Scuba and snakes

I've decided to do the rest of my experiences in Kenya by alliteration. Today is scuba and snakes, tomorrow will be running and...rest? Rum? Rainbows? Just kidding, even though my two experiences today really were scuba diving and seeing a snake farm.

I went diving out of Malindi Marine Park this morning with Blue Fin Diving on two sites, Tewa and Papa. The website even provides maps of the dive sites:

They were pretty good dives with reasonably good visibility and a lot of fish and octopi to see (and, at Papa, a large turtle). It was a pretty large group I went diving with (and all Italian...), but they had a lot of dive masters and split us up into small groups, so it was manageable.

After I was done diving, I went out to Watamu to meet up with Dr. Childs for lunch and to head out to Bio-Ken snake farm. But first we had lunch at Ocean Sports Resort, where we had to put up with terrible views like this:

Bio-Ken (http://bio-ken.com/) is a snake farm and research center, with many different missions, including milking snakes for venom to be sent off to India and used to make anti-venoms. I was under the impression before I went that they make the anti-venoms there, but it's too large and expensive of a venture that involves, among other things, injecting horses with increasing amounts of venom until they make antibodies against it.



This is a green mamba, which is one of the most poisonous snakes in Kenya and one that they harvest the venom from. The distribution of the green mamba in Kenya is the light blue and yellow:

We're obviously in the yellow. There's a lot of other cool stuff on the website, if you're interested in learning about snakes and snakebites. Probably wouldn't be very helpful with American snake bites, though (other than the general info on taking care of snake bites: don't apply tourniquets, keep the patient calm, etc).

That was pretty much my day. Tomorrow I'm going to try to get some running in in the morning (before the gym gets ridiculously hot), and then we'll see what happens after that.

Medical examinations and the falconry

 Yesterday and today, I spent a good portion of the day doing medical examinations of the food handlers at two local resorts (Blu Key and Coral Key, owned by the same outfit). "Medical examination" is probably a bit generous of a term for what we did: we collected urine and stool samples and checked them for urinary tract infections and parasite infections, a process that every food handler goes through semi-annually to keep his or her food handler license. We did detect a few probable urinary tract infections (hard to be definitive when the only thing you're using is microscopy), but no parasite infections. I was quite surprised (and a little disappointed, to be honest) at the lack of parasites, until the public health officer I was working with informed me that food handlers are routinely dewormed. Here are a few things that we were looking for:

 Hookworm eggs

 Ascaris egg (roundworm)

 Schistosomiasis egg

Actually, we did a schistosome egg today, but that was in an unrelated patient. But yes, I did spend most of my afternoon dealing with shit. During spring quarter of my master's, I took a class on medical parasitology (worst class ever, by the way), and every Friday afternoon, when everyone just wanted to go home and take a nap, we had parasitology lab, which consisted of us looking at slides of stool samples, trying to find parasites. So every Friday during lunch, I ended online conversations with Brad by saying, "Well, time for me to look at shit under a microscope." It became a bit of a joke for everyone in the class.

But back to the story... everyone passed their "medical examinations" and got their certificates to continue working as food handlers for another six months, and I wrapped up another week of work at Malindi District Hospital (only one week to go until I'm heading home!) After finishing at the hospital (and Dr. Childs finishing his first class of almost-ATLS), we decided to hit the town. Nothing terribly exciting: we went to the Malindi Falconry, which is more of a zoo than just a Falconry. Here's some of what we saw:

Giant, ancient turtle (the guide said he was 118 years old). He liked to be petted, so I petted him for a bit (it's like a leathery dog), but apparently he took a liking to me and started following me around. I was a little weirded out, but not too worried. I'm pretty sure I can outrun him.

Monitor lizard.

Green mambas. These are very poisonous and are found in Kenya (along with black mambas and a couple of other venomous snakes)

And, of course, falcons, which we got to play with. Not really; we just got to hold them, but that was kinda fun, too.

