In Conclusion

I left the blog abruptly. The last few days in Kenya went by quickly.

After my last post – I spent the following day in Rongo participating in World TB Day Festivities – “Mulika TB, Maliza TB” (“Shed light on TB, Finish TB”)

That evening, I headed back to Kisumu where I spent Friday shopping for gifts for friends and family. Saturday, I flew to Nairobi and Sunday morning I left Kenya!

Thank you all for following along with my on my Kenyan journey! I had a wonderful experience and hope that you enjoyed my raw, uncut, unedited reflections.

Finally, I wrote a slightly more refined reflection piece for FACES summarizing my experience and I have included this below:

 

REFLECTION POST

By Ali Khaki, MD

I’m a third year UCSF internal medicine resident that spent the month of March working with FACES in Rongo, Kenya.

The FACES clinic site in Rongo was based in the district hospital grounds making for a unique experience including both outpatient HIV care and exposure to inpatient hospital ward rounds. I also had an opportunity to do some field work with the FACES staff visiting some remote clinic sites in the villages of Osogo and Ongito as well as attending World TB Day festivities in Rongo.

 

FACES HIV Clinic

I enjoyed my time in the outpatient HIV clinic working side-by-side with the clinical officers (COs) to check-in with patients and refill their medications. I learned some basic Kiswahili to use while screening patients thanks to the tutelage of the fantastic COs by my side:

“Una shida gani leo” (What problems have you today)

“Chupa dawa” (Pill bottles)

With this elementary Kiswahili, I was able to connect with patients and participate in the process of routine symptom screening and refilling medications.

 

Medical Ward Rounds

At least once a week, I would join the hospital staff for their Medical Ward Rounds. The rounds were a multidisciplinary event with doctors, clinical officers, nurses, pharmacists and rehabilitation therapists as we rounded on all the admitted patients in the hospital. This was a memorable experience on medicine in resource poor settings and exposure to tropical medicine not seen in the USA. For example, I saw numerous patients with malaria – a diagnosis I had never seen in the USA.

I was impressed by the diagnostic skills of clinicians limited to very few diagnostic tests and how this changed their clinical practice. Absent microbiological diagnostics and even basic hematology and chemistry labs, providers are left treating patients empirically (with more liberal use of antibiotics) based on presenting symptoms, exam and epidemiology.

 

Field Work

During my field visits to rural villages amid sugar cane plantations, I was impressed by the extensive infrastructure of HIV care that has been developed by the Kenyan government in partnership with NGOs like FACES. Even in remote villages, difficult to access by car, FACES had a clinic present working to diagnose and treat patients with HIV. I was also impressed by the numerous local community workers who have committed their lives to HIV screening and education. This same infrastructure will be a valuable asset, if preserved, to expand relevant healthcare screening and treatment even in a future Kenya without HIV!

 

Final Thoughts

Finally, on a personal note, I have a particular interest in East Africa due to family roots in this region. My parents were both born in Tanzania so, as a child, we made frequent trips there to visit family. Since that time, I have always been looking for ways to return to the region to visit and to serve the local community. The partnership between UCSF and FACES made this return possible.

Despite multiple trips to Tanzania as a child, this was my first time visiting Kenya. One thing that struck me about my experience was some of the differences in the culture and people between the two countries. For example, I was struck by how well the people of Kenya spoke English compared to what I recall of people in Tanzania (with the caveat that my last visit to Tanzania was back in 2002). I was also struck by the educated, motivated Kenyan middle class that I interacted with both through the FACES staff and my exploration of Kisumu and Nairobi.

For more information about my experience – check out my blog documenting my experiences and reflections from my time in Kenya at www.alikenya.wordpress.com.

#21 – Wednesday, 23rd March – Antenatal clinic and CME

Another day in the antenatal clinic today after a second CME presentation that I delivered this morning. This morning’s CME was for the clinical staff alone. I spoke about tuberculosis – another disease present in the US and Kenya but in different segments of the population. The discussion we had allowed us to share about some of the similarities and differences in the delivery of medical care between our countries. As my time here comes to a close, I realize how much I have learned and shared with this clinical team and am grateful for the time we’ve had together to get to know one another and share knowledge and experiences from our respective backgrounds.

