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!