Val

Val Jackson, MD, Chair of Radiology at IU

Lecturing to a rapt audience

Humor was infused into the lectures.  Cornelius looks like he's tearing up from laughing so hard.

Mary in the background, with her mid- morning tea and mandazi (fried bread)

Christine, our patient volunteer, who underwent numerous breast biopsies.

Agnes Ochako, part 1 registrar, learning the hand- eye coordination needed to successfully perform an US guided biopsy.

Looking on are Ashiale, Benjamin, Juliette, Cornelius, and Mary.

Val gives Juliette some pointers, as Daniel, Mary, and Victor look on.

Val, looking like she just won an Oscar for best performance:

Holding a soapstone piece gifted by Dr. Joseph Abuya. Soapstone comes from his native region, Kisi.

Keeping malaria at bay, with some good old G&T.

This was at Sanjeel, a fantastic Indian restaurant, on a Wednesday night, when the entire group of 30-50 people at the IU compound hits the town for dinner.

Checking out the medical student hostel across from the hospital.

Buckets for "showering" line the hallway.

An efficient use of space, with clothes drying in the stairways

I was grateful not to need to use this bathroom. 

The electrical network...

Seen over two doors facing each other. Each room was made by splitting a room originally intended for one person. Two students share a bunk bed in each of these split rooms, leaving room just to stand beside the bed, and a small desk.

With Steven, one of the 6th year medical students.



I sortof ambushed Dr. Mamlin the other night, just before dinner- he's so busy running a compound and a blossoming health system, it seems to be the best way to set up a meeting.  He was on his way to feed the dogs prior to dinner, when I stuck out my hand to finally introduce myself.  Eating dinner together and discussing the Turbo experiment, he commented on me being a “hearty eater.” Given he’s from the Midwest, that probably means I was eating quite a lot.  It was about double what he had on his plate.  We spoke about Kelvin's, Otunga's and my visit to Turbo, and the potential points of failure in our setup. The clinic patients on the ministry side are treated sortof the way we the uninsured or those without primary care in the ED; it is simply episodic care, without any longitudinal follow up. Once the patient is treated, whether for malaria or acute HIV, the record is purged, and whatever chest x-ray taken as part of the visit is looked at by a physician’s assistant, never viewed by the eyes of a radiologist.

The goal of AMPATH is to change this model, offering longitudinal care which began as an HIV focused effort, now expanding to cover chronic conditions such as diabetes and hypertension.  Dr. Mamlin is concerned, because of the political and financial rift between the AMPATH and the Kenyan health ministry side, that our project may suffer from apathy, passive aggression, and failure.  We discussed possible solutions for problems which one could anticipate in the current environment. 

My other project is off the ground, and will need to be nurtured by the current registrars.  Since I wanted to have an image guided procedure focus, I strove to identify the barriers to providing image guided procedures, such as guided biopsy, drainage, and nephrostomy:  safe, effective and potentially cost- effective treatments for which there is a burgeoning need.  Currently, donated devices are pieced together for each given request.  

Our last patient for nephrostomy was extremely thin, and therefore the 7  cm access needle we had was adequate; however, a larger patient would not be able to undergo the procedure due to this limitation, despite the numerous locking catheters I brought. 

Since there is no consistent IR supply through MTRH, patients must have another option if these services are to be offered.  Orthopedic hardware, such as a hip replacement are stocked by pharmacies, so that patients who can afford it may buy it.  Our thought is that a similar setup could work for IR devices. So, I’ve e-mailed a number of distributors and am in the process of getting sample prices for the most important devices, including centesis catheters, guidewires, locking catheters, and biopsy devices, so that the registrars may pitch these devices to private pharmacies in the area.  Thus, patients who can afford the materials may purchase them, and the pharmacy can make a buck. 

Coming here, I heard the advice that one should pair up with a Kenyan counterpart to be most effective, and this fortunately happened for me quite easily.  Cornelius, a “part II,” or second year resident interested in interventions is the go- to  registrar for these kinds of procedures.  We got along seamlessly, and understand each other implicitly.  Over the course of the month, we’ve made a pact to get a consistent procedural service going at MTRH.  Since Cornelius plans to stay in Eldoret indefinitely, he also happens to be the person best poised for making progress in the department to this end.

