Final Post

Well, back home and greeted with too much snow. We had a good time on safari although the accommodations were fair. It was wild to see all the animals so close to our van. Below are some final shots from safari as well as some pics from the hospital. All in all Sara and I had a memorable experience and we hope to return. It is clear that the rewards are great in helping those with so little. Thanks for following!!

2 patients to a bed

making rounds

camera shy!

Simba! Yes he looks this impressive in real life.

Lions and Tigers and Bears

Thurs Jan 21st- flying to Nairobi tonight and starting safari in Masai Mara National Reserve Fri-Sun. Not sure if we will have internet access there ( I hope not). Stay tuned for some final pictures/ thoughts in the near future.

Jan 19

Starting to wind down in preparation for our plane ride back to Nairobi and then on safari. One of the docs who is heading the DM program here may be coming to the States in June for a meeting in Washington. We did talk about her coming to Lehigh Valley Hospital and working with our Endocrine  group to observe and learn about diabetes care. This would be a nice experience for all.

On a sad note, Kevin, who was pictured with Sara in an early blog (see above) died 2 days ago. He had sickle cell disease, but we are unclear of the cause of death. He was by Sara's side for the 2 weeks that she attended the hospital day care center and made him smile daily. She is, needless to say, heartbroken.

Sara and Kevin

Jan 17-18th

Mon, Jan 17th- nothing exciting except for making rounds in the am. The group has swelled to over 20 since the Kenyan med students have recently joined us. Rounds are difficult in this setting. The interns speak very softly and with so many people and the wards being chaotic and the heat by mid-day (let's not get into the aromas), after 3hrs I am ready for a break.

Tues, Jan 18th- I had a meeting with the Chief of OB-GYN as well as some other docs regarding DM in pregnancy (my special interest at home). Currently no pregnant woman is screened for DM;this is done routinely in the States. In addition, there is no one here who is really well versed in the care of a diabetic who gets pregnant. So once again it is exciting that I came here at a time when these initiatives are just getting off the ground.

In the long term, it looks like I can help with patient care protocols and we will hopefully be having monthly conference calls. There are a lot of challenges; most women present for their FIRST prenatal visit at about 32 weeks and 80% deliver at home. I offered to make house calls by giraffe if they give me a cell phone and a blood glucose monitor.

The weather here remains picture perfect and the running is finally getting easier as my body gets used to the altitude. Tomorrow our whole group goes out to supper for Chinese food!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Jan15-16th Lake Baringo

x

Hello-
This is probably my last e-mail. Nike has signed me up to run with the elite runners of the world to train at Iten, about 30 minutes north of Eldoret. The best of the best run here and Nike wants me to be the first male over 50 to win the Boston Marathon. They are paying me 100 Kenyan Shillings daily!!! ($1.25) and providing me with running shoes, 3 power bars a day a cold shower. By this time in April, I will be 10 lbs lighter and will drop my best marathon time from 3:17-2:02.."no worries" as they say in Kenya. With the winnings I will make my tribe in Lower Macungie the richest with many cattle and goats.

Oh, boy was that a good dream.

We did pass by Iten on the way to Lake Baringo which was about 3 hrs away. We stayed on an Island in the middle of the lake. It took about 15 minutes by boat to get to the island. Sara and I shared a tent which overlooked the lake. The drive to this lake was beautiful and very hilly with many winding mountain roads. It was nice a cool at the top, but in the 90s at the lake.






No swimming in the lake due to parasites and crocks (and lions and tigers and bears..oh my!). Most of the group headed for the (hopefully parasite free) pool for a day of R and R.

Freshwater pool overlooking lake. Marc snoring with ipod on far left (not visible)

We had a nice barbecue which didn't start until 8 pm. It became nice and cool and we went off to bed. Unfortunately one of the residents found a poison cobra on her floor so Sara wanted our tent zipped down tightly to thwart off crocks, frogs and lions (and tigers and bears). The lack of breeze resulted in a midnight sauna and we finally opened the flaps. Crickets and birds (many varieties of birds were on the island) woke us at about 5-6 am, just in time for coffee and the sunrise.

The light lit up our tent which had a bathroom and actual hot/cold shower.

The birds enjoyed sharing our coffee, mild, sugar and ginger cookies supplied pre-breakfast...I think these birds are getting obese and diabetic from all the junk they eat.