Finally, we had dinner at the Malindi Sea Fishing Club, where they have displayed Kenya's first grander (fish weighing over 1000 pounds). This sailfish (swordfish to us Americans) weighed in at 1250 pounds. It's quite large. There was a cricket game on the television, which I still do not understand at all, despite the fact that we were there watching for an hour and a half.

Tomorrow begins the last weekend in Kenya, and I'm going to be starting it off with a nice and relaxing scuba dive off the Malindi Marine Park :)

Teaching and training

Today was more of the same, unfortunately (or fortunately, I haven't quite decided yet). I'm again in public health, so I spent time with Katana on his weekly disease surveillance reports, which have to be submitted up to the next level. He gets reports from the local clinics (35 or so of them, I think they said), and then puts that all together to submit up to the district public health officer, who submits them up to the province, then to Nairobi, etc. What he usually does is count them all up by hand and submit it that way, so I introduced him to Excel, which will do the summations and keeps everything in a pretty handy place for the future. I've never taught anyone how to use Excel before, so it was a little interesting to see all the things that I do without thinking (like making the columns fit the headings), from the point of view of someone who doesn't know much about the program. I did teach him the basics and how to do summations, but that was about it. I also had to teach him how to save websites into his favorites... The things we take for granted having grown up with computers, I guess.

After that, I got a call that there was a post-mortem (an autopsy) that was about to start, and since I was interested in that process, I went over to the morgue/funeral home for that. Sadly, it was an 11-year-old girl who had been hit by a bus. She was missing the back of her skull and almost all of her brain, so cause of death was pretty obvious, but they still did an internal examination to get a full list of injuries for the police report. One main difference between autopsies here and in the States is that in Malindi, they don't have trained pathologists, so they don't do histology (looking at tissues under a microscope). For cases such as this one, with obvious cause of death, looking at the tissues isn't really all that necessary anyway, but if there's a question of cause of death, or if there's something that needs to be looked at to determine if it's cancer, the tissues get sent down to Mombasa, about 3-4 hour drive down the coast. Not nearly as streamlined of a process as what I'm accustomed to.

Following that, I decided to check out how the trauma training was going. Dr. Childs was using ATLS presentations, which was good, in that they cover the standard of care for trauma treatment, but also a bit difficult, in that Malindi doesn't have a lot of the resources that are needed for standard of care. It's an interesting balance, to present what is right but at the same time teach them what to do in their situations. There's a group of German med students who are the hospital for a month who were also attending the training, so I got to chat with them for a few minutes about school and what they were hoping to accomplish on this rotation.

Tomorrow, I think I'm going with the district public health officer to inspect some of the clinics, but I haven't heard from Jeremy, so I don't know what time I'm supposed to be at the hospital to leave. This could be interesting...

Dog bites and exchange students

As with yesterday, I spent the day with the public health office. Unlike yesterday, instead of starting with active case detection (which is done on Mondays), today we seemed to be having a special on dog bites, and because this is the developing world and dogs aren't vaccinated against rabies, with dog bites come rabies vaccines (in the States, the most common exposure to rabies is in bats, but in the developing world, it's still dogs). With this patient, he had been bitten by his neighbor's dog yesterday, after the dog bit a goat. After the dog bit the patient, the owners killed it, which makes sense, except when you consider that you can test the dog for rabies to determine whether or not the person needs to be vaccinated.

Since we didn't have the dog to test, the default is that the patient gets rabies vaccine, which is not cheap. In most parts of the developing world, one course of shots (five shots) is about 5% of the average family's annual income--and about half of all people have had a course at one point in their lives. Fortunately, Malindi has a supply of vaccines, which is free (when the alternative to getting the vaccine is getting a disease that is 100% fatal, it's best not to bring finances into the equation). So I saw the patient, saw the bite (which had been cleaned at a local clinic yesterday) and decided that he needs shots, so I gave him the schedule for the shots (days 0, 3, 7, 14, and 28), wrote it out on a calendar with circles for the days he needs to return for the next shot, and set him up to get a tetanus vaccination as well (since he had no idea when his last tetanus shot was, if ever). We also recorded all his information for the Ministry of Public Health and Sanitation's records of where the vaccines were going to.