Saying “kwa heri” to everyone in the department  was a several day process.  We had a dinner last week, when Val and Marc were on their way home.  We all went out to the edge of town for some nyama choma, or roast meat, the quintessential Kenyan meal out.  We had kilos and kilos of various kinds of meat, traditional greens, a mashed potato/ greens mixture, salads, chapati, and ugali, a tastless cornmeal I avoid, but is considered by most Kenyans a staple.  We got the registrars token gifts: jewelry for the female registrars, who are the majority, numbering 5 of a total 9, and stuffed animals for the guys, as they all happen to have multiple children.  We were showered with gifts, each receiving a soapstone sculpture from Dr. Abuya, from his native region, Kisi, as well as scarves, a dress for me, jewelry, paintings, and cards signed by all.  Everyone took turns to say what the visit meant to them and to thank us for visiting and contributing to the department.  It was truly touching, and we felt so appreciated.

Monday night, I was invited to Agnes’ home for dinner, where I spent the evening with her, her 3 children, and her housekeeper.  Her husband works in another region, hours away by car, so the family reunites on the weekends. It’s surprising to me how common that setup is in modern east African society.

I’m finally on my way homeward, and got a couple of marriage proposals in Nairobi today.  My driver gave me the hard sell all day; he only has one wife and one kid, and “wants a mzungu wife” because he “hears it’s nice.”  Despite awkwardly having to decline his offer, I had a great time seeing the National Museum, including the Hominids Exhibit, seeing the slums of Kibera west of town (life altering to see) and finally, having some more nyama choma and my final dose of Redd’s, a Tanzanian cider, while watching various Olympic events at a local pub near the airport with my driver and his friends.

There were hundreds of schoolkids at the museum today, all visually grouped by their uniform patterns.  Three beautiful little girls in uniform, probably twelve years old, all with buzzed black hair, came up to me while I was looking at some ancient skulls.  They wanted to shake my hand and say hello, as I was maybe the first mzungu they had seen.  I’ve become accustomed to this, and enjoy greeting them like they’re my new little friends.  These girls were not shy, however, and after shaking my hand reached up to feel my hair!  Two of them stroked the front of my head, smiling and saying, “smart!” which people use here in the British sense, meaning nice, pretty, what have you.  They got really excited, giggling and scampered off to join their group.

To anyone considering a trip to Kenya, it does not take much effort to gain kudos and appreciation for effort in learning Swahili.  Just a few words was enough to prompt people to ask where I was from, how long I was in Kenya, and when I will be back. 

Turbo Clinic: the pilot

Patrick, the IU house resident carptenter, with his rendition of our digital photography frame.

Today's Monday morning ride to Turbo Clinic, one of the AMPATH clinics located outside the city, was my first trip west of Eldoret.  We drove about 40 minutes toward the Ugandan border, on a newly paved highway, a full two lanes wide, with no potholes or ditches to be found.  Full of hulking Mercedes tractor trailors, as well as the requisite cyclists, mo- peds, pedestrians, peddlers, cattle, dogs, and children, all shuffling past each other in a game of leapfrog, it was a chaotic scene. The reason the beautifully smooth road exists, I learned, is that this is a major trade route stemming from Mombasa, stretching across Kenya and continuing through Uganda. 

We arrived at the clinic virtually unanounced, given the logistics of getting multiple people in one place at one time, getting the frame completed, and securing a driver.  We simply showed up and asked for the person in charge.  Greeted by one of the local AMPATH physicians, we explained the concept, a brain- child of Dr. Marc Kohli and Dr. Joseph Mamlin.

Several conventional chest radiographs are taken at these outlying clinic sites each day.  Barriers to getting a chest film from these outlying clinics read by a radiologist are myriad:

1. There is a sole film, property of the patient.

2. These films have previously been transported to Moi Teaching and Referrral for interpretation.

3. Films are lost along the way, or are sometimes not interpreted.

4. If all goes well, the clinician may receive a report on the x-ray in about a week. 

Our proposed system of taking digital photos of these radiographs aims to accomplish the following:

1. Preserve image quality so that it remains interpretable as normal or abnormal, similar to the system used at the University of MD.

