aid

While I have spent the last few weeks genuinely confused by Homayon Ghassemi IV, today may have helped me come to terms with the person I have spent far too much time disdaining. A privileged fellow hailing from Johns Hopkins University, Homayon has talked incessantly about  International Medical Aid since I have arrived in Mombasa. He pesters all of us to like his facebook page, gives us his business card, etc. and for a while there I thought he was just promoting a business.  He says things like “cosmetic surgery is the only place in medicine for me” so when he talks about mobilizing health clinics to impoverished areas around the world, you can see how I might be skeptical of a ruse or a ploy to beef up a medical school application.

However, today was the day for me to see for myself what International Medical Aid is really about. I joined Homayon and the rest of the team for a medical clinic in a village nearby. International Medical Aid hired 3 local doctors for the camp and our role was to simply take vitals and then line them up for a routine check-up. The most interesting medical case we saw was an umbilical hernia (see previous post for umbilical hernia repair) and the doctor had me push two fingers into the hernia and feel the tear in the abdominal wall (a creepy and cool experience). As much as I wanted to be actively involved in the medical aspect of today, it is so easy for me to become distracted by little fingers grabbing for my hand and smiles with missing teeth. I spent some time taking temperatures and weighing the kids but I spent a lot more time playing and talking.

The fact that these kids get to see a doctor is the most influential aspect of International Medical Aid because honestly it is an opportunity that may not have been granted them without this organization. The doctors then chart up the necessary medications and the prescriptions are filled and distributed later in the week. We saw almost 200 kids today and the profound effect made is still settling in my mind.

The obvious lesson from today is that I should give people a longer amount of time to truly unveil themselves. There are always going to be personalities that contradict mine but I can see how important it is to just get over it for days like today. My previous perception of Homayon’s “business” was changed by the major impact that I saw being made today and it was a joy and privilege to work with them.

                                                                           Lining up

                                                                weighing some babies

                                   

                                                                         Doctoring.

                                                                         Classroom.

                                                                     Nap time :)

                                                        
                              to learn more about international medical aid: http://www.iamaid.org/

23

It is not often that I get to experience something that is both interestingly beautiful and also disturbing. This sleepy day in Mombasa was one such day. I went into the main theatre and was just meandering around to see what surgeries were happening when I managed to bump into a fellow student who explained that a c-section was about to be preformed. I have observed many surgeries so, naturally, I thought I could handle observing this procedure.  I’m watching the surgeon make incisions and I’m thinking that it opening up looks like it always does. At this point the doctor manually breaks the water and I see her grab retractors and simply pull apart the sides of the abdomen and stick her hand in the incision. I don’t know all the logistics of what she was scrounging around for in there but it seemed like she was searching very slowly and thoroughly and then BAM! She has the baby by the leg and is wriggling her out of the womb. Once she is fully immersed in the cold harsh air of the operating room we here a few short cries and the doctor turns to show us this brand new person. The baby is whisked away and the doctor and first assistant turn back to the mother. I cannot take my eyes off the baby. She is making something that sounds like it could be crying but she is an almost perfect color blue. I see the nurse smack her on the back a few times and get the suction and oxygen situated. I know that right in front of me the doctor’s are working away on the mother and she’s got blood everywhere and I should turn my eyes back to her but I just can’t. After a few moments I see the nurse relax and I feel like I should go in and see the baby for myself. I am so relieved at the sight of the baby turning the right color pink that I immediately feel exhausted and want to have a lie down. I must’ve been holding my breath for the entire procedure. Both mama and baby were okay and I feel myself realizing that all the jokes I have made about opting for a c-section are not funny anymore. It was one of the more brutal procedures I have ever seen and I have gained a respect for my own mother for enduring this process and still loving me and Abram.

After that ordeal I went into the next theatre as a 3 year old was being brought in for an umbilical hernia repair. This procedure was totally chill and I was feeling much better about the whole situation because I knew when the surgeon made the incision nothing alive was going to come out.

I then skipped on down to minor for a bit and redressed some wounds before heading out for lunch and a nap.