I spent the rest of the day in Antenatal clinic seeing pregnant women again. One thing I did not mention earlier this week when I was in the clinic was that this clinic is beginning to roll out an online medical record which has changed the clinical work-flow. Just like electronic health records (EHR) in the US have added more work to the clinical work-flow, the same is true with the early implementation here in Kenya. While I’m here in Kenya, I have been reading Bob Wachter’s book, The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age. It was interesting as I worked on this EHR here in Kenya, I thought about my experience with our systems and America and about the early implementation of technology in medicine as discussed by Wachter. It is unfortunate, that the early implementation here in Kenya, much like in the US, is actually more of a burden than a convenience. Hopefully, with time, the extra work that this system is creating will pay its dividends by assisting with managing and tracking patients in the long run (though this is done remarkably well by staff here using the paper registers).

One other comment I’ll make about the medical records here in Kenya – they have a system here that leaves the medical record, at least for pregnant patients in need of routine monitoring, with the patient. This has been remarkably effective because patients can self-present at a new location and still get the necessary antenatal care without any repetition in diagnostics or treatment. Overall, it is solutions like these and infrastructural investments like those shared in earlier posts that has left me most impressed with the Kenyan health system and the potential for excellent medical care in the future.

#20 – Tuesday, 22nd March – Medical Wards Rounds and some final thoughts about my friend

Tuesday is always a highlight of the week – the day of the Major Wards Rounds – when I get to see the inpatients admitted at Rongo District Hospital.

This week the census on the wards was lower than the last couple weeks but still nice to see the higher acuity patients than what we see in clinic. The pediatric ward still had its malaria kids – this week only three or four of them. No admitted adult men but there were a couple women. One woman was difficult to wake when we arrived to see her. She was admitted the night before with concern for possible barbiturate toxicity – she takes phenobarbital for a diagnosis of epilepsy. I looked at 65 year old women and while the history suggested this overdose, I couldn’t help but think of all sorts other diagnoses that would explain this presentation, while still limited by the absence of most diagnostic tools we’d use in America. One thing we decided on rounds was to give her some sugar just in case she was hypoglycemic (they aren’t even able to check blood sugars L). We moved on to our next patient and before we knew it, after receiving some IV dextrose (sugar), this woman had awoken and walked off to go to the bathroom! I shared with the team a medical pearl form the beloved LT at the SFVA:

“A stoke is not a stoke without 50 of D50”

The other interesting patient we saw on the wards today was a pregnant woman with sickle cell anemia who was admitted for a pain crisis. In America, all the sickle cell patients I have cared for are on very high doses of opiate medications because these patients ALWAYS have pain as a result of their sickle cell disease. Here, this woman in her 20s was not on any chronic pain medications and was primarily getting NSAIDs or low-dose opiates to control her pain. The discrepancy was stark and makes you wonder why the difference in management and what leads to better long-term outcomes.

Finally, I want to spend a quick second to share some final thoughts about my friend that I have discussed at length on this blog. He left to rejoin his family in Kisumu today so we bid our final farewells. After initially questioning his motives and wondering about a secret agenda, I think today, as I bid him farewell, I realized that this person is indeed a good friend here in Kenya.

#19 – Monday, 21st March – Antenatal Clinic

Back to work today. Starting my last week here in Kenya.

Today, I had a chance to work in the antenatal clinic at the hospital. In this clinic, we would see pregnant women for routine check-ups – some HIV positive, others HIV negative. The majority of patients seen were in their late teens or early 20s, a far cry from the age of pregnant women in America. These young women were so young – some in their early 20s on a second or third pregnancy.

I haven’t done any obstetrics since medical school, so this was something I’m not used to doing. Not to mention, here in Kenya, palpation of the abdomen is the major way to monitor fetal growth. No bedside ultrasounds or Doppler machines to check for fetal heart rate. In addition to palpation for growth, there is a fetal scope – which is basically a plastic funnel – that can be placed on the pregnant belly to hear a fetal heart rate. It was cool working with the staff to re-learn some obstetrics basis. It was especially neat watching how good they were at palpating the abdomen, determining the lie of the fetus and identifying the fetal heart rate with the fetal scope.

#18 – Sunday, 20 March – Rusinga island + the friend saga continues

It’s my last full weekend in Kenya (time flies!) so I had set out to have one more fun excursion. I decided to visit the town of Mbita and the adjacent Rusinga Island on Lake Victoria. This initially seemed like a great distance to travel for a day trip so I had not considered it a possibility. However, I was advised by one of the Guesthouse owners that the journey was shorter than I thought, and so, I set out to on this adventure.