We drove home at 10 am. The valley by the lake is very, very dry. This last picture does not look like much....

just some lolli-pops and bread. But in the valley we passed through kids didn't have enough to eat or drink because of the conditions. Some of us stopped at a small market and bought food, milk and fruit juice. We stopped at several places and kids came running to the car. They shoved the food in their mouths and wanted seconds and thirds..pushing perhaps their brothers and sisters out of the way who had yet to get anything.  Sara and I could not give the food away fast enough and there was not time for cute pictures, hence the shot above.
I felt empty after leaving these sites knowing that the little we gave can't last long. I assume these images fade for many when they return home. Some of us feel compelled that they don't. The work being done by those I am working with here prove the work of a few can help many.

WHOSOEVER PRESERVES A SINGLE SOUL..., SCRIPTURE ASCRIBES [MERIT] TO HIM/HER AS THOUGH THEY HAD PRESERVED A COMPLETE WORLD."  Talmud, Sanhedrin 37a

Jan 14th- Outreach HIV clinic with Joe Mamlin

Jan 13 was pretty "quiet.." usual hospital stuff. However the Kenyan med students have started and now there are over 20 people rounding. It is very difficult to hear anything unless you are right at the bedside.

Today I have the privilege of going with Joe Mamlin to an outlying HIV clinic about 40 minutes from Eldoret. See this site if you want to see how this program has evolved with Joe's influence:

http://alumni.indiana.edu/magazine/issues/200703/kenya.shtml

Joe has taken HIV treatment to the field and his approach is comprehensive as you can see from the article above. We sent 2 pts to Moi Hospital this am, one with rheumatic heart disease in AF and another HIV with wt loss, fever and abnormal CXR- probably TB. Joe was teaching a nurse practitioner  ("clinical officer") and after 4 months this CO was quite adept at handling HIV. Joe is a true internist; very good a physical exams, reading Xrays, etc.

It will be hard to forget the 14 year old girl  with big brown eyes we saw today who was HIV +. She was being raised by her aunt as her mom died probably of HIV. She was started on HIV meds today and she smiled so brightly when I gave her some cookies I had with me. She also had asthma but of course the pharmacy doesn't have the proper inhalers for her.

Many of the pts we saw today would have not survived in the past since there were no outreach programs to treat HIV.

We are off Baringo Lake tomorrow and take a ferry to an island camp in the middle of the lack. Looking forward to 24 hrs of R and R.

Jan 12- Kitale

Drove with the diabetes team to Kitale, about 1.5 hrs north of Eldoret. Actually it would take about 45 minutes but the road in parts were filled with potholes and we were driving off the road just to avoid driving on the road!
Kitale hospital is a district hospital ( a step "down" from Moi and similar to Webuye Hospital (see prior post). The DM program was recently started and is booming. Only 1 patient was using glucose testing despite many being on insulin. The one using a monitor is a 7 months pregnant DM2 on insulin 70/30 twice daily. She is only able to check one blood sugar a WEEK. Our pregnant pts at home check 6-8 x daily. It is quite hard to make any sensible changes. She agreed to check 1 fasting this friday and 1 pre-supper next Monday and we will call her by phone.
Another woman had high blood sugars and was diagnosed with malaria during her visit. A young 20 year old boy was just released from a 5 day hospital stay for new onset DM1 (total bill=$30). His blood sugar was over 400. When we asked him how he was injecting insulin he was completely off base and was trying to inject like we give PPDs. Like many others, he is discharged without adequate teaching. He also could not afford a glucose meter. He was one of several pts who needed large amounts of oral hydration solution because of high sugars and dehydration.

After a long day, we all went out to a Sikh restaurant for supper.

Some of you have asked about a way to donate money to a worthy charity here.  The Tumaini Center was started by a group including Sonak, a Purdue faculty member who is working here full time. This center is open 4 days a week and gives homeless/street children a free meal and place to stay during the day. Some are not actually homeless, but the parents cannot afford to send them to school and make them go and beg for money. The money you give goes directly to an account which Sonak controls- no admit or other fees are taken from the donations. Knowing Sonak these few weeks, I would be assured that the money will be put directly to good use. Below are the instructions he sent me:

For tumaini center click on the following link and follow the subsequent instructions.

https://donate.purdue.edu/DesignateGift.aspx


CORRECTION- TRY THIS FIRST-http://www.pharmacy.purdue.edu/advancement/development/giveonline.php IT SHOULD TAKE DIRECTLY TO THE COLLEGE OF PHARMACY.
In the first drop down box (Designation Area), highlight “College of Pharmacy”  (You will have to scroll down to find it).

