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.

Thoughts from Mt. Kenya

I would love to post some photos but my internet connection is quite slow. For the past four days, I was off hiking Mount Kenya, and was unable  to bring my computer. 

Touted as more rugged and beautiful than Killiminjaro, and the second tallest mountain on the continent, I wanted a crack at it, and it was breath- taking!  Thanks to several new friends, some Diamox, and some anaerobic metabolism in my quadriceps muscle group (among others), I summitted Point Lenana, at 4,985 meters above sea level.  Photos will follow, when I have a more brisk internet connection.

As for the end of last week, we finally were able to get a percutaneous nephrostomy tube in one of our newly diagnosed GYN malignancy patients, who had been waiting for several days.  I placed the tube using only ultrasound guidance, a method I'm unaccustomed to. 

She is doing well, and I am hopeful that tube care will continue at home, as per the instructions we gave her daughter.  She may or may not return for a routine tube exchange in 3 months as we advised.  In this environment, with this patient population, I have learned to hope for the best, in the face of financial, geographic, and cultural barriers.  I have a plan to try to attack some of these barriers in the coming week, although my time here runs short.  The registrars, of course, will be instrumental in the process.

On the ride to and from Mt. Kenya, I had plenty of time to finish The Africans, a great book, which I passed on to Laura, a first year medical student from IU.  It promptly put her to sleep, as she had not been sleeping well this past week, so the book has thus far had a therapeutic effect for her. 

Through a series of interviews with presidents, revolutionaries, and everyone in between, I learned not only about the post- colonial reorganization of Africa during the Cold War era, but of the circumstances which made Africa rich soil for the HIV/AIDS epidemic to take hold.  Although published in the early 1980's, the trends Lamb cites remain highly relevant.

I also gained a deeper understanding of some of the cultural idiosynchrasies I had run across in the last few weeks, such as Swahili time, which runs seven hours later than western time, or about the context of the conditions of roads in Africa and the dangers of being a passenger on them.

To offset the political science, I then read an award winning Canadian fiction novel called Lullabies for Little Criminals, about a tween girl in the slums of Montreal, raised by her heroin- addicted father.  That little gem caught my eye one night waiting for dinner in the IU house library.

Imani Workshop

Peter, Kai, and Chris, painting with some of the Imani women, as part of a facelift for the Imani Workshop, an organization dedicated to employing HIV positive women who would otherwise be jobless & ostrasized from the community.

Converting a large industrial space from a drab, craft- stained, eggshell palette to a creative, tapestry- like motif.

Heading directly to the Workshop for painting after work Friday means that my right black work shoe is permanently stained with red acrylic paint.  I tested the theory that it could wash off today when the soaking rains got me walking back from the hospital, after finishing the ultrasounds of the afternoon.  It turns out the Totes- sized pink umbrella I bought downtown is no match for the winter rains here, and I was able to protect only my laptop, cradling it like a pregnant belly in front of me.  My back was soaked by the time I got to IU house, and my legs were spattered with mud to the level of my knees.  I didn't notice, until Dr. Jackson, our new arrival and the Chair of Radiology at IU, pointed out that the effect of the mud made it look like I hadn't shaved my legs in quite some time.  We all had a good laugh about it before I cleaned up for dinner. 

Even Michael, the most welcoming man on the planet, and the gatekeeper of the neighborhood in which the IU compound is located, did not come out of his sheltered guardpost to greet me, as he usually does.  Did I mention how wonderful the Kenyan people are?  They are all extemely friendly, and I have learned several ways to greet everyone I see, as is customary.  Michael takes this to another level, often holding my hand for what feels like a long time, shaking vigorously, saying, "Welcome, my American daughter!"  Today, he shouted from his guardpost, that the rain was welcoming me.  It's a beautiful thought. I would enjoy it even more if my shoes dried in a timely fashion!

The chest lecture this morning was fantastic, with lots of interaction.  We ran over the alotted hour by atleast 20 minutes, and the registrars didn't stop me, a good sign!  I'll give another talk tomorrow, a good reason to get to bed.  Lala salama!





Initiated and Inundated

                                    This was case of the day on Friday.  What do you think? 