The lesson from this morning is that I should respect the fact that so much has been done to allow us to save babies who are breech or who need to be delivered quickly for whatever reason but I should also respect the way that our bodies are made to have babies.

I returned to the hospital for a second shift tonight and it was not so pleasant. I haven’t felt this helpless since I have been here. A group of us went into the ER and the fact that they call it “Casualty” became increasingly ironic as the night went on. Joel was the presiding physician because the entire staff has no sense of urgency. The rest of us were doing things like putting in lines and getting oxygen. I sutured a little boys foot from start to finish without any supervision and it was only 2 stitches and maybe the most nerve wrecking experience since I’ve been here. We saw a little boy sitting waiting to be treated and then saw him being carried to a morgue.

It took someone else to make this situation positive for me tonight. As we are all sitting in minor sweating and totally discouraged by the sight of people still lying in beds being unattended to, Joel reminds us that because we were here tonight a man got upstairs much quicker for an appendectomy, a woman got her leaky IV changed, a baby got a breathing treatment and oxygen, a young boy received sutures for his foot wound, and a woman’s oxygen levels were raised because we managed to get a mask her.  I can see that a lot was done tonight but I have never been more motivated to hurry up and get my degree so that I can have the knowledge that I need to help people and not be trapped by my own ignorance.

 The lesson from tonight was simply a reminder that I am one small figure in a much larger picture. The arrogance that often accompanies a career in medicine has been effectively negated by my experience tonight in Casualty. I was in constant prayer tonight and have had the sinking and unnerving realization that I do not have the power to save these people, ever. Even if one day I have the knowledge to prolong their life, one day it must end. I need the Lord for nights like this, so that I can remember to put things in eternal perspective, and so that I can remember that when I am weak, He is strong.  

                                       This baby was pulled from the womb right before my eyes.

Little guy going in for his hernia repar

                                                                Hernia repair

                                  Women waiting to be treated in the morning.

22

A new group of students from South Dakota arrived this weekend and I had a wonderful time getting to know all of them. It’s a full house again and it’s nice to have people here who are so eager to be at the hospital and excited to learn. This morning in minor was SUPER busy. It seemed as if I glanced down at my clock and it was 9:00 and the next time I looked it was noon. We were removed tons of stitches from kids today which is always interesting and I had the pleasure (no) of teaching the new guys to put in a catheter. The gruesome injury of the day was an exposed Achilles tendon (pictures to come) from a man who had been bitten by a dog. He is diabetic so the wound really exacerbated before he came in for treatment. We had to use a local just to clean it and even then the patient was writhing in agony. We came back home during the afternoon lull and had a rest and then returned to the hospital around 6:00. Nothing much was happening this evening though so Joel and I took the liberty of teaching everyone to put an IV in. Admittedly I was really excited to teach at first and now my hands look a little like a pin cushion.

The big lessons from today:

1.       You don’t know something unless you can teach it. A catheter is not rocket science but I felt myself getting increasingly nervous as all of these people are looking to me for instructions. Fortunately everything went really smoothly and I was it was good to have that really full feeling of being able to bring information to the front of your brain.

2.       In all situations I should aim to respect the dignity of my patients. It is easy to fall into the trap of a scientific type a mind and just say “hey this is a catheter change” but really, it’s a man who has to expose himself to a complete stranger and trust that I am going to take care of him. Today I found myself being hyper aware of this sort of thing because there were a 15 Mzungus in minor and all of us are peering down at a woman who had a cyst removed from her breast. She came in for redressing but I found myself asking the boys to leave when it was over to help her get dressed again. It seems like it could be a small measure to take but im just thinking, would I want all of these people in here for this?

Here is the link for the donating to the orphanage: http://www.indiegogo.com/rebbeyjuniorschool

We are really close to making the goal of $1000 and I want to thank everyone who has already donated. Joel was able to go measure the orphanage and is planning to buy supplies so this group can get the project started. Thanks again!

