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

                                                                       

Day 12

 I promised myself that I would stay out of the operating room while I was Kenya, but that promise went flying out the window today. Rumor had it that a neurosurgeon from Nairobi was coming in today so a few of us went up to the main theatre to check it out. While waiting on him to arrive we stumbled upon one of the coolest procedures being done by an orthopedic surgeon. This woman had been in a severe car accident and the lower half of both legs had been severely mangled. The procedure being done today was a skin graft over the exposed portion of the leg. It was amazing to watch how a skin graft is done in a third world country when there are no donors available or allowed. The skin was harvested from the thigh and I found myself in that tricky place where I start to think that surgery gives as much pain as it eases. The surgeon explained that she was an amputee candidate but they were going to try this measure first. I was also sad to find out that this woman was pregnant during the accident and had lost the baby.  My prayers are for her today, for full recovery and for babies to come.

When the neurosurgeon arrived we went to the theatre to watch him treat a 2 week old baby with Spina Bifida. I had the privilege of holding this precious Hadija as they prepped her operating room. Spina Bifida has a characteristic swelling at the base of the spine and hers was removed today. We then saw a VP shunt put in for a patient with hydrocephalus and that was WAY COOL but also nerve wrecking because the patient was only a few weeks old as well.

I also saw an appendectomy done on a 10 year old girl. It was interesting to see how the doctors approached this situation as no ultrasound was available and the girl could only say she was having severe abdominal pain and had obvious swelling in the abdomen. I’m pretty sure that the incision for an appendectomy in the states is only an inch or two long. This girls incision spanned from the base of her sternum, around her belly button, and then bellow her belly button about 2 inches because they were not sure what was the cause. The surgery was deemed “exploratory”. Thoughts from the doctors and students in the room included Peritonitis, Intestinal Obstruction, etc. but I don’t remember anyone mentioning the appendix (My Swahili is not so good so it could have been mentioned). The bowels were taken out of the abdomen and all of the excess peritoneal fluid (?) was suctioned out. The doctor then found the appendix and yikes-a-bee it was so infected. They charted this as the cause and promptly removed it. After a warm water/ metronidazole bath her intestines were gently placed back inside her body. This situation was the most glaring difference between first world and third world technology but it is so interesting to me to see the doctors use basic technique to treat a patient just as successfully. She will have a bigger scar than if the procedure was done in America but saving someone’s life isn’t always aesthetic.

                                        The first case, her bone was completely exposed.

                                                                 Operating room.

                                                           attaching the first graft.

                                                        Harvesting the second graft.

                                                         Attaching the second graft.

               Oh I forgot to mention that we stumbled on this hysterectomy as they were finishing.

                                                                   Baby Hadija

                                                              The Appendectomy.                                

                                                                        Bowels!

The Culprit.

               Needless to say It was quite a full day and my heart and head are full of surgery

Day 11

Back in minor theatre today we started off with a really gruesome injury. This woman, Beatrice, was in a bus accident and suffered a severe arm and leg injury. The wound needed “surgical toileting” which turned out to mean that we were going to cut away all the gunk and debris so that her wound could heal properly. I watched the arm be done and then did her leg wound myself. It was tough because the doctor told me not to give her any local so she was basically screaming the entire time I was working on her. She was grateful for the help though and appreciated that we took our time to try to ease her pain. The rest of the morning was a lot of redressing wounds and I practiced suturing again on a man who had been hit with a carjack. He was also in a lot of pain so I felt like I needed to hurry through the sutures. I also had an audience when doing sutures and was feeling the pressure to do a good job. They ended up being pretty good sutures after all, but the combined pressure of the situation is putting me to bed early tonight. The take away from today is to remember to retain compassion for patients and not to become detached from the situation. After a while of looking at the wounds they started to look more like a dissection than a person and I don’t want to be that kind of doctor.

This afternoon was spent at another orphanage. It is a strange thing to come into a situation like that with presents and soccer balls and candy and not know the story behind these faces. It is always a good time because they are happy to see us but I don’t feel that I am making a very big investment in these lives. In the future I’d like a more intimate time with an orphanage so that I can really know them. They were wonderful though and so full of joy, I left with high spirits and a heavy heart.

                              This is the arm portion, I got to work on the leg edition of this one.

                                                                          dancing!

                                                                  The song leader :)

I'm going to try posting videos of these babies on facebook so check it out if you'd like.

Day 10

Day 10

I spent the morning in minor theatre and there wasn’t much going on at first. A woman who had come in previously was back to have her stitches removed. She came in with knife wounds and I redressed her last week. Basically I was just handed a scalpel blade and a needle and was left to remove the stitches that were ready to come out. I then assisted with a little girl who had a snake bite on her foot but I really just held her and hand and said “pole” (sorry) a lot. This experience was nice in that, for a moment, I was her source of comfort. Later a man came in who had been assaulted and had a severe chest wound and pneumothorax ( I will investigate what this means later). He needed a chest tube so I, and about 20 other anxious students, gathered around the doctor to watch the procedure. It seemed that taking initiative was best so I tried to answer questions and be of any assistance. I left for a bit to see if any patients were waiting since all of the students were in one room and when I returned the intern asked if I wanted to suture. I’d done a teensy bit of suturing in june but it turns out that its more tricky than I thought. The face flesh is really tough and I honestly thought I was hurting this guy more, only to have the doctor tell me to push harder. Anyway it was a success and Im anxious to get more practice with it.  The take away from today is to enjoy being around other students because we are all scrubs (no pun) anyway and it makes for a good time when you admit your vulnerability and answer a question incorrectly.

The afternoon was spent in Old Town, a market area that had a lot of cool products and spices. I love the feeling of being around people hustling and bustling about. It is also Ramadan now so we wore long skirts out of respect for the very vast Muslim population in Mombasa. It was interesting for me to make the decision about whether to where the skirt or not but in the end I decided that an extra-dose of modesty would not offend Jesus. I think this falls under the “live peaceably with all men” portion.

Picture time!