Tumor board was well attended this morning, with the consultant hematologist/ oncologist running the hour.  Attending level physicians are called consultants here, which seems appropriate, given that they spend a couple of hours providing patient care at each institution they serve, a couple to a few times per week.  They spend the rest of their time shuttling around to care for private patients in private hospitals, who help to pay the bulk of their salaries.
In any case, the first case at tumor board was a 14 year old boy who presented with chest pain and hemothorax, who underwent thoracotomy for diagnosis of his Non- Hodkin's lymphoma. He had incompletely responded to chemotherapy, and was brought up for discussion for the possibility and utility of a repeat biopsy.  Given the mass was plastered against the anterior chest wall, I thought it would be possible under ultrasound guidance.  My attending, Marc, and I brought this up for discussion, and the idea was very well received. 

It made me realize, again, how different the practice patterns are here, and how that takes time to change clinical behavior.  The Kenyan radiologist in attendance, who is less procedurally oriented, was of the opinion that it would be unsafe, given the mass' proximity to the pericardium.  Since there is a lack of people willing and able to provide this kind of service, most things are done surgically rather than by less invasive means, as we are used to in many centers in the US.  Given the suggestion and available expertise, the clinical dilemma of getting tissue or not becomes much easier.  I hope this young man comes in in the next couple of weeks so that we can do the biopsy with the registrars.
The second case was of a huge maxillary mass you would have to see to believe.  As with many of the patients I've seen, going to the hospital is the absolute last resort, and various homeopathic therapies had been attempted, scarring the skin overlying the enormous protuberant mass, which displaced her nose rightward and splayed her teeth widely apart.  On CT, the mass was clearly bone- forming, although the pathologists had called it a mucoepidermoid tumor.  We questioned the diagnosis, as the appearance was more compatible with something like a chondrosarcoma or osteosarcoma, although the differential is broad.  Staging using a chest x-ray was discussed.  There is no such thing as a staging chest abdomen and pelvis here, like we do every day at Rhode Island Hospital. 

Tomorrow promises to be my most scheduled day yet.  I'll give the first of many morning lectures to the radiology registrars at 8:30, since they're back from exams.  I have pending consults for a possible pancreatic biopsy as well as percutaneous nephrostomy tubes.  After lunch I will meet with Wyclif, the Swahili teacher, who also happens to know sign language.  He is going to help me speak with the IU House carpenter, so that we can build a camera stand for one of the outlying AMPATH clinics.  This is part of an attempt to centralize reading of chest x-rays taken at these remote locations, so that they may be uploaded to an online database, to hopefully be read by a radiologist.  At this point, less than half of the radiographs are read.  One of the many issues is lack of man- power, as there are something like 140 radiologists for all of Kenya, population 41.6 million.  Contrast that with over 50 attending radiologists in Rhode Island Medical Imaging, serving just part of Rhode Island's 1 million residents.

Today Lauren and Ada, a couple of AMPATH IT staff members living at the bed and breakfast with me, attended a goat roast hosted by their co-worker Wynn, who had slaughtered the goat himself earlier in the day.  I secretly wished I had been invited.  Maybe that's what I was smelling as I trotted over the goat trails earlier this evening...

Some photos.

Chris, responding to Rory's accusation that his pants are too tight

One of the (unfortunately many) non- functional second hand pieces of equipment stored in the rads dept.

An "urgent" postop film. 

(Look closely at the circled bit at the bottom: to be read within 2 weeks!)

Last weekend at the Mara.  Katie Martin's photo.

Nerding out!



Jane gets to town

Marc Kohli, wrapping up a conversation with Jane Carter, a well known pulmonologist and TB researcher, on "saving the world with x-rays."

Education nation

The secretaries in the department have decided it's time I get into full immersion mode, which is interesting, given the level of Swahili I've accomplished in the last week and a half.  I think they are having a good time making fun of me, but I'm enjoying it as well.  Words I am very comfortable with, i.e., can use without giggling every time, include:

jambo- hello
habari? how are you?
nzuri. fine.
nzuri sana- doing fine/ well.
sasa?  what's up?
kidogo, a little.
sawa. ok.
asante, thank you
asante sana, thanks a lot.

I've been a bit distracted from them the past few days, but the books I'm reading, besides the Rough Guide to Kenya, kindly lent/ given to me by Joanna, include Things Fall Apart by Chinua Achebe, and The Africans, by David Lamb. 

I met more interesting IU folk today, and got to know others much better.  It is such a distilled experience, being here together, and I find the people here to be great.  Kai came to spend the day in radiology with us, and as an IU student contemplating pediatric surgery, I hope, and I think that it was, a good learning opportunity for him!