Before I could even leave Rongo, the friend saga continued. I had initially planned to go to afternoon prayers and get lunch with him today. After the events at the end of the week – see #15-16 – I set out to check out Rusinga and cancelled on him. I set out for town at 930 or 10AM this morning and my friend phoned and insisted on not leaving before he could meet me – he advised he had some fruit for me. Sigh, now what? Do I wait for him? Fruit? I was already feeling a bit guilty about cancelling our lunch meeting, and now with the fruit…

I made my way to town slowly, letting him know he would see me on my typical path. When I met him, he walked with me to the station then just before I boarded my matatu, he gave me a TON of fruit!!! Bananas, papaya, grapes, it was plentiful! Feelings of gratitude and guilt overrode me! I was so suspicious, I cancelled my plans with him, I have NOT been a good friend, and now he gives me this! I was touched and humbled.

After this moving start to the day, the journey to Mbita/Rusinga Island was eventful on its own. The plan was to take a matatu to Homa Bay (~1 hour) then transfer to a second matatu to Mbita (~1 hour). The first leg of the journey went smoothly. Upon arrival in Homa Bay, I found a matatu to Mbita – unfortunately, this did not depart for over an hour! The matatus don’t depart until they are full (and often not until they are overfilled!). This matatu was NOT filling. I later learned that most people take smaller cars to Mbita rather than the larger matatus. I had already paid for the matatu so was stuck waiting…Upon arriving in Mbita, I was advised to visit the Rusinga Island Lodge on the far western side of the island. I called for a piki piki (motorcycle) which took another 20-30 minutes on a long bumpy road on the island. By the time I made it to the destination, the fruit from my friend was largely destroyed – the papaya had broken, the grapes were mostly juice, thankfully I was able to salvage the bananas (this feels like some odd metaphor of the relationship).

The journey was long, but the lodge was amazing! Beautiful views on the water, wonderful gardens, it was a peaceful, serene retreat that made the journey worth it. I had lunch in the lodge, sat by the lake and read and had a wonderful afternoon before making the long journey back to Rongo.

 

#16 – Friday, 18th March – Community outreach and CME + more about my friend

FACES plans once monthly community outreach fairs to target high risk populations and screen for HIV. Today was the day of one of these fairs. The was comprised of a large informational tent with music, short education pearls about HIV and safe sex practices (condom instruction) and smaller tents for private HIV screening. I sat in with an “HTC” (HIV testing and counseling) counselor for part of the morning to see their screening and counseling in action. I probably saw ~5-6 encounters over an hour (all five were HIV negative!). Thanks to rapid HIV screening tests, patients get the result of the test on the spot, and while the testing is being run (~5 min), the counselor has a few mins to do some focused, targeted messaging that is tailored to each patient individually.

In the afternoon, I delivered my “CME” (continuing medical education) talk to the staff. I spoke about HIV care in Kenya and the USA. Overall, I think it was well received.

After my presentation, I left work a bit early – I had to pick up a couple things from town (and this allowed me to dodge my friend who often waits for me around 5PM at the hospital gate). When I got home for the day, my guesthouse owner told me that she had done some sleuthing and gotten some information about him. I had mentioned to her (my guesthouse owner) yesterday that this friend had asked about a ticket or planned a prolonged visit to stay with me. So, this morning when I left home, a worker from the house followed me (to no knowledge of mine) to assure my safety but also to get some more information about my friend. It turns out, this individual is known to quickly befriend foreigners but is not harmful – though word in Rongo is that he may have some undiagnosed (or diagnosed?) mental health disorder. The plot thickens…

#15 – Thursday, 17th March – TB clinic and my friend

Thursday was a quiet day working in the TB clinic. Few patients have active pulmonary TB making the clinic one of the slower clinics on the hospital grounds.

One thing I forgot to mention earlier this week is that my friend is back. I thought I may have seen the last of him when he went to Kisumu and asked me for money as he set off on this journey. After the weekend away, he returned on Monday and was back to joining me on my walks to and from work. Today, the friend mentioned that he would like to visit me in America and even asked me to buy him a ticket. When I told him this was an unreasonable request, he then suggested that when he comes that he would stay with me for a month or longer. Sigh. This has been probably the most challenging thing about my time in Kenya – navigating this single relationship. There are times when I think that while he is somewhat “sticky,” he is pleasant, innocent, and excited to have met a Muslim friend from a different country at a time when he recently converted. Then there are interactions like today or last Friday where he is asking more of me than is appropriate for any friendship and it calls into question the intentions of the entire relationship. So as of today, I say the jury is still out on his intentions. Stay tuned.