After all this, we headed to a meeting with the Wellcome Trust's chief engineer (Wellcome Trust is the organization we visited down in Kilifi) and their contractor, because they are building an extension of the CCC, to create a lab that they will use for clinical TB research. This is the part of public health that I'm definitely still learning. It's one thing to say, "Okay, we want to build a lab," but it's another entirely to draw up blueprints, go the site, evaluate the site, determine where the wiring and plumbing is, etc, etc. I'm glad there are people who know this stuff, because I don't.

For lunch I got to meet with a student from Jeremy's NGO, Aiducation International (http://www.aiducation.org/). It's an organization that, through donations, sends kids to secondary school (tuition for primary school, or 1-8, is covered by the government, but secondary school, 9-12, is not); as far as I'm concerned, educating kids does more for a country than all the shipments of medications ever could. Anyway, this student, Henry, recently returned from a year as an exchange student in Michigan, so it was fun talking to him about living in the States and being back to Kenya. Like any teenager, his favorite restaurant is Burger King, and his favorite thing about being in Michigan was playing and watching basketball. I think it was a good educational experience as well. He hopes to return to Michigan State University for college to study physics or engineering, and wants to be a pilot. Here's a picture of us outside the Hilton (a nickname, not the real name of the restaurant):

After lunch, I did my typical lounging around (went for a swim, read on my iPad, etc). I know, it's a difficult life I lead. Tomorrow I'm back in the public health office, to see what fun preventive medicine things we can find this time.

More training

This time, the training isn't for me. Yay!

I started the day in the public health office, where we did active surveillance for polio and measles. This involves going to the outpatient physiotherapy and occupational therapy logs, and checking the diagnoses to make sure nothing sounds like "acute flaccid paralysis" (which is polio), and then going to the pediatrics ward and making sure nothing looks like "fever and a rash" (which could be measles). It would also be possible for acute flaccid paralysis to be the inpatient peds ward, but we didn't see that (or fever and a rash). This is good, because with the two cases of neonatal tetanus from before, Malindi District Hospital already has enough to report to the WHO.

That didn't take too long, so I was off to do more preventive medicine-type things, which was seeing how their vaccination clinic worked and what exactly happened in the family planning clinic. The vaccination clinic was interesting, just because there's so much logistics that we don't usually think about. Cold chain is very important, especially for the measles vaccine; if the vial gets to warm, it's useless (and no, I don't know what that magic number is). So they have the stocks of the vaccines in a freezer, which is only opened twice a day, once in the morning to remove what would be needed for the day, and once the evening, to return anything that wasn't used. The vials that are going to outlying clinics were placed in a cooler and packed with freezer packs (the fake ice stuff usually used in coolers). Those that were going to the vaccination clinic at MDH were placed in a fridge in the clinic, except what they needed at the moment, which was kept in a cooler with the freezer packs. Whenever that cooler was emptied, they opened the freezer to get more. It was somewhat complicated, but it works, which is the most important part.

"Family planning" is the PC term for birth control. I haven't seen the actually study that says this, so I don't know if it's true, but according to COL Coldren, women in Kenya seek family planning after they already have a kid. Men want it before they have a kid, but once they have one, they want more, so they don't want family planning anymore. Sometimes this means there's a little bit of sneakiness on the part of a wife, who will go in for Depo-Provera shots (birth control shots) when she has to go to the clinic for her baby's shots. From what I saw, Depo is the birth control of choice here, because it's cheap (70 KSH a shot, which is about $0.80) and you only have to think about it once every three months. Family planning is offered to anyone who wants it, but from what I saw, it's usually women who already have at least one kid and are trying to space kids out, which is good.