In the second drop down box (Select a Fund), highlight “Kenya Initiative”

Then go to  “Enter an amount” and insert the dollar amount of the gift you want to make.

Sonak Pastakia, PharmD, MPH, BCPS

Assistant Professor, Purdue University College of Pharmacy

spastaki@purdue.edu  spastaki@gmail.com

+254 72 902 7569

Jan 10th- Running with the Kenyans

Back to work today but first...a run with a Kenyan! I ran with John Maina, a 20 year old training for 1/2 and full marathons. He has already won a Kenyan marathon in 2:30 and 1/2 in 1:05. He trains with 10 other Kenyans here; there are about 3000 runners training in Eldoret at one time. They then go up to Iten which is about another 1000 feet higher to train 4-8 wks before a big race. John's main job is training and he helps his brother in a small shop in Eldoret. It is not clear how he can earn a living except by winning races. We past alot of other runners..or should I say they glided by me.

We went out about 615 am for 8 miles which was all uphill the first 4. I felt winded because of the pace and I think I was a little dehydrated from the weekend. This was an easy day for him; he usually runs 120-130 miles a week. Monday and Wed are easy runs am and pm, Tues and Thurs are interval runs. Easy on Friday and then 15-20 miles on Sat. They eat a big meal Friday night and don't carry any gels or water for the long runs. Once a month they run a 26 miler. I finally found a guy who weighs less than me! He is tall and thin and his gait is so light and easy.

Back to the wards today. New DM1 who was on regular insulin q 6 hrs with BS>300. The resident was arguing with me about the best way to treat her. They don't take kindly to suggestions here as it seems to question their authority.

I spend the afternoon with Dr. Kimoono who is the designated diabetes expert. She is the attending on the ward service and is an excellent teacher and clinician. She can easily discuss if a pt with a fever has malaria, TB, meningitis, pneumonia or just the flu! She is in charge of a regional initiative to diagnose and treat DM in the outlying areas of Eldoret.
Right now the severe cases are coming to Moi University inpt or outpt facility. The goal is to develop simple protocols for nurses/nurse practitioners  in the outlying areas to start treatment for DM.

It looks like I will be collaborating with the DM team long distance to review protocols, etc. This will involve monthly conference calls and maybe another trip back here.  Hopefully Dr, Kimoono will come to the states for training and our Endocrine division can sponsor her.

Sara has continued her work at the orphanage and read stories to the kids this am.

Jan 9, Lake Naivasha; another day another hippo

After a good night's sleep, we woke up to the sounds of chickens and multiple other unknown animal sounds at about 4 am. Breakfast a 7 am and then off to the lake! We saw many hippos; there are over 1 million around the lake (according to the guide). They were lying around and apparently come up on the land at night to feed on vegetation. They are very aggressive if you get to close. We saw an eagle and the guide threw a piece of fish in the water and started whistling; the eagle swooped down from high up and caught it. I think the eagle get's a piece of the tour guide's action.

We then pulled up on shore and walked through a field. We saw giraffes, waterbucks, impalas  and zebras very close up. It was really amazing to be so close!



We started the long drive home and stopped for a photo-op at the equator. It was very hot stepping on the equator line, but "hakuna matata"   "no worries..."

Back to the wards in the am.

Jan 8th Hell's Gate National Park

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We had the weekend free to travel. Sara, Mehdy (resident fron LVHN) and 3 med students from Indiana Univ and well as 4 PharmD students from Purdue piled into 2 cars. We drove about 4 hours to Naivasha which is about 60 min from Nairobi. The road was filled with trucks, potholes and crazy drivers.
First stop was Hell's Gate: Hell's Gate National Park lies south of Lake Naivasha in Kenya, north west of Nairobi. Hell's Gate National Park is named after a narrow break in the cliffs, once a tributary of a prehistoric lake that fed early humans in the Rift Valley (as per Wikipedia).
It was after lunch when we got started and went on an 8 mile bike ride. Sara, as some of you may know, hasn't been on a bike since my beard became grey, so you can imagine her trepidation when she picked out a mountain bike and started to ride on the rocky gravel trail. At some points one could see Sara kicking her bike and screaming, but for the most part she made it through a rocky terrain in good shape. I am not, however, ready to buy her a bike for PA. We did see zebras and other animals on the bike ride but not an abundance of wildlife.
By time we finished the ride it was about 2 pm and over 80 and bright sun.