                                                                Achille's tendon

friday, day 19

Initially I had planned on spending all my time in the main theatre today but Minor theatre was really busy so I spent most of the morning there. I had to go to the outpatient clinic to be able to dress Beatrice’s wounds. It was here that I encountered the first major efforts towards sterility since I have been in Kenya. The Matron, Margaret, went through step by step on how to properly dress a wound without cross-contaminating everything. Beatrice didn’t really like her though since she was such a tough cookie, but that Margaret sure knew her stuff. I returned to minor theatre and got to practice my suturing skills on a 25 year old guy who had been in a car accident and “degloved” his elbow and tore up the rest of it.

The highlight of the day was getting to see an orthopedic surgery on a fractured femur. Turns out orthopedic surgeons and carpenters are one in the same. The procedure required nails to be put in and a rod driven through the bone to restablize the fracture. The only complication was that there turned out to be two fractures and not one. I had the pleasure of wiping the sweat off the brows of these two very large German surgeons as they slaved away. Decidedly this is a job for the body builders. The surgeons were both great about explaining and describing what was happening. It was most startling that the patient was awake during the whole procedure because the noise of the drill is sure to make anyone’s hair stand on edge.

The big lesson from today is to take the opportunity to learn from all situations. I went into outpatient ready to just la dee daa my way in and dress Beatrice and leave but it turned out to be one of the most worthwhile moments of the day to just stop and listen to what the nurse had to say. 

the wound I sutured

gettin my suturin' on

The xray for the patient having surgery today

powertools

the procedure being done

The right side of the right leg, open to expose the bone

18

Today was an easy day to get frustrated. We arrived at the hospital at the same time that Beatrice did and as I was preparing to redress her wounds, the matron informed me that there was no more gauze in minor theatre. Running out of supplies is not a wholly unusual occurrence so we waited for a while and then we were brought exactly 4 pieces of gauze that I’m pretty sure were stolen from the emergency room next door. Beatrice was in great spirits today though and we exchanged numbers so that I can be sure to find her tomorrow in out-patient. The next patient that came in was a little boy who needed his wound to be redressed and evaluated. We waited another 45 minutes to get some more gauze and then proceeded to dress the wound. At this point in the afternoon I split to see what else was going on and found myself in ward 7 assisting the doctor in holding down a line of children who were having their blood drawn. What an ordeal! The lesson I learned from this point in my experience is that kids are pretty much the same everywhere and the second that they see white gloves and a needle, we are not friends anymore.  The wards are a pretty dismal place to be but I wanted to see for myself what things look like outside of the operating room.  Frustration seems to be a choice that I am running into a lot more often lately. Tonight I am choosing to rest my body and soul in the fact that while it seems I am doing so little, the Lord is doing so much more than what I can see.

In other news, a good pal of mine named Joel arrived last week and on one visit to the orphanage became inspired to get involved. He is now pioneering a major project to get some real walls for the orphanage and a suitable bathroom. The total cost for the project is somewhere around $1000 USD, which is pennies if we consider this a community project and all chip in. I’ll be posting a link on my facebook that can lead you to a spot to donate, if you feel so inclined. Any contribution is helpful and so so so appreciated.

                        this is awkwardly instagrammy but i cant figure out how to fix it. Anyway, this is Beatrice!

                                                                         Ward 7

                                                              Before we even got started.

                                                                Successful!

                                                    A view from a different part of the hospital

lip sutures

seventeen

I was joined in minor theatre today by a new couple from Canada. It was nice having some fresh faces in the hospital and I had a good time showing them the ropes. It started off really slow this morning. All of us were put into that awkward situation where you can’t really be wishing for people to be injured and need medical attention but we also don’t like just sitting around all morning. I found myself wondering whether or not people didn’t need to come in because they were healthy or because they didn’t have the funds to come in. The whole profession is a little deconstructive in the sense that I am essentially depending on people to be sick or harmed in order to be of any use in this world.