And now back to the title of the post. Today a trauma surgeon and Navy reservist arrived to provide training in care for trauma patients (this is his annual two weeks of active duty time... talk about having a hard life). His original plan was to do Advanced Trauma Life Support (ATLS) training, which is a 2.5 day training back in the States (I did it during C4, during intern year). Well, ATLS requires all sorts of skills demonstrations that they just don't have here, so his plan is to use a lot of the ATLS lectures and just teach whatever skills he can manage to teach, given the resources of the hospital. This training was requested by Dr. Buni, the medical superintendent, because they're opening up a Casualty ward (essentially an ER), and he wants to make sure he has medical officers and clinical officers who know what they're doing in it. It's going to be a busy two weeks for Dr. Childs, given that he has to make up some aspects of the course and given that there are about 50 people who want/need training. I'll drop in on some of the lessons, to see how the training goes and offer my assistance if he needs it.

After work, I lounged around for a bit before heading over to the gym and putting in some treadmill time (ugh). It's not exactly fun (in fact, compared to doing some real running, it's pretty much torture), but it has to be done. In a little less than two weeks, I'll be back home and will get to do all the running I can handle (hopefully without ending up in a fracture boot this time...)

Watamu Marine Park

It's not scuba diving, but I did get a chance to go snorkeling today, at Watamu Marine Park (like Malindi Marine Park, it's a national park run by the Kenya Wildlife Service). The situation was pretty much the same as Malindi Marine Park, only this time, I knew we were going snorkeling and I was prepared with my swim suit :)

It was me, Jeremy, his two sons, and two of the clinical officer interns from the hospital who went. Jeremy's sons (who are, I think, five and seven) stayed in the boat, Jeremy and I went snorkeling, and each of the interns went for a few minutes. Learning how to swim isn't a big priority in Kenya, even for those who grew up along the coast. Kids are told not to go to the beach, because bad things happen at the beach (which was pretty much the same story I got during my security briefs before coming to Kenya) and that the water is vicious or evil or some such thing. So Jeremy didn't learn how to swim until he was in college (and this was only his second time snorkeling, the first being with one of my tropical medicine classmates when she was here in May), and neither of the interns was that confident in the water, either.

I had a great time, though, and was probably in the water for an hour and a half :) We bought loaves of bread to feed to the fish, so they were all around us. I decided to try to pet one, then decided to try to catch one (they're fast little things, those fish). I did succeed in catching one, but I think I was more surprised by that than it was, and I immediately let it go. The boat captain was laughing at me and said I could keep one if I caught it, but then I couldn't manage to get another.

After snorkeling was a (very) late lunch, still down in Watamu, then we hung out at the beach for a bit before heading back. Since then, I've been living my very difficult life: I hung out on my balcony and read a book on my iPad :) Tomorrow, though, I will have to go to work, to begin my last two weeks in Kenya. Those last two weeks will be with the public health office, though, so it should go better than the wards.

Back in Malindi (Again)

Yes, I am again back in Malindi, my jet-setting days around Kenya coming to an end (for another two weeks, until I jet out of Kenya). The past two days in Kilifi were fun (and very relaxing), but it's nice to be back to having internet.

I did absolutely nothing today (no, really). I slept in, had breakfast, and had a massage before leaving Kilifi, and then after arriving back in Malindi, went out to lunch with Jeremy (the clinical officer who does all of the liaising with the visiting students and residents) and COL Coldren, and then we sat at the bar and had a couple of beers before it was time for COL Coldren to get on his plane to go back home. Then I lounged around, read some emails, read some of a free Kindle book (that's not all that good, but I'm reading anyway), and now I'm updating the blog. I know. Everyone wishes they had a life as interesting as mine.

I'm at my two-thirds point right now; four weeks down, two to go, and I'm at that point when I'm starting to be ready to be going home and getting back to my routines (and my home). I sat down with the marathon training program I found a few months ago, and realized I'm already several weeks behind getting started for training for the Marine Corps Marathon; fortunately, I'm not exactly starting from scratch, but I still need to find a treadmill, and that's at the top of my list of things to do tomorrow. I also miss getting to do laundry whenever I want/need to do laundry, and going to the grocery store when I need to, etc, etc.

But two weeks will go by before I know it, and then I'll be complaining because I miss the laid-back pace of Kenya :) I guess the grass is always greener on the other side.