Running the goat trails with Chris the other day was great, and I look forward to doing it again after the queasiness I've been feeling subsides.  Perhaps I've been too adventurous in my food choices.  The food here is great, and if it weren't for the lack of appetite, I'd be gaining many pounds.  Tonight maybe 50 of us ate at a restaurant in town called Sikh Union. The food was fantastic, and there were badminton courts in an adjoining room, which was incredible.  I sat between Katie, a med student from Utah, who went to Brown for her undergrad studies, and Kate, an Environmental Engineer PhD candidate from Purdue, with ties to Newport, RI.  Funny how that happens.

Besides the usual work, this week I'll be starting to help Marc Kohli, a body imager and informatics guru from IU, to provide better imaging services to outlying clinics surrounding Eldoret.  It's nice to have an immediate impact by helping out in the department, but this project could have the potential to have a wider and more durable impact for many patients in the AMPATH sphere. We shall see!

Mefloquine dreams

Coming back to Eldoret feels like settling back into my new home.  It's amazing how long a week can feel when you are in a new place, fully engaged, and out of your normal routine.  It is one of the things I love most about traveling, that time seems to expand!

Kai, Chris, Katie, Rory, Dara, and I had an amazing weekend on safari.  We stayed in a tent camp on the Maasai River, just a 2 minute walk from a hippo pool.  The beasts are terrifying.  Apparently, they are very territorial and aggressive.  So although they are amusing, even enthralling to watch, the thought of them rushing ashore was enough to bring out our most skittish sides, as we compared our footprints to the massive ones on shore where we stood watching. 

The way they peered directly at us and groaned,with just their eyes and ears above water, then suddenly submerged, had me imagining one suddenly surfacing 10 feet away, coming after us!  When they come out of the water even slightly, you can see how massive they are, sometimes weighing up to 2 tons.  Apparently they come out to explore our camp each night at around 1 a.m.  Our Kenyan guide, Felix, later informs us that they would sever us into not two, but three pieces, if given the opportunity.  He's overly informative at times.

The Masai Mara was incredible, and worth the bumpy 9 hour drive each way.  We saw zebra, elephants, ostrich, crocodiles, storks, lions with their cubs, water buffalo, giraffe,warthog, cranes, hyenas, baboons... with a backdrop too vast to believe, complete with mirages, dust, cavernous valleys, and endless grassy plateaus. 

End of the first week and headed for the Mara

Today I was busted taking a picture of sheep on the side of the road today by Agnes, one of the first year Kenyan residents.  How embarrassing!  She pulled over and shouted my name from the drivers seat, offering me a ride. 

The residents here are cramming for their exams which will last Monday through Thursday next week.  So that leaves me to all the ultrasounds I can handle.  Sadly, there is a small volume of ultrasound guided procedures, something I was hoping to do a lot of here.  For the trickle of requests that come in, I was able to furnish a half large suitcase full of donated Cook Medical equipment, which the radiologists here graciously accepted.  So far I've done one targetted liver biopsy, of a huge liver mass just below the skin surface.  They reuse automated Bard biopsy devices here.  I have to say, it was quite dull compared with the new ones I am accustomed to.  I get the feeling that diagnoses are not such a mystery here by the time they present to the hospital. 

In the meantime, I'm scanning a lot, and suggesting a biopsy or other procedure as I see appropriate.  Working extremely independently, today I diagnosed more unbelievable pathology including a bulky cervical mass obstructing the cervical canal, retained products of conception, and free intraabdominal air in a patient who walked in on her own (this happened 2 days in a row!).  The need here is indescribable, and I get the feeling I'm just scratching the surface.  Hearing what the medicine residents have to say about the wards at mealtimes seems to resonate with the sentiment that resources here are simply inadequate.  It seems a matter of not just materials and money, but of man power.  So we are helping out with what we can.

There's red mud absolutely everywhere and all over my clothes!

Today after work, we all congregated at the IU House for some beer, market pineapple, and PB&J.  It's our day to fend for ourselves for dinner, and atleast for a while, the conversation is more interesting than searching for real food.  We are planning our 9 hour trek to the Masai Mara tomorrow, to begin at 6 a.m.  For all of our sakes tomorrow, I hope those out on the town mind their intake, as there will be hours of bumpy road to drive tomorrow!  My medicine counterpart, Dara, asks if I will give radiology lectures on the ride.  Lucky for her, I've brought several!





The digs: this is my backyard.