 I redressed a lot of wounds and removed a lot of stitches today and unfortunately didn’t get to spend time with Beatrice. She was arriving as I was leaving for the day and we chatted for a bit and agreed to try for an earlier time tomorrow so I can see to her wounds. I also snuck into the supply closet to have a look around. I can see now why it is so difficult to get anything from the charge nurses: there is hardly anything in there. Maya, one of the nurses, will hand me one surgical blade at a time and when the next patient comes in I have to schmooze her all of again just get another. She is a testament to how supplies are treated in this hospital. The staff will drag out everything that they have to last as long as possible, will use things until they are broken. It was easier for me to respect the system when I saw what the staff has to work with. I have yet to see a handle for a scalpel, everyone just bare hands the blades. It seems like simple things like that are coming up and if anything I’m more motivated to find things to send their way. I can see how easy it is for apathy to build in this environment, after a while of not having the proper supplies the staff adopts their imaginary sign of “what am I supposed to do”. Its daunting really to think about how so many basic things can just be absent from the situation.

What I learned today is that pediatrics might not be for me. I’ve always thought this was maybe not my place in the medical world but today really sealed the deal. I had a 3 year old patient come in who was missing the top portion of his ring finger. He already had sutures and only needed the wound to be cleaned and recovered. The moment that I put on my gloves he flipped the switch into hysterical mode and it took 4 of us to hold him down for something that would have caused him minimal pain. He was glaring at me as he left the theatre in his mama’ arms. She was also angry with me because I made her baby cry and I just kept thinking to myself, no one in that situation liked having me around. I know this shouldn’t matter so much when I’m considering a specialty but I think I’ll keep my interactions with kids limited to playgrounds and chicken nuggets.

I also met a Kenyan man today who was 94 years old. The life expectancy here is something like 58.4 so he was a real anomaly. The students were all going over to have a look because he was still moving pretty good for 94.

The big lesson from today: I should be the kind of person who prefers when people are well, even if that makes me irrelevant, and from my sweet little grandpa who came in the lesson is: people can survive and thrive anywhere.

a wound that I redressed today

I took the stitches out of this one. He had been in a cast for 4 weeks and had these cuts hiding beneath. My congestion seemed to play a major role in being able to help this fellow out

The supply closet for Minor Theatre

 Its about 3 ft by 3 ft closet and this was after a big restock.

Day 16

It is amazing to me that it is already day 16, those first few days seemed to really drag by but now it seems they were just the tug of the rubber band being pulled back and now I have been shot into hyper speed. I stayed at the hospital for a longer day today, in the event that we had some interesting patients come in the afternoon. I did get to watch as a 2 day old baby had her extra fingers and toes removed. She came in with 12 fingers and 11 toes and left with the standard set. I spent time talking with her father who also has the abnormality and he explained how he would never want his baby to endure what he had to as a child. It was sweet and I took the time to reassure him that she wouldn’t even remember this procedure. He stood anxiously waiting until the process was over and I think I was just as relieved to be finished as he was. It still amazes me that someone so small can have minor (and sometimes major) surgery. The other extreme case that I saw today was a man who had been severely assaulted and had a huge gash behind his right eye. The interesting part of this situation was that he kept trying to get up and leave as the ophthalmologist was treating him. It was a circus in there for a while. The doctors and interns just stood back as this man continued to get up and fall down. He could hardly see due to the swelling and was either drunk or suffering brain damage from the beating because he could not stand up for longer than a few seconds and fell on the same side every time. Even after receiving local anesthetic he claimed that they were hurting him and would try to leave the room. He was maybe 6’5’’ so I was a little hesitant about getting too close. In the end, the doctor was able to get sutures in and we wheeled him back to casualty to await his further treatment. Everything else was just the typical day in minor, a lot of redressing and removing sutures. I was thanked profusely by a man when I took half an hour to remove his sutures. Here I am thinking that I should get a move on it and all he has to say at the end is that he can see I am going to be a good doctor because I took my time and made sure not to hurt him. It’s the little things, I tell you. I did see Beatrice again and her injuries are greatly improving. The take away from today is to make sure I have a snack if I am going to stick around for an 8 hour day. It is chapatti day at the house though, so I’m sure the feeling won’t last. I’ll log this in under the “taking care of others requires taking care of yourself” category.