#14 – Wednesday, 16 March – Osogo and Ongito

I had the opportunity to go visit some of the remote sites that are part of the Rongo District Hospital and FACES network. I went with a team of three FACES staff members who were surveying the documentation and work being done at some of the satellite sites.

We went to two small villages nestled within the sugarcane fields of southwest Kenya. The first was a village known as Osogo – the bigger of the two sites visited. Osogo had a single clinical officer, a nurse who served as the site coordinator and a total of ~10 staff members with different roles from HIV testing and medication adherence counseling to checking patient in and measuring vital signs. The staff were very receptive of our visit, provided the documentation we were checking and were incredibly receptive to feedback from the group. One of the motto’s of the staff and the feedback was to always remember that the first boss is our patients and the work we do is to help them control their HIV.

In the afternoon, we moved along to a second site visit – the village of Ongito on the banks of a small river amid tobacco and sugarcane fields. Ongito had two staff members we met, one of which was a clinical officer and then a support staff member. Despite the small office, the documentation and records provided were impeccable and this small team was committed to keeping track of patients failing on therapy very closely.

All in all, I was impressed by the educated, committed staff in these remote areas of the country. The number of people focused on working to control the HIV epidemic here in Kenya continues to amaze me. Large numbers of hard-working, talented individuals have made this work their mission and it is remarkable to see.

Just as impressive, is the organized clinical infrastructure that has been assembled as part of getting control over this epidemic. This was a small snap-shot of that infrastructure. But if it has been assembled in this fashion throughout the country, I have high hopes for the future. The organization, team work coordination and man-power are remarkable and would be enviable for anywhere in the world. The interesting challenge will be to see if the infrastructure persists as a broader clinical network even after HIV.

#13 – Tuesday, 15th March – Medical Wards Rounds

Tuesday means another day of Medical Wards Rounds, a highlight of the week when I get to join rounds on admitted patients at the Rongo District Hospital. This week there was less malaria and more diversity in the patients seen. One adult patient even had lobar pneumonia, a diagnosis I know something about. It was interesting, now with a week under my belt, to observe the differences in medical practice here in Kenya compared to the USA. At this district hospital, access to labs aside a rapid HIV, a malaria smear and a CD4 count are very limited. Yep, no complete blood counts or electrolyte panels. No LFTs, lactate, UA. These can be done, but much thought is put into any and all of these because of the cost associated and the additional difficulty in acquiring. Even radiology studies like a chest x-ray or ultrasound require sending the patient off the hospital grounds to the town to get these done.

This results in clinical care being done largely with history and physical exam alone. One patient admitted late last week with advanced AIDS and severe malnutrition admitted with difficulty swallowing related to candida esophagitis (fungal infection of the esophagus common in AIDS) and diarrhea. She was an interesting case study to highlight some differences in care. I forgot to mention that one of the clinical officers pulled me in to the hospital to see her last Friday. I remember seeing this very sick appearing patient and wondering, what is her CD4? Is she septic? She had swelling of her feet – could she have HIVAN (HIV associated nephropathy) – does she have evidence of protein spilling in her urine? Maybe she has significant liver disease from one of the numerous infections related to her AIDS – do we have LFTs? Maybe she has heart failure. What is her albumin (marker of nutrition)? We had absolutely none of the tests that I would want to help me better frame and work this patient up. I recommended some of these, CD4 was 50, many of the other tests – including a urinalysis and renal panel came back normal and the medical team continued to hydrate her and treat her candida and her malnutrition. Were my suggestions worth the extra cost to the family?

At the same time, on this day on rounds, the patient was markedly lethargic. I thought – let’s check a blood sugar, maybe a repeat renal panel to see if she has electrolyte derangements from refeeding. The team on rounds opted to give her some dextrose (sugar) – the blood sugar machine is not operable – and spent a lot of time discussing whether they believe their physical exam of lethargy and pallor suggesting severe anemia vs the hemoglobin measure of 8.5 from admission.

When we got to the lobar pneumonia patient, we discussed antibiotics and duration and I offered how we opt for a shorter rather than longer duration of antibiotics in the US. In response to this, one pearl from the senior medical officer best summarized the major difference in care that I had observed.

“In Kenya, we are limited by access to diagnostics, so we are left to treat empirically.”

This reigned true from the malnourished AIDS patient and patient with a lobar pneumonia described to the infants we saw with persistent fevers and another AIDS patient with confusion and lethargy.