8-4-11—CCC, CME, and Kilifi

I’m writing this on Thursday night, even though it covers Wednesday and won’t be posted until Friday. The joys of not having internet access everywhere, I guess.

Wednesday I was in the CCC for another morning, this time with the dermatologist. As on Tuesday, the CCC is for people with HIV, so the patients in the derm clinic are also HIV+. This was set up this way because there are a lot of skin conditions either associated with HIV, or associated with opportunistic infections of HIV. This way, they get to go to the same building, and it’s easier for everyone involved. I only saw three patients, because dermatology patients take a while. Two of those were fairly common skin conditions (one was eczema), but the other essentially had warts over his entire body. With one wart, you can just freeze it off, but when there are that many, there’s not much that you can do. The only thing that could be done is to get him started on HIV medications; once his immune system improves, the skin condition will also improve.

           

I also gave a CME (Continuing Medical Education) on Wednesday, on tropical hematology (blood diseases). Unfortunately, the computer and projector weren’t working, so I had to give the presentation off the cuff. I don’t know how well received it was, but I am disappointed that I didn’t get to use my PowerPoint with its nifty background (that I designed).

After the CME, COL Coldren and I headed down to Kilifi, to meet with one of his former employees from while he was stationed in Kenya, who is now a Ph.D. in virology and works at Wellcome Trust, which is a massive research facility. Here's a picture of COL Coldren and Clayton at Wellcome Trust:

We’re also staying at the hotel where COL Coldren got married, so that had a few funny stories associated with it (his wife isn’t Kenyan; she’s Australian, they just met in Kenya and eloped while they were both here). This is pretty much where they had their wedding pictures taken:

 

Anyway, the labs at Wellcome Trust rival those in the new research building at OSU, which was completed in 2008. It’s pretty amazing. Clayton, the former employee, got his Ph.D. from England, but did the work in Gambia (Western Africa) on HIV-2, which is a less virulent form of HIV (the most common HIV worldwide is HIV-1). There are some people who are infected with HIV-2 who never have any signs of it—no opportunistic infections, no immune problems, nothing—so his dissertation had to do with why some people have such a mild disease course, and if that can be used to come up with a way to fight HIV-1. Short story is, HIV-2 has some different genes than HIV-1, and some people have different immunology to it, and unfortunately, having HIV-2 does not protect against having bad effects of HIV-1. The hope was that it could be used to vaccinate against HIV-1, but that’s not the case at all.  

We got a tour of the lab facilities today, pictured above, but only after I got the opportunity to do some scuba diving. Unfortunately, conditions weren’t too great for diving in Kilifi Bay, so we did the dive in Kilifi Creek, which is a bit of a misnomer. It’s not a creek; it’s the mouth of the river that dumps into the Indian Ocean. So it’s actually quite wide and quite calm, but not too exciting. There was some coral, and some typical small reef fish, but nothing too terribly exciting. I guess I’ll still have to do some diving in Malindi to see some reefs.

After the tour of the lab, we went out to dinner with Clayton’s family. His wife is a journalist doing some correspondence work for a media outlet in South Africa, and they have two kids, a three-year-old daughter and 10-month-old son, both of whom were very cute and had a lot of energy. It was a very fun dinner, and very good, but I’m still sitting here very uncomfortably full from all the food. That’s life, I guess. Here's a picture from where we had dinner, near sunset:

Tomorrow: relaxing around the hotel in the morning, then heading back to Malindi, just in time to enjoy another grueling weekend J

Comprehensive Care Center

Today I was back at work, after about a week off from seeing patients (and, essentially, a week after having to do any real thought at all). I spent my time in the Comprehensive Care Center (or Centre), which is the HIV and TB outpatient area, where I learned not only the difference in HIV care between the US and Kenya, but also the difference in outpatient care in general.

At the CCC, we saw stable, uncomplicated HIV+ patients for their quarterly visits to check-in and get refills on their medications. Each encounter took about three minutes, during which answers to set questions were recorded ("Do you have cough?" "Are you taking all your medications?" "Do you have any other complaints?" and for the women, "Are you pregnant?" and "What are you using for family planning?") and prescriptions for refills were written. Every six months, the patients get a CD4 count, which tells how well the medications are working for them. If the CD4 count continues to decline despite good adherence to the therapy, the medications are changed in hopes that that will turn the disease course around.