After fueling up with some water, etc we started a 2 hr hike through the Hell's Gate Gorge. There were hot and cold springs and alot of up and down climbing through the George. Scenery was very nice and we all got a little muddy and wet. There was a group of Kenyan students on a class trip behind us; the guys were dressed in white shirts, ties and sweaters in addition to black dress shoes..go figure.


After all this we were pretty hot and tired. We went back to our camp site. Sara and I shared a small cottage. The showers were hot for at least 10 minutes (oh,and Sara went first). We were served dinner and the tilapia and veggies were very good.

We were all pretty tired and headed off to bed..Sara did not take kindly to the malaria net!

Jan 7

Went with the diabetes team to Webuye Hospital, about 1.5 hrs from Eldoret and about 1hr from the Ugandan border. Roads full of potholes much like Costa Rica. Driving in Kenya is like a free for all..people all over the road trying to avoid the potholes.
We had about 60 people waiting when we got there. Viv Buckwalter, a family doc from Lancaster Pa has been at this hospital about 15 years and we discussed how he treats DKA without insulin infusions. Prior to 6 mo ago the mortality rate was about 20%; since starting an IV push protocol it has been 0.

Most of the patients are subsistence farmers living on small plots of land. Many live in mud huts with straw or tin roofs. No electricity or running water. They all have cell phones!! They come dressed nicely and many of the men had sport jackets; old and worn, but very presentable.

Blood glucose control was very variable based on multiple factors. Do they have the insulin? Is it spoiled since they don't have a refrig? Do they have food for every meal? Are they out in the fields working or sitting at home....etc. Despite all these problems, their A1C levels are not terrible. When they come to the clinic they get a blood sugar and point of care A1c. Many pts check their readings twice a day on a regular basis..much better than my pts at home. I questioned the staff as to why they are so compliant; these pts were enrolled with very poor control,,A1cs>14 or were hospitalized with poor control. They know how much better they feel with better control. Also many cannot afford another hospitalization.

On the way home we stopped on the side of the road for fruit...women farmers brought them to our car and I have bananas and a very  big papaya. We also stopped at an orphanage and bought gouda cheese;all proceeds go to the school.

Off this weekend to Lake Naivasha for some touring, eating and bike riding.

Day 4 at Moi Hospital

Sara has been spending time at the Sally Test House. This is on the property of the hospital. It is open during the day. They care for children who are hospitalized and also for abandoned babies. Although some of the kids look sad, when Sara shows them their pictures they start to smile and laugh.

We had a good dinner at an Indian place last night in Eldoret. I didn't know what to expect since the streets were dusty and chaotic. However when you walked in the place was very nice.

Hospital rounds again pointed out how little the doctors have to work with. Several women needing LPs (spinal taps) for suspected meningitis. Cultures of the fluid cannot be done and medication is just started.
We saw a woman today who was in septic shock and needed to go to the ICU. Only 6 beds with 5 ventilators all in use. There are no IV pumps to try to give her meds to raise her BP which was 70/50.

I am traveling to Boringo tomorrow. This is a town about 90 minutes away and has a medical clinic. I am traveling with Soniak, a PharmD from Purdue and a junior Kenyan doctor to see diabetic patients. These 2 are responsible for instituting several outreach diabetic programs in the local region.

Days 2-3

Tues Jan 4th- made rounds in the am for a while and then helped out in the diabetes program. The hospital has set up a nice program that started 4 months ago. Pts are contacted by cell phone every week (all Kenyans have cell phones- it is very cheap) and staff writes down blood sugars and insulin doses. Most pts on insulin only take Humulin 70/30 twice daily and monitor their sugars twice a day. The staff enters the info on a computer and 1 doc (post internship), a PhD and an attending doc trained in IM review and make changes.
I have seen several young type 1 diabetics with several neuropathy and gastroparesis. There is very cute 18 yo girl named Edith who works in this program and is a DM1. She agreed to change to tid Humalog and Bid N for the first time. We will review her bs in person. (To you non-medical readers, the Humulin 70/30 is a terrible insulin regiment for an insulin dependent diabetic -something we used over 20 y ago).

Wed Jan 5th- rounds today again brought home how different things are. A woman may or may not have endocarditis (infection of the heart valves). It would be nice to get a blood culture to look for infection...oh they haven't had the blood culture bottles here for months (some say years).

Another woman came in yesterday with BP 210/140 (very high). Overnight they put her on minimal medication. Today she looks like she had a brain hemorrhage with  unequal pupils and not responding. She would have been in the ICU in the states last night, but not here.