2. A digital copy of the radiograph will always be accessible, and may serve as a baseline study for future comparison.

3. Films do not need to leave the clinic, and are therefore less likely to be lost.

4. Interpretation may occur with a quicker turn around time, improving TB and HIV/ AIDS related care, as well as public health surrounding these issues.

5. Films may be read at any time of day with password access to the online PACS, and may be read remotely at MTRH or even state-side.

The purpose of the actual wooden frame is to provide a consistent camera- to- radiograph distance and consistent image quality, regardless of the operator.  The meeting consisted of a full demonstration for the medical officer, the site manager at AMPATH, one of the physicians, and the radiographer.  The memory card from the camera will be couriered biweekly at minimum, so that Kelvin, the PACS manager, may upload them for interpretation. 

It is an experiment with many moving parts, but I'm hopeful it is a step in the right direction toward equalizing the level of care that patients receive throughout the AMPATH system.    

Iten

Running along the ridge of the Rift Valley this morning with Laura was the most new kind of adventure.  We began from the high altitude training center we were staying at, trotting down a muddy red path, in search of the stadium a few km away, which was built in the 50's for the Queen's visit.  Since then, it's been passively preserved. 

We were greeted by countless, tattered small children on the way, who excitedly parotted what they had learned in school: "How are you?!  How are you?!"  Some of them ran along with us.  We smiled, and answered their cries in a mixture of Swahili and English, because they got a kick out of it. We answered, "Nzuri sana!" or  "Good, how are you?!" to which we got huge smiles, and tens of frantically waving little hands.

We ran past the stadium, down a hill to check out the view of the Rift Valley, a chasm splitting East Africa longitudinally from north to south, spreading by a couple of centimeters per year.  We trotted through some kind of abandoned camp to the ridge, where the expanse opened before us.  In the early morning haze, it looked like we were standing at the edge of the earth.

Finding some narrow twisting trails along the ridge, we traveled east toward Kario View, a restaurant and view point.  I got snagged in a thorn bush so stubborn, Laura had to help free my hair.  We ran through corn fields and across streams, hopping through makeshift fences, and greeting the people we met, who luckily seemed to have a different concept of property than many in the US.  Wherever we went, we simply chose a path, left or right. We skated the ridge until we neared a road below, steep with a hairpin turn.  We cut straight down the hill, toward the floor of the valley.  At the bottom, a friendly gentleman offered me his son as a husband, after hearing I'm a doctor.  We politely moved on, running back up to the camp, accompanied by a pack of siblings ranging in age  from about 7 to 12, I'd guess.  I was distracted from the incline, running through groups of cattle being herded down the hill. 

Jordan, Laura and I went to Iten this weekend to see the high altitude training center frequented by athletes from around the world.  Mere mortals are permitted as well.  It was like a summer camp for grown- ups.  We ate well, swam in the chilly pool, and worked out barefoot in a gorgeous, empty gym.   The dwellings were reminiscent of tree houses.

I have a lot to write about the residents and all we have done over the past week.  More to come tomorrow!

More mountain shots.

 Lunch on the road: fried chicken in a bag.

 

 Nate's aviators framing Laura and I

 The view on the Chagoria route

 Beauty that was from another world, at about 3800m.

 Decorating the walls of our camp on the way down was this interesting depiction

Summit morning, heading down for breakfast!

 Bamboo forest

 A colorfully damp display of mountain wear, following soaking rains and hail which our group narrowly missed thanks to our expert guide's excellent planning!!

Rummy, new friends.

Wonderful day

My day began before 6, skyping with my darling boyfriend, who is toiling the entire month of July away, plucking guitar strings by the water on the coast of Maine.  Our daily routines are pretty different, so the time difference is just a minor detail in the scheme of things. In any case it's a great way to start the day, being able to see him.