In the States, the same encounter would take over 15 minutes, because it would involve a full physical exam and much more detailed questioning. CD4 counts, as well as HIV viral lodes, would be done much more frequently, and there would be no questions of whether or not the virus is resistant to certain medications, because before starting any of them, a full genotyping of the virus would have been done to look for genes that lead to drug resistance. And, of course, everything would have to be diligently documented, in order to avoid the potential for lawsuits in the future.

Different worlds.

There were a few other things I noticed about the CCC, and HIV care in general, during my morning. The most glaring of which is that partner notification and testing doesn't really happen. Patients who test positive are encouraged to tell their partners and encourage them to come in for testing, but it isn't required, like it is in the States. After I noticed this trend, I looked at the numbers from the surveillance data of the hospital, and sure enough, for more than 300 patients who tested HIV+ in the last year, there were only about 100 who had partner counseling and testing. That leaves quite a few people who are unaware of their need to come in and get tested for HIV, which is, as far as I'm concerned, an unacceptable situation.

Another thing I noticed is that HIV treatment is a great equalizer in this society (or maybe just in this situation). HIV testing, counseling, and treatment is entirely free, which is a good thing (and also the only way to take command of this epidemic, although it might be too late for that). This is due, in no small part, to PEPFAR (President's Emergency Plan For AIDS Relief), which is a US program for AIDS relief in the developing world. Because of that and deals struck with the drug companies, drugs are free at the level of the consumer, through government hospitals (I don't know if there are private hospitals out here; I know there's one in Nairobi, but that's quite a distance from Malindi). Therefore, everyone who is HIV+, regardless of social standing, goes to the same place for medications, so I saw people in business dress as well as women in traditional wraps and men in old and worn clothes.

Anyway, that was my morning, which was followed by lunch and working on my presentation on anemia for tomorrow while sitting at the hotel bar, a quick swim, and a lengthy dinner. Tomorrow I have another morning in the CCC (probably working with the dermatologist), then I give my presentation, and then COL Coldren and I are heading to Kilifi, to see how they do things there.

Back in Malindi

After almost a week away, I am back in Malindi for the last three weeks of my Kenyan stay. I'm in a new room, which has it's pros and cons. It's closer to the restaurant and bar, which is nice, except for the fact that it's 10:15 and I can still very clearly hear the sound of the band playing. Oh, well. Music in the evening is better than the sounds of building a new staircase in the morning, which is what I got at in the old room.

Anyway, here's a picture of the new room:

The new room comes with a couch, too:

No, the stuff on the couch won't stay forever. I'll probably unpack tomorrow, because I'm too lazy to do it today.

I didn't really do much today, when you consider the entire day. I did some running on the treadmill in Nairobi, then hung out in my room (mostly packing) until it was time to check out. It was too cold to hang out by the pool (I know, right? Too cold to be outside on the equator?), so I hung out in the hotel lobby with the computer until I decided to eat lunch, and then shortly after that, a Walter Reed Project came and picked me up to take me to the airport for my flight to Malindi. It turns out that my flight to Malindi was actually a flight to Lamu followed by a flight to Malindi, but I did eventually make it to Malindi, which was the goal (obviously). I did get to see some pretty beaches in Lamu on the flight (Lamu is an island off the coast, and essentially just a tourist resort area).

Since I came in in the evening, it was obviously too late to do anything at the hospital, so I just dropped my stuff off and met COL Coldren at the bar for a drink before we headed out to the Deep Sea Fishing Club for dinner. It's a member's only restaurant, but fortunately, they give day memberships, which is what we did (and what COL Coldren does every time he's in Malindi). The food is from I Love Pizza, right across the street, but it's a better atmosphere, so that was fun.

Tomorrow: back to the hospital for the first time in a week. I think I'm going to the Comprehensive Care Center (for HIV + patients), so that should be interesting.