Our older woman with blood sugars under 30 and coma (see prior posts) could afford a CT scan and today it showed a probable huge liver cancer. Everytime we stop iv dextrose her blood sugar drops.

..and this was just the morning!!
I lectured to the Kenyan residents this am..they are very quiet but attentive. I think their book knowledge is superior, but they need help on taking care of patients in real life.

We took a cab into Eldoret to get to the ATM and buy a few things. All very dusty dirt roads and cars all over the place- they drive like your grandmother in Miami! 2 of us went to the ATM together as we were told to watch our backs!

All the attendings, residents and students are off to Indian Restaurant for dinner (yeah!!). Every Wed we all go out together..other nights we eat all our meals at the compound. Accommodations are basic but fine-love the mosquito netting.

Day 1 at Moi Hospital

The day started out with a nice 4 mile run at 615 with a med student who went to Lafayette College (she was a pole-vaulter there) and is a 4th year med student at Univ of Med and Dentistry of NJ/ School of Osteopathic Medicine. Small world- she has a scholarship for 1 year doing TB research.

Off to the hospital at 830 am. Take about a new world. I am assigned to a team on the woman's ward about 60 beds. Everything is open- no private rooms. Each section has 8 beds with most beds shared by 2 women- head to toe. They have to pay for the beds and can't afford a single one. In the first 3 hrs I saw TB, several young women with stroke from rheumatic heart disease, HIV etc. One woman has a large left neck mass and has been in the hospital for 2 months waiting to get a blood donation so they could operate. Meanwhile the mass is growing and pressing on her trachea.
Another has a large mediastinal mass (chest mass) and has been waiting 1 week for some one to biopsy it.
I saw an endocrine case of a woman found with hypoglycemia ( blood sugar <20) presenting in a coma. She was found to have this at another hospital , they gave her dextrose and sent her home. She has a large abdominal mass.
Some blood tests here take 2 weeks to come back and they ask the pt first if they can afford a CT scan since it is out of pocket. The Kenyan residents ("registrars") are frequently on their own and have teaching attendings twice a week. The nurses ("sisters") don't seem very reliable. The patients don't question the docs about their diagnosis or treatment plan. Most are very stoic despite the pain and illness. Families sit by and feed and position their relatives in bed.


This is all just day one- sorry for the detail, but I am using this as my diary.

Day 1 or 2 or 3..losing track!

Jambo (hello!)
Well, we made it to Eldoret tonite. Flight from Phila on British Airways was very good. People were nice, plan was on time and food was hot..this ain't your US Airways.

Got to Nairobi at 930 pm on 1/1/11..or as they say in Europe and Africa..1/1/11. Hotel was Art Deco and nice. After some mangos and coffee we met Joseph our travel agent who arranged several things for us. He took us to Alex who was our driver for the day in Nairobi. First stop an elephant orphanage. These "babies" were rescued after poachers killed the moms for tusks. They ranged in age from 8-24 months. They were fed bottled milk and played around in the mud..just like a bunch of little kids. We were very close to them and got some good pics. Sara wanted to take one of the 200 lb babies home. These elephants are only brought out for the crowds once a day. The goal is to slowly teach them to survive in the wild and they are brought back to the herd as they get older.

Next stop the Giraffe Center. We climbed some stairs by a wooden stand and were face to face with Daisy, a 6 year old and a 6 month old. We were able to feed them food pellets. They don't have upper incisors so the can't bite. They have a long tongue to pick up the food. Some brave souls put the pellets in their mouths and the giraffes would lick it out...Sara and I took bets that Susan would have done that if she was here.

We had a nice lunch outside and then saw some music and African dancing..now I know where Paul Simon got his music (ask andy or matt). Andy would have liked all the drumming.

We took a 6pm 45 min flight from Nairobi to Eldoret. The compound looks fine- basic and clean. Sara and I are sharing a room and have our own mosquito nets. I am going running in the am with some other doc I haven;t met yet- he/she is picking me up at 615 am tomorrow. I am getting an orientation tomorrow and making rounds with my team. There is a PHD pharmacist from the states who runs the DM clinics and I will meet him when he comes on Wed. Sara has several options and we will see what shakes out. Looks like I will be lecturing to Kenyan and American students which should be fun.

Weather is 50s am, high 70s without humidity..can't complain. Well we are off to take our Malaria pills and go to sleep. More in the near future.