After breakfast at Pinetree, Marc and I caught a ride with Constantine, our regular driver, to the hospital, since it was particularly muddy and rainy this morning.  We met Val in the department so that we could take her to the Mother Baby Hospital for tumor board, where we saw more puzzling hematology/ oncology cases.  This week, a woman in her 80's with an ulcerating neck mass and associated jugular chain adenopathy that I scanned a couple of weeks ago was presented.  The pathologist thought that if there was a thyroid lesion, the biopsy was most likely reflective of metastatic thyroid cancer.  I was able to chip in that when I scanned her, the mass was completely separate from the thyroid, which was normal in appearance.  This interested the oncologist as the dermal involvement and presentation would have been atypical.  Since the biopsy and path were done  on the outside, it will be repeated at MTRH.  We are thinking it will probably be a squamous cell.

After the conference, the chief oncologist bemoaned the lack of consistent Radiology involvement at tumor board, and how desparate he felt for radiology input, not only in diagnosis, but in image guided biopsy and intervention.  Marc and I talked with the residents about this upon our arrival back at the department.  They apparently have conflicting didactics.  The chief residents plan to speak with the consultant radiologists about changing the schedule so that they are able to attend in the future.

Marc gave an hour and a half talk on ultrasound physics, followed by an ultrasound practicum, for which I served as the patient model.  My carotids and thyroid were imaged, as we learned more knobology and other useful skills.  The residents practiced on me, and it was interesting to have the patient's perspective, noticing that some people are more heavy- handed than others.  The heavy handed folks make really lovely ultrasound images.  I sortof knew this already, but was able to experience it first hand. 

I went back to IU for lunch to regale my colleagues with stories of glorious Mt. Kenya. Some of the others went rafting in Uganda for the weekend, which turned into a party on the Nile. It sounded like fun, but quite different from our trip!

In the afternoon I learned that our carpenter, Patrick had used inches instead of cm to build our digital photography structure, as I had been afraid of.  It's a beautiful piece of work aside from the few things which need to be fixed over the next couple of days.  We wasted some wood, and some of Marc's money!  Onward...

Val brought me a Tusker, the Kenyan beer taken in these parts, as we sat in the library this afternoon, after I had already decided she must be the most down- to- earth Dept. Chair I'll ever know.  We spent some time pooling photos of baby animals we had seen on safari to help Marc, who was trying to cheer up his stressed wife, Lisa, who is home in Indiana, preparing to begin the Bar exam tomorrow.  Our efforts resulted in a ridiculously cute powerpoint slideshow, which begins with two small bunnies kissing.  Although it was not an original safari photo, it was included for its intense cuteness.  I originally found this ridiculous photo on my engaged friends' fridge while visiting them one day.  Carolyn and Joe, you know who you are.  I explained to Marc and Val how there were arrows pointing at each respective bunny indicating your names, and they had a fit.  We marvel at your engaged bliss.  But I digress.

I then proceeded to my second Swahili lesson with Wycliffe.  Initially, going over lesson one, biffing my conjugations, I was feeling like somewhat of a slow learner.  When we finally moved onto lesson two, I learned to count not just to ten, but into the thousands, and was beginning to fancy myself quite the language savant.  We laughed through the whole lesson, as Wycliffe has a gift for keeping it light, when concentration is drawing creases across my forehead.

Jane is already leaving tomorrow night, and so she took us out to for an amazing Indian meal in town. Diners included Barbara, who started the diagnostic lab at MTRH, Jane, our favorite TB researcher and pulmonologist, Val, Marc's boss and the Chief of Radiology at IU, Rabia, Jane's research scholar, Marc, my "boss (mdozi, in Swahili)" here, and I.  We talked about everything from what we're working on, to the distinction between STI and STD (one of Barbara's specialties) to motherly instincts or lack thereof, and got to know each other well over cheese naan, palak paneer, chicken tika masala, stuffed capsicum, and something delicious termed "mushrooms Eldoret."

A few Mt. Kenya pics

The steep Chagoria route! 

Victorious, on Day 2, overlooking the Gorgeous Valley

Just before sunrise, about 6 a.m., after a 3 hour trek, we reached the summit, Point Lenana, 4985m.  Pure joy.

Zachary, one of the porters, and our driver, negotiating a treacherous dirt road to reach the gate of the park.  We're in a 1960's Land Rover.  We bottomed out and rocked about so much, I felt like I needed a helmet and a harness... the level of skill needed to drive this vehicle is beyond my comprehension.

 

Cast of characters: from left to right it's Nathan, IU peds resident, me, and Laura, IU medical student.