Eye wound

                                        in the middle of trying to get a handle on our escapee

                                                                 Beatrice on the first day

Beatrice today :)

Church day and Monday

Yesterday Lisa and I decided to accompany our housekeeper, Dollas, to church. Needless to say it was quite African and our pale faces were sticking out nicely in the crowd. This became most apparent when the preacher, making a very passionate point about the power of Christ, points to us and says “Look! The Blood of Christ brings all races together! Look at the Mzungus!” after which over 400 Kenyans turned to see who he was talking about. Lisa and I gave a sheepish wave and had to laugh. It is a true and powerful point that Jesus unites a variety of cultures; it was just funny to be the example in the illustration. After that we went to the other church just down the road which was very western and reminded me of home. The Pastor is actually from texas and its called Crossroads Fellowship, so i'll be investigating that further next week.

I was back in Minor Theatre today, I removed some sutures, did a catheter, redressed some wounds, etc. I’m getting a lot more confident about taking initiative in there but I’m also trying to be wary about “do no harm, cause no malice”. There isn’t a high standard for patient comfort in this hospital but I still don’t want to treat them like they are just experience for me. Today was also the first time anyone got onto me about being sterile. I went up to major theatre to see if any big surgeries were happening and the second that I stepped across the threshold a nurse came charging over to tell me about the microorganisms I was carrying on my shoes and could I please consider the danger of being unsterile. I was then promptly given a fresh pair of extra large scrubs, rain boots, and a hairnet, just to walk 10 steps in to look at the list of surgeries. I have to give her credit for making an effort towards sterility though; it was quite a refreshing reprimand. Later, Beatrice came back in to have her wounds cleaned and redressed. She was the one in the bus accident on the way to Nairobi who had a really torn up arm. She is getting to used to having me treat her. I am putting lack of patient interaction on the  “con” list for being a surgeon. She is an incredibly strong woman and I want to cry for her every day. I have to soak gauze in Biodine and basically wipe clean all the puss that her body is producing to get fresh blood to flow for the wound to heal. Its gruesome and looks incredibly painful every time. She is a champion screamer though and today she said “ Maya, MY DEAAA (dear), this pain is WOSE (worse) than childbirth!”  I also saw a really awful foot injury and a man whose fingers were basically dangling off from the top knuckle. I assisted in both instances, but it was Lisa’s last day so she got priority. The take away from the day is that patient interaction might be more important to me than I originally thought. I wish I could carve out my own specialty, so I could see my patients regularly and also be there surgeon, for the relationship aspect and the trust that it builds. Beatrice and I have a steady date for everyday at 2 o’clock and I find myself looking forward to it, not for the interest that I have in her wounds, but for the interest that I have in her healing.

                                                            Removing some sutures

                                                                       Foot Injury 

He said he stepped on a nail

                                         holding onto a wire as it was pulled through his hand

Using the glove wrapper as a sterile field

Day 13

After a good sleep-in this morning a few of us decided to go to into the hospital to find that nothing was going on in minor. I bandaged a few people’s wounds and then a few of us decided to walk around the rest of the hospital. Today was a tough one for me because the state of healthcare and public health became even more obvious. I went into maternity to find newborn twins lying next to each other completely unattended. One of them was perfectly pink, and the other was screaming crying and was dark blue. The three of us immediately noticed the urgency of the situation and tried giving him oxygen and suctioning out his secretions until a nurse meandered in to ask what was wrong. The suction machine ended up not being able to work and I found myself praying for the oxygen machine to be enough.

The ceiling is falling down. There is still no soap. Today I was told to wash my hands with water from a barrel. Warm, stagnant water.

I’m trying to suppress the reaction to be angry at this situation, to resist thinking that these people would have a better chance in a first world country. Most of this is not a healthcare issue because the staff is well equipped; it’s a public health issue. It’s an issue of caring. Caring about the sterile field and caring about contaminating the patient’s wound. I’m choosing to focus this anger into motivation but only after letting it simmer for several hours. Like I said, today was a tough one.  

                                                                 medical supplies

                                                               a room in Minor Theatre

                                                                     The Ceiling

 

                                                             An Xray amongst the trees

                                                            wound and catheter station